Date:  

 Location:  

 Class Requested:
 

 First Name:
 

 Last Name:
 

 Social Security Number:
  - -

 Date of Birth:
  mm/dd/yyyy

 Address:
 
 NOTE Please enter the address of your current residence.
 This is the address your check will be mailed to.

 City:

 State:   Zip:

 Cell Number:
 

 Driver License Number:
 

 TLC License Number:
 
 NOTE: Non-TLC Driver - Enter NA

 TLC Plate Number:
 
 NOTE: Non-TLC Driver - Enter NY State vehicle plate number.

 Company Base:
 
 NOTE Please select your company base from the list.

 Email Address:
 

As a driver for a Black Car base, you can be automatically enrolled in Drivers Benefits. Through the Drivers Benefits Program, The Black Car Fund provides Health and Wellness benefits to eligible enrolled drivers who drive for Black Car Member Bases in the state of New York. These benefits include Accidental Death Insurance, Critical Illness Insurance, Dental Insurance, Vision Coverage, Telemedicine and more, at no cost to you. For specific benefit coverage details, exclusions and eligibility information, see ny.driversbenefits.org

Would you like to be enrolled in Drivers Benefits for free?

     Yes      No

 

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