Project Managers Facility Association Residual Market (FARM)

Transcription

1 TO: Project Managers Facility Association Residual Market (FARM) BULLETIN NO.: All-Canada PJM DATE: July 25, 2012 SUBJECT: Facility Association Claims Guide (FARM) A copy of this bulletin should be provided to your Claims Manager. This is to advise that the Residual Market (FARM) Claims Guide is revised effective January 1, Litigation, Part 1, Reimbursement of Legal and Professional Fees has been changed to read: Requests for reimbursement must be submitted within 365 days of the closing of the claim. Proof of closing date must also be submitted. This rule is for Category 1 and II reimbursements of eligible Legal and Professional Fees. Prior to this change there was no time limit in place for Servicing Carriers to request reimbursement of Legal and Professional fees. This change will provide more timely reimbursements and will assist in the actuarial process. Members are reminded of the importance of this update. In addition to this rule change, there are minor housekeeping items that have no impact on day-to-day operations. All changes have been marked with a bar in the margin. An electronic copy of the revised Claims Guide will be posted shortly on our website at If you have any questions regarding this bulletin, please contact Jill Hepburn, Vice President, Underwriting and Claims at jhepburn@facilityassociation.com or at (416) David J. Simpson, M.B.A., FCIP, C. Dir. President & CEO

2 FACILITY ASSOCIATION CLAIMS GUIDE RESIDUAL MARKET (FARM) Effective: January 1, 2013

3 FACILITY ASSOCIATION CLAIMS GUIDE: RESIDUAL MARKET PAGE CONTENTS 1 F.A. OVERVIEW 2 PROJECT MANAGER APPOINTMENT/DUTIES 3 F.A. CLAIMS COMMITTEE 4-6 LARGE LOSS REPORTING - Categories - Procedures - General - Reconciliation 7-10 CLAIM PERFORMANCE AUDITS SERVICING CARRIER REPORTING - FAC 50: Completion Instructions 15 SUMMARY REPORT (Synopsis) FAC 51: BI a/o AB: General - Completion instructions LITIGATION Part 1 - Category 1 - Tort Description & Schedule - Category II Ontario AB Description & Schedule 22 Part 2 Litigation Management 23 LARGE CLAIMS REPORT FORM: FAC BI a/o AB WORKSHEET: FAC LARGE CLAIM CLOSURE WORKSHEET (TORT)(AB): FAC LEGAL REIMBURSEMENT FORM CATEGORY I & 11 Effective January 1, 2013 Residual Market Page 1

4 FACILITY ASSOCIATION "Residual Market" OVERVIEW There are a number of reasons why a person is insured in the Residual Market (FARM). Some relate solely to that person's level of driving experience, but the main reasons are accident frequency and violations of the Highway Traffic Act and/or the Criminal Code. It is expected that the claims will be handled on the basis of sound, proven methods and procedures. Facility Association claims must be adjusted and serviced on the same basis and with the same expertise as the Servicing Carrier s regular claims. Prompt and fair settlements are expected. Effective January 1, 2013 Residual Market Page 2

5 FACILITY ASSOCIATION APPOINTMENT OF PROJECT MANAGER BY PROVINCE Each Facility Association Servicing Carrier is required to submit the name of a Facility Association Project Manager for each province. This individual will be the contact point for all Facility Association claims correspondence and inquiries in the province. The Facility Association Servicing Carrier should immediately notify the Facility Association Claims Department of any changes. This is an important position and should only be assigned to a responsible, senior claims representative in each province. Duties of the Project Manager include, but are not limited to: - ensuring that all F.A. Claims Rules and Procedures as contained in this Guide are observed - ensuring that all Large Losses, as defined in this Guide, are reported in their totality, especially if the claim is separated by coverage. - receiving correspondence from the F.A. Claims Committee and ensuring that responses to their requests and inquiries are timely and in the proper format - advising the Facility Association of significant changes either in the Project Manager's provincial legislation or in the court system which might affect the handling of claims in their respective venues - directing local and company issues to the F.A. Claims Committee for their interpretation and direction - any other claims matters which might be of concern to the Facility Association, the Servicing Carrier or the Project Manager Effective January 1, 2013 Residual Market Page 3

