Claim Processing Checklist

Send written acknowledgement per the state's unfair claim settlement practices act. Texas Insurance Code Chapter 542 requires acknowledgement within 15 business days of receipt; other states vary. Document the acknowledgement date in ClaimCenter — this starts the prompt-pay clock.

Confirm named insured matches the dec page exactly, claimant contact info is reachable, and any AOB (assignment of benefits) is on file. Mismatches at intake create payment-routing problems later.

Screen insured, claimant, and any payee or assignee against the OFAC SDN list. Re-screen at every payment — parties can be added mid-claim. A hit blocks payment and requires Treasury reporting within 10 business days.

Severity drives routing: minor PD goes to fast-track; BI, total losses, and any matter likely to exceed 50% of the primary limit go to a senior adjuster and trigger excess-carrier notification.

Pull the in-force dec page, base form, and all endorsements as of the date of loss — not today's version. For claims-made policies, confirm the retroactive date and any ERP endorsement.

Check policy period, premium-payment status, and any cancellation or non-renewal notices. A lapsed policy at DOL is a denial; an active policy with a pending cancellation needs underwriting consultation before decisioning.

When coverage is in question, issue an ROR identifying the specific policy provisions in question. Generic ROR letters get challenged in bad-faith litigation; cite the exclusion or condition by section number.

Occurrence policies require notice 'as soon as practicable'; claims-made require notice within the policy period or ERP. Late notice is a coverage condition issue, not automatic denial — most states require the carrier to show prejudice.

Request the proof-of-loss form, photos, repair estimates, police or fire report, medical records (BI), and any third-party invoices. Send a single consolidated request — piecemeal requests reset prompt-pay clocks in some states.

Disclose the recording on the record at the start. Some states are one-party consent, some two-party — match the loss state. Undisclosed recordings are inadmissible and support bad-faith claims.

Pull LexisNexis CLUE for the insured and the loss location. Repeat losses or prior denials inform both reserve setting and SIU referral decisions.

States including NY, CA, FL, NJ, OH, KY, LA, MN, NM require fraud referrals under the carrier's filed Anti-Fraud Plan. Document the red flags that triggered the referral — staged-loss indicators, inconsistent statements, prior-loss patterns.

Set indemnity, ALAE, and (if applicable) ULAE reserves based on documented exposure, not on a placeholder. Placeholder reserves that don't update on the carrier's 30/60/90 cadence drive IBNR drift and surface in market-conduct exams.

Most excess policies require notice of any matter 'reasonably likely to involve' the excess layer; the practical trigger is 50% of the primary limit. Missing notice is a coverage-condition violation that the excess carrier can use to deny.

Put the at-fault party on written notice of subrogation interest within the state's statutory window — many states waive recovery if not noticed within 6 months. For total losses, document salvage value before any disposition.

Texas Chapter 542 requires decisioning within 15 business days of receipt of all requested information; missed deadlines trigger 18% statutory interest plus attorney's fees. Match your loss-state's statute — Florida, California, and New York all run on different clocks.

Cite the specific policy section and exclusion. Include the state-required appeal language and the DOI complaint address. Generic 'not covered under your policy' denials lose at appeal and surface in market-conduct exams.

OFAC re-screening at payment catches parties added to the SDN list mid-claim and any new payee from an AOB or settlement assignment. Skipping this is a common audit finding.

For full-and-final settlements, obtain a signed release before payment issues. For structured settlements or partial payments, document each tranche separately in the claim file.

Zero out indemnity and ALAE reserves on closure. Open files with zero reserves and no recent activity inflate IBNR and distort the loss ratio.

Most states require 5–7 years of claim file retention; workers comp typically requires 10+ years given lifetime medical exposure. Premature destruction creates spoliation risk in any future re-opening.