Personal Service Insurance Company NJ Quotes : www.personalserviceinsuranceagents.com
1000 River Road
Suite 300
Conshohocken, PA 19428
Personal Service Insurance Company NJ Quotes : www.personalserviceinsuranceagents.com
POLICY GUIDELINE
Section I. Definitions .......1
Section II. Insuring Agreement ...........................2
Section III. When and Where Coverage Applies 2
A. When Coverage Applies..............................2
B. Where Coverage Applies.............................2
Section IV. Coverages .....3
A. Liability Coverage ...3
B. Personal Injury Protection Coverage..............6
C. Uninsured and Underinsured Motorist Coverage...........................19
D. Comprehensive and Collision Coverages – Damage to Your Auto ......25
Section V. Duties After An Accident or Loss ...31
Section VI. Conditions...33
A. Policy Changes ....33
B. Cancellation..........33
C. Renewal/Nonrenewal ................................34
D. Our Right to Recover Payments ...............34
E. Suit Against Us .....35
F. Change of Interest 35
G. Bankruptcy or Insolvency..........................36
H. Past Premium Payment Obligations .........36
I. Limitation on Lawsuit Option ......................36
J. Concealment or Fraud ...............................36
K. Joint Ownership....36
L. Additional Insured-Lessor ..........................37
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NEW JERSEY STANDARD PERSONAL AUTO INSURANCE POLICY SECTION I.
Definitions Applicable to All Sections.
We define some words and phrases to shorten the policy. This makes it easier to read and understand. Defined words and phrases are printed in boldface italics. YOU can pick them out easily.
A. Additional Private Passenger Auto means a private passenger
auto newly owned by or leased to you in addition to any shown
on the policy declarations. This policy will automatically provide coverage for
an additional private passenger auto for up to 30 days after
you become the owner or lessee. To extend coverage beyond 30 days,
you must ask us to insure it on or before the 30th day
after you become the owner or lessee.
B. Auto means a land motor vehicle with four or more wheels. It does
not include:
1. Any vehicle while located for use as a dwelling or other premises; or
2. A truck-tractor designed to pull a semi-trailer.
C. Named Insured means the person named as the insured on the policy
declarations, and if an individual, named insured includes his or
her spouse by marriage or domestic partner by civil union, if the spouse by marriage
or domestic partner by civil union, is a resident of the household of the
named insured. If the spouse by marriage or domestic partner by civil union
ceases to be a resident of the named insured’s household, liability
coverage will continue for the spouse until the end of the policy period in effect
at the time he or she ceased to be a resident of such household.
D. Newly acquired private passenger auto means a replacement
private passenger auto or an additional private passenger auto
for which Comprehensive and Collision Coverage is subject to the New Jersey
Mandatory Inspection Provision at Section IV, Coverage D(2) of this policy.
E. Non-owned Auto means an auto not owned by, registered
to, leased to, or available or furnished for the regular use of:
1. you;
2. any other person residing in the same household as you;
3. any relative.
However, an auto owned by, registered to, leased to, or available
or furnished for the regular use of a relative will be considered
a non-owned auto for liability arising from your maintenance
or use of such auto. A non-owned auto must be an
auto in the lawful possession of the person operating it.
F. Occupying means in, on, entering into, or alighting from.
G. Private Passenger Auto means a self-propelled auto
designed for use principally on public roads and that is one of the following
types:
1. A private passenger or station wagon type automobile;
2. A pick up, panel truck, van, or delivery sedan;
3. A utility automobile designed for personal use as a camper or motor home or for
family recreational purposes; but a private passenger auto does not
include:
1. a motorcycle;
2. an automobile used as a public or livery conveyance for passengers;
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3. a pick up or panel truck, delivery sedan, van, or utility automobile customarily
used in the business, occupation or profession of an insured other than farming
or ranching; or
4. a utility automobile customarily used for the transportation of passengers other
than members of the user’s family or their guests.
H. Relative means a person who resides with you in
your household, and is related to you by blood, marriage,
civil union, adoption, or is a ward or foster child.
I. Replacement Private Passenger Auto means a private passenger
auto newly owned by or leased to you to replace your
private passenger auto listed on the declarations page.
J. Temporary Substitute Private Passenger Auto means a private
passenger auto not owned by you if it replaces your
private passenger auto. Its use has to be with the consent of the owner.
Your private passenger auto has to be out of use due to its breakdown,
repair, servicing, damage, or loss. A temporary substitute private passenger
auto is not considered a non-owned auto.
K. Trailer means a trailer of the utility type or a
trailer of the house, or camping type equipped or used as living quarters.
Trailer is limited to a trailer designed for use with a private
passenger auto. Farm implements and farm wagons are considered trailers
while pulled by an auto we insure for liability.
L. We, Us, or Our means the company providing
this insurance as shown on the policy declarations.
M. You or Your means the person or persons named as
the insured on the policy declaration and if an individual, includes his or her
spouse by marriage or domestic partner by civil union if the spouse or domestic
partner resides primarily in the same household.
N. The term Your Private Passenger Auto, when it appears in this policy,
means a private passenger auto that:
1. is owned by you or is leased for six months or longer to
you;
2. is described on the policy declarations.
SECTION II.
Insuring Agreement
This policy is a legal contract between you and us.
We agree to insure you according to the terms of this
policy based on your payment of premium for the coverages you
chose. You agree, by the acceptance of this policy that:
A. any statements made in conjunction with an application, renewal, or endorsement
are your representations and are true;
B. this policy is issued in reliance upon the truth of those representations;
C. this policy contains all of the agreements between you and
us relating to these coverages; D. you will register and
principally garage in New Jersey any auto covered by this policy.
SECTION III.
When and Where Coverage Applies
A. When Coverage Applies. The coverage you chose applies
to accidents and losses that take place during the policy period. The policy period
is shown on the policy declarations. The policy period begins and ends at 12:01
A.M. standard time, or the time at which the policy is issued, whichever is later,
at the address shown on the policy declarations.
B. Where Coverage Applies. The coverage you chose applies:
1. in the United States of America, its territories or possessions, Puerto Rico,
or Canada; or
2. while the insured auto is being shipped between their ports.
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SECTION IV.
Coverages
A. Liability Coverage
1. Additional Definitions Applicable to Liability Coverage
a. Bodily Injury means bodily injury, sickness or disease, including
death resulting therefrom.
b. Property Damage means damage to, or destruction of, tangible property
including its loss of use.
