Claims Assessment Checklist

Pull the dec page from PolicyCenter or the AMS and confirm the loss date falls within the policy period. Watch for mid-term cancellations, lapses for non-payment, and reinstatement gaps — coverage on the day of loss is what matters, not the day FNOL was reported.

Texas Insurance Code §542.055 requires acknowledgement within 15 business days of receipt; most other states have similar windows under their unfair claim settlement practices acts. Send written acknowledgement plus the claim number and assigned adjuster contact info, and log the acknowledgement date in ClaimCenter — missed acknowledgements trigger 18% statutory interest in TX.

Screen the claimant, any assignees, and lienholders against the OFAC Specially Designated Nationals list. Many carriers screen at policy issuance only — re-screen at FNOL because parties can be added mid-policy, and a hit blocks any indemnity payment.

Tier the claim by exposure: low-complexity first-party property under $10K, mid-complexity $10K–$100K, or high-exposure liability or BI requiring a senior examiner. Severity tier drives reserve authority, supervisor review cadence, and excess-carrier notification at 50% of the primary tower.

Order the LexisNexis CLUE report for property/auto losses and request five-year loss runs from prior carriers. Patterns of similar prior losses at the same risk are a primary SIU referral trigger.

Disclose the recording at the start of the call — most states require this and several (CA, FL, MA, PA among others) are two-party consent. An undisclosed recording is inadmissible and supports a bad-faith allegation. Capture the consent on tape before substantive questioning.

For property losses, dispatch a staff or independent adjuster and capture photos in CCC ONE or Snapsheet. For total-loss auto, pull comparable values from Mitchell or CCC. For BI, request medical records via signed HIPAA authorization.

Common indicators: loss within 30 days of policy inception, prior similar losses on CLUE, claimant pressure for fast cash settlement, missing or post-dated receipts, unrelated witness with same address. NY, CA, FL, NJ, OH require SIU referral when indicators are present per the carrier's filed Anti-Fraud Plan.

Open the SIU referral with the indicator narrative, CLUE excerpts, and recorded statement. Per most state Anti-Fraud Plans, the SIU has independent authority to extend the investigation timeline and to refer to the state Department of Insurance fraud bureau.

Set indemnity and ALAE reserves based on inspected damage and exposure analysis — placeholder reserves contribute to IBNR drift and are a market-conduct exam finding. Update at the carrier's defined cadence (typically 30/60/90 days).

Read the policy form, all endorsements, and any schedules — not just the dec page. Common gotchas: water-damage sublimits, anti-concurrent-causation language, business-interruption waiting periods, and named-peril vs. open-peril triggers.

If any coverage question exists — late notice, intentional acts exclusion, prior-acts retroactive date — issue a written ROR identifying the specific policy provisions in question before continuing the investigation. A defense funded without an ROR can waive the exclusion.

Most excess policies require notice of any matter reasonably likely to involve the excess layer; carriers commonly use 50% of the primary limit as the practical trigger. Missing this is a coverage condition violation that can void excess coverage.

Texas requires decision within 15 business days of receipt of all items; most states have similar windows. Document the decision in ClaimCenter with the supporting rationale and the policy provisions relied on.

Cite the specific policy provisions, attach the relevant form/endorsement excerpts, and disclose the appeal process and the state DOI consumer-complaint contact (required in most jurisdictions). Vague denials citing general exclusions invite bad-faith litigation.

Stay within reserve authority — escalate to the claims manager before exceeding it. For represented claimants, all communication routes through counsel; direct contact with a represented party is a bad-faith trigger.

SDN list updates frequently; a payee clean at FNOL may not be clean at payment. Screen the payee, any assignees, and lienholders again, and document the screening date and result in the file.

For BI, use a full release with indemnification language; for first-party property, a proof-of-loss is typically sufficient. Texas requires payment within 5 business days of acceptance — log the issue date to avoid §542 interest.

Determine whether the loss involves an at-fault third party whose carrier or assets could provide recovery. Subrogation rights are commonly waived if not noticed within the statutory window (often 6 months).

Send the at-fault carrier or party a preservation-of-evidence letter and a subrogation demand within the state's statutory window. Include the proof-of-loss, repair invoices, and any expert reports.

Confirm reserves are zeroed, payment ledger reconciles, and all documents are filed in ImageRight. Most states require 5–7 year retention for P&C; workers' comp claims often require 10+ years given lifetime medical exposure. Premature destruction creates spoliation risk.