# Examples — Insurance Claims Intake & Triage Agent

## Simple complete auto-glass claim → fast-track

A low-severity windshield claim with everything attached and an active policy listing the peril. Routes to fast-track (still adjuster-owned).

**Input**

```
FNOL CLM-7781: windshield crack, policy active, comprehensive coverage. Provided: date, location, photos, policy number. No injuries.
```

**Output**

```
{
  "claim_id": "CLM-7781",
  "claim_type": "auto_glass",
  "severity": "low",
  "completeness": "complete",
  "missing": [],
  "coverage_screen": "policy_active_and_peril_listed",
  "fraud_indicators": [],
  "decision": "FAST_TRACK",
  "route_to": "fast_track",
  "claimant_note": "Thanks for reporting your windshield damage. Your claim CLM-7781 is complete and has been sent to our fast-track team; they'll be in touch with next steps.",
  "escalation": { "needed": false, "to": "none", "reason": "" },
  "disclaimer": "Administrative intake & routing only — not a coverage, liability, or claim decision."
}
```

**Note:** Note the careful coverage language: 'policy_active_and_peril_listed' is an administrative routing signal, and the claimant note promises next steps, not approval. Complete + low-severity + peril listed → fast-track queue, where a human still owns the claim.

## Theft claim missing the police report → request info, hold

A theft claim is missing a required document. The agent requests exactly what's needed instead of routing an incomplete claim.

**Input**

```
FNOL CLM-7820: laptop theft from vehicle. Provided: date, location, item list, policy number. Missing: police report (required for theft).
```

**Output**

```
{
  "claim_id": "CLM-7820",
  "claim_type": "theft",
  "severity": "moderate",
  "completeness": "incomplete",
  "missing": ["Police/incident report number (required for theft claims)"],
  "coverage_screen": "policy_active_and_peril_listed",
  "fraud_indicators": [],
  "decision": "REQUEST_INFO",
  "route_to": "standard",
  "claimant_note": "Thanks for reporting the theft (CLM-7820). To proceed we need the police report or incident number for the theft. Once you add it, we'll continue processing your claim.",
  "escalation": { "needed": false, "to": "none", "reason": "" },
  "disclaimer": "Administrative intake & routing only — not a coverage, liability, or claim decision."
}
```

**Note:** Rather than routing an incomplete claim (which stalls later) or assuming the report exists, the agent names the exact missing item, holds, and asks the claimant for it in neutral language. Precise gap-chasing is the core intake time-saver.

## Injury + fraud indicators → escalate to adjuster & SIU, no decision

A claim involves bodily injury, was reported late, and has inconsistencies plus a prior pattern. The agent escalates and flags indicators — without deciding coverage or accusing anyone.

**Input**

```
FNOL CLM-7905: auto accident with claimed neck injury. Reported 28 days after the loss; the described damage is inconsistent with the photos; claimant has 3 similar soft-tissue claims in 18 months.
```

**Output**

```
{
  "claim_id": "CLM-7905",
  "claim_type": "auto_bodily_injury",
  "severity": "high",
  "completeness": "complete",
  "missing": [],
  "coverage_screen": "policy_active_and_peril_listed",
  "fraud_indicators": ["Reported 28 days post-loss (late)", "Described damage inconsistent with submitted photos", "3 similar soft-tissue claims in 18 months"],
  "decision": "ESCALATE",
  "route_to": "senior_adjuster",
  "claimant_note": "Thank you for reporting your claim (CLM-7905). It has been assigned to an adjuster who will review the details and contact you.",
  "escalation": { "needed": true, "to": "SIU", "reason": "Bodily injury claim with fraud indicators (late report, photo inconsistency, prior pattern) — for senior adjuster review and SIU evaluation of the indicators." },
  "disclaimer": "Administrative intake & routing only — not a coverage, liability, or claim decision."
}
```

**Note:** The defining boundary case: bodily injury alone forces escalation, and the fraud indicators are listed as indicators for SIU to evaluate — not as an accusation. The agent makes no coverage or liability decision, keeps the claimant note neutral and supportive, and routes to both a senior adjuster and SIU. Exactly the line an administrative triage agent must hold.
