Download Florida Claims Adjuster Exam| 203 Questions with 100% Correct Answers |26 Pages and more Exams Nursing in PDF only on Docsity! Florida Claims Adjuster Exam| 203 Questions with 100% Correct Answers |26 Pages Severability - Correct answerInsurance applies separately to each insured as if other insureds did not exist. Abandonment - Correct answerProperty insurance policies usually contain a(n) __________ clause, *stating the insured cannot dump damaged property on the insurer and demand its full value.* Insurable Interest - Correct answerOne wherein economic loss would be suffered from an adverse happening to the subject. Liberalization - Correct answerStates that if the insurer adopts a revision which would broaden coverage without additional premium within some period of time prior to the policy period or during the policy period, the insured receives the benefit of such broadened coverage.. Doctrine of Proximate Cause - Correct answerStates that when there is an unbroken connection between an occurrence and damage that grows out of the occurrence, then the resultant damage is all a part of the occurrence. Actual Cash Value - Correct answerThe Loss Settlement Valuation that subtracts an allowance for depreciation Warranty - Correct answerA policy condition, either based on information in the insured's application or inserted by the insurer Conditional Contract - Correct answerThe Insurer's responsibility to pay for a property loss may be conditioned on the insured having used reasonable means to avoid the loss, to protect the property against further loss, and to give the insurer proof of the loss is defined as? Under Mechanical Breakdown Coverage, *new cars are eligible for service up to:* - Correct answer36 Months/36,000 Miles Used vehicles: 12 Months/12,000 Miles If financial responsibility doesn't exist at the time of an accident, what happens? - Correct answerThe legally valid claims of others must be satisfied (10/20/10) The owner and operator must provide certification of future responsibility for future accidents As to required proof for future accidents by purchase of auto liability insurance, the insurer must make a filing (Form SR-22) certifying that coverage is in effect, and this certification must remain on file for __________ years - Correct answer3 The Business Automobile Policy includes all of the following coverage forms except: - Correct answerThe Trailer Interchange Coverage Form Personal Injury Protection, or PIP, has a __________ per person, per accident limit. - Correct answer10,000 Used to insure businesses engaged in selling, servicing, repairing, parking or storing automobiles: - Correct answerGarage Coverage Form The following examples are referred to as __________ liability limits: 25/50/25 or 10/20/10. - Correct answerSplit 10/20/10 = 10,000 per person injured 20,000 all injuries combined 10,000 property damage Example of straight liability limit = $30,000 Jeremy has a not at fault accident. If he has PIP with a $1,000 deductible, how much can he expect his PIP coverage to pay toward his medical bills that total $3,000? - Correct answer$1,600 3000 (bills) - 1000 (deductible) = 2000 x .80 (eighty percent) Frank has a not-at-fault accident, he has basic PIP, no deductible and Med pay of $5,000. How much will his Med Pay contribute to medical bills of $15,000? - Correct answer$5,000 Medical Payment limits apply per person; Frank will receive full amount towards medical bills. Which of the following is not one of the rating factors for a Homeowner's Policy? - Correct answerAge & Gender of Insured On a Homeowner's Policy, covers items that are not permanently attached to the dwelling. This is defined as: - Correct answerOther Structures Under Commercial Property Policies, Florida law requires an insurer to give the insured at least __________days advance written notice of non-renewal. A. 25 B. 90 C. 45 D. None of the Above - Correct answerC. 45 Also, notice must state reasons the policy is not to be renewed. When a business's personal property values fluctuate, a single, fixed amount of insurance could produce either over- or under-insurance at any given time. With this option, the limit of coverage is set at an amount somewhat higher than expected peak values. - Correct answerValue Reporting Replacement Cost is incorrect b/c it calculates monetary value of one's personal property Liberalization states, "The insured gets the benefit of any broadened coverage if the company, within __________ days of inception, adopts a form revision that is broader and without increase in premium." - Correct answer45 days Used to cover buildings in the course of construction - Correct answerBuilders Risk Policy Includes: structure being built (including foundations), fixtures and machinery, equipment to service building, owned materials and supplies used for construction. Temporary structures built or assembled on site are also included if not covered by insurance. First developed as an extension of Ocean Marine coverage, to provide coverage for cargo traveling over land, instead of by sea. - Correct answerCommercial Inland Marine Coverage Definition: to help identify kinds of risks which are eligible for either Ocean or Inland Marine