Do you have a case?Step 1 of 250%What 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 OtherWere you or your loved one injured in the accident?YesNoWas the accident reported to a supervisor at work?YesNoDo you or your loved one need medical attention for the injury?YesNoDid the accident happen in the past year?YesNoWere you or your loved one injured in the accident?YesNoWas the accident you or your loved one’s fault?YesNoDo you or your loved one need medical attention as a result of the accident?YesNoDid the accident happen in the past two years?YesNoWhat type of employment dispute?Wage and hourWrongful terminationSexual harassmentOtherDate employment started Date Format: MM slash DD slash YYYY Date of termination Date Format: MM slash DD slash YYYY Job TitleSalary or Hourly Wage?SalaryHourlyAnnual SalaryPay Rate per HourHow 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?YesNoHave you been fired as a result of your harassment?YesNoPlease 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 detailYour InformationPlease fill out the information below so that we may reach you.Name* First Last Email Phone*
