Claims Settlement Checklist

Texas Chapter 542 requires acknowledging a first-party claim within 15 business days; other states vary (CA 15 calendar days, NY 15 business days). Log the FNOL date in ClaimCenter — the prompt-pay clock runs from receipt, not from assignment.

Confirm the policy was in force on the date of loss — not the date of report. Watch for mid-term cancellations, lapses for non-payment, and reinstatements with gaps. Pull the dec page and any endorsements effective on the loss date.

Match the reported cause of loss against named perils, exclusions, and any anti-concurrent-causation language. Flag flood, earth movement, and ordinance-or-law issues for supervisor review before issuing any coverage position.

Screen the insured, claimant, and any third-party payees (mortgagee, repair vendor, public adjuster) against the OFAC SDN list. Re-screen at payment — parties can be added mid-claim.

Pull LexisNexis CLUE and internal claim history. Repeat losses on the same risk, especially within 12 months, are an SIU referral signal — not a reason to deny, but a reason to investigate before reserving.

Document the coverage analysis in the claim file before issuing any letter. If coverage is unclear, issue a reservation of rights — do not pay under a disputed coverage without ROR or you waive defenses.

Confirm the assigned adjuster holds an active license in the loss state — TX, FL, NY, and CA each require resident or non-resident adjuster licensing. Catastrophe deployments often miss this for non-resident adjusters.

Set indemnity and ALAE reserves based on the file evidence, not a placeholder. Carrier cadence typically requires reserve review at 30, 60, and 90 days; understated reserves are a market-conduct exam finding.

Photograph each damaged area with a scale reference and overview shot. Upload to ImageRight or the carrier's claim system. Note any pre-existing damage or wear-and-tear separately — this matters at the depreciation step.

Use current Xactimate price list for the loss ZIP. Apply ACV depreciation based on age and condition — not a flat percentage. Document the depreciation rationale in the line-item notes; insureds and public adjusters will challenge it.

For roof, structural, fire-origin, water mitigation, or large-loss content claims, engage an engineer, origin-and-cause investigator, or contents specialist. Issue an ROR before incurring expert fees if coverage is unresolved.

Common red flags: loss within 60 days of policy inception, prior similar losses, missing receipts on high-value contents, recorded statement inconsistencies. NY, FL, NJ, and CA require Anti-Fraud Plan compliance — document the referral decision either way.

Most states require referral to the DOI fraud bureau (NY DFS Insurance Frauds Bureau, CDI Fraud Division) within statutory windows when fraud is reasonably suspected. File the referral form even if the investigation later clears the insured.

Disclose recording at the start of the call — some states are two-party consent. EUO is a policy condition, not optional; insured non-cooperation can be a coverage defense if properly documented.

Apply the deductible once per loss, not per line item. For RCV policies, pay ACV first and hold recoverable depreciation pending proof of repair. For ACV policies, depreciation is final.

Texas Chapter 542 requires a coverage decision within 15 business days of receiving all requested information; the letter must state the basis. Missing the deadline triggers 18% statutory interest plus attorney's fees.

If the insured invokes the appraisal clause, the carrier and insured each name an appraiser and the two select an umpire. Track the appraisal demand date — some policies impose response windows.

Settlements above the adjuster's authority limit require manager or large-loss committee approval. Confirm the release covers all parties with potential subrogation interest, including the mortgagee on property losses.

Texas Chapter 542 requires payment within 5 business days of acceptance. Issue checks payable jointly to the insured and mortgagee for property losses with a lienholder on the dec page. Re-run OFAC at payment.

If a third party caused the loss, put them on notice within the state's statutory window (often 6 months) before closing. Set retention per the carrier's schedule — typically 5–7 years for property, longer for WC and liability with minor claimants.