insurance. Protects against *loss of business income* that results from damage to covered property from a covered cause of loss. (BIIC) - Correct answerBusiness Income Insurance Coverage Period of restoration begins 72 hours after date of direct damage. In effect, coverage has a 72 hour deductible. Coverage ends on either 1. date when damaged property could be repaired, rebuilt, or replaced 2. date business resumes operations at new, permanent location (whichever comes first) What payment covers several areas of costs related to claims, and are payable in addition to the policy limits? - Correct answerSupplementary Generally, all costs of litigation are covered (court costs, prejudgment interest, judgement interest, cost of bonds to release attachments) Three full-time employees from a local furniture company are horsing around and one is pushed into a machine that cut his foot. How will the company's General Liability respond? - Correct answerThe GL policy will not pay Coverage excludes liabilities under Workers Comp or similar law or arising from injuries to employees of the insured. The employees would have to file through Workers Comp. Which of the following can be found in a Commercial General Liability Contract? A. Declarations B. Common Policy Conditions C. Occurrence and Claims-Made Forms D. All of the Above - Correct answerD. All of the Above Also included: Nuclear Energy Liability Exclusion endorsement (other endorsements may be attached) There is __________ coverage for injury, damage or clean-up costs caused by pollutants, subject to minor exceptions. - Correct answer0% Under a Commercial General Liability Policy, a basic limit of __________ per person applies to Medical Payments: - Correct answer$5,000 The Commercial General Liability __________ identifies the named insured and address, states the policy period and premium and miscellaneous information about the insured, and specifies the limits of coverage that apply. - Correct answerDeclarations The Nuclear Energy Liability Exclusion endorsement, in general, __________ all hazards related to nuclear energy. - Correct answerExcludes Firms involved in Nuclear activities receive protection from special insurer pools organized for that purpose. Toxic wastes escaped from a gas station disposal tank. The insured operator discovers the leak and cleans up the spill. Unfortunately, the waste quickly seeped into the ground and has caused illness among the residents of a neighboring community This is an example of? - Correct answerKnown Loss Insurer should have been notified and further investigation of the spill and effective clean-up would have been observed. Applies to BI or PD which occurs during the policy period, regardless of any later time at which a claim is made: - Correct answerOccurrence Form vs. Claims-Made: applies only to BI or PD occurring on or after retroactive date for which claim is received/recorded during policy period Applies only to a BI or PD which occurs on or after the retroactive date, and for which the claim is received or recorded by an insured or the company during the policy period: - Correct answerClaims-Made Retroactive date is stated in Declarations and will normally be same date as issuing company's first claims-made effective date for insured. All of the following are components of Workers Compensation, except: A. Up to $750,000 in Death Benefits B. Reimbursement for Medical Expenses incurred C. Reimbursement for lost wages on percentage basis D. Funeral costs up to $7,500 - Correct answerUp to $750,000 in Death Benefits Compensation for death is payable if death results within one year of an accident or if it follows disability within five years of accident. The following are classes of disability, except: - Correct answerTemporary Full Also included: Temporary Partial The measure to determine disability benefits is the __________ of the employee at the time of injury: - Correct answerAverage Weekly Wage Disability - incapacity due to injury to earn same or any other employment wages that employee was receiving at time of injury. Mandatory for risks exceeding certain annual premiums, recognizes the prior loss experience of the risk and applies either a debit for unfavorable experience or a credit for better-than-expected loss results. This is defined as: - Correct answerThe Experience Rating Plan This, along with Retrospective Rating Plan, is a manual rating process until premiums reach a certain level. Under workers compensations, a rate is charged for every __________ of payroll to employees. - Correct answer$100 The National Council on Compensation Insurance enforces this rating. Covers for all types of property, when surrendered away from the premises as a result of a threat to do bodily harm to the insured or an employee, or to a relative or invitee of either, who is (or allegedly is) being held captive. This is defined as: - Correct answerExtortion Also triggered by threats to damage the premises or property within the premises. Employee Theft Coverage may be written in the following ways: A. Scheduled Persons Coverage B. Scheduled Position Coverage C. Blanket Coverage D. All May Apply - Correct answerD. All May Apply Employee Theft may be written