Grievance Claims Form

Employee Grievance Claims Form

"*" indicates required fields

Last Name*

First Name*

Middle Initial

Street Address*

Street Address Unit, Apt #

City*

State*

Zipcode*

Email*

Phone Number*

Are you represented by an attorney?*

Yes

Attorney's Name*

Attorney's Phone Number

Attorney's Email

Start Date of Employment*

Are you still an employee?*

Yes

Date of event giving rise to claim*

What is the $ amount of relief sought?*

Statute(s), regulation(s) or other body of law that provides the basis of claim for relief

Short statement of the facts, circumstances, actions and events giving rise to the claim*

Upload Attachments

Drop files here or

Max. file size: 16 MB, Max. files: 10.

This Grievance is intended to assert a Covered Claim the dispute-resolution process set forth in the Dispute Resolution Policy between me and _______________________________________ (Employer).

Consent*

Under penalty of perjury, the information above and on any attachments to this form is true and correct.*