111 Contact Code Vulnerable Consumer Application

Applicant details

Complete this section if you are applying on behalf of someone else.

Applicant's full name

Applicant's telephone number

Applicant's email address

3. Why is the consumer at particular risk of requiring 111?

Please briefly describe the specific circumstance * You only need to provide information relevant to determining whether the consumer is at particular risk of requiring 111.

4. Existing ways of contacting 111 during a power failure

Please tell us whether the consumer already has unrestricted access to any of the following at the premises.

5. Verification

Please either nominate an appropriate person whom Hero may contact to verify the circumstances, or provide supporting evidence.

Nominated person

The nominated person should be someone professionally able to confirm the circumstances, such as an appropriate health practitioner, police officer, registered social worker or lawyer.

Full name

Occupation

Telephone

I authorise Hero Internet to contact the nominated person for the purpose of verifying this application.

Supporting evidence

Upload supporting evidence PDF, JPG or PNG. Maximum file size 10 MB.

6. Declarations

I declare that the consumer is, or will become, at particular risk of requiring the 111 emergency service.

I declare that the consumer does not have a means of contacting the 111 emergency service that can operate for a continuous eight-hour period during a power failure at the premises.

I confirm that the information in this application is correct to the best of my knowledge.

I understand that Hero Internet will store the information in this application and may share relevant information with third parties where necessary to provide and manage the service and comply with the 111 Contact Code.

I understand that if Hero supplies an appropriate means of contacting 111 that meets the requirements of the 111 Contact Code and it is rejected, Hero may treat this application as withdrawn. A new application may be made later.

This application may contain sensitive personal information. Hero Internet will use the information for assessing and managing obligations under the 111 Contact Code.

If you are unable to use this online form, you can contact Hero Internet at support@hero.co.nz or by telephone for assistance with your application.