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 Reference Number*

Past Employee Number*

First Name*

Last Name*

Date of Birth

Has your name changed since you were a F&P employee?:

Yes
No

Previous First Name:

Previous Last Name:

Address 1*

Address 2:

City/Town*

Postcode:

Country*

Email Address*

Preferred Contact Method:

Email
Post

Bank Account Number*

IRD Number*

Tax Code:

Are you a contributing Kiwisaver Member?:

Yes
No

Please select your contribution rate:

IR330

Please select a file

KS2

Please select a file

Identity Verification

Please select a file

Proof of name changed

Please select a file

Confirmation:

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