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Get AAA Road Service Reimbursement Request 2014

NOTE In all cases reimbursement coverage is limited to road service detailed in your membership handbook visit AAA. com/MemberHandbook up to the maximum entitlement allotted by your membership. Submission Instructions Include an original itemized paid receipt from a service provider Be attached to a fully completed Road Service Reimbursement form Be submitted within the defined time period as detailed in the member handbook to be considered Please allow two weeks to process your request. REV081514 Please fill out this form completely and print legibly MEMBER INFORMATION Membership number 16 digit Name Address City Contact numbers Home Email FOR PROCESSING ONLY Approved Yes State Cell Zip code No Code Amount Processor initials Process date IMPORTANT Any correspondence in regards to your reimbursement consideration request will be sent to the address you provide on this form. To change your address on our membership records please go to AAA. com or contact your local AAA office. ROAD SERVICE INFORMATION Facility name Flat tire Jump-start Date of service mm.dd. Yyyy Type of problem check appropriate box Out of fuel Tow Who was called AAA local office AAA toll-free Reason AAA service was not used Additional comments Time of service Lockout/key made Winch/stuck Accident/police call Motorcycle coverage Called facility direct Did not call AAA Vehicle year Vehicle make Vehicle model Breakdown location address cross streets or reference points Vehicle towed to street city state Miles towed Amount paid for service If AAA service is available and not used reimbursement will be limited to what it would have cost AAA to provide the covered service. Signature Today s date Note Please make a copy of this form and all attachments for your records. Applications that are not completed or accompanied with the original receipt s may be returned. Submit the application and original receipts to. Com/MemberHandbook up to the maximum entitlement allotted by your membership. Submission Instructions Include an original itemized paid receipt from a service provider Be attached to a fully completed Road Service Reimbursement form Be submitted within the defined time period as detailed in the member handbook to be considered Please allow two weeks to process your request. Submit the application and original receipts to Inquiries regarding your reimbursement request may be made by calling 866-255-6757. REV081514 Please fill out this form completely and print legibly MEMBER INFORMATION Membership number 16 digit Name Address City Contact numbers Home Email FOR PROCESSING ONLY Approved Yes State Cell Zip code No Code Amount Processor initials Process date IMPORTANT Any correspondence in regards to your reimbursement consideration request will be sent to the address you provide on this form. To change your address on our membership records please go to AAA. Road Service Reimbursement Request Payment Limitation If you obtain non-AAA Roadside Assistance without first requesting service from AAA your reimbursement will be up to the contract rate paid to AAA service providers for similar services. .

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