ME Claims Adjuster cheat sheet

Maine's unfair trade practice law is 24-A M.R.S. §2161 et seq.; the Unfair Claims Settlement Practices Act is 24-A M.R.S. §2436-A, enforced by the Superintendent of Insurance.

A claimant receiving a written denial or settlement offer may request the insurer's claim file; Maine requires written explanation of the basis for denial, including policy provisions relied upon.

Maine requires insurers to acknowledge notification of a claim within a reasonable time (commonly 10 working days) and to affirm or deny coverage within a reasonable time after completing investigation.

Producers and adjusters are licensed under 24-A M.R.S. Chapter 16; a Maine adjuster license is required to investigate or settle claims for a fee, with limited exceptions for attorneys and salaried employees.

Continuing education: Maine resident adjuster licenses renew with CE hours per 24-A M.R.S. §1434; nonresident adjusters holding a home-state license generally qualify for reciprocity.

Maine's 24-hour notice rule: an insurer must report a cancellation or nonrenewal of a personal auto policy to the Secretary of State when required for financial responsibility purposes.

Maine requires auto liability minimum limits of 50/100/25 ($50,000 per person, $100,000 per accident bodily injury, $25,000 property damage) under 29-A M.R.S. §1605.

Maine's workers' compensation exclusivity and benefit rules are in 39-A M.R.S.; the Workers' Compensation Board, not the Insurance Bureau, adjudicates benefit disputes.

Maine's prompt-pay statute for health claims (24-A M.R.S. §2436) sets deadlines for clean claims; interest accrues on late payments.

Indemnity: the insured is restored to pre-loss financial position, no better; valued policies and agreed-value clauses are exceptions.

Insurable interest must exist at the time of loss for property (Maine requires it at loss) and at policy inception for life insurance.

Utmost good faith underpins representations, warranties, and concealment doctrines; material misrepresentation can void coverage.

Actual cash value = replacement cost minus depreciation; replacement cost = cost to repair or replace with new property of like kind and quality.

Coinsurance formula for property: (limit carried ÷ limit required) × loss = recovery, subject to the policy limit and deductible.

Deductible applies per occurrence (or per claim) before loss payment; the insured bears the deductible amount.

Subrogation transfers the insured's recovery rights against a negligent third party to the insurer after payment, preventing double recovery.

Proximate cause is the dominant, efficient cause of loss; concurrent causation clauses address losses with both covered and excluded causes.

Utmost good faith is enforced through the duty to disclose material facts; innocent misrepresentation of a material fact may still allow rescission.

Coverage A (Dwelling) covers the structure; Coverage B (Other Structures) is typically 10% of Coverage A; Coverage C (Personal Property) is typically 50-70% of Coverage A.

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

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

Replacement cost coverage requires insurance to at least 80% of replacement cost at time of loss; below that, a penalty applies.

Business income coverage pays net income loss plus continuing operating expenses during the period of restoration, typically with a 72-hour waiting period for civil authority.

Debris removal, preservation of property, and reasonable repairs are additional coverages that do not erode the Coverage A limit in many forms.

Mortgage clause: loss payment to the mortgagee is made to the extent of its interest; the mortgagee receives loss notice rights.

Flood coverage is written separately through the NFIP or private flood insurers; standard property policies exclude flood.

Pairing: named-peril forms list covered perils; open-peril (all-risk) forms cover all risks except those excluded.

CGL Coverage A (bodily injury/property damage) is triggered by an occurrence; Coverage B (personal and advertising injury) is triggered by enumerated offenses.

CGL limits: general aggregate, products-completed operations aggregate, personal and advertising injury limit, each-occurrence limit, and damage-to-premises limit.

The CGL 'your work' exclusion bars damage to the insured's own work; the subcontractor exception restores coverage in many ISO forms.

Occurrence means an accident, including continuous or repeated exposure to substantially the same general harmful conditions.

Professional liability (E&O) covers negligent acts, errors, or omissions in rendering professional services; it is claims-made, not occurrence-based.

Umbrella/excess policies respond after underlying limits are exhausted; umbrella policies may drop down for gaps, excess policies generally do not.

Personal injury coverage includes libel, slander, invasion of privacy, and wrongful eviction, but excludes knowing violations of law.

Additional insured status is granted by endorsement; the scope of coverage depends on the wording (e.g., 'ongoing operations' vs. 'sole negligence').

Claims-made policies require both the act and the claim to occur during the policy period or within an extended reporting period.

Maine personal auto minimums: $50,000 per person / $100,000 per accident bodily injury and $25,000 property damage; uninsured motorist coverage is mandatory unless rejected in writing.

Part A (Liability) covers third-party BI and PD; Part B (Medical Payments) pays medical expenses regardless of fault; Part C (Uninsured/Underinsured Motorist) covers hit-and-run and underinsured drivers.