in three ways. Which of the following are NOT a type of bond? - Correct answerApprentice Contract - fulfill obligation Fiduciary - make good to court for any deficiencies found in performance Court - protect opposing party from loss Which of the following are characteristics of a License Bond? A. To guarantee the licensee will act according to laws B. Protect public from unfair business practice C. Proper collection and payment of taxes D. All of the Above - Correct answerD. All of the Above Guarantees the performance between the principle and the obligee: - Correct answerSurety aka Bonding Company; Surety is a "guarantee" This bond guarantees indemnification to the obligee for any losses resulting from the principal's failure to complete the contract work in accord with specifications: - Correct answerPerformance Considered a contract bond One who undertakes to perform, to fulfill a contract or to meet an obligation is known as: - Correct answerPrincipal Obligee - needs guarantee principal will perform Surety - guarantees performance between principal and obligee This form of bond is required to accompany a bid for a contract which will require that the successful bidder furnish further bond if awarded the job: - Correct answerBid May act as part of the bonding party and agrees to reimburse the surety for any loss it may suffer from having bonded the principal: - Correct answerIndemnitor Which of the following are parties to a Bond? A. Principal B. Obligee C. Surety D. All of the Above - Correct answerD. All of the Above Principal - undertakes to perform/fulfill Obligee - guaranteed principal will perform Surety - guarantees performance *Indemnitor - may act as additional party; agrees to reimburse surety for any loss This type of bond covers streets, sidealks, sewers, etc.: - Correct answerSubdivision Falls under Maintenance Bond When a person has *lost* stock certificates, bonds or similar instruments, a bond is generally required by the issuing company to reissue the document. This is known as a: - Correct answerLost Instrument Bond Also guarantees to save issuer from any loss growing out of lost instrument A __________ is a selected group of hospitals and medical practitioners in a given area who have joined together in an effort to reduce medical costs. - Correct answerPPO Most plans provide that emergency treatment will be paid even if treated party does not go to service provider on approved list. Define the coverage that pays a flat amount per day for hospitalization, regardless of expenses or other insurance: - Correct answerHospital Indemnity This optional provision states that if the insured becomes totally disabled, premiums are waived but the coverage remains in force - Correct answerWaiver of Premium Provides coverage for expenses, including loss of income, arising from an accident. This is defined as? - Correct answerAccident Insurance Typical exclusions would be: hernia, war, disease and bacterial infections, suicide attempts, air travel injuries, accidents while committing felony, accidents while under the influence This type of provision states the insurer can refuse to renew the policy only under certain conditions. The policy must state the conditions under which the policy will not be renewed. This is defined as? - Correct answerConditionally Renewable vs. Optionally: company may not cancel during term but reserves right to non-renew upon expiration vs. Guaranteed: insurer required to renew policy at stated age (typically 65); company reserves right to increase premium The coverage that is intended to afford protection against catastrophic losses is defined as? - Correct answerMajor Medical Some forms designed to supplement basic policies; others provide both basic and catastrophic coverage A policy may contain a provision which states a period of time between issuance and acceptance before sickness benefits begin. This is defined as: A. Waiting Period B. Elimination Period C. Both A & B D. None of the Above - Correct answerC. Both A & B This helps keep premiums reasonable by eliminating chance of persons buying coverage only when they are sick Characteristics of an *HMO plan* usually include: (HINT: S F P B C) - Correct answerS - Small of non-existent Deductibles F- Fewer Exclusions P - Insurance services to members through employed physicians B - Broad coverage C - Coinsurance provisions Provides indemnification to the insured for basic hospitalization of room and board in the hospital, nursing care, laboratory fees, operating room, medical supplies, etc. This is defined as? - Correct answerHospitalization Expense Associated with a daily limit, not to exceed specified maximum A(n) __________ provides comprehensive health services to its members for a prepaid fixed fee, equivalent to an insurance premium. - Correct answerHMO Referred to as an emerging and increasingly important non-insurance alternative to dealing with risk of health care costs The law recognizes two types: express and implied. The principle of utmost good faith on which an insurance contract is based places serious responsibilities on the claims adjuster in regards to: A. Conduct B. Work Habits C. Claim Handling Activites D. All of the Above - Correct answerD. All