Submit the completed form along with all required documentation to your General Motors dealer. Ensure all information is accurate and the necessary signatures are provided. For any questions, contact the GM Customer Assistance Center at 1-800-204-0261. My advice: Keep copies of all submitted forms and documents for your records and follow up if you don't receive a response within 30 days.

Check with General Motors for any updates on reimbursement deadlines for 2024 and 2025. Ensure timely submission for prompt processing.

The purpose of this form is to request reimbursement for expenses incurred due to repairs covered under General Motors Product Field Action. Customers should fill out their personal, vehicle, and repair details along with attaching necessary documentation to authenticate their claims. This form ensures accurate processing and proper handling of reimbursement requests by both customers and General Motors dealers.

• 1. Customer Name: Enter the full name of the customer requesting reimbursement.
• 2. Street Address or P. O. Box Number: Provide the mailing address of the customer.
• 3. City: Enter the city of the customer's address.
• 4. State: Provide the state of the customer's address.
• 5. Zip Code: Enter the postal code for the customer's address.
• 6. Daytime Telephone Number: Provide a daytime contact number including the area code.
• 7. Evening Telephone Number: Provide an evening contact number including the area code.
• 8. Date Request Form Submitted to Dealer: Enter the date the form and documentation are submitted to the dealer.
• 9. Vehicle Identification Number: Provide the 17-character VIN of the involved vehicle.
• 10. Mileage at Time of Repair: Enter the mileage of the vehicle when the repair was done.
• 11. Date of Repair: Enter the date on which the repair was completed.
• 12. Amount of Reimbursement Requested: Specify the amount requested for reimbursement.
• 13. Customer's Signature: Customer needs to sign here to attest the genuineness of provided information.
• 14. Bulletin No.: To be completed by the dealer, indicating the bulletin number.
• 15. Request Approved or Denied: Dealer will check whether the request is approved or denied.
• 16. Date: Dealer provides the date of approval or denial.
• 17. Amount: Dealer specifies the approved reimbursement amount if applicable.
• 18. Reviewed By: Dealer indicates who reviewed the request.
• 19. Reason for Denial: If denied, a reason is provided and a copy is retained for records.

Failing to submit this form may result in not receiving the reimbursement for repair expenses. It is crucial to complete and submit the form promptly.

• Loss of Reimbursement: You may not get reimbursed for the covered repair expenses.
• Delayed Processing: Incomplete or late submission may result in delays in processing your request.

• 1. Covered Repair Expenses: To claim reimbursement for repairs listed in the General Motors Product Field Action.
• 2. Documenting Repair Costs: For keeping records of repair costs covered under the field action.