Insurance Ontology

Comprehensive domain knowledge for insurance operations including property & casualty, life, health, and specialty lines.

Overview

The Insurance ontology equips AI agents with deep understanding of insurance operations:

• Policy Management: Quoting, issuance, endorsements, renewals
• Claims Processing: FNOL, investigation, adjustment, settlement
• Underwriting: Risk assessment, pricing, guidelines
• Customer Service: Inquiries, changes, complaints
• Regulatory: State filings, compliance, reporting

Ontology Layers

Role Layer

roles:
  - name: Claims Agent
    responsibilities:
      - Process First Notice of Loss (FNOL)
      - Gather claim documentation
      - Coordinate with adjusters
      - Handle claim inquiries
    permissions:
      - read: claims, policies, claimants
      - execute: create_claim, request_docs, update_status
    authority_limit: $5,000  # Auto-approve below this

  - name: Policy Service Agent
    responsibilities:
      - Handle policy changes
      - Process endorsements
      - Manage renewals
      - Answer coverage questions
    permissions:
      - read: policies, coverages, billing
      - execute: quote_change, bind_endorsement, process_payment

  - name: Underwriting Support Agent
    responsibilities:
      - Gather underwriting information
      - Order inspections and reports
      - Apply rating rules
      - Prepare submissions
    permissions:
      - read: applications, risk_data, guidelines
      - execute: order_report, calculate_premium, refer_to_uw

Domain Layer

Key Entities

Entity	Description	Key Attributes
Policy	Insurance contract	Number, Type, Effective Date, Premium, Status
Claim	Loss report	Number, Type, Date of Loss, Status, Amount
Insured	Policyholder	ID, Name, Address, Risk Profile
Coverage	Protection scope	Type, Limit, Deductible, Conditions
Agent/Broker	Distribution	Code, Name, Commission, Appointments

Entity Relationships

erDiagram
    INSURED ||--o{ POLICY : holds
    POLICY ||--o{ COVERAGE : contains
    POLICY ||--o{ CLAIM : has
    POLICY }|--|| AGENT : sold_by
    CLAIM ||--o{ PAYMENT : settles_with
    CLAIM ||--o{ DOCUMENT : supported_by

Interaction Layer

Common Workflows

Claims Processing (FNOL)

sequenceDiagram
    participant C as Claimant
    participant A as Agent
    participant S as System
    participant J as Adjuster

    C->>A: Report Loss
    A->>S: Verify Policy
    S-->>A: Policy Active
    A->>A: Gather Details
    A->>S: Create Claim
    S-->>A: Claim Number
    A->>C: Confirm & Next Steps
    A->>J: Assign for Review

Policy Endorsement

graph LR
    A[Change Request] --> B{Valid Request?}
    B -->|Yes| C[Quote Change]
    B -->|No| D[Clarify with Customer]
    C --> E{Premium Impact}
    E -->|Increase| F[Collect Payment]
    E -->|Decrease| G[Issue Refund]
    F --> H[Update Policy]
    G --> H
    H --> I[Send Confirmation]

Lines of Business

Property & Casualty

Line	Key Coverages	Agent Focus
Homeowners	Dwelling, Contents, Liability	Claims, endorsements, renewals
Auto	Liability, Collision, Comprehensive	FNOL, policy changes, billing
Commercial	Property, GL, WC	COIs, audits, claims

Life & Health

Line	Key Products	Agent Focus
Term Life	Death benefit	Beneficiary changes, claims
Whole Life	Cash value, loans	Policy loans, surrenders
Health	Medical coverage	Eligibility, claims status

Regulatory Compliance

Regulation	Scope	Agent Actions
State DOI	Licensing, rates	Rate filing compliance
NAIC	Standards	Model law compliance
Fair Claims	Settlement practices	Timely processing
FCRA	Credit info	Permissible purpose

Prompt Templates

FNOL Intake

You are a claims intake agent processing a First Notice of Loss.

Policy Information:
- Policy Number: {policy_number}
- Named Insured: {insured_name}
- Coverage Type: {coverage_type}
- Policy Status: {status}

Gather the following information:
1. Date and time of loss
2. Location of loss
3. Description of what happened
4. Parties involved
5. Police/fire report filed?
6. Preliminary damage estimate

After gathering details:
- Verify coverage applies
- Create claim in system
- Provide claim number and next steps

Be empathetic - the claimant may be stressed.

Policy Change Quote

You are a policy service agent processing a change request.

Current Policy:
- Policy Number: {policy_number}
- Current Premium: {current_premium}
- Current Coverages: {coverages}

Requested Change: {change_description}

Calculate:
1. Premium impact (increase/decrease/none)
2. Effective date options
3. Any underwriting concerns

Provide clear explanation of the change and premium difference.

Integration Points

Policy Admin Systems

System	Type	Capabilities
Guidewire	P&C Suite	Policy, billing, claims
Duck Creek	Core systems	Multi-line administration
Majesco	Cloud platform	Digital distribution

Data Services

Service	Data Provided	Use Case
LexisNexis CLUE	Claims history	Underwriting
ISO	Loss costs, forms	Rating
Verisk	Analytics	Risk assessment

Metrics & KPIs

Metric	Description	Agent Monitoring
Loss Ratio	Losses / Earned Premium	Alert if > 65%
Claims Cycle Time	Days to settlement	Alert if > 30 days
FNOL Completion	% complete at intake	Target > 90%
Customer Retention	Renewal rate	Alert if < 85%

Sample Agent Configuration

const insuranceAgent = {
  name: "Claims Service",
  ontology: "insurance-v1",
  autonomyLevel: "L2", // Supervised

  capabilities: {
    fnolIntake: true,
    claimStatus: true,
    documentCollection: true,
    paymentProcessing: true
  },

  guardrails: {
    authorityLimit: 5000,
    requireApprovalFor: [
      "claim_denial",
      "coverage_dispute",
      "payment_above_limit"
    ],
    blockedActions: [
      "policy_cancellation",
      "legal_advice"
    ]
  },

  integrations: [
    "guidewire_claims",
    "document_management",
    "payment_system"
  ]
};

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Getting Started

To deploy an Insurance agent:

1. Select the Insurance ontology during workspace setup
2. Configure your policy admin system integration
3. Set authority limits appropriate for your organization
4. Start with L2 (Supervised) for claims handling