Loss Adjustment. (1) The Company and its affiliates shall not permit: (A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP. (B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company. (2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following: (A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities. (B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company). (i) The agent may: (I) Receive a notice of loss from the policyholder and transfer it to the Company; (II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer; (III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss; (IV) Facilitate the loss adjuster’s gathering of information directly from other parties; and (V) Assist the loss adjuster in locating the policyholder or vice versa. (ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss. (C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss. (i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in: (I) The preparation or presentation of information associated with a claim; (II) The determination or verification of facts or information associated with a claim; or (III) The determination of the cause of loss or the amount of a claim, (ii) Prohibited agent activities include, but are not limited to: (I) Riding with the loss adjuster to the field; (II) Being present with the loss adjuster during the loss inspection and related processes; (III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; or (IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation. (iii) Prohibited agent and loss adjuster contact does not include: (I) Social interactions; (II) Checking on the status of a claim or claim payment; (III) Facilitating follow up contact between the policyholder and loss adjuster; (IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; and (V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute). (D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured. (E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment. (i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim. (ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster. (F) Any other function reserved for loss adjusters in FCIC procedures. (3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for: (A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature; (B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or (C) A relative of the individual referred to in paragraph (3) above. (4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.
Appears in 10 contracts
Samples: Regulatory Duties and Responsibilities Agreement, Regulatory Duties and Responsibilities Agreement, Regulatory Compliance Agreement
Loss Adjustment.
(1) The Company and its affiliates shall not permit:permit:
(A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following:following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities.responsibilities.
(B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).Company).
(i) The agent may:may:
(I) Receive a notice of loss from the policyholder and transfer it to the Company;Company;
(II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;reviewer;
(III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;loss;
(IV) Facilitate the loss adjuster’s gathering of information directly from other parties; andand
(V) Assist the loss adjuster in locating the policyholder or vice versa.versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:in:
(I) The preparation or presentation of information associated with a claim;claim;
(II) The determination or verification of facts or information associated with a claim; oror
(III) The determination of the cause of loss or the amount of a claim,claim,
(ii) Prohibited agent activities include, but are not limited to:to:
(I) Riding with the loss adjuster to the field;field;
(II) Being present with the loss adjuster during the loss inspection and related processes;processes;
(III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; oror
(IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.documentation.
(iii) Prohibited agent and loss adjuster contact does not include:include:
(I) Social interactions;interactions;
(II) Checking on the status of a claim or claim payment;payment;
(III) Facilitating follow up contact between the policyholder and loss adjuster;adjuster;
(IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; andand
(V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment.adjustment.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster.adjuster.
(F) Any other function reserved for loss adjusters in FCIC procedures.procedures.
(3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.paragraph
Appears in 6 contracts
Samples: Regulatory Compliance Agreement, Regulatory Compliance Agreement, Regulatory Compliance Agreement
Loss Adjustment.
(1) The Company and its affiliates shall not permit:permit:
(A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities.responsibilities.
(B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).Company).
(i) The agent may:may:
(I) Receive a notice of loss from the policyholder and transfer it to the Company;Company;
(II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;reviewer;
(III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;loss;
(IV) Facilitate the loss adjuster’s gathering of information directly from other parties; andand
(V) Assist the loss adjuster in locating the policyholder or vice versa.versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:in:
(I) The preparation or presentation of information associated with a claim;claim;
(II) The determination or verification of facts or information associated with a claim; oror
(III) The determination of the cause of loss or the amount of a claim,claim,
(ii) Prohibited agent activities include, but are not limited to:to:
(I) Riding with the loss adjuster to the field;field;
(II) Being present with the loss adjuster during the loss inspection and related processes;processes;
(III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; oror
(IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.documentation.
(iii) Prohibited agent and loss adjuster contact does not include:include:
(I) Social interactions;interactions;
(II) Checking on the status of a claim or claim payment;payment;
(III) Facilitating follow up contact between the policyholder and loss adjuster;adjuster;
(IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; andand
(V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the the Company (the agent shall not engage the loss adjuster directly on a claim dispute).
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment.adjustment.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster.adjuster.
(F) Any other function reserved for loss adjusters in FCIC procedures.procedures.
