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Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *EmailAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNOTE: We only represent clients located in New York CityPreferred Method and Time of ContactAre you now, or have you ever been, represented by another attorney in connection with this matter? *YesNoAttorney nameReason(s) you are no longer represented, or wish to no longer be represented, by this attorney *How did you hear about us? Internet / Google SearchTikTokFacebook / InstagramAdvertisementReferral by attorneyReferral by friend, relative, colleague, etc.OtherIf you were referred by a friend/relative/colleague who is also an attorney, please select "Referral by Attorney"What advertisement? Attorney namePerson's nameOther referral sourceCase Type *Employment Discrimination / HarassmentPersonal InjuryPublic Accommodation DiscriminationHousing Discrimination OtherPublic Accommodation DiscriminationLocation of Incident *Date of Incident (if multiple, the most recent) *Housing DiscriminationName and location of housing owner, lessor/landlord *Date of Incident (if multiple, the most recent) *Type of Housing Discrimination *Failure to lease to youFailure to sell to youEviction / Lease TerminationHarassment / Hostile EnvironmentDiscriminatory advertisementOtherExplain "Other"Personal InjuryPersonal Injury Case Type *Motor Vehicle AccidentInjured on Someone's Property (Slip/Trip & Fall, etc.)Dog BiteDefective ProductOtherOther type of personal injury case *Accident/Incident DetailsDate of accident / incident *Approximate time of accident / incidentLocation of accident / incident *Dog breed, if knownProduct in questionProduct manufacturer (if known)Where/how did you obtain the product? Weather Conditions at Time of AccidentMotor Vehicle Accident - I was a(n) *Vehicle driverVehicle passengerMotorcyclistBicyclistPedestrianOtherYour role in the accident *Trip OriginTrip DestinationWas this a "Hit and Run" Accident?YesNoVehicle you were operating/traveling in Make, model, color, year, etc.Other involved vehicle(s) Make, model, color, year, etc.Names and roles of other person(s) involvedExample: 1. John Smith - driver of car that hit me, 2. Mary Jane - driver of car I was a passenger in, etc.Motor Vehicle Accident - What best describes the accident? *Rear-endHead-onSideswipeT-bonePedestrian knockdownOther Did the police arrive at the accident scene? *YesNoIs there a police report relating to this accident? *YesNoI don't knowDo you have a copy of the police report? *YesNoWas there a commercial vehicle involved in the accident? *YesNoI don't knowBusiness Name, if knownThis would likely be identified on the outside of the vehicleHave You Filed a Claim for "No Fault" Benefits? *YesNoPremises Liability (check all that apply) *Trip on ground defect (cracked sidewalk etc.)Trip on objectSlip on snow/iceSlip on liquid or other substanceStairway (interior)Stairway (exterior)Inadequate lightingObject fell on meOther Object you tripped on, if knownSubstance you slipped on, if knownObject that fell on you, if knownDid you give a statement regarding the accident? *YesNoDo you have a copy of the statement? *YesNoDescribe the Accident - What Happened? *Injuries/Treatment/DamagesBody Part(s) Injured in This Accident (check all that apply) *AnkleArmBackBrainChestEarElbowEyeFaceFinger / ThumbFootHand - RightHand - LeftHeadHipKneeLeg MouthNoseSpine - Cervical (Neck)Spine - ThoracicSpine - LumbarShoulderToeTooth/TeethWristOtherOther injured body part(s) *Prior to this accident, had you injured any of the selected body parts? *YesNoInjuries resulting from accident (check all that apply) *FractureAmputationLaceration / Cut / ScarringBurnBruisingCrush ElectrocutionHerniated DiscBulging DiscDisfigurementParalysisBrain injuryStitchesOtherOther Injury(ies) *Fracture details (if known); check all that applyStable fractureOpen fractureCompound fractureTransverse fractureOblique fractureComminuted fractureSpiral fractureLinear fractureOtherSpecify other type of fractureWere you taken in an ambulance from the accident scene? YesNoWhere did the ambulance take you?Were you taken to an emergency room? *YesNoDid you receive treatment at one or more medical facilities as a result of this accident? *YesNoList all medical facilities where you received treatment for injuries relating to this accident *Please provide the name and, if known, address of each facilityTreatment