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Step 1 of 4

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Personal Details
1. Title (Mr, Mrs, Miss, Ms, Other)*
2. First Name (or names)*
3. Surname (or names)*
4. Gender (male or female)
- Male
- Female
5. Address: house number or name
Street
Town/City
Country
Postcode
6. Phone number (including area code)*
7. Mobile number*
8. Email address*
Details of organisation you are claiming against
9. Name of your employer/ organisation*
10. Address: Name or Number
Street
Town/City
Country
Postcode
11. Phone number
Note: if there is more than one organisation then please provide their details (same as above) on a separate sheet of paper.
12. Job Title

13. Have you been dismissed from your employment?
- Yes
- No (selecting 'No' skips the next 3 questions)
Dismissal
14. When were you dismissed from your employment?*
(There is a three month time limit to bring the claim. However, in limited circumstances the Employment Tribunal may set this time limit aside.)
15. What was your salary at the time of dismissal (including bonuses and any commission) per month and per annum?*
16. Please also state what benefits were you in receipt of at the time of your dismissal (e.g. pension, medical insurance, company car, season ticket loan etc) and any values where known.
Any other acts
17. When did the acts you wish to complain about occur?
(There is a three month time limit to bring the claim. However, in limited circumstances the Employment Tribunal may set this time limit aside.)
18. Have you suffered any other act during your employment?
- Yes
- No (selecting 'No' skips the next next question)
19. How long have you been employed for?*
20. What compensation do you believe you are entitled to?*
21. Do you have funds to pay fees? If so, what level of fees can you afford to pay? (this will allow us to obtain the best lawyer in your fee bracket)*
22. Have you already issued an Employment Tribunal application (ET1)? If so
(a) When did you issue it? Please send us a copy
(b) Has a defence (ET3) been sent to you? If so, please send us a copy
- Yes
- No
(c) Have any Orders been made by the Tribunal? If so, please send us a copy
- Yes
- No
(d) Has a hearing date been listed?
- Yes
- No
If so please tell us the date of the hearing
Employment Appeal Tribunal
23. Are you appealing the decision of the Employment Tribunal? If so, please provide us with a copy of the original decision
- Yes
- No

Employment details
24. Date you started your employment
25. Is your employment continuing?
- Yes
- No
If ‘Yes’ then when will it stop?
If ‘No’ then on which date did you stop working?
26. Were you the subject of disciplinary proceeding/s?
- Yes
- No
If yes, please briefly describe what happened
27. Were you given a warning, whether oral or written?
- Yes
- No
28. Did your employer complete the grievance process in accordance with your handbook/contract of employment?
- Yes
- No
If no, please provide details of what steps or stages were not completed
If yes, on which date were you given this warning? (Please provide us with a copy)
Upload attachments here
Don't worry if you're unable to send attachments right now - we'll request anything we need when we next talk/email.
29. On what date did your of contract of employment end?*
30. Were you given notice?
- Yes
- No
31. Were you paid for the notice period?
- Yes
- No
32. Have you received any other payment from your former employer? If yes, please give details
33. How many hours on average do you or did you work each week?
34. How much do you or did you get paid before tax each week?
35. Since leaving your employment have you got another job?
- Yes
- No
If yes, then have you started this job? Please provide the date on which you started this job.
If you have not started this new job then when will you start this new job?
How much do you or will you get paid in this new job before tax? (weekly/monthly/yearly)
Please list any benefits of this new job
36. Are you a member of a Trade Union?
- Yes
- No
If yes, please give details.

Dismissal
37. Do you believe that your employer was wrong to dismiss you?
- Yes - Please set out details in point 46 below.
- No
38. Do you believe that you had no alternative but to resign?
- Yes
- No
Discrimination
39. Do you believe that you have been dismissed because of your age, race, sex, religion/belief, disability or sexual orientation?
- Yes
- No
40. Do you believe that you have been paid less than your colleague because of your age, race, sex, religion/belief, disability or sexual orientation?
- Yes - Please set out details in point 46 below.
- No
41. Do you believe that you have been treated unfairly or less favourably than a colleague because of your age, race, sex, religion/belief, disability or sexual orientation?
- Yes
- No
42. Do you believe that there has been a failure to make or consider reasonable adjustments to accommodate your disability?
- Yes
- No
43. Do you believe that you have been victimised by your employer?
- Yes
- No
44. Does your claim relate to ‘whistleblowing’ (protected disclosure)?
- Yes
- No
Your Claim
45. Are you claiming (redundancy pay, notice pay, holiday pay, arrears of pay, other payments)? (if all then please state this)*
46. Please provide us with details of your claim and of event/s you are complaining about (include dates and times where known) below*
47. What compensation or remedy you are seeking? (for example financial or re-instatement) (optional)*
48. Do you have insurance to cover the costs of your claim?*
(Please check your home insurance policy for legal expenses insurance for Employment matters)
- Yes
- No
49. Do you suffer from any disability?
- Yes
- No
If Yes, what can we do to assist you in this process e.g. send documents with plenty of time to read/respond, use larger fonts, correspond in writing rather than by telephone
50. Are you receiving any state benefits?
- Yes
- No
If Yes, then please provide details and the amount which you are receiving (weekly/monthly/yearly)
Please can you also ensure that you have copies of the following documents which we may need:
1. Employee Handbook/Contract of Employment
2. Any letter of Grievance/copies of documents used in any grievance procedure
3. Letter of severance
Email address you would like us to respond to*

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Copyright © 2011 - 2015 Damian McCarthy. All rights reserved.

I am a Senior Advocate (England and Wales) at Nationwide Employment Lawyers(www.natemplaw.co.uk) and not a barrister in independent practice. This means I can offer a superior level of service to clients. Nationwide Employment Lawyers Ltd is regulated by the Claims Management Regulator in respect of regulated claims management activities (CRM number: 40221). For peace of mind you can find information about our authorisation by checking the authoritative public register at www.claimsregulation.gov.uk. Nationwide Employment Lawyers Ltd is not a firm of solicitors - instead it offers an exceptional level of service using specialist employment law solicitors, barristers and a Senior Advocate. Please contact me using either the questionnaire, quick contact form above or on 020 8263 6080.

Nationwide Employment Lawyers is regulated by the Claims Management Regulator in respect of regulated claims management activities.

We want to be completely clear and open with you - so have set out below examples of the type of paperwork we use. These documents will help you understand your rights and how we will work on your behalf. These documents will be slightly amended in each case so that you have your own individualised "client care" documents.

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