(3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.paragraph
Appears in 4 contracts
Samples: Regulatory Duties and Responsibilities Agreement, Regulatory Duties and Responsibilities Agreement, Regulatory Duties and Responsibilities Agreement
Loss Adjustment. (1) The Company and its affiliates shall not permit:permit:
(A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following:following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities.responsibilities.
(B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).Company).
(i) The agent may:may:
(I) Receive a notice of loss from the policyholder and transfer it to the Company;Company;
(II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;reviewer;
(III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;
(IV) Facilitate the loss adjuster’s gathering of information directly from other parties; andand
(V) Assist the loss adjuster in locating the policyholder or vice versa.versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:in:
(I) The preparation or presentation of information associated with a claim;claim;
(II) The determination or verification of facts or information associated with a claim; oror
(III) The determination of the cause of loss or the amount of a claim,
(ii) Prohibited agent activities include, but are not limited to:to:
(I) Riding with the loss adjuster to the field;field;
(II) Being present with the loss adjuster during the loss inspection and related processes;processes;
(III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; or
(IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.
(iii) Prohibited agent and loss adjuster contact does not include:include:
(I) Social interactions;interactions;
(II) Checking on the status of a claim or claim payment;payment;
(III) Facilitating follow up contact between the policyholder and loss adjuster;
(IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; andand
(V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the the Company (the agent shall not engage the loss adjuster directly on a claim dispute).
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment.adjustment.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster.adjuster.
(F) Any other function reserved for loss adjusters in FCIC procedures.procedures.
(3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.paragraph
Appears in 3 contracts
Samples: Regulatory Compliance Agreement, Regulatory Compliance Agreement, Regulatory Compliance Agreement
Loss Adjustment.
(1) The Company and its affiliates shall not permit:permit:
(A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following:following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities.responsibilities.
(B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).Company).
(i) The agent may:may:
(I) Receive a notice of loss from the policyholder and transfer it to the Company;Company;
(II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;reviewer;
(III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;loss;
(IV) Facilitate the loss adjuster’s gathering of information directly from other parties; andand
(V) Assist the loss adjuster in locating the policyholder or vice versa.versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:in:
(I) The preparation or presentation of information associated with a claim;claim;
(II) The determination or verification of facts or information associated with a claim; oror
(III) The determination of the cause of loss or the amount of a claim,claim,
(ii) Prohibited agent activities include, but are not limited to:to:
(I) Riding with the loss adjuster to the field;field;
(II) Being present with the loss adjuster during the loss inspection and related processes;processes;
(III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; oror
(IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.documentation.
(iii) Prohibited agent and loss adjuster contact does not include:include:
(I) Social interactions;interactions;
(II) Checking on the status of a claim or claim payment;payment;
(III) Facilitating follow up contact between the policyholder and loss adjuster;adjuster;
(IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; andand
(V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).dispute).
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment.adjustment.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster.adjuster.
(F) Any other function reserved for loss adjusters in FCIC procedures.procedures.
(3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.paragraph
Appears in 2 contracts
Samples: Regulatory Compliance Agreement, Regulatory Duties and Responsibilities Agreement
Loss Adjustment. (1) The Company and its affiliates shall not permit:
(A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities.
(B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).
(i) The agent may:
(I) Receive a notice of loss from the policyholder and transfer it to the Company;
(II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;
(III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;
(IV) Facilitate the loss adjuster’s gathering of information directly from other parties; and
(V) Assist the loss adjuster in locating the policyholder or vice versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:
(I) The preparation or presentation of information associated with a claim;
(II) The determination or verification of facts or information associated with a claim; or
(III) The determination of the cause of loss or the amount of a claim,
(ii) Prohibited agent activities include, but are not limited to:
(I) Riding with the loss adjuster to the field;
(II) Being present with the loss adjuster during the loss inspection and related processes;
(III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; or
(IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.
(iii) Prohibited agent and loss adjuster contact does not include:
(I) Social interactions;
(II) Checking on the status of a claim or claim payment;
(III) Facilitating follow up contact between the policyholder and loss adjuster;
(IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; and
(V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster.
(F) Any other function reserved for loss adjusters in FCIC procedures.
(3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.paragraph
Appears in 1 contract
Samples: Regulatory Compliance Agreement
Loss Adjustment.