6 F.A. CLAIMS COMMITTEE The Committee is presently made up of volunteers who are senior claims personnel from both Servicing Carriers and non-servicing Carriers. The Committee meets every second month and is a working Committee. Its purpose is to review reported Large Losses and to comply with the following mandate which has been approved by the F.A. Board of Directors. FACILITY ASSOCIATION: CLAIMS COMMITTEE MANDATE Review large losses as outlined in the Claims Guide and make recommendations to the member on case reserves and strategy to bring the claim to a conclusion. In support of the Provincial Operating Committee decide on coverage and/or liability in disputed claims. Consider all claims related matters, both procedural and technical in accordance with the Claims Guide. Advise on issues which are industry related to properly interpret their meaning and impact in relation to F.A. procedures. Effective January 1, 2013 Residual Market Page 4

7 LARGE LOSS REPORTING I CATEGORIES The Facility Association Claims Committee requires notice of any occurrence that meets any of the following conditions: 1. An aggregate incurred (paid and outstanding) loss of $250,000 or more (total of all sub files). Note - The F.A. bases its reporting scheme on the TOTAL INCURRED for each file, i.e., all lines of reserve for the ENTIRE file. 2. If the file is separated by coverage, both the Accident Benefits incurred and the Tort incurred aspects of the file must be reported. This reporting will be accommodated under one F.A. claim number. 3. A policy limit reserve. 4. A serious bodily injury including but not limited to: (a) (b) (c) (d) (e) fatality with dependants brain damage any plegia; para, quadra, hemi, etc. amputation of a limb at or above the elbow or knee serious disfigurement These injuries shall be reported regardless of the Servicing Carrier's assessment of liability or the amount of the incurred loss. 5. An Ontario Accident Benefit claim that results in continuous payments under the disability section of the policy for two (2) years or more. 6. All class actions or any situation where an action has been instituted naming the Facility Association or where Facility Association will be presented with the legal fees for defending such an action, including where the member may be exposed to an excess judgment under an End 44, must be brought to the attention of the F.A. VP of Claims with an estimate of the amount of legal fees the action might incur. This must be done before any expenses are incurred in the defence of such an action. The VP of Claims will then provide instructions on how to request reimbursement by way of a submission to the Board of Directors. Effective January 1, 2013 Residual Market Page 5

8 II PROCEDURES Initial Report 1. All losses which qualify as a Large Loss must be reported within 60 days of the Servicing Carriers knowledge of meeting the reporting criteria using FAC 50 and FAC 51 forms accompanied by an initial Summary Report (See page 12). The FAC 50 should be marked "INITIAL REPORT". Please refer to the instructions on completing each form and report. Revision or Update 2. Anytime the incurred on a reported Large Loss increases or decreases by $100,000 or more, a one page summary of the Liability, Medical and Legal status of each claimant, as well as the completed FAC 50 and Fac 51 must be forwarded to the Claims Committee within 30 days of the change. 3. All reported claims MUST be updated every six (6) months from the date of reporting with a one page summary of the Liability, Medical and Legal status of each claimant and forwarded to the Claims Committee. Closing 4. Any REPORTED claim which has been concluded, i.e., all sub-files or lines of reserves closed, must be reported to the Claims Committee using the FAC 52: "Large Claim Closure Worksheet" within 30 days of closure. This form is only required on PREVIOUSLY REPORTED LARGE LOSSES. 5. If the Servicing Carrier should determine that a reported claim no longer meets the reporting conditions after the Initial Report has been submitted to the Committee, the Servicing Carrier should advise the Committee of the reasons for the disqualification of that particular file. The file will continue to be reported until the Committee advises the member of its decision on the reporting status. Effective January 1, 2013 Residual Market Page 6

