Employment Tribunal Claim | My Assignment Tutor

Employment TribunalClaim form Official Use OnlyTribunal officeCase numberDate received You must complete all questions marked with an ‘*’1 Your details 1.1 TitleMrMrsMissMs1.2* First name (or names) 1.3* Surname or family name1.4 Date of birth1.5* Address/ /Are you? MaleFemale Number or nameStreetTown/CityCountyPostcode1.6 Phone numberWhere we can contact you during the day1.7 Mobile number (if different)1.8 How would you prefer us to contact you?(Please tick only one box) Email Post Fax Wh cannot be sent electronically atever your preference please note that some documents1.9 Email address1.10 Fax number1.11 Would you be able to take part in ahearing by video?(Requires internet access).Yes No Further details on video hearings can be found on the followinglink https://www.gov.uk/guidance/hmcts-telephone-and-videohearings-during-coronavirus-outbreakET1 – Claim form (09.20) © Crown copyright 2020Page 22 Respondent’s details (that is the employer, person or organisation against whom you are making a claim)2.1* Give the name of your employer or theperson or organisation you are claimingagainst (If you need to you can add morerespondents at 2.5)2.2* AddressNumber or nameStreetTown/CityCountyPostcodePhone number2.3* Do you have an Acas early conciliationcertificate number? Yes NoNearly everyone should have this number before they fill in a claim form.You can find it on your Acas certificate. For help and advice, call Acas on0300 123 1100 or visit www.acas.org.ukIf Yes, please give the Acas earlyconciliation certificate number. If No, why don’t you have this number?Another person I’m making the claim with has an Acas early conciliation certificate numberAcas doesn’t have the power to conciliate on some or all of my claimMy employer has already been in touch with AcasMy claim consists only of a complaint of unfair dismissal which contains an application for interimrelief. (See guidance) 2.4 If you worked at a different address from the one you have given at 2.2 please give the full addressAddressNumber or nameStreetTown/CityCountyPostcodePhone numberPage 32.5 If there are other respondents please tick this box and put theirnames and addresses here. (If there is not enough room here for the names of all the additionalrespondents then you can add any others at Section 13.)Respondent 2 NameAddress Number or nameStreetTown/CityCountyPostcodePhone number2.6 Do you have an Acas early conciliationcertificate number? Yes NoNearly everyone should have this number before they fill in a claim form.You can find it on your Acas certificate. For help and advice, call Acas on0300 123 1100 or visit www.acas.org.ukIf Yes, please give the Acas earlyconciliation certificate number.If No, why don’t you have this number? Another person I’m making the claim with has an Acas early conciliation certificate numberAcas doesn’t have the power to conciliate on some or all of my claimMy employer has already been in touch with AcasMy claim consists only of a complaint of unfair dismissal which contains an application for interimrelief. (See guidance) Respondent 32.7NameAddressNumber or nameStreetTown/CityCountyPostcodePhone numberPage 42.8 Do you have an Acas early conciliationcertificate number? Yes NoNearly everyone should have this number before they fill in a claim form.You can find it on your Acas certificate. For help and advice, call Acas on0300 123 1100 or visit www.Acas.org.ukIf Yes, please give the Acas earlyconciliation certificate numberIf No, why don’t you have this number? Another person I’m making the claim with has an Acas early conciliation certificate numberAcas doesn’t have the power to conciliate on some or all of my claimMy employer has already been in touch with AcasMy claim consists only of a complaint of unfair dismissal which contains an application for interimrelief. (See guidance)3 Multiple cases3.1 Are you aware that your claim is one ofa number of claims against the sameemployer arising from the same, or similar,circumstances?Yes NoIf Yes, and you know the names of any otherclaimants, add them here. This will allow us tolink your claim to other related claims.4 Cases where the respondent was not your employer4.1 If you were not employed by any of the respondents you have named but are making a claim for some reason connected to employment (for example,relating to a job application which you made or against a trade union, qualifying body or the like) please state the type of claim you are making here.(You will get the chance to provide details later):Now go to Section 85 Employment detailsIf you are or were employed please give thefollowing information, if possible. 5.1 When did your employment start?Is your employment continuing?YesNo If your employment has ended,when did it end?If your employment has not ended, are you in aperiod of notice and, if so, when will that end?5.2 Please say what job you do or did.Page 56 Earnings and benefits6.1 How many hours on average do, or did you workeach week in the job this claim is about? hours each week6.2 How much are, or were you paid?Pay before tax £ Weekly MonthlyNormal take-home pay(Incl. overtime, commission, bonuses etc.) £ Weekly Monthly6.3 If your employment has ended, did you work(or were you paid for) a period of notice? Yes NoIf Yes, how many weeks, or months’ notice didyou work, or were you paid for? weeks months6.4 Were you in your employer’s pension scheme? Yes No6.5 If you received any other benefits, e.g. companycar, medical insurance, etc, from your employer,please give details.7 If your employment with the respondent has ended, what has happened since?7.1 Have you got another job? Yes NoIf No, please go to section 87.2 Please say when you started (or will start) work.7.3 Please say how much you are now earning(or will earn). £Page 68 Type and details of claim8.1* Please indicate the type of claim you are making by ticking one or more of the boxes below.I was unfairly dismissed (including constructive dismissal)I was discriminated against on the grounds of: agegender reassignmentpregnancy or maternitysexual orientationreligion or beliefracedisabilitymarriage or civil partnershipsex (including equal pay) I am claiming a redundancy paymentI am owednotice payholiday payarrears of payother paymentsI am making another type of claim which the Employment Tribunal can deal with.