Jobrights Claims Form

Please complete the detailed form below in order to make an enquiry. All forms received will be replied to as soon as possible:

Section 1: About You

Title

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 (Work)

Phone (Home)

Phone (Mobile)

Email (required)

Section 2: Your Case

Type of employer you intend to claim against

Job title

Brief description of your role

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

	Dismissal
	Constructive dismissal (resignation due to your employer's breach of contract)
	Notice entitlement
	Race discrimination
	Sex discrimination
	Disability discrimination
	Religious belief discrimination
	Sexual orientation discrimination
	Injury at work
	Stress related injury at work
	The number of hours you work
	Deductions from your pay
	References
	Leave entitlements
	Terms in your contract of employment
	Bullying or harassment at work
	Anything else
	Sexual harassment
	Pregnancy related dismissal
	Age discrimination
	Equal Pay claim
	Compromise Agreement

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.

Contracts of employment
Job descriptions
Disciplinary notes and procedures
Warnings
Relevant memos
Letters of dismissal
Tribunal or court documents
Medical reports
Wage slips
Diaries
Evidence
Appraisals

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

	A reference
	Financial compensation
	Your job back
	Relocation
	Other

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

Section 8: Declaration

I believe that the facts stated in this questionnaire are true and accurate to the best of my knowledge.

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.