Rideshare Pre-Qualification Form

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Were you or a loved one harmed during a ride with a rideshare service?

Yes

No

Which rideshare platform were you using?

Uber

Lyft

Other

Were you a passenger or a driver?

Passenger

Driver

Other

What type of incident occurred? (Select all that apply)

Sexual Assault

Physical Assault

Kidnapping or forced detainment

Do you have your rideshare trip receipt or confirmation from the app?

Yes

No

Did you file a police report?

Yes

No

Did you seek medical treatment or therapy as a result?

Yes

No

Are you currently represented by an attorney for this matter, or have you previously worked with an attorney regarding this claim?

Yes

No

I consent to being contacted by Poca Lead Logic by phone, email, or text regarding my potential case.

I confirm that all information provided is truthful and accurate. I understand that my claim will require verification through rideshare trip receipts, police reports (if applicable), medical records, identification, and/or any other supporting documentation. Providing false information will result in immediate disqualification.

Rideshare Assault? You Shouldn't Pay the Price. They Should.