Claims
Emergency Ride Reimbursement Form
Complete, print or save as PDF, attach your receipt, and submit. Reimbursements up to $100 per approved incident.
| Member name | |||
|---|---|---|---|
| Certificate # | |||
| Date of incident | Time | ||
| Incident location | |||
| Rideshare / taxi used | |||
| Drop-off address | |||
| Fare paid (member) | $ | Emergency type | |
| Tow company (if any) | |||
| Law enforcement agency | |||
Notice of emergency reimbursements must arrive within TEN DAYS of incident to qualify for full reimbursement up to $100.00 per approved incident.
PAYMENTS MADE TO STUDENT MEMBER WITHIN 72 HOURS OF RECEIPT OF REIMBURSEMENT FORM.
Student Lifeline possesses exclusive determination rights of each reimbursement request; all questions on this form must be fully completed.
Any attempt to provide misstatements of any kind shall result in the cancellation of services and a full prorated refund will be issued.
REIMBURSEMENT REQUESTS FOR AUTHORIZED EMERGENCY RIDES MUST BE RECEIVED BY STUDENT LIFELINE NO LATER THAN TEN (10) DAYS OF THE DATE OF THE EMERGENCY RIDE INCIDENT OR NO PAYMENTS SHALL BE CONSIDERED.
Submission options
- Mail: P.O. Box 570200, Whitestone, NY 11357
- Email: studentlifeline@aol.com
- Fax: 718-357-4702
Reimbursement policy
Notice of emergency reimbursements must arrive within TEN DAYS of incident to qualify for full reimbursement up to $100.00 per approved incident.
PAYMENTS MADE TO STUDENT MEMBER WITHIN 72 HOURS OF RECEIPT OF REIMBURSEMENT FORM.
Student Lifeline possesses exclusive determination rights of each reimbursement request; all questions on this form must be fully completed.
Any attempt to provide misstatements of any kind shall result in the cancellation of services and a full prorated refund will be issued.
REIMBURSEMENT REQUESTS FOR AUTHORIZED EMERGENCY RIDES MUST BE RECEIVED BY STUDENT LIFELINE NO LATER THAN TEN (10) DAYS OF THE DATE OF THE EMERGENCY RIDE INCIDENT OR NO PAYMENTS SHALL BE CONSIDERED.