Resulting From Accident (check all that apply) *SurgeryPhysical TherapyChiropracticOtherHow many surgeries have you had in connection with the injuries sustained in this accident? *Surgery detailsFor each procedure, provide the date, location (e.g., hospital), body part(s) on which surgery was performed, and describe the procedure (e.g., Open Reduction Internal Fixation (ORIF), arthroscopic surgery, etc.).Physical Therapy DetailsPlease provide as much detail as you can, including dates and names of facilities/providersChiropractic Treatment DetailsPlease provide as much detail as you can, including dates and names of facilities/providersOther treatment details *Diagnostic tests performed (if any)X-RayMRICT-ScanOtherOther tests Do you have copies of medical records relating to your treatment for injuries sustained in this accident?YesNoWere you employed at the time of the accident?YesNoEmployment InformationProvide employer name, wages, and your job dutiesWere you performing your job duties at the time of the accident?YesNoAre you claiming lost wages as a result of this accident?YesNoDid you incur any out-of-pocket expenses for your medical treatment? YesNoDo you have health insurance?YesNoAre there any medical liens by any medical provider relating to any treatment you received for injuries sustained in this accident? *YesNoI don't knowMedical bills were paid by (check all that apply) *Private insuranceMedicareMedicaidMyself, out-of-pocketOtherI don't knowPlease explain *Out-Of-Pocket Expenses Incurred as a Result of the AccidentTell us how your injuries resulting from this accident have affected youFilingsFilings Relating to this Case (Personal Injury) *NoneLawsuit in courtWorkers' CompensationUnemploymentOther Lawsuit - Court & Index #Have you received Workers' Compensation benefits in connection with this accident? *YesNoI don't knowStatus of Workers' Compensation Claim *Status of Unemployment ClaimEmployment Discrimination / HarassmentEmployer Name of Employer in Question *Please provide the employer's formal name as identified on your paystub/paycheck, as well as any "doing business as" (d/b/a) name(s)Employer Type *PrivateGovernment - FederalGovernment - StateGovernment - New York CityEmployer size (if known)1-4 employees5-14 employees15 or more employeesEmployer's industry/businessExample: restaurant, hotel, education, entertainment, publishing, legal, medical, etc.Employment TimelineStart date *Please be as specific as possible. If you do not know the exact date, please approximate as best as you can (e.g., "about three years ago", "last summer", "January 2019", etc.).Are you still employed by this employer? *YesNoWhy are you no longer employed by this employer? *I was fired / terminated / laid offI quit / resignedWhat was your last date of employment? *Why did you quit?Did you provide your employer with a resignation letter? *YesNoEmployment Terms & ConditionsYour connection to / relationship with the employer *Direct EmployeeInternProspective EmployeeContractor, subcontractor, vendor, consultant or other person providing services to employerEmployee of contractor, subcontractor, vendor, consultant or other person providing services to employerOtherRelationship *Worksite Location *Physical location(s) where you reported for workJob Title *If still employed, your current title; if no longer employed, your last-held titleJob DutiesBriefly summarize the nature of the work you do/did for this employerDo/did you have an employment agreement/contract with this employer? *YesNoI don't knowWages / HoursMethodSalaryHourlyOtherPlease explain *Amount *Are there any weeks in which you worked more than 40 (forty) hours? *YesNoFor any week(s) in which you worked more than 40 (forty) hours, did your employer pay you an overtime premium? *YesNoI don't knowBenefits (check all that apply)Bonus401(k)Health insurance (medical, dental, vision, etc.) Paid vacationOtherOther benefitsHours worked per week (approximate/average)How did your employer treat you for tax purposes?W21099OtherI don't knowPerformanceDid you receive performance reviews? YesNoWere your performance reviews in writing?YesNoDo you have copies of your performance reviews? YesNoDescribe performance reviewsDid your employer give you any promotions or pay raises?YesNoPromotions/pay raises - detailsDiscrimination AllegationsAdverse/negative actions suffered (check all that apply) *Harassment / Hostile Work EnvironmentSexual