DriverCare Scheme Application Form

A full explanation of the DriverCare Scheme is contained in the leaflet “DriverCare Explained” available at www.unitedrivercare.org.uk. Please read through the form before completing and make sure you understand the information you are being asked to provide. Should you require any guidance please call DriverCare on 01708 339 046. Please return to your regional office or Allclear House, 1 Redwing Court, Ashton Road, Romford, RM3 8QQ.

Cover commences on the date on which a completed application form is received by the DriverCare Administration Unit and the first subscription is paid to the DriverCare Scheme.

IT IS IMPORTANT TO UNDERSTAND THIS SCHEME WILL NOT PROVIDE LOSS OF LICENCE BENEFIT IN RESPECT OF A PRE-EXISTING MEDICAL CONDITION.


Please complete all of the details below


Title
Forename(s)
Surname
Address
Town
Post Code
Email Address
Home Telephone
Mobile Telephone
Membership Number (if known)
Date of Birth*
*Loss of Licence Benefit will cease on reaching your 60th birthday or retirement (whicheveris soonest) unless you are in the Supplementary Loss of Licence (Top-up) Scheme
EMPLOYMENT DETAILS
Occupation
Are you (please select)
Employer
Pre-Existing Condition: relates to any physical or mental defect, infirmity, medical condition or chronic recurring illness which you could reasonably be expected to know existed at the date of entry into the Scheme and which might lead to the relevant Licensing Authority revoking or refusing to renew your professional licence.
Licence Type
Please select Yes or No for all questions. It is important to register all licence categories that you wish to be covered.
Group 1 Licence - Car Licence
Group 2 Licence - PCV
Group 2 Licence - LGV
Other Licence (please specify)
CATEGORY OF BENEFITS
Please choose the level of cover which best suits your needs. Cover is 95p per week if you are aged under 60 and 60p per week if you are aged 60 and over, except where indicated. If in doubt please contact the DriverCare Administration Unit on 01708 339 046.
Standard DriverCare

Benefit

Group 1 and Group 2 Licence Holders

Group 1 and Other
Licence Holder* Conductors

Over 60 Licence Holders Conductors

Loss of Licence

£7,500

Not Included

Not Included

Assault

£1,000

£3,000

£3,000

Personal Accident

Up to £5,000

Up to £25,000

Up to £30,000

Hospitalisation

Not Included

£50 per day

£50 per day

Legal Assistance

Included

Included

Included

Select which Benefit type you would like:
*Group 1 and Other Licence Holders may opt out of Loss of Licence cover and choose the enhanced PA/Assault/Hospital Confinement benefits insteadM
Wage Support Payment - up to a maximum of £15,600.
Only available to those who have opted for Loss of Licence Cover, for just an additional payment of £2 per week.
Please select Yes if you would like to add Wage Support Payment
DECLARATION AND CONSENT - Please now READ and COMPLETE the following


I declare that the information given in this application form is true and complete to the best of my knowledge and belief and I have completed the section below.

I understand that any pre-existing condition is excluded from cover.

I will tell the DriverCare Administration Unit about any employment changes.

I will tell the DriverCare Administration Unit about any changes in my state of health which may lead to the relevant Licensing Authority revoking or refusing to renew my professional licence.

Please select Yes if you understand and agree with all of the above
NOTE: A copy of this completed form will be supplied on request within a period of three months after its completion. Please note that we may return the application form if completed incorrectly or if any information is missing.

Data Protection Act
The information you have provided will become part of the personal data held by Unite the Union, and will be used by AllClear Insurance Services for the provision and administration of the Schemes. It may be disclosed to other companies for claims handling purposes. In addition, we may seek information from other companies to check the answers you have provided. Where fraud is suspected, we may disclose data to other parties if they request information in writing from us.