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General Motors Mobility Reimbursement Application

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General Motors Mobility Reimbursement Application GENERAL MOTORS MOBILITY REIMBURSEMENT APPLICATION APPLICATION PAGE 2 of 2 REIMBURSEMENT PROGRAM FEATURING ONSTAR 4. VALIDATE APPLICATION AT GM DEALER AND CONNECTED SERVICES Take your adapted vehicle and application to your GM dealer. Have your GM dealer representative sign the application. If you are physically unable to return to the GM dealer you bought the vehicle from (e.g., you are now residing in another state or have moved a considerable distance from your original dealer), any participating GM dealer representing the brand purchased may sign your application. DEALER INFORMATION 5. VERIFY YOUR APPLICATION IS COMPLETE REMOVE, COMPLETE, AND RETURN FORM COMPLETE, REMOVE, Dealer Name: _________________________________________ Gather your reimbursement application and all necessary attachments. Incomplete applications will delay claims processing. Make sure you have the following: Dealer BAC Code: ______________________________________ Copy of itemized invoice(s), including proof of payment Phone: _______________________________________________ Letter of authorization from your lessor if this is a leased vehicle If dealer is requesting payment, remember to provide ONE of the following: Fax: _________________________________________________ Customer Incentive Acknowledgment and/or Assignment Form, copy of dealer check(s) issued to adaptive equipment installer(s), or copy of sales contract CONFIRMATION (REQUIRED) refl ecting mobility incentive deduction For reimbursement of assist steps/running boards ($200 maximum), remote I have examined the eligible vehicle identifi ed on this application, liftgate opener ($500 maximum), assist handles, electric parking brake, inverter, and it is equipped with the adaptive mobility equipment described on the attached invoice(s). and pedal extenders, provide signed letter from physician describing disability/ _____________________________________________________ limitation with physician’s name, license number, address and phone number GM Dealer Representative Signature Copy of completed and signed reimbursement application _____________________________________________________ Print Name 6. APPLICATION SUBMISSION _____________________________________________________ Mail, fax, or e-mail your application and all required attachments to: Date Mail to: Fax to: E-mail to: GENERAL MOTORS 1-866-234-3036 [email protected] MOBILITY PROGRAM HEADQUARTERS Send reimbursement payment to (check one): P.O. BOX 33170 The GM dealer above The vehicle purchaser DETROIT, MI 48232 If the dealer is requesting payment, one of the following documents must accompany the application: PLEASE KEEP A COPY OF THE APPLICATION AND ALL SUPPORTING DOCUMENTS FOR YOUR FILES. • Customer Incentive Acknowledgment and/or Assignment Form This claim and any payment made under this claim are subject to the O cial Program Rules and Guidelines that are • Copy of dealer check(s) issued to equipment installer(s) in e ect from 10/01/19 to 1/02/21 and have been made available to all authorized GM dealers. General Motors • Copy of sales contract refl ecting mobility incentive deduction reserves the right to modify or terminate this program without notice. SERVICE REQUEST NUMBER FOR INTERNAL USE ONLY Providing the capability and confi dence to live a life in motion. $1,000 Reimbursement on Adaptations. GENERAL MOTORS MOBILITY REIMBURSEMENT APPLICATION Through the General Motors Mobility Reimbursement Program, customers who purchase or lease an eligible 2019-2021 Please review the step-by-step instructions and list of eligible adaptive equipment found at gmfl eet.com/mobility. Incomplete applications APPLICATION Chevrolet, Buick, Cadillac or GMC vehicle can receive up to $1,0001 in reimbursement ($1,200 on Chevy Express and GMC will delay claims processing. If you have questions or need help, please contact the GM Mobility Assistance Center at 1-800-323-9935 PAGE 1 of 2 (TTY 1-800-833-9935). Savana) toward the cost of eligible adaptive equipment installed (or reinstalled) on their new vehicle. Eligible adaptive equipment must be permanently installed in the vehicle, and installed for a driver or passenger with a permanent disability. Seat belt extenders are eligible for reimbursement but do not qualify for OnStar® Safety & Security o er. 19607b should never be used on actual 3D applications Master Art No. 19607b This — For Reorders Call: Generalapplication Motors Media Archive, (313) 667-6141, email: [email protected] is valid for eligible new and unused 2019-2021 model-year Chevrolet, Buick, Cadillac, and GMC vehicles delivered between 10/01/19 and 1/02/21. Vehicles must be adapted or downlad from www.gmassetcentral.com: Browswe Browse Brand Guide GM