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Scenario for Opening and Managing a Claim for Auto Damage

This scenario features sample tasks performed by call center agents and claims adjusters. Your company might follow a different workflow according to its business requirements.

A call center agent for an insurance company is on the phone with a policy holder whose car was damaged in a road traffic accident. The call center agent must first check that the policy holder has a valid policy and that there is appropriate coverage.

To report the first notice of loss, the call center agent opens a claims file in Siebel Insurance by navigating to the Claims screen and creating a new Claims record. She enters the loss date and selects a policy that was effective at the time of the loss. She then moves to the Loss Description view to capture some details about the damage to the vehicle and whether there were injuries or fatalities.

The call center agent navigates to the Involved Parties view to capture the contact and account information. She then goes to the Insured Property view to capture more information about the damaged vehicle and the damage that occurred.

The call center agent assigns the claim to an adjuster who then reviews the claim and assigns part of the claim to other people or third parties as necessary. As part of the evaluation, the adjuster navigates to the ISO Database Search view to check whether the policy holder has already made a claim for the same vehicle with another insurance company.

The adjuster creates an activities plan based on the appropriate loss code in the Activities Plan view, then assigns an activity to a particular appraiser who appraises the damage. The adjuster creates claim elements and assigns them as necessary to third-party vendors, such as a repair shop to fix the damage, or a glass vendor to replace the car windshield.

The next step is to set up a reserve, which is a set amount of money that the insurer puts aside to make a claims payment. The adjuster navigates to the Loss Details - Auto view and creates reserves for the coverages that apply to the policy. He then navigates to the Reserves view and opens the reserves.

In due course, the adjuster receives the invoices associated with the claim and creates a record for each invoice in the Claims screen, then the Invoices view. In the Claims screen, then the Invoices view, he clicks the Generate Payment button to create a payment record for the invoices. The adjuster navigates to the Payments view and clicks the Submit Payment button to make the necessary payment and settle the claim.

Throughout the claims process, an adjuster can assign the claim to a specialist unit such as a subrogation unit or a fraud unit. The specialist unit then processes the claim in their area.

In this scenario, the end users are call center agents and claims adjusters. They enter information to:

• Check that the claimant has a valid policy with the appropriate coverage
• Create a loss claim and record details about it
• Associate the loss with a contact and account
• Record details about the damage to the vehicle
• Check whether the claimant has filed a similar claim with another insurance company
• Create an activities plan and assign activities to appraisers
• Assign claim elements to appropriate third-party vendors
• Create and open reserves
• Record invoice details
• Generate and submit payments