3950406.1 1 ATTACHMENT A – APPLICATION FORM TO BE CONSIDERED A VULNERABLE CONSUMER Vulnerable Consumer Application form (111 Code) Complete this application form if you want Spark to consider you (or someone else you are applying on
The 111 Contact Code ensures that people who are more likely to need to contact 111, and who have a home phone line that doesn't work during a power cut ...
ATTACHMENT A APPLICATION FORM TO BE CONSIDERED A VULNERABLE CONSUMER
Vulnerable Consumer Application form (111 Code)
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Complete this application form if you want Spark to consider you (or someone else you are applying on behalf of) as a Vulnerable Consumer under the 111 Contact Code.
The 111 Contact Code ensures that people who are more likely to need to contact 111, and who have a home phone line that doesn't work during a power cut (with no other means of contacting 111 at their house that they can use), are provided with a means to contact the 111 emergency services in the event of a power cut.
IMPORTANT INFORMATION
A Vulnerable Consumer must meet all the following criteria: · You or the person you are applying on behalf of is at particular risk of needing to call 111emergency services (either now or sometime in the near future) for health, safety, or disability reasons. · You have no other way to call the 111 emergency service at your premises that can work for a continuous 8-hour period, in the event of a power cut. For example, if you have access to a mobile phone or medical alarm with a power backup, the Vulnerable consumer can use to make calls to 111 emergency services, or your services are already protected by a backup generator or battery,then you will not qualify. · You have a landline service provided over Fibre or Fixed Wireless. This is because these services need mains power in the home to operate. Copper landline services will continue to work during a power cut if you're using a compatible home phone. Customers using naked broadband or copper landline services will not qualify.
You can apply for yourself or on behalf of someone who lives at the premises where the phone line is supplied.
This form can ONLY be completed by one of the following people: · a customer (the account holder); or · a person who is listed as an authority on the customer's account
Instructions for completing the form: 1. Fill in Parts A, B and C of the form. 2. Complete the declaration in Part D of the form. 3. Email the completed form to vulnerable@spark.co.nz. Alternatively, you can post the form to: Freepost 10053 Vulnerable Consumer Spark New Zealand P O Box 1473 Christchurch
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Part A: Applicant's personal details
How to complete Part A · Read Guidance Note 1 (provided in Part E). · Complete Q1 and Q2
Q1. Are you the account holder or listed as an authority on the account?
Yes (fill out Q2) No
NOTE: Only the account holder or an authority on the account can make this application. If you want to add someone as an authority on your account, contact us on 123 or via Live Chat.
Q2. Details of the account holder/ authority on the account
* Please only fill out this section if you are the account holder or an authority on the account.
First name(s):
Preferred first name (if different):
Surname or family name:
Title: Mr Ms Mrs Miss Dr Other, please specify
Account Number:
Landline Number:
Account Name:
Telephone:
Mobile:
Email address:
What is the preferred method of contact (please tick)
Telephone
Mobile
Mail
Email
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PART B: Information on the person at particular risk
How to complete Part B · Read Guidance Note 1 (provided in Part E). · Complete Q3, Q4, Q5 , Q6, and Q7. · If you have more than one Vulnerable Consumer at a premises, you will have to fill in one application form for each person
Q3. Details of the person who wants to register as a Vulnerable Consumer
First name(s):
Preferred first name (if different):
Surname or family name:
Title: Mr Ms Mrs Miss Dr Other, please specify
Date of birth:
NHI Number (for medical/disability):
Address (where the landline service is provided and the vulnerable consumer normally resides):
Street address
Suburb
Town/City
Postal address:
Same as address above
Postcode
Flat/street name
Suburb
Town/City
Postcode
Q4. Please select which category most closely relates to the specific circumstance of the person who wants to be part of the Vulnerable Consumer Register. (See guidance note 1 for explanation of these categories)
Health (for example, a known medical condition) Safety (for example, family violence) Disability (for example, sensory impairment, intellectual impairment or
physical impairment)
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Q5. Is the specific circumstance of the person permanent or temporary?