of the Above The adjusters basic activities in claims handling are: A. Investigation B. Evaluation C. Negotiation D. All of the Above - Correct answerD. All of the Above Investigation - establish coverage, determine liability, verify damages qualify Evaluation - determine fair payment in accordance with contract and law Negotiation - settlement based on facts discovered during evaluation Under the Florida Unfair Insurance Trade Practices Act, penalties are provided for misrepresentation of business practices, which include all of the following except: A. Failing to act promptly B. Failure to explain claim denials in writing C. Denying claims with reasonable investigation D. Failure to maintain complaint handling procedures - Correct answerC. Denying claims with reasonable investigation An adjuster who represents the financial interests of the insured named in the policy is defined as a(n): - Correct answerPublic Adjuster When investigating liability insurance claims, which of the following three major elements are determined: (CLD) - Correct answerCoverage Liability Damages A relationship that requires maintenance of a high degree of fidelity and loyalty to the interests of the principal, whether or not the adjuster is a direct employee is defined as: - Correct answerFiduciary Should always be maintained whether or not the adjuster is a direct employee An adjuster who is self employed and not affiliated with either insurers or bureaus is defined as a(n): - Correct answerIndependent Adjuster The adjuster's investigation may include all of the following except: A. Verification of Bills and Estimates B. Photographs C. Witness Canvasses D. Policy Cancellation - Correct answerPolicy Cancellation The assertion of an alleged legal right against an insurer, which carries with it a demand for appropriate relief, is defined as: - Correct answerClaim Relieving the financial burden on the claimant by making certain payments to the claimant even before the claim can be negotiated is defined as: - Correct answerAdvanced Payment The process of disposing of an insurance claim is defined as: - Correct answerAdjusting Also "the negotiation period that results in an agreement" All of the following are requirements for the "Code of Ethics," except: A. Adjusters should not give legal advice B. Adjusters may negotiate with a claimant who is represented by an attorney C. A witness who requests a copy of a statement given must be provided with one D. Adjusters will keep an unprejudiced and open mind - Correct answerB. Adjusters may negotiate with a claimant who is represented by an attorney Adjusters MAY NOT. Bad, adjuster, bad! A written statement given by the insured to the insurer acknowledging that money received in the settlement of damages is received, not as a final payment, but as an advance pending an outcome of a claim against the person responsible for the damage. This is defined as a(n): - Correct answerLoan Receipt Enables insurer to bring an action for recovery against a third party Duties and functions of the Department of Financial Services include all of the following except: A. Approve the issuance of licenses B. Rating and underwriting rules C. Claims Supervision D. Investigate charges of unethical behavior - Correct answerRating and underwriting rules An adjuster who is a salaried employee under the supervision of the home, branch, or regional claims department of insurers is defined as a(n): - Correct answerCompany or Staff Adjuster Which of the following are not considered to be an adjuster: A. Employee or Staff Adjuster B. Independent Adjuster C. Public Adjuster D. General Lines Adjuster - Correct answerD. General Lines Adjuster Bureau Adjusters are also considered adjusters. An applicant for a license as an adjuster may qualify as an adjuster in the following fields (but not limited to): A. All lines of insurance except life and annuities B. Property and Casualty C. Workers Compensation Insurance D. All of the Above - Correct answerD. All of the Above Also: motor vehicle physical damage and health insurance A motor vehicle or mobile home which is a total loss is defined as: - Correct answerSalvage It cannot be restored to prior condition When making any payment for damage to an automobile for a partial loss, the insurer shall have printed on the loss settlement, "Failure to use the insurance proceeds in accordance with the security agreement, if any, could be a violation of s.812.014, Florida Statutes." This is payment for a(n): - Correct answerThird Party Claim The District of Columbia and any state or territory of the United States in which an insurance agent maintains his or her principal place of residence or principal place of business and is licensed to act as an insurance agent. This is defined as: - Correct answerHome State Any material which is or may have been a motor vehicle or mobile home, which is inoperable and which material is in such condition that its highest or primary value is either in its sale or transfer as scrap metal or for its component parts, or a combination of the two. This is defined as: - Correct answerDerelict Umbrella Policy - Correct answerCovers much higher limit and goes above/beyond claims directly relating