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Please use the form below to submit all of the information about your injury.

First Name(Required)

Last Name(Required)

Email(Required)

Enter Email Confirm Email

Your Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address Of Your Job(Required)

City State / Province / Region

Address Of Company Headquarters(Required)

City State / Province / Region

Please select which situation applies to your case.(Required)

Unvaccinated

Did you submit to your employer a request for medical or religious exemption from the COVID-19 vaccine?(Required)

Yes

Please describe in detail the exemption request you submitted to your employer, including date and all details of the type of exemption and accommodation(s) you requested.(Required)

Was your request for religious or medical accommodation granted or denied?(Required)

Granted

Denied

Please provide all details regarding the grant or denial of your accommodation request, including date, reason for grant or denial, and any details about the process your company undertook regarding your accommodation request such as number of conversations/interviews regarding your request and whether these took place in writing, over the phone or in person.(Required)

Did your employer deny your religious or medical exemption request without engaging in correspondence or discussion with you about reasonable accommodations?(Required)

Yes

Did your employer discuss accommodations with you but ultimately offer you an unreasonable accommodation- such as unpaid leave or a substantial demotion or change of position?(Required)

Yes

What harm have you suffered as a result of being discriminated against for your religious or medical based refusal to take the COVID-19 vaccine? For example, what is your hourly or annual income that has been lost, what benefits such as medical insurance, car insurance, per diem, car allowance, cell phone allowance, seniority or other employment benefits have been lost? What physical pain and suffering has this caused you? For example anxiety, insomnia or weight change.(Required)

Please describe in detail the exemption request you submitted to your employer, including date and all details of the type of exemption and accommodation(s) you requested.(Required)

Religious Exemption

Was your request for religious exemption and accommodation granted, denied, or did your employer fail to provide a response to you?(Required)

Granted

Denied

Failed to provide response

Please provide all details regarding the grant, denial, or refusal to respond regarding your accommodation request, including date, reason for grant or denial, and any details about the process your company undertook regarding your accommodation request such as number of conversations/interviews regarding your request and whether these took place in writing, over the phone or in person.(Required)

Did your employer require you to show “proof” or documentation to support your religious exemption request?(Required)

Yes

Please explain in detail the proof or documentation that was required by your employer.(Required)

Did your employer deny your religious exemption request without engaging in correspondence or discussion with you about reasonable accommodation(s)?(Required)

Yes

How many vaccines have you received?(Required)

None

Vaccine 1 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 1 Date(Required)

Vaccine 2 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 2 Date(Required)

Vaccine 3 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 3 Date(Required)

Did you receive the vaccine at a location operated by your company or an off-site location?(Required)

Operated by company

Off-site

Medical Exemption

Did you submit to your employer a request for medical exemption from the COVID-19 vaccine?(Required)

Yes

Please describe in detail the medical exemption request you submitted to your employer, including date and all details of the type of medical exemption and accommodation(s) you requested.(Required)

Did you provide any documentation with your medical exemption request, such as a doctor’s note, medical history, etc.?(Required)

Yes

Please describe in detail all such documentation provided and if you were requested to provide the documentation by your employer.(Required)

Was your request for medical accommodation granted, denied, or did your employer fail to provide you with a response?(Required)

Granted

Denied

Failed to provide response

Did your employer deny your medical exemption request without engaging in correspondence or discussion with you about reasonable accommodations?(Required)

Yes

How many vaccines have you received?(Required)

Vaccine 1 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 1 Date

Vaccine 2 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 2 Date

Vaccine 3 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 3 Date(Required)

Did you receive the vaccine at a location operated by your company or an off-site location?(Required)

Operated by company

Off-site

What harm have you suffered as a result of being forced to take the COVID-19 vaccine? Please provide details regarding the harm suffered, such as appendicitis, acute myocardial infarction, cerebrovascular accident, blood clots, cardiovascular issues, issues with reproductive health, insomnia, anxiety, loss of work or change in daily living. Please provide dates for all hospitalization(s) or doctor visits related to your adverse reaction to receiving the vaccine.(Required)

Natural Immunity

Did you submit to your employer a request for medical exemption from the COVID-19 vaccine based on natural immunity?(Required)

Yes

Please describe in detail the exemption request you submitted to your employer, including date and all details of the exemption and accommodation(s) you requested.(Required)

Did you provide any documentation with your medical exemption request, such as a doctor’s note, medical history, proof of antibodies, etc.?(Required)

Yes

Please describe in detail all such documentation provided and if you were requested to provide the documentation by your employer.(Required)

Was your request for medical accommodation granted, denied, or did your employer fail to provide you with a response?(Required)

Granted

Denied

Failed to provide response

Did your employer deny your medical exemption request without engaging in correspondence or discussion with you about reasonable accommodations?(Required)

Yes

How many vaccines have you received?(Required)

None

Vaccine 1 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 1 Date(Required)

Vaccine 2 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 2 Date(Required)

Vaccine 3 Type(Required)

Moderna

Pfizer-BioNTech

Johnson & Johnson's Janssen

Vaccine 3 Date(Required)

Did you receive the vaccine at a location operated by your company or an off-site location?(Required)

Operated by company

Off-site

Are there other co-employees or co-contractors who were mistreated in the same way?(Required)

Yes

How many would you estimate?(Required)

Do you have a information board or portal at your work that we could advertise on to get sign ups?(Required)

Yes

Please provide more information about workplace information board or portal.

Can you pay a $2500 retainer up front?(Required)

Yes

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Unvaccinated

Religious Exemption

Medical Exemption

Natural Immunity

RESOURCES

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