SG Website: Weight Loss Drug Survey

1
Did you refuse to get the COVID-19 vaccine while employed during the past 3 years?* This field is required.
Yes
No
2
Do you currently or did you formerly get health insurance coverage via your employer?* This field is required.
Yes
No
3
Do you currently or did you formerly pay a vaccine surcharge, extra fees or a higher premium for coverage because you did not get the COVID-19 vaccine?* This field is required.
Yes
No
4
List the name of the company or entity that charged a fee for not receiving the Covid-19 vaccine.* This field is required.
5
Are you a current or former employee of this company?* This field is required.
Current Employee
Former Employee
6
If you are a former employee, did you work for the company in question sometime within the past 3 years?* This field is required.
Yes
No
7
Thank you! Based on your responses, it appears that you may qualify for substantial compensation!

There is no out-of-pocket cost for representation. If you would like to speak to one of our representatives to learn more, please submit your contact information on the next screens.
8
What is your first and last name?* This field is required.
First Name
Last Name
9
What is your email?* This field is required.
example@example.com
10
What is your phone number?* This field is required.
Please enter a valid phone number.
11
Your state:* This field is required.
Please Select
Please Select
Alabama
Alaska
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Arkansas
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Colorado
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District of Columbia
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Hawaii
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Maryland
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New York
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
12
Please verify that you are human* This field is required.
Should be Empty: