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Last Post 11/30/2006 10:27 AM by  leaanddan
Claim Scenario for Discussion
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Janice_Toll
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11/19/2006 3:46 PM

     

    Forum Transfer; First posted by Janice Toll

    The following scenario is presented for discussion:

    Ms. Insured notices that the shingles on her roof are in pretty bad condition, and being one who likes to keep her home in top notch condition, asks some friends to assist her in replacing the shingles.  The friends are not roofing contractors and will not be paid for their work.  Ms. Insured checks the weather Friday morning and finds that the outlook is for three days of sunshine and 85 degrees. She then purchases the materials and they are delivered on Friday afternoon so she and the friends can start the job early Saturday morning. 

    Early Saturday morning, Ms. Insured and her friends begin tearing off the existing shingles and discover that some of the roof decking is warped and decide to replace it.  One of the friends, and Ms. Insured, take the friend’s truck to the lumber yard, the roof decking is purchased and they return.  The remaining shingles and roof decking are torn off.  Ms. Insured and her two friends work diligently for the remainder of the day; however, darkness comes before the roof decking can be replaced.  Ms. Insured and friends cover the roof with tarps and wait for morning’s light to finish the job.

    Exhausted, after her long day of work, Ms. Insured goes to bed and is sleeping peacefully, when suddenly she is awakened by water falling on her face.  She arises to find there is a locally heavy downpour and the tarps have blown off the roof. Water is pouring into every room of the dwelling.

    Ms. Insured calls her two friends and does what she can to control the interior damage while she waits for the friends to arrive.  When the friends arrive with their ladder, they are unable to locate the tarps that have blown off the roof and go to the local all-night store that supplies such things, and buy more.

    By the time the friends have obtained new tarps and gotten them installed on the roof, there is a lot of interior damage, ceiling drywall and insulation has fallen; walls, carpet, laminated wood floors, etc., are wet, and most of Ms. Insured’s personal property is soaked.  They spend the rest of Sunday trying to control the damage to the interior and personal property.  The dwelling is uninhabitable and Ms. Insured finds a motel room.  The motel, the only one available, will not accept Ms. Insured’s pets.  Ms. Insured places Fifi and Fido in a boarding kennel. The motel does not have cooking facilities (no, not even a micro/fridge), and is 14 miles one-way further from Ms. Insured’s place of employment than from her home. 

    Ms. Insured has an HO-3 policy and on Monday morning, calls her agent and reports the damage.  The agent files a claim, which you receive late Monday afternoon.  How do you proceed?  Describe in detail how you would handle this claim.  What items are covered, what items are not covered, and what would be your plan of action?

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    11/19/2006 3:48 PM
    Forum Transfer; posted by Victor210


    Well, I will take a stab at this.
    Since I read that Ms. Insured thought her roof was in pretty bad condition and not necessarily needing repair, I would classify the roof replacement as a maintenance issue and not a peril covered issue. So the resulting damage to the interior would be from maintenance and not damage. Since she didn't hire a licensed, insured contractor to do the work, she only has herself and her friends to go back on for resolution.

    No Coverage A or B payment available.

    Coverage C payment available. Since some HO-3 state that they cover personal property anywhere in the world, I would say this appl

    As for the house being uninhabitable, it would depend on which version of the HO-3 she has. In some of the newer HO-3's there is wording that states "(we) the insurer insure against risk of direct physical loss to covered property", which most people would assume to mean that there needs to be a direct physical loss but with the word "risk" could mean a chance of loss.

    As for ALE, it is triggered when the premise is unlivable, and there is a covered loss, (Coverage C) which would fall into this scenario.

    ALE would pay room (difference between mortgage and actual cost) , food (since there is no kitchen), and gas for the 28 mile round trip to work, but would not pay for animals in kennel.


    Hope I am close....
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    11/19/2006 3:50 PM
    Forum Transfer; Posted by kds008


    This is a little tricky because of the tarps. At first I was thinking no coverage for contents since the "opening" was intentionally created by the insured. After giving that a little thought I think that the tarps were a temporary "roof" that did not have an opening until the wind blew them away so it was windstorm (a Coverage C covered peril) that created the opening. If that guess is correct, there should be coverage for the damaged contents under Cov C.

