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Last Post 08/17/2012 3:10 PM by  Medulus
You receive a commercial claim assignment
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ChuckDeaton
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08/11/2012 8:28 AM
Certainly the answer to what can be covered is an unqualified YES. Any element of any business can be provided cover in a brokered manuscript policy. There are brokers who specialize in this area, Arthur J. Gallagher comes to mind. Trees are frequently provided coverage and, at least in some instances, individual trees are provided coverage. Hail damage cover for landscape features such as greens, shrubbery, trees and lawns can also be provided in brokered manuscript policies written by the non-admitted market. My expectation is that the manuscript and schedule detailing cover for Augusta National is several inches thick and entails literally hundreds of pages. Note that my initial suggestion was to secure a copy of the coverage before making any decision to accept the loss. If the assignment springs from a source that cannot immediately supply a complete copy of the policy it is very likely that your efforts will go unrewarded.
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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sbeau4014
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08/12/2012 12:02 PM
Just a note on this thread in that I would guess most larger more established golf courses and country clubs would carry the "Greens, Tees and Fairways" endorsement that some of the larger carriers may specialize in. I know that St Paul Ins (Travelers) started writing this type of coverage around 1988 and when Hugo hit in 89 every golf course/country club we insured in SC had it. It was a great endorsement for the insureds and they could get cover from $50k up to $250k, and wind/hail damage to the trees was covered (an intregal part of the fairways). In a hurricane situation like that the destruction to the trees, greems and fairways will almost always mean a policy limit for those endorsements.
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ChuckDeaton
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08/12/2012 1:29 PM
http://www.ksre.ksu.edu/library/hort2/mf632.pdf

A publication I used for years to assist in writing estimates involving damage to trees and shrubs.
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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HuskerCat
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08/14/2012 9:48 PM

Initial settlement has been made on this claim now, after the loss was re-assigned.

IA #2 responded immediately to me the evening of reassignment.  I had left him my personal cell # & we discussed the coverages available.  If there were any questions, he would call me back.  #2 met with the insured the following day.  It was a 2 hr drive, with a subsequent time spent of 6 hours with the clubhouse manager/controller, head greens keeper, and local tree service contractor.  There were no real coverage questions, except for damage to some pothole bunkers and a wooden bridge that led to an island hole.

Rather than provide 398 pages of policy forms/endorsements to the IA, we spent 15 minutes on the phone initially and another 10 during his inspection.  The coverage is Blanket Real & Personal Property in the amount of $28.5M which includes the clubhouse, banquet facility, 12 unit lodging, tennis/pool & fitness facility, maintenance buildings, halfway house (9th hole concessions), restrooms, etc.;  additional coverages are added for "debris removal of covered property" in the amount of $250K.  There are more than 24 endorsements added to the form, of which the most applicable is the "tee to green".  This endorsement not only defines "covered property", but also amends the specified perils for damage to trees, shrubs, etc., to include the perils of wind or hail.  There is also an endorsement adding limited flood coverage to this particular insured, but it did not come into play.  Had it come into play, there was also another endorsement that re-defined "flood", meaning it included surface water as a covered cause of loss.  However, another endorsement re-defines the exclusions and explains that bunkers & fairways are not covered for flood or surface water....unless endorsement XYZ is added, and then the loss is covered up to the amount shown on the declarations of endorsement XYZ.

It can go on & on, as these are all tailored to fit the insured.  And these only address the property coverages, not their liability, work comp, auto, etc.

I'll move on to a new window now.

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HuskerCat
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08/14/2012 9:52 PM
First, to answer some questions, and respond to some prior posts...I'll go in reverse order, starting with Chuck's offering of a source.
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HuskerCat
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08/14/2012 10:22 PM
Posted By ChuckDeaton on 12 Aug 2012 01:29 PM
http://www.ksre.ksu.edu/library/hort2/mf632.pdf

A publication I used for years to assist in writing estimates involving damage to trees and shrubs.

This source provided by Chuck is very similar to what I provide to the field IA's, or use myself.  The only difference is the current pricing, the tree species selections, and that the excel sheet I provide to them calculates the tree values once you plug in the variables.  Chuck's might do that also, but maybe not in the format he was able to download here.