(1) The Company and its affiliates shall not permit:permit:
(A) Its sales agents, agency employees, or sales supervisors to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph (1)(A) and (B) include the following:following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any duty or obligation of the agent to provide information to the policyholder on his or her policy options, duties, rights, and responsibilities.responsibilities.
(B) Obtaining sales or production records for purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).Company).
(i) The agent may:may:
(I) Receive a notice of loss from the policyholder and transfer it to the Company;Company;
(II) Provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;reviewer;
(III) Provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;loss;
(IV) Facilitate the loss adjuster’s gathering of information directly from other parties; andand
(V) Assist the loss adjuster in locating the policyholder or vice versa.versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:in:
(I) The preparation or presentation of information associated with a claim;claim;
(II) The determination or verification of facts or information associated with a claim; oror
(III) The determination of the cause of loss or the amount of a claim,claim,
(ii) Prohibited agent activities include, but are not limited to:to:
(I) Riding with the loss adjuster to the field;field;
(II) Being present with the loss adjuster during the loss inspection and related processes;processes;
(III) Accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; oror
(IV) Allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.documentation.
(iii) Prohibited agent and loss adjuster contact does not include:include:
(I) Social interactions;interactions;
(II) Checking on the status of a claim or claim payment;payment;
(III) Facilitating follow up contact between the policyholder and loss adjuster;adjuster;
(IV) Business contact on other insurance matters not related to a specific open claim covered by this Agreement; andand
(V) Interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).dispute).
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustment.adjustment.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall not discuss the matter directly with the loss adjuster.adjuster.
(F) Any other function reserved for loss adjusters in FCIC procedures.procedures.
(3) The Company and its service providers shall not permit any individual involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.paragraph
Appears in 1 contract
Loss Adjustment. (1) The In accordance with Appendix IV, the Company and its affiliates shall not permit:
(A) Its sales agents, agency employees, or sales supervisors supervisors, to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, employee or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, employee or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph paragraphs (1)(A) and (B) include the following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any the duty or obligation and responsibility of the agent to provide information guidance and advice to the policyholder on his or her policy options, duties, rights, and responsibilities.
(B) Obtaining sales or production records for the purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).
(i) The agent may:
(I) Receive may receive a notice of loss from the policyholder and transfer it to the Company;
(II) Provide ; provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;
(III) Provide ; provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;
(IV) Facilitate ; facilitate the loss adjuster’s gathering of information directly from other parties; and
(V) Assist and assist the loss adjuster in locating the policyholder or vice versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a the third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other An agent shall not influence the policyholder or loss adjuster in the preparation or presentation of information associated with a claim; the determination or verification of facts or information associated with a claim, or the determination of the cause of loss or the amount of a claim, other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:
(I) The preparation or presentation of information associated with a claim;
(II) The determination or verification of facts or information associated with a claim; or
(III) The determination of the cause of loss or the amount of a claim,.
(ii) Prohibited agent activities include, but are not limited to:
(I) Riding , riding with the loss adjuster to the field;
(II) Being field or being present with the loss adjuster during the loss inspection and related processes;
(III) Accompanying ; accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; or
(IV) Allowing offering the use of or allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.
(iii) Prohibited agent and loss adjuster contact does not include:
(I) Social include social interactions;
(II) Checking ; checking on the status of a claim or claim payment;
(III) Facilitating ; facilitating follow up contact between the policyholder and loss adjuster;
(IV) Business ; the normal course of business contact on other crop insurance matters not related to a specific open claim covered by this Agreementclaim; and
(V) Interaction and interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).;
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustmentadjustment procedures.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall must not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall must not discuss the matter directly with the loss adjuster.
(F) Any other function reserved for loss adjusters in FCIC the procedures.
(3) The Company and its service providers shall not permit any individual person involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:
(A) A policyholder with whom the individual referred to in paragraph (3) above has they have a business, financial or legal relationship including(Business, financial and legal interests include but are not limited to, to lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature. The sale and purchase of crop insurance does not constitute a business, financial or legal relationship with the policyholder that must be reported);
(B) A policyholder, or an individual a person with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) aboveperson; or
(C) A relative of the individual referred to in paragraph (3) aboveperson.
