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Web Questionnaire</font>

Web Questionnaire

(*Indicates Required Field)

CONTACT INFORMATION
Full Name*:
Email Address*:
Have confirmation of your email sent to you?
Address:
City:
State:
Zip-Code:
Home Phone: (Include Area Code)
Cell Phone: (Include Area Code)
Date of Birth:
Gender:
 
EMPLOYMENT INFORMATION
Employment Start Date:
Job Title (At Time of Leave of Absence):
Job Duties (At Time of Leave of Absence):
Shift Worked (At Time of Leave of Absence):
Hours Worked (At Time of Leave of Absence):
Hourly Wage (At Time of Leave of Absence):
 
INJURY
Injury Date (mm/dd/yy)
Leave of Absence Dates (mm/dd/yy)
What caused your injury?
Did your doctor release you to work?
If yes, when?
Did you try to return to work between 10/1/09 and 4/1/2010?
If yes, please describe when and what happened.
 
POTENTIAL DAMAGES
Have you already signed and returned the General Release
of All Claims (Severance Agreement)? 
If you had not been on disability at any time between
October 1, 2009 and April 1, 2010, how much additional
compensation would you have received? 
 
GENERAL INFORMATION

Additional information about your potential case:
Please use this area to include any additional information about your potential case not asked above.

NUMMI LAWSUIT
Tony Lawson
Lawson Law Offices
700 Edgewater Rd., Suite 255
Oakland, CA 94621
info@nummilawsuit.com
(510) 878-7818 (office)


All information submitted will be treated confidentially.
Submitting this information does NOT create an attorney-client relationship.
By telling us about your potential case, you acknowledge that
no attorney has agreed to represent you.
An attorney-client relationship with NUMMILawsuit.com
will only be created upon the signature of a
written agreement by the attorney and the client.


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