IA #2 used this for us on this assignment, as he had previously.  Since we had discussed the coverage, we had solid information after his inspection with the head greens keeper & local tree service.   As directed, the IA identified all destroyed and/or damaged trees & shrubs.  They toured the entire 18 holes, and marked the trees that had been or needed to be removed.  All were photo'd with a tape measure of the stump or remaining tree.  A copy of the course map was scanned, and each tree numbered/ID'd for documentation.

This particular coverage form allowed up to $5K per tree/shrub/plant "if replaced".  Many of the trees destroyed were mature and exceeded the limit, thus absorbing the deductible.  Debris removal, as mentioned in the previous post, is a separate issue, so not integral to the $5K limit per tree.


 

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HuskerCat
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08/14/2012 10:42 PM
Posted By ChuckDeaton on 11 Aug 2012 08:28 AM
Certainly the answer to what can be covered is an unqualified YES. Any element of any business can be provided cover in a brokered manuscript policy. There are brokers who specialize in this area, Arthur J. Gallagher comes to mind. Trees are frequently provided coverage and, at least in some instances, individual trees are provided coverage. Hail damage cover for landscape features such as greens, shrubbery, trees and lawns can also be provided in brokered manuscript policies written by the non-admitted market. My expectation is that the manuscript and schedule detailing cover for Augusta National is several inches thick and entails literally hundreds of pages. Note that my initial suggestion was to secure a copy of the coverage before making any decision to accept the loss. If the assignment springs from a source that cannot immediately supply a complete copy of the policy it is very likely that your efforts will go unrewarded.
My response to this (and Leland's as well), is that you are correct.  The coverage forms & endorsements can entail hundreds of pages.  Once I've gotten a general scope of the loss from the insured, it probably isn't necessary to burden the IA with spending hours reviewing the coverage.  I'd rather spend the time with them on the phone initially, and however long is necessary on the phone from the site or while they are putting their report together.  Coverage decisions are the responsibility of the carrier, not the IA.  I will never ask an IA to prepare a ROR letter, nor should anyone, unless there is some kind of agreement between a carrier and an IA firm.  That happened to me about 15 years ago as a branch IA, when a carrier requested that I send a ROR letter but didn't provide us with specific coverage forms.  I refused pending receipt of the policy, and we lost the assignment.  Our branch also lost the account, but my manager had my back.   
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Leland
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08/14/2012 11:53 PM
I would like to clarify my earlier comments, and also respond to some of the new details Mike has provided.

Personally, I would be willing to go to the loss without a copy of the policy, I just would be very wary of doing so and even more wary of trying to proceed much further after the inspection.

What Mike is doing here to provide the policy analysis changes the math a little bit. If my file examiner is going to read the policy for me and tell me what is covered, maybe I don't need to read it myself or maybe I can wait until after my inspection.

But, as in any relationship, some boundaries should be defined. Who is relying on who?

If I make an incorrect payment recommendation, is it my fault for only having a verbal description of the coverage?

I want to be a team player, but I also want to be professional, and make sure there is no misunderstanding. After all, a third party (like a jury) might read my report.

So I could do the inspection and report without a copy of the policy, but my report might look like this:

COVERAGE

It is our understanding that the coverage includes blah blah blah and xyz. We have not reviewed a copy of the policy as of the date of this report, so any opinions expressed herein must be viewed in that light. This report does not make any coverage determination, and we are not certain what coverages, exclusions, limits or deductibles may apply. We have prepared a schedule of the loss and damage but have not prepared a Statement of Loss for the reason above. Our schedule of loss should not be relied on as an accurate accounting of what may be owed under the policy. Our understanding of the coverage is based on a conversation with Mr. Smith of the company on April 1, 2011. We request that the company provide a copy of the coverage as soon as possible and also carefully review our report for any coverage issues we may not have been aware of.


If the adjuster types something like this it will protect both the adjuster and the company. It might irritate the file examiner, but if for some reason the company doesn't pay something due to a coverage issue the company will also be somewhat protected from a false claim of bad faith. And if the company wants a Statement of Loss they have several choices: 1) send the policy 2) tell the adjuster what figures to use 3) send the adjuster a written synopsis of the coverage.

If the company uses #3, the adjuster can send a second report that says:

..... Our understanding of the coverage is based on an email from the company dated April 4, 2011. .....

