Andrew J. Pianka, Attorney At Law

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Free Case Appraisal

Have you recently been injured in an accident? We have made it easy for you to see if you have a potential claim for money damages for your injuries. Simply fill out the sections below in our innovative Free Case Appraisal and click the "SUBMIT" button. A Case Appraisal Manager will call you by the end of the business day if you submit this form between 9:00 a.m.-5:00 p.m. Eastern Time or by the next business day if you submit after 5:00 p.m. Eastern Time. This form should take less than two minutes to complete.

If you would rather speak to our Case Appraisal Manager about your case, please call (203) 575-1131 directly and ask for Attorney Andrew Pianka.

All required fields are marked with *

* Your Relation to the injured person:
Relationship if Other:

Tell Us About The Injured Person

* Full Name:
* Street Address 1:
Street Address 2:
* City:
* State:
* Zip Code:
* Home Phone Number:
Work Phone Number:
Other Phone Number:
E-Mail Address:
* Date of Birth (MM/DD/YYYY):
* Gender:	Male Female
* Did the injured person lose his/her job, have unpaid time off, or lose work-related benefits as a result of the injury?	Yes No
* Is injured person currently out of work due to the accident?	Yes No
* Did injured person require surgery due to the accident?	Yes No
* Is injured person currently in treatment?	Yes No

Tell Us What happened

* Date of Accident:
* Type of Accident:
Type of Accident, if Other:
Driver or Passenger, if automobile, moped, or motorcycle accident?
* Is injured person at fault?	Yes No I don't know

Tell Us About The Injury

Please select the injury(ies) that you received for each part of the body, by selecting that type of injury from the drop down boxes below. If you have more than one type of injury for a particular part of the body, you can select additional injuries by holding the "Ctrl" button (for PC users) or the "Apple" button (for Mac users). If you suffered an injury to an arm, hand, leg, or foot, please click the appropriate side (left or right). If you make a mistake, just click on the pull down menu again and click on the correct response or "Not applicable" as appropriate.

(NOTE FOR BURNS: We have categorized blistering burns as "second-degree burns" and charring as "third-degree burns." We do not consider first-degree burns (redness) to be a serious bodily injury in most cases.)

* Please fill in at least one injury
Left Arm/Shoulder	Right Arm/Shoulder
Head	Left Hand
Right Hand	Torso
Left Leg	Right Leg
Reproductive System

Contact Information

* Your Full Name:
* Your Street Address 1:
Your Street Address 2:
* Your City:
* Your State:
* Your Zip Code:
* Your Home Phone Number:
Your Work Phone Number:
Other Phone:
Your E-Mail Address:
* Are you 18 or older?	Yes No

Additional Information/Comments

Validation:

86 Buckingham Street. Waterbury, Connecticut 06710	Telephone: (203) 575-1131 Fax: (203)754-1675
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