Employment - Lawsuit Questionnaire

Name(Required)

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Introduction

We are preparing to file your lawsuit in District Court. Once we file the lawsuit, we will begin the process of exchanging information with the defense through a process called discovery. To be prepared to provide the information that we will be required to provide according to the court rules governing discovery, we need you to answer the following questions as completely as you can.

I. FINANCIAL HARM

Please provide a list of all employers you have had in the last ten years to present:(Required)

We will be required to provide a complete employment history for you. If you do not recall specifics, please provide estimates or approximate information. We understand you may have some information on a resume. However, any information that is not included on your resume, we will need you to input here.

Name of employer:

Address:

Position:

Dates of employment:

Approximate annual earnings:

Reason employment ended:

Please provide a list of all places where you have applied for work since your employer's wrongdoing occurred:(Required)

We will be required to provide a list of all places where you have sought employment since your employer committed the wrongdoing. When indicating the outcome of the application, please specify, for example, “offer received and accepted”; “interviewed but no offer”, “no interview”, etc. If you have kept this information in a separate document, please type, “See attachment” and send us the list you already have saved elsewhere.

Name of employer:

Address:

Position applied for:

Salary or wages for position (if known):

Outcome of application:

Please describe the financial losses you believe you have suffered because of your employer's conduct. Include any specific amounts, if appropriate.(Required)

Please list all other sources of income you have had since your job ended or since the adverse employment action occurred:(Required)

For example, please list the following types of income: Unemployment; Social Security Retirement or Disability; Short-Term Disability; Long-Term Disability; Workers’ Compensation; and other similar types of income.

Source of Income:

Amount Received (please indicate weekly v. monthly v. annually):

II. EMOTIONAL DISTRESS

Please list all locations where you have sought medical treatment for the last ten (10) years.(Required)

We are alleging that you are owed compensation for the emotional distress that your employer has caused. Because an emotional distress claim is part of your case, the discovery rules require us to provide a list of your healthcare providers, including both physical and mental health providers. In the “Why do you see this provider” box, please briefly indicate the nature of your treatment, e.g. “family doctor”, “surgeon for back”, “counseling” etc.

Provider Name (if known)

Clinic/Facility Name

Clinic/Facility Address

When did you first seek treatment here?

When did you most recently seek treatment here?

Why do you see this provider?

Are you enrolled in Medicare?(Required)

What is your Health Insurance Claim Number (HICN)?(Required)

If you prefer to provide this over the phone, please indicate that in your answer and call our office to provide this information.

III. OTHER

Provide a list of all names you have ever used:(Required)

If none, please write “none” in the first box.

Name:

Dates when you used this name:

List all social media accounts that you use:(Required)

***Examples of social media accounts include: Facebook, Instagram, Twitter, Snapchat, LinkedIn, etc.***

Account type:

Your Username:

How frequently do you post something?

Have you posted about your employment?

Have you ever been involved in any criminal proceedings?(Required)

Please provide the following information for each proceeding:(Required)

Date:

County, State:

Case No.:

Description of Charge:

Outcome:

Your attorney's name

Have you ever been involved in any other legal proceedings such as a divorce, property dispute, injury lawsuit, workers' compensation claim, etc.?(Required)

Please provide the following information for each proceeding:(Required)

Date:

County, State

Case No.

Description of Case:

Outcome:

Your attorney's name

Gathering Required Documents

While you have likely provided us with several documents already, there are additional types of documents that we need now that we are filing a lawsuit. We need to gather these documents from you now.

Please indicate which of the following documents you have:(Required)

Copies of your tax returns for the last five years

Copies of all your W2’s and 1099s for the last five years (if not included in your tax return)

Copy of your most recent paystub, showing your year-to-date earnings, from the current year

All documents related to any job search you have conducted (cover letters; resumes; application forms; emails with prospective employers, etc.)

None of the above

How would you like to get us these files?(Required)

Please let us know how you prefer to get these documents to us.

Upload now

Mail, fax, or physically bring to the office

I would like someone to contact me to discuss options

Other

Please upload any files you have

Drop files here or

Max. file size: 50 MB.

Mailing, faxing, or bringing documents to us

Fax: 319-365-1114 | RSH Legal 425 2nd St SE, Suite 1140 Cedar Rapids, IA 52401 | Monday – Friday, 8:30 am – 5:00 pm