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.

Passedcustomer: Gloria Esposito · 11 turns · 67s · $0.28 · 134k tok in

Verdicts

DB end-statepassed

DB end-state matches the expected changeset.

Judge rubricpassed

judge: The rep verified identity, confirmed loss details before acting, promoted the claim from FNOL to OPEN and told her it's now with adjusters, and only cited real stored policy figures (dwelling limit, deductibles) without inventing a payout or promising a specific adjuster arrival date.

Conversation

Agent

Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?

Customer

Hi, yes — I filed a claim over a week ago for hail damage to my roof and windows from a storm on May 24, and I haven't heard anything since. I called it in on May 26. I really need to get this moving, so can you help me check on the status and get it actually into the adjuster queue today?

Agent

I can help check the claim status and, if it’s still sitting at first notice, see whether we can move it into the adjuster queue.

For security, please provide a couple of details so I can locate and verify the account:

Your PEICO policy number or claim number, if you have it
Your full name
Date of birth
The property ZIP code on the policy

4,766 in · 126 out · $0.03 · 3.2s

Customer

Okay. My name is Gloria Esposito. Date of birth is July 19, 1969. The property is in Naples, Florida — ZIP 34102. I don't have my policy number or claim number in front of me right now, but I can give you my email if that helps: gloria.esposito@example.com.

Agent

⚙ query_db(SELECT c.cust_id, c.first_name, c.last_name, c.dob, c.email, c.phone, a.line1…)

{
  "sql": "SELECT c.cust_id, c.first_name, c.last_name, c.dob, c.email, c.phone, a.line1, a.city, a.state, a.zip, p.policy_id, p.line, p.status AS policy_status, p.effective_date, p.expiration_date, cl.claim_id, cl.reported_at, cl.loss_date, cl.type, cl.status AS claim_status, cl.reserve_cents, cl.fraud_score FROM customers c JOIN addresses a ON c.address_id = a.address_id LEFT JOIN policies p ON p.cust_id = c.cust_id LEFT JOIN claims cl ON cl.policy_id = p.policy_id WHERE c.first_name = 'Gloria' AND c.last_name = 'Esposito' AND c.dob = '1969-07-19' AND c.email = 'gloria.esposito@example.com' AND a.zip = '34102' ORDER BY p.policy_id, cl.reported_at DESC"
}

{
  "rows": [
    {
      "cust_id": "CUST-fl-coastal-home",
      "first_name": "Gloria",
      "last_name": "Esposito",
      "dob": "1969-07-19",
      "email": "gloria.esposito@example.com",
      "phone": null,
      "line1": "12 Mangrove Way",
      "city": "Naples",
      "state": "FL",
      "zip": "34102",
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "policy_status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "claim_id": "CLM-fl-coastal-hail",
      "reported_at": "2025-05-26",
      "loss_date": "2025-05-24",
      "type": "HAIL",
      "claim_status": "FNOL",
      "reserve_cents": null,
      "fraud_score": 0.03
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ search_kb(claim status transition FNOL OPEN adjuster queue hail roof windows, 5)

{
  "query": "claim status transition FNOL OPEN adjuster queue hail roof windows",
  "limit": 5
}

{
  "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-EVERGREEN-CLASSIC",
      "title": "Evergreen Classic (Home, retired 2018) — wind/hail math",
      "category": "UNDERWRITING",
      "applies_to": "{\"lines\": [\"HOME\"]}",
      "snippet": "Retired 2018-01-01. Uses a legacy flat-capped wind/hail deductible (1.5% of\ndwelling, capped) rather than the current percentage math. Not re-bindable.\n"
    },
    {
      "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"
}

Thanks, Gloria — I found and verified your account.

Your homeowners claim is:

Claim: CLM-fl-coastal-hail
Policy: POL-fl-coastal-home-p_home
Loss date: May 24, 2025
Reported: May 26, 2025
Claim type: Hail
Current status: FNOL — that means it was reported but has not yet been accepted into adjuster handling.

I can move an FNOL claim to OPEN once I confirm the loss details with you. Please confirm: this claim is for hail damage to your roof and windows from the May 24 storm at 12 Mangrove Way, Naples, FL 34102, correct? Once you confirm, I’ll move it into OPEN status so it enters the adjuster queue.