9 III GENERAL 1. On the Initial Report to the F.A. once the Committee has reviewed the information contained on the FAC 50 and 51 and the Summary Report, an acknowledgement status letter will be returned to the Servicing Carrier with the Committee comments, observations and suggestions. 2. Occasionally, the Claims Committee will disagree with the reserves being carried by the Servicing Carrier. In such cases, the Committee will advise the Carrier of its decision. The Servicing Carrier should then modify or adjust the reserve level and confirm to the Committee that the modification or adjustment has been completed. If the Committee has recommendations to make regarding the handling of the claim, they will provide this input for consideration to the Servicing Carrier. 3. The setting of reserves for injuries in Ontario requires the consideration of whether the injury will meet the threshold criteria. The Claims Committee recommends that if it cannot be determined whether or not an injury will meet the threshold test, a reserve that reflects 100% of the assessed value be maintained. 4. The Committee requires SUMMARY REPORTS ONLY. Any original or copy of independent agents /vendors reports, i.e., lawyers, doctors, adjusters, etc., will be returned to the Servicing Carrier. IV RECONCILIATION Semi-annually, the Facility Association will supply to each carrier in each province, a list of claims that have been reported to the Claims Committee and are still open. The member branch/company should check this list against their outstanding register and report any discrepancies to the Claims Committee using the appropriate forms, i.e. FAC 50, 51 or 52. Effective January 1, 2013 Residual Market Page 7

10 CLAIM PERFORMANCE AUDITS FOR SERVICING CARRIERS The audits will be performed at the Servicing Carrier's offices by highly qualified claims professionals appointed by F.A.. The audit will primarily concentrate on compliance with the Facility Association's procedures as outlined in the Plan of Operation and this FARM Claims Guide. The review will include: 1) Review of Servicing Carrier's current Claims Procedure Manual or Guide and Adjuster's Handbook or Manual. 2) Review of Management Information reports. These claims audits will be performed annually. Criteria for a satisfactory score will be determined by the Audit Committee. Files for the review will be selected randomly from the most recent available IBC printout of Paid and Outstanding files for the Company and Region where the audit is to be conducted. The auditor will review each file and provide an objective rating for each file based upon the above description and the following criteria: Effective January 1, 2013 Residual Market Page 8

11 1) CONFIRMATION OF COVERAGE Is the claims handler consistently determining coverage, properly applying the deductible, discrepancy procedures on new policies with losses close to inception, promptly reporting and setting up claims? 2) INVESTIGATION Is the fact gathering commensurate with claim requirements and in accordance with the Company's claims investigation procedures as outlined in their claims manual or adjuster's handbook? ICPB / CCIB / CATB being filed? 3) RESERVING Are reserves for all potential claims being set promptly taking into consideration proper evaluation techniques and assessment of liability? Are AB and/or BI Worksheets completed and updated promptly to justify the appropriate lines of reserves? What type of reserves are posted initially? Are case reserves input within the proper time frames? What are the levels of control (authority) and are they monitored to avoid exceeding individual authority levels? 4) ABEYANCE Are the claims being properly followed-up on a proactive basis rather than a reactive basis? Are the time intervals between abeyance reviews realistic? Is activity generated by Company personnel when files are reviewed? 5) APPRAISAL/DAMAGE CONTROL Are there controls in place to ensure that physical damage claims are resolved on the most reasonable and economic basis possible? Are there glass controls in place? 6) SALVAGE If Servicing Carrier using the most appropriate methods to maximize salvage recovery? What methods are used to control disposal, towing and storage? Do they measure performance against present criteria? Is there a procedure for non-recovered total thefts? Effective January 1, 2013 Residual Market Page 9

