RS-01 Rideshare Sexual Assault | Maas Attorney Intake

1Center information

Center Code

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Agent Name

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TF Link (TrustedForm certificate URL)

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Call type

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Lead source / publisher (optional)

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2Qualification

Are you currently represented by an attorney for this matter?

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DQ: Represented by attorney

Have you spoken to or signed with another law firm about this before?

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Have you already settled or signed a release for this injury?

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DQ: Already settled / released

Have you been convicted of a felony?

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Have you filed for bankruptcy since the injury / diagnosis?

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3Client information

Client First Name

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Middle Name

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Client Last Name

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Suffix

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Gender

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Birthdate

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Marital status

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Client Street (Primary)

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Apt / Unit

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Client City (Primary)

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Client State (Primary)

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Client Zip Code (Primary)

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Client Phone (Primary) (10 Digit Number Only - No Hyphens or Parenthesis)

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Alternate Phone

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Client Email (Primary)

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Best time to call

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Preferred language

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4Injured person

Is the client the injured person?

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Injured person's full name

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Injured person's date of birth

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Client's relationship to the injured person

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Date of death

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Cause of death (per death certificate)

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Is the client the executor / estate representative?

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5Medical & insurance

Main treating doctor / hospital (name & city)

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Primary care doctor (name & city)

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Pharmacy used (name & city)

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6RS-01 · Rideshare Sexual Assault questions

What is your gender?

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Were you sexually assaulted by a Rideshare driver or Passenger?

Required

DQ: No assault by driver/passenger

What is the name of the Rideshare company?

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What state did the incident occur in?

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DQ: Incident in California

What date did the incident occur?

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Were you the driver or passenger?

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Do you have a Rideshare receipt for this incident?

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What type of abuse did you experience?

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Have you reported the incident to any of the following? (select all that apply)

Select at least one

7Case summary & documents

Case summary – what happened, in the client's own words

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Upload documents (optional – attach anything the client has already sent)📎 Click to attach documents or drag files herePDF, photos (JPG / PNG / HEIC), Word · up to 10 files · 10 MB each

Check the files: max 10 files, 10 MB each

Agent notes (internal)

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RS-01 Rideshare Sexual Assault Intake

1Center information

2Qualification

3Client information

4Injured person

5Medical & insurance

6RS-01 · Rideshare Sexual Assault questions

7Case summary & documents

Submitted