WTY014_REIMB

REQUEST FOR REIMBURSEMENT FORM
2011-2013 MY Optima and Optima HEV Headlamp Assembly
New Vehicle Extended Warranty Program – WTY014
If you have incurred expense to remedy this issue prior to the date of this notice, you may have the opportunity to
obtain reimbursement for that expense. You may submit your receipts, along with this Request for Reimbursement
form online to Kia via the Owners section (Contact Kia) of www.kia.com.
If you do not have access to a computer or prefer to submit your request by mail, please complete this Request for
Reimbursement and mail it directly to Kia for review and consideration, along with backup documentation, at 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:
o
o
Repair Order showing::
Name & address of person paying for the repair
o
Vehicle Identification Number (VIN) of vehicle repaired
o
Description of the problem repaired

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:
o
Date of Payment
o
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 safety recall campaign.
CLAIMANT’S SIGNATURE:
____________________________________________
Signature
_________________________________________
Print Name
WTY014