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.

Nature of 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.

Nature of Wage Claims:








Rate of pay

Did You Have an Oral or Written Employment Contract?
)
Where You told that You Would Only be Terminated for Just or Good Cause?

Did You Sign an Arbitration Agreement?

Are you Employed Pursuant to a Union Contract (CBA)?

Was There an Employee Handbook?


What Damages Have You Suffered to Date?

Lost Wages:

$
Benefits (E.g., Bonus, Commissions, Health, Dental, Retirement, Etc.):


Other (Including Emotional Distress, Depression, Anxiety, Insomnia, Crying, Weight Change, Libido). If You Have Received Medical of Psychological Treatment, Please Identify The Types of Doctors, Medication and Treatment:


If Unemployed, Please Provide an Estimate of Future Unemployment?


If You Have New Employment, Please State Your New Compensation and Benefits?


Unpaid Wages


(E.g., Preparation Before Shift Starts, Wrapping up After Shift Ends, Working Through Lunch, Off the Clock Work, Off The Clock meetings, Off the Clock Trips)
Amount of Unpaid Overtime


(E.g., Work Over 8 Hours in One Day, or 40 Hours in One Week, or Double Time after 12 hours in One Day)
Number of Missed 10 Minute Breaks (One Break in the Middle of Every 4 Hours of Work)


Number of Missed, Late or Short Meal Periods


(E.g., Late Meal Periods [after 5 hours of work], Meal Periods of Less Than 1/2 Hour, and the Failure to Provide 2nd Meal Periods for Work Shifts Over 10 Hours or 12 Hours)
Were You Paid an Extra Hour of Compensation for Missed Breaks or Meal Periods?

Have You Filed Any Complaint with a Federal or State Agency or Court Concerning Your Employment or Termination (Including EDD, DFEH, EEOC & State Court, etc.)?

 

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.

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