2. Coverage
a. You have this coverage only if a premium for it appears on the
policy declarations. b. We will:
(1) pay damages that an insured becomes legally liable to pay because of bodily
injury to others and property damage caused by an accident
resulting from the ownership, maintenance, or use of your private passenger
auto;
(2) defend any suit against an insured for such damages with attorneys hired and
paid by us. We will not defend any suit after
we have paid the applicable limit of liability for the accident that is
the basis of the lawsuit;
(3) have the right to investigate, negotiate, and settle any claim or suit.
c. In addition to the limits of liability, we will pay for an insured
the costs listed below resulting from such accident: (1) all defense costs
we incur;
(2) interest accruing after a judgment is entered in any suit we defend
on behalf of an insured. Our duty to pay interest ends when
we pay, offer, or deposit in court the amount due under this coverage;
(3) the premiums or costs of bonds:
(a) necessary to secure the release of an insured’s property attached under a court
order in any other suit that we defend on behalf of an insured. The
amount of the bond we pay for shall not be more than our
limit of liability;
(b) required to appeal a decision in a suit for damages that we defend
on behalf of an insured if we have not paid our limit
of liability that applies to the suit;
(c) up to $250 for each bail bond needed because of an accident resulting in liability
covered under this policy or a traffic violation related to such accident.
We have no duty to furnish or apply for any bonds.
(4) expenses incurred by an insured, at our request, for loss of wages
or salary up to $50 per day if we ask the insured to attend the trial
of a civil suit. We will not pay for loss of other income.
d. Other Autos. The Liability Coverage extends to the use, by an insured, of a
newly acquired private passenger auto, a temporary substitute
private passenger auto, or a non-owned auto.
e. Trailer Coverage. The Liability Coverage extends to a trailer while
owned by, leased to, or used by you or
your relative.
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3. Who Is an Insured
a. For your private passenger auto, a newly acquired private
passenger auto, or a temporary substitute private passenger auto,
including any trailers attached to such auto, insured
means:
(1) you;
(2) your relatives;
(3) any other person while using such an auto if its use is with
your consent. b. For a non-owned auto, insured means:
(1) you;
(2) your relatives.
4. Limits of Liability
a. The amount of Bodily Injury Liability Coverage is shown on the policy declarations
under Limits of Liability- Bodily Injury, Each Person, Each Accident. The limit
stated for Each Person is the maximum amount of coverage for all damages due to
bodily injury to one person in any one auto accident.
“Bodily injury to one person” includes all injury and damages to others,
including but not limited to damages for care, loss of services, or death resulting
from this bodily injury. The limit stated for Each Accident is the
total amount of coverage, subject to the amount shown under Each Person, for all
damages due to bodily injury to two or more persons in the same accident.
The amount of Property Damage Liability Coverage is shown on the policy declarations
under Limits of Liability- Property Damage, Each Accident. The limit stated for
Property Damage, Each Accident is the maximum
amount of coverage for all property damage resulting from any one
auto accident, regardless of the number of property damage claims
presented. We will pay damages for which an insured is legally liable
up to these bodily injury and property damage limits.
b. The limit of liability is not increased because more than one person or organization
may be insured. c. An auto and attached trailer are
considered one vehicle. Therefore, the limit is not increased.
5. Exclusions-What Is Not Covered
There is no Liability Coverage for:
a. any person for liability arising out of the ownership or operation of any
auto while being used as a public or livery conveyance. This exclusion
(5.a.) does not apply to shared-expense carpools;
b. any person who intentionally causes property damage or bodily
injury;
c. any person while using a vehicle without reasonable belief that he or she has
the right to do so;
d. any person for property damage to property owned by or being transported
by that person;
e. any person for property damage to property rented to, used by,
or in the care or custody of that person.
However, coverage applies to a residence or private garage damaged by an auto
we insure;
f. any person while employed or engaged in any way in the selling, leasing, repairing,
servicing, transporting, storing, or parking of land motor vehicles or trailers.
This includes road testing and delivery. For your private passenger auto,
a newly acquired private passenger auto, or a temporary private
passenger substitute auto, this exclusion (5.f.) does not apply to:
(1) you or your relatives;
(2) any partner, agent, or employee of you or any relative.
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g. any person maintaining or using a non-owned auto in any business,
occupation, or profession other than farming or ranching and not described in exclusion
5.f. This exclusion (5.g.) does not apply to a private passenger auto
or a trailer used with a private passenger auto
driven or occupied by you or your relatives;
h. any person for bodily injury to any employee of that person arising
out of his or her employment. This exclusion (5.h.) does not apply to a household
employee who is not covered or required to be covered under any workers’ compensation
insurance;
i. any person for bodily injury or property damage for
which that person would also be covered under nuclear energy liability insurance
issued by American Nuclear Insurers, Mutual Atomic Energy Liability Underwriters,
Nuclear Insurance Association of Canada, or their successors. This exclusion (5.i.)
applies even if the limits of that insurance are exhausted;
j. any person who is a named insured under the terms of a Basic Automobile
Insurance Policy issued pursuant to N.J.S.A.. 39:6A-3.1. This exclusion (5.j.) does
not apply to you if you are occupying your private
passenger auto, a newly acquired private passenger auto,
a temporary substitute private passenger auto, or a non-owned
auto.
k. any person for any trailer used for business, occupational, or
professional purposes with other than a private passenger auto;
l. any person for any trailer used with an auto that:
(1) is owned by or hired by you; and
(2) we do not insure for Liability Coverage.
m. any person or company which assumes liability under a bailment or other agreement;
n. any person or company with respect to demands for punitive or exemplary damages.
6. If There Is Other Liability Coverage
a. Basic Automobile Insurance Policies
This policy provides no Liability Coverage for any person other than you
who is a named insured under a
Basic Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C.
11:3-3. b. Other Liability Coverage Available from Other Sources
If other motor vehicle Liability Coverage applies, we are liable only
for our share of the damages. Our share is the percent
that the limit of liability of this policy bears to the total of all motor vehicle
Liability Coverage applicable to the accident.
c. Other Liability Coverage Including Temporary Substitute Private Passenger
Auto, Non-owned Auto, or
Trailer
If a temporary substitute private passenger auto, a non-owned auto, or a trailer designed for use with a
private passenger auto:
(1) has other vehicle Liability Coverage on it; or
(2) is self-insured under any motor vehicle financial responsibility law, motor
carrier law, or any similar law;
then Liability Coverage under this policy is excess over such insurance or self-insurance.
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d. Newly Acquired Private Passenger Auto
This coverage does not apply if there is other auto Liability Coverage
on a newly acquired private passenger auto that is a pickup, panel
truck, van, delivery sedan, or utility automobile.
