Contingency Fee Agreement Questionnaire

Have you been unfairly dismissed or the victim of discrimination in the work place?

The Employee Service may be able to help. They offer a contingency fee scheme which could make it affordable for you to make a claim in the Employment Tribunal to secure compensation.

It’s quick and easy to see if you could be eligible for legal assistance under this agreement.

Just complete the form below and the Employee Service will email you back to let them know whether they could help you get the compensation you deserve.

Your Details

Full name:*

Address:*

Email:*

Contact Telephone Number: *

Date of Birth *

Name of Employer:*

Have you been dismissed?:*Yes No

If you have been dismissed, what was the date of termination?:

When did you start working for your employer?:*

What was your weekly take home pay?:*

Have you secured alternative employment?:

When did any alternative employment commence?:

What is your annual take home pay in your new job, (if you have secured one)?:

How long was your notice period?:*

Were you paid for that notice period?:*

Does your employer owe you any salary or benefits?:*

Did you have any outstanding holiday pay?:*

Were you in the employer’s pension scheme?:*

Did you receive any additional benefits (For example, life insurance, company car, gym membership)?:*

Do you believe you have been discriminated against?:*Yes No

If yes, on what grounds?

Do you have legal expenses insurance on any home or motor insurance policies?:*Yes No

If there is any additional information which may assist the Employee Service to assess your claim, please type it in the box.

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