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UK Freephone: 0800 298 4 298
International: 0044 1442 430900
Quality without compromise  
Personal Injury  

YOUR DETAILS
Title
Forename
Surname
   
Telephone Number
Mobile Number
Email Address
Address
   

Please complete the following details relevant to your enquiry:

Do you have legal expense insurance?
(This may form part of your (or your spouse's) car or home contents policy, please contact the insurance company to obtain a claim form.)

EMPLOYER'S DETAILS
(i.e., registered office) NB. Director's details if your employer is not a limited company or PLC

Name (in full):
   
Address

 

Telephone
Fax
   
Place of work:
Postcode

 

EMPLOYMENT DETAILS

First day at work: Last day at work:
Breaks in employment: Length of Breaks: Number of Breaks:
Dismissed: Notice Given: Written:
Right of Appeal: Appeal Exercised: Outcome same:
Resigned: Notice Given: Written:
Did you make a complaint about anything prior to dismissal/resignation?
If Yes what was the complaint?

CONTRACT DETAILS

Written Contract: Document available at meeting:
Employee Handbook: Document available at meeting:
Miscellaneous documents e.g., changes in contractual terms:
Job Title:
Job Duties:
Hours Worked:
Holidays: Taken:
Notice Period: Worked:
Salary Pay slips available:
Benefits:
  Car: Pension: Type:
PHI: Healthcare: Share Options:
Death in Service: Life assurance:    
Bonuses: Commission:    

QUESTIONS
Did you complain about not receiving written particulars of employment? When?
Did you complain about not receiving wages? When?
Did you complain about not receiving pay slip? When?
Did you complain about health and safety? When?
Did you complain about change in terms? When?
Are you a health and safety representative?  
Are you a trade union representative?
Are you an elected employee representative?
Are you a pension scheme trustee?
Has there been a change of employer? When?
 
POST TERMINATION
Outstanding pay and benefits: Amount:
Earnings from new employment: Salary:
Loss of benefits:
State benefits claimed i.e.; Job Seekers Allowance or Incapacity benefit Type: Amount per
week:

YOUR OBJECTIVE IS TO OBTAIN
Notice Pay :  
Compensation:
Reinstatement:
Re-engagement:
Will you settle any claim that is made?

SEX/RACE/DISABILITY DISCRIMINATION
Reasons:
Did you complain?  
To whom ?
Date of complaint(s):
Requirement/condition/provision/
practice/criterion:

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