(4) If a claims supervisor adjusts a Claims supervisors shall not be permitted to perform any loss adjustment in any county in which they supervise loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisoradjustment.
Appears in 1 contract
Samples: Regulatory Compliance Agreement
Loss Adjustment. (1) The In accordance with Appendix IV, the Company and its affiliates shall not permit:
(A) Its sales agents, agency employees, or sales supervisors supervisors, to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, employee or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, employee or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph paragraphs (1)(A) and (B) include the following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any the duty or obligation and responsibility of the agent to provide information guidance and advice to the policyholder on his or her policy options, duties, rights, and responsibilities.
(B) Obtaining sales or production records for the purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).
(i) The agent may:
(I) Receive may receive a notice of loss from the policyholder and transfer it to the Company;
(II) Provide ; provide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;
(III) Provide ; provide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;
(IV) Facilitate ; facilitate the loss adjuster’s gathering of information directly from other parties; and
(V) Assist and assist the loss adjuster in locating the policyholder or vice versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from a the third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other An agent shall not influence the policyholder or loss adjuster in the preparation or presentation of information associated with a claim; the determination or verification of facts or information associated with a claim, or the determination of the cause of loss or the amount of a claim, other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an agent shall not influence the policyholder or loss adjuster in:
(I) The preparation or presentation of information associated with a claim;
(II) The determination or verification of facts or information associated with a claim; or
(III) The determination of the cause of loss or the amount of a claim,.
(ii) Prohibited agent activities include, but are not limited to:
(I) Riding , riding with the loss adjuster to the field;
(II) Being field or being present with the loss adjuster during the loss inspection and related processes;
(III) Accompanying ; accompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; or
(IV) Allowing offering the use of or allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.
(iii) Prohibited agent and loss adjuster contact does not include:
(I) Social include social interactions;
(II) Checking ; checking on the status of a claim or claim payment;
(III) Facilitating ; facilitating follow up contact between the policyholder and loss adjuster;
(IV) Business ; the normal course of business contact on other crop insurance matters not related to a specific open claim covered by this Agreementclaim; and
(V) Interaction and interaction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).;
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any field inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustmentadjustment procedures.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall must not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall must not discuss the matter directly with the loss adjuster.
(F) Any other function reserved for loss adjusters in FCIC the procedures.
(3) The If the Company and its service providers elects to allow the same loss adjuster to work claims on which an indemnity was paid for more than two consecutive years for the same policyholder, the Company shall not permit any individual involved in the loss adjustment determination or verification be required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:
(A) A policyholder with whom the individual referred to review claims identified by FCIC as required in paragraph (3) above has a business, financial or legal relationship including, but not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature;
(B) A policyholder, or an individual with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) above; or
(C) A relative of the individual referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a loss in any county in which loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by an individual who is not under the direct supervision of the supervisor.
Appears in 1 contract
Loss Adjustment. (1) The In accordance with Appendix IV, Tthe Company and its affiliates shall not permit:
(A) Its sales agents, agency employees, or sales supervisors supervisors, to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of any AIP.
(B) A relative of a sales agent, agency employee, or sales supervisor to be involved in loss adjustment activities in a county or adjoining county where the sales agent, agency employee, or sales supervisor performs sales functions (except receipt and transfer to the Company of a notice of loss) on behalf of the Company.
(2) Prohibited loss adjustment activities for all individuals referenced in paragraph paragraphs (1)(A) and (B) include the following:
(A) The supervision, control, or adjustment of a claim. The Company is solely responsible for the supervision and control of the loss adjustment process for a loss determination and all loss adjustment oversight. The agent’s prohibition in loss adjustment activities is not intended to preempt any the duty or obligation and responsibility of the agent to provide guidance and advice information to the policyholder on his or her policy options, duties, rights, and responsibilities.
(B) Obtaining sales or production records for the purposes of loss adjustment on behalf of the policyholder (other than simply collecting information directly from the policyholder and providing it to the Company).
(i) The agent may:
(I) Receive Rreceive a notice of loss from the policyholder and transfer it to the Company;
(II) Provide Pprovide a copy of the Company’s official file folder, as applicable, to the loss adjuster or reviewer;
(III) Provide Pprovide the loss adjuster or reviewer with any information provided by the policyholder related to the loss;
(IV) Facilitate Ffacilitate the loss adjuster’s gathering of information directly from other parties; and
(V) Assist Aassist the loss adjuster in locating the policyholder or vice versa.
