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    Insurance & AAA Rebate Receipt Form

    Many auto and long-term care insurers treat a monitored safety device as a premium-reducing safety asset. Download the receipt form below, attach your RideAlert payment confirmation, and submit it to your parent's carrier.

    Request a Signed Copy

    Tip: in the print dialog choose "Save as PDF" to keep a digital copy for your records.

    How to submit it to AAA, State Farm, or a long-term care insurer

    1. Print the Rebate Receipt Form below

    Use the Download / Print button. Save it as a PDF or print a paper copy — both are accepted by most carriers.

    2. Fill in the policyholder details

    Use your parent's name exactly as it appears on their auto or long-term care policy, plus the policy number.

    3. Attach your RideAlert payment receipt

    Your Ride Local confirmation email lists the one-time hardware & setup bundle and the monthly subscription. Attach it to the form.

    4. Submit to the carrier

    Email or upload both documents to your agent (AAA, State Farm, Allstate, or the long-term care insurer) and ask them to apply it under safety-device / mobility-assistance benefits.

    What to tell the agent

    • RideAlert is a monitored personal safety device: double-click summons a vetted local driver, press-and-hold triggers a 24/7 emergency response.
    • It reduces at-fault accident exposure by giving an aging driver a reliable alternative to driving themselves.
    • Trip status alerts are sent automatically to family members, documenting safe pickup and drop-off.
    • Includes a 1-year device protection plan, so the safety asset stays in service for the full policy year.
    • Many carriers classify it alongside medical alert systems, which commonly qualify for premium credits or LTC reimbursement.

    Ride Local cannot guarantee a rebate or premium reduction — eligibility is set by each insurer and policy. This form simply documents your purchase in the format carriers ask for.

    Ride Local · RideAlert

    Safety Device Rebate Receipt Form

    Submit this form with your RideAlert payment confirmation to your auto insurance carrier (AAA, State Farm, Allstate, etc.) or long-term care insurance provider to request a safety-device credit, rebate, or reimbursement.

    Section 1 — Policyholder (the senior)

    Full legal name
    Date of birth
    Phone
    Home address
    City / State / ZIP

    Section 2 — Insurance policy

    Insurance carrier (AAA, State Farm, other)
    Policy number
    Policy type (auto / long-term care)
    Agent name
    Agent email or phone

    Section 3 — Submitting family member / caregiver

    Full name
    Relationship to policyholder
    Phone
    Email

    Section 4 — RideAlert purchase details

    Order / receipt number
    Purchase date
    Plan name
    Monthly subscription amount
    One-time hardware & setup bundle amount
    Total paid to date

    Device & service description (for the carrier)

    RideAlert is a monitored one-button personal safety and mobility device provided by Ride Local, a locally owned transportation company in Yuma, Arizona. A double-click dispatches a vetted, insured local driver; a press-and-hold triggers a 24/7 emergency response and automatic notification of designated family contacts. The device includes a 1-year protection plan and is owned by the customer. It is used as a driving alternative and fall/emergency response aid for an aging policyholder.

    Section 5 — Certification

    Signature of submitting family member
    Date

    Verification contact — Ride Local

    (928) 488-1497 ridelocalride@gmail.com

    2837 W 1st Street, Yuma, AZ 85364 · www.ridelocalride.com

    Ride Local does not provide insurance or tax advice. Rebate eligibility is determined solely by the insurance carrier.