THIS IS NOT SOME HR SCRIPT, THIS IS HOW TO DO YOUR JOB THE CLAIMS NINJA WAY!

CONTENTS:

*To be created and will bring you to the section you click*

Claims Managers, PAs, & Appraisers
Education
– 3rd Party
– In-House

…

CLAIMS MANAGERS, PAs, & APPRAISERS: 

Education: 

3rd Party Education: 

  • Articles 
    • In Monday SOPs, Training, and Docs + will add internally curated links here
  • Appraisal education (what it is vs isn’t, when/why/how, demand structure, compliance boundaries) 
  • State-specific Public Adjuster (PA) compliance education (when required, contracts, handoff standards, regulatory risk boundaries) 

In-House Education: 

  • Training Documents 
    • Daily Expectations & Work Standards 
    • Estimate Creation Document 
    • Negotiation & Settlement Process 
    • Client Communication Plan
    • Payment Direction & Check Status Communication SOP 
    • KPI Documents
    • Escalation Triggers Document 
    • Escalation to Public Adjuster SOP 
    • Appraisal Procedures Guide
    • Common Mistakes to Avoid 
    • + 


Intro to the Company: 

Company History: 

  • Where we were 
    • From just Alex and James to a team of 15+
  • Where we are 
    • Just hitting the compounding scale up phase 
  • Where we are going 
    • National take over 

What you’ve gotta know: 

  1. Our Systems, Structures, and Operations 
    • Operations = execution of Systems 
  1. Insurance Estimating 
  1. Insurance’s games 
  1. Construction know-how 
  1. Customer Service and Sales 
  1. Creative Problem Solving 

Systems: 

  • Hierarchy of Structures and dynamics + evolution 
    • Whimsical graph 
  • Hardware, software, subscriptions, SaaS 
    • Computer. Phone. Printer. Internet. Workspace 
    • Wispr. Xactimate. Symbility. Monday. RingCentral. Microsoft Suite. Chat GPT. Brelly. Code Book Access. Jotform (required for PA contracts/appraisal authorization, if used internally), +  
  • SOPs (Standard Operating Procedures) 
    • The majority of your training comprises of learning the SOPs within our systems 
    • These processes are living documents. If you find a better way, speak up — we update and improve continuously
    • Questions about any process? Ask leadership immediately. Don’t guess

Curriculum Steps for Onboarding and Training (Systems and Operations proficiency): 

  • Pre Shadow: 1-3 Days: Absorb all training. Grasp, Study, and Observe. Via physical observation, training, and training videos of steps from start to finish 
  • Day 1: total shadow of TL 
  • Day 2-3: Practice Projects: Wtr. Sewage. Mold. Smoke. Fire. Recon. Roof. TL review 
  • Day 3-5: Live Project(s) with TL shadow
  • 30-60 days of TL estimate, settlement, and supplement examination/review before submissions until Ninja certified to submit without intensive oversight 
  • Home free and continue growing and learning 

In-House relationships with: 

  • Clients 
  • Policyholders 
  • Partners 
  • Each Other 

Types of Projects (all large and small): 

  • Water 
  • Mold 
  • Sewage 
  • Smoke 
  • Fire 
  • Recon 
  • Roof 
  • + 

Standard Project Sequence for Projects: 

  • Diagram 
  • Bible steps 

Profit Points: 

  • Difference in Labor and Materials 
  • Additional Line Items 
  • Profit 
  • Overhead 
  • Initial Estimate 
    • $100 minimum for estimate value less than $12,500 
    • 1.25% rate for estimate value $12,500–$100,000 
    • 0.75% rate for estimate value $100,001–$200,000 
    • 0.50% rate for estimate value $200,000+ 
  • Approved Settlements 
    • $150 minimum for negotiation 
    • 4.00% rate for settlement value $5,000–$24,999 
    • 3.66% rate for settlement value up to $49,999 
    • 3.33% rate for settlement value up to $124,999 
    • 3.00% rate for settlement value $200,000+ 
  • Supplements: 8-10% 
  • Free Money Supplements: 50% 
  • Required reports – fees pass through to Client (ie: Eagleview Fees $60 ea) 
  • PA Fees TBD 
  • Appraisal Fees TBD 
  • Attorney Fees TBD 

What Clients expect from us and what we expect from them 

  • Found in New Client Signup Onboard and Client Help Center  

Why We Are the BEST: 

  •  We are Easier, Faster, Higher-Quality, Less-Costly… just BETTER 
  • Experienced Team with track record of Success 
  • High Gross and Net Profit Margins 
  • Recession Proof 
  • Scalable 
  • Highly automatable, yet human responsiveness 
  • Minimal Turnover of all parties involved 
  • Ethical on all fronts 
  • Minimal overhead since primarily digital 
  • Minimal liability due to maximum delegations via structures and contracts 
  • Quality services in a market with immense demand 
  • We have systems that are already market-proven and continue to be enhanced 
  • Sustainable, Innovative, and Stimulates the Economies in which we do Business 

Monday Tour of Estimating Dash and Client View: 

  • Loom:  CLAIMS NINJA DASH – MONDAY
    • Edits since the video:
      • Public Adjuster SOPs. Next to “Escalated to PA” column buttons near the far right of the Estimator Board is the PA handoff sheet. It is gray; once clicked, it activates and auto-uploads information, but has manual information to fill out.
  • Side bar of boards. 
  • Estimating Dash and Views 
    • Go through columns from left to right 
    • Show Supplement subtask 
    • Click Project and show views 
  • Client Dash 
    • Fast review of columns from left to right

Ninja Xactimate Tour: 

  • Loom: TCN v Whitelabel 

Ninja Time and Material Tour: 

  • TCN v Whitelabel 
  • From scratch v AI assistance 

Client Onboarding Info: 


BIBLE: 

Contents: 

  • CM Rules 
  • CM Per Project 
  • CM SOPs 
  • TL SOPs 
  • Tool Belt 


CM RULES: 

CORE STANDARD (NON-NEGOTIABLE) 

This is non-negotiable
The Standard: Move Files Forward
Moving files forward is your primary job. Everything else is secondary
Passive waiting is failure
Our target closure dates depend on this — 21-day average only works if EVERY file moves EVERY 2 days
This is how the business survives — stalled files = unhappy clients = failed business

