AMF Claims Adjuster (Quebec) cheat sheet

The adjuster's core duties are to investigate the loss, determine coverage under the policy, quantify the indemnity, and report to the insurer; the adjuster acts for the insurer, not as an arbitrator between parties.

A claim file must document: the policy and endorsements in force, the date and cause of loss, the insured's duties after loss, proof of loss, damage quantification, and the coverage decision with reasons.

The adjuster must distinguish indemnity (what the policy pays) from expenses (investigation, experts, defence costs) and must know which limit or sub-limit each item is charged against.

Reservation of rights: when coverage is uncertain, the insurer may continue investigating while reserving its rights; a reservation letter must identify the specific coverage issues and must not be treated as a denial.

Conflict of interest: an adjuster must not act on a file where a personal or financial interest exists; the duty of loyalty runs to the insurer, while the duty of good faith runs to the insured.

Subrogation: after paying, the insurer is subrogated to the insured's rights against the third party up to the amount paid; the adjuster must preserve evidence and avoid prejudicing those rights.

Salvage and abandonment: the insured may not abandon damaged property to the insurer unless the policy so provides; salvage value is credited against the loss.

The adjuster's authority is limited by the mandate from the insurer; settlements above the delegated authority require approval, and unauthorized commitments may not bind the insurer.

Good-faith handling requires prompt communication, a reasonable investigation, a clear coverage position, and no misrepresentation of policy terms to the insured.

The Civil Code of Québec (C.C.Q.) governs insurance contracts in Québec; the insurer's obligation is to indemnify the insured for loss covered by the policy, and the insured must pay the premium.

Insurer's duty of good faith (C.C.Q. art. 1375 and insurance provisions): the insurer must act in good faith toward the insured; breach may give rise to damages independent of the policy indemnity.

Misrepresentation and concealment: a false declaration that reduces the insurer's risk assessment may entitle the insurer to rescind or reduce indemnity; the insurer must prove the misrepresentation was material and made in bad faith for certain remedies.

The policy is interpreted in favour of the insured where a clause is ambiguous; exclusions are interpreted narrowly and coverage clauses broadly.

Notice of loss: the insured must notify the insurer promptly; failure may reduce or defeat the claim only if it prejudices the insurer.

Proof of loss: the insured must provide a sworn proof of loss within the time set by the policy; the insurer may require examination under oath and production of documents.

Prescription: the limitation period for a claim under an insurance contract is generally three years from the day the right of action arises (C.C.Q. art. 2925), subject to specific rules.

Insurable interest: the insured must have an insurable interest in the property at the time of loss; a person without insurable interest cannot claim indemnity.

Subrogation and conventional subrogation: the insurer that pays is subrogated to the insured's rights against the responsible third party, up to the amount paid, and may exercise them in the insured's name.

Coverage trigger: the policy covers direct physical loss or damage to insured property caused by a covered peril; the insured bears the burden of proving the loss falls within the insuring agreement.

Exclusions: the insurer bears the burden of proving an exclusion applies; common exclusions include wear and tear, deterioration, faulty workmanship, intentional acts, and vacancy.

Actual cash value (ACV) = replacement cost minus depreciation; replacement cost value (RCV) pays the cost to repair or replace with new property of like kind and quality, subject to policy conditions.

Coinsurance clause: if the insured carries less than the required percentage of the property's value, the indemnity is reduced by the ratio (insurance carried ÷ insurance required) × loss, subject to the policy limit.

Deductible: the deductible is subtracted from the loss before applying the limit, unless the policy states otherwise; separate deductibles may apply to specific perils.

Business interruption: coverage typically pays lost profits and continuing expenses during the period of restoration, subject to a waiting period and a limit; the adjuster must verify the period and the financial records.

Proof of loss and documentation: the adjuster must obtain inventories, receipts, photographs, and expert reports; the insured must cooperate and mitigate the loss.

Total loss and salvage: in a total loss, the insurer may pay the limit and take the salvage; the insured cannot recover more than the limit of insurance.

Replacement cost conditions: the insured must actually repair or replace the property within the time stated in the policy to recover the full replacement cost; otherwise, the claim is settled on an ACV basis.

Insuring agreement: the insurer agrees to pay sums the insured becomes legally obligated to pay as damages because of bodily injury or property damage caused by an occurrence, and to defend the insured.

Occurrence vs. claims-made: an occurrence policy covers injury or damage that happens during the policy period; a claims-made policy covers claims first made during the policy period, subject to a retroactive date.

Duty to defend: broader than the duty to indemnify; the insurer must defend if any allegation in the claim is potentially covered, and defence costs are usually outside the limit unless stated otherwise.

Exclusions: common exclusions include intentional acts, contractual liability, pollution, professional services, and damage to the insured's own property; the insurer must prove the exclusion applies.

Reservation of rights and independent counsel: when a conflict of interest arises between insurer and insured, the insurer may have to pay for independent counsel chosen by the insured.

Limits: per-occurrence and aggregate limits; defence costs may erode the limit; the adjuster must track payments against each limit.

Settlement: the insurer may settle within policy limits; a failure to settle within limits in good faith may expose the insurer to liability for the excess judgment.

Third-party claims: the adjuster must investigate liability, gather evidence, interview witnesses, and assess damages, while protecting the insured's interests and privacy.

Subrogation and recovery: after paying a liability claim, the insurer may pursue recovery against other responsible parties, subject to the policy and legal rights.