    The damage to the interior of the dwelling should be covered regardless of the correctness of my guess above because under Cov A it is not necessary for a Covered Peril to create an opening for coverage to apply.

    If that assumption is correct then Cov D should also apply. Ms. Insured would be eligible for reimbursement for the incurred cost of motel rental, mileage for the extra miles she would have to drive to work, the kennel for the dogs and her increased cost of meals over what she would normally spend when in her home. If any normal costs at the risk did not continue during the restoration period those would be deducted from her Cov D payments.

    There would not appear to be any subrogation potential since Ms. Insured seemed to be directing the work and her helpers were not being paid for their assistance.


    Kim
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    11/19/2006 3:51 PM
    Forum Transfer; Posted by Randy C

    I agree with Victor210; the roof is a maintenance issue and the responsibility of the insured. However, the roof was in a state of repair and covered with a blue tarp. A storm came and blew the tarp off...and away. The form HO 3 policy does not have a stupid exclusion, and we don't know but the blue tarp was appropriately installed anyway, as it disappeared from the site. The wind gusts were probably storm level.

    Anyway, I find an opening in the roof through which water came. The opening was due to sudden physical damage from the wind blowing away the blue tarp. The tarp is gone; it could have been vandalism if there was no wind, still covered loss. If there never was a tarp, and the insureds were making up the tarp story, we could deny the claim on the basis of fraud, but I would tend to believe the insured and the insured's helpers. I'd call it wind damage.

    NOTE: "(recommend we)" was inserted after the original post to emphasize the adjusters role as information gatherer, not final decision maker, and certainly not the payer of monies due the insured. Read it with and without the parenthetical to see why one is the preferred language to the other. Thanks to dcmarlin for pointing out the problem.

    I (recommend we) pay for the blue tarp to be replaced. I (recommend we) do not pay for the roof or any of the decking that was warped or delaminated from age, rot, or long term seepage. If there is any old decking that is damaged from the new water entering the wind created opening, I might consider that, but I didn't see anything like that when I was crawling around in the attic, so that will have to be a supplement.

    I (recommend we) pay for damaged drywall, insulation, texture, seal and paint. I'll (recommend we) pay to drag the wet carpets and padding outside. If any wood floors are buckled, I'd wait to see if they return to normal upon drying. If they don't, I'll (recommend we) pay for them. I'll (recommend we) pay to refinish any damaged floor that is not covered by a tacked down or glued carpet. I'll (recommend we) pay for new carpet and padding if they are water stained which they most likely will be. One could try to clean the carpet and even dry the padding, but that is usually not cost effective. I (recommend we) pay coverage A at replacement costs, but defer amounts for depreciation until the work is done. If the carpets are not fixed to the floor, I'll (recommend we) only pay for them as Coverage C ....ACV. I'll (recommend we) pay for clean up and debris removal.

    I'll take all the usual pictures. I'll take pictures of the damaged contents and help the insured to fill out a contents form. I'll check their prices, apply depreciation according to the reported age and observed condition, and pay them Actual Cash value.

    If the cat drowned, I'll (recommend we) not pay for the cat. I wouldn't (recommend we) pay for a drowned dog either, but I might pay for a nice Hallmark card out of my own pocket. I like dogs :-) If the fish bowl broke and dumped the fish, I'll (recommend we) pay for the fishbowl as contents, but the fish is in God's hands.

    Since the house is unlivable, I'll (recommend we) pay additional living expenses for a reasonable time to get the place livable. We will pay for additional mileage insured has to drive for work, shopping, and school. After determining the average food bill for the family we'll deduct that amount from the new food bill, but the insured should be cautioned that extravagant restaurant bills will paid at reasonable amounts only. While the house is unlivable we will pay for loss of use, which would include the function of shelter for the pets. So we will not pay for the loss of pets but we will pay reasonable expenses for their boarding. We'll pay motel expenses, but if it is to be prolonged I would try to help the insured find a house to rent similar to his own.

