אוטומציית קליטת FNOL וטריאז' תביעות עם n8n ו-Claude — מדריך שלב אחר שלב

קליטת FNOL מרובת ערוצים

{
  "intake_id": "fnol_01HXYZ...",
  "channel": "email" | "portal" | "phone" | "edi",
  "received_at": "2026-05-03T14:22:09Z",
  "raw_source_id": "imap:msgid-...",
  "claimant": {
    "name_provided": "Maria Lopez",
    "phone": "+1-512-555-0188",
    "email": "[email protected]",
    "policy_number_provided": "AUT-3399201",
    "relationship": "insured" | "third_party" | "agent" | "attorney"
  },
  "loss": {
    "date_of_loss_provided": "2026-05-02",
    "type_provided": "auto_collision",
    "narrative": "rear-ended at stoplight on I-35...",
    "location_text": "I-35 N near exit 230, Austin TX"
  },
  "attachments": [
    { "kind": "police_report", "s3": "s3://...", "mime": "application/pdf" },
    { "kind": "photo",         "s3": "s3://...", "mime": "image/jpeg" }
  ],
  "language": "en",
  "signature": "sha256=..."
}

OCR וחילוץ ב-Claude

You are a Property & Casualty FNOL extraction engine. You read the
OCR text of one or more documents plus a free-text claimant narrative
and emit a single JSON object describing the claim.

Rules:
- Never invent fields. If a value is not present in the source, return null.
- Quote the source span verbatim in `evidence` for every populated field.
- Confidence is your honest estimate, 0.0 to 1.0. Below 0.85 means a
  human adjuster MUST verify before the claim is opened.
- Dates as ISO-8601. Money as integer cents.
- Coverage type uses the carrier ontology in `<coverage_taxonomy>`.

Output schema (strict):
{
  "claimant_name": str|null,
  "policy_number": str|null,
  "date_of_loss": str|null,
  "time_of_loss": str|null,
  "loss_location": { "address": str|null, "lat": num|null, "lng": num|null },
  "loss_type": "auto_collision" | "auto_comprehensive" | "property_water" |
               "property_fire" | "property_theft" | "liability_bi" |
               "liability_pd" | "workers_comp" | "other",
  "vehicles": [...],
  "injuries_reported": bool,
  "injury_descriptions": [...],
  "third_parties": [...],
  "police_report_number": str|null,
  "estimated_damage_cents": int|null,
  "narrative_summary": str,    // 2-3 sentences, neutral, no speculation
  "fields": { "<name>": { "value": ..., "confidence": num,
                          "evidence": "verbatim quote" } }
}

שליפת פוליסה

{
  "method": "POST",
  "url": "https://pc.internal.carrier.com/rest/policy/coverage-at-date",
  "headers": {
    "authorization": "Bearer {{ $credentials.policycenter.token }}",
    "x-correlation-id": "{{ $json.intake_id }}"
  },
  "body": {
    "policy_number": "{{ $json.extraction.policy_number }}",
    "as_of_date":    "{{ $json.extraction.date_of_loss }}",
    "include": ["coverages","deductibles","sublimits","named_insureds","drivers","vehicles"]
  }
}

// Response shape (truncated)
{
  "policy_number": "AUT-3399201",
  "in_force": true,
  "effective": "2025-09-12",
  "expires":   "2026-09-12",
  "named_insureds": [{ "name": "Maria Lopez", "dob_last4": "1988" }],
  "coverages": [
    { "code": "BI",  "limit_each_person_cents": 10000000, "limit_occurrence_cents": 30000000 },
    { "code": "PD",  "limit_cents": 5000000 },
    { "code": "COLL","deductible_cents": 50000 },
    { "code": "COMP","deductible_cents": 25000 },
    { "code": "UM",  "limit_each_person_cents": 5000000 }
  ],
  "vehicles": [{ "vin": "1HGCM82633A...", "year": 2019, "make": "Honda", "model": "Civic" }]
}

מסווג חומרה

You are a P&C claims severity classifier. You read a structured FNOL
extraction and the in-force policy schedule, and you assign a severity
tier and a recommended initial reserve range.

You DO NOT make coverage decisions. You DO NOT make payment decisions.
You DO NOT deny anything. A licensed adjuster owns those decisions.

Severity tiers (carrier-tuned):
- tier_1_minor_pd:        PD-only, est < $5k, no injuries
- tier_2_moderate_pd:     PD $5k-$25k, multi-party PD allowed, no injuries
- tier_3_bi_low:          BI reported, ER-only, no hospitalization
- tier_4_bi_high_or_total: hospitalization, surgery, total-loss vehicle
- tier_5_catastrophic:    fatality, brain/spinal injury, mass casualty

Output (strict JSON):
{
  "tier": "tier_1_minor_pd" | ... | "tier_5_catastrophic",
  "tier_confidence": 0.0-1.0,
  "reserve_recommendation": {
    "currency": "USD",
    "low_cents": int, "high_cents": int
  },
  "supervisor_alert_required": bool,
  "reasoning": "2-4 sentences citing the specific FNOL evidence",
  "evidence_spans": ["verbatim quote 1", "verbatim quote 2"]
}

Rules:
- If injuries_reported is true and you cannot verify ER-only, default UP
  one tier (precautionary).
- If a fatality is mentioned anywhere in the source, tier=5, confidence
  may be lower but supervisor_alert_required = true regardless.
- tier_confidence below 0.7 forces human review before reserve is set.

