• Tell us about your case as best you can by providing answers to the
  questions below.

1

Title

2

First name(s)

3

Surname

4

Date of birth

5

Email address

6

Telephone number

7

What is the name of your employer/former employer?

8

Date of commencement of employment

9

Date of termination of employment (unless continuing)

10

Salary

11

Benefits (please list)

12

Did you resign or did your employer terminate your contract of
employment?

ResignEmployer Terminated

13

What was the reason given?

14

Did you appeal?

YesNo

15

What do you say about the circumstances in which your employment ended?

16

Were you subjected to any disciplinary action?

YesNo

17

Describe the allegations against you

18

What do you say about the allegations?

19

Have you attended a disciplinary hearing?

YesNo

20

If yes, what was the outcome?

21

Do you have any earlier disciplinary warnings on your record?

YesNo

22

If so, on what dates were they issued and what for (identify all)?

23

Have you since got another job?

YesNo

24

When did you start the job?

25

How much do you earn?

26

Are you owed any money by your employer?

YesNo

27

What are you owed the money for

[e.g. wages, commission, expenses etc.]

[If so, answer questions 28 and 29 below]

28

How much are you owed?

£

29

Describe here any additional complaints

you have against your employer

30

Have you submitted a grievance to your employer?

YesNo

31

Describe the outcome

[If necessary, put “No outcome yet”

if, for example, you are awaiting a grievance meeting]

32

Have you commenced any tribunal action in relation to the above?

YesNo

33

If so, on what date did you file your claim?

34

Describe the stage that the proceedings have reached

(specify the final hearing date if you have been notified of one)

35

Do you have legal expenses insurance as part of your

insurance policy that you have (e.g. home buildings or contents
policies).

YesNo