24801 Pico Canyon Road, Suite 100

Stevenson Ranch, CA 91381

Tel: (661) 310-1363 | Fax: (661) 310-1480

Thank you so much for contacting Miller Wilmers, APC! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. Most courts require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

Contact information

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First name *

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Last name *

Date of birth

Company

Emails

Address *

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Upon submission, a copy of this form will be sent to the primary email.

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Addresses

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Phone numbers

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Preferred Contact Method

How were you referred to our law firm?

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Employment/Employer Information

Please anaswer the below questions in regards to the Employer you wish to seek legal action against.

Input the Employer's name, phone number, and address below.

Do you know the HR contact for the Employer?

Yes

Select your current employment status with the Employer

What was your most recent status with the Employer?

Do you have your most recent paystub from this Employer?

Yes

Wage and Hour Details

Please answer the following questions with information regarding your employment with the employer you are consulting us for.

Hire Date?

Job title?

Termination and/or Resignation Date, if any?

If you were terminated and/or resigned, please state the reason(s).

How were you paid?

Enter your hourly wage or annual salary, whichever is applicable

How were your wages reported?

If you have one, please upload the most recent tax form provided to you by your employer (i.e. 1099, W2, etc.)

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On average, how many hours did you work per day?

On average, how many hours did you work per week?

Did you have a fixed weekly schedule?

Yes

Were you provided uninterrupted meal periods of at least 30 minutes every day?

Yes

If you missed meal breaks, tell us why. Please select all that apply.

Were you provided uninterrupted breaks of at least 10 minutes every day?

Yes

If you missed 10 minute rest periods, tell us why. Please select all that apply.

Discrimination/Harassment/Retaliation

Please answer the following questions with information regarding your employment with the employer you are consulting us for.

Do you believe you were discriminated against, harassed, or retaliated against by your Employer?

Yes

On what basis do you believe you were discriminated against, harrassed, or retaliated? Select all that apply.

Is your claim related to a medical condition or disability (including pregnancy)?

Yes

Were you suspended at any time during your employment?

Yes

Please provide the name, number, and email addresses (if known), of the relevant witnesses to your claims.

i.e. co-workers who may have witnesses the discrimination/harassment/retaliation, etc.

Please describe any other relevant facts you want us to know. Please include dates, witnesses and a description of events that form the basis of your complaint.

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

DISCLAIMER: The submission of information does not establish an attorney-client relationship. This form is for case evaluation purposes only. Our office will contact you after review to further discuss hiring/retaining Miller Wilmers, APC for your legal matter. Thank you.