Who Does What?
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When filing an insurance claim, several key individuals and parties are involved, each playing a specific role in the process. This at times may seem overwhelming with the amount of people you will be in communication with to get your home restored. The purpose of this article is to clarify who plays what role within your insurance claim and home restoration process. Here’s a breakdown of the main people and what they do:
- Policyholder (You, the Homeowner)
Role: The person who owns the insurance policy and initiates the claim.
• Reports the damage or loss to the insurance company.
• Provides documentation (photos, estimates, receipts).
• Works with adjusters and contractors to move the claim forward.
• Responsible for paying any deductibles.
- Insurance Adjuster
Role: An employee or representative of the insurance company who investigates and evaluates the claim.
• Inspects the property damage.
• Assesses the cause, extent, and value of the loss.
• Determines how much the insurance company should pay.
• May negotiate with contractors or the policyholder.
There are three main types:
• Staff Adjusters – Work directly for the insurance company.
• Independent Adjusters – Hired by the insurance company but are third-party contractors.
• Public Adjusters – Hired by the policyholder to represent their interests (see more below).
- Insurance Agent or Broker
Role: The person who sold the insurance policy to the homeowner.
• Helps explain coverage details and policy terms.
• May assist the policyholder in initiating a claim.
• Typically does not make claim decisions but important to note.
- Public Adjuster (Optional)
Role: A licensed professional hired by the policyholder to represent them in the claims process. Not a required contact throughout this process. However we would recommend working with one if and only if you feel your insurance is not giving you a fair amount of compensation for the damages incurred. In this case the public adjuster will do the following.
• Advocates on behalf of the homeowner.
• Reviews the claim and may prepare their own damage estimates.
• Helps maximize the settlement and ensure fair compensation.
• Charges a fee, usually a percentage of the final claim payout.
- Contractors / Restoration Professionals
Role: Hired by the homeowner (or sometimes recommended by the insurer) to assess and repair damage.
• Provide repair estimates or scopes of work.
• Work with the adjuster to justify costs.
• Complete the actual rebuild or restoration once approved.
• Instances where permitting is required, They would typically handle the filing of that permit.
- Insurance Company (Carrier)
Role: The entity that provides the coverage and ultimately pays out the claim.
• Makes the final decision on claim approval, payment, and coverage.
• Issues the payment (minus deductible and depreciation, if applicable).
• May offer resources like preferred contractors or claim support.
- Mortgage Company
Role: To protect their financial interest in the insured property.
A mortgage company plays a key role in the insurance claims process when a home with a mortgage is damaged. Because they have a financial interest in the property, they’re often listed on the insurance policy and included on any claim payments. Their involvement can affect how and when funds are released, so clear communication is essential.
• Listed as a loss payee on your insurance policy to stay informed and protect their investment.
• Included on claim checks to ensure funds are used for repairs.
• Release funds in stages, often requiring documentation and inspections.
• Manage escrow accounts to ensure insurance premiums are paid on time.
• Can cause delays if paperwork is incomplete—stay in contact early and often.
In addition to the primary parties involved, several other professionals may also take part in the claims process depending on the situation, including:
- Appraisers
Role: Provide an objective evaluation of the property damage and determine the repair or replacement cost.
• Who They Work For: They can be hired by either the insurance company or the policyholder. In some cases, both parties may hire separate appraisers during a dispute.
• When They’re Involved: Commonly used when there is disagreement over the value of a claim or during the appraisal process (a formal method to settle disputes).
• What They Do:
• Inspect damaged property.
• Estimate the cost of repairs or replacement based on materials, labor, and local prices.
• May participate in an appraisal panel, where a neutral umpire helps resolve differences between two appraisers.
- Claim Examiners
Role: Review submitted claims to verify their validity and ensure they comply with policy terms and internal procedures.
• Who They Work For: Insurance companies.
• When They’re Involved: During the internal review phase of the claim process, often before a claim is approved and paid.
• What They Do:
• Double-check the claim details and the adjuster’s findings.
• Confirm that the claimed loss is covered by the policy.
• Ensure compliance with regulatory and company standards.
• Prevent overpayments or mispayments.
• Approve, deny, or request additional information for the claim.
- Claim Investigators
Role: Detect and investigate signs of potential insurance fraud or suspicious claims.
• Who They Work For: Insurance companies or third-party investigative firms.
• When They’re Involved: In complex, high-value, or potentially fraudulent claims.
• What They Do:
• Conduct interviews with policyholders, witnesses, or involved parties.
• Review surveillance footage, police reports, or public records.
• Visit the loss site to assess inconsistencies.
• Determine whether the claim is legitimate or if fraud is suspected.
• Work closely with adjusters, examiners, and sometimes law enforcement.
These roles are especially important in larger, disputed, or suspicious claims and help protect both the insurer and policyholder from errors, overpayments, or fraud.
As you can see there may be many parties involved in your claims and restoration process. However, knowing who's who, and what roles they play will certainly ease the stress of restoring your home back to its glory. If you have any additional questions or concerns about a specific person's role in your unique situation, please schedule a consultation call where one of our dedicated concierge will point you in the right direction. Wishing you a stress-free restoration.