Property applications are often required to have a picture of the property, or an underwriter may require an inspection of the property. This is where a picture truly is worth a thousand words; pictures that show debris in the yard, loose dogs that will not let an inspector out of the car, or trees growing in the gutters are pieces of information an underwriter will use to decline a risk. Insureds have the right to file a complaint with the insurance department if they dispute a cancellation or nonrenewal. The insurance department will send a request to underwriting to explain their reasons for the cancellation or nonrenewal. Underwriters tend to be analytical and must be able to explain why a risk has been declined, nonrenewed or canceled.

Loss Control

The loss control representatives work through the commercial underwriting department. They visit commercial properties to verify that the property meets the eligibility guidelines for the company. They will review a company's work processes, safety procedures, storage areas, and other elements to ensure that the company is an acceptable risk. While a loss control inspection doesn't warrant that the property is safe, the loss control department will make recommendations to a company for best practices. For example,  loss control will verify that the employees are wearing protective gear, that machinery has proper safety features installed and operational, and other things that would prevent injury or property damage.

Actuary 

While the underwriters approve or decline the risk, the actuary sets the rates. An individual must pass a series of difficult exams in order to become an actuary. Actuaries are very analytical and look at loss data as well as other variables to determine how to establish adequate rates for every type of risk, and what types of variables should be considered in the development of the rates. For example, the actuary determines that males between the ages of 16-25 have poor driving skills and that their rates need to be higher. Actuaries must be sure that the rates are adequate so that the company is able to pay claims when they arise and cover expenses. Statistics are a very large part of the data actuaries review in order to determine rates. Actuaries also determine where discounts may be applied to certain coverages. All rates must be filed with the insurance department for approval, and actuaries will create and submit those filings to the insurance department. They will field any questions the department has concerning the proposed rates. Actuaries are very mathematical and numbers oriented, and are incredibly analytical.

Claim Call Center Representatives 

Once the policy has been underwritten, rated, sold, and the policy issued, it may sit there for years without a loss. However, if a loss occurs, a number of different professionals will be involved. An insured may call his agent or the company call center. The call center is staffed with service representatives who will take all the information about the loss – what kind of damage happened to what property, were there injuries, when did the loss occur, what was the cause of loss, and other details. The representative will then assign a claim number to the loss and assign a claim adjuster who works in that area or that type of loss. Depending on the type of loss, it may be assigned to an inside or outside adjuster.

Adjusters

Inside adjusters are company employees who will handle injury claims, liability claims, glass and towing claims; auto claims when the vehicle is a total loss; basically any claim where the adjuster does not need to see the damage. For auto claims the inside adjuster will also set up the insured with a rental car if it is needed and that coverage is available on the policy. A carrier may at times use non-employee adjusters for areas they do not have an office in or for catastrophic losses.  With the increase in technology more and more companies are allowing insureds to photograph the damage and email it to an adjuster, so more claims are being handled internally.

 Outside, or field, adjusters will go to the site of the property and inspect the damage; for vehicle losses, there may be a drive-in center, although carriers more commonly work with repair shops to review the damages for them or have the insured send in photos of the damage. Outside adjusters will review the cause of loss and the resultant damage, and are generally assigned a particular area to work so they can efficiently handle claims without being spread too far out. They will also review the policy coverages and exclusions, in order to determine if there is coverage for the loss. They will advise the insured if the damage is covered or not and will process the claim from there.

Following company guidelines, they will handle salvage property, set up contractors for repairs, set up the insured in substitute housing or offices if the damaged building is uninhabitable, and settle the claim. At times the claim will be handed off to an inside adjuster for completion. Once coverage has been determined, an inside adjuster may work with a repair shop or contractor to complete the repairs while the field adjuster goes on to look at other losses. Like agents, claims adjusters are often personable and enjoy working with people. They must also have specific training so they know what type of damage has occurred and whether the property is repairable. Injury adjusters need to have some degree of medical knowledge to know if the injuries being claimed are likely to have been caused by the type of accident reported.

Public Adjusters

Public adjusters do not work for the insurance company but work for the insureds. Their role is to help insureds assess the damage and file a claim with the company. They help the insured understand coverages, document damages, and ensure that the insured is paid correctly by the insurer for the loss. The public adjusters are hired by the insured and are also paid by the insured for their services.

Special Investigators

 However, not all claims are legitimate, and there may be indications that everything is not as it seems. A field or inside adjuster who suspects that something fraudulent is happening will then assign the claim to a special investigator. Special investigators are trained to spot inconsistencies in the details of a claim and interview the claimant to try to determine what actually happened. They may look at the salvage and talk to fire or police personnel to determine what actually happened. Often special investigators are former police officers trained to interview people. They may surveil the claimant or verify addresses and confirm that the claimant lives where he says he does. Fraud is an enormous issue for the insurance industry, and special investigators are very important in detecting fraud.

Attorney

 Insureds and claimants at times will sue the company when they feel they have been treated unfairly in a claim. When a company is sued, they may have an employed in-house attorney who will handle the case for the company. The in-house attorney will review the suit and the claims files in order to determine if the declination or the amount of settlement was reasonable, and will deal with the claimant's attorney and represent the company in the case if and when it goes to court.

IT

 Like many corporations, insurance companies use computer systems to store insured's data including who and what is covered, what coverages are on the policy, have payments been made, and other information. Accounting tracks premium and claim payments. Information Technology (IT) systems ensure that the policies are correctly rated according to the actuarially defined specifications. A reduction may need to be added to the premium calculation at a particular point in the rating process, and it is IT's duty to ensure that the system properly rates the policy and tracks premium and claim payments.

Auditors

Many insurance companies employ staff auditors who are responsible for periodically reviewing underwriting and claims files for compliance with state regulatory requirements. This enables a company to monitor its own employees and make sure that the decisions made and the forms and rates applied are in accordance with the company filings made with the state. In addition, some commercial policies with fluctuating exposures are written on an auditable basis. At the end of the policy term, the exposures used in pricing and writing the policy will be matched against the insured's actual exposures for that year, and depending on the result the insured may be required to pay an additional premium or receive a return premium if the exposures were less.

Compliance

Finally, yet importantly, some carriers maintain staff to ensure the company policies and procedures comply with state regulations and aware of new bulletins. Agents must be properly licensed and appointed, and carriers need to know that agents' licenses have been renewed. Legal staff may review new coverage forms before they are filed.

Original 2/2018