    I would try to agree upon scope of damage and negotiate an amount to cover Contents. We can only pay the ALE as they happen so as a Cat adjuster I would probably turn the claim in as an open claim and let the Carrier handle the ongoing ALE and other deferred or adjusted expenses on the back end...unless I'm still on site when they come up.

    RandyC

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    11/19/2006 3:54 PM
    Forum Transfer; Posted by dcmarlin

    This post is not to criticize but just to help avoid a potential problem. In the field, try to avoid saying "I" can pay or "I" can't pay. Refer to the company or policy, especially if you are going to deny something. It takes the onus off of you personally.
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    11/19/2006 3:55 PM
    Forum Transfer; Posted by RandyC

    That is an important reminder. I remember the first time I heard an adjuster talk like this. It sounds so arrogant! It sounds like the adjuster feels omnipotent and God-like as if before him comes one who prays for relief and the adjuster alone decides what to grant and what not to grant.

    Of course, it is meant only as a quick way to get through one point and on to another, but things like this can become habit and surely would best be avoided in adjuster small talk as well as in the presence of the insured.

    Thanks for stepping up,
    RandyC

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    11/19/2006 3:58 PM

    Forum Transfer; Posted by rass3742

    This is off to a great start; good job guys.  I have a couple of follow-up questions, to get you thinking about things you pointed out: (all of these were taken from RandyC's post, but anyone jump in with an answer).

    quote:


    If there never was a tarp, and the insureds were making up the tarp story, we could deny the claim on the basis of fraud, but I would tend to believe the insured and the insured's helpers. 



    How could you prove if the tarp existed or not?




    quote:


    If there is any old decking that is damaged from the new water entering the wind created opening, I might consider that, but I didn't see anything like that when I was crawling around in the attic, so that will have to be a suppliment. 


    Randy, can you help clarify your thought here?  If you can't find additional damage now, while the roof is opened up, how would you verify it later as a supplement?




    quote:


    If any wood floors are buckled, I'd wait to see if they return to normal upon drying.


    How long would you wait?




    quote:


    One could try to clean the carpet and even dry the padding, but that is usually not cost effective.


    The carpet, sure.  The pad, I never do.  Not cost effective, nor do I want the chance of laying carpet back over pad that may still be wet/damp; that's a mold explosion waiting to happen.  I realize there are those that will disagree with me (especially those selling top-down drying equipment and/or services), but this is my opinion and the way I would want it done if it were my house.




    quote:


    After determining the average food bill for the family we'll deduct that amount from the new food bill, but the insured will be warned that extravagant restaurant bills will paid at reasonable amounts only.


    How will you determine "reasonable?"  Your version of reasonable may not match the insured's. 


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    11/19/2006 3:59 PM
    Forum Transfer; Posted by RandyC


    quote:


    How could you prove if the tarp existed or not?



    Very good question.  This  should be dealt with first thing, since the absence of the tarp is material to the story of the claim.  If the missing tarp was purchased at the same time as the new roofing materials there should be a receipt.  If it came out of the garage, there might be an older receipt for it.  If a relative or neighbor supplied it there would be that story.  Perhaps a neighbor may have seen them putting it on as the storm blew in.  If none of these are available, I'd look around and under the edges of the new tarp for nail or screw holes other than those holding down the new tarp.  I'd ask them how they installed the first tarp.  If they look at each other nervously before they answer, I'd think maybe they stapled or nailed it lightly or less securely than the second tarp was installed.  They might hesitate to tell me they put it on poorly.  That's OK; stupid is not an exclusion, so long as they don't actually lie.  I hope they don't lie, because that would be grounds for denial and my job is to find coverage if it exists. 

    What if they had just laid a tarp over the hole and weighed the tarp down with bundles of shingles, but that blows off?  I think it would still be covered as wind blowing it off would be creating an opening from sudden physical damage by a covered peril.  What do others think?

