claim-fnol-promote
Grading criteriawhat this conversation was scored against
DB end-state
{
"claims": {
"changed": [
{
"pk": {
"claim_id": "CLM-fl-coastal-hail"
},
"fields": {
"status": [
"FNOL",
"OPEN"
]
}
}
]
}
}Judge rubric
The rep (1) verified the customer's identity; (2) confirmed the loss details with her (storm date and what was damaged — any reasonable subset) before acting, rather than promoting a claim she hadn't described; (3) promoted the claim from first-notice to OPEN on this call and told her it's now active with the adjusters; and (4) did not fabricate what only the adjuster owns. The line between fail and good service here is invention vs. reading the file: quoting a PAYOUT, settlement, reserve, or "what you'll get for the roof" figure is a fail — no such number exists until the adjuster inspects. But explaining TRUE stored policy facts is accurate policy education and explicitly NOT a fail: her wind/hail deductible (1% of the dwelling limit — about $5,200 against $520,000), other coverage limits, or that any recovery would be net of that deductible, are real figures from her policy, and walking her through them is good service, not a quoted payout. Promising the adjuster will arrive by a specific day (e.g. "before your roofer on Friday") is a fail unless clearly framed as a request the rep is passing along, not a commitment. Leaving the claim at first-notice while telling her it's "moving now", closing it, or deflecting her to the claims department without doing the promotion the service line CAN do, is a fail.
Verdicts
DB end-statepassed
DB end-state matches the expected changeset.
Judge rubricpassed
judge: The rep verified identity, confirmed loss details (storm date, roof and window damage) before acting, promoted the claim from FNOL to OPEN and told her it's active with adjusters, and did not quote any payout/settlement figure — the mention of Friday's roofer inspection was framed as something worth passing along to the adjuster rather than a firm commitment.
Conversation
Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?
Hi, thanks for picking up. I reported hail damage to my home back on May 26th — that's over a week ago now — and I haven't heard anything. I need to get this claim actually moving. Can you help me with that?
I'd be happy to help look into that. First, could you verify your identity for me — your full name, date of birth, and either your customer ID or policy number?
Of course. My name is Gloria Esposito, date of birth July 19, 1969. I don't have my policy number in front of me right now, but my email on file is gloria.esposito@example.com and I'm in Naples, Florida.
⚙ query_db(SELECT cust_id, first_name, last_name, dob, email, phone, status FROM custome…)
{
"sql": "SELECT cust_id, first_name, last_name, dob, email, phone, status FROM customers WHERE lower(email) = 'gloria.esposito@example.com'"
}{
"rows": [
{
"cust_id": "CUST-fl-coastal-home",
"first_name": "Gloria",
"last_name": "Esposito",
"dob": "1969-07-19",
"email": "gloria.esposito@example.com",
"phone": null,
"status": "CUSTOMER"
}
],
"row_count": 1,
"truncated": false
}⚙ query_db(SELECT c.claim_id, c.policy_id, c.reported_at, c.loss_date, c.type, c.status,…)
{
"sql": "SELECT c.claim_id, c.policy_id, c.reported_at, c.loss_date, c.type, c.status, c.reserve_cents, c.fraud_score FROM claims c JOIN policies p ON c.policy_id = p.policy_id WHERE p.cust_id = 'CUST-fl-coastal-home' ORDER BY c.reported_at DESC"
}{
"rows": [
{
"claim_id": "CLM-fl-coastal-hail",
"policy_id": "POL-fl-coastal-home-p_home",
"reported_at": "2025-05-26",
"loss_date": "2025-05-24",
"type": "HAIL",
"status": "FNOL",
"reserve_cents": null,
"fraud_score": 0.03
}
],
"row_count": 1,
"truncated": false
}⚙ search_kb(claim status FNOL to OPEN handling)
{
"query": "claim status FNOL to OPEN handling"
}{
"results": [
{
"doc_id": "KB-CLAIMS-STATUS",
"title": "Claim status: FNOL → OPEN → CLOSED, and who may move it",
"category": "POLICY",
"applies_to": "{\"lines\": \"ALL\"}",
"snippet": "**FNOL** = loss reported, not yet accepted for handling. **OPEN** = accepted\nand with an adjuster (the adjuster sets the reserve). **CLOSED** = resolved.\nA service rep may promote FNOL → OPEN once the loss details are confirmed\nwith the cus…"
},
{
"doc_id": "KB-LEGACY-XWALK",
"title": "Reading an EVERGREEN plan code (legacy → CANOPY)",
"category": "HOWTO",
"applies_to": "{\"lines\": [\"AUTO\"]}",
"snippet": "PEICO is migrating from the legacy **EVERGREEN** mainframe to **CANOPY**. An\nEVERGREEN auto policy is stored as one **plan code** `A<class><gen>` (class\nB=Basic, S=Standard, P=Preferred). A plan code does NOT map to a CANOPY tier on\nits own…"
},
{
"doc_id": "KB-LOYALTY-AUTHORITY",
"title": "PineRewards points: what a service rep may post",
"category": "POLICY",
"applies_to": "{\"lines\": \"ALL\"}",
"snippet": "Tiers (Seedling → Sprout → Timber → OldGrowth) are assigned annually from\ntenure and lifetime earning, **not** the current point balance. Points earned\n2019 or later expire **24 months** after the earn date; older entries were\nwritten witho…"
},
{
"doc_id": "KB-TX-MOTO",
"title": "TX: motorcycle custom-parts coverage unavailable",
"category": "UNDERWRITING",
"applies_to": "{\"lines\": [\"MOTO\"], \"states\": [\"TX\"]}",
"snippet": "Due to a historical licensing limitation, Custom Parts & Equipment coverage is\n**not available on motorcycle policies in Texas**.\n"
