Contact Form – Pospis Law, PLLC

You may use the below form to tell us about your case, so that we have an opportunity to determine whether we might be able to assist you. Using this form does not create an attorney-client relationship between you and the firm, or obligate the firm to represent you. We only represent persons who live and/or work in New York City.

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Method and Time of Contact

Are you now, or have you ever been, represented by another attorney in connection with this matter? *

Attorney name

Reason(s) you are no longer represented, or wish to no longer be represented, by this attorney *

How did you hear about us?

Internet / Google Search
TikTok
Facebook / Instagram
Advertisement
Referral by attorney
Referral by friend, relative, colleague, etc.
Other

If you were referred by a friend/relative/colleague who is also an attorney, please select "Referral by Attorney"

What advertisement?

Attorney name

Person's name

Other referral source

Case Type *

Employment Discrimination / Harassment
Personal Injury
Public Accommodation Discrimination
Housing Discrimination
Other

Public Accommodation Discrimination

Location of Incident *

Date of Incident (if multiple, the most recent) *

Housing Discrimination

Name and location of housing owner, lessor/landlord *

Date of Incident (if multiple, the most recent) *

Type of Housing Discrimination *

Failure to lease to you
Failure to sell to you
Eviction / Lease Termination
Harassment / Hostile Environment
Discriminatory advertisement
Other

Explain "Other"

Personal Injury

Personal Injury Case Type *

Motor Vehicle Accident
Injured on Someone's Property (Slip/Trip & Fall, etc.)
Dog Bite
Defective Product
Other

Other type of personal injury case *

Accident/Incident Details

Date of accident / incident *

Approximate time of accident / incident

Location of accident / incident *

Dog breed, if known

Product in question

Product manufacturer (if known)

Where/how did you obtain the product?

Weather Conditions at Time of Accident

Motor Vehicle Accident - I was a(n) *

Vehicle driver
Vehicle passenger
Motorcyclist
Bicyclist
Pedestrian
Other

Please explain *

Trip Origin

Trip Destination

Was this a "Hit and Run" Accident?

Vehicle 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) involved

Example: 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-end
Head-on
Sideswipe
T-bone
Pedestrian knockdown
Other

Did the police arrive at the accident scene? *

Is there a police report relating to this accident? *

Yes
No
I don't know

Do you have a copy of the police report? *

Was there a commercial vehicle involved in the accident? *

Yes
No
I don't know

Business Name, if known

This would likely be identified on the outside of the vehicle

Have You Filed a Claim for "No Fault" Benefits? *

Premises Liability (check all that apply) *

Trip on ground defect (cracked sidewalk etc.)
Trip on object
Slip on snow/ice
Slip on liquid or other substance
Stairway (interior)
Stairway (exterior)
Inadequate lighting
Object fell on me
Other

Object you tripped on, if known

Substance you slipped on, if known

Object that fell on you, if known

Did you give a statement regarding the accident? *

Do you have a copy of the statement? *

Describe the Accident - What Happened? *

Injuries/Treatment/Damages

Body Part(s) Injured in This Accident (check all that apply) *

Ankle
Arm
Back
Brain
Chest
Ear
Elbow
Eye
Face
Finger / Thumb
Foot
Hand - Right
Hand - Left
Head
Hip
Knee
Leg
Mouth
Nose
Spine - Cervical (Neck)
Spine - Thoracic
Spine - Lumbar
Shoulder
Toe
Tooth/Teeth
Wrist
Other

Other injured body part(s) *

Prior to this accident, had you injured any of the selected body parts? *

Injuries resulting from accident (check all that apply) *

Fracture
Amputation
Laceration / Cut / Scarring
Burn
Bruising
Crush
Electrocution
Herniated Disc
Bulging Disc
Disfigurement
Paralysis
Brain injury
Stitches
Other

Other Injury(ies) *

Fracture details (if known); check all that apply

Stable fracture
Open fracture
Compound fracture
Transverse fracture
Oblique fracture
Comminuted fracture
Spiral fracture
Linear fracture
Other

Specify other type of fracture

Were you taken in an ambulance from the accident scene?

Where did the ambulance take you?

Were you taken to an emergency room? *

Did you receive treatment at one or more medical facilities as a result of this accident? *

List all medical facilities where you received treatment for injuries relating to this accident *

Please provide the name and, if known, address of each facility

Treatment Resulting From Accident (check all that apply) *

Surgery
Physical Therapy
Chiropractic
Other

How many surgeries have you had in connection with the injuries sustained in this accident? *

Surgery details

For 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 Details

Please provide as much detail as you can, including dates and names of facilities/providers

Chiropractic Treatment Details

Please provide as much detail as you can, including dates and names of facilities/providers

Other treatment details *

Diagnostic tests performed (if any)

X-Ray
MRI
CT-Scan
Other

Other tests

Do you have copies of medical records relating to your treatment for injuries sustained in this accident?

Were you employed at the time of the accident?

Employment Information

Provide employer name, wages, and your job duties

Were you performing your job duties at the time of the accident?

Are you claiming lost wages as a result of this accident?

