Section A- Personal Information

First Name *

Last Name *

Date of birth *

Social Security Number (SSN) (Required for VA Claims): *

Phone Number *

Email Address *

Address

Street Address *

City *

State *

Country *

Postal code *

Branch of Service *

Service Period:

From *

to *

Discharge Type *

Section B- Intent to File (ITF)

(Completing this section allows UAG to submit your ITF, securing your effective date for VA benefits.)

What type of claim are you planning to submit? *

Do you have an existing VA claim or rating? *

Yes

If yes, what is your current VA rating? *

Have you previously filed an ITF for this claim? *

Yes

If yes, when was it filed?

By submitting this form, I authorize UAG to file an ITF on my behalf to protect my effective date for VA benefits *

I Agree

By providing your phone number, you consent to receive marketing messages, including automated SMS, from UAG. Standard message and data rates may apply. You may opt out at any time by replying STOP.