Employment Law Case Evaluation Form

Your Contact Information

* Indicates the field is required.

Name*

FirstLast

Address

Street AddressAddress Line 2CityStateZip Code

E-Mail Address*

Phone*

Information About Your Employer

Name of your employer*

Location (City)

Number of employees at the location

0 - 50
50 - 200
200+
Not Sure

Are you contacting us about a Discrimination, Harassment, Retaliation, FMLA, Wage & Hour, or related issue?

Yes
No

Are you contacting us about contract review or negotiation?

Yes
No

Are you contacting us because an Unemployment or Workers Compensation claim denial or appeal?

Yes
No

Discrimination, Harassment, Retaliation, FMLA, Wage & Hour, or Related Issue

Are you currently employed by the employer

Yes
No

Reason for leaving

Fired/Terminated
Quit

Quit/Termination Date

Job title or name of the position for which you applied

Start Date

Salary or Hourly Rate

Hours worked per week

Union Member

Yes
No

Reason you are contacting us

Have you filed a complaint with any of the following agencies: The Equal Employment Opportunity Commission (EEOC), Wisconsin Equal Rights Division (ERD), Department of Labor (DOL), Wisconsin Labor Standards (LS)?

Yes
No

Date Filed

Have you received a determination?

Yes
No

Date the determination was received

Determination result

Probable Cause (in your favor)
No Probable Cause (not in your favor)

Did you appeal the determination?

Yes
No

Determination appeal date

Did you sign any documents before your employment began?

Yes
No

Did you sign any documents once employment ended?

Yes
No

Have you worked with another attorney relating to this issue?

Yes
No

Have you ever filed for bankruptcy?

Yes
No

Bankruptcy Filing Date

Disposition

Briefly describe your situation

Contract Review Details

What type of contract review will this be?

Severance Agreement
Non-Compete Agreement
Pre-Employment Contract

Date you received the contract

Is the contract new (unsigned) or existing (signed)?

New (unsigned)
Existing (signed)

Unemployment Denial or Appeal Details

When was your Unemployment Claim denied?

Have you appealed the decision?

Yes
No

Do you have a hearing date?

Yes
No

When is the hearing date?

For Our Information

How did you hear about us?

Is there any other information you'd like to share with us before we contact you?

Submitting this form does not create or constitute an attorney-client relationship with Walcheske & Luzi, LLC. Any information submitted over the Internet is not guaranteed to be confidential. If you are communicating time-sensitive or confidential information, please contact our firm directly at 262-780-1953.

Comments

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