Section 1: About You
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| Title |
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| First Name |
(*Required) |
| Last Name |
(*Required) |
| Date of Birth |
|
| Place of Birth (country) |
|
| |
| Please provide the details where you are
most likely to be contactable: |
Address
(*Required) |
|
Phone
(*Required) |
|
| Phone W |
|
| Phone M |
|
Email
(*Required) |
|
Section 2: Your Case
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| Type of employer you intend to claim against |
|
| Job title |
|
| Brief description of your role |
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| Date started |
|
| Are you still employed? |
Yes
No |
| IMPORTANT |
|
| If no, what date did your employment end? |
|
| Were you taken on via an agency? |
Yes
No |
| Have you worked for your employer on a "self employed" basis? |
Yes
No |
| Are you a UK citizen? |
|
| Pay: Gross per annum |
|
| Take home pay (Net pay) per month |
|
| Please provide details of any bonuses, including amount and how
often they were received |
|
| Please provide details of any benefits. For example, car, phone,
pension, etc. |
|
| Number of people employed with you |
|
| Have you been subject to any form of discipline at work (eg
written or verbal warnings/ suspension)? |
Yes
No |
| Have you lodged any grievances at work? |
Yes
No |
If "yes" please provide details
|
|
| Have you ever been involved in any previous court or tribunal
cases? |
Yes
No |
| Number of hours worked per week |
|
| Overtime |
|
| Does your employer pay all of your tax and National Insurance
for you? |
Yes
No |
Section 3: Evidence your employer may possess
|
IMPORTANT - Are you
aware of any evidence that your employer may be in possession of OR
may seek by way of disclosure - that could damage your case? This
question is very important and should be answered truthfully:
- Compromising emails that you may have sent to or from work
(whether or not they have been deleted)
- Criminal records
- Previous problems at work (including other places of
employment)
- Documents that may damage your case
- Any claim, which your employer might have against you - eg
negligence or any other monetary claim.
|
| Are you aware of any such evidence? |
Yes
No |
| If yes, please provide details |
|
Section 4: Looking for work
|
| Since losing your job, have you been looking for work? |
Yes
No |
| If yes, please provide details of your efforts to find a job,
including applications, adverts, job centre records and diaries. |
|
If no, please explain why:
eg medical reasons? |
|
Section 5: What type of case do you want to pursue?
|
| |
Please tick any of the following
that relate to your circumstances
|
|
| Are there any other
issues you might wish to discuss? |
|
| Most cases
have to be brought within 3 months of the matter complained of. If
you are too late, please explain why. |
| Have you lodged a claim already? |
Yes
No |
| If so when? |
|
| If no claim has been lodged within 3 months - please explain why |
|
Section 6: Useful evidence
|
| |
Please indicate if you have any of
the following documents.
|
|
| Do you have any witnesses who are likely to support
you in your case? |
|
|
|
| What are you hoping to achieve in pursuing this case
against the employer? |
| Tick the appropriate box or boxes for what you hope to achieve |
|
| If preferred please provide a brief description |
|
Section 7: Statement of Case
|
| Please provide a summary in your own words of why
you are bringing this claim and what circumstances have led you to
seek legal advice. It would be
helpful to receive dates of key events and meetings. This
information is very important.
|
| Your statement |
|
| |
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Section 8: Declaration
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| I believe that the facts stated in this
questionnaire are true and accurate to the best of my knowledge. (*Required) |
| |
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Thank you for completing
this questionnaire. One of our employment team members will contact
you by telephone or by email as soon as possible.
Please be aware that we do offer NO WIN NO FEE advice but this will
not apply to all claims. When we respond to you we will advise how
your particular claim might proceed.
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