CONSTANT RULES:  

  • CONSTANT ANNOTATION. Take notes on all things always
  • ALWAYS inform Clients and Policyholders of any updates, even if no update! We serve them, and constant communication keeps them happy. Ball on a hill
  • ALWAYS RESPOND to team messages w thumbs up. Message me separately unless it contributes to whole group
  • 5 min rule, if it takes you 5 min do it then and there
  • ALWAYS schedule follow up for any task (when merited) 
  • ALWAYS unread messages if you opened them and they are not yours (when/where merited) 
  • ALWAYS IMMEDIATELY add ALL things pertaining to project like financial documentations, project notes, pictures, videos, contracts, documents, receipts, pics of sketches or notes, etc. to the appropriate locations if not uploaded correctly (when/where merited) 
  • We funnel everyone we interact with through our systems as much as possible, while making them feel like it takes the load off their plates, because it does

Working Hours 

  • Start Time: 8:00 AM local time 
  • Employee must be logged into the system and actively working at 8:00 AM 
  • Ready to engage with clients and adjusters immediately 
  • No exceptions without prior approval 

Two-Day Contact Cycle (CRITICAL) 

Every active claim in your workload must have meaningful progress within 2 days

Adjuster Contact Requirements: 

  • MUST reach out via phone to every adjuster on active claims 
  • Contact cycle resets every 2 days maximum 
  • Phone contact is required — emails alone don’t count 

Client Updates via Monday.com: 

  • Update EVERY active claim in Monday.com within 2 days 
  • Updates must reflect real progress on the file 

What Counts as Progress (REQUIRED): 

  • Reached out to adjuster via call text and email. Left voicemail. NA yet 
  • Spoke with adjuster, discussed specific line items, waiting on response by 2026 
  • Escalated to adjuster’s supervisor 
  • Sent supplement with supporting documentation, set follow-up for 2026 
  • Scheduled inspection for 2026 
  • Obtained additional vendor quotes to support our estimate 
  • Filed formal escalation / appraisal demand 
  • Any action that moves the claim toward settlement 

Daily Action Checklist: 

  • Start work at 8:00 AM sharp 
  • Review all active claims 
  • Identify which files need contact (2-day rule) 
  • Call, text, and email every adjuster on those files 
  • If no answer within reasonable period: escalate or take comparable action 
  • Update Monday.com with meaningful progress 
  • Document next action and deadline for each file 
  • Repeat cycle — no file sits idle more than 2 days 

Time Management: 

  • Overview, Prioritize, Plan, Schedule 
  • 7-12ish for claims settlement 
  • 12ish-5ish estimates 
  • Finish current task before next one unless major fire. It can skip the queue but doesn’t have to cut you off

TL Fires: 

  • ALWAYS come with 2 potential solutions when needing help w an issue
  • M – F: Working hours 

COO Fires: 

  • ALWAYS come with 2 potential solutions when needing help w an issue
  • W – F: Call 12-2:30 and 3:30-5 EST
  • M – T: Call 12-5 EST
  • Call anytime for mega emergencies. Keep in mind COO is PST

CM Weekly Schedule: 

8:00 AM: Get after it
11:00 AM M W F Team Meetings
Individual meetings as needed

CM Per Project: 

Loom:  

(Standard Project Sequence diagram governs execution.) 


CM SOPs (that can occur at any point of the Claims Process): 


PER TOUCH STANDARD 

Per Touch: 

  • Check call/vm/text/email for updates 
  • If need more info, see “More Info Request” 
  • Appropriate Touche(es): 
    • Adjuster 
    • Supervisors 
    • Agents 
    • Vendors 
    • Client / Policyholder 

Update: 

  • Client 
  • Policyholder 
  • Agent (if merited) 

Every touch must move the claim forward. 


Claims Timeline if NA Communication and/or Stagnation: 

  • Call, text, email Adjuster daily (72 hr) 
  • Call, text, email Supervisor daily (48 hr) 
  • Call, text, email Agent daily (48 hr) 

Then: 

  • Alert TL of imminent escalation 
  • Once permitted: 
    • Escalation threat communication daily 
    • Alert policyholder of escalation strategy 
    • Create and send escalation evidence complaint packet for DOI submission 


Escalation Triggers to Leadership

Escalate when: 

  • Client expressing dissatisfaction 
  • Claim stuck for more than 7 days with no progress 
  • Adjuster being unreasonable 
  • Settlement offer significantly below expectations 
  • Any situation that might result in losing client 


How/When to do Requests: 

Loom:  https://www.loom.com/share/3deb557591684397b2576d3f7f2900ed

  • Submit a Request when an issue cannot be solved at your level and is preventing progress. 
  • Merited when: 
  • Claim movement is blocked 
  • Leadership approval or decision is required 
  • PA, Appraiser, or Attorney involvement is needed 
  • Client escalation or exception approval is required 
  • TL guidance does not resolve the issue 
  • Internal system or operational issue prevents execution 
  • Attempt resolution first and come with 2 proposed solutions when possible. 


Checklist for Viable Estimate Info from Client 

This is the first thing you check when you have a new Project assigned to you  

  • Contract w ICA, AOB, Appraiser Contract 
  • Sufficient Files (ideally not screenshots) 
  • Sufficient Photos 
  • Sufficient Job Notes 
  • Sketch + measurements (LxWxH)  
    • Especially for scenarios requiring continuous replacements, commonly walls for paint and texture, roofs, flooring, +) 
  • Insurance Estimate 
  • Policy 
  • Claim # 
  • Adjuster Name, Phone, Email 
  • Job site distance from office (helps w supervisory and trip fees) 

If Mitigation: 

  • Demo Sheets 
  • Dry logs 

Added Requirements: 

  • Coverage endorsements reviewed 
  • Policy conditions noted 
  • Documentation organized defensibly 
  • Appraisal clause verified when relevant 


If Need Info/Decision from Client or Policyholder 

  • Request from appropriate party 
  • SOP: Contact via Monday daily for 3 business days. If NA, Call → VM → Text daily until received. If scheduled date of when they will deliver required info, hold off on SOP until that due date, then continue 
  • Receive 
  • Ensure properly inputted 
  • Submit 


More Info Request from Insurance 

  • Check if already submitted 
  • If yes → resubmit or redirect to submission 
  • If unnecessary → articulate why professionally 
  • If needed from client → follow Client SOP contact cycle directly above 


Requested Supplements 

Triggered in Monday subtask. 