HarassmentTerminationDemotionTitle changeLoss of benefitsTransfer / ReassignmentDisciplinePlacement on a Performance Improvement Plan (PIP)Excessive criticismUnequal payFailure to hireFailure to promoteFailure to accommodate disabilityFailure to accommodate pregnancyFailure to accommodate religionRetaliation/punishment for complaining about discrimination/harassment Retaliation/punishment for participating in a discrimination/harassment caseRetaliation/punishment for requesting medical leaveRetaliation/punishment for requesting leave under the Family and Medical Leave Act (FMLA)Other Harassment / Hostile Work Environment / Sexual Harassment Details *Please provide as many details as you can, including (for each instance of harassment): (1) WHEN it occurred, (2) WHAT comprised the harassment (comments, jokes, physical touching, etc.), (3) WHO did it, and (4) WHERE it occurred (at the workplace, outside the workplace at a work function, etc.)Status of the harasser(s) relative to youSupervisor / ManagerCo-WorkerCo-Worker - Subordinate (someone who reports to you and/or whom you supervise)Client / CustomerOtherExplain "other"Reason(s) given by employer for terminating your employment *Please provide the reason(s) given, regardless of whether you agree with it/them.Do you believe that one or more reason(s) given by your employer for terminating your employment are false/inaccurate? *YesNoPlease explain why you believe the reason(s) given by your employer for terminating your employment are false/inaccurate *Did your employer terminate any other employees when they terminated your employment? *YesNoI don't knowDid your employer provide you with a termination letter (or other document explaining their reasons for terminating your employment)? *YesNoDemotion - detailsDescribe/explain the circumstances of your demotion, including the date of the demotion; your position/pay before the demotion; and your position/pay after the demotionTitle change - detailsLoss of benefits - detailsTransfer / reassignment - detailsDiscipline - detailsCriticism - detailsUnequal pay - detailsPosition sought/applied forDid the employer continue to seek applicants for this position?YesNoI don't knowDid the employer fill the position? YesNoI don't knowYour disability/medical conditionYour religionRequested accommodation(s) *Please provide as much detail as possible, including what accommodation(s) you requested and when you requested it/them.Reason(s) given by your employer for denying your accommodation request *Other adverse action(s) *Date of the last negative/bad thing that happened to you in connection with this employer *What happened on that date? *You allege that the discrimination/unfair treatment was because of your (check all that apply) *Sex/Gender or Gender IdentityRace / Color / EthnicityReligionNational OriginAgeDisability / Medical ConditionPregnancySexual OrientationArrest / Conviction RecordMarital StatusMilitary StatusDomestic Violence Victim StatusComplaint about discrimination/harassmentParticipation in a discrimination case (e.g., as a witness)OtherI identify asMaleFemalePlease explain why you believe you were discriminated against or treated unfairly because of your sex/gender or gender identityYour race / color / ethnicityPlease explain why you believe you were discriminated against or treated unfairly because of your raceYour religionPlease explain why you believe you were discriminated against or treated unfairly because of your religionYour national originPlease explain why you believe you were discriminated against or treated unfairly because of your national originYour date of birth *Please explain why you believe you were discriminated against or treated unfairly because of your ageYour disability/medical conditionPlease explain why you believe you were discriminated against or treated unfairly because of your disability or medical conditionDid you inform your employer that you were pregnant?YesNoPlease explain why you believe you were discriminated against or treated unfairly because of your pregnancyPlease explain why you believe you were discriminated against or treated unfairly because of your sexual orientationPlease explain why you believe you were discriminated against or treated unfairly because of your arrest/conviction recordPlease explain why you believe you were discriminated against or treated unfairly because of your marital statusPlease explain why you believe you were discriminated