Invoking “Our Option” – Increased Use of Preferred Contractor Networks
What's the Scenario? with PLRB
A Texas adjuster gets an assignment for a simple hail damage claim. He anticipates having to argue with the roofing contractor, debate whether overhead and profit is owed, deal with the supplementing company, receive an appraisal demand, and finally face a lawsuit. About Our Guest Steven J. Badger, Partner, Zelle LLP [email protected] https://www.linkedin.com/in/steven-badger-467b0322/ Notable Timestamps [ 00:20 ] - Because of his years of experience, he knows that the 30 square comp shingle roof should cost about $20,000 to replace. (Amount provided is for reference and...
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The PLRB Insurance Services Expo & You
What's the Scenario? with PLRB
Let’s say you’re a service provider in the insurance industry. You’ve been attending PLRB Conferences for a few years, and you’re thinking about taking the next step to increase exposure and build relationships with the right people in the industry. Notable Timestamps [ 01:20 ] - Exhibiting and sponsoring at the PLRB Claims Conference can be an impactful option, and PLRB has a variety of offerings to help each service provider reach their goals. [ 01:50 ] - For our trivia question today, last year at the Claims Conference we had over 3000 attendees, and over 950 of those...
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The Police Shot My Heating Oil Tank (and a Burglar)
What's the Scenario? with PLRB
In the middle of the night, a burglar broke into the policyholder’s house. Nearby police arrived, and the suspect was apprehended. Debbie filed a claim for the police’s bullet holes in her house and cleanup of heating oil spilled when a bullet hit the tank. Notable Timestamps [ 00:15 ] - The bullet holes were all from police guns. 150 gallons of heating oil spilled in the basement. [ 01:40 ] - Heating oil tanks are most commonly found in what region of the United States? [ 03:30 ] - Tim reads through the Pollutants exclusion. Heating oil is most likely going to be considered a...
info_outline![[REPLAY] Join Us at the 2025 Claims Conference show art](https://assets.libsyn.com/content/186169870?height=50&width=50)
[REPLAY] Join Us at the 2025 Claims Conference
What's the Scenario? with PLRB
Joining us next week? Enjoy this replay of our recent episode on the Claims Conference. A supervisor is leading a small but mighty teams of adjusters, and they're taking their team to Indianapolis this spring for the 2025 PLRB Claims Conference. The only problem? They’ve never been before and have no idea where to start. Notable Timestamps [ 00:15 ] - One more salute to our once and future host, Alissha Watley. [ 00:40 ] - Our team of claims professionals is headed to Indiana Convention Center in Indianapolis, IN for the 2025 PLRB Claims Conference, held on March 31 to April 2....
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Investigating a Garage Fire
What's the Scenario? with PLRB
Homeowner Lisa claims she was asleep when she woke up to smoke alarms blaring. She safely evacuated her home, but the fire destroyed her garage and spread to part of her home. The adjuster requests that Alex determine the fire’s cause. Notable Timestamps [ 00:15 ] - The scenario outlines a garage fire claim and a need to investigate the cause of the fire. [ 01:00 ] - When investigating a fire claim, is it origin and cause or cause and origin? Why? [ 03:00 ] - NFPA 921 provides standards for fire investigators conducting origin and cause investigations. [ 03:50 ] - Ring doorbell...
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It’s Getting Smokey in Here
What's the Scenario? with PLRB
Homeowner Jane Thompson lived 20 miles from the large Badone wildfire. One week after the fire department fully contained the wildfire, Jane called Evergreen Mutual and reported a strong smoke odor throughout her home. Notable Timestamps [ 00:20 ] - Jane also noticed discoloration on her walls and soot on her furniture. Jane was understandably concerned about her family’s health and potential long-term damage to her home and personal property. [ 01:10 ] - Can you name at least four of the major wildfires that have occurred in the US since 2016? [ 03:25 ] - The adjuster might...
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Hand Me That Certificate (of Insurance)!
What's the Scenario? with PLRB
Just before purchasing a policy, the insured subcontractor says “I need to provide something called a ‘Certificate of Insurance’ to my general contractor,” and add them as an additional insured. What issues does this create from an underwriting or claims perspective? Notable Timestamps [ 00:15 ] - The adjuster is giving him the Coverage A limits to rebuild the house. But he is also making a claim for Fair Rental Value (Coverage D). ISO HO 00 03 05 11. Is there coverage? [ 01:07 ] - The team diagrams the parties. [ 01:43 ] - Employees, officers, and directors generally qualify as...
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My Insurance Company Forgot to Bill Me...
