Please fill out the form below and click "submit."

First Name *
 Last Name *
Address
City
 State
 Zip Code
Phone
 Work Number
E-mail Address *

The employer against whom you may have a claim

Employer Name
Dates Employed
Location/Address
Est. # of Employees
1. How often did you work in excess of 40 hours a week during any time within the past three years for which you were not paid overtime: Estimate the number of hours worked but not paid overtime.
2 . What was your regular rate of pay during any time that you worked unpaid overtime? (Rough estimates are OK.)
3. What was the title(s) of your job at any time that you worked unpaid overtime?
4. For all job titles you listed above please generally describe the nature and duties of that job.
5. Describe the extent of any supervisory responsibly held during any the time listed above.
6. In the last 2 years, have you:
(check all that apply)
Been paid at straight time (or less than time and a half) for overtime hours? For example, you make $10 per hour for all hours you work even if you work more than 40 hours in the week.   
Worked off-the-clock either because you were told to or because you were expected to?   
Not been paid for overtime that you worked (maybe because the company said it wasn’t approved in advance or the boss just didn’t pay it)?   
Been told you will get "Comp Time" instead of overtime.   
Been paid a bonus based on productivity, profits, company performance, or other productivity measures?   
Reported to work early or stayed late for meetings that were not counted in the hours you worked in a day?   
Traveled between job tasks or assignments in the day, but not been paid for the travel time between jobs or assignments?   
Had your salary or wages docked for any reason (i.e. discipline)?   
Had lunch breaks of less than 30 minutes, but not been paid for the lunch period?   

7. Please choose the statement which best describes your job during the period when you were not paid overtime:

Work Place
Other
Work Supervision
Other
Decision Making
Other
Work Hours
Other
Work Assignment
Other
8. Are there any other factors which you think that we should know which relate to your claim?

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