(Please state the nature of the claim. Examples are provided in the Guidance.)Page 78.2* Please set out the background and details of your claim in the space below.The details of your claim should include the date(s) when the event(s) you are complaining abouthappened. Please use the blank sheet at the end of the form if needed.Page 89 What do you want if your claim is successful?9.1 Please tick the relevant box(es) to say what youwant if your claim is successful:If claiming unfair dismissal, to get your old job back and compensation (reinstatement)If claiming unfair dismissal, to get another job with the same employer or associatedemployer and compensation (re-engagement)Compensation onlyIf claiming discrimination, a recommendation (see Guidance).9.2 What compensation or remedy are you seeking?If you are claiming financial compensation please give as much detail as you can about how much you are claiming and how you have calculated thissum. (Please note any figure stated below will be viewed as helpful information but it will not restrict what you can claim and you will be permitted to revise thesum claimed later. See the Guidance for further information about how you can calculate compensation). If you are seeking any other remedy from the Tribunalwhich you have not already identified please also state this below.Page 910 Information to regulators in protected disclosure cases10.1 If your claim consists of, or includes, a claim that you are making a protected disclosure under theEmployment Rights Act 1996 (otherwise known as a ‘whistleblowing’ claim), please tick the box if youwant a copy of this form, or information from it, to be forwarded on your behalf to a relevant regulator(known as a ‘prescribed person’ under the relevant legislation) by tribunal staff. (See Guidance).11 Your representativeIf someone has agreed to represent you, please fill in the following. We will in future only contact your representative and not you.11.1 Name of representative11.2 Name of organisation11.3 AddressNumber or nameStreetTown/CityCountyPostcode11.4 DX number (If known)11.5 Phone number11.6 Mobile number (If different)11.7 Their reference for correspondence11.8 Email address11.9 How would you prefer us to communicatewith them? (Please tick only one box) Email Post Fax11.10 Fax number12 Disability12.1 Do you have a disability? Yes NoIf Yes, it would help us if you could saywhat this disability is and tell us whatassistance, if any, you will need as yourclaim progresses through the system,including for any hearings that maybe heldat tribunal premises.Page 1013 Details of additional respondentsSection 2 allows you to list up to three respondents. If there are any more respondents please provide their details hereRespondent 4 NameAddress Number or nameStreetTown/CityCountyPostcodePhone numberDo you have an Acas early conciliationcertificate number? Yes NoNearly everyone should have this number before they fill in a claim form.You can find it on your Acas certificate. For help and advice, call Acas on0300 123 1100 or visit www.acas.org.ukIf Yes, please give the Acas earlyconciliation certificate number.If No, why don’t you have this number? Another person I’m making the claim with has an Acas early conciliation certificate numberAcas doesn’t have the power to conciliate on some or all of my claimMy employer has already been in touch with AcasMy claim consists only of a complaint of unfair dismissal which contains an application forinterim relief. (See guidance)Page 11Respondent 5NameAddressNumber or nameStreetTown/CityCountyPostcodePhone numberDo you have an Acas early conciliationcertificate number? Yes NoNearly everyone should have this number before they fill in a claim form.You can find it on your Acas certificate. For help and advice, call Acas on0300 123 1100 or visit www.acas.org.ukIf Yes, please give the Acas earlyconciliation certificate number.If No, why don’t you have this number? Another person I’m making the claim with has an Acas early conciliation certificate numberAcas doesn’t have the power to conciliate on some or all of my claimMy employer has already been in touch with AcasMy claim consists only of a complaint of unfair dismissal which contains an application forinterim relief. (See guidance)14 Final checkPlease re-read the form and check you have entered all the relevant information.Once you are satisfied, please tick this box.General Data Protection RegulationsThe Ministry of Justice and HM Courts and Tribunals Service processes personal information about you in the context of tribunal proceedings.For details of the standards we follow when processing your data, please visit the following address https://www.gov.uk/government/organisations/hm-courts-and-tribunals-service/about/personal-information-charter.To receive a paper copy of this privacy notice, please call our Customer Contact Centre:England and Wales: 0300 123 1024Welsh speakers: 0300 303 5176Scotland: 0300 790 6234Textphone: 18001 0300 123 1024 (England and Wales)Textphone: 18001 0300 790 6234 (Scotland)Please note: a copy of the claim form or response and other tribunal related correspondence may be copied to the other party and Acas for