Did you incur any out-of-pocket expenses for your medical treatment?

Do you have health insurance?

Are there any medical liens by any medical provider relating to any treatment you received for injuries sustained in this accident? *

Yes
No
I don't know

Medical bills were paid by (check all that apply) *

Private insurance
Medicare
Medicaid
Myself, out-of-pocket
Other
I don't know

Please explain *

Out-Of-Pocket Expenses Incurred as a Result of the Accident

Tell us how your injuries resulting from this accident have affected you

Filings

Have You Made any Filings Relating to this Matter? *

Filings Relating to this Case (Personal Injury) *

None
Lawsuit in court
Workers' Compensation
Unemployment
Other

Lawsuit - Court & Index # *

Have you received Workers' Compensation benefits in connection with this accident? *

Yes
No
I don't know

Status of Workers' Compensation Claim *

Status of Unemployment Claim *

Employment Discrimination / Harassment

Employer

Employer Name *

Employer's formal name as identified on your paystub/paycheck, as well as any "doing business as" (d/b/a) name(s)

Employer Type *

Private
Government (Federal, State, New York City)

Thank you for your interest, but we will be unable to assist you, as this firm does not handle cases against governmental entities.

Employer size (if known)

1-4 employees
5-14 employees
15 or more employees

Employer's industry/business *

Example: restaurant, hotel, education, entertainment, publishing, legal, medical, etc.

Employment Timeline

Start 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? *

Why are you no longer employed by this employer? *

I was fired / terminated / laid off
I quit / resigned

What was your last date of employment? *

Why did you quit?

Did you provide your employer with a resignation letter? *

Employment Terms & Conditions

Your connection to / relationship with the employer *

Direct Employee
Intern
Prospective Employee
Contractor, subcontractor, vendor, consultant or other person providing services to employer
Employee of contractor, subcontractor, vendor, consultant or other person providing services to employer
Other

Please explain *

In-person or Remote *

Fully In-Person
Fully Remote
Hybrid (In-Person & Remote)

Hybrid - Please Explain *

Worksite Location *

Physical location(s) where you reported for work at any time during your employment. NOTE: We only represent persons whose employment is related to New York City.

Job Title *

If still employed, your current title; if no longer employed, your last-held title

Job Duties

Briefly summarize the nature of the work you do/did for this employer

Do/did you have an employment agreement/contract with this employer? *

Yes
No
I don't know

Wages / Hours

Method *

Salary
Hourly
Other

Please explain *

Amount *

Are there any weeks in which you worked more than 40 (forty) hours? *

For any week(s) in which you worked more than 40 (forty) hours, did your employer pay you an overtime premium? *

Yes
No
I don't know

Benefits (check all that apply)

Bonus
401(k)
Health insurance (medical, dental, vision, etc.)
Paid vacation
Other

Other benefits

Hours worked per week (approximate/average)

How did your employer treat you for tax purposes?

W2
1099
Other
I don't know

Performance

Did you receive performance reviews?

Were your performance reviews in writing?

Do you have copies of your performance reviews?

Describe performance reviews

Did your employer give you any promotions or pay raises?

Promotions/pay raises - details

Discrimination Allegations

Adverse/negative actions suffered (check all that apply) *

Harassment / Hostile Work Environment
Sexual Harassment
Termination
Demotion
Title change
Loss of benefits
Transfer / Reassignment
Discipline
Placement on a Performance Improvement Plan (PIP)
Excessive criticism
Unequal pay
Failure to hire
Failure to promote
Failure to accommodate disability
Failure to accommodate pregnancy
Failure to accommodate religion
Retaliation/punishment for complaining about discrimination/harassment
Retaliation/punishment for participating in a discrimination/harassment case
Retaliation/punishment for requesting medical leave
Retaliation/punishment for requesting leave under the Family and Medical Leave Act (FMLA)
Other

The harassment included: *

Jokes
Comments
Slurs
Physical Touching
Other

Location of harassment *

At workplace
Outside the workplace
Both at and outside the workplace

Date of last instance of harassment *

Who engaged in the harassment? *

Supervisor / Manager
Co-Worker
Co-Worker - Subordinate (someone who reports to you and/or whom you supervise)
Client / Customer
Other

Harassment summary/narrative *

Explain "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? *

Please 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? *

Yes
No
I don't know

Did your employer provide you with a termination letter (or other document explaining their reasons for terminating your employment)? *

Demotion - details

Describe/explain the circumstances of your demotion, including the date of the demotion; your position/pay before the demotion; and your position/pay after the demotion

Title change - details

Loss of benefits - details

Transfer / reassignment - details

Discipline - details

Criticism - details

Unequal pay - details

Position sought/applied for

Did the employer continue to seek applicants for this position?

Yes
No
I don't know

Did the employer fill the position?

