111 Contact Code — application form

Use this form to apply to be recognised as a vulnerable consumer, so that Zylex can supply you — free of charge — with a way to contact the 111 emergency service during a power failure. You can fill this in yourself, or someone can complete it on your behalf. What this is about.

If you need help filling it in, contact us and we will complete it with you:

Email: 111code@zylex.nz
Phone: (04) 333 0333 8.30am to 5pm, Monday to Friday, excluding public holidays
Post: Zylex, PO Box 38207, Wellington Mail Centre, Lower Hutt 5045

1. About the person who needs this

Full name of the person who needs this

Service address (where the landline is)

Postal address, if different

Landline number

Zylex account number, if known

Contact phone

Anything we should know when contacting or visiting you For example: please phone rather than email, or knock loudly.

How would you prefer us to contact you?

2. Who is filling in this form

I am the person who needs this

I am applying on their behalf

If you are applying on someone's behalf, please give your details:

Your name

Your relationship to them (family member, carer, support worker, health professional)

Your phone

Your email

3. Why 111 may be needed

Please tick all that apply:

A health condition or medical need

A disability

A personal safety risk

Other

Please describe briefly You do not need to give detailed medical information.

Is this situation temporary?

Yes

If temporary, roughly how long is it expected to last?

4. Other ways of contacting 111

Is there a working mobile phone at the service address?

Yes

Is there usable mobile coverage at the service address?

Yes

Not sure

Any other way of contacting 111 during a power failure lasting up to 8 hours

5. Someone who can confirm this

Please give us one person we can contact to confirm the situation — for a health condition or disability that is a health practitioner; for a personal safety risk it is a police officer, a registered social worker, a lawyer, or a Family Court judge.

Please do not attach or post medical records, letters or court orders through this form. If you would rather provide a document than a contact person, call us and we will arrange that securely.

Their name

Their role or relationship to the person

Their phone

Their email

I authorise Zylex to contact this person about this application

6. Declaration

I declare that the person named is at particular risk of needing to contact the 111 emergency service.

I declare that they do not have a means of contacting 111 that will work for at least 8 hours during a power failure.

The information in this form is true and correct to the best of my knowledge, and I understand Zylex will store it and may share it with the person named above in order to assess this application.

Your name

Fields marked * are required. We will be in touch within 10 working days.

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111 Contact Code — application form