CLAIMS REPRESENTATIVE JOB DESCRIPTION

A Claims Representative handles something most policyholders encounter only once: the moment a loss becomes real. In property and casualty insurance, that moment involves interpreting policy wording, assessing liability across auto and property lines, and negotiating settlements within delegated authority limits. Regulatory frameworks such as the Statutory Accident Benefits Schedule and provincial adjuster licensing requirements shape how every file is handled. No two claims are identical.

As the Claims Representative, you investigate, evaluate, and settle personal and commercial claims across auto, property, and casualty lines, ensuring fair outcomes for policyholders while protecting the organization's financial position. You operate within a claims unit alongside adjusters, technical services staff, and external counsel, managing an active pending file count from first contact through resolution.

Career Impact: Earning a Chartered Insurance Professional designation while handling multi-line claims builds recognized technical authority in a sector where credentialed adjusters command consistent market demand.

Business Impact: Policyholders rely on timely, accurate claim settlements at their most financially vulnerable moments, and the quality of each file directly shapes client retention and the organization's loss ratio performance.

Growth Opportunity: Managing increasingly complex files, from moderate auto losses to casualty and subrogation recoveries, opens a defined path toward senior adjuster, technical specialist, or claims supervisor roles within the carrier.

• Investigate assigned claims by securing statements from insureds, witnesses, and third-party adjusters to establish liability and coverage position.
• Interpret policy wording across personal and commercial lines to determine coverage applicability, exclusions, and entitlements for each file.
• Negotiate settlements with claimants, attorneys, and opposing insurers within delegated authority limits to achieve equitable and timely resolutions.
• Pursue subrogation and salvage recovery opportunities by developing action plans and coordinating with internal teams and external legal counsel.
• Maintain accurate claim files by documenting all contacts, reserve recommendations, and decisions in compliance with departmental procedures.
• Collaborate with technical services, underwriting, and legal staff to escalate complex files and ensure appropriate reserving and risk reporting.
• Monitor active pending files for compliance with service timelines, regulatory requirements, and corporate quality standards.
• Prepare estimates and reports on auto and property losses, summarizing findings for management and contributing to large loss meetings as required.

• Bachelor's degree or college diploma in a related field, or equivalent work experience.
• 2 or more years of auto, property, casualty, or accident benefit claims handling experience, with demonstrated file management from intake through settlement.
• Working knowledge of insurance policy wording interpretation, coverage analysis, and liability assessment across personal and commercial lines.
• Familiarity with the Statutory Accident Benefits Schedule or equivalent provincial auto insurance legislation governing claims entitlements.
• Strong negotiation and problem-solving ability, with experience settling claims involving claimants, legal representatives, and third-party insurers.
• Excellent written and verbal communication skills, with the ability to convey clear decisions to clients, counsel, and internal stakeholders.
• Valid adjuster licensing as required by the province, or demonstrated eligibility and commitment to obtain within a defined period.

• Chartered Insurance Professional designation or active enrollment, demonstrating commitment to technical development in the insurance field.
• Experience with subrogation recovery processes, including civil action assessment, third-party negotiation, and recovery documentation.
• Bilingual proficiency in English and French, an asset in markets with dual-language service obligations.
• Exposure to bodily injury reserves, medical terminology interpretation, or independent medical examination coordination.

• Pending file volume managed within departmental service level targets, reflecting workload capacity and prioritization discipline.
• Reserve accuracy rate, measuring how closely initial reserving aligns with final settlement values across the assigned portfolio.
• Settlement cycle time from first notice of loss to file closure, indicating efficiency in investigation and negotiation.
• Subrogation recovery rate on eligible files, tracking dollars recovered relative to total recoverable exposure.
• Litigation referral rate, reflecting the proportion of files escalated to legal counsel versus resolved within authority limits.
• Typical tools: Claims management systems (commonly Guidewire or equivalent); imaging and document management platforms (commonly Applied or proprietary RMS).

• Base Salary Range: $48,000 to $72,000 annually, depending on experience and licensing
• Bonus: Performance-based, typically 5% to 10% of base salary annually
• Equity: Not standard at this level in insurance carriers
• Health Benefits: Medical, dental, and vision coverage; standard US employer-sponsored plans
• PTO: 15 to 20 days annually, plus standard holidays
• Common Perks: Licensing fee reimbursement, CIP designation support, continuing education allowance

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Candidates for this position must be authorized to work in the United States. Employment is contingent upon successful completion of a background check, which may include verification of prior claims handling credentials and driving record where applicable. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, or any other characteristic protected under applicable federal, state, and local law. Reasonable accommodations are available to applicants and employees with disabilities upon request.

