We handle cases that change lives. Please fill out the form below to participant in the settlement process. Name* First Last Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth:* Emergency Contact (name/relationship/contact)* Please describe what happened in detail:*Please check off the following acts that occurred during the sexual/physical abuse:* Lewd and/or Inappropriate Comments or Questions or Gestures Solicitation (ex. Perform sexual acts in exchange for free ride or other payment) Verbal or implied threats of violence or adverse consequences Touching or forcing a touch of hand, leg, thigh, shoulder, back over the clothes Touching or forcing a touch of hand, leg, thigh, shoulder, back under the clothes Touching of genitalia, breast, mouth, buttocks without penetration over the clothes Touching of genitalia, breast, mouth, buttocks without penetration under the clothes Kissing of hand, leg, thigh, shoulder or back Kissing of genitalia, breast, mouth, buttocks Penetration including Oral Copulation/Sex (Rape) Involve masturbation and/or indecent exposure Kidnapping Carjacking or attempted carjacking Threat with a deadly weapon Use of deadly weapons (gun, knife, etc.) Physical Assault with medical treatment Physical Assault without medical treatment When did the incident occur? (Date)* Where did the incident occur? (City, State)* Name of person who ordered the ride:* Phone number and email associated with the account that ordered the ride:* Where did you live at the time of the assault? (City, State)* Do you know the name of the assailant? If so, please list the name. Did you report the incident to Uber/Lyft?* Yes No If yes, how? (Please check the appropriate box)* Over the phone Through the chat on the app Low rating and/or review Other If applicable, what action was taken by Uber/Lyft after you reported the incident?Did you report the incident to the police? If yes, what action was taken by the police?Do you have the Police Report number? If so, please provide.Is a copy of the Ride Receipt available?* Yes No Unsure If no or unsure, please describe why the Ride Receipt is unavailable:If Ride Receipt is unavailable, please provide the pick-up and drop-off locations that were requested:Did you tell any friends or family about this incident? If yes, please list their name and phone below:Did you seek medical/mental health attention? If yes, please describe and provide the date of treatment, the provider’s name, facility name, and contact information.PhoneThis field is for validation purposes and should be left unchanged. Δ
