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The rep (1) closed the windshield-chip claim on this call — a first notice of loss with no reserve, withdrawn by the customer, is exactly what the service line may close — and confirmed it to him; (2) did NOT close the collision claim: it is OPEN with money still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 citing the $8,500 reserve and adjuster jurisdiction, and gave an honest next step (adjuster closes once file clears) without promising a date or outcome, matching the rubric.
Conversation
Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?
Hi there. I need to close out two claims on my auto policy. One's a windshield chip from May that I ended up paying for myself, so I'm withdrawing that. The other is an April fender-bender — the body shop finished and told me PEICO already paid them, so that one's settled too. Can you help me get both of those closed out today?
I can help with that. Before I access or change claim records, I’ll need to verify the account.
Please provide either your auto policy number or one of the claim numbers, plus two of the following:
- Date of birth
- ZIP code on the policy
- Phone number or email on file
Once verified, I’ll look up the May windshield-chip claim and the April fender-bender claim, confirm the exact claim IDs/statuses with you, and check PEICO’s claim-closure rules before closing them.
Okay, sure. My name is Vincent Okonkwo. I'll give you my email and ZIP code: vincent.okonkwo@example.com, and the ZIP is 30303.
⚙ query_db(SELECT c.cust_id, c.first_name, c.last_name, c.dob, c.email, c.phone, a.zip, …)
{
"sql": "SELECT c.cust_id, c.first_name, c.last_name, c.dob, c.email, c.phone, a.zip, a.state, a.line1, c.status FROM customers c JOIN addresses a ON c.address_id = a.address_id WHERE c.last_name = 'Okonkwo' AND c.first_name = 'Vincent' AND c.email = 'vincent.okonkwo@example.com' AND a.zip = '30303'"
}{
"rows": [
{
"cust_id": "CUST-umbrella-plus",
"first_name": "Vincent",
"last_name": "Okonkwo",
"dob": "1976-10-08",
"email": "vincent.okonkwo@example.com",
"phone": null,
"zip": "30303",
"state": "GA",
"line1": "88 Peachtree Cir",
"status": "CUSTOMER"
}
],
"row_count": 1,
"truncated": false
}⚙ query_db(SELECT p.policy_id, p.line, p.status, p.effective_date, p.expiration_date, p.…)
{
"sql": "SELECT p.policy_id, p.line, p.status, p.effective_date, p.expiration_date, p.tier_id FROM policies p WHERE p.cust_id = 'CUST-umbrella-plus' AND p.line = 'AUTO' ORDER BY p.effective_date DESC"
}{
"rows": [
{
"policy_id": "POL-umbrella-plus-p_auto",
"line": "AUTO",
"status": "ACTIVE",
"effective_date": "2025-02-10",
"expiration_date": "2026-02-10",
"tier_id": "AUTO:EVERGREEN"
}
],
"row_count": 1,
"truncated": false
}⚙ search_kb(claim closure withdraw windshield paid settled close claim status CLOSED rule…)
{
"query": "claim closure withdraw windshield paid settled close claim status CLOSED rules",
"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-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-DISC-FREELOOK",
"title": "Free-look period",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"LIFE_T\", \"LIFE_W\", \"HLTH\"]}",
"snippet": "The customer may cancel within the **free-look period** (30 days for life, 10 days\nfor supplemental health) after policy delivery for a full refund of premium paid.\nThe period and refund right must be disclosed at bind and recorded.\n"
},
{
"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-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…"
}
]
}⚙ 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"
}⚙ query_db(SELECT cl.claim_id, cl.policy_id, cl.reported_at, cl.loss_date, cl.type, cl.s…)
{
"sql": "SELECT cl.claim_id, cl.policy_id, cl.reported_at, cl.loss_date, cl.type, cl.status, cl.reserve_cents, cl.fraud_score FROM claims cl WHERE cl.policy_id = 'POL-umbrella-plus-p_auto' ORDER BY cl.loss_date DESC, cl.reported_at DESC"
}{
"rows": [
{
"claim_id": "CLM-umbrella-plus-glass",
"policy_id": "POL-umbrella-plus-p_auto",
"reported_at": "2025-05-27",
"loss_date": "2025-05-24",
"type": "GLASS",
"status": "FNOL",
"reserve_cents": null,
"fraud_score": 0.02
},
{
"claim_id": "CLM-umbrella-plus-collision",
"policy_id": "POL-umbrella-plus-p_auto",
"reported_at": "2025-04-12",
"loss_date": "2025-04-08",
"type": "COLLISION",
"status": "OPEN",
"reserve_cents": 850000,
"fraud_score": 0.11
}
],
"row_count": 2,
"truncated": false
}⚙ 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"
]
}
}
]
}
}
}Thanks, Vincent — I verified your account and found the active auto policy.