(ii) Loss adjusters and reviewers are directly responsible for the verification and validation of the information from the a third party source of such information and nothing in the facilitation of such interactions or information gathering permits activities that may allow the agent to influence the loss adjustment process or the loss adjuster’s or reviewer’s independent determination of loss.
(C) A loss adjustment determination or verification required to complete a claim or the determination or verification of a cause of loss.
(i) Other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder, an aAn agent shall not influence the policyholder or loss adjuster in:
(I) The T influence the policyholder or loss adjuster in the preparation or presentation of information associated with a claim;
(II) The T; the determination or verification of facts or information associated with a claim; ;, or
(III) The Tthe determination of the cause of loss or the amount of a claim,, other than to facilitate the loss adjuster or reviewer’s gathering of information from the policyholder.
(ii) Prohibited agent activities include, but are not limited to:
(I) Riding R, riding with the loss adjuster to the field;
(II) Being B or being present with the loss adjuster during the loss inspection and related processes;
(III) Accompanying Aaccompanying the loss adjuster or reviewer in their independent verification and validation of claim information from third parties; or
(IV) Allowing Aoffering the use of or allowing a loss adjuster to use the agent’s or agency’s office, computer, or other similar resources to prepare the claim and related documentation.
(iii) Prohibited agent and loss adjuster contact does not include:
(I) Social S social interactions;
(II) Checking Cchecking on the status of a claim or claim payment;
(III) Facilitating Ffacilitating follow up contact between the policyholder and loss adjuster;
(IV) Business Bthe normal course of business contact on other crop insurance matters not related to a specific open claim covered by this Agreement; and
(V) Interaction Iinteraction on a claim after the loss adjuster has filed the appropriate claim documentation with the Company (the agent shall not engage the loss adjuster directly on a claim dispute).;
(D) Verification of yields for the purpose of validating insurance coverage or the guarantee. The agent must not be present during any inspections performed by the Company for the purposes of determining insurability of the crop or the amount of the crop to be insured.
(E) After a notice of loss is filed by the policyholder, advising or assisting the policyholder in any manner regarding the preparation of the claim and the determination of the indemnity, including, but not limited to, whether the loss adjuster correctly applied FCIC procedures regarding loss adjustmentadjustment procedures.
(i) The agent is permitted to consult with the policyholder to explain crop insurance terms and conditions, insurance processes, and the implications of decisions or actions that may be taken by the policyholder under the policy. However, such consultation shall must not include opinions, influence, or coercion as to the facts of a claim on policies written by the agent or the determinations of the loss adjuster on a claim.
(ii) If the agent suspects that a claim has been adjusted improperly or contains factual errors, the agent may contact the Company’s field supervisor or claims manager for review and assistance, but shall must not discuss the matter directly with the loss adjuster.
(F) Any other function reserved for loss adjusters in the FCIC procedures.
(3) The Company and its service providers shall not permit any individual person involved in the loss adjustment determination or verification required to complete a claim, or the determination or verification of a cause of loss, to adjust a loss for:
(A) A policyholder with whom the individual referred to in paragraph (3) above they have has a business, financial or legal relationship relationships (Business, financial and legal interests including, e but are not limited to, lending money, custom farming, leasing land or other property, selling other goods or services besides insurance, or activities of a similar nature. The sale and purchase of crop insurance does not constitute a business, financial or legal relationship with the policyholder that must be reported);
(B) A policyholder, or an individual person with a substantial beneficial interest in the policyholder, whose eligible crop insurance contract was sold by a relative of the individual referred to in paragraph (3) aboveaboveperson; or
(C) A relative of the individual individualperson. referred to in paragraph (3) above.
(4) If a claims supervisor adjusts a Claims supervisors shall not be permitted to perform any loss adjustment in any county in which they supervise loss adjustment, unless the loss adjustment is subject to his or her supervision, and if the claim is one subject to review in accordance with Appendix IV, the review shall be performed by the supervisor is reviewed by an individual independent third party who is not under the direct supervision of the supervisor. .
Appears in 1 contract
Samples: Regulatory Compliance Agreement