12 7) SUBROGATION Does the Servicing Carrier give recovery proper commitment? Is this followed up regularly? Do they demonstrate Loss Transfer awareness and do they take the necessary steps to handle it? 8) LITIGATION How is this managed? Do they negotiate at Company level? Do they have approved counsel? Who directs follow-ups, cost containment and measures results? Is there a Litigation Management Program? 9) LARGE LOSS REPORTING TO F.A. Are F.A. reporting forms FAC 50, 51, 52 being completed properly and submitted in a timely fashion? Is F.A. Claims Guide being adhered to? Are they aware of the proper reporting procedures? Are they responding to F.A. Claims Committee inquiries and directives? 10) OTHER Any other extraneous issues which may affect the handling of files? These may include but not be limited to: excessive backlog, staffing, internal controls and authority levels. Within 30 days of completion of the audit a report will be produced which will contain a brief elaboration by Category with appropriate recommendations and an explanation of the scoring especially in the Unsatisfactory category. Any Servicing Carrier claims operation which scores Unsatisfactory in any category on an audit will be re-audited in 6 months. Each audit and situation will be assessed individually. Effective January 1, 2013 Residual Market Page 10

13 Each individual performance audit will be reviewed by the Board of Directors and the Executive Committee of the Facility Association with the appropriate recommendations based upon the results of the audit. Any audit of Unsatisfactory for two consecutive audits will require special consideration by the F.A. Board of Directors. The consequences of deficient performance audits may be that the F.A. Board could either take legal action against the Servicing Carrier, suspend the Servicing Carrier from writing F.A. policies, bring the C.E.O. of the Servicing Carrier before the F.A. Board of Directors or any combination of the preceding. Effective January 1, 2013 Residual Market Page 11

14 SERVICING CARRIER REPORTING: FORMS FAC 50: Large Claims Report: General The use of this form is to facilitate the reporting of claims which fall into the categories as outlined in the Large Losses section of this Guide in a simple condensed format. If the completion instructions are followed there should be sufficient information for the Claims Committee to adequately assess the claim. A "Summary Report" MUST accompany the FAC 50 Initial Report. A description of this report follows this section. Once the Claims Committee has reviewed the submission, an acknowledge status letter will be returned to the Servicing Carrier with any suggestions or recommendations from the Committee. Retain copies of all F.A. forms and correspondence both to and from the F.A. This will assist anyone reviewing the file to determine the status of the F.A. file. Effective January 1, 2013 Residual Market Page 12

15 FAC 50: LARGE CLAIMS REPORT - COMPLETION INSTRUCTIONS Line 1: Initial Report, Please check box so that we can Revision or distinguish the status of information being Update submitted. F.A. Claim # DO NOT COMPLETE. This number will be provided to the Servicing Carrier via the acknowledgement copy from the Claims Committee. Line 2: Company # Your Servicing Carrier # Company Name & Address Claim # Reporting Company's name and address of the underwriting Branch. Servicing Carrier reference number for that particular claim. Line 3: Assured Name & Address e.g., John Doe, Toronto Policy # Policy that applies to this claim. Line 4: TP Limits Section A policy limits. AB Schedule Policy Term Loss Date Indicate whether standard AB limits or the particular legislation applicable e.g., Ontario Bill 164. Applicable term under which loss falls. Exact & correct Date of Loss for this occurrence (dd/mm/yy). Line 5: Describe Circumstances A brief description of the circumstances of Accident & Liability of this claim and any issues which may Issues affect the liability. Effective January 1, 2013 Residual Market Page 13

16 FAC 50: LARGE CLAIMS REPORT - COMPLETION INSTRUCTIONS - cont'd Line 6: Location of Loss Where did loss occur as opposed to the underwriting province. Degree of Liability Please check box and enter percentage e.g. Insured 100%. This percentage should be reflected on the FAC 51- BI Worksheet Line 7: Note: Attach "Summary This line ONLY applies to the Initial Report" and a FAC 51 Report. A "Summary Report", as For Each Claimant described in this Guide, must be With Initial Report enclosed. A FAC 51 for each claimant must also accompany the Initial Report. Line 8: Name of Claimant Provide the claimants name for the "KIND (1 Claimant & 1 KIND OF LOSS) the paid and reserve apply OF LOSS per line) to on that line. i.e. only BI or PH or PD etc. If that claimant also has a claim for another KOL use a second line. FAC 51 KIND OF LOSS Paid To Date Reserve If the reserve and paid require substantiation for that KIND OF LOSS then a FAC 51 must be completed and attached. Check this area if this applies for that claimant. Please check the applicable cover that applies. ONLY one KOL per line. Amounts paid for the checked KOL for that line and claimant. Amount of money anticipated to satisfy the indicated (checked) KOL. Effective January 1, 2013 Residual Market Page 14

