Claims Request Form

Please complete the following details and answer all questions regarding the claim you wish to make. Please note that by completing this form you are requesting a paper claim form. The DriverCare Administration Centre will then be in contact shortly.

Name
Email Address
Address
Post Code
Membership Number
Date of Birth
Telephone Number
Assault
How many days were you off work for?
Did you report the incident to the police?
Did you attend A&E immediately following the incident? (within 24 hours)
Loss of Licence
What date did you notify the DVLA of your medical condition?
What date was your license revoked?
What was the last date you drove using your professional licence?
Are you still employed as a driver?
If no what date did your employment cease?
Personal Accident or Hospitalisation
Please submit contact details only