7. Motor Vehicle Compulsory Insurance Law or Financial Responsibility Law
a. Out-of-State-Coverage
If an insured under the Liability Coverage is in another state or Canada and, as
a nonresident, becomes subject to higher limits of liability coverage than are shown
on the policy declarations as a result of motor vehicle compulsory insurance, financial
responsibility, or similar law:
(1) this policy will be interpreted to give the liability coverage required by the
law; and
(2) the liability coverage so given replaces any liability coverage in this policy
to the extent required by the law for the insured’s operation, maintenance, or use
of an auto insured under this policy.
Any coverage so extended shall be reduced to the extent other coverage applies to
the accident. In no event shall a person collect for the same elements of loss more
than once.
b. Financial Responsibility Law
When certified under any law as proof of future financial responsibility and while
required during the policy period, this policy shall comply with such law to the
extent required.
B. Personal Injury Protection Coverage
1. Personal Injury Protection Coverage
a. Additional Definitions Applicable to Personal Injury Protection Coverage
(1) Actual Benefits means those benefits determined to be payable
for allowable expenses.
(2) Allowable Expenses means medically necessary, reasonable,
and customary items of expense covered by the named insured’s or
relative’s health insurance benefit plan(s) or by Personal Injury
Protection Coverage as an eligible charge. The reasonable monetary
value of benefits provided in the form of services shall be considered as both an
allowable expense and a paid benefit.
(3) Bodily Injury means bodily injury, sickness or disease, including
an identified injury or death resulting therefrom.
(4) Catastrophic Injury Treatment means medically necessary
treatment of permanent or significant brain injury, spinal cord injury or
disfigurement, or other permanent or significant injuries rendered at a trauma center
or acute care hospital immediately following the accident and until the eligible
injured person is stable, no longer requires critical care, and can be safely
discharged or transferred to another facility in the judgment of the attending physician.
(5) Clinically Supported means that a health care provider,
prior to selecting, performing or ordering the administration of a treatment or
diagnostic test, has satisfied all of the following requirements:
(a) personally examined the eligible injured person to ensure that
the proper medical indications exist to justify ordering the treatment or test;
(b) physically examined the eligible injured person including making
an assessment of any current and/or historical subjective complaints, observations,
objective findings, neurologic indications, and physical tests;
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(c) considered any and all previously performed tests that relate to the injury
and the results, and which are relevant to the proposed treatment or test;
(d) recorded and documented these observations, positive and negative findings,
and conclusions on the patient’s medical records.
(6) Death benefits means the amount or amounts payable in the event
of the death of an eligible injured person as determined in subdivision
(a) or (b) hereof, as appropriate:
(a) if the eligible injured person was an income producer
at the time of the accident, an amount equal to the difference between $5,200
and all income continuation benefits paid for any loss of income
resulting from his or her injury prior to his or her death;
(b) if the eligible injured person ordinarily performed essential
services for the care and maintenance of himself or herself, his or her family,
or family household, an amount not to exceed the difference between $4,380 and all
essential services benefits paid with respect to his or her injury
prior to death.
(7) Diagnostic Test means a medical service or procedure utilizing
biomechanical, neurological, neurodiag- nostic, radiological, vascular or any means,
other than bioanalysis, intended to assist in establishing a medical, dental, physical
therapy, chiropractic or psychological diagnosis, for the purpose of recommending
or developing a course of treatment for the tested patient to be implemented by
the treating practitioner or by the consultant.
(8) Eligible Charges means that portion of the medical expenses incurred
for treatment of bodily injury that, without considering any deductible
or co-payment, does not exceed:
(a) the percent or dollar amounts specified on the medical fee schedules promulgated
by the New Jersey Department of Banking and Insurance, or the treating health
care provider’s usual, customary and reasonable charge, whichever is less;
or
(b) the reasonable amount, as determined by us, considering the medical
fee schedules promulgated by the New Jersey Department of Banking and Insurance
for similar services or equipment in the region where the service or equipment was
provided, when an incurred medical expense is not included on the medical fee schedules
promulgated by the New Jersey Department of Banking and Insurance.
(9) Eligible Injured Person means:
(a) the named insured or any relative of the named
insured, if the named insured or relative sustains
bodily injury:
(i) as a result of any accident while occupying, using, entering into,
or alighting from a private passenger auto; or
(ii) while a pedestrian, caused by a private passenger auto
or by an object propelled by or from a
private passenger auto; or
(b) any other person who sustains bodily injury while, with the permission of the named insured,
occupying, using, entering into, or alighting from the insured automobile.
(10)Emergency Care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in death, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part. Emergency Care shall include all medically necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency Care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Emergency Care shall be presumed when medical care is initiated at a hospital within 120 hours of the accident.
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(11)Essential Services Benefits means an amount not exceeding a limit
of $12 per day and a total limit of
$4,380 payable to an eligible injured person as reimbursement for
payments made to others for substitute essential services of the type actually rendered
during his or her lifetime and that he or she would ordinarily have performed not
for income but for the care and maintenance of himself or herself
and his or her relatives.
(12)Funeral Expense Benefits means an amount not exceeding $1,000
for reasonable funeral, burial, and cremation expenses incurred.
(13)Health Care Provider means those persons licensed or certified
to perform health care treatment or services compensable as medical expenses and
shall include, but not be limited to:
(a) a hospital or health care facility that is maintained by a state or any political
subdivision;
(b) a hospital or health care facility licensed by the Department of Health and
Senior Services;
(c) other hospitals or health care facilities designated by the Department of Health
and Senior Services to provide health care services, or other facilities, including
facilities for radiological and diagnostic testing, freestanding emergency
clinics or offices, and private treatment centers;
(d) a nonprofit voluntary visiting nurse organization providing health care services
other than in a hospital; (e) hospitals or other health care facilities or treatment
centers located in other states or nations;
(f) physicians licensed to practice medicine and surgery; (g) licensed chiropractors;
(h) licensed dentists;
(i) licensed optometrists; (j) licensed pharmacists;
(k) licensed chiropodists (podiatrists);
(l) registered bio-analytical laboratories; (m) licensed psychologists;
(n) licensed physical therapists; (o) certified nurse midwives;
(p) certified nurse practitioners/clinical nurse-specialists; (q) licensed health
maintenance organizations;
(r) licensed orthotists and prosthetists; (s) licensed professional nurses;
(t) providers of other health care services or supplies including durable medical
goods.
(14)Identified Injury means those injuries identified by the New Jersey
Department of Banking and Insurance as being subject to medical treatment protocols
in accordance with N.J.S.A. 39:6A-3.1a and 39:6A-4a.
(15)Income means salary, wages, tips, commissions, fees, and other
earnings derived from work or employment.
