Suzuki Secure Advantage Roadside Assistance Customer Claim Form - Suzuki SX4 2012 Warranty & Maintenance Information

Suzuki Secure Advantage Roadside Assistance Customer Claim Form

Complete this form when claiming reimbursement for Roadside Assistance or Emergency Travel Expense
important: Please refer to the Warranty & Maintenance Information booklet for coverage details. Submit all claims, fully docu-
Way of Life!
mented, within 20 days of disablement. Please retain a copy of all receipts and send original documentation. Please include
original paid receipts, validated by the service establishment, which clearly detail the nature of the service provided.
1. your Suzuki Secure Membership number is your
vehicle identification number
2. owner information
First Name
Street
Prov
Postal Code
3. roadside Assistance Claim
Road Service: $
4. emergency Travel expense Claim (maximum $300)
Meals:
Accomodation:
Commercial Transportation:
You must include the following documents: Paid receipts for reasonable covered expenses incurred within 3 days of disablement. For disablement due
to collision, a copy of the Accident Report which was filed with the appropriate police authority.
(enter the 17 digit vehicle identification number - VIN)
Last Name
Apt
Residence Phone
(maximum $75)
$
$
$
City
Business Phone
Towing: $
Rental Vehicle:
Other: (Please Specify)
Detailed Description:
- 35 -
Extension
(maximum $100)
$
$