Rideshare Form

1

Did you experience assault while using a common rideshare service, such as Uber or Lyft?If you are uncomfortable answering any of these questions, simply click "NEXT" to skip

Yes

No

I'm not sure

2

When did the incident occur?If you are uncomfortable answering any of these questions, simply click "NEXT" to skip

Within the last month

Within the last year

Within the last two years

Over two years ago

3

What type of assault did you experience?If you are uncomfortable answering any of these questions, simply click "NEXT" to skip

Physical assault

Verbal assault

Both physical & verbal assault

I'm not sure

4

Which state do you live in?* This field is required.

5

Is there anything else you would like us to know about your experience?Provide any information you feel comfortable sharing here, or click "NEXT" to skip

6

Name* This field is required.

First Name

Last Name

7

Email* This field is required.

example@example.com

8

Phone Number* This field is required.

Please enter a valid phone number.

9

Legal Disclosure* This field is required.By checking this box, I agree to the terms and consent to be contacted.

10

Consent to Contact* This field is required.By checking this box, I agree to the terms and consent to be contacted.

11

Please verify that you are human* This field is required.

12

Thank you for answering. If you did not experience any form of physical assault while using a rideshare service like Uber or Lyft, we will not be able to assist you with this type of case.

If you think you're seeing this message by mistake and you may qualify, or you have questions about something else, feel free to contact us.