Fillable Claim form Employment Tribunal 1 Your details Ocial (Cabinet Office)

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Claim form Employment Tribunal 1 Your details Ocial (Cabinet Office)

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Employment Tribunal
Claim form
1 Your details
ET1 - Claim form (06.21) © Crown copyright 2020
1.1 Title
Mr Mrs Miss Ms
1.2* First name (or names)
1.3* Surname or family name
1.4 Date of birth
/ /
Are you? Male Female
1.5* Address
Number or name
Street
Town/City
County
Postcode
1.6
Phone number
Where we can contact you during the day
1.7 Mobile number (if dierent)
1.8
How would you prefer us to contact you?
(Please tick only one box)
Email Post Fax
Whatever your preference please note that some documents
cannot be sent electronically
1.9 Email address
1.10 Fax number
1.11
Would you be able to take part in a
hearing by video?
(Requires internet access).
Yes No
Further details on video hearings can be found on the following
link https://www.gov.uk/guidance/hmcts-telephone-and-video-
hearings-during-coronavirus-outbreak
Official Use Only
Tribunal office
Case number Date received
You must complete all questions marked with an ‘*’
Page 2
2 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 the
person or organisation you are claiming
against (If you need to you can add more
respondents at 2.5)
2.2* Address
Number or name
Street
Town/City
County
Postcode
Phone number
2.3*
Do you have an Acas early conciliation
certificate number?
Yes No
Nearly 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 on
0300 123 1100 or visit www.acas.org.uk
If Yes, please give the Acas early
conciliation 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 number
Acas doesn’t have the power to conciliate on some or all of my claim
My employer has already been in touch with Acas
My claim consists only of a complaint of unfair dismissal which contains an application for interim
relief. (See guidance)
2.4
If you worked at a different address from the one you have given at 2.2 please give the full address
Address
Number or name
Street
Town/City
County
Postcode
Phone number
Page 3
2.5 If there are other respondents please tick this box and put their
names and addresses here.
(If there is not enough room here for the names of all the additional
respondents then you can add any others at Section 13.)
Respondent 2
Name
Address
Number or name
Street
Town/City
County
Postcode
Phone number
2.6
Do you have an Acas early conciliation
certificate number?
Yes No
Nearly 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 on
0300 123 1100 or visit www.acas.org.uk
If Yes, please give the Acas early
conciliation 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 number
Acas doesn’t have the power to conciliate on some or all of my claim
My employer has already been in touch with Acas
My claim consists only of a complaint of unfair dismissal which contains an application for interim
relief. (See guidance)
Respondent 3
2.7
Name
Address
Number or name
Street
Town/City
County
Postcode
Phone number
Page 4
2.8
Do you have an Acas early conciliation
certificate number?
Yes No
Nearly 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 on
0300 123 1100 or visit www.Acas.org.uk
If Yes, please give the Acas early
conciliation 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 number
Acas doesn’t have the power to conciliate on some or all of my claim
My employer has already been in touch with Acas
My claim consists only of a complaint of unfair dismissal which contains an application for interim
relief. (See guidance)
3 Multiple cases
3.1 Are you aware that your claim is one of
a number of claims against the same
employer arising from the same, or similar,
circumstances?
Yes No
If Yes, and you know the names of any other
claimants, add them here. This will allow us to
link your claim to other related claims.
4 Cases where the respondent was not your employer
4.1 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 8
5 Employment details
If you are or were employed please give the
following information, if possible.
5.1
When did your employment start?
Is your employment continuing?
Yes No
If your employment has ended,
when did it end?
If your employment has not ended, are you in a
period of notice and, if so, when will that end?
5.2 Please say what job you do or did.
Page 5
6 Earnings and benefits
6.1
How many hours on average do, or did you work
each week in the job this claim is about?
hours each week
6.2 How much are, or were you paid?
Pay before tax
£
Weekly Monthly
Normal take-home pay
(Incl. overtime, commission, bonuses etc.)
£
Weekly Monthly
6.3
If your employment has ended, did you work
(or were you paid for) a period of notice?
Yes No
If Yes, how many weeks, or months’ notice did
you work, or were you paid for?
weeks months
6.4 Were you in your employer’s pension scheme?
Yes No
6.5 If you received any other benefits, e.g. company
car, 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 No
If No, please go to section 8
7.2 Please say when you started (or will start) work.
7.3
Please say how much you are now earning
(or will earn).
£
Page 6
8 Type and details of claim
8.1*
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:
age race
gender reassignment disability
pregnancy or maternity marriage or civil partnership
sexual orientation sex (including equal pay)
religion or belief
I am claiming a redundancy payment
I am owed
notice pay
holiday pay
arrears of pay
other payments
I 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 7
8.2*
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 about
happened. Please use the blank sheet at the end of the form if needed.
Page 8
9 What do you want if your claim is successful?
9.1
Please tick the relevant box(es) to say what you
want 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 associated
employer and compensation (re-engagement)
Compensation only
If 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 this
sum. (Please note any gure stated below will be viewed as helpful information but it will not restrict what you can claim and you will be permitted to revise the
sum claimed later. See the Guidance for further information about how you can calculate compensation). If you are seeking any other remedy from the Tribunal
which you have not already identified please also state this below.
Page 9
10
Information to regulators in protected disclosure cases
10.1
If your claim consists of, or includes, a claim that you are making a protected disclosure under the
Employment Rights Act 1996 (otherwise known as a ‘whistleblowing’ claim), please tick the box if you