Checklist: 

  • Sufficient Files 
  • Sufficient Photos 
  • Sufficient Description 

Then: 

  • Create 
  • Submit 
  • Negotiate 
  • Follow Two-Day Contact Cycle 
  • Once settlement on supplement, inform Client 


Free Money Supplements (NOT YET ENACTED W CLIENTS):

Upon or near project completion: 

  • Review documentation across entire project lifecycle 
  • Identify additional claim value 
  • Create, submit, negotiate, Follow Two-Day Contact Cycle 
  • Once settlement on supplement, inform Client 


Certificate of Completion (COC) 

  • COC column has link Clients use for policyholder to sign COC 
  • Clients must use our COC if they want TCN to handle it 
  • COC auto emails adjuster, Client, Policyholder receipt, and our CM team email


Public Adjuster SOPs:

CM stuck and needs a PA 

CM requests and obtains approval from TL indicated via the TL selecting the “Escalated to PA” button in Estimator Dash

CM gets approval from Client 

CM completes PA sheet. (Column next to “Escalate to PA?” Button))

CM TL handoff to PA via assignment in the Estimator Column in Monday

PA gets policyholder to sign contract (Contract depends on State)

Executes to settlement or withdrawal 

  • If PA cannot obtain a Client approved settlement, appraiser SOPs 


Appraiser SOPs:

CM stuck and needs appraiser/appraisal

CM requests and obtains approval from TL indicated via the TL selecting the “Escalated to Appraisal” button in Estimator Dash

CM requests and obtains approval from Client for appraisal (impersonal template below):

  • “Hi [Client],
    We suggest pushing this project to appraisal as insurance is stuck below a reasonable threshold for scope and/or pricing regardless of irrefutable justifying evidence presented. Appraisal ranges from $500 – $1,500. Do you approve so we can move this claim forward?
    ~ [CM]” 

CM files an Appraisal Demand Letter to insurance

  • If Insurance denies appraisal and requires attorney:
    • CM requests and obtains approval from TL
    • CM requests and obtains approval from Client
      • “Hi [Client]
        Insurance is denying appraisal, so the next steps are to force appraisal via a court ordered appraisal. This requires obtaining your approval. The fee is typically between $5,000 – $15,000 with the aim of obtaining an award letter to appraisal. There is a possibility insurance walks back this escalation, but not a guarantee.
        ~ [CM]”
    • Attorney court ordered appraisal
      • If litigation (TBD):
        • TL requests and obtains approval from Client
        • Attorney handoff
  • If Insurance walks it back after threat of appraisal or threat of pursuing a court ordered appraisal, see if fair settlement, otherwise continue

CM TL handoff to Appraiser via assignment in Estimator Column in Monday

Appraiser requests and obtains signed contract from policyholder and inputs in Monday files column

Executes until Appraisal Award (agreed amount btw appraisers) and scope if possible or withdrawal


ESTIMATE CREATION SOP 

Goal 

Deliver comprehensive, accurate estimate within 24 hours of complete documentation. 

Timeline 

Day 1 after documentation received. 

Steps 

1. Claim Review (Within 24 Hours of Assignment) 

  • Review all documentation thoroughly 
  • Identify missing information immediately 
  • Contact client immediately (do not wait) 
  • Review insurance policy 
  • Note special conditions or endorsements 

2. Estimate Creation 

  • Use Xactimate and/or T&M 
  • Include all line items with justification 
  • Add photos to relevant line items 
  • Include code citations where applicable 
  • Price per pricing database/client standards 
  • Add O&P where applicable 
  • Include detailed scope narrative 

3. Client Delivery 

  • Upload to client portal 
  • Send update 
  • Schedule review call if needed 
  • Get client approval before submitting to insurance 

Quality Check 

  • Comprehensive? 
  • Accurate? 
  • Defensible? 
  • Client approved? 

Red Flags 

  • Rushing estimates = more pushback later, longer negotiations. 
  • Clients pushing for more unethically (false measurements or doubling line items ie: paint covers R&R outlet covers, but client wants it in a separate line item. Could lead to high estimate, but will likely lead to lower settlement and/or prolonged negotiations leaving disgruntled Clients 


NEGOTIATION & SETTLEMENT PROCESS 

Goal 

Maximize settlement efficiently. 
Close within 21–35 days of estimate submission. 

Timeline 

Days 3–21 (post submission). 

Step 1 — Submit to Insurance 

  • Client approves estimate 
  • File moves to Stage 2 in Monday 
  • Submit to adjuster 
  • Set follow-up reminder for 48 hours (in Monday) 
  • File moves status to Submitted to Insurance 

Step 2 — Initial Adjuster Response 

(Within 48 hours) 

If no response: 

  • Follow up immediately (phone required) 

Then: 

  • Document response 
  • Identify agreement/disagreement 
  • Log in platform for client visibility 
  • Move to Negotiation Stage 

Step 3 — Prepare Negotiation Strategy 

  • Review objections 
  • Gather: 
    • Photos 
    • Code citations 
    • Vendor quotes 
    • Policy language 
    • Prepare documented response 
    • Identify escalation triggers 

Step 4 — Negotiation Process 

  • Respond within 24 hours 
  • Provide documented justification 
  • Reference policy language 
  • Stay professional but firm 
  • Document all communication 
  • Update Client every 2 days minimum 

Step 5 — Escalation Decision Point (Day 7–14) 

If progress: 

  • Continue negotiation 
  • Set resolution deadline 

If stalled and with TL approval: 

  • Invoke PA authority 
  • Send escalation letter 
  • Set appraisal deadline 
  • Notify Client 
  • Consider attorney involvement 

Step 6 — Settlement Agreement 

  • Review final offer with Client 
  • Move to Review & Approve Final Settlement 
  • Explain outcome achieved 
  • Get approval 
  • Document settlement amount 

Step 7 — Close-Out 

  • Update status to Completed 
  • Client pays final invoice 


CLIENT COMMUNICATION PLAN  

Goal 

Proactive, transparent communication throughout the claim lifecycle. 