    If I get the impression that there was never a tarp and they lied about it,  it might be time for me to take a few pictures and tell them I had what I needed for now and I'd get back to them.  Then I'd call my claim manager and get further instructions.
    quote:


    If there is any old decking that is damaged from the new water entering the wind created opening, I might consider that, but I didn't see anything like that when I was crawling around in the attic, so that will have to be a supplement. 

    quote:



    Randy, can you help clarify your thought here?  If you can't find additional damage now, while the roof is opened up, how would you verify it later as a supplement?



    I mentioned this as the stream of  thoughts and procedures that might go through my mind as I scoped this loss.  I would have considered it, and looked for it, I wouldn't expect to find it, and would not have mentioned it in my estimate.  I might take a photo from below the hole as well as above. On these photos I would note the absence of damage on the new replaced decking, and would note "old" damage to the old decking that had not been replaced yet, .   If there were new damages to the old decking arising from the physical damage, it would be covered, but I really can't imagine how there would be such damage unless some of the new decking was interior grade instead of exterior.  I mean the exterior glue should be able to withstand some water without damage.

    I wouldn't recommend we pay for any damage I didn't see.  If such hidden damage comes to light, the roofer (insured or professional) would have to uncover it and the insured would have to request a re-inspection.  If the damage was real and related to this loss...then it would be paid as a supplemental. Suppose there was delamination on the top plys only covered by old shingles not yet removed or replaced.  It would almost have to be on another slope, or I would have seen it.  I wouldn't be able to see such damage from the roof or the attic.  When they took off the shingles from this slope, found  delamanation, they might claim new damage. I would really want to see some water marks leading up to the opening in the ridge.  It would be a stretch...but it would probably be paid unless the decking was dark or rotted without link to the opening.. 

    We are really getting into fuzzy areas now, since this is only an imaginary scenario.  Like a dream every time we look at it the details  can change.  Even a nightmare type loss should have some consistency that our scenario does not :-)

    RandyC 


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    11/19/2006 4:00 PM
    Forum Transfer; posted by rass3742

    Those are pretty good answers Randy. One important thing you noted in your last post was a link to the original area of loss. If the hole that was created by this scenario was at one end of the house, then they came and said they found more damage, at the other end, you would be remiss if you didn't question the connection between the areas. Don't just take the roofers word for it. If there's no direct connection, it would be hard to recommend payment of the second area.

    This can be true in other losses as well. If you have a broken pipe below a sink on the west end of the bldg, don't let the insd talk you into water damage to the basement ceiling at the east end of the bldg. (now keep in mind, water can travel laterally, so make sure that you've investigated, but even then, it will usually only travel a few feet sideways before finding another conduit to travel down; I'm talking the more blatant "clear across the house."
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    11/19/2006 4:02 PM
    Forum Transfer; Posted by RandyC

    quote:


    If any wood floors are buckled, I'd wait to see if they return to normal upon drying


    How long would you wait?.




    If the floor has not flattened when the ambient relative humidity gets below 50% and the wood is down to 7% or 8% moisture content, I'd recommend removing and replacing it.  A very slight cupping could be sanded out, but only an expert floor man would know when and how to do that. 

    Actually, I'd call my claims manager and ask him how I should handle it.  It doesn't make sense to replace a floor that might not need replacing, but it is a rather complicated procedure requiring patience,  monitored ventilation and dehumidification.  All the drywall repair, tape, bead, and texture should be done and allowed to dry before hardwood  floors are refinished or replaced. The easy way would be to price it as remove and replace, but I don't think that would be the best way. 

    RandyC
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    11/19/2006 4:03 PM
    Forum Transfer; Posted by Russ

    Remember that you can get an advance payment for ALE with a signed lease agreement. I always try to find a house or apt. to rent rather than letting the insured stay in a hotel. Some apts and house's require first , last, and security deposit. A loss like this should not be longer than two to three months. I have gotten advances up front for 6 months on large losses. I always try to steer the insured to hiring a general contractor.(never recommend anyone). You can get an agreed price easier and a more accurate timtable for ALE.
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    11/19/2006 4:05 PM
    Forum Transfer; Posted by swink_d

    I am not experienced

    So I will just say coverage begins with a covered peril..

    added
    All the interior and contents are covered.
    The emergency tarping is covered.
    Fido is not.
    Mrs Smiths ALE is covered ( for the purpose of discussion going with what the policy says) as an accrued expense
    - Motel Bills- food receipts for her- and mileage as accrued basis to drive the additional 14 miles to work and mileage to her home to work on it
    Mrs Smiths boyfriends can be allowed minimum wage for the mitigation.

