ROADSIDE ASSISTANCE REFUND APPLICATION To insure that AAA members receive quality Roadside Assistance, AAA has contracted with qualified facilities to provide members with roadside assistance 24 hours a day, 365 days a year. Because of the volume of service we can provide to these facilities, we are able to negotiate rates, lower than normal private rates, for the Roadside Assistance they provide to AAA members. This, in turn, helps us to maintain your annual membership dues at reasonable levels. Members who obtain road side assistance from other sources reduce the effectiveness of our Roadside Assistance program. THEREFORE, PLEASE ALWAYS CONTACT AAA FIRST WHEN YOU REQUIRE SERVICE. If you contacted AAA for Roadside Assistance and service was not available, please fully complete the application on the reverse side and forward to the address shown within 60 days of the service date. Be sure to attach the original, itemized receipt showing the road service charges paid. The following refund provisions apply: Reimbursement will be considered only if it is a service allowed by the AAA's Roadside Assistance Guidelines and if it is a service we provide without charge. Reimbursement will be based on the reasonable prevailing commercial rates for the region where the vehicle became disabled. If AAA service was available, and you elected to use some other source for your road side assistance, or a valid membership card was not presented, reimbursement will be adjusted according to the servicing contractor's rate for the area where the vehicle became disabled. PLEASE MAIL COMPLETED APPLICATION TO: RAS Refund Department PO Box 14611 St. Louis, MO 63178

Please fully complete all questions regarding your reimbursement request. We realize this form may seem to ask for information that is not necessary, but too little information may cause us to delay or disqualify the service for reimbursement. PLEASE PRINT OR TYPE.

PLEASE READ THE OTHER PAGE BEFORE COMPLETING

Section 1 - Identification Your Membership Number: ___________________________________________ Phone: (___) ___________________ Your Name: _____________________________________________________________________________________ Your Address: ___________________________________________________________________________________ Check here if this is a new address: _____

Section 2 - Service Call Information Date of Service: ________________   Time of Service: ________ AM PM    Amount paid for road service only: $_________ Year of Vehicle: ________________   Make of Vehicle: ________________    Model of Vehicle: _____________________ Exact Location of Breakdown: ________________________________________________________________________ Name of Nearest Town: ____________________________________________________________________________

Section 3 - Requesting Service Who did you call to obtain service? ____ AAA's 24 Hour Communication Center                                                                 ____ Other (specify): __________________________________________________ If AAA's 24 Hour Communication Center was not called, explain why: _________________________________________ ______________________________________________________________________________________________ Were you present when the driver arrived and with the vehicle to receive service? ____ Yes    ____ No Were you driving or riding in the vehicle when it broke down?                                     ____ Yes    ____ No If you paid for service, did you present your AAA membership card?                          ____ Yes    ____ No

Section 4 - Towing Was the vehicle towed? ____ Yes (If yes, complete this section)    ____ No (If no, go to Section 5) Where was vehicle towed? ________________________________________________________________________ How many miles was the vehicle towed? ____________Miles Was the tow requested by the police?       ____ Yes    ____ No If yes, give reason: ____ Accident    ____ Stolen    ____ Abandoned Vehicle                                    ____ Other (specify) _______________________________________________________________

Section 5 - Other Services If the vehicle was not towed, what type of service was provided:    ____ Start    ____ Tire    ____ Gas    ____ Lock-out                                                                                                                      ____ Other (specify): ______________________

Section 6 - Member's Signature I have read the reverse side of this application and understand that reimbursement will be 1) considered only if it is allowed by the Club's Roadside Assistance Guidelines, and 2) based on my original paid, itemized receipt, on printed company letterhead, that I have attached. X: ________________________________________________         Date: ____________________________________

Form 576 (Rev 9/97) PLEASE BE SURE TO ATTACH YOUR ORIGINAL RECEIPT