to home and auto; protects assets from unforeseen events Known Loss - Correct answerPrevents insured from coverage if insured knew the loss was probable at time of contract Commercial Property Insurance - Correct answerSometimes referred to as Commercial Fire and Allied Lines; Covers direct and indirect losses related to properties other than 1-4 family dwelling and farm properties Value Reporting - Correct answerLimit of coverage set at an amount higher than expected peak values Employee Theft - Correct answerProvides coverage for loss or damage to money, securities, and other property resulting from theft committed by an employee Bid - Correct answerForm of bond required to accompany a bid for a contract which will require that successful bidder furnish further bond if awarded job. Agreement to fulfill a contractual obligation used frequently in construction and supplying goods PPO - Correct answer(Preferred Provider Organization) Selected group of hospitals and medical practitioners in given area who have joined together in an effort to reduce medical costs HMO (pre-paid fixed fee) - Correct answer(Health Maintenance Organization) Provides comprehensive health services to its members for a prepaid fixed fee equivalent to an insurance premium Domestic - Correct answerInsurer formed under laws of this state Foreign - Correct answerInsurer formed under laws of another state, district territory, or commonwealth of U.S. Alien - Correct answerInsurer other than domestic or foreign (outside U.S.) Sliding - Correct answerSelling an item and stating that it is required by law Waiver - Correct answerVoluntary relinquishment or surrender of some right or privilege Fiduciary - Correct answerA relationship that requires maintenance of a high degree of fidelity and loyalty to the interests of the principal, whether or not the adjuster is a direct employee Evaluation - Correct answerEstablishing a dollar value on a claim. Determines the fair payment in accordance with the contract and applicable law Negotiation - Correct answerA quality settlement based on facts discovered during the evaluation process Estoppel - Correct answerAn equitable principle to the effect that if one intentionally or unintentionally creates the impression that a certain fact exists, an innocent party relies on that impression and is damaged as a result, the guilty party may be legally prohibited (estopped) from asserting that the fact does not exist. Junk - Correct answerAny material which is or may have been a motor vehicle or mobile home, with or without all component parts, which is inoperable and which material is in such condition that its highest or primary value is either in its sale or transfer as scrap metal Salvage - Correct answerDamaged property that may be retrieved, reconditioned and sold to reduce an insured loss. Motor vehicle or mobile home is a total loss Appointment - Correct answerAuthority given by an insurer or employer to a licensee to transact insurance or adjust claims on their behalf Derelict - Correct answerMaterial which is or may have been a motor vehicle or mobile home, with or without all component parts, which is inoperable and which material is in such condition that its highest or primary value is either in its sale or transfer as scrap metal or component parts or both Implied Waiver - Correct answerMay result from some act of neglect on part of the adjuster Express Waiver - Correct answerOccurs when insurer or its representative knowingly gives up a known right under insurance contract Mechanical Breakdown Coverage - Correct answerCovers repairs to mechanical parts of your vehicle that break; even covers in events not related to an accident Identify examples of peril. - Correct answerFire, windstorm, flood after hurricane, etc. (something that causes a loss) How long does one have to notify the Department of Financial Services for a name and/or address change? - Correct answer30 days What is the coinsurance clause and how might it apply to a given scenario? - Correct answerA coinsurance clause on a property policy requires the policyholder to carry, at minimum, a specified percent of the dwelling's replacement cost. Failure results in monetary penalty. Almost without exception, the percentage is 80% in coinsurance clauses of homeowner policies - this means the insured should carry 80% of replacement cost if they don't want to be penalized at the time of loss. What are the minimum requirements for the Financial Responsibility Law? (there are two) - Correct answer1. legal valid claims of others must be satisfied up to the 10/20/10 requirements 2. owner/operator must provide certification of financial responsibility for future accidents What is PIP and how may it apply to a given scenario? - Correct answerPersonal Injury Protection with limit of $10,000 per person, per accident If Jeremy has a not-at-fault accident and he has PIP with a $1000 deductible, he can expect PIP to pay $1,600 of his $3,000 medical bill. (3,000 - 1,000 = 2,000 x .80 = 1,600) What is the difference between PIP and Workers Compensation? Which one is excess? - Correct answerPIP is primary against all other forms of medical and disability insurance coverage. Florida courts have