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) *
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? *
Please indicate the fire that affected your home *
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.
Submit
Never submit passwords through Google Forms.
This form was created inside of United Policyholders. Report Abuse