(16)Income Continuation Benefits means an amount not exceeding a limit
of $100 per week and a total limit of $5,200 payable for the loss of income
of an eligible injured person who is an income producer
during his or her lifetime, as a result of bodily injury disability.
In no case shall income continuation benefits exceed the net
income normally earned during the period in which the benefits are payable.
(17)Income Producer means a person who, at the time of the accident,
was in an occupational status, earning or producing income. The status
of an income producer will cease when the recipient is no longer an
income producer for reasons other than bodily injury
disability.
(18)Insured Automobile means an automobile with respect to which the
named insured is required to maintain automobile liability insurance
coverage under New Jersey statutes, to which the liability insurance of this policy
applies and for which a specific premium is charged.
(19)Medical Expense Benefits means the reasonable and necessary expenses
for:
(a) treatment or services rendered by a provider, including medical, surgical, rehabilitative,
and diagnostic services and hospital expenses;
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(b) ambulance services or other transportation; (c) medication;
(d) clinically supported necessary non-medical expenses that are prescribed
by a treating medical provider for a permanent or significant brain, spinal cord,
or disfiguring injury. Necessary non-medical expense means charges for:
(i) products and devices, not exclusively used for medical purposes or as durable
medical equipment, such as any vehicles, durable goods, equipment, appurtenances,
improvements to real or personal property, fixtures;
(ii) services and activities such as recreational activities, trips, and leisure
activities.
Medical expense benefits include any non-medical remedial treatment rendered in accordance with a recognized religious method of healing. Medical expense benefits are subject to the limitations set forth in the policy and as approved by the Commissioner of Banking and Insurance.
(20)Medically necessary or medical necessity means
that the medical treatment or diagnostic test is consistent with the
clinically supported symptoms, diagnosis, or indications of the injured
person, and:
(a) the treatment is the most appropriate standard or level of service that is in
accordance with standards of good practice and standard professional treatment protocols,
as such protocols may be recognized or designated by the Commissioner of Banking
and Insurance;
(b) the treatment of the injury is not primarily for the convenience of the injured
person or provider; (c) does not include unnecessary or inappropriate testing or
treatment;
(d) does not include testing or treatment that is considered by the medical community
to be experimental;
and
(e) does not include testing or treatment that is strictly palliative (treating
the symptoms of a condition rather than the condition itself).
(21)Named insured means the person named as the insured on the policy
declarations, and if an individual, named insured includes his or
her spouse by marriage or domestic partner by civil union, if the spouse by marriage
or domestic partner by civil union, is a resident of the household of the
named insured. If the spouse by marriage or domestic partner by civil union
ceases to be a resident of the named insured’s household, Personal
Injury Protection will continue for the spouse until the end of the policy period
in effect at the time he or she ceased to be a resident of such household.
(22)Pedestrian means any person who is not occupying,
entering into, or alighting from a vehicle propelled by other than muscular power
and designed primarily for use on highways, rails, and tracks.
b. Insuring Agreement
(1) You have this coverage only if a premium for it appears on the
policy declarations. (2) We will pay Personal Injury Protection Coverage
Benefits consisting of:
(a) medical expense benefits,
(b) income continuation benefits, (c) essential services benefits,
(d) death benefits,
(e) funeral expense benefits,
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with respect to bodily injury sustained by an eligible injured
person, caused by an accident and arising out of the ownership, maintenance,
or use, including loading or unloading, of a private passenger auto
as an automobile.
c. Limits of Liability-
(1) Medical Expense Benefits
(a) Limit
The following per person, per accident limit of liability for medical expense
benefits applies:
(i) For the named insured and relatives, who are not
named insureds under another policy, the limit is shown on the declarations.
However, for catastrophic injury treatment, the available limit of
coverage will be an amount not to exceed $250,000.
(ii) For all other eligible injured persons, the limit is shown on
the declarations. However, for
catastrophic injury treatment, the available limit of coverage will be an amount not to exceed
$250,000.
(iii) Under no circumstances will more than $250,000 in medical expense benefits
be paid for any one person for any accident involving catastrophic
injury treatment.
(b) Limitation Set by Medical Fee Schedule
Payments of medical expense benefits shall not exceed the applicable
amount set forth in any medical fee schedule promulgated by the New Jersey Department
of Banking and Insurance for specific injuries or services. If a claimed eligible
charge is not included on the medical fee schedule, payment will be determined
by us, on a reasonable basis, considering the medical fee schedules
for similar services or equipment in the region where the service or equipment was
provided.
(c) Co-Payment
Our payment of medical expense benefits is subject to a per accident co-payment of 20% for the amount between the applicable deductible and $5,000.
(d) Deductible
The amount shown in the medical expense benefits deductible section
on the policy declarations is the deductible amount that applies to medical
expense benefits payable to the named insured and relatives,
who are not named insureds under another policy.
(e) Primary Health Insurance Option
(i) If the policy declarations indicate that the Primary Health Insurance Option
has been elected:
a) any health insurance coverage or benefits applying to the named insured
and relatives shall be the primary coverage for medical
expense benefits for allowable expenses. Personal Injury Protection
Coverage will apply as secondary coverage for medical expense benefits
that
remain uncovered. An explanation of benefit payment calculations when Personal Injury
Protection Coverage is secondary is given below in the Coordination of Benefits
provision.
b) However, if it is determined that the health insurance certified by the
named insured, or another comparable plan, was not in effect at the time
of the accident then:
1) the terms and conditions applicable if the Primary Health Insurance Option had
not been elected on the policy declarations will apply;
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2) an additional $750 deductible per accident will apply to the medical expense
benefits;
3) we will be entitled to recover as additional premium the total
amount of any reduction applied to the premium for the policy period in which the
accident occurred, due to the insured’s election of the Primary Health Insurance
Option.
(ii) If the policy declarations indicate that the Primary Health Insurance Option
has not been elected to provide primary coverage, Personal Injury Protection Coverage
shall be the primary coverage for medical expense benefits payable
to the named insured and relatives, who are not
named insureds under another policy.
(iii) Health Insurance includes individual, blanket, or group accident insurance;
medical or surgical reimbursement plans; health care services provided by a health
maintenance organization; a state- sanctioned flexible spending account, or any
coverage or benefits provided under any federal or state program.
(iv) Coordination of Benefits
a) When this coverage applies as primary, we will pay medical
expense benefits without reduction for amounts collected from health insurance
coverage.
b) When this coverage applies as secondary, we will pay actual
benefits to be calculated as follows:
1) We will first determine the amount of eligible charges
which would have been paid under this coverage after application of the
deductible and co-payment requirements, if this coverage applied as primary.
