north carolinasouth carolina
Discrimination Submission Form

   We are anxious to help you.  There are two ways you can contact us about your case.  You can either call us at 1.800.556.8404 to talk to one of our client service representatives or you can fill out the on-line form below and submit it to us from this website at any time.  After completing the form you may submit it by simply clicking on the I AGREE button after reading our necessary disclaimer. 



Personal Information

Your last Name   Your First Name   Your Gender  

Physical Address (Include City, State, Zip)  
Email Address    
Cell Phone (xxx-xxx-xxxx)   Home Phone (xxx-xxx-xxxx)   Work Phone (xxx-xxx-xxxx)  

 

Accident Information

Employer (when injured):  
Supervisor's Name:  
Name(s) of everyone who harassed or discriminated against you:
Last Name: First Name Gender



Nature of harassment or discrimination (check any that apply):



 
Your Job title/Job you held:  
Length of time employed

 
Hours worked per day
 
Days worked per week

 
Hourly rate of pay



 
Annual salary (if not hourly)

 
Date of first incident of harassment/discrimination:  
Did you notify supervisor of incident?
 
Did you notify supervisor of incident in writing?
 
Date of notification:  
Did you notify management of incident?
 
Did you notify management of incident in writing?
 
Date of notification:  
Consequences to you of harassment/discrimination (check any that apply)



 
If terminated, did you sign any agreement?
 
Did you receive any severance payment as a result of agreement?
 
Place of Employment: City:
State:
Description of Incident (optional):
Did you lose retirement benefits as a result of harassment/discrimination?
 
Has anyone else other than you been subjected to such harassment/discrimination at this employer?
 
Have you found new work?
 
Date:  
Did your new position result in less pay?
 
Have you given a recorded or written statement about the incident?
 
Any previous harassment/discrimination claims?
 
Have you viewed our tutorial on harassment/discrimination?
 
Are you presently represented by an attorney?
 

 

Disclaimer
WARNING:
If you are a Pre-Paid Legal Services, Inc. Member you may not use this method of seeking legal assistance. You must call the 1.800 number on your membership card. If you submit a request in this manner we will not be able to process you as a Pre-Paid Legal member which could result in significant delays.
     
Disclaimer:    
Before you can submit your case for potential review, you must read and agree to the following: "I understand that by submitting this information to MFWWC, I have not created an attorney/client relationship with MFWWC and that MFWWC has no responsibility to protect my interests in this matter in any way unless and until I enter into a signed, written fee agreement with MFWWC. I understand that MFWWC has no obligation to reply to this email and are not responsible for this matter. By clicking on the I Agree button below, I hereby submit my information on this basis and certify that I have read the GENERAL Disclaimer."  





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