    None of the material removed before the peril is covered.
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    11/19/2006 4:07 PM

    Forum Transfer; Posted by PORTASATGUY

    SINCE HO3 IS "ALL RISK" and a BROAD FORM Policy, and Very Typical I WOULD

    • At time of receipt of loss notice, I would review coverages, amounts, deductible, and DEC sheet. UNDER THE ASSUMPTION THIS IS A BASIC HO3 POLICY, and there are NO EXCLUSIONS. I WOULD PROCEED AS A COVERED LOSS.

    • Create Activity Diary for Claim, and Notate Conversations, Times, Dates and Names, Create Claim File with Loss Notice, Activity Diary, and Notes if any.

    • Call insured, Listen to how loss was caused her story, verify coverages, verify mortgage information and make Appointment to meet and Scope Loss, have insured write an entire contents list and verify contents with possible pictures (Offer Contents Worksheet via Email or Fax) , Previous Lists, and or Receipts. And List Pricing thereto preferably on a computer. And Identify anything in personal contents that are Salvageable through cleaning, Refinishing, refurbishing, and or anything other than replacement. (Remember Coverage "C" is 50% of Coverage "A".) Also Discuss Mitigation And the Responsibility of the Insured to "PROTECT AGAINST FURTHER DAMAGES" Explain Policy Coverages & Limits with emphysis on Coverage "A" (Dwelling)  Coverage "C" (Contents)  and Coverage (D) ALE (REMEBER COVERAGE "D" IS 20% OF Coverage "A") . Update Activity Diary, Give all My Contact information 

    • Show up at scheduled appointment, Take Pictures of Front Right and Front Left of dwelling, Go to Door, Knock and introduce myself. Explain the Procedure Of  my Inspection (ROOF, FRONT ELEVATION, RIGHT ELEVATION, BACK ELEVATION, LEFT ELEVATION, INTERIOR Starting From Front Door, them onto the right side of Interior, Room to Room Damaged or Not) Take PLENTY OF PICTURES Whether Damaged or not. Document all Damages, Obtain Contents List as mentioned in Initial Call, REVERIFY CAUSE OF LOSS, Obtain Expenses Paid out for "COVERAGE "D" Which is Usually 20% of Coverage "A" under these Above Assumptions and provided there are No named Exclusions on Dec Sheet. Make sure all My Diagrams, Dimensions, Comments, Notes, Contents list, Receipts for Loss of Use, and Mitigation were in order. Finally Explain to Insured How We will Proceed, and explain how the recovery will begin, Including finding reputable contractors to perform the Work Needed. ( make Sure I saw All contents and determined if there is any Salvage Values, or Salvageable Cleaning that could be done to salvage, or save Contents with pictures thereto, Tile Floors etc. Make sure I have Many Pictures. And explain to Insured to Proceed with Roof Repairs. Leave My Contact information, And the Information of The Carrier and reiterate the Recovery Process. Excuse Myself, and inform Insured Ill be In Contact With them as soon As I Write the Estimate. Explain What was discovered, Obtain Agreed upon Scope, Determine that Insured is Happy with Scope of Loss, and All Issues are Answered Covered, And Update Activity Diary Notes with all pertinent Information.

    • Write Estimate, Utilizing Proper Depreciation and determinations of Recoverable or Non Recoverable, Research Pricing on Contents List Price Contents List with verification of Replacement costs evidencing reinforcement documents, Upload Pictures, Scan and Upload Receipts, Fill out Proper Reports, Update Activity Logs, Create Invoice, Property Appraisal reports, PDF Stack Reports in Order of Invoice, Property Appraisal Report, Completed Activity Diary, Completed Estimate, All Diagrams, and Elevations with measurements thereto, All Supporting Documents of Value's, Risk Review Report, And Finally All Supporting Pictures in Order of Inspection, Numbered Dated, And With Comments Supporting Claim.

