REQUEST FOR REIMBURSEMENT FORM
2021-2022 MY K5 VEHICLES – HEATING, VENTILATION, AND AIR CONDITIONING (HVAC) BLOWER MOTOR
NEW VEHICLE LIMITED WARRANTY EXTENSION (WTY037)
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 online to Kia via the Owners section of www.kia.com (Owners>Contact Us or directly at this
link: http://customercare.kiausa.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 to the following address for review and consideration, along with backup documentation:
Kia Customer Care Center
Kia 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 First Name:

Customer Last Name:

Customer Address:

Customer City:

Phone #:

State:

(

)

-

Zip:

Email:

Vehicle Identification Number:
Mileage at Time of Repair:

Date of Repair:

Amount of Reimbursement Requested

/

/

$

Attach the following:
o

Repair Order showing:
o

Name & address of person paying for the repair

o

Vehicle Identification Number (VIN) of vehicle repaired

o

Description of the problem repaired


o

Date of repair, mileage at the time of repair and total cost of claimed repair expense

Evidence of Payment of Repair showing:
o
o

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 campaign.
CLAIMANT’S SIGNATURE:
____________________________________________
Signature

_________________________________________
Print Name