Refund_ roadside - Global Assistance

REQUEST FOR A REFUND
of costs of roadside assistance services

Personal details of the individual filing the request:

First name *

Last name *

Mailing adress *

E-mail *

Telephone *

Bank ccount number *

Vehicle details:

Registration plate number *

Make

Type/model

Details of the insurance:

Insurance company

Insurance contract number *

Insurance contract number

Details of the insured event

Breakdown

Accident

Date of the event *

Place of the event *

(state, address)

Tow destination

Did you contact GLOBAL ASSISTANCE’s roadside assistance centre?

YES

Date of call

Time of call

What telephone number did you call from?

What telephone number did you call?

If you were unable to contact GLOBAL ASSISTANCE due to a medical examination and/or treatment, please provide the medical report issued by the health care facility that examined and/or treated you. An explanation of why assistance was not arranged and/or paid in the standard way – that is, by contacting and requesting assistance from GLOBAL ASSISTANCE’s roadside assistance centre – should be included in the event description.

Please, attach to this request the invoice and/or receipt issued by the company that provided assistance services. *

Choose a file

Event description and notes