{
  "tier": "tier_4_bi_high_or_total",
  "tier_confidence": 0.91,
  "reserve_recommendation": {
    "currency": "USD",
    "low_cents":  1500000,
    "high_cents": 4500000
  },
  "supervisor_alert_required": true,
  "reasoning": "Claimant reports two-vehicle collision with airbag deployment and transport by ambulance to St. David's. Police report cites suspected fracture. Vehicle photos show A-pillar deformation consistent with possible total-loss assessment.",
  "evidence_spans": [
    "transported by ambulance to St. David's",
    "vehicle towed from scene, frame appears bent",
    "officer notes possible left tibia fracture"
  ]
}

ציון סיגנלי הונאה

{
  "fraud_signal_score": 0-100,
  "band": "low" | "elevated" | "high",
  "siu_referral_recommended": bool,
  "rules_hits": [
    { "rule_id": "ISO_HIT_24M", "weight": 0.25,
      "evidence": "matching VIN in ISO ClaimSearch, prior claim 2024-11" },
    { "rule_id": "LATE_REPORT_GT_14D", "weight": 0.10,
      "evidence": "date_of_loss 2026-04-15, FNOL received 2026-05-02" }
  ],
  "narrative_signals": [
    {
      "signal": "passive voice on key facts",
      "evidence": ""the vehicle was caused to leave the roadway""
    }
  ],
  "reasoning": "Late-report combined with prior ISO hit on same VIN and a single-vehicle nighttime loss in claimant's home zip. Recommend SIU referral; do not delay adjuster assignment.",
  "do_not_communicate_to_claimant": true,
  "model_version": "fnol-fraud-v3.2"
}

ניתוב לחוקר תביעות

-- Pick the lowest-loaded eligible adjuster for this LOB + severity + state.
-- Open-file count is refreshed every 5 minutes from ClaimCenter.

SELECT a.adjuster_id,
       a.full_name,
       a.open_files,
       a.languages
FROM   adjusters a
JOIN   adjuster_licenses al  ON al.adjuster_id = a.adjuster_id
WHERE  a.line_of_business = $1     -- 'auto' | 'property' | 'gl'
  AND  a.tier_max         >= $2   -- numeric tier value 1-5
  AND  a.status           = 'active'
  AND  al.state_code      = $3     -- claimant state, e.g. 'TX'
  AND  al.expires_on      > now()
  AND  ($4 = ANY(a.languages))     -- claimant preferred language
ORDER  BY a.open_files ASC,
          a.last_assigned_at ASC
LIMIT  3;

פתיחת תיק תביעה ואישור

{
  "policy_number":   "AUT-3399201",
  "loss_date":       "2026-05-02",
  "reported_date":   "2026-05-03T14:22:09Z",
  "loss_type":       "auto_collision",
  "loss_location":   { "address": "I-35 N exit 230, Austin TX" },
  "claimant": {
    "name":  "Maria Lopez",
    "phone": "+1-512-555-0188",
    "email": "[email protected]",
    "preferred_language": "en"
  },
  "ai_metadata": {
    "intake_id":          "fnol_01HXYZ...",
    "severity_tier":      "tier_4_bi_high_or_total",
    "severity_confidence":0.91,
    "reserve_low_cents":  1500000,
    "reserve_high_cents": 4500000,
    "fraud_band":         "elevated",
    "siu_referral":       false,
    "human_review_required": false,
    "model_versions": {
      "extractor":  "fnol-extract-v4.1",
      "severity":   "fnol-severity-v3.0",
      "fraud":      "fnol-fraud-v3.2"
    }
  },
  "assigned_adjuster_id": "ADJ-1188",
  "documents":  [...],
  "ai_notes":   "Auto-generated by intake workflow — see ai_metadata. Adjuster review required before any coverage decision or payment."
}

{
  "to":   "+15125550188",
  "from": "+18335550100",
  "body": "Hi Maria — your claim CLM-2026-118334 has been opened. Sara Patel ([email protected]) is your adjuster and will call you within 1 hour. Reply STOP to opt out of claim updates."
}

{
  "audit_id":      "aud_01HXYZ...",
  "claim_number":  "CLM-2026-118334",
  "intake_id":     "fnol_01HXYZ...",
  "step":          "severity_classification",
  "actor":         "system:claude-sonnet-4-5",
  "actor_version": "fnol-severity-v3.0",
  "input_hash":    "sha256:b41d...",
  "output_hash":   "sha256:c0a9...",
  "input_summary": "extraction object + policy schedule (PII redacted)",
  "output":        "tier_4_bi_high_or_total, conf 0.91",
  "human_override": null,
  "occurred_at":   "2026-05-03T14:22:31Z",
  "correlation_id":"req_01HXYZ...",
  "prev_audit_id": "aud_01HXYW...",
  "ledger_hash":   "sha256:..."
}