What's the Scenario? with PLRB
The insured signed up for a “retrospective rating plan.” Under this plan, the insured promised to reimburse Unforgettable for its paid losses. The insurance company discovered invoices left unsent due to a computer programming error. Notable Timestamps [ 00:15 ] - Total Surprise Transportation promised to reimburse Unforgettable Insurance for its paid losses, including "Allocated Loss Adjustment Expenses." [ 01:25 ] - Tim asks for his paycheck to be decreased, and Brennan gets paid to buy a workbench. [ 02:43 ] - Usually premiums are calculated based on industry knowledge and...
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Singer Sings Against Assailant to Get a Defense
What's the Scenario? with PLRB
A concert attendee filed suit against a band's lead singer based on the singer's alleged "onslaught" of blows to the attendee's face, head, and body over a dispute. However, the singer's claimed that the confrontation only became violent when the attendee threw the first punch. Notable Timestamps [ 00:25 ] - The singer tendered the suit to his insurer, who agreed to defend under a reservation of rights, but is there a duty to defend? [ 01:25 ] - Seventies, eighties, nineties? The crew chats concerts. [ 02:30 ] - This scenario is based on New York Marine and General Ins. Co. v. Ness, 2021...
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Shooter Shatters Funeral Reception
What's the Scenario? with PLRB
A restaurant was hosting a funeral lunch. During the lunch, a gunman entered and shot an individual who was not related to the funeral reception, but who was in eyeshot of lots of the patrons and children. The victim survived & the gunman fled. Notable Timestamps [ 00:24 ] - The insured restaurant has a CGL policy and sought coverage after a group of the patrons filed a lawsuit against the restaurant alleging emotional distress [ 01:50 ] - The coverage crew discuss The Godfather and their favorite mob movies. [ 02:45 ] - Bodily Injury under the CGL policy is usually defined as...
info_outlineAfter a storm, a warehouse roof seems to leak more often, and a manager notices some water pooling on the edge. The adjuster’s inspection reveals only minor dents, and the policy has a cosmetic damage exclusion. The manager argues the damage is not cosmetic.
Notable Timestamps
[ 00:19 ] - The manager even hires an expert to contest coverage.
[ 01:25 ] - Tim and Mike discuss the leaks in the PLRB offices.
[ 02:46 ] - See prior episode "That Damage is Just Cosmetic!" for the version of this scenario with no exclusion.
[ 03:50 ] - When cosmetic damage exclusions first debuted, many courts found the clause ambiguous.
[ 05:13 ] - Let's say there's no leak, just pooling. In Dragoo v. Allstate Veh. and Prop. Ins. Co., No. 4:16-CV-984-O, 2018 WL 1536639 (N.D. Tex. 1/05/18), cosmetic damage was read as damage that "only changes its appearance."
[ 06:30 ] - If the damage increased the likelihood of future damage, that may not be considered cosmetic.
[ 07:20 ] - In Fisher v. Am. Fam. Mut. Ins. Co., No. 17-CV-01949-MEH, 2019 WL 142204 (D. Colo. 1/09/19), the exclusion applied to components that would not "(1) prevent water from entering the building; or (2) perform any other intended function." The second clause was found to potentially include aesthetics.
[ 08:00 ] - In Valleyview Church of Nazarene v. Church Mut. Ins. Co., No. 2:20-CV-222-Z-BR, 2023 WL 4504595 (N.D. Tex. 6/13/2023), the policy read "cosmetic damage means that the wind and/or hail caused marring, pitting or
other superficial damage that altered the appearance of the roof surfacing, but such damage does not prevent the roof from continuing to function as a barrier to entrance of the elements to the same extent as it did before." This was found to be not ambiguous.
[ 09:11 ] - In J&S Welding, Inc. v. Liberty Mut. Ins. Co., No. 1:22-cv-01122-STA-jay, 2023 WL 6150730 (W.D. Tenn. Sept. 20, 2023), the court said that testimony about the functionality of a metal roof qualified as a matter of scientific, technical, or other specialized knowledge.
[ 12:07 ] - Check for Cosmetic Damage Regulatory Bulletins, e.g. https://www.plrb.org/documents/2017-regulatory-cosmetic-damage-exclusions-wy/ or https://portal.ct.gov/cid/-/media/cid/1_protertycasualty/aerial-imagery-notice.pdf
[ 14:30 ] - Jeff provides a recap of the scenario and the points above.
Your PLRB Resources
For Regulatory Bulletins and State-By-States, check out PLRB's hubs, e.g. https://www.plrb.org/property-lines/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
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The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License.
Font: Metropolis by Chris Simpson. SIL OFL 1.1.
Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription).
Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
Hail Sounds: Buckine. Freesound.org. https://freesound.org/people/Buckine/sounds/574928/