The Claims Representative owns the end-to-end handling of insurance claims, analyzing gathered information, determining liability, and negotiating settlements in line with company standards. Working with insureds, witnesses, and internal teams, this role delivers accurate coverage determinations and quality service outcomes that protect both policyholders and the organization.

Key Responsibilities

• Analyze information gathered, determine liability, review assessment of damages, and settle claims.
• Check details of the insured's policy to determine coverage.
• Interview the insured and/or witnesses to collect statements of events.
• Negotiate and authorize settlements in line with company standards.
• Provide quality service to external or internal customers.
• Answer queries relating to investigations and the claims process.

Required Qualifications

• Bachelor's degree or college diploma, or equivalent business experience.
• Chartered Insurance Professional (CIP) designation is an asset.
• 1 year of claims adjusting experience is an asset.
• Strong time management skills.
• Excellent written and verbal communication skills.
• Bilingualism in English and French is considered a strong asset.

Embedded within the claims division, the Claims Representative I investigates, negotiates, and settles automobile, property, and commercial automobile claims while upholding client service quality standards. Working closely with policyholders, business partners, and stakeholders, this role shapes the client experience by delivering timely claim resolutions and identifying salvage and subrogation recovery opportunities.

Core Functions

• Interpret and apply coverages, participate in major event responses, and negotiate and settle service claims with a focus on behaviour-based outcomes.
• Communicate with clients to deliver clear messages and resolve concerns while liaising with stakeholders to ensure efficient and timely settlement of claims.
• Investigate and identify opportunities for salvage and subrogation recoveries using approved guidelines and procedures.
• Share claims handling knowledge and feedback with key business partners on process efficiencies to enhance the client experience.
• Provide exceptional client service in accordance with claims service and quality standards.

Qualifications & Experience

• Post-secondary education in insurance or a related discipline.
• Provincial Adjuster Licence (Claim Adjuster and Personal Lines) required, with the CIP designation and Commercial Licence considered an asset.
• 1 year of experience in insurance or a related field.
• Basic knowledge of insurance claims, policy wordings, the vehicle repair process, and provincial legislation and regulations.
• Experience working in a contact centre, including in-depth knowledge of client service principles.
• Committed to continuous improvement and exceeding client expectations.
• Strong critical thinking skills with the ability to proactively identify problems and propose solutions.
• Effective team player with the ability to share knowledge and support peers.
• Strong written and verbal communication skills.

Reporting to claims management, the Claims Representative I, Subrogation investigates and negotiates the settlement of property and automotive physical damage subrogation claims to ensure prompt and equitable recovery. Partnering with third-party adjusters, legal counsel, and service providers, this role builds compliant recovery outcomes that protect the organization's financial position and uphold corporate quality standards.

Primary Duties

• Investigate losses with moderate complexity.
• Ensure prompt and equitable recoveries in line with corporate policies and standards.
• Develop action plans for conducting investigations by determining necessary contacts, collection feasibility, and civil action to protect recovery on a claim.
• Analyze and document the claim file by collecting and securing reports and statements from third-party adjusters, claimants, witnesses, and pertinent experts to determine damage, liability, and recovery opportunity.
• Negotiate with third parties, lawyers, and insurers within established authority limits to settle claims, and formulate recommendations for further action as necessary.
• Provide quality customer service to external or internal customers.
• Answer queries relating to investigations and the claims process.
• Maintain effective communication channels with claims departments and liaise with adjusters, experts, and management on technical and administrative issues.
• Maintain productive business relationships with service providers.
• Monitor performance to ensure compliance with professional and corporate standards.
• Identify process improvement needs and recommend changes to policies or procedures to maintain quality service and competitiveness.

Skills & Qualifications

• Bachelor's degree or college diploma, or equivalent business experience.
• Chartered Insurance Professional (CIP) designation is an asset.
• Minimum 1 year of auto, property, casualty, and/or subrogation claims handling experience.
• Superior negotiation and problem-solving ability.
• Good time management and organizational skills.
• Excellent written and verbal communication skills.

Sitting at the intersection of field investigation and claims resolution, the Field Claims Representative determines carrier liability and settles moderate to severe claims across commercial property and casualty lines. Operating across assigned coverage territories, this role leads mediations, arbitrations, and litigation support while mentoring junior claim representatives and building policyholder relationships.

