AMF Claims Adjuster (Quebec) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Insuring agreement

The clause that states what the insurer promises to cover; in property insurance it identifies covered property and perils, and in liability insurance it identifies the obligation to pay damages and defend.

Actual cash value

The replacement cost of damaged property minus depreciation, reflecting the property's value at the time of loss; used when the policy settles on an ACV basis.

Replacement cost

The cost to repair or replace damaged property with new property of like kind and quality, without deduction for depreciation, subject to policy conditions such as actually repairing or replacing.

Coinsurance clause

A property policy provision requiring the insured to carry insurance equal to a stated percentage of the property's value; if underinsured, the indemnity is reduced by the ratio of carried to required insurance.

Deductible

The amount of each loss the insured must bear before the insurer pays; it is subtracted from the covered loss before applying the limit, unless the policy states otherwise.

Proof of loss

A sworn statement by the insured detailing the loss, the property damaged, and the amount claimed; the policy sets the time to file it and the insurer may require supporting documents.

Reservation of rights

A written notice by the insurer that it will continue investigating or defending a claim while preserving the right to deny coverage later; it must identify the specific coverage issues.

Subrogation

The insurer's right, after paying a claim, to step into the insured's shoes and pursue recovery from the third party responsible for the loss, up to the amount paid.

Insurable interest

A financial interest in the property or liability insured such that the insured benefits from its preservation or suffers loss from its damage; required at the time of loss for property claims.

Utmost good faith

The duty of both insurer and insured to act honestly and disclose material facts; in Québec, the insurer must act in good faith toward the insured under the Civil Code.

Material misrepresentation

A false statement by the insured that would influence the insurer's decision to accept the risk or set the premium; it may entitle the insurer to rescind or reduce indemnity.

Prescription period

The time within which a legal action must be brought; for insurance claims in Québec, the general period is three years from the day the right of action arises, subject to specific rules.

Occurrence policy

A liability policy that covers injury or damage that happens during the policy period, regardless of when the claim is made, provided the policy was in force at the time of the occurrence.

Claims-made policy

A liability policy that covers claims first made against the insured during the policy period, subject to a retroactive date; the occurrence date may be earlier.

Duty to defend

The insurer's obligation to provide a defence for the insured against claims potentially covered by the policy; it is broader than the duty to indemnify and may apply even if coverage is uncertain.

Duty to indemnify

The insurer's obligation to pay damages the insured is legally liable to pay, up to the policy limit, once coverage and liability are established.

Per-occurrence limit

The maximum amount the insurer will pay for all damages arising out of a single occurrence or accident, before applying any aggregate limit.

Aggregate limit

The maximum amount the insurer will pay for all covered claims during a policy period, in addition to any per-occurrence limit.

Independent counsel

A lawyer chosen by the insured and paid by the insurer when a conflict of interest prevents the insurer-appointed lawyer from representing the insured fairly.

Bad faith refusal

An insurer's unreasonable denial or delay in paying a claim without a reasonable basis; it may expose the insurer to damages beyond the policy limit.

Salvage

The remaining value of damaged property after a loss; the insurer may take salvage when it pays a total loss, and salvage value is credited against the claim.

Abandonment

The insured's surrender of damaged property to the insurer; the insured may not abandon property unless the policy expressly permits it.

Mitigation duty

The insured's obligation to take reasonable steps to prevent further damage after a loss; failure may reduce the amount recoverable if it increases the loss.

Business interruption

Coverage for lost profits and continuing expenses during the period of restoration after a covered property loss, subject to a waiting period and a policy limit.

Period of restoration

The time reasonably required to repair or replace damaged property to its pre-loss condition; business interruption benefits are paid for this period, subject to policy terms.

Notice of loss

The insured's prompt notification to the insurer of a loss; failure may reduce or defeat the claim only if it prejudices the insurer's ability to investigate.

Examination under oath

A formal interview of the insured, under oath, conducted by the insurer during claims investigation; the policy may require cooperation and the insured's answers may be used in coverage disputes.

Coverage opinion letter

A written communication from the insurer or adjuster to the insured explaining the coverage position, the policy provisions relied on, and the reasons for acceptance, denial, or reservation of rights.

Conflict of interest

A situation where the adjuster's or insurer's personal or financial interest could influence the handling of a claim; it must be disclosed and managed, and may require independent counsel.

Delegated authority

The limit of settlement or payment authority granted by the insurer to the adjuster; commitments above that limit require approval from a higher authority.

Third-party claim

A claim brought by a person injured or whose property was damaged by the insured, which the liability insurer must investigate, defend, and possibly indemnify under the policy.

Retroactive date

The date in a claims-made liability policy before which occurrences are not covered; claims made during the policy period for occurrences before that date are excluded.