Fillable AAA - Auto Pay Plan Revocation Request

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AAA - Auto Pay Plan Revocation Request

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8254 03/13
Please verify the
last 4 digits
of your Checking or
Credit
/
Debit Card Account #
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS.
AAA Auto Pay Plan Revocation Request
Letter
Prefix (up to 3) 9 Digit
Policy
Number
Please cancel my
enrollment in the AAA
Auto Pa
y
Plan for:
Named Insured
Please cancel my
enrollment in the AAA
Auto Pay Plan for:
l
Named Insured
Please cancel my
enrollment in the AAA
Auto Pay Plan for:
l
Named Insured
Please cancel my
enrollment in the AAA
Auto Pay Plan for:
l
Named Insured
I (We) hereby authorize the
Interinsurance Exchange of the Automobile Club
to discontinue automatic payments from my
(our) financial institution checking account(s) or credit/debit card account(s) for the above insurance policy(ies), as
applicable.
NAME(S) OF ACCOUNT HOLDER(S) DATE SIGNATURE(S) OF ACCOUNT HOLDER(S)
FOR OFFICE USE
AAA Employee # Branch Office/Section #
COMPLETE AND RETURN
To terminate enrollment in the AAA Auto Pay Plan as to one or more of your insurance policies, complete the
entire form, as applicable, and sign your name. Please mail this request in the envelope provided, or return it to:
Interinsurance Exchange of the Automobile Club
P.O. Box 25006
Santa Ana, CA 92799-5006
REMAINING INSTALLMENTS
Automatic payments, as applicable, from your financial institution checking account(s) or credit/debit card
account(s) will terminate after this request is received and processed. Installments remaining for the current
insurance policy period will be billed on your regular payment plan with statements mailed to you.
RE-ENROLL
You may apply to re-enroll in AAA Auto Pay at any time in the future by completing a new AAA Auto Pay
Authorization Agreement. If you require any information about your account, please contact us at
1.800.924.6141. We will be glad to assist you.
P R I N T
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8254 03/13
AAA Auto Pay Plan Revocation Request
DO SUBMIT THIS FORM IF:
Terminating AAA Auto Pay for
Insurance from Checking (ACH) or Credit/Debit Card Account and
Transferring to Manual Billing
DO NOT SUBMIT THIS FORM IF:
Transferring AAA Auto Pay from Checking Account (ACH) to Credit/Debit Card Account
Instead Of This Form, Do The Following: Complete an Authorization Agreement for Credit/Debit and fax to Corporate
Cashiering at 714-850-8097
Transferring AAA Auto Pay from Credit/Debit Card Account to Checking Account (ACH)
Instead Of This Form, Do The Following: Complete an Authorization Agreement for Checking Account and fax to
Corporate Cashiering at 714-850-8097
Transferring AAA Auto Pay from current Checking Account (ACH) to a different Checking Account (ACH)
Instead Of This Form, Do The Following: Complete an Authorization Agreement for Checking Account and fax to Corporate
Cashiering at 714-850-8097
Transferring AAA Auto Pay from Credit/Debit Card Account to a different Credit/Debit Card Account
Instead Of This Form, Do The Following : Complete an Authorization Agreement for Credit/Debit and fax to Corporate
Cashiering at 714-850-8097
If any of the “Do Submit” conditions apply, please click the ‘GO’ button to proceed.
G O
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AAA - Auto Pay Plan Revocation Request

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Completed 26 May 2020

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