First Name:*

Last Name:*

Email:*

Telephone:

State Where Incident Occurred:*
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Type of Gas Station Suspected:
---OtherAmerican GasAmocoARCOBPBuc-eeChevronCircle KCitgoClark BrandsConocoCostco brand gasolineCumberland FarmsDelta Sonic - Buffalo, New YorkExxonFlying JGas City, Ltd.GettyGo-MartGulfHessHigh's Dairy StoresHolidayIrving OilKroger brand gasolineKum & GoKwik TripLassus Handy DandyLove'sLukoilMarathon OilMobilMurphy USAPhillips 66PilotQuickChekQuikTripRaceTrac/RacewayShellRoyal FarmsRutter's Farm Stores7-Eleven brand gasoline76Sam's ClubSheetzSinclairSpeedwaySpinxSunocoTexacoTravelcenters of AmericaValeroWawa

When Were You Victimized?

Why Do You Suspect A Gas Station?*

How Did You Learn Of The Fraud?

Location of Gas Station (i.e. address, cross street, exit on highway)

Were Any Fraudulent Charges Made?*
 Yes No

Were You Forced To Pay Any Fees (i.e. replacement card, overdraft)?*
 Yes No

Have You Purchased ID Theft Insurance?*
 Yes No

Have You Purchased Credit Monitoring Services?*
 Yes No

Were You Notified By The Gas Station?*
 Yes No

Is Your Card-Issuing Financial Institution Aware?*
 Yes No

Did Lose Any Ancillary Benefits (i.e. rewards points)?*
 Yes No

Additional Information:

DISCLAIMER: Please note, by submitting your claim, you hereby acknowledge and agree that you have read the entirety of this disclaimer and agree to its terms. By submitting a claim you are simply reporting suspected gas station fraud by virtue of completing an online questionnaire and, in exchange, requesting more information on that topic. Nothing about the claim submission process, or that an attorney will respond to it by contacting you, should be construed or interpreted as creating or commencing an attorney-client relationship. Only if you execute a separate written agreement for legal services with an attorney or law firm shall create and establish an attorney-client relationship. You further agree to have the information it contains reviewed, stored, maintained, and used by an attorney working for or with the law firm of Redavid Law PLLC, Law Offices of Mark Eiglarsh, and/or Fischer Law Firm PLLC, a law firm based in Miami, Florida, in a manner within its sole discretion, but consistent with the regulations of the American Bar Association and Florida Bar Rules of Professional Conduct. By submitting a claim, you consent to be contacted by an attorney or attorneys working for or with Redavid Law PLLC, Law Offices of Mark Eiglarsh, and/or Fischer Law Firm PLLC. You also agree to subscribe in Redavid Law PLLC's, Law Offices of Mark Eiglarsh, and/or Fischer Law Firm PLLC's informational email-based newsletter, which may be opted-out of at anytime.

 By checking this box and clicking “SUBMIT,” I hereby affirm that I have thoroughly reviewed the disclaimer above and agree to be bound by its terms.