2) If the allowable expenses that remain unpaid by the health insurance
that applies as primary are less than the benefits calculated in 1) above,
we will pay actual benefits equal to the allowable
expenses that remain unpaid, without reducing the remaining allowable
expenses by the deductible or co-payment amounts of Personal Injury Protection
Coverage.
In determining the allowable expenses that remain unpaid, we
shall not consider any amount for items of expense which exceed the dollar
or percent amounts recognized by the medical fee schedules promulgated by the New
Jersey Department of Banking and Insurance.
3) If the allowable expenses that remain unpaid by the health insurance
that applies as primary are greater than the amount calculated in 1) above, without
reducing the remaining allowable expenses by the deductible or co-payment
amounts of this coverage, we will pay the amount calculated in 1)
above.
c) The total amount of medical expense benefits for the named
insured or any relative per accident shall not exceed the
maximum amount payable for medical expense benefits under this policy.
(2) Income Continuation Benefits
The applicable limit on income continuation benefits applies separately
to each full regular and customary workweek of an eligible injured person.
We will prorate the limit of liability shown in the policy declarations
for weekly income continuation benefits for any period of bodily
injury disability shorter than one week.
(3) Medical Expense Benefits Only Option
If the policy declarations indicate that the Medical Expense Benefits Only Option
has been elected, there is no coverage for the named insured and
relatives for any benefit provided by Personal Injury Protection Coverage
except medical expense benefits.
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(4) Reduction of Personal Injury Protection Coverage Benefits
Any amount payable by us as Personal Injury Protection Coverage benefits
with respect to bodily injury
shall be reduced by all amounts:
(a) paid, payable, or required to be provided under any workers’ compensation or
employees’ temporary disability law; or
(b) paid, payable, or required to be provided under Medicare provided under federal
law; or
(c) actually paid as benefits provided under federal law to active and retired military
personnel. d. Exclusions
(1) Personal Injury Protection Coverage does not apply:
(a) to bodily injury to a person whose conduct contributed to the
injury in any of the following ways:
(i) while committing a high misdemeanor or felony or seeking to avoid lawful apprehension
or arrest by a police officer; or
(ii) while acting with specific intent to cause injury or damage to himself or others.
(b) to bodily injury to the named insured or any
relative of the named insured sustained while occupying,
using, entering into or alighting from a private passenger auto which
is not an insured automobile under this policy, if he or she is required
to maintain automobile liability insurance coverage with respect to that automobile
under New Jersey statutes.
(c) to bodily injury to any person who at the time of the accident:
(i) was the owner or registrant of a private passenger auto registered
or principally garaged in New
Jersey that was being operated without Personal Injury Protection Coverage; or
(ii) was operating or occupying a private passenger auto
without the permission of the owner or other named insured.
(d) to bodily injury to any person who is not occupying
an insured automobile if the accident occurs outside of New Jersey.
This exclusion ((1)(d)) does not apply to:
(i) the named insured; or
(ii) a relative of the named insured; or
(iii) a resident of New Jersey.
(e) to bodily injury arising out of ownership, maintenance, or use,
including loading or unloading, of any vehicle while located for use as a residence
or premises other than for transitory recreational purposes.
(f) to bodily injury due to war, whether or not declared, civil war,
insurrection, rebellion, or revolution, or to any act or condition incident to any
of the foregoing.
(g) to bodily injury resulting from the radioactive, toxic, explosive,
or other hazardous properties of nuclear material.
(h) to bodily injury to any person who is entitled to New Jersey Personal
Injury protection Coverage as a named insured or relative
under the terms of any other policy. This exclusion ((1)(h)) does not apply
to the named insured under this policy.
(i) to bodily injury to any relative who is entitled
to New Jersey Personal Injury Protection Coverage as a
named insured under the terms of another policy.
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(j) to bodily injury to any person who is a named insured
under the terms of a Standard Automobile
Insurance Policy issued pursuant to N.J.S.A. 39:6A-3 and 39:6A-4.
(2) We do not provide Personal Injury Protection Coverage with respect
to those diagnostic tests prohibited by the New Jersey Department
of Banking and Insurance or by statute or regulation.
e. Mandated Medical Expense Conditions
(1) Voluntary Networks
(a) upon receiving notification of bodily injury covered under this
policy, we will make available to the named insured
and the treating health care provider information about our
approved voluntary network providers for certain types of testing, durable
medical equipment, or prescription drugs.
(b) If an eligible injured person does not use a voluntary network
provider, we will impose a co-payment not to exceed 30% of the
eligible charges for medically necessary diagnostic tests,
durable medical equipment, or prescriptions.
(2) Care Paths for Identified Injuries
(a) The New Jersey Department of Banking and Insurance has established standard
courses of medically necessary treatment including diagnostic
tests for identified injuries that are reimbursable as
medical expense benefits. The standard treatments and practices are based
on the diagnosed injury and are known as Care Paths. Care Paths do not apply to
treatment administered during emergency care.
(b) We will advise an eligible injured person of the
Care Path requirements established by the New Jersey
Department of Banking and Insurance upon receiving notice of a bodily injury
covered under this policy.
(c) Within the Care Path, certain treatments and diagnostic tests
are subject to the Decision Point Review Plan and pre-certification requirements.
The administration of any test listed in N.J.A.C. 11:3-4.5(b) 1-10 also require
decision point review, regardless of the diagnosis.
(d) Medical care provided to persons injured in auto accidents that is consistent
with the Care Paths will be reimbursable by the Personal Injury Protection Coverage
medical expense benefits. Medical care that deviates from these Care
Paths will not be reimbursable except by reason of specific medical necessity
based upon adequate clinically supported findings in the particular
case. Medical treatments, diagnostic tests, or durable medical equipment
that are not medically necessary will not be reimbursable through
Personal Injury Protection Coverage.
(3) Decision Point Review Plan and Pre-Certification
The following Decision Point Review Plan and pre-certification requirements are
applicable only after the tenth day following the accident, and do not apply to
treatment administered in emergency care.
(a) Upon receipt of notice of bodily injury covered under this policy,
we will make available to the eligible injured person our
Decision Point Review Plan and pre-certification requirements, if any.
(b) If the eligible injured person or an eligible injured person’s
health care provider requests either: (i) A decision point review; or
(ii) Pre-certification of certain diagnostic tests, specific proposed
treatment, non- medical expenses, or
durable medical equipment;
then we will provide a written authorization, denial, or request for
more information within 3 business days.
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(c) We must be provided with the appropriate clinically supported
findings, that the administration of a test allowable by the New Jersey
Department of Banking and Insurance, proposed treatments, non-medical expenses,
or durable medical equipment is medically necessary.
