GA, SD, WV
Multistate
PI-PLSP-CASUPP 09/11 Page 1 of 2
COVER-PRO
SM
APPLICATION
CLAIMS ADJUSTER SUPPLEMENT
1. Full name of the Applicant Firm:
2. Provide the percentage of the Applicant’s gross annual revenue derived from the following lines of business:
Insurance Claims Adjustment
Life Insurance % Health Insurance %
Personal Property & Casualty
Personal Auto Insurance: % Homeowner’s Insurance: %
Commercial Property & Casualty
Commercial auto: % Workers Compensation: %
Inland Marine: % Commercial Multi-Peril %
Wet Marine: % Products Liability: %
Professional Liability: % Other Commercial Property: %
Aviation: % Medical Malpractice: %
Stop Loss: % Reinsurance: %
Other: %
Providing Cost/Risk Management Services:
%
Providing Cost/Risk Management Consulting Services:
%
Claims Auditing:
%
Other (specify):
%
Other (specify):
%
TOTAL MUST EQUAL:
100 %
3. What percentage of the Applicant’s number of annual clients are insurance carriers and/or self
insured entities:
%
What percentage of the Applicant’s number of annual clients are policyholders: %
4. What is the average length of claims adjuster experience, in years, per claims adjuster:
yrs.
5. Does the Applicant have pre-authorization from insurance company and/or self insured
clients to settle claims?
Yes
No
If yes, up to what dollar value: $
6. Does the Applicant’s operation contain[s
] controls to guard against the following? Check all that apply.
Overpayments Payments to ineligibles
Underpayments Unfair/Unjust enrichment
Late payments Improper refusal of benefits
Payments from incorrect plan Failure to follow payment guidelines or procedures
7. Does the Applicant’s computer system print checks? Yes No
If yes, are two signatures required on printed checks? Yes No
If so, over what amount: $
