WTY011_REIMB

REQUEST FOR REIMBURSEMENT FORM
2012-2013 MY OPTIMA BRAKE STOPPER PAD
Kia New Vehicle Limited Warranty Extension
If you have paid to have your brake stopper pad repaired/replaced due to the stop lamps remaining
illuminated after the brake pedal has been released 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 and the repairs made (e.g., replaced brake stopper
pad)
• Date of repair and mileage on the vehicle at the time of repair
• Total cost of repair expense being claimed
□ 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: ________________________________________
WTY011