(d) During our review of the information required in paragraph (3)
(c) above, we may:
(i) approve the proposed treatment, test, non-medical expenses, or durable medical
equipment; (ii) request further information;
(iii) schedule a physical examination of the injured person in accordance with (g)
below where the notice and supporting materials and other medical records, if requested,
are not sufficient to authorize or deny reimbursement of further treatment,
diagnostic tests or durable medical equipment; and/or
(iv) deny reimbursement of further treatment, diagnostic tests, non-medical
expense, or durable medical equipment pursuant to N.J.A.C. 11:3-4.7(b).
(e) After consideration of the further information and/or physical examination,
we will then authorize or deny reimbursement for the treatment, tests,
non-medical expense, or durable medical equipment. Our authorization
or denial will be based on medical necessity and will not encourage
over or under utilization of benefits.
(f) Any denial of decision point review or pre-certification requests based on
medical necessity will be the determination of a physician. If the
treatment is prescribed by a dentist, any denial will be determined by a dentist.
(g) Physical Examination
(i) We will notify the eligible injured person or his
or her designee if a physical examination is required for reimbursement of further
treatment, diagnostic tests, or durable medical equipment.
(ii) The medical examination will be:
a) scheduled within seven calendar days of receipt of the notice described above
unless the
eligible injured person agrees to extend the time period;
b) conducted by a health care provider similar to the treating
health care provider;
c) conducted at a location reasonably convenient to the eligible injured person.
(iii) Upon our request, the treating health care provider
or the eligible injured person will provide medical records
and other pertinent information to the health care provider conducting
the medical examination. The requested records will be provided no later than the
time of the examination.
(iv) We may deny reimbursement of further treatment, testing or use
of durable medical equipment for an eligible injured person’s repeated
unexcused failure to appear for a physical examination required by us
in accordance with our plan.
(v) We will notify the eligible injured person, his
or her designee, and the treating healthcare provider whether reimbursement
for further treatment, diagnostic tests, or durable medical equipment
is authorized as promptly as possible but no later than three business days after
the examination. A copy of the healthcare provider’s report, if prepared,
is available upon request.
(h) Penalty
If the eligible injured person or healthcare provider
fails to:
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(i) request a decision point review or pre-certification where required; or
(ii) provide clinically supported findings that support the treatment,
diagnostic tests or durable medical equipment;
we will impose an additional co-payment applicable to eligible charges for medically necessary diagnostic tests, treatments, surgery, durable medical goods, and non-medical expenses that were provided between the time notification to us was required and the time that proper notification is made and we have an opportunity to respond in accordance with our Decision Point Review Plan.
The co-payment will be 25% when the request or findings are provided 30 to 59
days after the accident. The co-payment will be 50% when the request or findings
are provided 60 or more days after the accident. We will not impose
the additional co-payment where we received the required notice but
failed to act in accordance with the Decision Point Review Plan to request further
information, to modify or deny reimbursement of further treatment, diagnostic
tests, or durable medical equipment.
f. Conditions
(1) Notice
In the event of an accident, written notice containing both particulars sufficient
to identify the eligible
injured person, and reasonably obtainable information respecting the time, place, and circumstances of the accident shall be given by or on behalf of each eligible injured person to us within 29 days following the accident.
If any eligible injured person, his or her legal representative,
or survivors shall institute legal action to recover damages for injury against
a person or organization who is or may be liable in tort therefore, a copy of the
summons and complaint or other process served in connection with such legal action
shall be forwarded to us promptly by such eligible injured person,
his or her legal representative, or his or her survivors.
(2) Medical Reports; Proof of Claim
Within 29 days following the accident, the eligible injured person
or someone on his or her behalf shall give to us written proof
of claim, including full particulars of the nature and extent of the injuries and
treatment received and contemplated, and such other information as may assist us
in determining the amount due and payable. The eligible injured person
shall, at our request, submit a timely PIP Application. The
eligible injured person shall submit to physical examination by physicians
when and as often as we may reasonably require and a copy of the medical
report will be forwarded to such eligible injured person
if requested. (3) Penalty
If an eligible injured person fails to provide us with
notice, proof of claim and other reasonably obtainable information regarding an
injury or claim, we may impose an additional co-payment as a penalty.
The additional co-payment shall be an amount no greater than:
(a) 10 percent when notification is received 21 to 30 days after the commencement
of treatment; (b) 25 percent when notification is received 31 to 60 days after the
commencement of treatment; (c) 50 percent when notification is received 61 to 120
days after the commencement of treatment;
(d) 76 percent when notification is received 121 to 160 days after the commencement
of treatment; and
(e) 100 percent when notification is received 161 or more days after the commencement
of treatment.
Such co-payment will reduce the amounts reimbursed for eligible charges
that are incurred after notification to us is required and
until we receive notification.
Any reduction in the amount of reimbursement in eligible charges shall
be in addition to any other deductible or co-payment requirement.
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(4) Multiple Policies Applicable to One Accident; Non-duplication of Benefits; Priority
of Complying Policies
This policy provides no Personal Injury Protection Coverage Benefits for a person
who is a named insured
under a Basic Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3.1
and N.J.A.C. 11:3-3.
Regardless of the number of automobiles insured for Personal Injury Protection Coverage
pursuant to Section 4 of the New Jersey Automobile Reparation Reform Act, or the
number of insurers or policies affording such coverage, there should be no duplication
of payment of Personal Injury Protection Coverage benefits and the aggregate maximum
amount payable under this and all applicable policies with respect to bodily
injury to any one person as the result of any one accident shall not exceed
the applicable amount or limits specified in Section 4 of said Act.
Personal Injury Protection Coverage applies on a primary basis to bodily injury
to the named insured and his or her relative
and on a secondary basis to all other eligible injured persons.
Similarly, the Personal Injury Protection Coverage provided by other complying policies
applies on a primary basis to bodily injury to those persons who are
named insureds under such policies and their relatives.
If an eligible injured person to whom Personal Injury Protection Coverage
applies on a secondary basis has other Personal Injury Protection Coverage under
another complying policy applicable to his or her bodily injury on
a primary basis, all claims for Personal Injury Protection Coverage benefits shall
first be made against the insurer issuing the other complying policy.
No Personal Injury Protection Coverage benefits shall be due and payable under Personal
Injury Protection Coverage unless the other insurer fails to pay such benefits by
reason of insolvency and we have been given written notice by the
claimant of such failure.
“Complying Policy” means a policy of automobile liability insurance maintained pursuant
to the requirements of Section 3 of the New Jersey Automobile Reparation Reform
Act and providing Personal Injury Protection Coverage as approved by the Department
of Banking and Insurance.