17 FAC 50: LARGE CLAIMS REPORT - COMPLETION INSTRUCTIONS - cont'd Line 9: Signature of Claims The Claims Manager or a Senior Claims Rep Rep. must review the submission to verify that it reflects the present position of the file. Date MANDATORY field which must be filled in on the date the submission is made. Line 10: Committee Comments LEAVE BLANK - this is for the F.A. Claims Committee use only. Effective January 1, 2013 Residual Market Page 15

18 SUMMARY REPORT (Synopsis) The Summary Report must be submitted with the "Initial Report" (FAC 50). It should provide the F.A. Claims Committee with a complete overview of the claim. Its purpose is to provide the Committee with information which is pertinent to the file and is not contained in the completed accompanying FAC 50 and 51 forms. It should include synopsis of medical information, reconstruction reports, statements, legal summaries and any information pertinent or unique to that particular claim. It must also elaborate on the intended action that is necessary to bring the claim to a satisfactory conclusion. If the Committee requires additional information it will be requested. Note - The Committee will NOT accept copies of medical reports or assessments, legal opinions, reconstruction reports, etc. and would appreciate your adherence to this requirement. Effective January 1, 2013 Residual Market Page 16

19 FAC 51: Bodily Injury &/or Accident Benefits Worksheet: General The FAC 51 form is intended to supplement the FAC 50 and justify the various reserve calculations for injury claimants and their respective Kind Of Loss (KOL) checked off on the FAC 50. The form is only intended for individual claimants, e.g., only one claimant per FAC 51 but can demonstrate the calculation for that claimant for both Tort and Accident Benefits. The form is divided into two sections: The information section and the reserve calculation for Tort and Accident Benefits. The top of the form deals with the pertinent individual information that will effect the calculation of the reserve. The bottom section of the form is the worksheet for either the Tort or Accident Benefits reserves or both. The calculations for the reserves should not consider any "PAID TO DATE" amounts. Paid Losses should only be reflected in the appropriate KOL section of the FAC 50. As well, the amounts of calculated reserve should be reflected in the appropriate KOL section of the FAC 50. The major problem that should be considered is the claimant who could possibly make a claim under both the Tort and the Accident Benefits sections of the auto policy. In this situation, the FAC 51 can be used to calculate both reserves but if there is a separation of the files due to "conflict of interest" issues, or company policy, separate FAC 51's can be completed by the separate claims Reps. but both MUST be submitted with the INITIAL REPORT. If there are separate claim numbers then the respective FAC 51's should reflect the company s claim number for the appropriate KOL. The "Summary Report" can cover the different issues for Tort and Accident Benefits. A copy of the FAC 51 should be kept in the Servicing Carrier claim file. If submitting an electronic version, a copy of the should be kept on file. Effective January 1, 2013 Residual Market Page 17

20 FAC 51: BODILY INJURY AND/OR ACCIDENT BENEFIT WORKSHEET Line 1: Company Number Your Servicing Carrier number (see: page 24) Company Name & Address Reporting Company's name and address of the underwriting branch. Your Claim Number Report all reference claim numbers for this claimant; e.g. if file bifurcated and separate claim numbers apply to Tort and Accident Benefits show all applicable numbers. Line 2: Claimant Individual's name who is making claim ONLY 1 CLAIMANT PER FAC 51 Age Sex Employment The number of years since birth or the birth date (either is acceptable) Male or Female If Tort issue: present status - type of work. If AB issue: present status plus any applicable previous employment that might affect the calculation. Line 3: Marital Status Applicable status at the time of loss. Dependants Time In Hospital W.C.B./WSIB Benefits Position in Accident Those that will affect the calculation. Number of days claimant was in hospital. Check appropriate box to determine if the entitlement or lack of entitlement will affect the reserve calculation. Check appropriate box for this claimant. Effective January 1, 2013 Residual Market Page 18