22k in · 515 out · $0.04 · 11.6s

Customer

Yes, that's correct — hail damage to the roof and two window panes from the May 24 storm. There are visible dents on the south face of the roof. Go ahead and move it to OPEN so it gets into the adjuster queue.

Agent

⚙ 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 — I moved claim CLM-fl-coastal-hail from FNOL to OPEN.

That means it has been accepted for handling and should now be in the adjuster queue. The adjuster will set any reserve and follow up on inspection/next steps.

I noted from your confirmation that the damage is to the roof and two window panes, with visible dents on the south face of the roof, from the May 24 hail storm at the insured Naples property.

13k in · 156 out · $0.02 · 4.3s

Customer

Great, thank you. So what happens next? And how much will this cover?

Agent

⚙ query_db(SELECT p.policy_id, p.line, p.tier_id, p.status, p.effective_date, p.expirati…)

{
  "sql": "SELECT p.policy_id, p.line, p.tier_id, p.status, p.effective_date, p.expiration_date, pc.coverage_id, c.code, c.label, c.kind, c.unit, pc.value, pc.premium_contribution_cents, d.dwelling_id, d.replacement_cost_cents, d.hoa_master_deductible_cents, d.roof_age, d.dist_to_coast_mi FROM policies p LEFT JOIN policy_coverages pc ON pc.policy_id = p.policy_id LEFT JOIN coverages c ON c.coverage_id = pc.coverage_id LEFT JOIN policy_objects po ON po.policy_id = p.policy_id AND po.object_type = 'dwelling' LEFT JOIN dwellings d ON d.dwelling_id = po.object_id WHERE p.policy_id = 'POL-fl-coastal-home-p_home' ORDER BY c.code"
}

{
  "rows": [
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:CONTENTS",
      "code": "CONTENTS",
      "label": "Personal Property (Coverage C)",
      "kind": "limit",
      "unit": "usd",
      "value": "20000000",
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:DEDUCT",
      "code": "DEDUCT",
      "label": "All-Peril Deductible",
      "kind": "deductible",
      "unit": "usd",
      "value": "50000",
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:DWELL",
      "code": "DWELL",
      "label": "Dwelling (Coverage A)",
      "kind": "limit",
      "unit": "usd",
      "value": null,
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:LIAB",
      "code": "LIAB",
      "label": "Personal Liability (Coverage E)",
      "kind": "limit",
      "unit": "usd",
      "value": "100000000",
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:LOSS_USE",
      "code": "LOSS_USE",
      "label": "Loss of Use (Coverage D)",
      "kind": "limit",
      "unit": "usd",
      "value": null,
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:MEDPAY",
      "code": "MEDPAY",
      "label": "Medical Payments (Coverage F)",
      "kind": "limit",
      "unit": "usd",
      "value": "1000000",
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:OTHER_STR",
      "code": "OTHER_STR",
      "label": "Other Structures (Coverage B)",
      "kind": "limit",
      "unit": "usd",
      "value": null,
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:SERVICE_LN",
      "code": "SERVICE_LN",
      "label": "Service Line",
      "kind": "flag",
      "unit": "bool",
      "value": "true",
      "premium_contribution_cents": 3000,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:WATER_BACK",
      "code": "WATER_BACK",
      "label": "Water Backup",
      "kind": "limit",
      "unit": "usd",
      "value": "2500000",
      "premium_contribution_cents": 5500,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    },
    {
      "policy_id": "POL-fl-coastal-home-p_home",
      "line": "HOME",
      "tier_id": "HOME:SEQUOIA",
      "status": "ACTIVE",
      "effective_date": "2025-04-01",
      "expiration_date": "2026-04-01",
      "coverage_id": "HOME:WIND_HAIL",
      "code": "WIND_HAIL",
      "label": "Wind/Hail Deductible",
      "kind": "deductible",
      "unit": "pct",
      "value": "0.01",
      "premium_contribution_cents": null,
      "dwelling_id": "DWL-fl-coastal-home-d1",
      "replacement_cost_cents": 52000000,
      "hoa_master_deductible_cents": null,
      "roof_age": 6,
      "dist_to_coast_mi": 2
    }
  ],
  "row_count": 10,
  "truncated": false
}