Communication Schedule 

Day 0 — Onboarding (Supervisor Performs) 

  • Welcome email with expectations 
  • Portal access and training 
  • Timeline overview 

Day 1 — Submit Job – Estimate Phase 

  • Confirmation work has begun 
  • Request missing documentation 
  • Estimate completion notification 

Day 3–21 — Negotiation Phase 

  • Update every 2 days minimum 
  • Immediate Monday update for major developments 
  • Transparent about challenges 
  • Clear next steps always provided 

Proactive Communication Triggers 

Communicate immediately when: 

  • Estimate completed 
  • Estimate submitted 
  • Adjuster responds 
  • Negotiation milestone reached 
  • Escalation initiated 
  • Settlement reached 

Client Can Always: 

  • Check portal for real-time status 
  • Monday update, Email, or call with questions 
  • Request call anytime 

Red Flag 

Client asking “what’s happening?” = communication failure. 

APPRAISAL PROCEDURES GUIDE (FULL INTEGRATION) 

Compliance Boundary (CRITICAL — RESTORED) 

Claims Manager is NOT acting as a Public Adjuster. 

What Appraisal IS 

  • Contractual valuation dispute mechanism 
  • Determines amount of loss 
  • Binding valuation outcome 

What Appraisal IS NOT 

  • Coverage determination 
  • Liability decision 
  • Policy interpretation beyond valuation 

When to Use 

  • Scope disputes remain 
  • Pricing discrepancies persist 
  • Carrier stalls repeatedly 
  • Documentation strong 

Avoid when: 

  • Coverage dispute active 
  • Cause of loss unresolved 
  • Weak documentation 

Required Authority Documents 

  1. Client Appraisal Authorization 
  1. Appraiser Contract 

No demand without both executed. 

Pre-Appraisal Checklist 

Confirm: 

  • Policy contains appraisal clause 
  • Dispute is valuation only 
  • Carrier given reasonable opportunity 
  • Documentation complete 
  • Client understands binding nature, fees, timeline 

Appraisal Demand Email Requirements 

  • Clear subject line 
  • Identify insured & claim 
  • Reference policy provision 
  • Define valuation dispute only 
  • Formal invocation wording 
  • Identify appraiser 
  • Request carrier appraiser 
  • Attach documents 
  • Avoid emotional or argumentative language 

Appraiser Phase 

  • Appraisers communicate directly 
  • CM does not negotiate 

Umpire Phase 

If disagreement persists. 

Award Issued — CM Duties 

  • Confirm award accuracy 
  • Track carrier payment 
  • Ensure payment aligns 
  • Confirm depreciation handling per policy 

Compliance Red Flags 

  • Carrier alleges unauthorized adjusting 
  • Appraiser contract unclear 
  • Client confusion about fees/outcomes 

Escalate immediately. 

COMMON MISTAKES TO AVOID 

DON’T: 

  • Start work without documentation 
  • Rush estimates 
  • Fail follow-ups 
  • Accept lowball offers 
  • Communicate reactively 
  • Delay escalation 
  • Repeat mistakes 

DO: 

  • Get everything upfront 
  • Build thorough estimates 
  • Follow up aggressively 
  • Fight for every dollar 
  • Over-communicate 
  • Escalate strategically 
  • Learn from every claim 

FINAL OPERATING PRINCIPLES 

  1. Files move every 2 days. 
  1. Communication is proactive. 
  1. Documentation wins negotiations. 
  1. Escalation is strategic. 
  1. Speed + defensibility = profitability. 
  1. Compliance protects the company. 
  1. Systems create scale. 


TL SOPs (TL Eyes Only) 

New Claim Assignment 

Assign within 1 business hour based on Team Member Board: 

  • Capacity 
  • Skillset 
  • Geography 
  • Client alignment 

KPI Reviews 

Weekly monitoring of: 

  • Speed metrics 
  • Settlement lift 
  • File movement compliance 


EXEC SOPs (Exec Eyes Only) 

Accidental Direct Pay 

  • Identify immediately 
  • Notify all parties 
  • Facilitate endorsement 
  • Track resolution 



TOOL BELT 

EMAIL TEMPLATES

***Incoming***

CONTINUING EDUCATION 

  • Meetings 
  • Assignments 
  • Teams Updates: 
    • Bible edits 
    • Fundamental reminders 
    • Announcements 

TECHNIQUES AND KEY PHRASES

  • Disarming soft start 
  • Good cop / bad cop 
  • Deadline framing 
  • Documentation anchoring 
  • Policy language leverage 

Profit Maximization — Line Item Strategy (When Merited) 

Maximize claim value by identifying scope realities that require continuous work, trade interaction, and full restoration standards — not patch repairs. 

Always justify increases through construction logic, code, and restoration practicality, not opinion. 

Continuous Replacement (When Merited) 

Push continuous replacement when partial repair creates mismatch, damage risk, or improper restoration. 

Common triggers: 

  • Roofing 
    • Repair requires moving flashings, vents, or penetrations 
    • Shingles cannot be lifted without damaging surrounding areas 
    • Seal integrity broken during repair 
    • Matching unavailable or discontinued 
    • Repair creates visible patching 

→ Result: full slope or full roof replacement. 

  • Flooring 
    • Material cannot match (color, wear, dye lot). Typically doable if older than 2 years.  
    • Continuous installation runs room-to-room 
    • Floating or glued systems disturbed 
    • Transition removal damages adjacent flooring 

→ Result: continuous flooring replacement. 

When flooring goes continuous: 

  • Remove/reset baseboards 
  • Paint affected areas end-to-end 
  • Furniture manipulation 
  • Additional protection & cleaning 
  • Paint 
    • Spot paint flashes or blends improperly
    • Texture cannot match 
    • Sheen differences visible 

→ Result: wall-to-wall or room continuous paint. 

Trade Interaction Expansion 

If one trade requires disturbance of another trade → include both. 

Examples: 

  • Drywall removal → insulation replacement 
  • Cabinet detach → plumbing reconnect 
  • Roofing → gutter detach/reset 
  • Flooring → base, doors, trim adjustments 
  • Demo → cleaning & protection 

Rule: 
If it must be touched, it must be estimated. 

Access & Protection 

Always include: 

  • Contents manipulation 
  • Floor protection 
  • Dust containment 
  • Daily cleanup 
  • Equipment setup/tear-down 

Small line items compound heavily. 

