R2R Intake Form
Please use this form to submit any claim related questions you have for our upcoming webinar. Thank you for taking the time to complete this form.
Your full name
Your email address
Please indicate your insurance problem (choose all that apply)
Examination Under Oath (EUO)
Please state your claim-related question here. We will do our best to provide a response during the webinar.
Name of your insurance company
Was your home damaged or destroyed by a wildfire in 2020?
Damaged (partial/standing/smoke loss)
Destroyed (total loss)
Please indicate the fire that affected your home
2020 CZU Wildfire
2020 LNU Wildfire
2020 Glass Fire
2020 Oregon wildfire (any)
2020 Washington wildfire (any)
If you selected "other," please tell us the name of your wildfire.
If you're willing to talk to the media about your insurance problem, please share your phone number.
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This form was created inside of United Policyholders.