This is a voluntary questionnaire designed to help us better evaluate your potential claim. You are not required to complete this questionnaire. If you prefer, you can call us Monday through Friday 9:00 AM to 5:00 PM

1) Please provide some information about yourself:


2) If you believe you were wrongfully terminated, please answer the following:

What do you believe are the real reasons for your termination? The following are examples of some prohibited reasons for an employee’s termination:
  • Discrimination: If you believe you were terminated for a discriminatory reason, please answer the following:
  • Filing a Workers Compensation Claim: If you believe you were fired because you sustained an on-the-job injury and/or filed for workers compensation, please answer the following:
  • Whistleblowing (i.e., reporting a safety hazard or violation by your employer): If you believe you were terminated because you reported a safety concern or potential criminal act by your employer, please answer the following:
  • Other:

3) If you have been harassed on the job, please answer the following:


4) If there is a dispute involving a non-compete or confidentiality agreement, please briefly describe the dispute:


5) If you have another employment-related concern, please briefly describe it here:


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