Yes
No
I don't know

Your disability/medical condition

Your religion

Requested 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: *

Sex/Gender or Gender Identity
Race / Color / Ethnicity
Religion
National Origin
Age
Disability / Medical Condition
Pregnancy
Sexual Orientation
Arrest / Conviction Record
Marital Status
Military Status
Domestic Violence Victim Status
Complaint(s) about discrimination/harassment
Participation in a discrimination case (e.g., as a witness)
Other

I identify as

Male
Female

Please explain why you believe you were discriminated against or treated unfairly because of your sex/gender or gender identity *

Your race / color / ethnicity *

Please explain why you believe you were discriminated against or treated unfairly because of your race *

Your religion *

Please explain why you believe you were discriminated against or treated unfairly because of your religion *

Your national origin *

Please explain why you believe you were discriminated against or treated unfairly because of your national origin *

Your date of birth *

Please explain why you believe you were discriminated against or treated unfairly because of your age *

Your disability/medical condition *

Please explain why you believe you were discriminated against or treated unfairly because of your disability or medical condition *

Did you inform your employer that you were pregnant? *

Please explain why you believe you were discriminated against or treated unfairly because of your pregnancy *

Please explain why you believe you were discriminated against or treated unfairly because of your sexual orientation *

Please explain why you believe you were discriminated against or treated unfairly because of your arrest/conviction record *

Please explain why you believe you were discriminated against or treated unfairly because of your marital status *

Please explain why you believe you were discriminated against or treated unfairly because of your military status *

Please explain why you believe you were discriminated against or treated unfairly because of your domestic violence victim status *

Other basis for discrimination/unfair treatment *

Explain why you believe your employer has treated you unfairly.

Complaint(s) About Discrimination/Harassment

Does your employer have a procedure for complaining about discrimination or harassment? *

Yes
No
I don't know

Did you complain about discrimination/harassment? *

Did you submit your complaint(s) in writing? *

Do you have copy(ies) of your complaint(s)? *

Why didn't you use the complaint procedure? *

Complaint details *

For 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? *

Severance

Have you been offered a severance payment or provided with a severance agreement? *

Date on which you were given the agreement *

Have you accepted the severance? *

Deadline for accepting severance / signing severance agreement *

Damages

Are you claiming lost wages? *

Since leaving this job, have you obtained new employment? *

New employer name

New employment start date

New employment salary

Have you undergone any medical treatment (including counseling or therapy) as a result of the discrimination/harassment? *

Have you been prescribed or taken any medication as a result of the discrimination/harassment? *

Please explain how the discrimination/harassment has affected you *

Filings

Have You Made any Filings Relating to this Matter? *

Filings Relating to this Case (Employment) *

Unemployment
Lawsuit in court
EEOC - US Equal Employment Opportunity Commission
New York State Division of Human Rights
New York City Commission on Human Rights
Workers' Compensation
Other

Filings Relating to this Case (Public Accommodation Discrimination) *

None
Lawsuit in court
New York State Division of Human Rights
New York City Commission on Human Rights
Other

Has your employer challenged your unemployment claim?

Employer's reason(s) for challenging your unemployment claim

What is the status of your unemployment claim?

Include the date for a hearing, if any

Other filings *

Lawsuit - Court & Index #

EEOC - Date you filed EEOC charge

EEOC - Has the employer submitted a response or "position statement" to your EEOC charge?

EEOC - Have you submitted a rebuttal to the employer's position statement?

EEOC - Have you received a "Right to Sue" letter from the EEOC? *

EEOC - What is the date on the "Right to Sue" letter? *

NYSDHR - Has the employer submitted a response or "position statement" to your complaint?

NYSDHR - Have you submitted a rebuttal to the employer's position statement?

NYSDHR - Has the NYS Division of Human Rights Issued a Decision?

NYCCHR - Has the employer submitted a response or "position statement" to your complaint?

NYCCHR - Have you submitted a rebuttal to the employer's position statement?

NYCCHR - Has the NYC Commission on Human Rights Issued a Decision?

What was the NYCCHR's decision? *

Probable Cause
No Probable Cause
Administrative Closure
Other

Please explain *

Evidence

Evidence supporting your claims (check all that apply) *

Discriminatory jokes, comments, slurs, etc.
Worse treatment relative to persons outside your protected class(es)
Witness(es)
Emails
Text messages
Audio recording(s)
Photo(s)
Video(s)
Other

Witness(es) is/are

Currently employed by the employer
Formerly employed by the employer
Neither currently nor formerly employed by the employer (i.e., they never worked for the employer)

Witness Name(s)

What other evidence do you have?

Union

Are you a union member?

Union name

Have you submitted a union grievance in connection with this matter?

What is the status of your union grievance?

Documents

Documents in your possession relating to this case (check all that apply)

Offer letter
Pay stubs (or other confirmation if paid by direct deposit)
Company manual/handbook
Employment contract
Profit-sharing agreement
Commission agreement
Bonus plan
Performance reviews
Disciplinary documents (formal warnings, write-ups, Performance Improvement Plan (PIP), etc.)
Severance agreement
Union contract / Collective Bargaining Agreement (CBA)
Complaint(s) about discrimination/harassment
Litigation documents
Resignation letter
Termination letter

Briefly summarize your case *

By checking the below box, you understand and agree that using this form does not create an attorney-client or other contractual relationship *

I Agree

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