held PIP is excess over Workers Comp. To eliminate duplicate recoveries, the law prohibits persons who have received PIP from recovering same amounts from others in legal liability actions. What are the basic PIP benefits? - Correct answer1. Medical; 80% of reasonable expenses are paid for necessary medical, surgical, x-ray, dental, and rehab services 2. Work Loss; 60% of any loss of gross income and loss of earning capacity is reimbursed 3. Replacement Services; 100% for cost of having household services performed by others which the injured person would have normally performed 4. Death; $5,000 IN ADDITION to the $10,000 in medical/disability benefits afforded by PIP How does PIP apply to pedestrians (in and out of state)? - Correct answerPIP applies to Florida residents if struck by insured's motor vehicle while not occupying a self- propelled vehicle (a pedestrian). In situations wherein PIP does not apply, named insured and relatives occupying or struck by others vehicles out-of-state; nonresident passengers out-of-state; and nonresidents as pedestrians in Florida - The No-Fault Law has no applicability and usual legal remedies and other insurance coverage's are to be relied upon. When can Other-Than-Collision (Comprehensive Coverage) be used? - Correct answerWhen there is damage to your vehicle not caused by a collision (hail storm damages hood, animal runs into car, windshield replacement) What are the penalties for not complying with the *No-Fault Law*? (3) In Florida, windshields are replaced for free and you ARE NOT responsible for paying a deductible. What is the time frame for a Non-Renewable Temporary License? - Correct answerA period not to exceed 6 months What types of insurance licenses are offered by the Department and how do they differ? - Correct answer1. General Lines Agent 2-20: licensed to write property/casualty, surety or health insurance. 2. Customer Representative 4-40: must be licensed, appointed by a General Lines Agent and may assist in transactions in the OFFICE ONLY 3. Limited Customer Representative 4-42: must be licensed, appointed by a General Lines Agent and transact AUTO insurance in the OFFICE ONLY. 4. All Lines Claims Adjuster 6-20: investigates, Evaluates and Negotiates Claims What are some reasons for suspension, revocation, or termination of a license? - Correct answer1. Transacting insurance outside of scope of one's license ►For example, an individual cannot sell life insurance if he or she has a Customer Service license but has not obtained a life license. 2. Misrepresentation or Fraud. 3. Participating in unfair methods of competition. ►Using discriminatory practices, making false entries on an insurance application or defaming others. 4. Sliding: Selling an item and stating that it is required by law (when it is not). 5. Demonstration of unworthiness or lack of fitness. 6. Misappropriation of funds. 7. Failure to inform Department of Financial Services, within 30 days, after pleading guilty or no contest to a felony. Compare/contrast different types of adjusters. - Correct answer1. Independent Adjuster - self-employed and not affiliated with either insurers or bureaus 2. Company/Staff Adjuster - salaried employee under supervision of home, branch, regional claims department of insurers 3. Public Adjuster - represents the financial interests of the insured named in the policy 4. Claims Adjuster - one who is involved in the investigation, adjustment, negotiation and/or trial preparations of claims arising under insurance policies 5. Bureau Adjuster - agent of adjustment bureau which serves multiple company clients *Independent and Bureau are both "Fee Adjusters" What is an Insurance Contract? - Correct answerInsurance is a contract whereby one undertakes to indemnify another or pay or allow a specified amount or a determinable benefit upon determinable contingencies What are the components that make up the investigation process? - Correct answerInquiry, verification, comparison What are the Code of Ethics for adjusters? - Correct answerFormal rules which impact on adjuster practices 1. Adjusters may not directly negotiate with a claimant who is represented by an attorney. 2. In interviewing witnesses, adjusters must avoid any actions tending to induce a suppression or deviation from the truth. A witness who requests a copy of a statement given must be provided with a copy. 3. Adjusters shall not give legal advice. 4. Adjusters shall not draft special releases; they are permitted only to fill in blanks of forms provided by the insurer. 5. Adjusters will not take advantage of an incapacitated claimant which would be to the detriment of the claimant. 6. Adjusters will not knowingly fail to advise claimants of their rights under contracts and laws of the state. 7. Adjusters will approach all aspects of the process with an unprejudiced and open mind, make truthful and unbiased reports, handle all processes with integrity and accept no remuneration other than that to which there is legal entitlement, and act with diligence and due dispatch in achieving proper disposition of claims. 8. The adjuster must put the duty for fair and honest treatment of the claimant above the adjuster's own interests, in every instance.