against or treated unfairly because of your military statusPlease explain why you believe you were discriminated against or treated unfairly because of your domestic violence victim statusOther basis for discrimination/unfair treatment *Complaints About Discrimination/HarassmentDoes your employer have a procedure for complaining about discrimination or harassment?YesNoI don't knowDid you complain about discrimination/harassment? *YesNoDid you submit your complaint(s) in writing?YesNoDo you have copy(ies) of your complaint(s)?YesNoWhy didn't you use the complaint procedure?Complaint detailsFor each complaint of discrimination or harassment, provide: (1) the date, (2) the name(s) of the person(s) to whom you complained, and (3) the substance of the complaint.What happened after you complained about the discrimination/harassment?SeveranceHave you been offered a severance payment or provided with a severance agreement?YesNoDate on which you were given the agreementHave you accepted the severance? YesNoDeadline for accepting severance / signing severance agreementDamagesAre you claiming lost wages?YesNoSince leaving this job, have you obtained new employment? YesNoNew employer nameNew employment start dateNew employment salaryHave you undergone any medical treatment (including counseling or therapy) as a result of the discrimination/harassment?YesNoHave you been prescribed or taken any medication as a result of the discrimination/harassment? YesNoPlease explain how the discrimination/harassment has affected youFilings Filings Relating to this Case (Employment) *NoneUnemploymentLawsuit in courtEEOC - US Equal Employment Opportunity CommissionNew York State Division of Human RightsNew York City Commission on Human RightsWorkers' CompensationOther Filings Relating to this Case (Public Accommodation Discrimination) *NoneLawsuit in courtNew York State Division of Human RightsNew York City Commission on Human RightsOther Has your employer challenged your unemployment claim?YesNoEmployer's reason(s) for challenging your unemployment claimWhat is the status of your unemployment claim?Include the date for a hearing, if anyOther filings *Lawsuit - Court & Index #EEOC - Date you filed EEOC chargeEEOC - Has the employer submitted a response or "position statement" to your EEOC charge?YesNoEEOC - Have you submitted a rebuttal to the employer's position statement?YesNoEEOC - Have you received a "Right to Sue" letter from the EEOC? *YesNoEEOC - What is the date on the "Right to Sue" letter? *NYSDHR - Has the employer submitted a response or "position statement" to your complaint?YesNoNYSDHR - Have you submitted a rebuttal to the employer's position statement? YesNoNYSDHR - Has the NYS Division of Human Rights Issued a Decision?YesNoNYCCHR - Has the employer submitted a response or "position statement" to your complaint?YesNoNYCCHR - Have you submitted a rebuttal to the employer's position statement? YesNoNYCCHR - Has the NYC Commission on Human Rights Issued a Decision?YesNoWhat was the NYCCHR's decision? EvidenceEvidence supporting your claims (check all that apply) *Witness(es)EmailsText messagesAudio recording(s)PhotosVideoOther / To Be DiscussedYour witness(es) is/areCurrently employed by the employerFormerly employed by the employerNeither currently nor formerly employed by the employer (i.e., they never worked for the employer)Witness Name(s)What other evidence do you have?UnionAre you a union member?YesNoUnion nameHave you submitted a union grievance in connection with this matter?YesNoWhat is the status of your union grievance?DocumentsDocuments in your possession relating to this case (check all that apply)Offer letterPay stubs (or other confirmation if paid by direct deposit)Company manual/handbookEmployment contractProfit-sharing agreementCommission agreementBonus planPerformance reviewsDisciplinary documents (formal warnings, write-ups, Performance Improvement Plan (PIP), etc.)Severance agreementUnion contract / Collective Bargaining Agreement (CBA)Complaint(s) about discrimination/harassmentLitigation documentsResignation letterTermination letterBriefly summarize your case *By checking the below box, you understand and agree that (1) using this form does not create an attorney-client or other contractual relationship, (2) the information provided is true and accurate, and (3) you are using this form for the sole purpose of seeking legal representation. *I AgreeWebsiteSubmit Share This:
