Application for Roadside Assistance Reimbursement

For AAA Allied Group Inc - Club Code 007 Details ofyour recent Roadside Assistance event are necessary in order for AAA to consider your request for reimbursement. Forms must be completed fully and your orieinal receiot must be attached. Nlail to: AAA Allied Group, l5 West Central Pkwy., Cincinn ati, OH 45202, Attn: ERS Reimbursement

allow 30 davs from date we receive this form

Date of Request: Roadside Assistance provided

for:

CIub Code-007-

Membership # - include all letters & numbers

Name:
Home Address: Street

Town

State

Mail Reimbursement to: (if other than home address)

Street

zip

Town

State

zip

Daytlme Pholc: (

Ccll Phone: {
Make

Email

Vehicle Serviced: Year

State Vehicle Registered In? Date of Breakdown

Model

License Plate #

Vehicle Registered to

You? Yes

No

Was valid registration and insurance in the

car? Yes (State)_

No

Exact location of breakdown: (Street)

(Town)
back ofform if more space is needed)

Please explain why you did not call

AAA for emergency road service (Continue on

Why did vehicle need service?

Type ofservice rendered:
Was vehicle in an

(Ex. No strt, flat tire, out of gm, lock out, etc.)

(Ex. Jumpstart, change rire, deliver gas, tow, erc.)

accident? Yes

No No

Was tow due to an alleged motor vehicle

violation? Yes

No

Was tickeUwaming

issued? Yes

If yes, note infraction:

Who requested service?

_Member

Good Samaritan

_Police _

Passenger

Other (explain)

Did Vehicle require extrication or

winching? Yes _No

lfvehicle was towed please supply address oftow destination

Was vehicie repaired at rhe tow

destination'/ Yes
TIRE REPAIR IMPOUND FEES

No

Items Not Reimbursed by

AAA:

STORAGE PARTS & LABOR

RECEIPT OVER 60 DAYS OLD

UNREGISTERED VEHICLE

I understand that there is a toll-free number, 1-800-AAA-HELP (listed on the back of my membership card), for AAA members in the United States or Canada. If I should require Roadside Assistance in the future, I understand that by calling this number and validating my membership, I will incur no
expense for needed emergency service up to the limits of my membership.

I authorize AAA to verify all infonnation stated above, in consideration ofthis claim, where I called otherthan the above number and was serviced by private service facility.
Member's Signature Member reimbursements are consistent with AAA contract rates and generally OfiiceUseOnly:

will not

equal your private garage charge.

Initials

lrlS:_CKAnt:

____DateRec'd:

DateMqilcd:
7

ilof RudsideAssistanceColbtoDate

AAA Roadside Assistance is uvuiluble 24 hours a doy, Help is onb) a phone csll an)q).

doys a b'eek.