You can obtain an application form via:
Chrysler, Jeep, Dodge, Ram Truck dealerships
Download a printable PDF here
Once you have purchased a 2010-2012 Chrysler, Jeep, Dodge, Ram or Fiat vehicle that fits your transportation needs, contact a reputable and qualified adaptive equipment installer to ensure that it can be adapted to your specifications.
Steps for Reimbursement
1. Obtain a prescription or note from a licensed medical doctor on physician’s letterhead for reimbursement of the adaptive equipment. (Some adaptations like hand controls and wheelchair or scooter hoists do not require a doctor’s approval. Check with your dealer and adaptive equipment installer to determine if a prescription or note is needed for your adaptations.)
2. Complete an Automobility Application.
3. Select a qualified adaptive equipment installer. Shop around and ask a few different installers for estimates to ensure a fair and reasonable price. It’s important to consider warranty and service information as well as initial cost. Also, it’s a good idea to ask each company for a list of references. Find qualified adaptive equipment installers and factory-approved conversion specialists at the National Mobility Equipment Dealers Association website.
4. After your vehicle has been adapted, submit your application and required documentation for reimbursement. (All required signatures listed on the form must be obtained before sending.)
Terms & Conditions
The application form must be used to submit a claim for reimbursement under the terms and conditions of the program. Through this program Chrysler Group will provide a reimbursement to each eligible customer who installs qualifying adaptive driver or passenger equipment on a purchased or leased new 2010, 2011 or 2012 Chrysler, Jeep, Dodge, Ram or Fiat. Contact your local dealer for Program eligibility dates. Only Chrysler Group vehicles purchased or leased new and unused are eligible for payment under this program. Used vehicles are not eligible for this program. Certain types of fleet sales and leases may also qualify. Consult your dealer for eligibility requirements.
The adaptive equipment must be installed within six months of vehicle purchase or lease. A claim form and all associated paperwork must be submitted to the Automobility Headquarters within 60 days of complete installation of adaptive equipment. Note that for a limited number of adaptations, such as hand controls and wheelchair or scooter hoists, the requirements for a medical note or prescription will be waived. Running boards, alerting devices and similar type adaptations must have medical documentation. Automobility Program Headquarters can answer questions about other adaptations at 1-800-255-9877.
Adaptive equipment is defined as equipment required by persons with a permanent disability to drive, enter, exit and/or be transported safely in a motor vehicle. Factory optional equipment is not reimbursable under this program. A prescription or letter from a licensed medical doctor on physician’s letterhead may be required for reimbursement.
Conversions to Chrysler, Jeep, Dodge, Ram or Fiat models qualify for a maximum reimbursement of $1,000. Running boards qualify for a maximum reimbursement of $400. Alerting devices qualify for a maximum reimbursement of $200. This application form must be completed in its entirety and signed by the customer and the selling dealership.
Chrysler Group will be the final judge as to the eligibility, interpretation and fulfillment of all elements of Chrysler Group consumer incentive programs. Any payment or benefits received are subject to the Official Program Rules, provided to all participating dealers.
A copy of this application form, a copy of the adaptive equipment company’s itemized paid invoice, copy of signed Buyer’s Order/Lease Agreement, the vehicle registration, and a prescription or note from a licensed medical doctor on physician’s letterhead stating the specific diagnosis (when required) must be mailed to the following address:
AUTOMOBILITY PROGRAM HEADQUARTERS
Toll Free: 800-255-9877
P.O. BOX 5080
TROY, MI 48007-5080
CONTACT US BY E-MAIL: firstname.lastname@example.org
Payment to the individual Automobility Program customer will be mailed within six weeks after receipt of an approved claim form and all required documentation.