Detach & Reset Strategy 

Anything preventing work must be: 

  • Detached 
  • Stored 
  • Reset or replaced 

Common misses: 

  • Toilets 
  • Vanities 
  • Appliances 
  • Light fixtures 
  • Doors & hardware 
  • Window treatments 

Code & Practical Construction Reality 

Use when applicable: 

  • Code upgrades 
  • Manufacturer install requirements 
  • Safety access requirements 
  • Moisture barrier replacement 
  • Fastener patterns 
  • Underlayment replacement 
  • Forced into small spaces 

Repair must meet current install standards, not pre-loss shortcuts. 

Matching Requirement Logic 

When materials cannot match: 

  • Appearance uniformity required 
  • Repair leaves visible damage 
  • Adjacent materials affected 

→ Expand scope to uniform finish area. 

Supervisory Hours 

If supervisory required, articulate reason why it does not fall under Overhead and is specialized or justified.  

O&P (Overhead & Profit) 

Push O&P whenever project requires coordination of multiple trades or supervision. 

Indicators: 

  • 3+ trades involved or enough merited complexity 
  • Scheduling coordination required 
  • Project management necessary 
  • Safety oversight required 

Rule: 
If complexity exists → O&P justified. 

Supplement Mindset 

Every project has three estimate phases: 

  1. Initial Scope 
  1. Construction Reality Adjustments 
  1. Documentation-Based Supplements (“Free Money”) 

Review files near completion for missed scope supported by documentation gathered during project life. 

Estimator Rule 

Do not ask: 

“What will insurance approve?” 

Ask: 

“What does proper construction require?” 

Then document and justify. 

Core Principle 

Patch repair is insurance’s starting point. 
Proper restoration is our standard. 

Estimate the work required to restore correctly — not minimally. 

Profit Maximization — Time & Material Strategy (When Merited) 

Use Time & Material (T&M) estimates when scope uncertainty, access limitations, or construction reality prevents accurate fixed pricing at the outset. Also use them as leverage to get Xactimate estimates pushed to settlements. If a T&M is higher, it can help push through your estimates.  

T&M shifts approval from price debate to work verification. 

Document labor, time, and materials so real construction conditions justify increased claim value. 

When T&M Is Merited 

Use T&M when: 

  • Damage extent unknown until demolition 
  • Hidden damage likely 
  • Mitigation transitions into reconstruction 
  • Structural or layered assemblies involved 
  • Access limitations slow production 
  • Carrier disputes scope completeness 
  • Conditions change during work 

T&M is justified when accurate scope cannot be determined without performing work. 

Using T&M to Support Supplements 

T&M establishes real-world production data. 

Use documented: 

  • labor hours 
  • crew size 
  • equipment usage 
  • material quantities 
  • daily conditions 

to justify supplements after scope exposure. 

Construction reality becomes evidence. 

Converting T&M Into Xactimate Approval 

When carrier disputes Xactimate pricing: 

  1. Perform work under T&M where approved. 
  1. Track actual labor + production rates. 
  1. Compare real cost vs Xactimate estimate. 
  1. Demonstrate Xactimate is equal or cheaper than actual field cost. 

Result: 
Carrier approves Xactimate as reasonable benchmark. 

T&M validates the estimate instead of arguing it. 

Labor Expansion Strategy 

Track all labor categories: 

  • Setup & teardown 
  • Protection installation 
  • Equipment movement 
  • Material handling 
  • Dry time monitoring 
  • Cleanup cycles 
  • Access delays 

If labor occurred → it is billable. 

Idle time caused by site conditions is still labor time. 

Hidden Condition Discovery 

Demolition frequently expands scope. 

When new damage discovered: 

  • Photograph immediately 
  • Document condition change 
  • Log time interruption 
  • Update daily logs 

Hidden damage converts directly into supplement justification. 

Daily Documentation Rule 

Every T&M job requires: 

  • Daily logs 
  • Crew count 
  • Hours worked 
  • Work performed 
  • Materials used 
  • Photos of progress 
  • Site conditions noted 

If not documented, it does not exist. 

Equipment & Small Tool Recovery 

Track: 

  • Air movers 
  • Dehumidifiers 
  • HEPA filtration 
  • Moisture monitoring 
  • Power distribution 
  • Specialty tools 

Equipment duration increases claim value legitimately. 

Production Reality Leverage 

Real-world production rarely matches estimating assumptions. 

Use T&M to demonstrate: 

  • slower access conditions 
  • confined work areas 
  • protection requirements 
  • occupied structure limitations 

Field reality supports higher valuation. 

Transition Strategy (T&M → Fixed Scope) 

Once scope fully known: 

  • Convert documented T&M work into supplement or revised estimate. 
  • Lock remaining work into Xactimate pricing. 

T&M defines scope → Xactimate finalizes settlement. 

Estimator Rule 

Do not use T&M to guess pricing. 

Use T&M to prove actual cost of proper restoration. 

Core Principle 

Documented reality wins negotiations for both Xactimate and T&M Estimates 

ChatGPT — Estimate Final Boost Prompts 

Use ChatGPT after completing an estimate to identify missed scope, expand justified line items, strengthen documentation language, and maximize settlement defensibility before submission. 

ChatGPT is used to audit and strengthen, not fabricate scope. 

How to Use 

  1. Finish estimate normally. 
  1. Export or copy scope notes / line items / summary. 
  1. Run prompts below. 
  1. Review suggestions. 
  1. Add only items supported by construction reality and documentation. 

Final Boost Prompts 

1. Master Scope Audit (Primary Prompt) 

Prompt: 

Act as a master insurance restoration estimator specializing in maximizing defensible claim scope. Review the following estimate and identify missing line items, trade interactions, detach/reset items, access requirements, protection needs, and continuous replacement opportunities that are commonly overlooked but justified by construction standards. Explain WHY each item is required. 

(Paste estimate summary) 

2. Continuous Replacement Expansion 

Prompt: 

Analyze this scope and identify where partial repair would realistically require continuous replacement (roofing, flooring, paint, trim, or assemblies). Explain construction logic that justifies full-area replacement instead of patch repair. 

3. O&P Qualification Check 

Prompt: 

Review this estimate and determine whether Overhead & Profit is justified based on trade coordination, supervision requirements, scheduling complexity, and project management involvement. List supporting justification language suitable for adjuster submission. 

