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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.

Full Name: (Required) Home AddressStreet Address 1: Street Address 2: City: State: ZIP: Email: (Required) Phone Numbers - Daytime and Evening: (Required) Employer's Name: Number of Employees: Job Title/ Description of Duties: Date of Hire: (mm/dd/yyyy) Dates on Which Your Employer Took Most Severe Adverse Employment Action Against You.Date Conduct Began: (mm/dd/yyyy) Last Date of Conduct: (mm/dd/yyyy) Reasons Given By Your Employer for Advers Action(s): Reasons You Believe that Your Employer's Conduct was Unfair or Unlawful, Including Any Facts to ShowPlease describe the "Who, What, When, Where, Why and How" of the Incidents: Do You Fall Under a Protected Category? If yes, describe what and why.

Example: Age; Race; Religion; Marital Status; National Origin; Sex; Sexual Orientation; Pregnancy; Genetic Status; Disability; Taking Medical Leave; Making Complaints About Wages, Discrimination, Harassment, Working Conditions, Health/Safety Issues, Corporate Fraud, Etc.; Filing A Workers’ Compensation Claim; Performing Jury Duty; Taking Time Off After Sexual Assault/Rape; Engaging In Personal Activities Outside Of Work; Getting Together With Other Employees To Discuss Working Conditions, Etc.

Nature of Wage Claims:

Overtime Failure to Provide Rest Breaks Failure to Provide Meal Breaks Periods Failure to Pay Exempt Employee a Bona Fide Salary Failure to Calcluate Pay Correctly Failure to Pay Daily Overtime or Double Time Unpaid Vacation se It or Loose It Vacation Policy Other

Please Explain Why You Believe that Your Employer Has Not Paid You Properly: Please describe the "Who, What, When, Where, Why and How" of the Incidents:

Rate of pay

Per Hour Per Year

Number of Hours Worked Normally Per Week Classification: Did You Ever Protest The Unfair or Unlawful Conduct? If so, please describe the "Who, What, When, Where, Why and How" of the Complaints Was Any Action Taken in Response to Your Complaints? If so, please describe. Were You Ever Suspended/Terminated By This Employer for Violating Company Policy or In Relation To Some Kind of Discipline? Is, Please Explain. Please Identify Any Documents you feel may assist us in understanding and evaluating your case.

(such as Employee Handbook, Employee Policies, Performance Reviews, Offer letters of employment; Documents regarding any promotion, discipline, demotion, termination, or any complaint made by you or others; Emails and other correspondence; Notes and calendar; EDD and/or unemployment documents; Notices from your employer (i.e. wage rates, policy changes); Administrative complaints (i.e., Department of Fair Employment and Housing (DFEH), Equal Employment Opportunity Commission (EEOC), Department of Labor (DOL), Department of Labor Standards Enforcement (DLSE)); Communications regarding complaints, requests for leave, requests for accommodation made to employer; Check Stubs; Time Clock Records;Time cards and punch details; Collective bargaining agreements; Employment Contracts).

Please Identify any Witnesses Regarding the Conduct or Actions About Which You are Complaining, as well as What They Witnessed:

Did You Have an Oral or Written Employment Contract?

Yes No (Contract)

Where You told that You Would Only be Terminated for Just or Good Cause?

Yes No (Told for Cause)

Did You Sign an Arbitration Agreement?

Yes No (Arbitration)

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

Yes No (CBA)

Was There an Employee Handbook?

Yes No (Employee Handbook)

Date of Birth: (mm/dd/yyyy) What Damages Have You Suffered to Date?

Lost Wages:

Yes No

$ a Month for Months

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

Yes No

Benefits

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:

Yes No

Other

If Unemployed, Please Provide an Estimate of Future Unemployment?

Yes No

Unemployed

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

Yes No

New Employment

Unpaid Wages

Yes No

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

Yes No

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)

Yes No

Number of Missed 10 Minute Breaks

Number of Missed, Late or Short Meal Periods

Yes No

Number of Missed

(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?

Yes No

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.)?

Yes No

If You Have, Please State to Which Agency or Courts?: When did you file?: (mm/dd/yyyy) Have You Received any Right to Sue Letter, Award or Ruling? When Did You Receive the Award, Ruling or Right to Sue Notice?: (mm/dd/yyyy) How did you hear about our firm?

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.

Client Reviews

Our firm has engaged Blady Workforce Law Group over the past several years for a variety of corporate issues. We always encountered a high level of professionalism along with an excellent outcome. We were informed throughout the process so that we were able to make the best decision. Our...

S. D.

Dear Ben, Thank you for the hard work, determination, and professionalism that you demonstrated throughout this process. As I indicated, I knew I was in good hands from the beginning.

J.T.

I would like to thank you for the wonderful job you did with my case. You are a brilliant attorney. Take care and God bless you.

R.C.

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Employment / Wage & Overtime Claims Questionnaire

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