About Us | Fisher & Paykel Healthcare

Holiday Pay Remediation Claim Form

This form is only for former New Zealand employees to complete if they have received notification that they are owed a payment as part of the Holidays Act Remediation Project.
If you are unable to submit your claim online or would prefer to email your documents to us, please download the PDF version of the form by clicking here, print it out, fill it in, scan or photograph the completed form with your supporting documents and email it to HolidaysAct@fphcare.co.nz
* Indicates required field

Claim Details

Claim Reference Number*:
From the top right hand corner of your claim letter if you have received one

Past Employee Number*:
Identified in your letter if you have received one.

First Name*:

Last Name*:

Date of Birth*:
By including your date of birth we can process your claim quicker.

Name Changes

Has your name changed since you were a F&P employee?*: If "Yes" complete the below

Yes
No

Previous First Name :
If it has changed since you were a F&P employee

Previous Last Name:
If it has changed since you were a F&P employee

You will need to provide documentation showing the name change from old to new, e.g. a marriage certificate or a statutory declaration.

Current Contact Details

This may be used for correspondence and/or payment information.

Address 1*:

Address 2:

City/Town:

Postcode*:

Country*:

Email Address*:

Preferred Contact Method*:

Email
Post

Payment Details

Payment will be made into a New Zealand bank account only.

Bank Account Number*:
Please ensure you check that the bank account number you have entered is correct.

IRD Number*:

Tax Code*:

Are you a contributing Kiwisaver Member? *:
If "Yes" complete the below

Yes
No

Please select your contribution rate:

Document Uploads

Please scan or photograph and upload these documents with your claim. Ensure the images are in JPEG, PNG, GIF or PDF format. Please ensure the documents are captured clearly and are able to be read.

Please note: if your identified document has text on both sides (e.g. driver licence), both sides need to be scanned for it to be accepted.

You can download the IR330 form from here.

You can download the KS2 form here.

IR330*:
This contains your tax code, IRD number and signature. (A PDF version of this form and further information is available on the IRD website).

KS2*:

Identity Verification*:
Any one of birth certificate, passport, certificate of citizenship, Immigration New Zealand visa, driver’s licence, firearms licence or HANZ 18+ card. Please note: if your identity document has text on both sides (e.g. driver licence), both sides need to be scanned for it to be accepted.

Proof of name changed :
Please attach documentation showing the name change from old to new, e.g. a marriage certificate or a statutory declaration

If you are unable to submit your claim online or would prefer to email your documents to us, please download the PDF version of the form by click here, print it out, fill it in, scan or photograph the completed form with your supporting documents and email it to Holidaysact@fphcare.co.nz

Declaration

I confirm that I am the person named in this application and that the details I have provided are true and correct.

Enter security code:*

To view our Holidays Act Remediation FAQs, please click here .

By providing your personal information in this claims process, you consent to Fisher & Paykel Healthcare using that information to consider and process your claim. We will not use or disclose personal information collected in this process for any other purpose. If you do not provide the information requested, we may not be able to process your claim. We deal with all personal information in accordance with the Privacy Act. Our Privacy Policy can be found here. For additional information and support, check out our Frequently asked Questions or email HolidaysAct@fphcare.co.nz