Worley, Schilling & Randall Insurance

IMPORTANT: Progressive, Travelers and Montgomery/Peerless require you to report your claim directly to them. Read the information below and then click here to access their reporting claim numbers.

All other companies: If your claim occurs after hours, on a weekend, or holiday, click here to access reporting claim numbers to contact your insurance company directly. Otherwise, please follow the instructions below to report your claim to Worley, Schilling & Randall.

REPORTING PROCEDURES:

Complete the claim form below after reading the following information.
Always call the police, even if on private property. Get the case number from the officer in order to obtain a copy of the Police Report.
Do not admit fault or offer any payment for injuries or damages.
Obtain the other party’s name, phone number, their insurance company, and policy number. If the other party is clearly at fault, call their insurance company to see if the claim has been reported and to verify coverage. Secure names, phone numbers, and addresses of all other parties involved in the accident, including witnesses.
Drivable vehicle: Get a repair estimate from a body shop.
Non-drivable vehicle: Tow your vehicle to a body shop. Get a repair estimate, but do not begin repairs until your insurance company has given approval.
Immediately notify Worley, Schilling & Randall if you are served with a summons or suit papers. These legal documents require a timely response.

NOTICE:

Only Worley, Schilling & Randall customers may report a claim here. Claims need to be reported in a timely manner or your insurance coverage may be jeopardized.

Please fill out the form below to the best of your knowledge
to report your Auto Claim.

* Required
Insured's Personal Information
Insured's Name*
Address Line #1*
Address Line #2
City*
State/Province*
Zip/Postal Code*
Daytime Phone Number*
Evening Phone Number*
Cell Phone Number
Which contact number do you prefer?*
E-Mail Address

Insured's Current Insurance Information (optional)
Insurance Company Name
Policy Number

Accident Information
Date of accident (mm/dd/yyyy)*
Time of accident*
Accident Location*
City*
State/Province*
Were the police contacted?	Yes No
Case number on ticket or police report
Were any tickets issued?	Yes No
To whom was the ticket issued?
For what was the ticket issued?
How many witnesses were present? (Include witnessing passengers)





Please provide details of the accident including any injuries:

Insured's Vehicle Information
Make*
Model*
Year (yyyy)*
VIN Number
Describe damage to your vehicle*
Damage estimate amount
Where can the car be seen?* (Body Shop, Wrecker, Residence...)
Who was driving your vehicle?*

Information of Driver of vehicle:
Check box if Driver of the vehicle was different than insured


OTHER PARTY INFORMATION
Current Insurance Information of other parties (optional)
Company Name
Policy Number
I believe the other party to be uninsured or underinsured*

Information of other parties involved:
Name of owner of other vehicle
Address Line #1
Address Line #2
City
State/Province
Zip/Postal Code
Daytime Phone Number
Evening Phone Number
Cell Phone Number

Check box if Driver of the vehicle is different from the owner


Property Damage
What was damaged? (if auto, include year, make, & model)
How many vehicles were involved in the accident?





Total other vehicle(s) damage estimate amount
Where can the vehicle(s) be seen? (Body Shop, Wrecker, Residence...)

Injuries
Number of injuries resulting from this accident?





Additional Remarks

If you have not heard back from us or the insurance company within two business days,
please call Worley, Schilling & Randall at (770) 428-1565. Thank you.