Corporate Plus Two Years of OnStar® and Remote Access Plan— and a claim must be submitted within six months of the date of purchase/lease. You have chosen to hire your own mobility equipment installer to alter your vehicle. By o ering an incentive, GM is not reviewing or taking any responsibility for the quality or safety of Only from General Motors. your alteration. Please consult the vehicle alterer making changes to your vehicle to ensure that the work done on your vehicle is consistent with the Federal Motor Vehicle Safety Act. Alterations are not covered under the GM new vehicle limited warranty. Customers who purchase properly equipped eligible GM At the touch of a button, OnStar connects you to a real person, 2 1. OBTAIN ADAPTIVE EQUIPMENT AND 2. VEHICLE PURCHASER INFORMATION — PLEASE USE INK AND COMPLETE ALL INFORMATION vehicles also get 2 years of the OnStar Safety & Security 24/7—with a world of services to help you stay connected PURCHASE RECEIPT Plan Coverage and Remote Access3 Plan with available safely, including: PURCHASER INFORMATION VEHICLE/EQUIPMENT INFORMATION 4 TTY equipment requested 4G LTE Wi-Fi® Hotspot when eligible adaptive equipment OnStar: Mr. Ms. ________________________________________ Vehicle ID No. (VIN)__________________________________ After your vehicle adaptations are completed, obtain LAST FIRST M.I. 5 Mailing Address _____________________________________ Delivery Date ________/________/________ is installed. This o er is on top of the OnStar Safety & • Automatic Crash Response an itemized paid invoice from the licensed equipment Security coverage and connected services trial included • Emergency Services5 installer(s). The invoice must include the following: City _______________________________________________ Vehicle Make _____________ Model___________ Year______ on new GM eligible vehicles. Remote Access: Preprinted installer company name, address, State/ZIP _____________________________/____________ Check appropriate box: and phone number Retail Sale Retail Lease Commercial Sale • Remote Door Unlock (requires power door locks)6 Home Phone # (__________)__________________________ Your name, address, and phone number • Vehicle Diagnostics7 Work Phone # (__________)___________________________ DESCRIPTION OF ADAPTIVE EQUIPMENT INSTALLED Vehicle Identif ication Number (VIN) E-mail Address ______________________________________ ______________________________________________________ Description of the adaptive equipment Vehicle sold/traded in: Date of Adaptation ________/________/_________ installed on vehicle Vehicle Make _____________ Model___________ Year______ Total Cost of Adaptation $ _____________________________ Date of adaptation (sale) First-time GM Mobility Reimbursement Program user? Reimbursement Amount Requested* $____________________ To get an application or learn more, visit gmfl eet.com/mobility or call 1-800-323-9935 or TTY 1-800-833-9935. FORM AND RETURN COMPLETE, REMOVE, Itemized cost of parts AND labor Yes No Primary personal mobility aid used: Wheelchair NOTE: A letter from your physician describing the limitations of your disability is (listed separately) required for assist steps/running boards, assist handles, electric parking brake, Scooter Cane/Walker/Crutches Other None inverter, pedal extenders, remote liftgate opener, and TTY equipment Proof of payment for the adaptation (copy of For information on GM’s privacy statement, please visit gm.com/privacy *Please see dealer or gmfl eet.com/mobility for limits. credit card receipt, canceled check, or paid invoice) or call 1-866-MY-PRIVACY (1-866-697-7482). 1Limit $1,000 total reimbursement per eligible vehicle ($1,200 for Chevrolet Express and GMC Savana). See General Motors Mobility Reimbursement Program Application for complete program details, limitations, and eligibility. Offer ends 1/02/21. 3. REVIEW AND SIGN APPLICATION (VEHICLE OWNER[S] OF RECORD) GM regular production options and accessories are not eligible for reimbursement under the General Motors Mobility Program, except for OnStar TTY equipment and seat belt extenders. This includes, but is not limited to, assist steps/ running boards and all aftermarket equivalents. Call the General Motors Mobility Assistance Center if you have questions I/We certify that the information entered on this application is correct and that the adaptive equipment described on the attached invoice(s) has been about equipment eligibility. 2Services subject to user terms and limitations. Certain services require working electrical system, cell service and GPS signal. OnStar links to emergency services. Data plan offered by AT&T. Visit gmfleet.com/ permanently installed on the eligible GM vehicle identifi ed on this application. I/We understand that GM has no responsibility for my vehicle alterations. connectedservices for more details. Requires
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