◑ Claims & adjudication
One platform for bind and claims. Same audit trail. Same agent fabric.
Top-level workbench for adjusters and supervisors. FNOL parser, Coverage Analyst, Claim Memo writer — three agents that move a claim from broker email to adjudication memo in minutes. Reserve revision history, payment authority gating, statutory letters with state-specific UCSPA language, supervisor queue, and book insights.
Intake from email, voice, portal — auto-acknowledged in minutes.
Broker email, claimant voice transcript, portal form, or mobile photo upload — all into one structured FNOL. The acknowledgment letter dispatches 5 minutes after intake with state-specific UCSPA language; cancellable from the claim detail page during the undo window.
- ✓Multi-channel FNOL parser
- ✓State-specific acknowledgment (CA / FL / NY / TX + generic)
- ✓5-minute undo window before letter sends
Joined against the policy — covered, partial, not covered. Every clause cited.
Coverage Analyst agent joins the FNOL against the linked bound risk and returns a decision with cited exclusions, deductible, limit remaining, and fraud flags. Refers rather than denies under uncertainty — denial without basis is bad-faith exposure under most state UCSPAs.
- ✓Linked to bound_risks policy summary
- ✓Fraud flag detection (rapid-post-bind, round losses)
- ✓Conservative: refers under uncertainty
Pay / deny / partial / refer. Per-adjuster authority gating, full audit trail.
Live authority preview as the adjuster types the pay amount: $50k for adjuster / $250k for senior / $1M for supervisor. Over-authority disables the pay button and routes through refer-to-senior. Every decision lands on a claim_decisions row with snapshot of the agent outputs at decision time.
- ✓Per-adjuster bind-equivalent limits
- ✓Refer-to-senior with proposed pay attached
- ✓Audit trail with agent_outputs snapshot per decision
Rule engine + LLM + ISO ClaimSearch + NICB Forewarn. One fraud score.
Six deterministic rules (rapid-post-bind tiers, round-loss, prior-similar by frequency, no-police-report by cause, high-value-low-doc, inception-to-loss-mismatch) plus an LLM narrative agent for witness contradictions and suspicious phrasing. Wired to real ISO ClaimSearch + NICB Forewarn API clients with mock fallback for preview. Cross-claim pattern matcher catches repeated claimants, attorneys, and repair-shop clusters across your own book.
- ✓Aggregate fraud score 0–100 with severity-weighted math
- ✓Refer-to-SIU workflow with status + audit row
- ✓Subrogation lead detector + demand letter draft generator
Acknowledgment, RoR, denial, payment. UCSPA-compliant. State-aware.
Four high-volume states have cited statutory language baked in: Cal. Code Reg. § 2695.5(b) + § 2695.7(j), Fla. Stat. § 626.9541, 11 NYCRR 216.4(a), Tex. Ins. Code § 542.055 — each with the right DOI complaint phone number. RoR letters include the non-waiver language. Denials include appeal rights. Every letter is reviewable before send.
- ✓CA / FL / NY / TX statute-aware language
- ✓Acknowledgment auto-schedules, others land as draft
- ✓Reviewable + cancellable before dispatch