21 FAC 51: BODILY INJURY AND/OR ACCIDENT BENEFIT WORKSHEET -cont'd Line 4: Nature & Extent of Injuries Complete description of the resultant Injury or injuries suffered in this accident and/or any associative medical problems that may affect the reserve calculation. The remainder of the form is divided into the Tort and/or Accident Benefits reserve calculation If the loss occurs in Ontario or Ontario auto legislation is applicable please check the appropriate area indicating the applicable regulation in either calculation for this particular claimant. For claims occurring in provinces other than Ontario please check the "OTHER" area. Effective January 1, 2013 Residual Market Page 19

22 FAC 52: Large Claim Closure Worksheet - General This form is primarily used to advise the Facility Association Claims Committee that a REPORTED Large Loss, i.e., a file that has been reported to the Claims Committee which has met the requirements for reporting as contained in this Guide, has been concluded. Any expenses which have been or are to be recovered from the F.A. should be shown in the column entitled "Expense (charged to F.A.)" under the appropriate KOL. These would be expense payments as outlined in the "Legal and Professional Fees" section of this Guide. All other expenses paid on this particular file should be shown in the "Expense (Not Charged to F.A.) under the appropriate KOL. Expenses Recoverable from the F.A. will not be paid if the file has been reported to the Claims Committee and the FAC 52 has not been submitted. Effective January 1, 2013 Residual Market Page 20

23 LITIGATION PART I: REIMBURSEMENT OF LEGAL & PROFESSIONAL FEES Category I Tort The Facility Association will reimburse the Servicing Carrier in all jurisdictions for first party legal fees resulting from any one claim occurrence subject to the $10,000 deductible. The Facility Association will reimburse the Servicing Carrier in all jurisdictions for Professional consulting fees (as per the following schedule) resulting from any one claim occurrence; it is no longer subject to the $10,000 deductible, effective May 1, It will be the responsibility of the Servicing Carriers to make the appropriate submission to the Facility Association along with supporting documentation for reimbursement of these fees upon FINAL settlement of the claim. NO interim billing will be entertained under this Category. On REPORTED LARGE LOSSES you MUST submit a FAC 52 - Large Claims Closure worksheet before the F.A. will consider reimbursement. (There are now 2 separate FAC 52 forms (AB and Tort) to allow the payment on a settled Tort before AB settles.) Requests for reimbursement must be submitted within 365 days of the claim closing. Proof of closing date must also be submitted. Approved Professional consulting fees to be considered are: Category I: Schedule Accounting Services Actuarial Services * Private Alternate Dispute Resolution Services (not FSCO - mediation or arbitration) Architectural Services Autopsy Reports Coroners' Court Transcripts CRC reports invoiced after May 1, 2004 * Defence Medical Reports & Assessment Reports Engineering and Accident Reconstruction Investigation Services Investigation services - invoiced after May 1, 2004 Notarial Services Surveillance - invoiced after May 1, 2004 Translations *Applies only to medical & assessment reports requested by defence counsel. We will NOT pay for Third Party or Plaintiff medical reports. These are Loss payments. Effective January 1, 2013 Residual Market Page 21

