Reimbursement Application Form - American Automobile Association Hawaii printable pdf download

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 Hawaii member.

•

This application with your receipt must be postmarked or received 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 Hawaii, LLC 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:_______ Make:__________________ Model:_________________ Color: _______________ License:______________

State:_____________

Location of Service:___________________________________________________________

City/State:_________________________________________

Problem with

Vehicle:___________________________________________________________________________________________________________

Service provided: (Circle) Flat Tire, Battery, Fuel, Start, Vehicle Lockout, Towing, Collision, Winch, Vehicle Locksmith, Home Lockout Service

If towed, to what destination?:__________________________________________________City/State:____________________ How many

miles?________

Did you call AAA for service? Yes______ No ______

Was service provided by a AAA service provider? Yes_______ No_______

Were you present when service arrived? Yes______ No ______

Was a valid AAA card & matching photo ID presented at the time of service? Yes______ No _______

If AAA was not contacted for service, please explain:

__________________________________________________________________________________

If AAA was called and/or used, why were you

charged?______________________________________________________________________________

Comments:________________________________________________________________________________________________________________

____

(Use separate sheet for further comments)

Amount charged for service: $________________ 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 Administration

toll free at 1-888-222-9441

See Member Guide 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

__________(RF 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 C) AAA Premier RV/Motorcycle towing or RV tire change reimbursement to a AAA Premier-RV/Motorcycle 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 Covered Amt S/C Deduct Amount Reimbursed

__________ Yes____ No____ $__________ $__________ $_________ $________________

Processed by:_______________________________ Authorized Signature:________________________________

Date:______________

Reimbursement Application Form - American Automobile Association Hawaii

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