Duties

• Settle moderate to severe claims by determining the insurance carrier's liability.
• Handle mediations, arbitrations, and subrogation within authority level.
• Determine coverage by meeting with insureds, securing evidence, inspecting losses, investigating incidents, interpreting and explaining policy coverage, and determining subrogation.
• Document repairs by scoping losses, hiring experts, preparing estimates, and reviewing exposures.
• Complete claims by obtaining, providing, and exchanging information with relevant third parties.
• Prepare reports by collecting, analyzing, and summarizing claim information.
• Meet with policyholders and agencies to build brand awareness.
• Assist with litigation by analyzing settlement options and evidence, and overseeing attorneys.
• Assist home office claim representatives on claims in assigned coverage territories.
• Mentor and train Claim Representatives in areas of claims expertise.

Requirements

• Bachelor's degree required.
• Adjuster licensing must be obtained and maintained before handling claims in states that require it.
• 5 years of claims-handling experience, or 7 years of field claims-handling experience.
• Technical proficiency in commercial property and/or casualty claims.
• Familiarity with PC applications.
• Composed under pressure with strong negotiation skills that preserve working relationships.
• Analytical mindset with a strong commitment to accountability and regulatory compliance.
• Valid driver's license and a satisfactory driving record required.

A key member of the claims unit, the Claims Representative manages a pending file of Accident Benefit claims ranging from moderate to complex, analyzing policy wording to determine coverage and assess entitlements. Collaborating across legal counsel, rehabilitation experts, technical services, and internal business units, this role delivers fair, well-documented claim outcomes that meet regulatory and reserving requirements.

Functions

• Handle a pending caseload of Accident Benefit files while receiving regular intake of moderate to complex claims.
• Analyze and interpret insurance policy wording to determine coverage and assess entitlements that are fair and equitable.
• Communicate in a timely and respectful manner with customers, claimants, lawyers, and rehabilitation experts, and report findings.
• Instruct counsel on files in dispute.
• Conduct investigations and identify additional information, such as independent medical examinations or medical and employment history, required to clarify or justify a claim.
• Complete regular reporting and liaise with technical services to ensure appropriate action and reserving is in place.
• Collaborate and network with different business units.
• Participate in large loss meetings on own files where appropriate.

Experience & Qualifications

• Bachelor's degree or college diploma preferred.
• Minimum 2 years of Accident Benefit claims handling experience.
• Thorough knowledge of the Statutory Accident Benefits Schedule (SABS), from basic limits through CAT claims.
• Knowledge of provincial legislation governing auto insurance and ancillary legislation.
• Strong analytical skills with demonstrated exposure recognition through proactive file handling.
• Strong negotiation and problem-solving ability.
• Excellent communication and interpersonal skills across all levels of staff; fluency in French and English is considered an asset.
• Excellent customer service skills.

Accurate, timely claim resolution depends on the Claims Representative, who contacts insureds, attorneys, and other parties to gather information, evaluate negligence, and negotiate first- and third-party automobile claims. Based within the claims department and working in conformance with applicable guidelines, this role delivers coverage determinations and settlement outcomes that protect policyholders and the organization.

Accountabilities

• Contact insureds, attorneys, and other parties in conformance with applicable guidelines to gather required information.
• Develop and maintain case files that document all actions.
• Apply knowledge of personal lines automobile coverage and adhere to the policy contract, including related coverages and exclusions.
• Conduct telephone contact with all parties encompassing an automobile accident.
• Apply negligence assessment principles to evaluate claim circumstances.
• Evaluate and negotiate first and third-party claims, including comparative negligence.
• Manage workload effectively through an imaging system.

Technical Qualifications

• 1 or more years of claims handling experience preferred.
• Knowledge of total loss and total theft claims is helpful.
• Strong written and verbal communication skills.
• Exceptional telephone customer service skills.
• Demonstrated competency in time management, priority setting, action orientation, customer focus, and composure.
• Strong attention to detail and sense of urgency.
• Team-oriented with excellent interpersonal skills.
• Ability to effectively utilize a task manager or claims system to manage messages, diary entries, and system-generated reminders.

As the Claims Representative, this role investigates, evaluates, negotiates, and settles auto and property claims while preparing estimates and submitting reserve recommendations within established departmental procedures. The claims department relies on this work to maintain accurate claim files, support underwriting risk reviews, and ensure policyholders and claimants receive fair and timely resolutions.

Activities

• Investigate, validate, evaluate, negotiate, and settle all claims as assigned.
• Submit reserve recommendations on assigned claims.
• Communicate with the public regarding procedures, problems, and coverages.
• Negotiate fair settlements with individual claimants or attorneys.
• Maintain claim files and follow departmental reporting procedures.
• Report risk reviews to the underwriting department.
• Participate in training and continuing education courses as requested or required.
• Prepare estimates on auto and property losses.

