WTY004FORM

REQUEST FOR REIMBURSEMENT FORM
2011–2014 My Optima Engine Connecting Rod
Kia New Vehicle Limited Warranty Extension
If you have paid to have your engine repaired/replaced due to connecting rod failure, you may be eligible
for reimbursement for some or all of that expense. Mail this completed Request for Reimbursement Form
to Kia, along with documentation specified below, for review and consideration to the following address:
Consumer Assistance Center
Kia Motors America, Inc.
P.O. Box 52410
Irvine, CA 92619-2410
1-800-333-4542
Please allow at least sixty (60) days for review and response.
Customer Name: ___________________________________________________________________
Customer Address: _________________________________________________________________
Customer City, State, Zip Code: ______________________________________________________
Daytime Phone: _______________________ Evening Phone: ____________________________
Vehicle Identification Number: __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ (17 digits)
Mileage at Time of Repair: _________________________ Date of Repair: _________________
Amount of Reimbursement Requested: $______________
Attach the following:
□ Repair Order showing:
 Name & address of person paying for the repair
 Vehicle Identification Number (VIN) of vehicle repaired
 Description of the problem repaired (e.g., engine knocking noise, engine repair/replacement
due to engine connecting rod failure) and the repairs made (e.g., replaced engine)
 Date of repair and mileage on the vehicle at the time of repair
 Total cost of repair expense being claimed
 Copy of maintenance repair receipts (e.g. oil and filter change). Refer to your Optima
Owner’s Manual, Maintenance Section 7 for maintenance requirements. If you are a
subsequent owner please provide a copy of your Bill of Sale/Sales Contract.
□ Evidence of Payment of Repair showing:
 Date of payment
 Amount paid (e.g., copies of cancelled check or credit card receipt)
I certify that the documents attached to this Request for Reimbursement are true and accurate and should
be used as the basis for a reimbursement to me under this warranty extension.
CLAIMANT’S SIGNATURE:
___________________________________________________
Signature
Print Name: ________________________________________