*Are your potential legal claims against anyone else? Select Yes No
*What is the name of the organization that engaged in wrongdoing?
*How many people are employed by this organization? Select 1 - 9 employees 10 - 19 employees 20 - 49 employees 50 - 99 employees 100 - 249 employees 250 - 499 employees 500 - 1,000 employees Over 1,000 employees
*Do you currently work for this employer? Select Yes No
*When did you start working for this organization?
*Where do you work for this organization?
*What is your position at this organization?
*What did you earn working for this organization last year? Select Under $50,000 $50,000 - $69,999 $70,000 - $84,999 $85,000 - $99,999 $100,000 - $149,999 $150,000 - $199,999 $200,000 - $299,999 $300,000 - $499,999 $500,000 - $1,000,000 Over $1,000,000 I prefer to disclose at a later time
Do you participate in this organization’s 401(k) or pension plan? Select Yes No
*Are you aware of any other employees who have the same or similar potential legal claims? Select Yes No
How many other individuals have the same or similar potential legal claims?
Are the individual(s) who have the same or similar potential legal claims interested in taking legal action against this organization? Select Yes No I don't know
Would you be able to contact the individual(s) who have the same or similar potential legal claims? Select Yes No
*Have you reported the wrongdoing to anyone at this organization? Select Yes No
*Have you received any legal advice or legal representation regarding your potential legal claims? Select Yes No
*Have you taken any legal action (e.g., sending a demand letter or filing a lawsuit) against this organization and any other wrongdoers in connection with your potential legal claims? Select Yes No
*Have you signed any agreement (e.g., arbitration agreement or settlement agreement) related to your potential legal claims? Select Yes No
*What was your position at this organization?
*What did you earn in your last year working for this organization? Select Under $50,000 $50,000 - $69,999 $70,000 - $84,999 $85,000 - $99,999 $100,000 - $149,999 $150,000 - $199,999 $200,000 - $299,999 $300,000 - $499,999 $500,000 - $1,000,000 Over $1,000,000 I prefer to disclose at a later time
Did you participate in this organization’s 401(k) or pension plan? Select Yes No
*When did your employment start and end at this organization?
*Since your employment ended at this organization, have you worked for any other organizations? Select Yes No
*Did you report the wrongdoing to anyone at this organization? Select Yes No
*Are you aware of any other employees who have the same or similar potential legal claims? Select Yes No
How many other individuals have the same or similar potential legal claims?
Are the individual(s) who have the same or similar potential legal claims interested in taking legal action against your former employer? Select Yes No I don't know
Would you be able to contact the individual(s) who have the same or similar potential legal claims? Select Yes No
*Have you received any legal advice or legal representation regarding your potential legal claims? Select Yes No
*Have you taken any legal action (e.g., sending a demand letter or filing a lawsuit) against your former employer and any wrongdoer in connection with your potential legal claims? Select Yes No
*Have you signed any agreement (e.g., arbitration agreement or settlement agreement) related to your potential legal claims? Select Yes No
*Who are your potential legal claims being brought against?
*What is your relationship to the wrongdoer(s)?
*Are you aware of any other people who have the same or similar potential legal claims? Select Yes No
How many other individuals have the same or similar potential legal claims?
Are the individual(s) who have the same or similar potential legal claims interested in taking legal action against the wrongdoer(s)? Select Yes No I don't know
Would you be able to contact the individual(s) who have the same or similar potential legal claims? Select Yes No
*Have you received any legal advice or legal representation regarding your potential legal claims? Select Yes No
*Have you taken any legal action (e.g., sending a demand letter or filing a lawsuit) against the wrongdoer(s) in connection with your potential legal claims? Select Yes No
*Have you signed any agreement (e.g., arbitration agreement or settlement agreement) related to your potential legal claims? Select Yes No