4. Detach & Reset Audit 

Prompt: 

Identify all items that must be detached, reset, protected, or manipulated to complete the listed work properly. Focus on commonly missed estimator items. 

5. Hidden Scope Discovery 

Prompt: 

Based on this scope, identify likely hidden damage or secondary work that typically appears once demolition begins and should be anticipated or documented for supplements. 

6. Labor Reality Expansion 

Prompt: 

Evaluate this estimate and identify labor activities that occur in real construction but are often under-scoped, including setup, protection, access limitations, cleanup, and material handling. 

7. Code & Standards Justification Builder 

Prompt: 

Generate defensible justification language explaining why this scope must meet current building standards and cannot be repaired minimally. Keep wording professional and adjuster-facing. 

8. Supplement Pre-Planning Prompt 

Prompt: 

Predict the most likely supplements that will arise during this project based on the provided scope and explain what documentation should be collected now to support them later. 

9. Carrier Pushback Defense 

Prompt: 

Act as an insurance adjuster challenging this estimate. List likely objections. Then provide professional rebuttals supported by construction logic and industry standards. 

10. Estimate Strength Score (Final Check) 

Prompt: 

Evaluate this estimate for completeness, defensibility, and settlement strength on a scale of 1–10. Identify weaknesses that could reduce approval likelihood and suggest improvements. 

11. Xactimate vs Reality Reinforcement 

Prompt: 

Explain how real construction conditions support the pricing and scope in this estimate and provide language demonstrating the estimate represents reasonable market cost. 

12. Final Submission Rewrite (VERY HIGH VALUE) 

Prompt: 

Rewrite a concise professional submission summary that clearly explains scope necessity, project complexity, and justification for full approval while remaining cooperative and non-adversarial. 

Final Estimator Rule 

ChatGPT is used to find: 

  • missed scope 
  • missing justification 
  • weak explanations 

Not to invent damage. 

If it happened or must happen → estimate it. 

Brelly AI — Estimate & Claim Maximization Prompts 

Use Brelly AI to analyze claim information, policies, and estimates to identify missing scope, strengthen bid positioning, and bridge gaps between construction reality, coverage language, and carrier valuation. 

Brelly helps connect: 

  • claim facts 
  • policy obligations 
  • estimate scope 

into defensible settlement positioning. 

How to Use 

  1. Upload policy, carrier estimate, our estimate, and claim details. 
  1. Run prompts below. 
  1. Extract coverage + scope insights. 
  1. Apply findings to estimate revisions, supplements, and negotiations. 

Brelly Prompts 

1. Estimate Gap Analysis (Primary Prompt) 

Prompt: 

Compare the carrier estimate and contractor estimate using the provided claim information and policy. Identify missing scope, under-scoped items, and construction tasks likely required but not included. Explain why each item would reasonably be required. 

2. Scope Bridging Analysis 

Prompt: 

Analyze this claim and identify gaps between observed damage, restoration requirements, and the current estimate scope. Suggest areas where additional work may be justified based on typical construction sequencing. 

3. Bid Bolstering Review 

Prompt: 

Review this estimate and generate professional justification explaining why the pricing and scope are reasonable based on claim conditions, restoration standards, and project complexity. 

4. Coverage + Scope Alignment 

Prompt: 

Identify where policy language supports the work described in this estimate and explain how the scope aligns with restoration obligations under the policy. 

5. Continuous Replacement Support 

Prompt: 

Using claim details and policy language, explain where partial repair may not restore the property properly and where continuous replacement may be justified. 

6. Carrier Estimate Weakness Scan 

Prompt: 

Identify assumptions, omissions, or scope limitations in the carrier estimate that may conflict with claim facts or restoration requirements. 

7. Supplement Opportunity Detection 

Prompt: 

Based on claim information and current scope, predict likely supplement items and explain what additional work commonly emerges during restoration. 

8. Labor & Production Reality Analysis 

Prompt: 

Evaluate whether the estimate reflects realistic labor effort considering access, protection, sequencing, and site conditions. Identify areas where labor scope may be understated. 

9. Policy Endorsement Opportunity Scan 

Prompt: 

Review endorsements and identify coverage provisions that may justify additional scope, upgrades, or expanded repair requirements. 

10. Negotiation Position Builder 

Prompt: 

Create a concise explanation supporting this estimate using both construction reasoning and policy alignment suitable for adjuster communication. 

11. Documentation Strength Check 

Prompt: 

Identify missing documentation or evidence that would strengthen approval of disputed scope items. 

12. Final Claim Position Summary (High Value) 

Prompt: 

Generate a professional claim summary explaining why the submitted estimate represents a reasonable and necessary cost to restore the property to pre-loss condition. 

Core Rule 

ChatGPT strengthens construction scope. 
Brelly strengthens claim intelligence and coverage alignment. 

Together they: 

  • find gaps 
  • justify scope 
  • support higher approvals 
  • reduce negotiation friction. 

Pre-Loss Condition Builder (PLCB System) 

(Value Anchoring & Scope Expansion Doctrine) 

Purpose 

The Pre-Loss Condition Builder establishes the probable quality, finish level, and construction standard of a property before damage occurred, allowing estimates and negotiations to anchor restoration value correctly from the start. 

Insurance policies require restoration to pre-loss condition, not minimum functional repair. 

The PLCB system ensures that pre-loss condition is: 

  • defined early 
  • documented objectively 
  • supported logically 
  • positioned before negotiation begins 

Core Principle 

Settlement value is anchored by perceived pre-loss quality. 

If pre-loss condition is undefined, the carrier defines it downward. 

If pre-loss condition is documented, scope expands naturally. 

Why This Matters 

Most claims fail here: 

Carrier assumption: 

Average materials + minimal finish level. 

Reality: 

Homes rarely reflect minimum-grade construction after years of upgrades, wear patterns, and market expectations. 

Without a defined baseline: 

  • flooring downgraded 
  • cabinets minimized 
  • paint scope reduced 
  • roofing simplified 
  • finishes undervalued 

The PLCB system prevents value erosion. 

