Lecker & Associates

To review you case please provide your information and details. We will contact you within one to two business days. Should you require immediate assistance call 416.223.5391

Name * First Last
Email *
Phone * - (###) - ### ####
Your Age *

This is important when it comes to assessing your claim.
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Name of Company that you are / were employed at. *

Provide company name.
Company Phone - (###) - ### ####
Company Fax - (###) - ### ####
Were you a member of a Union or Employee Association? * Yes No
Position *
Have you been absent from work due to injury, ill health or any medical reason. If Yes, why?
Are you currently disabled from performing the ordinary duties of your employment due to illness or injury?
Have you applied for STD/LTD benefits within the last 90 days?
Did you have Supervisory duties?
Have you received a written disciplinary notice from employer? Yes No
Did you join the company at their request?
Have you signed an employment contract? If Yes - When?
Reason provide for termination.
Was reason for termination provided in writing? Yes No
Did you sign a release form? * Yes No
Was working notice or salary continuance provided in lieu of notice? Yes No
What monies have you received from your employer since the date of termination?
Were you provided with a letter of reference, outplacement counselling, and / or retraining on termination?
What was your Annual Total Gross Income as per T4
Date Hired * / MM / DD YYYY
Termination of Employment Date * / MM / DD YYYY
How did you hear of us?
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