General Motors Accessibility Reimbursement Application Form

Gather your reimbursement application and all necessary attachments. Ensure you have a copy of itemized invoices, proof of payment, and a letter from your physician if applicable. Submit the completed application by fax to 1-866-234-3036 or email to mobility@gm.com. Keep a copy of the application and all supporting documents for your files.

The form is valid for eligible new and unused 2022-2023 model-year Chevrolet, Buick, Cadillac, and GMC vehicles delivered between January 4, 2022, and January 3, 2023. Ensure that your vehicle is adapted, and a claim is submitted within six months of the purchase/lease date.

The General Motors Accessibility Reimbursement Application form is designed to help individuals with permanent disabilities who have installed adaptive equipment in their GM vehicles. The form outlines the eligibility criteria for reimbursement, providing detailed instructions on the necessary documentation and steps to complete the application. By submitting this form, individuals can receive financial assistance for the costs associated with making their vehicles accessible, thus enhancing their mobility and quality of life.

• 1. Dealer Information: Includes the dealer's name, BAC code, phone, and fax numbers. This section must be completed by the GM dealer representative.
• 2. Purchaser Information: Requires the applicant's name, address, contact information, and vehicle details. This section must be completed by the individual applying for reimbursement.
• 3. Vehicle/Equipment Information: Includes the vehicle identification number (VIN), description of adaptive equipment, date of adaptation, and total cost. The applicant must provide an itemized invoice and proof of payment.
• 4. Signature Section: Includes signature lines for the purchaser, co-purchaser, and GM dealer representative. This section confirms that the adaptive equipment has been installed and the information provided is accurate.
• 5. Supporting Documents: Lists the required attachments, such as itemized invoices, proof of payment, and a letter from a physician if necessary. Incomplete applications will delay claims processing.

If you fail to submit this form, you may not receive the reimbursement for the adaptive equipment installed in your GM vehicle. Delays or incomplete applications can impact the processing time and approval of your claim.

• Missed Reimbursement: You may forfeit the opportunity to receive financial assistance for your adaptive equipment.
• Claim Processing Delays: Incomplete applications can result in delays in processing and potentially lead to denial of your claim.
• Additional Out-of-Pocket Costs: Failure to submit the form may result in having to cover the full cost of the adaptive equipment without reimbursement.

• 1. New Vehicle Purchase: Use this form if you have bought a new GM vehicle and installed adaptive equipment.
• 2. New Vehicle Lease: Submit the form if you have leased a new GM vehicle and made it accessible with adaptive equipment.
• 3. Adaptations Completed: Ensure that all installations are completed and obtain necessary documentation before submitting the form.
• 4. Claim Submission: Submit your reimbursement claim within six months of the vehicle's purchase or lease date.
• 5. Supporting Documentation: Provide all required attachments, such as invoices, proof of payment, and a physician's letter if needed.