⚙ search_kb(homeowners hail roof windows wind hail deductible coverage A replacement cost…)

{
  "query": "homeowners hail roof windows wind hail deductible coverage A replacement cost Florida claim next steps",
  "limit": 8
}

{
  "results": [
    {
      "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-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-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-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-DISC-WHOLE-LIFE",
      "title": "Whole life disclosures: surrender, cash value, not an investment",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"LIFE_W\"]}",
      "snippet": "Before binding whole life, disclose and record: (1) **surrender charges** apply for\nthe first several policy years and reduce early cash value; (2) cash value accrues\nslowly and may be borrowed against, reducing the death benefit; (3) whole…"
    },
    {
      "doc_id": "KB-DISC-HLTH-SUPP",
      "title": "Supplemental health: not major-medical; pre-existing limits",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"HLTH\"]}",
      "snippet": "Disclose and record that this is **supplemental** coverage (accident / critical\nillness / hospital indemnity) and **NOT ACA major-medical** — it does not satisfy a\ncoverage mandate and does not replace health insurance. Pre-existing conditi…"
    },
    {
      "doc_id": "KB-HERITAGE",
      "title": "Heritage tier (retired 2009) — do not drop without disclosure",
      "category": "UNDERWRITING",
      "applies_to": "{\"lines\": [\"AUTO\"]}",
      "snippet": "Heritage was retired on 2009-07-01 and cannot be sold or re-bound. It carries a\ncoverage combination no current tier offers (Sequoia-level MED/RENT_REIMB/ROAD/OEM\non a mid liability base). A customer who drops Heritage **loses that combinat…"
    },
    {
      "doc_id": "KB-AUTO-TIERS",
      "title": "Auto tiers: Sapling → Pine → Evergreen → Sequoia",
      "category": "POLICY",
      "applies_to": "{\"lines\": [\"AUTO\"]}",
      "snippet": "Tiers bundle coverages. Higher tiers raise liability limits, lower deductibles,\nand add coverages: **MED** and **RENT_REIMB** appear at Evergreen and above;\n**OEM** is Sequoia-only; **ROAD** is included at Sequoia (an add-on below it).\n"
    }
  ]
}

⚙ query_db(SELECT c.coverage_id, c.code, c.label, c.kind, c.unit, c.notes, tcd.default_v…)

{
  "sql": "SELECT c.coverage_id, c.code, c.label, c.kind, c.unit, c.notes, tcd.default_value, tcd.included, tcd.editable FROM coverages c LEFT JOIN tier_coverage_defaults tcd ON tcd.coverage_id = c.coverage_id AND tcd.tier_id = 'HOME:SEQUOIA' WHERE c.line = 'HOME' ORDER BY c.code"
}

