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 * Required First Last Your phone number * RequiredEmail * Required Club Code * RequiredFirst 6 digits on your AAA Membership card.AAA Membership Number * RequiredLast 10 digits on your AAA Membership card.Membership expiration date - must be mm/dd/yyyy format * Required Address associated with the AAA Membership * Required 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 * RequiredModel * RequiredLicense plate number * RequiredLocation of DisablementName of person driving at the time of disablement * Required First Last City * RequiredState * RequiredDescription of ServiceName of business providing the service * RequiredDate of service - must be mm/dd/yyyy format * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of service * Required : HH MM AM/PM AM PM Description of service providedCost of service * RequiredUpload your itemized receipts * RequiredYou may upload up to 6 documents under 2MB. Drop files here or Accepted file types: jpg, pdf, png. Was the vehicle towed? * RequiredYesNoDestination of the tow * RequiredNumber of miles towed * RequiredWas the service due to an accident? * RequiredYesNoWere the repairs covered by insurance? * RequiredYesNoName of insurance company * RequiredWas the AAA Member present when the vehicle became disabled? * RequiredYesNoWas AAA called for service? * RequiredYesNoWhy was AAA not called to the scene? * RequiredCommentsPlease add any details you feel are relevant to this application for refund.