Claim CLM-20260119-F5E777

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Document Extraction

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Policy Verification

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Fraud Detection

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Complexity Assessment

Claim Details

Claimant John Smith

Policy Number AUTO-2026-12345

Claim Type auto

Incident Date December 17, 2025

Claim Amount $2.00

Last Updated Jan 19, 2026 01:01 PM

Incident Description

accident

Documents

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police_report_john_smith.txt form

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repair_estimate_john_smith.txt form

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auto_claim_form_john_smith_correct.txt form

Analysis Results

Document Extraction

claimant name John Michael Smith

contact info Phone: (217) 555-0134, Email: john.smith@email.com, Address: 456 Oak Avenue, Springfield, IL 62701

policy number AUTO-2024-123456

incident date 2026-01-15

incident location Intersection of Main Street and 5th Avenue, Springfield, IL 62701

incident type collision

incident summary John Smith was rear-ended while stopped at a red light by another driver who admitted to being distracted by their phone. The impact caused moderate damage to the rear of Smith's vehicle.

damages description Rear bumper severely dented and cracked requiring replacement, trunk lid dented with paint damage, both tail light assemblies shattered, minor dents on rear quarter panels, bent exhaust tip

estimated loss amount $4,850.00

witnesses Sarah M. Johnson (217) 555-0167 - in vehicle behind the Ford F-150, Michael Chen (217) 555-0189 - pedestrian on sidewalk at intersection

police report number SPD-2026-00142

medical providers None specified - claimant declined medical transport but reported neck stiffness and plans to seek chiropractic evaluation

vehicle info 2022 Honda Accord EX-L, VIN: 1HGCV1F34NA123456, Color: Lunar Silver Metallic, License: IL ABC1234, Mileage: 28,450

property info Not applicable - auto claim

documentation quality complete

missing information []

vehicle validation {'claimed_vehicle': '2022 Honda Accord EX-L', 'vehicle_exists': True, 'validation_notes': 'The 2022 Honda Accord EX-L is a valid model that exists. Honda has manufactured the Accord continuously and the EX-L is a legitimate trim level.', 'image_vehicle_match': 'no_vehicle_images', 'discrepancies': []}

Vehicle Validation

Claimed Vehicle 2022 Honda Accord EX-L

Vehicle Make/Model/Year Exists ✓ Verified

Images Match Claimed Vehicle No vehicle images provided

Validation Notes The 2022 Honda Accord EX-L is a valid model that exists. Honda has manufactured the Accord continuously and the EX-L is a legitimate trim level.

Policy Verification

policy found ✓ Yes

policy active ✓ Yes

coverage applies ✓ Yes

coverage type match ✓ Yes

within policy period ✓ Yes

coverage limit 50000

deductible 500

estimated payout 0

exclusions triggered []

eligibility status ineligible

eligibility reason Claimed amount of $2.00 is below the policy deductible of $500.00, resulting in no payout

policy holder match ✓ Yes

verification notes All coverage requirements are met, but the extremely low claim amount ($2.00) appears to be below the deductible threshold, making this claim financially ineligible for payout. Consider verifying if the claimed amount is accurate as $2.00 seems unusually low for moderate vehicle damage.

Fraud Detection

Risk Score

85/100

Fraud Indicators

⚠ Policy ineligibility status high

The policy verification shows eligibility status as 'ineligible', meaning the policyholder may not have valid coverage at the time of the incident on 2025-12-17. This could indicate the policy was cancelled, suspended, or lapsed before the incident occurred, making this claim invalid and potentially fraudulent if the claimant is aware of the ineligibility.

⚠ Extremely low claim amount suspicious medium

The claimed amount of $2.0 for a rear-end collision described as causing 'moderate damage' is unrealistically low. Typical rear-end collision repairs cost hundreds to thousands of dollars. This discrepancy suggests either significant underreporting of damages, a testing claim to verify policy status, or potential manipulation of claim amounts.

⚠ Delayed claim submission medium

The claim was submitted 33 days after the incident (2025-12-17 to 2026-01-19). While not extremely delayed, this timing combined with the ineligible policy status suggests the claimant may have been attempting to resolve coverage issues or obtain coverage after the fact before submitting the claim.

Complexity Assessment

Complexity Score 8/10

Routing Recommendation siu review

Reasoning

This claim exhibits multiple serious red flags requiring specialized investigation. The combination of policy ineligibility, extremely suspicious claim amount ($2 for moderate collision damage), high fraud risk score (85/100), and delayed submission strongly suggests potential fraudulent activity. The fraud detection system specifically recommends SIU referral, and the claim meets clear criteria for investigation rather than standard processing or denial.

Final Decision

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Referred to Special Investigations

This claim requires investigation by the Special Investigations Unit.

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