Regarding the ROR letters:

There is new case law that just came out (I can't remember what state!) that says the ROR letter needs to be specific. If the carrier doesn't give specific reasons, they can't raise them later as a defense.

So if the carrier issues a ROR for one possible coverage exclusion, but fails to mention a second reason, they might be precluded from using the second reason later on.

Even if this is not yet recognized case law in your state, it makes sense: When writing a ROR letter, put all of the specific reasons the claim is under investigation for possible denial. That's why the adjuster's shouldn't write them, unless the carrier specifically asks them to, and hopefully helps them write a good one.
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ChuckDeaton
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08/15/2012 11:50 AM
"That happened to me about 15 years ago as a branch IA, when a carrier requested that I send a ROR letter but didn't provide us with specific coverage forms. I refused pending receipt of the policy, and we lost the assignment. Our branch also lost the account, but my manager had my back." HuskerCat

This is one of a catastrophe adjuster's worst nightmares. The adjuster jumps on the claim, makes contact, visits a large loss and has time invested. Then has the loss jerked and reassigned. Best to insist on the the coverage and suffer the reassignment prior to investing time and effort. The fact that your manager has your back does not put beans on the table.
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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HuskerCat
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08/15/2012 10:02 PM
Posted By ChuckDeaton on 15 Aug 2012 11:50 AM
"That happened to me about 15 years ago as a branch IA, when a carrier requested that I send a ROR letter but didn't provide us with specific coverage forms. I refused pending receipt of the policy, and we lost the assignment. Our branch also lost the account, but my manager had my back." HuskerCat

This is one of a catastrophe adjuster's worst nightmares. The adjuster jumps on the claim, makes contact, visits a large loss and has time invested. Then has the loss jerked and reassigned. Best to insist on the the coverage and suffer the reassignment prior to investing time and effort. The fact that your manager has your back does not put beans on the table.
In this case, T&E beans were paid.  I'd provided a full investigation & scope/estimate of the loss, but pointed out that there were coverage questions in my mind (having had 10 years prior staff experience, but no coverage language provided).  The carrier examiner realized too late into the game that it was a sizable loss that required a GA to be assigned (per their own parameters), and since I did not carry that particular designation nor did we have anyone who could "claim to be" a GA...the loss was reassigned.  To this day I don't know what transpired, but I suspect the carrier examiner (or someone at the carrier office) authored an ROR letter as they should anyway, and/or provided the entire specific policy documents to the GA.  This was not a complicated loss, just large $-wise based on quantity of damaged property with issues involving frozen pipes & water damage to a vacant 8-story commercial building.    

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ChuckDeaton
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08/16/2012 8:26 AM
Just another pitfall for the working field adjuster to be wary of, once the loss is inspected and a reserve set, suddenly it is too large for the assigned adjuster and has to be reassigned to a General Adjuster.

Generally speaking, I author letters to be sent to the insured, including Reservation of Rights letters, and forward them to the desk adjuster/reviewer for consideration.
 
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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Banyan Rider
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08/17/2012 7:35 AM
This isn't a thread, it reads like part of a certification course!

Very informative, detailed, and every sentence seems weighted with extremely important decisions. Reading this feels like a training book I purchased.
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Medulus
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08/17/2012 2:55 PM
Concerning ROR Letters, the standard in California (where I began my adjusting career in 1990 and am working once again these past 5 years) has been that Reservation of Rights must be specific and cover all possible coverage issues as soon as they are known to be an issue. The carrier generally cannot even raise a coverage issue, no matter how obvious, that has not been raised fairly early on in the claims handling. I have written a lot of these letters. On the plus side, a good ROR letter can serve as the framework for a good denial letter if the coverage issues are not resolved in a way that allows for coverage. One can take a well written ROR letter, delete the issues that that investigation reveals are not reasons for denial, leave the ones that are reasons for denial, and update the letter with details about the findings of an investigation and - voila- a denial letter. I personally do not entrust ROR or Denial letters to independent adjusters and do not believe it is the IA's place to deny a claim on behalf of the carrier. I work with excellent independent adjusters like Lee Baker and John Nieman in Florida, Jud Gardner in Alabama, Craig Burdick, Jim Cullen and Doug Jackson in Southern California, Kevin Hromas in Texas, and others. Many of these people are either more experienced or more knowledgeable (or both) than I am, but it is still my job as carrier staff - not the IA's job - to prepare, sign, and send any Reservation of Rights or Denial letters. Often these take some time and a good deal of knowledge about the claim before they can be sent out. That is why I earlier recommended that the IA should handle the claim under a non-waiver until there is enough information to write a cogent ROR letter (while still not delaying the ROR for very long).