Position Requirements

• Bachelor's degree from a four-year college or university.
• Adjuster's license to be obtained within 6 months of hire.
• Strong product knowledge across relevant insurance lines.
• Strong verbal communication and listening skills.
• Effective negotiation and conflict management skills.
• Strong technical aptitude with the ability to work with mathematical operations relevant to daily tasks.
• Ability to simultaneously handle multiple priorities.
• Ability to influence internal and external stakeholders.

Claims Representative leads the research and resolution of wholesale customer deductions, reconciling credit and debit balances and negotiating settlement agreements to prevent income loss for the organization. The work directly supports finance, compliance, and sales teams by routing claim documentation accurately and maintaining productive account relationships across internal departments.

Operational Focus

• Research and resolve customer deductions and reconcile credit and debit balances on customer accounts.
• Identify customer behavioural patterns to prevent income loss for the organization.
• Maintain communications with customers, customer service, logistics, EDI, compliance, sales, finance, and other internal departments.
• Communicate with wholesale customers and internal stakeholders regarding individual account portfolios on all aspects of claims.
• Route claim documentation to the appropriate department for further research and information concerning deductions, as well as approval or denial.
• Reconcile account balances as they pertain to deductions and credit or debit memos.
• Issue credit or debit memos for deductions proven valid, and work with the customer for repayment of deductions proven invalid.
• Negotiate partial claim payments or settlement agreements with customers.
• Analyze customer behaviours to quickly identify problems or negative trends and escalate to the claims manager immediately when items are identified.

Knowledge, Skills & Abilities

• Extensive knowledge of credit and claims processes, account reconciliation, supply chain processes, and relationship management.
• Advanced knowledge of Microsoft Office applications, including proficiency in Excel with spreadsheets, formulas, and pivot tables.
• Knowledge of SAP, Access, and document management systems is a plus.
• Solid analytical and decision-making skills, with the ability to independently identify and implement solutions to problems.
• Ability to prioritize and organize workload with proven experience challenging existing processes and developing solutions.
• Excellent verbal and written communication and negotiation skills.
• Fluency in English and French, both spoken and written.
• Ability to quickly adapt communication style and approach as appropriate.

The Claims Representative owns the investigation, negotiation, and resolution of bodily injury, automobile accident benefit, property, and general liability claims within authorized limits, including subrogation recovery and small claims court proceedings. Working alongside legal counsel, outside experts, and internal management, this role delivers complete, legally defensible claim files while applying risk management practices to identify loss trends and support prevention efforts.

Key Deliverables

• Investigate, negotiate, resolve, or deny claims for bodily injury, automobile accident benefits, property losses, and general liability within authorized limits.
• Pursue subrogation recoveries and other recovery matters, including through the small claims court process.
• Prepare court filings and other legal process documents under the direction of a legal team.
• Negotiate with defendants and their insurance or legal representatives, and attend small claims pre-trials and trials as necessary.
• Attend and photograph accident or loss scenes as required.
• Secure statements from claimants and witnesses to assist in determining liability and negotiating resolution of losses.
• Retain outside experts such as appraisers, engineers, medical specialists, and rehabilitation firms, and review their reports to take necessary action.
• Enter and maintain new and existing claims in the claims management system with appropriate reserves and data in accordance with departmental procedure.
• Receive and answer inquiries from the public, internal staff, legal representatives, and insurance company representatives.
• Document and maintain claims files to ensure complete and accurate records are available for reference and legal requirements.
• Apply risk management practices to identify trends, patterns, risks, and hazards, and advise on loss prevention and reduction techniques.
• Prepare reports and system records as directed, and participate in departmental and professional association activities to maintain current knowledge.

Professional Experience

• Secondary school graduation with post-secondary training in insurance-related courses, or a combination of education and insurance industry experience.
• Associate of the Insurance Institute (AIIC), Chartered Insurance Professional (CIP), or Canadian Risk Management (CRM) designation is an asset.
• Progressive experience in claims processing, investigation, administration, quality control, and financial tracking.
• Demonstrated experience adjusting and processing claims, including significant exposure to bodily injury claims, medical terminology, and bodily injury reserves.
• Knowledge of applicable statutes including insurance, traffic, occupier's liability, negligence, and municipal legislation relevant to claims handled.
• Knowledge of risk management principles, including risk identification, risk transfer, and risk finance.
• Knowledge of ethical and professional standards in the legal and adjusting professions, including insurance wording interpretation for property and casualty lines.
• Working knowledge of Word, Excel, and database software.
• Strong written and verbal communication skills.
• Ability to maintain a high level of confidentiality.