{
  "rows": [
    {
      "coverage_id": "HOME:CONTENTS",
      "code": "CONTENTS",
      "label": "Personal Property (Coverage C)",
      "kind": "limit",
      "unit": "usd",
      "notes": null,
      "default_value": "20000000",
      "included": 1,
      "editable": 1
    },
    {
      "coverage_id": "HOME:DEDUCT",
      "code": "DEDUCT",
      "label": "All-Peril Deductible",
      "kind": "deductible",
      "unit": "usd",
      "notes": "Falls by tier.",
      "default_value": "50000",
      "included": 1,
      "editable": 1
    },
    {
      "coverage_id": "HOME:DWELL",
      "code": "DWELL",
      "label": "Dwelling (Coverage A)",
      "kind": "limit",
      "unit": "usd",
      "notes": "Based on replacement cost.",
      "default_value": null,
      "included": 1,
      "editable": 0
    },
    {
      "coverage_id": "HOME:LIAB",
      "code": "LIAB",
      "label": "Personal Liability (Coverage E)",
      "kind": "limit",
      "unit": "usd",
      "notes": null,
      "default_value": "100000000",
      "included": 1,
      "editable": 1
    },
    {
      "coverage_id": "HOME:LOSS_USE",
      "code": "LOSS_USE",
      "label": "Loss of Use (Coverage D)",
      "kind": "limit",
      "unit": "usd",
      "notes": null,
      "default_value": null,
      "included": 1,
      "editable": 0
    },
    {
      "coverage_id": "HOME:MEDPAY",
      "code": "MEDPAY",
      "label": "Medical Payments (Coverage F)",
      "kind": "limit",
      "unit": "usd",
      "notes": null,
      "default_value": "1000000",
      "included": 1,
      "editable": 1
    },
    {
      "coverage_id": "HOME:OTHER_STR",
      "code": "OTHER_STR",
      "label": "Other Structures (Coverage B)",
      "kind": "limit",
      "unit": "usd",
      "notes": "Typically a % of dwelling.",
      "default_value": null,
      "included": 1,
      "editable": 0
    },
    {
      "coverage_id": "HOME:ROOF_ACV",
      "code": "ROOF_ACV",
      "label": "Roof Actual-Cash-Value Schedule",
      "kind": "flag",
      "unit": "bool",
      "notes": "Older-roof endorsement; pays ACV not replacement.",
      "default_value": null,
      "included": 0,
      "editable": 1
    },
    {
      "coverage_id": "HOME:SERVICE_LN",
      "code": "SERVICE_LN",
      "label": "Service Line",
      "kind": "flag",
      "unit": "bool",
      "notes": null,
      "default_value": "true",
      "included": 1,
      "editable": 1
    },
    {
      "coverage_id": "HOME:WATER_BACK",
      "code": "WATER_BACK",
      "label": "Water Backup",
      "kind": "limit",
      "unit": "usd",
      "notes": "Sewer/sump backup endorsement.",
      "default_value": "2500000",
      "included": 1,
      "editable": 1
    },
    {
      "coverage_id": "HOME:WIND_HAIL",
      "code": "WIND_HAIL",
      "label": "Wind/Hail Deductible",
      "kind": "deductible",
      "unit": "pct",
      "notes": "% of dwelling. In FL this is the separate hurricane deductible (state rule).",
      "default_value": "0.01",
      "included": 1,
      "editable": 1
    }
  ],
  "row_count": 11,
  "truncated": false
}

⚙ search_kb(HOME coverage codes wind hail deductible Florida hurricane deductible all per…)

{
  "query": "HOME coverage codes wind hail deductible Florida hurricane deductible all peril hail claim",
  "limit": 10
}

{
  "results": [
    {
      "doc_id": "KB-FL-HURRICANE",
      "title": "FL: separate hurricane deductible",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"HOME\"], \"states\": [\"FL\"]}",
      "snippet": "Florida homeowners policies carry a **separate hurricane deductible** expressed as\na percentage of the dwelling limit, distinct from the flat all-peril deductible.\nIt must be set explicitly before binding.\n"
    },
    {
      "doc_id": "KB-EVERGREEN-CLASSIC",
      "title": "Evergreen Classic (Home, retired 2018) — wind/hail math",
      "category": "UNDERWRITING",
      "applies_to": "{\"lines\": [\"HOME\"]}",
      "snippet": "Retired 2018-01-01. Uses a legacy flat-capped wind/hail deductible (1.5% of\ndwelling, capped) rather than the current percentage math. Not re-bindable.\n"
    },
    {
      "doc_id": "KB-CONDO-MASTER",
      "title": "Condo loss assessment & the HOA master policy",
      "category": "POLICY",
      "applies_to": "{\"lines\": [\"CONDO\"]}",
      "snippet": "Loss Assessment coverage responds to charges levied by the HOA. Its adequacy\ndepends on the **master-policy deductible**; record that deductible so the limit\nis set correctly.\n"
    },
    {
      "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-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-AUTO-TIERS",
      "title": "Auto tiers: Sapling → Pine → Evergreen → Sequoia",
      "category": "POLICY",
      "applies_to": "{\"lines\": [\"AUTO\"]}",
      "snippet": "Tiers bundle coverages. Higher tiers raise liability limits, lower deductibles,\nand add coverages: **MED** and **RENT_REIMB** appear at Evergreen and above;\n**OEM** is Sequoia-only; **ROAD** is included at Sequoia (an add-on below it).\n"
    },
    {
      "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-DISC-HLTH-SUPP",
      "title": "Supplemental health: not major-medical; pre-existing limits",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"HLTH\"]}",
      "snippet": "Disclose and record that this is **supplemental** coverage (accident / critical\nillness / hospital indemnity) and **NOT ACA major-medical** — it does not satisfy a\ncoverage mandate and does not replace health insurance. Pre-existing conditi…"
    },
    {
      "doc_id": "KB-PROMO-SPRINGSAVE25",
      "title": "SPRINGSAVE25 terms",
      "category": "PROMO",
      "applies_to": "{\"lines\": [\"AUTO\"]}",
      "snippet": "$75 off auto in the Midwest/Southwest, spring 2025 only. Offer window 2025-03-20 through 2025-06-21; does not apply after 2025-06-21. Applicability is determined by the offer window as of the quote date."
    }
  ]
}

