Case Submission Form

For a free, no-obligation consultation with an experienced attorney regarding cases of personal injury and wrongful death, please submit the following response form. We will respect the confidentiality of your information to the fullest extent. Form submissions are relayed to us through our highly secure servers.

If you prefer, you may contact us at:
Crown Point: (219) 308-1673
Fort Wayne Office: (260) 804-4928
Indianapolis Office: (317) 658-0107
South Bend: (574) 386-7960

Tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be communicated with anyone. It is necessary only for purposes of enabling us to do a conflict of interest check prior to responding to you. We cannot respond without being able to do our conflict check. ALL fields are required.

First Name

Last Name

Number, Street & Apt.

City

State

Zip

Email

Day Phone

Night Phone

Please provide a brief personal background of the person needing assistance. Many times we are contacted by someone other than the person in need of help, such as a parent on behalf of a child, or wife on behalf of a husband. Please provide the following information on behalf of the person who needs assistance.

The following information is for myself: Yes No

If "No" my relationship to the following person is:

First Name

Last Name

Age

Occupation

For how long

Current or last employed

City and State where last employed

Highest grade completed

Schools/College attended

Degrees

Year degree granted

Special training or experience in

Why Do You Need Help? Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request. You can provide more detailed information below, but for now please confine yourself to providing us with a brief statement of the general facts of your case, injury and damages.

State the date you were injured or when you first learned that you had been injured?

What occurred?

Where did it happen? Please type in the City, County and State where it happened:
City
State
County

Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:

What damages were suffered? Describe the damage you have suffered:

Has anyone already filed a suit? Yes No

When is the best time to reach you by telephone?

When the information you have provided is complete, please press the Submit button below to send it to the The Law Offices of Tony Zirkle. Your information will be kept strictly confidential.

Security Code

The nursing home malpractice injury information offered by The Law Offices of Tony Zirkle and contained herein, regarding Indiana nursing home malpractice injury statutes and Indiana nursing home malpractice injury claimants' rights is general in scope. No attorney client relationship with our Indiana nursing home malpractice injury attorneys is hereby formed nor is the nursing home malpractice injury information herein intended as formal legal advice. Please contact an Indiana personal nursing home malpractice injury lawyer regarding your specific inquiry. Visiting this website does not create an attorney - client relationship.