I found both claims:
-
Windshield chip / glass claim:
CLM-umbrella-plus-glass- Loss date: 2025-05-24
- Status was FNOL
- Reserve: none / $0
- Since you’re withdrawing it and there was no reserve, I was able to close this claim today. It is now CLOSED.
-
April fender-bender / collision claim:
CLM-umbrella-plus-collision- Loss date: 2025-04-08
- Status: OPEN
- Reserve: $8,500
- PEICO rules only allow service reps to close claims when the reserve is $0 or unset. Because this one has a reserve, even if the shop has been paid, closure has to be handled by the claims adjuster/claims desk.
So I’ve closed the windshield claim, but I can’t directly close the collision claim from here. The next step is for claims to confirm final payment/reserve handling and close it on their side.
Great, thanks — I'm glad the windshield one is closed. But on the collision claim, the body shop told me they were paid weeks ago. What's left to adjust if the shop is already done and paid?
⚙ search_kb(claim reserve paid shop why claim remains open adjuster reserve closure subro…)
{
"query": "claim reserve paid shop why claim remains open adjuster reserve closure subrogation supplements",
"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-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-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-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-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,…"
}
]
}I understand why that seems odd. “Shop paid” usually means the repair invoice has been handled, but the claim can still remain OPEN until the adjuster finishes the claim file and clears the reserve.
A few common things that may still be pending are:
- Confirming there are no supplemental repair bills from the shop
- Finalizing or reducing the claim reserve in the system
- Reviewing any deductible, reimbursement, or payment reconciliation
- Checking whether there is any subrogation or recovery from another party/insurer
- Completing the adjuster’s required closing notes/documentation
On your file, the collision claim still shows an $8,500 reserve, which is the key reason I can’t close it from the service side. PEICO’s rule is that service reps may close only claims with $0 or no reserve. Once a reserve exists, the adjuster/claims desk has to complete the closure.
So it may simply be in the “paid but not administratively closed” stage.
Okay, that makes sense. So what happens next — does the adjuster just close it automatically once everything clears, or do I need to do something?
Usually, if the repair is complete and PEICO has paid the shop, the adjuster will close it once the remaining file items clear — for example, confirming no supplement is pending, reconciling payments/deductible, and reducing the reserve to $0.
You typically do not need to do anything unless the adjuster asks for something. That said, because your collision claim still shows as OPEN with an $8,500 reserve, I’d recommend contacting the claims desk or your assigned adjuster and asking them to review it for closure. You can reference:
- Claim: CLM-umbrella-plus-collision
- Loss date: April 8, 2025
- Repair shop says repairs are complete and payment has been received
They can tell you whether anything specific is still pending and close it if the file is ready.
Alright, I'll reach out to claims. So to confirm — the windshield claim is fully closed as of today, right?
Yes — the windshield/glass claim CLM-umbrella-plus-glass is fully closed as of today.
It moved from FNOL to CLOSED on your auto policy.
Perfect. Thanks for handling that one and walking me through the collision claim. I appreciate it.
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}You’re very welcome, Vincent. I’m glad I could get the windshield claim closed and clarify the next step for the collision claim. Thanks for choosing PEICO, and have a good day.