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)*During the ride when the incident happened, were you a driver or passenger?* Driver Passenger When did the incident occur? (Date)*At approximately what time did the incident occur? (00:00 am/pm)Where did the incident occur?City*State*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 Please describe what happened in detail:*What was the ride pick-up location address?What was the ride drop-off location address?Is a copy of the Ride Receipt available?* Yes No Unsure If no or unsure, please describe why the Ride Receipt is unavailable:Name of person who ordered the ride (if you're a driver, reply with N/A):*Phone number associated with the account that ordered the ride OR your driver account:*Email associated with the account that ordered the ride OR your driver account:*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 Lyft?* Yes No If you reported the incident to Lyft, how? (Please check all that apply)* Phone Call In-App chat By submitting a low rating and/or review Email Other Did not report If you reported the incident to Lyft, what was the date of the report?If applicable, what action was taken by Lyft after you reported the incident?Do you have any audio, video, or photographic evidence of the incident? This includes the events leading up to or immediately after the incident. You will have to provide the audio, video, or photo file to us separately via email or text.Did you report the incident to the police? (Y/N) Yes No If you reported the incident to the police, what was the date of the report?Do you have the Police Report number? If so, please provide.Was there a criminal investigation related to the incident? If so, what was the outcome of that investigation?Did you tell any friends or family about this incident? If yes, please list the date(s) you told them and their name and phone below.Did you seek medical treatment for physical injuries due to the incident? If yes, please describe and provide the date of treatment, the provider’s name, facility name, and contact information.Did you seek mental health treatment due to the incident? If yes, please describe and provide the date of treatment, the provider’s name, facility name, and contact information.NameThis field is for validation purposes and should be left unchanged. Δ