Reimbursement claim

Use this form to submit your information and supporting documentation and our Roadside Assistance team will review your reimbursement request.

Good Sam Roadside Assistance

This form is required for reimbursement consideration.

*Required fields

Member information

Member name*

Subscriber ID*

Phone Number*

Email*

Address (listed on plan)*

Disablement information

Date of service*

Phone number used to call dispatch*

Vehicle type*

Vehicle year*

Vehicle make*

Vehicle model*

Type of Service*

Location of Disablement ( City, State, Mile Marker, Highway, Road, GPS Coordinates, etc.)*

Address of drop off location (if towed)

What was the cause of your disablement?*

Did you attempt to call Good Sam Roadside Assistance dispatch for assistance with this service?*

Yes

Description - Please provide details on why you are submitting a claim. If you did not contact Good Sam dispatch, please state the reason why.*

Amount requested for reimbursement (USD)*

Upload Receipt*

ITEMIZED RECEIPTS REQUIRED! – For your claim to be considered, it must include a broken down or itemized receipts for all requested charges. Multiple attachments are not accepted. Please add all documents under one file for submission. If you are unable to combine all files into one, please fax or mail the documentation to support your claim to the following:

Fax – 303.728.7305 Good Sam Roadside Assistance PO BOX 6900 Englewood, CO 80155-6900

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Reimbursement claim

Good Sam Roadside Assistance

Member information

Disablement information

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