BAA – USA Enrollment Form – …Sharing makes a difference…

BAA USA Enrollment

Brotherhood Auto Aid USA
Enrollment Application

Policyholder Information

Name *

Telephone *

Mobile

Fax

Address *

City *

State *

Zip *

Date of Birth *

Marital Status *

Are you a member of the Church of God in Christ Mennonite? *

Yes

Name of Congregation *

Vehicle Information

Year *

Make *

Model *

Trim *

VIN (17 characters) *

Miles *

Value

Is there a lien against this vehicle? *

Yes

Lien Holder *

Lienholder Address *

City *

State *

Zip *

Primary driver of this vehicle *

Primary driver's DOB *

Vehicle Rates - Collision & Comprehensive
Please mark the rate that most correctly applies. An invoice will be mailed to you.

Vehicle Rates - Collision & Comprehensive *

Rate 1 - $3.40 per $100.00 value - Cars, pickups, vans, except where Rate 4 or 5 applies

Rate 2 - $3.80 per $100.00 value - All trailers, heavy trucks, used more than 20,000 miles annually

Rate 3 - $1.70 per $100.00 value - All trailers, heavy trucks, used less than 20,000 miles annually

Rate 4 - $4.90 per $100.00 value - Cars or pickups of which the primary driver is a single male less than age 25

Rate 5 - $3.80 per $100.00 value - Cars or pickups of which the primary driver is a single female less than age 25

Deductibles and Guidelines - partial listing

Cars, pickups, vans, light-duty trailers (for each incident) Comprehensive….$200.00 Collision and/or Upset….$300.00

Heavy trucks or trailers (for each incident) Comprehensive….$300.00 Collision and/or Upset….$750.00

Pre-owned vehicles shall be entered at their current value as listed in NADA and new cars at a fair purchase price. No vehicle, regardless of its value, shall be entered for less than a flat fee of $15.00. Towing, recovery, or storage coverage (accident only) up to $1,000.00 for cars, pickups, vans, and utility vehicles, and light trailers and up to $5,000.00 for heavy trucks and trailers is included at no extra charge. If proper age group rate is not paid, BAA is only responsible for 50 percent of any loss. BAA reserves the right to refuse coverage for any vehicle that is deemed inconsistent with the teachings of the Church of God in Christ, Mennonite. Non-licensed drivers on public roads are not eligible for BAA coverage. Losses by non-licensed drivers, other than on public roads, shall be considered by BAA for settlement. If applicant is not 18 years of age, a parent or guardian must sign with the applicant.

Signature of Applicant *

Clear

(Parent's Signature - if applicable)

Clear

If you are human, leave this field blank.

Brotherhood Auto Aid USA Enrollment Application

Policyholder Information

Vehicle Information

Brotherhood Auto Aid USA
Enrollment Application