Permanent Temporary
*If you selected `Temporary', what is the estimated period of time the category of particular risk will apply to the person? Our support team will follow up with you at the end of this period to reconfirm your situation.
Expected start date: ______________ End date : ______________
Q6. Does the person who wants to be registered as a Vulnerable Consumer, have a mobile phone or a power backup solution for their home power (e.g., generator/battery backup) that can be used in case of an emergency to contact 111 emergency services?
No Yes Yes, but it is not suitable. Please explain why ________________________________
Q7. Does the person who wants to be registered as a Vulnerable Consumer, have a medical alarm that can be used in case of an emergency to contact 111 emergency services during a power cut?
No (Go to question 8)
Yes (Fill in the fields below)
NOTE: We recommend that you speak with your medical alarm provider to discuss if your device will work in a power cut, and what your backup options are. If you are unable to contact your alarm provider Spark can do this on your behalf with your permission.
I would like Spark to confirm this with my provider:
Yes
No
Name of alarm provider:
Make/model of device (if known):
Will your device work for at least 8 hours during a power cut?
Yes
Will your provider put you through to Fire/Ambulance/Police?
Yes
No
Not sure
No
Not sure
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Part C: Supporting information
How to complete Part C:
· Read Guidance Note 2 (provided in Part E). · Complete Q8
Q8. What information is being provided in support of the application?
Sufficient evidence to support that you (or the person you are applying on
behalf of) is (or will become) at particular risk of requiring the 111 emergency service (fill in 8a)
Examples of supporting evidence: · a completed Electricity Authority `Notice of Potential Medically Dependant
Consumer (MDC) Status' form, which includes a certification from a DHB, private hospital or GP (accessible from their website here: https://www.ea.govt.nz/operations/retail/retailers/retailer-obligations/ medically-dependant-and-vulnerable-customers/); · a protection order; · a letter from a health practitioner (e.g., a GP); or · documentation of impairment (e.g., an ID card)
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Details of a nominated person we can contact to verify that you (or the
person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (fill in 8b and 8c).
Examples of nominated persons: · Health practitioner (e.g., GP) · A currently registered social worker · Lawyers (with a current practicing certificate) · A police officer · A family court judge
Q8a. Sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service. IMPORTANT: Please attach this supporting evidence to your application. Please only provide us with copies of
supporting evidence, do not send the original documents.
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Q8b. Details of nominated person
Note: Do not fill this if you have completed 8a and are providing Spark with supporting evidence
We recommend that before you make your application to us, you (or the person you are applying on behalf of) first contact the nominated person to discuss the application.
Details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service
First name(s):
Surname or family name:
Occupation:
Organisation (if applicable):
Telephone:
Mobile:
Email address: Postal address: Street address
Suburb
Town/City
Postcode
Q8c. Declaration regarding nominated person
*Please note before completing this declaration, if you are making this application on behalf of someone else you must
have received permission from them to authorise us to contact the nominated person.
· I authorise Spark NZ to contact
for
(Full name of nominated person)
the purposes of verifying that I (or the person I am applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.
Signature:
Date:
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PART D: General declaration to be filled by the applicant
How to complete Part D: 3. Read Guidance Note 3 (provided in Part E). 4. Complete the declaration.
I acknowledge and declare that, to the best of my knowledge, the information given in this form is correct;
· I acknowledge and declare that
:
(please insert your name here, or the person you are applying on behalf of)
o is (or will become) at particular risk of requiring the 111 emergency service; and o does not have a means to contact 111 emergency service at the premises that can be operated for a
continuous 8-hour period in the event of a power cut (i.e. a mobile phone, medical alarm with a power
back up or battery power back up).
· I understand that o the information I have provided in this form will be stored with Spark New Zealand. o if anything on the application is missing we may contact you for more information, and add it on to the application on your behalf after you have signed it o the information regarding the application status, Vulnerable Consumer status and the device provided will be available on the account and therefore would be accessible by the account holder and all authorities on the account o the information I have provided in this form may be shared with relevant third parties for the purposes of providing and managing my service. o the device is Spark property that may not be sold or disposed of without Spark's permission, and may need to be returned (at no cost) if I am no longer a Vulnerable Consumer.