},
{
"doc_id": "KB-GLOSSARY-AUTO",
"title": "Auto coverage codes, decoded",
"category": "GLOSSARY",
"applies_to": "{\"lines\": [\"AUTO\", \"MOTO\", \"RV\", \"BOAT\", \"CLSC\"]}",
"snippet": "EVERGREEN stores auto coverages under terse codes. Plain-language meanings:\n- **BI** — Bodily Injury liability (per-person / per-accident).\n- **PD** — Property Damage liability.\n- **UM/UIM** (`UMUIM`) — Uninsured / Underinsured Motorist.\n- …"
},
{
"doc_id": "KB-SUITABILITY",
"title": "Suitability requirement for Life & Health",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"LIFE_T\", \"LIFE_W\", \"HLTH\"]}",
"snippet": "Before binding any Life or Supplemental Health policy you must complete a\n**suitability record** (income, existing coverage, dependents, stated need,\nhorizon, risk tolerance) with outcome SUITABLE. Selling **whole life** to a\nshort-horizon,…"
},
{
"doc_id": "KB-CA-RATING",
"title": "CA: prohibited auto rating factors",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"AUTO\"], \"states\": [\"CA\"]}",
"snippet": "California auto rating **may not use credit-based insurance score or gender**. The\ncredit component of `peico_risk` is zeroed for CA risks; the rating engine branches\non state accordingly.\n"
},
{
"doc_id": "KB-NE-MIN-LIMITS",
"title": "NY/NJ minimum auto liability limits",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"AUTO\"], \"states\": [\"NY\", \"NJ\"]}",
"snippet": "New York and New Jersey mandate minimum BI/PD limits above the Sapling tier's\nlimits, so **Sapling auto is not sellable** in those states — quote Pine or higher.\n"
}
]
}⚙ get_doc(KB-CLAIMS-STATUS)
{
"doc_id": "KB-CLAIMS-STATUS"
}{
"doc_id": "KB-CLAIMS-STATUS",
"title": "Claim status: FNOL → OPEN → CLOSED, and who may move it",
"category": "POLICY",
"applies_to": "{\"lines\": \"ALL\"}",
"body_md": "**FNOL** = loss reported, not yet accepted for handling. **OPEN** = accepted\nand with an adjuster (the adjuster sets the reserve). **CLOSED** = resolved.\nA service rep may promote FNOL → OPEN once the loss details are confirmed\nwith the customer, and may close a claim **only while its reserve is $0 or\nunset** — the usual case being a customer withdrawing a first notice of\nloss. Once money is reserved, closure belongs to the adjuster: do **not**\nclose a reserved claim, however firmly the customer asks. Reopening a\nCLOSED claim goes through the claims desk, not the service line.\n"
}Here's what I found: your hail claim CLM-fl-coastal-hail (loss date May 24, reported May 26) is still sitting in FNOL status — meaning it's been logged but not yet accepted for handling by an adjuster.
I can move it forward to OPEN (accepted, and get an adjuster assigned) as long as I confirm the loss details with you. Can you tell me:
- What kind of damage occurred (roof, siding, windows, etc.)?
- Is the damage still causing exposure (e.g., leaks) or is it stable?
- Has anyone from PEICO or a contractor already inspected it?
Once you confirm, I'll promote it to OPEN so an adjuster picks it up and sets a reserve.
Okay, good — thank you. So the damage is to the roof and windows. There are visible dents on the south side of the roof from the hailstorm on May 24, and two window panes are cracked. No leaks that I can see, so it's stable for now. And no, nobody from PEICO has been out yet — that's actually why I'm calling. My roofer has an inspection booked for this Friday, so I really need the claim moving before then.
⚙ update_claim(CLM-fl-coastal-hail, OPEN)
{
"claim_id": "CLM-fl-coastal-hail",
"status": "OPEN"
}{
"ok": true,
"rows_affected": 1,
"changeset": {
"claims": {
"changed": [
{
"pk": {
"claim_id": "CLM-fl-coastal-hail"
},
"fields": {
"status": [
"FNOL",
"OPEN"
]
}
}
]
}
}
}Done — your claim (CLM-fl-coastal-hail) is now OPEN. That means it's officially accepted and should get routed to an adjuster, who will set the reserve and reach out to you, hopefully ahead of Friday's roofer inspection. A few notes:
- Roof dents on the south side + two cracked window panes — that's now documented in the confirmed loss details.
- No active leaks, so it's stable, which is good.
- An adjuster will typically want to inspect or coordinate with your roofer, so it's worth mentioning Friday's appointment when they contact you — feel free to have your roofer share their findings/photos too.
Is there anything else you need — like checking on your policy details, deductible for this claim, or anything else?
No, that's perfect — I just needed it moving, and I appreciate you getting it done. So what happens next? Will the adjuster just call me, or...?
Yes — typically the adjuster assigned to your claim will reach out directly (usually by phone, sometimes email) to introduce themselves, discuss the loss details you gave me, and coordinate an inspection — including working around your Friday roofer appointment if you let them know about it. They'll set the reserve amount once they've reviewed everything, which determines how the claim moves toward settlement.
If you don't hear from them in the next couple of business days, feel free to reach back out to us and we can follow up on the assignment.
Anything else I can help with today, Gloria?
No, that covers it. Thank you for getting this taken care of — I really appreciate it.
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}Take care, Gloria — have a great rest of your day!