REIMBURSEMENT APPLICATION
Please be aware of these eligibility requirements:
• Include the ORIGINAL receipt. Reimbursement requests cannot be processed with a photocopy or facsimile.
• The receipt must be made out to a valid AAA member.
• This application and your receipt must be postmarked within sixty (60) days of the service date.
Please follow these instructions: Complete this application form fully. Please type or print legibly to expedite processing. Keep copies of this
Reimbursement Application and your receipt for your records. Attach the ORIGINAL receipt to this Reimbursement Application and mail to:
AAA Club Services, Attn: ERS A-321, PO Box 25001, Santa Ana, CA 92799-5001.
Member’s Name: __________________________________ Day Phone: _________________ E-Mail (optional):___________________________
Mailing Address: _____________________________________________ City/State: ____________________________ Zip Code: ___________
Club Code: __________ Membership Number: ______________________________________ Expiration Date: ____________________________
Date of Service: ______________ Time of Service: ___________ AM PM
Vehicle Year: _______ Mak
e: __________________ Model:_________________ Color: _____________ License:____________ State:_________
Location of Service: ____________________________________________________ City/State: ______________________________________
Problem with Vehicle: ___________________________________________________________________________________________________
Service provided: Flat Tire Battery Fuel Start Vehicle Lockout Towing Collision Winch Vehicle Locksmith Home Lockout
If
towed, to what destination? __________________________________________City/State: ____________________ How many miles? _______
Did you call AAA for service? Yes No
No
Was service provided by a AAA service provider? Yes
Were you present when service arrived? Yes
No
Was
a valid AAA card & photo ID presented? Yes No
If AAA was not contac
ted for service, please explain:
____________________________________________________
If
AAA was called and/or used, why were you charged?
____________________________________________________
Comments:
______________________________________________________________________________________________________________________
(Us
e separat
e sheet for further comments)
Amount charged for service: $__________Amount Requested: $______ Name of company rendering service: ______________________________
MEMBER’S SIGNATURE:
_________________________________________ DATE: ___________________
Dear Member: Thank you for your Reimbursement Application. Please be assured that your request will be processed as quickly as
possible. You should receive a written response within ten (10) working days after your request has been received. If not, please feel free
to call ERS toll free at 1-888-222-9441
. See Member Guide for applicable member reimbursement provisions.
For office use only:
Date Received: __________________ ERS/CSR / Field Office ___________________________________
Allow Refund: Yes_______ No_______ If Yes, reason: ____________________________________________________________
Reimbursement type:
__________(RF 1) Standard towing, winch, tire, battery or lockout reimbursement to a Standard, AAA Plus, or AAA Premier member
__________(RF 2) Standard locksmith reimbursement to a Standard, AAA Plus, or AAA Premier member
__________(RF 3) RV/Motorcycle towing or RV tire change reimbursement to a Standard or AAA Plus-RV/Motorcycle member
__________(RF 4) AAA Plus towing, fuel, or locksmith reimbursement to an individual AAA Plus or AAA Premier member
__________(RF 5) AAA Plus towing, fuel, or locksmith reimbursement to a family AAA Plus or AAA Premier member
__________(R
F A) AAA Premier towing or locksmith reimbursement to an individual AAA Premier member
__________(RF B) AAA Premier towing or locksmith reimbursement to a family AAA Premier member
__________(RF D) Home Lockout Service reimbursement to an individual AAA Premier member
__________(RF E) Home Lockout Service reimbursement to a family AAA Premier member
__________( ) Other reimbursement types: ________________________________
Reimbursement Calculation:
# Prev Calls Svc Chg Reimbursement Receipt Amt S/C Deduct Amount Covered Amt Reimbursed
YES / NO $ $ $ $
Processed by: ______________________________ Authorized Signature: ________________________________ Date: ______________
