Claims Investigation Clause Samples

Claims Investigation. In the event of a claim the Company may make any investigation it deems necessary and both the Insured Person and the Policyholder shall co-operate fully with such investigation. Failure by the Insured Person or the Policyholder to co-operate with the Company’s investigation may result in denial of the claim or cancellation of the Policy.

Claims Investigation. A. Complete initial investigation answering questions such as who, what, where, when and why. Investigations shall be completed within forty-five (45) days of the Member’s knowledge of claim, including statements from participants and witnesses, appropriate official reports, investigative reports, site inspections, relevant documents and photos/videos. B. Identify liability issues, including immunities, comparative negligence, joint tortfeasors and joint and several liability. C. Initiate the development of information on damages including, but not limited to: 1. Property damage 2. Nature and extent of injuries 3. Medical costs (billed and paid) 4. Lost wages (past and future) 5. Other economic damages 6. Non-economic damages D. Obtain and review relevant contracts and insurance documents, to determine whether there is any sharing or complete transfer of the risk. 1. Hold-harmless and/or indemnity agreements 2. Additional insured requirements E. Ensure proper preservation of evidence.

Claims Investigation. (i) Investigate all reported claims to the extent the Administrator deems reasonably necessary. (ii) Determine and evaluate any coverage issues in connection with the Claims and refer same to the Company or counsel with recommendations. (iii) Deny coverage for those Claims, which the Company reasonably determines, should be denied. (iv) Adjust, handle, or settle to a conclusion Claims in accordance with state law and the terms of the Policies. (v) Administrator is authorized to settle Claims up to fifty thousand dollars ($50,000) per Claim. All Claims in excess of ($50,000) must be approved in writing by Company (letter, fax, or e-mail). (vi) Adjust all Claims only through adjusters who are currently licensed (either independent or employee). (vii) When authorized by the Company, appoint independent counsel, as necessary to provide legal services as part of the investigation of Claims and/or the determination of policy coverage applicable. Counsel shall be selected from a list approved by the Company and Administrator. (viii) Prepare checks, vouchers, drafts, compromise agreements, releases, and other documents reasonably necessary to pay Claims, close out Claims and pay authorized fees and legal expenses on behalf of Company. (ix) Review outstanding Claim reserves monthly and recommend any changes to such reserves. (x) Record and report each loss and ALAE Expense paid. (xi) Report loss information to ISO Claim Search, or any other loss reporting service to which the Company subscribes. (xii) Coordinate any third-party or litigation related services. (xiii) Prepare and distribute required federal and state 1099 filings. (xiv) Report suspected fraud as required by any applicable statute or regulation in the state(s) where the Policies are issued.

Claims Investigation. INS shall require the assigned adjuster to handle claims in accordance with the Company's rules and regulations and generally accepted insurance industry standards. All claims will be processed in compliance with law. INS will monitor all open claim files utilizing means deemed appropriate for claims settlement. INS will require appropriate documentation of each claim file which provides a tracing record of each loss, the investigation, the damage assessment and other pertinent information associated with each claim handling decision.

Claims Investigation. DDAZ will conduct the necessary investigations and, if the facts as stated in the claim or as determined upon such investigation entitle the Plan Participant or beneficiary to receive payment of dental benefits, DDAZ will make payment according to the Plan provisions. If DDAZ finds that the Plan Participant or beneficiary is not entitled to dental benefits under the Plan, the claim for dental benefits will be denied with DDAZ's reasons for denial.

Claims Investigation. Manager shall require the assigned adjuster to handle claims in accordance with the Company’s rules and regulations and generally accepted insurance industry standards. All claims will be processed in compliance with the laws of Florida. Manager will monitor all open claim files in accordance with the Claims Guidelines, as reasonably amended from time to time. Manager will require appropriate documentation of each claim file which provides a tracing record of each loss, the investigation, the damage assessment and other pertinent information associated with each claim handling decision.