want 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 representative
If 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 representative
11.2 Name of organisation
11.4 DX number (If known)
11.5 Phone number
11.6 Mobile number (If dierent)
11.7
Their reference for correspondence
11.8
Email address
11.9
How would you prefer us to communicate
with them? (Please tick only one box)
Email Post Fax
11.10
Fax number
12 Disability
12.1 Do you have a disability?
Yes No
If Yes, it would help us if you could say
what this disability is and tell us what
assistance, if any, you will need as your
claim progresses through the system,
including for any hearings that maybe held
at tribunal premises.
11.3 Address
Number or name
Street
Town/City
County
Postcode
Page 10
13 Details of additional respondents
Section 2 allows you to list up to three respondents. If there are any more respondents please provide their details here
Respondent 4
Name
Address
Number or name
Street
Town/City
County
Postcode
Phone number
Do you have an Acas early conciliation
certificate number?
Yes No
Nearly 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 on
0300 123 1100 or visit www.acas.org.uk
If Yes, please give the Acas early
conciliation 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 number
Acas doesn’t have the power to conciliate on some or all of my claim
My employer has already been in touch with Acas
My claim consists only of a complaint of unfair dismissal which contains an application for
interim relief. (See guidance)
Page 11
14 Final check
Please re-read the form and check you have entered all the relevant information.
Once you are satisfied, please tick this box.
Respondent 5
Name
Address
Number or name
Street
Town/City
County
Postcode
Phone number
Do you have an Acas early conciliation
certificate number?
Yes No
Nearly 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 on
0300 123 1100 or visit www.acas.org.uk
If Yes, please give the Acas early
conciliation 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 number
Acas doesn’t have the power to conciliate on some or all of my claim
My employer has already been in touch with Acas
My claim consists only of a complaint of unfair dismissal which contains an application for
interim relief. (See guidance)
General Data Protection Regulations
The 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 1024
Welsh speakers: 0300 303 5176
Scotland: 0300 790 6234
Textphone: 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 purpose
of tribunal proceedings or to reach settlement of the claim.
Page 12
15 Additional information
You 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 13
It 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 are
effective 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.
Diversity Monitoring Questionnaire
Claim type
Please confirm the type of claim that you are bringing to the employment
tribunal. This will help us in analysing the other information provided in
this form.
(a)
Unfair dismissal or constructive dismissal
(b)
Discrimination
(c)
Redundancy payment
(d)
Other payments you are owed
(e)
Other complaints
Sex
What is your sex?
(a)
Female
(b)
Male
(c)
Prefer not to say
Which 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 say
Age group
Ethnicity
What is your ethnic group?
White
(a)
English / Welsh / Scottish / Northern Irish / British
(b)
Irish
(c)
Gypsy or Irish Traveller
(d)
Any other White background
Mixed
/ multiple ethnic groups
(e)
White and Black Caribbean
(f)
White and Black African
(g)
White and Asian
(h)
Any other Mixed / multiple ethnic background
Asian / Asian British
(i)
Indian
(j)
Pakistani
(k)
Bangladeshi
(l)
Chinese
(m)
Any other Asian background
Black
/ African / Caribbean / Black British
(n)
African
(o)
Caribbean
(p)
Any other Black / African / Caribbean background
Other ethnic group
(q)
Arab
(r)
Any other ethnic group
(s)
Prefer not to say
Page 14
The Equality Act 2010 defines a disabled person as ‘Someone who has a
physical or mental impairment and the impairment has a substantial and
long-term adverse effect on his or her ability to carry out normal day-to-day
activities’.
Conditions covered may include, for example, severe depression, dyslexia,
epilepsy and arthritis.
Do you have any physical or mental health conditions or illnesses lasting or
expected to last for 12 months or more?
(a)
Yes
(b)
No
(c)
Prefer not to say
Disability
Are you?
(a)
Single, that is, never married and never
registered 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 is
now legally dissolved
(I)
Surviving partner from a same-sex civil partnership
(J)
Prefer not to say
Marriage and Civil Partnership
Religion and belief
What is your religion?
(a)
No religion
(b)
Christian (including Church of England, Catholic, Protestant and
all other Christian denominations)
(c)
Buddhist
(d)
Hindu
(e)
Jewish
(f)
Muslim
(g)
Sikh
(h)
Any other religion (please describe)
(I)
Prefer not to say
Caring responsibilites
Do you have any caring responsibilities, (for example; children, elderly
relatives, partners etc.)?
(a)
Yes
(b)
No
(c)
Prefer not to say
Sexual identity
Which 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 say
Were you pregnant when the issue you are making a claim about
took place?
Pregnancy and maternity
(a)
Yes
(b)
No
(c)
Prefer not to say
Thank you for taking the time to
complete this questionnaire.
Page 15
Employment Tribunals check list
Please check the following:
1. Read the form to make sure the information given is correct and truthful, and that you have
not 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 information
please 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 receipt
from the office dealing with your claim within five working days. If you have not heard from
them within five days, please contact that office directly. If the deadline for submitting the
claim is closer than five days you should check that it has been received before the time limit
expires.
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-claim
A 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 provide
general procedural information about the Employment Tribunals.
Customer Contact Centre:
England and Wales: 0300 123 1024
Welsh speakers: 0300 303 5176
Scotland: 0300 790 6234
Textphone: 18001 0300 123 1024 (England and Wales)
Textphone: 18001 0300 790 6234 (Scotland)
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Claim form Employment Tribunal 1 Your details Ocial (Cabinet Office)

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Completed 26 August 2021

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