Reimbursement Form - Emergency Road Service

Your reimbursement will be made in accordance with the Emergency Road Service rate that applies in the area where you received service. All questions must be answered. Please print and complete this form, then mail it to:

AAA Washington
Attn: Automotive Services
P.O. Box 91246
Bellevue, WA 98009-9845

Name			Membership No.
Address			Expiration date
			Club Code
City	State	Zip	Home Phone
Vehicle Make and Year			If truck give GVW
If recreational vehicle or motorcycle, give type

Did you call AAA for service?	Yes	No
If yes, why were you charged?
If no, please explain why
Did you identify yourself as an AAA Member to the station or driver who rendered service?	Yes	No
Did you present your membership card?	Yes	No
If locksmith was needed-Did you call AAA first and get referred to a locksmith	Yes	No
If no, please explain what happened

Date of Service (must be received within 180* days)*		Amount Paid for Service
Location of Breakdown

Nature of Trouble

Type of Use	Pleasure	Business		Commercial
Were you driving or a passenger in this vehicle when the trouble occurred?			Driving		Passenger
If towing involved - state distance towed

Remarks

If towing was a result of accident, fire or vandalism, please complete following information

YOUR AAA EMERGENCY ROAD SERVICE BENEFITS APPLY ONLY IF THE ACCIDENT, FIRE OR VANDALISM IS NOT COVERED BY YOUR INSURANCE COMPANY OR CANNOT BE CLAIMED AGAINST A THIRD PARTY.

Accident Report

Complete the following only if service was a result of motor vehicle accident, fire or vandalism.

Description:

Is loss being claimed against:	Your Ins. Co.		Third Party
Estimated Damage		Do you have towing insurance coverage		Yes	No
Is vehicle covered by collision coverage?				Yes	No
If so, how much deductible?
Insurance Company or agency?
Policy #
Name
Address
Phone number
Remarks:
MEMBER'S SIGNATURE

PLEASE INCLUDE YOUR PAID RECEIPT FOR SERVICE

For Office Use Only:

Comments		Amount $
		OK'd by
		Type of Service
		Check No.
Date Received		Date Paid

Print and mail this form

Mail reimbursement form and all other pertinent information to:

AAA Washington
Attn: Automotive Services
P.O. Box 91246
Bellevue, WA 98009-9845