Employment / Wage & Overtime Claims Questionnaire

The following questionnaire is requested for an initial evaluation of an Employment / Wage & Overtime claim. The submission of information is for review only. BWLG is not agreeing to accept your case by reviewing this questionnaire. BWLG is not your attorney unless and until a written Retainer Agreement is signed by both you and a member of the firm.

It takes time to review the material submitted and to reply. If you do not receive a response within 1 week, please accept the non-response as an indication we are unable to accept your case.

The information you provide to us is for the purposes of obtaining advice and therefore we consider the informtion subject to the attorney-client privilege, even prior to us agreeing to accept your case.

Contact Information:

Home Address

Dates on Which Your Employer Took Most Severe Adverse Employment Action Against You.

Reasons You Believe that Your Employer's Conduct was Unfair or Unlawful, Including Any Facts to Show the Unlawful Reason and That the Employer's Reasons are Not True.

What Damages Have You Suffered to Date?


Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.