    • Call Insured, Discuss Finding, Facts And Figures, Have Insured Agree with Scope, Estimate, And Dollr Amounts. Explain This is all Subject to Carrier Approval, Close Claim And Upload to Carrier or IA Vendor.

    THEN I WOULD CALL WHO I WAS WORKING WITH AND ASK THEM "WHERE IS MY CHECK" ; )
    THATS WHAT I WOULD DO. AND IF I HAD ANY QUESTIONS I WOULD CALL MY STORM MANAGER, UNLESS I WAS THE STORM MANAGER ; ) 

    But thats Just me!



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    11/19/2006 4:11 PM
    Forum Transfer; Posted by misty

    Between Randy C, Rass and Portasataguy, the claim is well covered. There are some things that I would like to bring up for thought.
    First, using a contractor. Check with the carrier to see if they have a list of contractors. If so, have one of them meet you at the loss to go over the claim and agree on all visable damages. This can ease the insured's mind as to what needs to be done. Remember to tell the insures that she is under no obligation to use this contractor. They are only there as a professional set of eyes. If the carrier does not have a list and will not allow a contractor to be called out by you, then do your scope, measurements and photos. In either case, go over everything with the insured everything you see.

    Second, on the contents. Call the carrier to see if a contents restoration company can meet with you at the loss. Sometimes a clean water loss will not result in as much contents damage as thought. Again, advise the insured that she is under no obligation to use this vendor. The insured may have items that are very dear to her and if they can be restored, you make the insured happy.

    Third. The laminate floor. Since it is laminate, that means that usually the flooring is not pure hardwood. there is normally a pad underneath this used as a creak reducer. This can hold in water. In today's world, anything that can hold water against wood type products can bring up the M word (mold). Be very careful. If possible, get a flooring person out to gently remove some of the planks to see what is under there.

    Fourth. Pets under ale. While the policy says that pets are not covered under C and A will not cover loss caused by pets, Cov D stated that the insured is covered for over and above normal expenses. Some companies will consider having to board the pets an additional expense. Check with the carrier.

    Finally, as has been said before, the loss will be presented to the carrier for their review and acceptance. Payment is up to the carrier. Lots of good information by the folks.
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    11/19/2006 4:12 PM
    Forum Transfer; Posted By Portasataguy

    I beleive in the KISS method, Sometime WE as Adjusters CREATE PROBLEMS FOR OURSELVES, Like calling or suggesting insured to call a contractor, or specialist, to reiterate your findings. Its Likely that the insured will call Contractors For Bids anyway. ON VERY RARE OCCASIONS there are suppliments.

    To all you Good People out there a big huge KISS to you!

    Just my opinion is all!


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    11/19/2006 4:13 PM
    Forum Transfer; Posted by texascatadjuster

    KISS -Keep It Simple Stupid
    My thoughts exactly Roy as a qualified adjuster we should not require backup from a contractor of our scope. The insured should feel confident in our ability if you do our job correctly.

    Great exercise Janice makes for interesting reading

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    11/29/2006 6:40 PM
    If you were the inside adjuster and the policyholder was on the phone with you. The coverage was on your screen for a HO-3 policy Cov. A 120,000. with a 1% Ded. The peril was a broken supply line pipe in the wall between the bath and master bedroom broke and water was seeping into the carpet in the master and the tile in the bath. Mrs insured found the cut off and turned the water off. Her husband will be home at 4PM and told her he would try to fix it himself, but to call the insurance company for advise.

    What advise would you give her ? And how would you handle this customer?
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    leaanddan
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    11/30/2006 10:27 AM
    First, I would advise her to try and remove all the standing water she could to keep further damage at bay. If her husband is able to temporarily stop the leak, I would advise her to go ahead and turn the water back on, but to call a plumber immediately. Then, I would tell her to get an estimate for repairs and to file a claim if the estimate was over $1200.
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