Do You Have a Case? Name* Email* PhoneWhat type of case do you have? Personal Injury (ie: Car Accidents, Slip and Fall, Medical Malpractice, etc) Workers Compensation (Physical or Emotional Injury at Work) Employment Disputes (Owed Wages / Breaks, Employment Termination, Illegal Firing, Sexual Harassment) What type of accident? (Select All That Apply) Automobile accident Slip and fall Medical Malpractice Toxic Exposure Dog Bite Defective Product Other Were you or your loved one injured in the accident? Yes No Was the accident reported to a supervisor at work? Yes No Do you or your loved one need medical attention for the injury? Yes No Did the accident happen in the past year? Yes No Were you or your loved one injured in the accident? Yes No Was the accident you or your loved one’s fault? Yes No Do you or your loved one need medical attention as a result of the accident? Yes No Did the accident happen in the past two years? Yes No What type of employment dispute? Wage and hour Wrongful termination Sexual harassment Other Date employment started MM slash DD slash YYYY Date of termination MM slash DD slash YYYY Job Title Salary or Hourly Wage? Salary Hourly Annual Salary Pay Rate per Hour How many hours per week did you work? How many 30 min meal breaks and 10 min rest breaks did you receive per day? Reason given for terminationReason you think you were illegally firedWas the harasser a supervisor? Yes No Have you been fired as a result of your harassment? Yes No Please provide details as to who you reported your sexual harassment to and what was their response?Other information regarding the casePlease explain your employment dispute in detail
