Reimbursement Request Form


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 FieldsGet Started >
First we need to find your policy. Please fill out your name and policy number, then click "Validate Policy":

Enter full policy number without hyphens
*Required Fields Validate Policy
Select the vehicle that received service. If the vehicle is not listed, select "Vehicle Not Listed".
Please Validate your Policy Details first
*Required FieldsContinue >
Please enter the following details of the service.
$
*Required FieldsContinue >
Where was the vehicle at when service was needed?
*Required FieldsContinue >
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.
*Required FieldsContinue >
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.
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