the purposeof tribunal proceedings or to reach settlement of the claim.Page 1215 Additional informationYou can provide additional information about your claim in this section.If you’re part of a group claim, give the Acas early conciliation certificate numbers for other people in your group. If they don’t have numbers, tell us why.Page 13Diversity Monitoring QuestionnaireIt is important to us that everyone who has contact with HM Courts & Tribunals Service, receives equal treatment. We need to find out whether our policies areeffective and to take steps to ensure the impact of future policies can be fully assessed to try to avoid any adverse impacts on any particular groups of people.That is why we are asking you to complete the following questionnaire, which will be used to provide us with the relevant statistical information.Your answers will be treated in strict confidence.Thank you in advance for your co-operation.Claim typePlease confirm the type of claim that you are bringing to the employmenttribunal. This will help us in analysing the other information provided inthis form.(a) Unfair dismissal or constructive dismissal(b) Discrimination(c) Redundancy payment(d) Other payments you are owed(e) Other complaintsSexWhat is your sex?(a) Female(b) Male(c) Prefer not to sayWhich age group are you in?(a) Under 25(b) 25-34(c) 35-44(d) 45-54(e) 55-64(f) 65 and over(g) Prefer not to sayAge groupEthnicityWhat is your ethnic group?White(a) English / Welsh / Scottish / Northern Irish / British(b) Irish(c) Gypsy or Irish Traveller(d) Any other White backgroundMixed / multiple ethnic groups(e) White and Black Caribbean(f) White and Black African(g) White and Asian(h) Any other Mixed / multiple ethnic backgroundAsian / Asian British(i) Indian(j) Pakistani(k) Bangladeshi(l) Chinese(m) Any other Asian backgroundBlack / African / Caribbean / Black British(n) African(o) Caribbean(p) Any other Black / African / Caribbean backgroundOther ethnic group(q) Arab(r) Any other ethnic group(s) Prefer not to sayPage 14DisabilityThe Equality Act 2010 defines a disabled person as ‘Someone who has aphysical or mental impairment and the impairment has a substantial andlong-term adverse effect on his or her ability to carry out normal day-to-dayactivities’.Conditions covered may include, for example, severe depression, dyslexia,epilepsy and arthritis.Do you have any physical or mental health conditions or illnesses lasting orexpected to last for 12 months or more?(a) Yes(b) No(c) Prefer not to sayMarriage and Civil PartnershipAre you?(a) Single, that is, never married and neverregistered in a same-sex civil partnership(b) Married(c) Separated, but still legally married(d) Divorced(e) Widowed(f) In a registered same-sex civil partnership(g) Separated, but still legally in a same-sex civil partnership(h) Formerly in a same-sex civil partnership which isnow legally dissolved(I) Surviving partner from a same-sex civil partnership(J) Prefer not to sayReligion and beliefWhat is your religion?(a) No religion(b) Christian (including Church of England, Catholic, Protestant andall other Christian denominations)(c) Buddhist(d) Hindu(e) Jewish(f) Muslim(g) Sikh(h) Any other religion (please describe)(I) Prefer not to sayCaring responsibilitesDo you have any caring responsibilities, (for example; children, elderlyrelatives, partners etc.)?(a) Yes(b) No(c) Prefer not to saySexual identityWhich of the options below best describes how you think of yourself?(a) Heterosexual/Straight(b) Gay /Lesbian(c) Bisexual(d) Other(e) Prefer not to sayGender identityPlease describe your gender identity.(a) Male (including female-to-male trans men)(b) Female (including male-to-female trans women)(c) Prefer not to sayIs your gender identity different to the sex you were assumed to be at birth?(f) Yes(g) No(h) Prefer not to sayWere you pregnant when the issue you are making a claim abouttook place?Pregnancy and maternity(a) Yes(b) No(c) Prefer not to sayThank you for taking the time tocomplete this questionnaire.Page 15Employment Tribunals check listPlease check the following:1. Read the form to make sure the information given is correct and truthful, and that you havenot left out any information which you feel may be relevant to you or your client.2. Do not attach a covering letter to your form. If you have any further relevant informationplease enter it in the ‘Additional Information’ space provided in the form.3. Send the completed form to the relevant office address.4. Keep a copy of your form posted to us.If your claim has been submitted on-line or posted you should receive confirmation of receiptfrom the office dealing with your claim within five working days. If you have not heard fromthem within five days, please contact that office directly. If the deadline for submitting theclaim is closer than five days you should check that it has been received before the time limitexpires.You have opted to print and post your form. We would like to remind you that forms submitted online are processed much faster than ones posted to us.If you want to submit your claim online please go to www.gov.uk/employment-tribunals/make-a-claimA list of our office’s contact details can be found at the hearing centre page of our website at – www.gov.uk/guidance/employment-tribunal-offices-and-venues;if you are still unsure about which office to contact please call our Employment Tribunal Customer Contact Centre (Mon – Fri, 9am – 5pm) they can also providegeneral procedural information about the Employment Tribunals.Customer Contact Centre:England and Wales: 0300 123 1024Welsh speakers: 0300 303 5176Scotland: 0300 790 6234Textphone: 18001 0300 123 1024 (England and Wales)Textphone: 18001 0300 790 6234 (Scotland)

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