The eligible injured person shall not collect under more than one
policy. If an eligible injured person under this policy qualifies
for payments under other policies providing Personal Injury Protection Coverage
benefits, the insurer paying benefits to such person shall be entitled to recover
from each of the other insurers an equitable pro rata share of the benefits paid.
The pro rata share is the proportion that the insurer’s liability bears to the total
of all applicable limits. Any deductible amounts applicable shall be taken into
consideration in determining each insurer’s pro rata share.
(5) Reimbursement and Trust Agreement
Subject to any applicable limitations set forth In the New Jersey Automobile Reparation
Reform Act, in the event of any payment to any person under Personal Injury Protection
Coverage:
(a) we shall be entitled to the extent of such payment to the proceeds
of any settlement or judgment that may result from the exercise of any rights of
recovery of such person against any person or organization legally responsible for
the bodily injury because of which such payment is made; and
we shall have a lien to the extent of such payment. Notice of our
lien may be given to the person or organization
causing such bodily injury, his or her producer of record, his or
her insurer, or a court having jurisdiction in the matter;
(b) such person shall hold in trust for our benefit all rights of
recovery that he or she shall have against such other person or organization because
of such bodily injury;
(c) such person shall do whatever is proper to secure and shall do nothing after
loss to prejudice such rights;
(d) such person shall execute and deliver to us such instruments and
papers as may be appropriate to secure the rights and obligations of such person
and us established by this provision.
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(6) Payment of Personal Injury Protection Coverage Benefits
Medical expense benefits may be paid at our option to the eligible injured person or the person or organization furnishing the products or services for which such benefits are due. These benefits shall not be assignable except to providers of service benefits who comply with the Care Paths, pre-certification and decision point review requirements of this policy. The first recourse for disputes regarding payment of Personal Injury Protection Coverage for assignees of benefits shall be the procedure specified in paragraph
3 of this Section.
In the event of the death of an eligible injured person, any amounts
payable, but unpaid prior to death, for
medical expense benefits are payable to the eligible injured person’s estate.
Benefits payable under subdivision (a) of the definition of death benefits are payable to the eligible injured person’s surviving spouse by marriage or domestic partner by civil union, or if there is no surviving spouse by marriage or domestic partner by civil union, to his or her surviving children, or if there are no surviving spouse or surviving children, to the eligible injured person’s estate. Benefits payable under subdivision (b) of the definition of death benefits are payable to the person who has incurred the expense of providing essential services.
Funeral expenses benefits are payable to the eligible injured person’s estate. (7) Our Right to Apply for Employee Benefits
If an eligible injured person has not applied for workers’ compensation
or employees’ temporary disability benefits, we may immediately apply
directly to the provider of such benefits paid under this coverage.
(8) Proof of Health Benefits Plan Coverage
If you have elected the Medical Expense Benefits-As-Secondary option,
you must provide proof that you and your relatives
are insured by health insurance coverage or benefits in a manner and to
an extent approved by the New Jersey Department of Banking and Insurance.
g. Policy Period; Territory
Personal Injury Protection Coverage applies only to accidents that occur during
the policy period and anywhere in the world.
2. Extended Medical Expense Benefits Coverage
a. Definitions
The definitions under Personal Injury Protection Coverage apply to Extended Medical
Expenses Benefits
Coverage, and under Extended Medical Expense Benefits Coverage. (1) Highway
Vehicle means a land motor vehicle or trailer other than:
(a) a private passenger auto;
(b) a farm type tractor or other equipment designed for use principally off public
roads, while not upon public roads;
(c) a vehicle operated on rails or crawler-treads; or
(d) a vehicle while located for use as a residence or premises. (2) Insured
Person means:
(a) the named insured or any relative of the named
insured, if the named insured or relative sustains
bodily injury:
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(i) while occupying, using, entering into, or alighting from a
highway vehicle; or
(ii) while a pedestrian, caused by a highway vehicle;
(b) any other person who sustains bodily injury while occupying
a highway vehicle (other than a motorcycle or a vehicle while
being used as a public or livery conveyance) if such highway vehicle
is being operated by the named insured or a relative
of the named insured or any other person using such highway
vehicle with the permission of the named insured;
b. Insuring Agreement
(1) You have this coverage only if a premium for it appears on the
policy declarations.
(2) We will pay medical expense benefits not to exceed
the total aggregate amount stated on the policy declarations with respect to
bodily injury sustained by an insured person, caused by
an accident occurring during the policy period anywhere in the world and arising
out of the ownership, maintenance, or use, including loading and unloading, of an
insured automobile or of a highway vehicle not owned
by or furnished or available for the regular use of the named insured
or any relative of the named insured.
c. Limit of Liability
The limit of our liability under Extended Medical Expense Benefits
for each person entitled to benefits who sustains bodily injury in
any one accident shall not exceed the amount shown in the Extended Medical Expense
Limit section on the policy declarations.
No eligible injured person will recover duplicate benefits for the
same elements of loss under Personal Injury
Protection Coverage. d. Exclusions
(1) Extended Medical Expense Benefits Coverage is subject to all of the exclusions
applicable to Personal Injury
Protection Coverage except that the word “person” in exclusion 1.d.(1)(c) is replaced
by the word “pedestrian”. (2) The following exclusions also apply
to Extended Medical Expense Benefits Coverage:
(a) Extended Medical Expense Benefits Coverage does not apply to any insured who
would be entitled to benefits under Personal Injury Protection Coverage except for
the application of the medical fee schedule promulgated by the New Jersey Department
of Banking and Insurance.
(b) Extended Medical Expense Benefits Coverage does not apply to any person, other
than the named insured or a relative of the named
insured or a resident of New Jersey, if the accident occurs outside of New
Jersey.
e. Conditions
Conditions (1), (2), (5), and (8) of Personal Injury Protection Coverage apply to
Extended Medical Expense Benefits Coverage, substituting the term insured
person for eligible injured person wherever it appears therein.
The following additional condition applies under Extended Medical Expense Benefits
Coverage:
Other Insurance or Benefits
Extended Medical Expense Benefits Coverage does not apply to loss or expense with
respect to which an insured person is entitled to benefits under any
Medicare provided under federal law, any workers’ compen- sation law, or under Section
4 of the New Jersey Reparation Reform Act.
Extended Medical Expense Benefits Coverage does not apply to loss or expense to
the extent that benefits are payable or are required to be provided therefore under
any other automobile no-fault law or under any other automobile medical payments
insurance.