Of course, any good claim adjuster will:
1. Read the policy and not trust to her/his memory.
2. Recognize coverage issues based on a reading and understanding of the policy language.
3. Always look for a way to cover the loss rather than deny the loss.
4. Recommend denial only if there is no ambiguity that can be interpreted in the insured's favor.
Steve Ebner CPCU AIC AMIM

"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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Medulus
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08/17/2012 3:10 PM
As an aside to the main point of this thread, here is a sample set of instructions. Most experienced adjusters have seen these many times. Some of the newer adjusters may be unfamiliar with these types of documents. My suggestion is that when you are assigned a claim for a carrier you have not worked with before, you ask your independent adjusting firm if that company has specific written instructions and obtain a copy of them. It will greatly decrease your returned assignments if you read and follow the directions. These instructions are carrier-specific so do not use the instructions provided by one carrier to fulfill an assignment by another carrier. Here is the substance of one such document:


Property Claims Handling Instructions for Independent Adjusters

1.Assignments: Many assignments will be accompanied by specific instructions. In the absence of specific instructions, assignments should be accepted as full adjustments. Accept claims only from the claim department of XYZ Insurance Company.
2.Coverage Verification: XYZ will supply necessary documents and policy forms to indicate coverage and alert the adjuster to potential coverage questions. XYZ will make all coverage determinations and prepare all reservation of rights and denial letters. The adjuster may prepare a non-waiver if there is valid reason to believe a coverage issue exists. The adjuster is not to commit XYZ to coverage. Handle all claims where there is a question of coverage under a non-waiver or reservation of rights.
3.Reporting Requirements: Contact Insured within 24 hours. Acknowledgement within 48 hours. First Report within 20 days. Scope and cause of loss with reserve recommendations should accompany first report. Subsequent Reports: Every 30 days unless otherwise requested by XYZ. Contact XYZ immediately upon inspection if reserve will exceed $100,000.00 or if any issue of coverage or possibility of SIU involvement is discovered.
4.Settlement Authority: Unless otherwise instructed, the assigned adjuster has no settlement authority.
5.Checks: Issued by XYZ.
6.Reports: Reports should be full captioned reports with all supporting documents attached.
7.Billing: All assignments should be handled at time and expense according to our agreed rates. Phone and fax charges are included in the hourly rate. Set up should be charged at clerical rates not to exceed one hour.
8.Statements: Statements should be taken when requested by XYZ.
9.Subrogation: Investigate subrogation on all claims. Preserve all evidence. Inform XYZ immediately if an expert is needed for subrogation investigation.
10.Photographs: One photo of risk and enough photos to document the damage, or lack of damage where damage might be expected.
11.Experts: XYZ’s approval required. In many cases XYZ will ask the expert to report directly to them.
12.Public Records: Only if advised by XYZ
13.Valuations of the Risk: If requested to do so, provide detailed calculations to demonstrate Replacement cost, depreciation and ACV of the risk.
14.Estimate: Whenever possible, the adjusters are to prepare their own estimate using an automated estimating program including both RCV and ACV figures. This should be done whether there appears to be coverage or not. Do not release the estimate to the insured before we approve it. In most cases a preliminary estimate should accompany the first report. Each line of coverage and element of the loss is to be written as a separate estimate. Do not include more than one building, or building and business personal property, on the same estimate. When the loss involves specialty items that are not generally included in the database of automated estimating programs, it is acceptable to use reasonable contractor estimates. If a portion of the loss may not be covered, prepare a separate estimate for that portion of the loss.
15.Business Personal Property/Contents: Use of replacement vendors should be considered on large business personal property claims. Consult with the XYZ examiner for qualified replacement vendors.
16.Salvage: Always investigate salvage. When possible sell it back to the insured for a reasonable amount. Otherwise, inform us of salvage potential and advise the insured to retain the salvage for our disposal.
17.Proof of Loss/Release: Obtain a proof of loss or release if instructed to do so by XYZ.


Steve Ebner CPCU AIC AMIM

"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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