Signature:
Date:
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PART E: Guidance
GUIDANCE NOTE 1
For a person to be part of Spark's Vulnerable Consumer Register they must be `at particular risk of requiring the 111 emergency service'. Part B asks for information that will allow us to know that the person who is applying to be covered by the 111 Contact Code is `at particular risk of requiring the 111 emergency service'. The person could be `at particular risk' now, or sometime in the near future, and they may be at risk on a temporary or permanent basis. The person must not have a means of accessing 111 in a power cut (e.g., no access to a mobile phone or medical alarm with a power back up that they can use).
What does `at particular risk of requiring the 111 emergency service' mean? A person who is 'at particular risk of requiring the 111 emergency service' means a person who is more likely than other people to require the 111 emergency service because of a specific circumstance applicable to that consumer.
The following scenarios illustrate some situations where a person may be considered `at particular risk' under the 111 Contact Code.
Scenario one Mary and Joe are pensioners living together. Joe does not currently have a mobile phone, medical alarm or battery back up. These days Joe is unsteady on his feet. He has fallen over a couple of times recently. Mary is active but spends most of her time at home looking after Joe. Mary is worried that the next time Joe falls he might seriously injure himself.
Scenario two Fatima has type 2 diabetes and is in the early stages of dementia. Fatima needs to take medication every day to manage her conditions but does not have a mobile phone to use during an emergency.
Scenario three Jennifer's father has moved back into the family home. He's been verbally and physically abusive to family members in the past and Jennifer is worried that it might happen again. She also does not have a mobile phone to use.
Scenario four Tane is booked in to have both knees replaced. He lives alone without a mobile phone or battery back up and is worried about complications or a fall and needing to access the 111 emergency service during recovery over the next three months.
What do the `Health', `Safety' and `Disability' categories in Question 4 mean? This question asks you to select which of three categories (health, safety or disability) most closely relates to the specific circumstance you (or the person you are applying on behalf of) has that means you (or the person you are applying on behalf of) is at particular risk of requiring the 111 emergency service.
If you tick the `health' category, this means the specific circumstance that makes you (or the person you are applying on behalf of) at particular risk of requiring the 111 emergency service is related to health. For example, it is a known medical condition.
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An example of a specific circumstance that may mean you tick the `safety' category is family violence. An example of a specific circumstance that may mean you tick the `disability' category is sensory impairment, intellectual impairment, or physical impairment.
Do I have to be `at particular risk' now, or could it be sometime in the future? A person may not be `at particular risk' now, but they know they will become `at particular risk' sometime in the near future. For example, a person who has a planned surgical operation.
How can a person be `at particular risk' on a temporary or permanent basis? A person may be `at particular risk' because they have suffered a physical injury, but the person expects to recover from this injury after a certain period of time. In these circumstances, the person is only `at particular risk' on a temporary basis.
An example of a person who may be `at particular risk' on a permanent basis is a person who has congenital blindness and will not recover.
Question 5 asks you to tell us whether the specific circumstance that makes you (or the person you are applying on behalf of) `at particular risk' is on a temporary or permanent basis.
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GUIDANCE NOTE 2
Part C asks for information to support the answers given to Q3, Q4, Q5,Q6 and Q7 in Part B.
One of the following must be provided:
(a) sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service; or
(b) the details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.
Who can be a `nominated person'? A nominated person must be someone who, by virtue of their occupation, is competent to give an opinion on whether you (or the person you are applying on behalf of) is at particular risk of requiring the 111 emergency service.
For example, if the `health' or `disability' category has been ticked in response to Q4, then a health practitioner (such as a GP) could be a nominated person. If the `safety' category has been ticked, then a police officer, a currently registered social worker, a lawyer (with a current practicing certificate), or a family court judge could be a nominated person.
