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Roadside Refund Claim Form - CAA South Central Ontario

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    Member Details

    All fields are required unless marked optional.

    (Format: 16-digit number)Format 16 digit number
    (Format: L#L #L#)Format Letter Number Letter Space Number Letter Number
    (Format: ###-###-####)Format 3 digit area code and a 7 digit telephone number
    (Format: name@url.com)Sample Format name at url dot com

    Vehicle Details


    Service Provider/Service Details

    (Optional Format: ###-###-####)Optional Format 3 digit area code and a 7 digit telephone number
    (Format: MM/DD/YYYY)Format MM slash DD slash YYYY
    (Format: HH:MM)Format HH colon MM
    Format: Street address, City, Province/ State and Country name
    (Format: ###-###-####)Format 3 digit area code and a 7 digit telephone number
    (Format: ###-###-####)Format 3 digit area code and a 7 digit telephone number
    (Optional)

    Whether an accident tow or not, please complete the following:
    (Optional)
    Emergency Road Service Terms & Conditions

    Supporting Documents

    Please upload any applicable documents (PDF, JPG, JPEG and PNG):

    1. Receipts
    2. Membership Card
    3. Letter from your insurer confirming they will not be covering the claim
    4. Corresponding incident report / provide report number
    5. Police Report
    6. Insurance Slip
    7. Applicable documentation from a government-authorized tow provider
    Note: If your total files size exceeds 20 MB your reimbursement request will not be processed. The max number of files allowed is 10.
    Please upload any applicable documents in any of the following format: PDF, JPG, JPEG and PNG
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    2 mb
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    reciept.jpg
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    reciept.jpg
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    reciept.jpg
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    (Optional)

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