Fillable AAA - Auto Pay Plan Revocation Request Hawaii

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AAA - Auto Pay Plan Revocation Request Hawaii

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8168 03/13
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS.
AAA Auto Pay Plan Revocation Request
COMPLETE AND RETURN
To terminate enrollment in the AAA Auto Pay Plan as to one or more of your insurance policies and/or your AAA
Hawaii, LLC (“AAA”) membership, complete the entire form, as applicable, and sign your name. Please mail this
request in the envelope provided, or return it to:
AAA/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 and outstanding
membership dues and fees will be billed with statements mailed to you periodically.
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
1.808.593.2221 on Oahu or at 1.800.736.2886 on neighboring islands. We will be glad to assist you.
MEMBERSHI
P
Please verify the
last 4 digits
of your Checking Account #
Club Code First 8 Digits of
Membership
Number
Please cancel my
enrollment in the AAA
Auto Pa
y
Plan for:
-
Member Name
INSURANC
E
Please verify the
last 4 digits
of your Checking or
Credit/Debit Card Account #
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
I (We) hereby authorize the
Interinsurance Exchange of the Automobile Club
and
AAA Hawaii, LLC (“AAA”),
as
applicable, to discontinue automatic payments from my (our) financial institution checking account(s) or credit/debit card
account(s) for the above insurance policy(ies) and/or AAA membership, as applicable.
NAME(S) OF ACCOUNT HOLDER(S) DATE SIGNATURE(S) OF ACCOUNT HOLDER(S)
FOR OFFICE USE
AAA Employee # Branch Office/Section #
P R I N T
Would you like a fill-able form to complete for the Member/Insured
OR
Print a blank form for the Member/Insured?
FILL-ABLE
PRINT BLANK
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signature
click to edit
8168 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
Terminating AAA Auto Pay for
Membership from Checking Account (ACH) and Transferring to Manual
Billing
DO NOT SUBMIT THIS FORM IF:
Terminating AAA Auto Pay for
Membership from Credit/Debit Card Account
Instead Of This Form, Do The Following (For Membership): Change the bill plan from AC to AM and collect payment, if any
Transferring AAA Auto Pay from Checking Account (ACH) to Credit/Debit Card Account
Instead Of This Form, Do The Following (For Membership): Complete an Authorization Agreement for Credit/Debit and
forward to Membership Processing or fax to the number on the agreement (cannot change bill code in branch or call center)
Instead Of This Form, Do The Following (For Insurance
): 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 (For Membership): Change bill plan from AC to AH and obtain a Checking Account
ACH Authorization Agreement. Scan locally or forward to Membership Processing or fax to the number on the agreement.
Instead Of This Form, Do The Following (For Insurance
): 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 (For Membership): Complete a new Checking Account ACH Authorization Agreement
and update the account number on the Payment screen, scan locally or forward to Corporate Cashiering or fax to the number
on the agreement.
Instead Of This Form, Do The Following (For Insurance
): 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 (For Membership): Complete a new Credit/Debit Authorization Agreement and
update account number in the Payment screen. Scan locally or forward to Membership Processing or fax to the number on the
agreement
Instead Of This Form, Do The Following (For Insurance
): 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.
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AAA - Auto Pay Plan Revocation Request Hawaii

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Completed 26 May 2020

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