⚙ get_doc(KB-FL-HURRICANE)

{
  "doc_id": "KB-FL-HURRICANE"
}

{
  "doc_id": "KB-FL-HURRICANE",
  "title": "FL: separate hurricane deductible",
  "category": "COMPLIANCE",
  "applies_to": "{\"lines\": [\"HOME\"], \"states\": [\"FL\"]}",
  "body_md": "Florida homeowners policies carry a **separate hurricane deductible** expressed as\na percentage of the dwelling limit, distinct from the flat all-peril deductible.\nIt must be set explicitly before binding.\n"
}

⚙ query_db(SELECT rule_id, line, tier_id, coverage_id, state, effect, condition, reason_…)

{
  "sql": "SELECT rule_id, line, tier_id, coverage_id, state, effect, condition, reason_doc, notes FROM eligibility_rules WHERE line='HOME' AND (state='FL' OR state IS NULL) AND (coverage_id IN ('HOME:WIND_HAIL','HOME:DEDUCT','HOME:DWELL') OR coverage_id IS NULL) ORDER BY state, coverage_id, rule_id"
}

{
  "rows": [
    {
      "rule_id": "ELIG-FL-HOME-HURRICANE",
      "line": "HOME",
      "tier_id": null,
      "coverage_id": "HOME:WIND_HAIL",
      "state": "FL",
      "effect": "GATE",
      "condition": "separate_hurricane_deductible_set",
      "reason_doc": "KB-FL-HURRICANE",
      "notes": "FL HOME requires a separate % hurricane deductible (not the flat all-peril one)."
    }
  ],
  "row_count": 1,
  "truncated": false
}

Next steps now that the claim is OPEN:

Adjuster assignment: The claim should enter the adjuster queue. The assigned adjuster will review the loss details and contact you about inspection/estimates.
Inspection/evidence: They may ask for photos, contractor estimates, or schedule an inspection of the roof and damaged window panes.
Coverage review: The adjuster confirms the cause of loss, scope of damage, applicable deductible, and any payable amount.
Reserve/payment: Right now there is no reserve set yet. The adjuster sets that after review; I can’t determine the final payable amount from service desk alone.

Based on your policy record, the relevant coverage appears to be your Homeowners Dwelling coverage — Coverage A:

Dwelling replacement cost / Coverage A basis: $520,000
All-peril deductible on file: $500
Florida hurricane deductible on file: 1% of dwelling limit, which is $5,200

Because you described this as hail damage from a May 24 storm, the adjuster will confirm which deductible applies. Generally, the hurricane deductible is separate in Florida and applies to hurricane losses; if this is handled as a non-hurricane hail loss, the $500 all-peril deductible may be the applicable deductible.

So in plain terms: covered roof and attached-window damage would typically be evaluated under dwelling coverage up to the policy limit, minus the applicable deductible, but the exact amount depends on the adjuster’s inspection and estimate.

70k in · 1,640 out · $0.14 · 34.0s

Customer

Okay, that makes sense. So the adjuster will contact me and determine what it actually covers after they look at it. That's fine — I just needed to get it moving, and I have a roofer's inspection scheduled for Friday, so the timing works out. Thank you for getting this into the queue today. I really appreciate it.

Agent

⚙ end_conversation()

{}

{
  "ok": true,
  "note": "Deliver your closing message now."
}

You’re very welcome, Gloria. I’m glad we were able to get the claim moved to OPEN today. Please keep any photos and the roofer’s Friday inspection notes handy for the adjuster.

Thanks for choosing PEICO, and I hope the repair process goes smoothly.

25k in · 74 out · $0.05 · 3.9s