September 17, 2019

test forms

BAA Claim

Section A - Policyholder Information

Was the driver properly licensed? *

Section B - Vehicle Information

Is there a lien against this vehicle? *

Section C - Comprehensive Claim

Section D - Collision Claim

Was this a single or multi-vehicle incident? *
Drop a file here or click to upload
Maximum upload size: 15MB
Who was at fault in this accident *
Was the incident reported to the authorities? *
Is your liability company responsible for damage to the other party's vehicle?
Have you tried to obtain payment from the other party's liability?

Section E - Claim Amounts

TWO ESTIMATES ARE REQUIRED FOR LOSSES WITH THE FOLLOWING EXCEPTIONS: (1) the shop is owned by our brethren, or (2) the claim is less than $2,500.00, or (3) it is a glass claim. If it is impossible to obtain two estimates, please discuss the claim with the office personnel before the claim is filed. BAA will pay the lowest bid per rules and regulations. Checks will be issued to the policyholder unless other arrangements have been made. Non-Licensed drivers on public roads are not eligible for BAA Coverage.
Please list estimate amounts.
Please list salvage bids if total loss.
Please upload the complete estimates with this claim report to Brotherhood Auto Aid.
Upload Estimates
Maximum upload size: 30MB
BAA enrollment

Policyholder Information

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

Vehicle Information

Is there a lien against this vehicle? *
Vehicle Rates - Collision & Comprehensive
Please mark the rate which most correctly applies. An invoice will be mailed to you.
*

Deductibles and Guidelines - partial listing

Cars, pickups, vans, light-duty trailers (for each incident)     Comprehensive….$100.00       Collision and/or Upset….$200.00

Heavy trucks or trailers (for each incident)               Comprehensive….$200.00       Collision and/or Upset….$350.00

Pre-owned vehicles shall be entered at their current value as listed in the Canadian Black Book 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 $500.00 for cars, pickups, vans, utility vehicles, and light trailers and up to $1,000.00 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.

Direct Pay
I/we authorize Brotherhood Auto Aid (BAA), and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin deductions as per my/our instructions for monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our BAA account(s). Regular monthly payments for the full amount of services delivered will be debited to my/our specified account on the 25th day of each month. BAA will provide ten (10) days written notice of any change in the amount of each regular debit. BAA will obtain my/our authorization for any other one-time or sporadic debits.
This authority is to remain in effect until BAA has received written notification from me/us of its change or termination. This notification must be received at least ten (10) business days before the next debit is scheduled at the address provided below. I/We may obtain a sample cancellation form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca.
BAA may not assign this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing at least ten (10) days prior written notice to me/us.
I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not consistent with the PAD Agreement. To obtain a form for a Reimbursement Claim, or for more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.sdnpay.ca.

Customer Information

Bank Account Information

Upload an image of a Voided Cheque *
Maximum upload size: 134.22MB

Pre-Authorized Debit (PAD) Details

These services are for: *

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