Appendix A

Authorised Vehicle User Application

to be completed by GPStR and retained on file by the GP Trainer (please note trainees employed under the Single Lead Employer may be required to complete the Trust forms)

PART 1for completion by the GPStR (Block Capitals)

Name of Claimant

Name and address of GP training practice

Insurance CompanyPolicy No

Make of VehicleReg NoCubic Capacity

I confirm that I will

AObtain and maintain, during all official use, no less than full third party insurance, including cover against risk or injury to, or death of, passengers and damage to property

BI confirm that the policy in respect of the above specifically provides for cover on journeys on the GPStR business activities as described by the KSS Deanery.

CEnsure that the vehicle is maintained in a safe and roadworthy condition whenever it is used for the purpose of my employment as a GPStR.

DI understand that the GP training practice does not accept any responsibility for any claims arising out of the use of a private vehicle.

EI will notify the GP training practice in the event of changes in the Insurance policy referred to above.

FHold a full, current driving licence for the start of the GP training placement.

GPStRs should ensure that, if they are requested to carry goods/articles belonging to the GP training practice, which they would not normally transport as part of their duties, they have adequate cover.

Where you are proposing to use a vehicle, which is not wholly owned by you, you must obtain written confirmation (before the vehicle is used on GP training practice business) from the Insurers that any necessary extension to the policy cover has been made and that the other requirements of the Department of Health have been complied with.

Please ensure that a copy of your Insurance Policy is attached.

Signature of Applicant

DesignationDate

PART 2for completion by the GP Trainer

Authorised User Status (Delete as appropriate)STANDARD / REGULAR

Form to be effective from (placement dates) ______to ______

Signature of GP Trainer

Name of GP Trainer Date

Appendix B
Claim for Car Mileage Allowance
(please note trainees employed under the Single Lead Employer may be required to complete the Trust forms)
Date / Purpose of journey/business activity / Car Mileage
Total Mileage
I certify
(a) The insurance policy in respect of my motor-car provides cover while this car is used on official business, for full appropriate work related insurance, including cover against risk of injury to, or death of, passengers and damage to property and that the policy is now in force and covers the journeys claimed.
(b) My car (Make)……………….………………………… Reg No. ……….…………….. Hp/cc………………..…..
(c) the amounts claimed are in accordance with the rules of theKSS Deanery; are in respect of expenses actually and necessarily incurred on the journeys stated and are not subject to a claim made on any other authority (eg PCT or the Deanery)
Signed: / Approved by Trainer:
Print Name: / Print Name:
Address:
Reimbursement£
This form should be submitted to and retained on file by the GP Trainer

1

KSS GP Training Handbook September 2009 (updated Sept 2010, May 2012)