FL Claims Adjuster cheat sheet

Florida's Department of Financial Services (DFS), headed by the elected Chief Financial Officer, licenses agents and adjusters and handles consumer complaints.

The Office of Insurance Regulation (OIR), whose Commissioner is appointed by the Financial Services Commission, reviews insurer rates, policy forms and solvency.

License classes include 2-20 General Lines, 2-15 Life/Health/Variable Annuity, 4-40 Customer Representative, 6-20 All Lines Adjuster and 3-20 Public Adjuster.

An insurer must file a notice of appointment with DFS before a licensee may act on its behalf; termination of the appointment must also be reported.

Continuing education: 24 hours per two-year license period, including a 4-hour Law and Ethics Update course specific to the license type.

Administrative fines run up to $5,000 per non-willful violation and $10,000 per willful violation, in addition to suspension or revocation of the license.

FIGA pays covered claims of insolvent Florida property and casualty insurers, generally capped at $300,000 per claim; surplus lines and unauthorized insurers are not covered.

Surplus lines coverage must be placed by a licensed surplus lines agent with an eligible unauthorized insurer, filed through the FSLSO, with a required disclosure statement.

Public adjusters must hold a 3-20 license, file a $50,000 surety bond, and limit fees to 20% of the claim payment, or 10% when a state of emergency has been declared.

Indemnity means the insured is restored to approximately the pre-loss financial position and cannot profit from a loss.

Insurable interest must exist at policy inception for life insurance and at the time of loss for property insurance.

ACV = replacement cost minus depreciation; replacement cost pays for new property of like kind and quality, usually after repair or replacement.

Coinsurance payment = (limit carried divided by limit required) multiplied by the loss, then reduced by the deductible.

Adverse selection is the tendency of high-risk insureds to buy or retain coverage; underwriting, deductibles and exclusions counter it.

Hazards are classified as physical (fire, ice), moral (dishonesty, intentional loss) and morale (carelessness, indifference).

Subrogation lets the insurer pursue the responsible third party after paying a loss; salvage is the insurer's right to take the damaged property.

Proximate cause is the uninterrupted cause that sets the loss in motion; direct loss follows immediately while consequential loss follows indirectly.

Insurance contracts are contracts of adhesion, conditional, unilateral and aleatory, and ambiguity is construed against the drafter.

Policy structure follows DICE: Declarations, Insuring Agreement, Conditions and Exclusions.

HO-3 insures the dwelling on an open-peril basis and personal property on a named-peril basis; HO-5 is open peril for both.

Typical homeowners limits: Coverage B about 10% of Coverage A; Coverage C commonly 50-70% of Coverage A and Coverage D commonly 30%.

Dwelling fire forms: DP-1 basic, DP-2 broad, DP-3 special; DP forms cover the dwelling and generally do not include personal liability.

Florida residential policies must state hurricane deductibles as a percentage of Coverage A (commonly 2%, 5% or 10%) and disclose the deductible conspicuously.

Duties after loss: prompt notice, protect property from further damage, cooperate, submit proof of loss, allow inspection, and make no voluntary payments.

A mortgagee clause protects the lender with loss payments, notice of cancellation, and non-voiding of coverage for the insured's acts.

Common property exclusions: ordinance or law, earth movement, flood, neglect, intentional loss, and wear and tear.

Commercial causes of loss forms are basic, broad and special; a BOP combines property and general liability coverage for small businesses.

Claims cycle: report and acknowledge, verify coverage, investigate, document, evaluate damages, negotiate, pay or deny in writing, and close the file.

Florida requires insurers to acknowledge and act promptly on claim communications and to pay or deny a residential property claim within 60 days after a completed proof of loss.

A reservation of rights letter preserves the insurer's coverage defenses; a non-waiver agreement is signed by the insured for the same purpose.

Investigation evidence: policy and endorsements, date and cause of loss, photos and measurements, recorded statements, prior claims history and subrogation potential.

Fraud indicators include recent policy inception or limit increase, prior losses, inflated or handwritten inventories, altered receipts and inconsistent statements.

An examination under oath and a sworn proof of loss are policy conditions; material misrepresentation in either can defeat the claim.

Appraisal resolves disputes over the amount of loss, not coverage; each party selects an appraiser and the appraisers select an umpire.

Under Fla. Stat. 624.155 a Civil Remedy Notice must be filed with DFS and the insurer, which has 60 days to cure before a bad-faith action.

Unfair claim practices include misrepresenting policy provisions, failing to investigate, denying without explanation, and offering substantially less than the amount due.

Fla. Stat. 626.9541 lists unfair trade practices: misrepresentation, twisting, false advertising, boycott, coercion, unfair discrimination, rebating and illegal inducements.

Twisting is a misrepresentation that induces a policyholder to lapse or replace coverage; churning is repeated replacement for commission.

Rebating is offering anything of value not stated in the policy as an inducement; the insured may keep the benefit while the licensee is disciplined.

Premium funds handled by a licensee are held in a fiduciary capacity; commingling or failure to remit is a violation and may be a crime.

Unfair claim settlement practice focuses on the act or the pattern of conduct rather than intent; a single willful act can be actionable.

Bad faith under section 624.155 requires a civil remedy notice and a 60-day cure period; the duty runs to the insurer's own insured.

Adjusters must disclose conflicts of interest, must not acquire an interest in salvage or claim proceeds, and must protect confidential insured information.

Insurance fraud, including presenting a false claim, is a felony; good-faith reports to the Division of Investigative and Forensic Services carry immunity.