First Name *

Last Name *

Email *

Phone Number *

Male or Female *

Date of Birth *

Street Address *

City *

State/Province *

Zip Code *

TLC License Number *

Re-Enter TLC License Number *

Which Black Car Company(s) do you work for? *

Uber

Lyft

Vital

Other

Preferred Language *

Do you currently have health insurance? *

Yes

No

Unsure

If yes, is your coverage through a plan from the state (such as Medicaid or the New York Essential Health Plan)?

Yes

No

Unsure

If you have health insurance, do you pay MORE than $20 per month for your coverage?

Yes

No

Unsure

Activate Your Benefits

All eligible drivers of NY Black Car Services including Lyft, Uber, Via, and the more traditional Black Car bases in the industry can sign up, for free, to receive a valuable package of Drivers Benefits, provided by The Black Car Fund and the Independent Drivers Guild!

Complete the information below to activate your Drivers Benefits. Or, call us at (833) 814-8590 from Mon-Fri 8:00 am-8:00 pm.

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