24 Category II - Ontario Accident Benefits Expenses invoiced after October 1, 1994 Expenses incurred under Category II are not to be included in Category I and shall not be considered in qualifying for reimbursement of expenses under Category I. It will be the responsibility of the Servicing Carriers to make the appropriate submission to the Facility Association along with supporting documentation for reimbursement of these fees upon FINAL settlement of the claim. NO interim billing will be entertained under this category. On REPORTED LARGE LOSSES you MUST submit a FAC 52 Large Claims Closure worksheet before the F.A. will consider reimbursement. Requests for reimbursement must be submitted within 365 days of the claim closing. Proof of closing date must also be submitted. The Facility Association will reimburse Servicing Carriers for professional consulting fees in Category II as listed in the following schedule on Ontario claims occurring under OMPP, Bill 164, Bill 158 and (Bill 198 or any subsequent legislation) under the Accident Benefits section of the auto policy. Such expenses will not be subject to the $10,000 deductible. Category II: Schedule Accident Reconstruction Investigation Services Accountant fees-invoiced after May 1, 2004 CRC reports- invoiced after May 1, 2004 Investigation- invoiced after May 1, 2004 Legal defence fees- invoiced after May 1, 2004 OT assessments- invoiced after May 1, 2004 Private Mediation and Arbitration (excluding Ontario Bill 59 mediation costs) ** Private Medical Reports & Assessment Reports Rehab case-management- invoiced after May 1, 2004 Surveillance Translation fees- invoiced after May 1, 2004 Note: Submissions under Category I & II must contain a completed copy of the enclosed F.A. form entitled "Request for Reimbursement of Legal Fees". ** Under the IBC Automobile Statistical Plan, after January 1, 1994 ALL medical reports, IME, FAC, DAC, assessments, etc. fall under the S.A.B.S. regulations and are indemnity payments. They are coded under "Cost of Examination" KOL (Kind of Loss) codes 86 which is a LOSS code not Expense code. Therefore, the only medical and assessment reports that are expense items would be those that were paid under the OMPP legislation. Effective January 1, 2013 Residual Market Page 22

25 PART II: LITIGATION MANAGEMENT Submission of Legal & Professional Fees which qualify for reimbursement from the Facility Association under either Category I or II must use the following form (see page 26). The mandatory fields which must be completed before consideration can be given are: Company Name Claim Number Policy Number Underwriting Province Date of Loss Documentation required for CAT I and II reimbursement: 1) Copy of the detailed expense invoice identifying the type of service to which the invoice applies. 2) Copy of the cheque identifying date of issue and payee information. 3) Summary of payment transactions to identify expense payment allocation and details of recovery on these eligible expenses (ie: shared expenses). 4) Adding machine tape of the total sums claimed/submitted. 5) Proof of closing date must also be submitted (i.e. system screen prints). Once the Legal Expense Reimbursement Request (see: page 26) and all above required documentation has been reviewed, all qualified submissions will be paid. Should there be items which do not qualify but have been submitted by the Servicing Carrier, a YELLOW photocopy of the Legal Expense Reimbursement Request form will be returned to the Servicing Carrier explaining the reason for rejection. Should the entire submission not qualify, the original documents will be returned along with a letter explaining the reason for rejection. Any disagreement by the member MUST be submitted to the F.A. Claims Department in writing. Effective January 1, 2013 Residual Market Page 23

26 Effective January 1, 2013 Residual Market Page 24

27 Effective January 1, 2013 Residual Market Page 25

28 Facility Association FAC 52 - Large Claim Closure Worksheet Company #: Name: Address: NOTE - Final Closing Notice on previously reported losses only. ALL Lines of Coverage must be closed prior to submission to F.A. Named of Insured: Policy #: F.A. Claim #: Co. Claim #: Date of Loss (d/m/y): Kind of Loss BI PH PD UIM/Under Comp/Coll AB Payments Ins. Loss $ $ $ $ $ $ Expense $ $ $ $ $ $ Total $ $ $ $ $ $ Grand Total (All Items): $ Signed: Date: Effective January 1, 2013 Residual Market Page 26

29 Facility Association Request for Reimbursement of Legal Fees Category: I or II Company Name: Claim #: Policy #: Insured: U/W Province: D.O.L.: Note: If Invoice does not identify type of service you must do so. Item(s) Amounts Category I Deductible: (If applicable) Net: Enclose Invoices, copies of cheques & adding machine tapes Effective January 1, 2013 Residual Market Page 27