Claims Adjuster Guide

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Claim Lifecycle

FNOL Submitted
    ↓
Assigned to Adjuster
    ↓
Investigation (reserve set)
    ↓
Evaluation (coverage confirmed / denied)
    ↓
Negotiation & Settlement
    ↓
Payment Issued
    ↓
Closed

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Receiving a New Claim

• You receive an email and Teams notification with the claim number
• The claim appears in your Claims Queue
• Initial reserve is auto-set based on reported loss amount (adjustable)
  1. Open the claim from the queue or notification link 2. Review the FNOL details: date of loss, description, reported amount, attached photos 3. Click Accept Assignment to confirm you’re working the claim 4. Set an initial reserve if the auto-reserve needs adjustment

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Investigation

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Setting reserves

1. In the claim, click Reserves 2. Enter the updated incurred amount (paid + expected) 3. Add a note explaining the change (required for audit) 4. Save — the reserve change is logged with your name and timestamp

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Requesting documents

1. Click Request Documents 2. Select what you need: police report, medical records, repair estimates, photos 3. The policyholder receives an email with a secure upload link 4. Uploaded files appear in the Documents tab

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Adding notes

• Recorded statements
• Site inspection findings
• Coverage analysis
• Correspondence with third parties

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Coverage Determination

1. Click Coverage Determination 2. Select: Covered / Partially Covered / Denied 3. If denied or partial, select the policy provision(s) that apply 4. Add a written coverage opinion (required) 5. Save — the policyholder and producer are notified

Caution: Coverage denials require a formal Reservation of Rights letter for certain jurisdictions. The system will prompt you if required based on the state of domicile.

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Settlement

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Making a settlement offer

1. Click Settlement 2. Enter the settlement amount 3. Select payment method: check, ACH, or wire 4. Add settlement terms (e.g., general release required) 5. Click Send Offer — the policyholder receives an email with offer details

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When the offer is accepted

1. The policyholder clicks Accept in their portal 2. The settlement moves to Pending Payment 3. Finance is notified to issue payment 4. Once payment is confirmed, the claim status changes to Settled

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Subrogation

1. Click Subrogation tab 2. Document the subrogation opportunity: liable party, amount recoverable, supporting evidence 3. Set a recovery target 4. Track recovery progress — partial recoveries reduce the net cost of the claim

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Litigation

1. Click Litigation 2. Record: plaintiff, defense counsel, court venue, trial date 3. Update legal spend and reserve regularly 4. Log all significant litigation events in Notes

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Closing a Claim

• Settlement payment is confirmed, or
• Coverage is denied and no further action is needed, or
• The claimant withdraws
  1. Click Close Claim 2. Select close reason 3. Confirm outstanding reserve is zeroed (or document why a reserve remains) 4. Click Confirm Close

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Notifications

• New claim assignments
• Document uploads from policyholders
• Reserve approval decisions (if approval was required)
• Settlement acceptances
• Litigation status changes