Battery Reimbursement Application
To expedite the processing of your request, please follow these instructions:
1.
Please include:
a. A copy of the paid invoice/warranty provided by the service provider for the battery purchase.
b. A copy of the battery service invoice, receipt, and test strips.
c. A receipt for a new battery and test results for the failed AAA battery if the replacement was purchased from a third party
2.
Please complete all sections below to the signature line. Type or print legibly to expedite processing.
3.
Mail all attached documents to:
Dear Member: Thank you for your submittal. Be assured that your request will be processed as quickly as
possible. Please allow up to 4 weeks from the date of receipt for processing. Please keep a copy of this
reimbursement form and the original battery service invoice for your records. Incomplete documents may delay
processing. Please feel free to call the Member Relations Department at 1-800-243-0594 with any questions.
FOR OFFICE USE ONLY –
Service Order #: __________
Receipt Amount: $ __________ Covered Amount: $ __________ Amount Reimbursed: $ __________
Allow Refund: Yes___ No: ____ Authorized Signature: _______________________________ Date: ___________________
____ 004 CA – CBW 797 ____ 252 TX – TBW 797 ____ 601 NM – NBW 797 ____ 018 HI – HBW 797 ____001 AL-ABW 797
Member Name:
Automobile Club of Southern California
EMERGENCY ROAD SERVICE
MEMBER RELATIONS GROUP T1E85
POX BOX 630588
IRVING TX, 75063-9951
Member Number:
Mailing Address:
Expiration Date:
Date of Service:
Day Contact Number:
City:
State:
Zip:
Comments:
Member Signature
_______________________________________________________________________
Date:
click to sign
signature
click to edit
![]()
