Claims Adjuster Guide

The Claims module is accessible through the Admin Dashboard (admin.openinsure.dev) and the Underwriting Workbench (uw.openinsure.dev). Adjusters assigned to claims receive notifications and work the full lifecycle from FNOL to closure.

Claim Lifecycle

FNOL Submitted
    ↓
Assigned to Adjuster
    ↓
Investigation (reserve set)
    ↓
Evaluation (coverage confirmed / denied)
    ↓
Negotiation & Settlement
    ↓
Payment Issued
    ↓
Closed

Receiving a New Claim

When a policyholder submits an FNOL:

You receive an email and Teams notification with the claim number
The claim appears in your Claims Queue
Initial reserve is auto-set based on reported loss amount (adjustable)

Open the claim from the queue or notification link 2. Review the FNOL details: date of loss, description, reported amount, attached photos 3. Click Accept Assignment to confirm you’re working the claim 4. Set an initial reserve if the auto-reserve needs adjustment

Investigation

Setting reserves

Reserves represent the estimated total cost to settle the claim. You update them as you gather information:

In the claim, click Reserves 2. Enter the updated incurred amount (paid + expected) 3. Add a note explaining the change (required for audit) 4. Save — the reserve change is logged with your name and timestamp

Reserve changes above a threshold require supervisor approval based on your delegated authority.

Requesting documents

Click Request Documents 2. Select what you need: police report, medical records, repair estimates, photos 3. The policyholder receives an email with a secure upload link 4. Uploaded files appear in the Documents tab

Adding notes

Use the Notes tab to log all investigation activity:

Recorded statements
Site inspection findings
Coverage analysis
Correspondence with third parties

Notes are immutable once saved — they form the legal claim file.

Coverage Determination

After investigation, document your coverage position:

Click Coverage Determination 2. Select: Covered / Partially Covered / Denied 3. If denied or partial, select the policy provision(s) that apply 4. Add a written coverage opinion (required) 5. Save — the policyholder and producer are notified

Settlement

Making a settlement offer

Click Settlement 2. Enter the settlement amount 3. Select payment method: check, ACH, or wire 4. Add settlement terms (e.g., general release required) 5. Click Send Offer — the policyholder receives an email with offer details

When the offer is accepted

The policyholder clicks Accept in their portal 2. The settlement moves to Pending Payment 3. Finance is notified to issue payment 4. Once payment is confirmed, the claim status changes to Settled

Subrogation

If you identify a third-party responsible for the loss:

Click Subrogation tab 2. Document the subrogation opportunity: liable party, amount recoverable, supporting evidence 3. Set a recovery target 4. Track recovery progress — partial recoveries reduce the net cost of the claim

A subrogation_update notification is sent when recovery status changes.

Litigation

For claims where legal action is initiated:

Click Litigation 2. Record: plaintiff, defense counsel, court venue, trial date 3. Update legal spend and reserve regularly 4. Log all significant litigation events in Notes

Litigated claims appear with a Litigation badge in the queue for easy filtering.

Closing a Claim

A claim can be closed when:

Settlement payment is confirmed, or
Coverage is denied and no further action is needed, or
The claimant withdraws

Click Close Claim 2. Select close reason 3. Confirm outstanding reserve is zeroed (or document why a reserve remains) 4. Click Confirm Close

Closed claims can be reopened if new information emerges. All reopens are logged.

Notifications

Adjusters receive email and Teams notifications for:

New claim assignments
Document uploads from policyholders
Reserve approval decisions (if approval was required)
Settlement acceptances
Litigation status changes

Configure your preferences in Profile → Notifications.