Reimbursement Request Form
Instructions
We're sorry your vehicle needed service, but we're here to help.
You’ll need the following information to request reimbursement for a roadside event:
1. Your NJM policy number.
2. Information about the service and the service provider.
3. A digital copy, scan, or photo of all relevant receipts.
*Required Fields
Get Started >
Policy Lookup
First we need to find your policy. Please fill out your name, service date and policy number, then click "Validate Policy":
First Name*
Last Name*
Service Date*
Company Name
NJM Policy Number*
Enter full policy number without hyphens
*Required Fields
Validate Policy
Continue >
Vehicle
Select the vehicle that received service. If the vehicle is not listed, select "Vehicle Not Listed".
Policy Vehicles*
Please Validate your Policy Details first
Vehicle Year*
Vehicle Make*
Vehicle Model*
Vehicle VIN
Is this vehicle a rental?*
Select...
Yes
No
Rental Company Name
*Required Fields
Continue >
Service Details
Please enter the following details of the service.
Service Type*
Select...
Tow
Lockout
Tire Change
Fuel Delivery
Jump Start
Winch-Out
Requested Reimbursement Amount*
$
Was the service required because of an accident?*
Select...
Yes
No
Service Provider Name
Service Provider Phone Number
*Required Fields
Continue >
Service Address
Where was the vehicle at when service was needed?
Was the vehicle impounded?*
Select...
Yes
No
Disablement Address
Address Line 2
City
State
Zipcode
*Required Fields
Continue >
Contact Details
Finally, we’ll need your contact information in the event we need to follow up with you. Also, if your request is approved, your reimbursement will be sent to this mailing address.
Phone Number*
Email*
Mailing Address*
Address Line 2
City*
State*
Zipcode*
*Required Fields
Continue >
Review and Submit
Please make sure you have your receipts and other any other documentation needed before you continue. You will be able to upload your documents on the next step.
Policyholder
Vehicle
Service Details
Service Address
Contact Details
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