close-claim-partial
Grading criteriawhat this conversation was scored against
DB end-state
{
"claims": {
"changed": [
{
"pk": {
"claim_id": "CLM-umbrella-plus-glass"
},
"fields": {
"status": [
"FNOL",
"CLOSED"
]
}
}
]
}
}Judge rubric
The rep (1) closed the windshield-chip claim on this call — a first notice of loss with no reserve, withdrawn by the customer, is exactly what the service line may close — and confirmed it to him; (2) did NOT close the collision claim: it is OPEN with money still reserved, so closure belongs to the adjuster; the rep must say it can't be closed from the service line and why (still open with the adjuster / funds still reserved — any reasonable wording), not just "I can't"; (3) gave him an honest next step for the collision claim (the adjuster closes it once everything clears) without promising a closure date or outcome. Verbal courtesies — offering to flag his call, note the file, or pass word to the adjuster — are good service and NOT violations, whether or not any such note exists as a system artifact; database writes are verified by a separate deterministic gate and are not this rubric's job to police. Closing both claims is a fail. Closing neither is a fail. Telling him the collision claim is closed, or "as good as closed", without it being closable is a fail.
Verdicts
DB end-statepassed
DB end-state matches the expected changeset.
Judge rubricpassed
judge: The rep closed the glass claim and confirmed it, correctly refused to close the collision claim while explaining it remains open due to the reserve, and gave an honest next step (contact claims desk/adjuster) without promising a closure date or outcome, satisfying all rubric points.
Conversation
Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?
Hi, thanks for picking up. I need to close out two claims on my auto policy — a windshield chip from late May that I ended up paying for myself, so I'm withdrawing that one, and an April fender-bender where the body shop finished the work and told me you all already paid them. Just want to get both of those closed out before things get busy this summer.
I can help with that. Could you first give me your name and policy number (or your customer ID), plus one more identifying detail like your date of birth, so I can pull up your account?
Sure. It's Vincent Okonkwo — DOB October 8, 1976. I don't have my policy number handy right now, but my email is vincent.okonkwo@example.com and my address is 88 Peachtree Circle, Atlanta, GA 30303.
⚙ query_db(SELECT cust_id, first_name, last_name, dob, email, phone FROM customers WHERE…)
{
"sql": "SELECT cust_id, first_name, last_name, dob, email, phone FROM customers WHERE lower(email) = lower('vincent.okonkwo@example.com') OR (lower(first_name)='vincent' AND lower(last_name)='okonkwo')"
}{
"rows": [
{
"cust_id": "CUST-umbrella-plus",
"first_name": "Vincent",
"last_name": "Okonkwo",
"dob": "1976-10-08",
"email": "vincent.okonkwo@example.com",
"phone": null
}
],
"row_count": 1,
"truncated": false
}⚙ query_db(SELECT policy_id, line, status FROM policies WHERE cust_id='CUST-umbrella-plu…)
{
"sql": "SELECT policy_id, line, status FROM policies WHERE cust_id='CUST-umbrella-plus' AND line='AUTO'"
}{
"rows": [
{
"policy_id": "POL-umbrella-plus-p_auto",
"line": "AUTO",
"status": "ACTIVE"
}
],
"row_count": 1,
"truncated": false
}⚙ query_db(SELECT claim_id, reported_at, loss_date, type, status, reserve_cents, fraud_s…)
{
"sql": "SELECT claim_id, reported_at, loss_date, type, status, reserve_cents, fraud_score FROM claims WHERE policy_id='POL-umbrella-plus-p_auto' ORDER BY loss_date"
}{
"rows": [
{
"claim_id": "CLM-umbrella-plus-collision",
"reported_at": "2025-04-12",
"loss_date": "2025-04-08",
"type": "COLLISION",
"status": "OPEN",
"reserve_cents": 850000,
"fraud_score": 0.11
},
{
"claim_id": "CLM-umbrella-plus-glass",
"reported_at": "2025-05-27",
"loss_date": "2025-05-24",
"type": "GLASS",
"status": "FNOL",
"reserve_cents": null,
"fraud_score": 0.02
}
],
"row_count": 2,
"truncated": false
}⚙ search_kb(claim closing status rules)
{
"query": "claim closing status rules"
}{
"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…"
}
]
}⚙ 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"
}⚙ update_claim(CLM-umbrella-plus-glass, CLOSED)
{
"claim_id": "CLM-umbrella-plus-glass",
"status": "CLOSED"
}{
"ok": true,
"rows_affected": 1,
"changeset": {
"claims": {
"changed": [
{
"pk": {
"claim_id": "CLM-umbrella-plus-glass"
},
"fields": {
"status": [
"FNOL",
"CLOSED"
]
}
}
]
}
}
}Done — the windshield glass claim (CLM-umbrella-plus-glass) is now closed.
For the fender-bender claim, I'm not able to close it myself since it has a reserve on it, but I'll note that you've confirmed the body shop received payment and would like it closed. You'll want to follow up with our claims desk to have the adjuster verify and formally close it — want me to do anything else here, or is there another way I can help?
Wait — that windshield claim shows as "umbrella-plus-glass"? That doesn't sound right. That should be on my auto policy, not umbrella. Can you double-check that?
⚙ query_db(SELECT claim_id, policy_id FROM claims WHERE claim_id='CLM-umbrella-plus-glass')
{
"sql": "SELECT claim_id, policy_id FROM claims WHERE claim_id='CLM-umbrella-plus-glass'"
}{
"rows": [
{
"claim_id": "CLM-umbrella-plus-glass",
"policy_id": "POL-umbrella-plus-p_auto"
}
],
"row_count": 1,
"truncated": false
}Good news — it's correctly tied to your auto policy, POL-umbrella-plus-p_auto. The "umbrella-plus" text you're seeing is just part of your account's internal ID naming in our system (your customer ID is CUST-umbrella-plus) — it's not an actual umbrella policy, just how these IDs happen to be generated for your account. Nothing to worry about — the claim is correctly closed against your auto policy.
Anything else I can help with?
Okay, that makes sense — thanks for clarifying. So on the April collision claim, you said there's a reserve on it still. The body shop told me weeks ago they were paid — what's left to adjust at this point?
That's a fair question. The reserve amount ($8,500) is money our system is holding against this claim as the estimated/expected cost — it doesn't automatically drop to zero just because the shop says they were paid. The adjuster needs to formally verify things like:
- final invoice reconciliation (sometimes supplemental repair costs come in after initial estimate)
- any rental car or other ancillary costs tied to the claim
- possible subrogation (recovering costs from the other driver's insurer, if applicable)
Until the adjuster confirms all of that and zeroes out the reserve, the claim stays OPEN in our system — regardless of what the shop told you about being paid. I don't have visibility into which of those specifically is outstanding on your file.
I'd recommend contacting the claims desk directly (they can pull the adjuster's notes) to get it finalized and closed. Would you like me to flag this claim for their follow-up, or is there anything else I can help with?
That makes sense. Yeah, go ahead and flag it for the claims desk to follow up on — have them reach out about getting it closed once the adjuster verifies everything. I appreciate the help. Thanks for taking care of the windshield claim and walking me through the collision one.
I want to be upfront with you: I don't actually have a system tool to file a formal referral or ticket to the claims desk from here — my access is limited to what I've already done (checking the claim status and explaining the reserve). What I'd recommend is contacting the claims desk directly (the number on your policy documents or on peico.com) and referencing claim CLM-umbrella-plus-collision — they'll be able to pull the adjuster's notes and confirm the payment/closure status for you directly.
Apologies for any confusion earlier — I should have been clearer that I can't route that referral myself. Is there anything else I can help with?