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    Untitled Document

    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
    Gross £ per (month,week, etc)
    Net £ per (month,week, etc)
    11 Benefits (please list)
    12 Do you consider that you have been
    discriminated against by reason of your
    sex, race, age or disability or other reason
    13 What is your characteristic which you
    consider has given rise to this discrimination?
    [e.g. sex – female, race – black African, age – in my 60s,
    disability – multiple sclerosis etc.]
    14 Describe in full what you consider to have constituted discrimination?
    15 Are you owed any money by your employer?
      [If so answer questions 16 and 17 below]
    16 What are you owed the money for
    [e.g. wages, commission, expenses etc.]
    17 How much are you owed? £
    18 Describe here any additional complaints
    you have against your employer
    19 Have you submitted a grievance to your employer?
    20 Describe the outcome
    [If necessary, put “No outcome yet”
    if, for example, you are awaiting a grievance meeting]
    21 Have you commenced any tribunal action in relation to the above?
    22 If so, on what date did you file your claim?
    23 Describe the stage that the proceedings have reached
    (specify the final hearing date if you have been notified of one)
    24 Do you have legal expenses insurance as part of your
    insurance policy that you have (e.g. home buildings or contents policies).