Restoration Standard Rule 

Repair must return property to: 

  • Like kind 
  • Like quality 
  • Like appearance 
  • Like functionality 
  • Market-consistent condition 

Not: 

  • cheapest replacement 
  • partial visual match 
  • functional-only repair 

PLCB System Structure 

The system consists of six operational layers: 

  1. Property Intelligence Collection 
  1. Quality Tier Classification 
  1. Pre-Loss Reconstruction Modeling 
  1. Estimate Anchoring 
  1. Negotiation Positioning 
  1. Supplement Reinforcement 

1. Property Intelligence Collection 

Immediately after intake, collect indicators of property standard. 

Observable Indicators 

Document: 

  • home age vs renovation evidence 
  • flooring continuity 
  • trim profiles 
  • cabinet construction 
  • fixture quality 
  • paint finish level 
  • roof complexity 
  • architectural consistency 
  • appliance tier 
  • landscaping investment 

Photos should capture context, not just damage. 

Required Photo Categories 

  • wide room views 
  • ceiling height relationships 
  • trim transitions 
  • adjacent undamaged areas 
  • material continuity 
  • finish transitions 
  • exterior elevation context 

Damage photos alone are insufficient. 

Intelligence Rule 

Undamaged areas prove pre-loss condition. 

2. Quality Tier Classification 

Assign property a working tier: 

Tier Levels 

Builder Grade 

  • basic materials 
  • minimal trim 
  • standard finishes 

Mid-Grade Residential 

  • upgraded flooring 
  • consistent finishes 
  • coordinated materials 

Custom / High-End 

  • specialty materials 
  • architectural detailing 
  • premium installations 

AI Prompt Example 

Based on provided photos and property details, classify likely construction quality tier and explain reasoning. 

This becomes internal claim positioning. 

3. Pre-Loss Reconstruction Modeling 

Use evidence to reconstruct probable pre-loss state. 

Inputs 

  • photos 
  • listing history 
  • Zillow/Realtor archives 
  • Google Street View 
  • renovation indicators 
  • neighborhood comparables 

AI Modeling Prompt 

Using these property details, describe the probable pre-loss finish level and construction quality expected for similar homes in this market. 

Output becomes justification narrative. 

Key Concept 

You are not guessing. 

You are reconstructing probability using evidence. 

4. Estimate Anchoring 

Before submission, estimate must reflect reconstructed pre-loss quality. 

Applications 

Flooring 

Higher-tier property → continuous flooring expectation. 

Paint 

Higher finish → full wall repaint justified. 

Roofing 

Architectural systems → slope continuity required. 

Cabinets 

Custom alignment → partial replacement unacceptable. 

Anchoring Rule 

Scope follows quality expectation. 

Quality expectation must be established first. 

5. Negotiation Positioning 

Position estimate as compliance, not expansion. 

Language Framework 

Instead of: 

We believe replacement is necessary. 

Use: 

Restoration must return property to documented pre-loss condition consistent with observed finish level. 

Carrier argument shifts from cost → obligation. 

Adjuster Psychology Effect 

Adjuster must now argue: 

property was lower quality than evidence shows. 

Most avoid this position. 

6. Supplement Reinforcement 

When hidden damage discovered: 

Tie supplements back to pre-loss condition. 

Example: 

  • Continuous flooring justified because original installation was continuous. 
  • Paint expansion justified by uniform finish requirement. 
  • Trim replacement justified by profile continuity. 

Pre-loss condition becomes recurring justification engine. 

Documentation Package (PLCB File) 

Each claim should contain: 

  • quality tier classification 
  • supporting photos 
  • property intelligence notes 
  • pre-loss narrative summary 

This travels with claim throughout lifecycle. 

AI Prompts for PLCB Usage 

Pre-Loss Quality Analysis 

Analyze these property photos and identify indicators of construction quality and finish level prior to loss. 

Market Expectation Prompt 

Based on property location and style, what restoration standard would reasonably be expected? 

Scope Justification Builder 

Explain why partial repair would fail to restore the property to its documented pre-loss condition. 

Carrier Defense Prompt 

Provide professional justification defending restoration scope based on pre-loss condition evidence. 

Operational Timing 

Claim Stage PLCB Action 
Intake collect intelligence 
Estimate Draft establish quality tier 
Pre-Submission anchor scope 
Negotiation reinforce obligation 
Supplement reuse justification 

KPI Impact 

Organizations implementing PLCB typically see: 

  • higher initial estimate acceptance 
  • fewer downgrade disputes 
  • faster negotiation resolution 
  • larger settlements without escalation 

Cultural Doctrine 

Damage defines the problem. 
Pre-loss condition defines the value. 

We restore what existed — not what is cheapest. 

Master Estimator Principle 

The strongest estimate is not the biggest. 

It is the one anchored to reality before negotiation begins. 

Justification Language Library (JLL System) 

(Institutional Knowledge & Settlement Acceleration Doctrine) 

Purpose 

The Justification Language Library (JLL) exists to standardize, preserve, and deploy proven claim justification language that consistently results in faster approvals, higher settlements, and fewer negotiation cycles. 

Every successful argument becomes reusable company intelligence. 

Claims Managers should never reinvent explanations already proven effective. 

Core Principle 

Approval speed is directly tied to clarity of justification. 

Adjusters approve work when: 

  • reasoning is familiar 
  • language sounds professional 
  • scope appears reasonable 
  • decision feels defensible internally 

The JLL system ensures every submission sounds like it came from a senior expert. 

Why This Matters 

Without a language system: 

  • each CM writes differently 
  • justification quality varies 
  • arguments weaken under pressure 
  • negotiation cycles increase 
  • knowledge disappears when employees leave 

With JLL: 

  • best arguments compound over time 
  • approval friction decreases 
  • training accelerates 
  • outcomes become predictable 

Fundamental Doctrine 

We are not arguing for more money. 

We are explaining why proper restoration requires specific work. 

Language must frame scope as: 

  • logical 
  • necessary 
  • policy-consistent 
  • construction-driven 
  • easy to approve 

JLL System Structure 

The system consists of six operational layers: 

  1. Language Capture 
  1. Categorization 
  1. Validation 
  1. Deployment 
  1. AI Integration 
  1. Continuous Improvement Loop 

1. Language Capture 

Whenever a claim succeeds due to explanation quality, capture the exact wording used. 

