Brotherhood Mutual Insurance Company Ministry Driver Screening Form (A99) Instructions

Enter the short text used as an additional identifier or note for this form (for example an internal reference number, short code, or brief remark) as requested by your organization or the insurer.

Check this box if the driver’s license is a commercial driver license (CDL).

Check this box if the driver’s license is not a commercial driver license.

Provide full details for any question answered “Yes,” including dates, descriptions of incidents, amounts, locations, and any other explanations needed to clarify the circumstances. Fill only if 'Past 3 Years - Question 4 (License revoked/suspended) - Yes', 'Question 5 (Past 3 Years) - Yes (Physical impairments)', 'Question 6 — Yes (DUI/DWI)', 'Past 3 Years - Question 2: Yes (Have you had any moving traffic violations?)', 'Question 1 - At-fault accidents: Yes', 'Past 3 Years - Question 3: Yes (insurance cancelled/refused)' are 'Yes' any.

Enter the driver's date of birth.

Enter the issuing state abbreviation followed by the driver's license number as shown on the license.

Enter the driver's full name exactly as it appears on their driver's license, including first, middle (if any), and last name.

Enter the city, two‑letter state abbreviation, and ZIP code for the ministry's address (e.g., Anytown, OH, 12345).

Enter the secondary address information such as suite, unit, building, or additional address lines.

Enter the primary street address or PO box for the ministry.

Enter the ministry's insurance policy number as shown on the policy documents.

Enter the full official name of the ministry as it should appear on insurance records.

Check this box if, in the past three years, you have been at fault for one or more accidents.

Check this box if, in the past three years, you have not been at fault for any accidents.

Check this box if, in the past three years, you have had one or more moving traffic violations.

Check this box if, in the past three years, you have not had any moving traffic violations.

Check this box if, in the past three years, any insurance company cancelled your auto insurance or refused to provide you with auto insurance.

Check this box if, in the past three years, no insurance company has cancelled your auto insurance or refused to provide you with auto insurance.

Check this box if, in the past three years, your driver's license has been revoked, suspended, or restricted.

Check this box if, in the past three years, your driver's license has not been revoked, suspended, or restricted.

Check this box if, in the past three years, you have had any physical impairments other than corrective glasses.

Check this box if, in the past three years, you have not had any physical impairments other than corrective glasses.

Check this box if, in the past three years, you have been charged with or convicted of driving while intoxicated (DUI) or driving under the influence (DWI).

Check this box if, in the past three years, you have NOT been charged with or convicted of driving while intoxicated (DUI) or driving under the influence (DWI).

Check this box if you are the primary driver of the vehicle (you drive the vehicle more than once per month or more than 12 times per year).

Check this box if you are not the primary driver of the vehicle (you drive the vehicle less than once per month and fewer than 12 times per year).

Enter the signer’s full name or handwritten signature to acknowledge and certify the information provided on this form.

Enter the date on which the signer signed and dated this form.

Enter the vehicle manufacturer or brand (for example, Toyota, Ford, Honda) as shown on the vehicle registration.

Enter the vehicle's model year (the four-digit year the vehicle was manufactured).

Enter the vehicle model name or designation (for example, Camry, F-150, Accord) as shown on the vehicle registration.