Name:*

Address:*

Postcode:*

Identity of employer and job title:*

We must have this information to establish any conflict of interest that may exist

When did you start your job

and how much are you paid?

Where do/did you work?:

(Exact post code please if possible)

When did your problem happen?:

(There is usually a time limit for bringing a claim)

Have you put in a Tribunal claim?:

(If yes, when was the claim lodged, at which Tribunal and do you have a hearing date?)

Do you have any legal expenses insurance?

This insurance could be with a mortgage, credit card, home contents insurance, car insurance etc.

Financing a case:

NB. If there is no legal expenses insurance cover, we will need to ask you for some money on account of costs. We need to assess your financial position and the complexity of the case before deciding on the hourly rate and we may be able to offer a concessionary rate in some circumstances.

Who referred you to Palmer Wade?

Finally, what actually happened to you?:

Please mark as appropriate if you feel able to.

Have you been treated badly because of:

Please say briefly below what has happened:

Before you send this form to us, click on the 'Print' button below to print a copy for your records. You will need to change your page setup to 'landscape' to fit the entire form on the page.

Palmer Wade is registered under the Data Protection Act, registration Z 5914678