Full Name*

First Name * Last Name *

Email*

Phone

Mobile

May We Contact You By Text Message?

Yes
No

Address

Street Address City State ZIP Code

Job Title:

Name of company you work for:*

Approximate number of employees with your job title?

Employment Start Date:

If actual date is unknown, please select the first day of the month and the year you were hired.

Employment End Date:

Leave blank if you are still employed with the same company. If actual date is unknown, please select the first day of the correct month and year.

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

How are you paid?

How much are you paid?

dollars per

Are you paid time and a half if you work more than 40 hours a week?

Yes
No

How are you paid for hours over 40 per week?:

Straight Time
Not At All
Comp Time
Other

If you were paid for your overtime, are your bonuses, shift differential and/or other incentive pay included when your employer calculates your overtime pay rate?:

Yes
No
Don't Know

Please briefly describe your primary job duties and responsibilities.:

Do you supervise two or more full-time employees?

Yes
No

Can you hire or fire employees?

Yes
No

Do you make suggestions and recommendations as to the hiring, firing, or promotion of other employees that are/were given particular weight?

Yes
No

Do you discipline employees?

Yes
No

Are you given Comp Time instead of Overtime pay?

Yes
No

During the last 3 years, were you paid time and a half for overtime at your prior job(s)?

Yes
No

Additional Information and/or your comments

Submitting this form does not establish an attorney client relationship and does not obligate this firm to represent you. We may or may not be able to undertake representation on your behalf, but we will gladly review the information you provide and respond to you. The information contained on this site is not and is not intended to be legal advice. You should always consult an attorney for individualized advice about your particular situation. I have read and understand the above.

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No

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Protecting Worker's Rights

Every Hour, Every Dollar, Every Day

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Form Submission – Thank You

It looks like you may be entitled to back overtime pay. If you have time to provide more details, please fill out the form below. It will help us evaluate your claim more quickly. As always, our review is free and confidential.

Case Evaluation Form

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