Sources include: 

  • approved supplements 
  • adjuster acceptance emails 
  • supervisor approvals 
  • appraisal outcomes 
  • PA negotiations 
  • attorney correspondence 

Capture Rule 

If wording helped approval → save it. 

No exceptions. 

Capture Template 

  • Claim Type 
  • Carrier 
  • Disputed Item 
  • Original Objection 
  • Final Approved Language 
  • Outcome Result 

2. Categorization 

Language organized by restoration scenario. 

Core Categories 

Continuous Replacement 

  • roofing slopes 
  • flooring transitions 
  • paint continuity 
  • trim alignment 

Detach & Reset 

  • cabinets 
  • plumbing fixtures 
  • appliances 
  • electrical components 

Access & Protection 

  • containment 
  • contents manipulation 
  • safety requirements 

O&P Justification 

  • multi-trade coordination 
  • supervision necessity 

Code Compliance 

  • modern install requirements 
  • manufacturer standards 

Hidden Damage 

  • demolition discovery 
  • layered assemblies 

Matching Requirements 

  • visual uniformity 
  • discontinuation 

Labor Reality 

  • access limitations 
  • occupied structures 

3. Validation 

Language added only after proven effectiveness. 

Validation criteria: 

  • approved without escalation OR 
  • approved after limited negotiation OR 
  • repeated success across claims 

Language becomes “Certified Justification.” 

Certification Levels 

Level 1 — Tested 
Worked once. 

Level 2 — Proven 
Worked multiple times. 

Level 3 — Institutional Standard 
Consistently approved across carriers. 

4. Deployment 

CMs pull language before submission. 

Workflow: 

Estimate complete → identify dispute risk → insert justification. 

Language is adapted, not rewritten. 

Example Deployment 

Instead of writing: 

Flooring must be replaced. 

Use certified language: 

Due to continuous installation and inability to achieve uniform appearance through partial repair, replacement across the affected continuous area is required to restore pre-loss condition. 

Approval probability increases immediately. 

5. AI Integration 

AI becomes retrieval engine. 

Retrieval Prompt 

Pull strongest approved justification language for continuous flooring replacement involving matching issues. 

AI returns certified wording. 

Enhancement Prompt 

Rewrite this justification using professional adjuster-facing tone consistent with approved language patterns. 

Objection Response Prompt 

Generate response using certified justification language addressing carrier denial. 

AI ensures consistency without memorization. 

6. Continuous Improvement Loop 

Every closed claim updates the library. 

Cycle: 

Claim → Success → Capture → Validate → Deploy → Improve. 

Knowledge compounds indefinitely. 

Psychological Advantage 

Adjusters encounter familiar reasoning patterns. 

Familiar language feels safer to approve. 

Approval becomes administrative rather than adversarial. 

Language Design Rules 

All justification must be: 

  • professional 
  • neutral tone 
  • construction-based 
  • policy-aligned 
  • concise 
  • non-emotional 

Never: 

  • accusatory 
  • argumentative 
  • speculative 

Core Language Framework 

Every justification should follow: 

Condition → Construction Reality → Restoration Requirement → Conclusion 

Example: 

Observed condition requires disturbance of adjacent materials → disturbance prevents isolated repair → restoration requires continuous replacement → scope expanded accordingly. 

Claims Manager Workflow Integration 

Stage JLL Use 
Estimate Draft anticipate disputes 
Pre-Submission insert justification 
Negotiation respond to objections 
Supplement reinforce scope 
Escalation strengthen position 

KPI Impact 

Organizations implementing structured language systems typically achieve: 

  • fewer negotiation cycles 
  • faster approvals 
  • higher supplement success 
  • reduced CM variability 
  • shorter training ramp 

Cultural Doctrine 

Skill should not disappear when people leave. 

Knowledge belongs to the system. 

Master Estimator Principle 

The best estimator is not the best writer. 

The best estimator uses the best language already proven to work. 

Final Rule 

If you explained something successfully once, 
you should never have to explain it from scratch again. 

🟣 UNDERSTANDING INSURANCE ADJUSTERS 

(How Claims Actually Move Forward) 

This section exists to help everyone understand how insurance claims are reviewed and approved so expectations stay realistic and projects move smoothly. 

Insurance adjusters are not construction experts, and they are not personally paying for claims. Their role is to make decisions that are documented, defensible, and compliant with internal carrier guidelines. 

Understanding this helps explain why certain requests, reviews, or delays happen during the process. 

What Adjusters Are Responsible For 

Adjusters are typically managing many claims at once and must ensure every payment they approve can be justified internally. 

They are primarily focused on: 

  • Clear documentation 
  • Policy compliance 
  • Consistent decision-making 
  • Verifiable scope and pricing 
  • Avoiding approvals they cannot defend later 

Their job is not to argue — it is to approve what can be supported. 

Why Insurance Often Pushes Back Initially 

Initial pushback is a normal part of the claims process and does not mean a claim is failing. 

Common reasons include: 

  • Limited initial documentation 
  • Need for internal review or supervisor approval 
  • Missing context about construction requirements 
  • Standard carrier review procedures 
  • Requests for clarification before approval 

Most claims evolve through documentation and explanation, not confrontation. 

How Strong Claims Get Approved 

Approvals typically happen when three things align: 

  1. Clear field documentation 
  1. Well-supported estimating 
  1. Consistent communication 

When documentation shows the full story, adjusters can approve scope more confidently and quickly. 

Why Centralized Communication Matters 

Insurance claims move best when communication stays organized. 

To avoid confusion: 

  • Pricing and scope discussions are handled through The Claims Ninja. 
  • Questions from insurance are answered using project documentation and estimate support. 
  • Consistent messaging prevents misunderstandings or conflicting information. 

This allows negotiations to remain structured and efficient. 

What This Means for the Project 

Insurance review is a process — not a single decision. 

Typical progression: 

Documentation → Review → Questions → Clarification → Agreement → Payment 

Each step moves the claim closer to resolution. 

The Key Takeaway 

Adjusters approve claims when decisions are easy to justify. 

Good documentation and organized communication make approvals easier — which helps projects move forward faster for everyone involved. 

Why this section works 

It quietly accomplishes several things: 

✅ lowers client anxiety 
✅ reduces adversarial mindset 
✅ supports your One Voice model without sounding controlling 
✅ teaches CMs how to frame conversations 
✅ aligns everyone around documentation-driven approvals