We recommend that before you make your application to us, you (or the person you are applying on behalf of) first contact the nominated person to discuss the application. Please provide your date of birth and NHI number (where applicable) to help the nominated person identify you when we contact them.
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If I don't provide the details of a nominated person, what sort of evidence must be provided? It must be sufficient information to show that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service. Examples of evidence that may be sufficient include: · a completed Electricity Authority `Notice of Potential Medically Dependant Consumer (MDC)
Status' form, which includes a certification from a DHB, private hospital or GP (accessible from their website here: https://www.ea.govt.nz/operations/retail/retailers/retailer-obligations/medicallydependant-and-vulnerable-customers/); · a protection order; · a letter from a health practitioner (e.g., a GP); or · documentation of impairment (e.g., an ID card)
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GUIDANCE NOTE 3
Part D asks you to make some declarations regarding the content you have provided in the application, and to acknowledge that you understand what we (the provider) may do with the information you have provided in the application.
One of the declarations asks you to declare that the person who wants to be part of Spark's Vulnerable Consumer Register:
· is (or will become) at particular risk of requiring the 111 emergency service (information on what this means is provided in Guidance Note 1); and
· does not have a means to contact the 111 emergency service that can be operated at the premises for a continuous 8-hour period in the event of a power cut.
What is the 111 emergency service? The 111 emergency service includes the ambulance service, police service and fire and emergency service.
What does `a means to contact the 111 emergency service that can be operated at the premises for a continuous 8- hour period in the event of power cut mean? It means that the person has a way of contacting the 111 emergency service at the premises where they live.
The 'means' must be available to use to contact the 111 emergency service during an eight-hour period. It does not mean, however, that the device must be able to be actively used for eight hours.
A person will have a way of contacting the 111 emergency service if: · the premises where they live is receiving a copper landline service (because this service will continue to work in a power cut); or · the person has unrestricted access to a mobile phone and the premises where they live has adequate mobile phone network coverage; or · the person has a medical alarm with a power back up that they can use to connect them to emergency services during a power cut; or · the person has an uninterruptable power supply to maintain a means for contacting the 111 emergency service in the event of a power cut (e.g., a battery back-up).
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GENERAL GUIDANCE
What is the 111 Contact Code? The purpose of the 111 Contact Code is to ensure that consumers who are at particular risk of requiring the 111 emergency service, and do not have a means for contacting the 111 emergency service, have reasonable access (or persons on their behalf do) to an appropriate means (e.g., a mobile phone) to contact the 111 emergency service in the event of a power cut.
If you have a dispute about your (or your telecommunication company's) rights and obligations under the 111 Contact Code, you have a right for that dispute to be referred to an industry dispute resolution scheme to resolve. A consumer's right to take a dispute under the 111 Contact Code to an industry dispute resolution scheme is protected under the Telecommunications Act 2001 (sections 241-245). Currently, the relevant industry dispute resolution scheme is the Telecommunications Dispute Resolution Scheme. The 111 Contact Code is administered by the Commerce Commission. More information on the 111 Contact Code, and a copy of the 111 Contact Code, is available on the Commerce Commission's website here: https://comcom.govt.nz/regulated-industries/telecommunications/projects/commission-111-contact-code.
What is the Telecommunications Dispute Resolution Scheme? The Telecommunications Dispute Resolution Scheme is a free, independent service to help consumers with complaints about their telecommunications provider. A dispute between a consumer and a telecommunications company about their rights and obligations under the 111 Contact Code may be referred to this Scheme. For more information on the Telecommunications Dispute Resolution Scheme you can contact us at Spark on 123 and we will refer to where to find more information, or you can read more about the Scheme and how to contact them on their website here: https://www.tdr.org.nz/about-tdr/all-about-tdr. Who should I contact if I have any questions about this form? Please contact us at Spark NZ on 123 if you have any questions about the form, or the 111 Contact Code more generally.
Alternatively, you can contact the Commerce Commission at contact@comcom.govt.nz, or phone the Commission's Enquiries team on 0800 943 600.
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