Application for Refund Form For those times when AAA is unable to provide services during a covered situation, we’ll cover the costs of alternate service. If you obtained your own service and met our requirements for reimbursement, please fill out the form below, attach an itemized provider receipt for the service received and click "SUBMIT". You may choose to print and mail a fillable pdf form along with the receipt instead. Submission of an application does not guarantee reimbursement. Name* First Last Your phone number*Email* Club Code*First 6 digits on your AAA Membership card.AAA Membership Number*Last 10 digits on your AAA Membership card.Membership expiration date* Address associated with the AAA Membership* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Vehicle DescriptionMake*Model*License plate number*Location of DisablementName of person driving at the time of disablement* First Last City*State*Description of ServiceName of business providing the service*Date of service*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of service* : HH MM AM PM Description of service providedCost of service*Upload your itemized receipts*You may upload up to 6 documents under 2MB. Drop files here or Accepted file types: jpg, pdf, png. Was the vehicle towed?*YesNoDestination of the tow*Number of miles towed*Was the service due to an accident?*YesNoWere the repairs covered by insurance?*YesNoName of insurance company*Was the AAA Member present when the vehicle became disabled?*YesNoWas AAA called for service?*YesNoWhy was AAA not called to the scene?*CommentsPlease add any details you feel are relevant to this application for refund.