Part D (Collision) covers damage to the insured auto from collision or overturn; Other Than Collision covers theft, fire, vandalism, and glass.

PIP is not mandatory in Maine; medical payments coverage fills a similar role and typically pays within a stated limit per person.

Comparative negligence in Maine: a claimant 50% or more at fault recovers nothing; below 50%, recovery is reduced by the claimant's percentage.

Uninsured motorist coverage applies to hit-and-run, uninsured, and underinsured drivers; UM limits cannot exceed liability limits in Maine.

Commercial auto forms use symbols (1-9) to designate covered autos; symbol 1 designates any auto, symbol 7 specifically scheduled autos.

Loss of use and rental reimbursement are optional coverages; towing and labor coverage is typically a small sublimit.

Ride-sharing and delivery use are typically excluded under personal auto policies and require commercial or endorsement coverage.

HO-2 broad form covers named perils; HO-3 special form covers the dwelling open-peril and personal property named-peril; HO-4 is renters; HO-6 is condo; HO-8 is modified for older homes.

Section I coverages: A (Dwelling), B (Other Structures), C (Personal Property), D (Loss of Use); Section II covers E (Personal Liability) and F (Medical Payments to Others).

Loss of use covers additional living expenses and fair rental value when the residence is uninhabitable due to a covered peril.

Section II exclusions: intentional acts, business activities, motor vehicle liability, and watercraft liability (with limited exceptions).

Personal property special limits apply to money, jewelry, silverware, firearms, and business property; scheduled endorsements raise limits.

Ordinance or law coverage is limited or excluded; endorsement HO 04 77 adds coverage for increased cost of construction due to code upgrades.

Water backup, sump pump overflow, and service line coverage are endorsements; none are included in the unendorsed HO-3.

Loss settlement: replacement cost on the dwelling, actual cash value on personal property unless replacement cost endorsement is purchased.

Matching of undamaged siding or roofing is generally not owed unless required by policy or law.

BOP eligibility: small-to-medium businesses such as apartments, offices, and retail; ineligible for auto dealers, restaurants with cooking on premises in some forms, and large manufacturing.

BOP property is written on a special (open-peril) basis; liability includes premises, products-completed operations, and medical expense.

BOP includes business income and extra expense for 12 months; optional endorsements add spoilage, employee dishonesty, and equipment breakdown.

Commercial package policy (CPP) combines commercial property and CGL with a common policy period and declarations; each coverage part has its own forms.

Commercial property coinsurance: limit required = 80% (or 90%/100%) of value; penalty applies if underinsured at loss.

Building and personal property coverage form includes debris removal (limited), preservation of property, and pollutant cleanup (limited).

Business income period of restoration begins 72 hours after the physical loss for civil authority and runs through repair or replacement.

Equipment breakdown (boiler and machinery) covers mechanical and electrical breakdown, which property policies exclude for wear and tear.

Employee dishonesty is a crime coverage, not a property coverage; it is written with a limit per occurrence or per employee.

Workers' compensation is no-fault: benefits are paid regardless of fault; the exclusive remedy bars most employee tort suits against the employer.

Maine workers' compensation benefits include medical, wage replacement (typically 2/3 of average weekly wage, subject to a maximum), and permanent impairment.

Maine's Workers' Compensation Board handles disputes; the insurer must file a First Report of Injury within the statutory period after notice.

Part One (workers' compensation) pays statutory benefits; Part Two (employer's liability) covers tort suits not barred by exclusivity, with limits per accident, per employee, and policy aggregate.

Part Three (other states) coverage applies when the policy is endorsed to cover multi-state exposures.

Experience modification factor adjusts premium based on the employer's loss history relative to its classification; a factor above 1.0 increases premium.

Sole proprietors and partners are excluded unless they elect coverage; corporate officers may elect or be excluded by endorsement.

Premium audit adjusts premium based on actual payroll and classification exposure at policy expiration.

Return-to-work and light-duty programs reduce indemnity costs and are considered in claims management.

The claim investigation establishes coverage, liability, and damages; adjusters must document the policy language and facts supporting each determination.

Reservation of rights letters preserve the insurer's right to deny coverage later while the investigation continues.

Bad faith exposure arises from unreasonable delay, failure to investigate, and denial without a reasonable basis; Maine's §2436-A enumerates these practices.

Unfair claims practices include misrepresenting policy provisions, failing to acknowledge communications, and offering substantially less than the amount ultimately owed.

Adjuster ethics: avoid conflicts of interest, disclose compensation arrangements, and never alter claim documentation.

Prompt payment and interest statutes apply to first-party claims; late payment may trigger interest and statutory penalties.

Salvage and subrogation recoveries reduce net loss cost; subrogation requires timely notice to the third party to preserve the statute of limitations.

Total loss valuation uses market value comparables, not replacement cost; Maine requires disclosure of valuation methodology to the claimant.

Documentation standards: photographs, witness statements, estimates, and a claim diary entry for each material contact.