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.
Sign in to Google
to save your progress.
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
Please indicate the fire that affected your home
2018 Camp Fire
2018 Woolsey Fire
2019 Kincade Fire
If you selected "Other wildfire," 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.
Never submit passwords through Google Forms.
This form was created inside of United Policyholders.