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Extended Medical Expense Benefits Coverage does not apply to amounts not paid under
the New Jersey No- Fault Law because of the application of the deductible or the
co-payment stated in the Limit of Liability provision for Personal Injury Protection
Coverage.
3. Dispute Resolution
The New Jersey Department of Banking and Insurance established procedures for the
resolution of disputes concerning the payment of medical expense and other benefits
provided by Personal Injury Protection Coverage.
A request for dispute resolution for Personal Injury Protection Coverage may be
submitted by the injured party, the insured, a provider of service benefits who
is an assignee of Personal Injury Protection Coverage benefits, or the insurer in
accordance with New Jersey Law. The request for dispute resolution may include a
request for review by a medical review organization.
4. Added Personal Injury Protection Coverage
The amount indicated for Income Continuation Benefits, Essential
Services Benefits and Funeral Expense
Benefits includes the benefits payable under the Personal Injury Protection Coverage.
a. The weekly and total limits applicable to income continuation benefits
as stated in the policy declarations are amended by substituting therefore,
respectively, the amounts shown in the policy declarations for income continuation
benefits under Added Personal Injury Protection Coverage.
b. The per day and total limits applicable to essential services benefits
as stated in the policy declarations are amended by substituting therefore,
respectively, the amounts shown in the policy declarations for essential services
benefits under Added Personal Injury Protection Coverage.
c. The limit applicable to funeral expense benefits as stated in the
policy declarations is amended by substi- tuting therefore the amount shown in the
policy declarations for funeral expense benefits under Added Personal
Injury Protection Coverage.
d. The income continuation benefits and essential services benefits
shall cease upon the death of the eligible injured person
and shall not operate to increase the amount of any death benefits
payable under the Section IV.B. Personal Injury Protection Coverage of the policy.
e. We will pay an added death benefit of $10,000 to
the surviving spouse by marriage or domestic partner by civil union; or if there
is no surviving spouse by marriage or domestic partner by civil union, to the surviving
children; or if there is no surviving spouse by marriage, domestic partner by civil
union or surviving children, to the estate of the person insured for Added Personal
Injury Protection Coverage if his or her death results from bodily injury
for which Personal Injury Protection Benefit Coverage is payable and occurs
within 2 years of the accident.
f. Subject to the limits of liability shown in the policy declarations, we
shall not be liable for more than 75% of weekly income in
excess of $100, provided however, that after $5,200 has been paid as income
continuation benefits at the rate specified in the Section IV.B. Personal
Injury Protection Coverage of the policy, we shall
not be liable for more than 75% of weekly income thereafter. C. Uninsured and
Underinsured Motorist Coverage
1. Additional Definitions Applicable to Uninsured and Underinsured Motorist Coverage
a. Bodily Injury means bodily injury, sickness or disease, including
death resulting therefrom. b. Underinsured Motor Vehicle means:
(1) For you and any insured who is not insured as a named insured,
spouse by marriage or domestic partner by civil union or relative
under any policy providing Uninsured and Underinsured Motorist Coverage:
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a land motor vehicle or trailer, the ownership, maintenance, or use
of which is insured or bonded for bodily injury and property
damage liability at the time of the accident, but the limits of liability
are less than the limits you carry for Uninsured and Underinsured
Motorist Coverage under this policy.
(2) For any insured who is insured as a named insured, spouse by marriage,
domestic partner by civil union, or
relative under any other policy providing Uninsured and Underinsured Motorist Coverage:
a land motor vehicle or trailer, the ownership, maintenance, or
use of which is insured or bonded for bodily injury and property
damage liability at the time of the accident, but the limits of liability
are less than the highest applicable limit of liability under any other policy providing
Uninsured and Underinsured Motorist Coverage to that insured as a named insured,
spouse by marriage, domestic partner by civil union, or relative.
An underinsured motor vehicle does not include: (1) an uninsured
motor vehicle;
(2) a land motor vehicle or trailer that is owned by, or leased to,
or furnished for the regular use of:
(a) you; or
(b) any relative; or
(c) a resident of your household; (3) a land motor vehicle or
trailer:
(a) owned or operated by a self-insurer under any motor vehicle financial responsibility
law, motor carrier law, or any similar law;
(b) owned by any government or any of its political subdivisions or agencies; (c)
designed for use mainly off public roads except while on public roads;
(d) used as a residence or stationary structure; (e) operated on rails or crawler
treads.
c. Uninsured Motor Vehicle means:
(1) a land motor vehicle or trailer, the ownership, operation, maintenance,
or use of which is:
(a) not insured or bonded for bodily injury and property damage
liability at the time of the accident; or
(b) insured or bonded for bodily injury and property damage
liability at the time of the accident, but the insuring company denies coverage
or is or becomes insolvent, or the Commissioner of Banking and Insurance has undertaken
control of the insurer for purposes of liquidation; or
(2) with respect to bodily injury, a hit-and-run land motor vehicle
whose owner and driver remains unknown and:
(a) that strikes the insured or the vehicle the insured is occupying
and causes bodily injury to an insured; or
(b) that causes bodily injury to the insured without striking the
insured or the vehicle the insured is
occupying.
(3) an auto covered by a New Jersey Special Automobile Insurance
Policy. An uninsured motor vehicle does not include:
(1) an underinsured motor vehicle;
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(2) a land motor vehicle or trailer that is owned by, or leased to,
or furnished for the regular use of:
(a) you; or
(b) any relative; or
(c) a resident of your household; (3) a land motor vehicle or
trailer:
(a) owned or operated by a self-insurer under any motor vehicle financial responsibility
law, motor carrier law, or any similar law;
(b) owned by any government or any of its political subdivisions or agencies; (c)
designed for use mainly off public roads except while on public roads;
(d) used as a residence or stationary structure; (e) operated on rails or treads;
(f) insured under the terms of a Basic Automobile Insurance Policy issued pursuant
to N.J.S.A 39:6A-3.1 and N.J.A.C. 11:3-3
2. Coverage
a. You have this coverage only if a premium for it is shown on the
policy declarations.
b. We will pay damages for bodily injury or property
damage an insured person is legally entitled to collect from the owner or
operator of an uninsured motor vehicle or underinsured motor
vehicle because of:
(1) bodily injury sustained by an insured person, (2) damage to or
destruction of:
(a) your private passenger auto or your owned
trailer; (b) a newly acquired private passenger auto;
(c) a temporary substitute private passenger auto; or
(d) property owned by:
(i) you or any relative while in:
a) your private passenger auto or your owned trailer;
b) a newly acquired private passenger auto;
c) a temporary substitute private passenger auto; or
(ii) any other insured while in your private passenger auto, a
newly acquired private passenger auto, or temporary substitute
private passenger auto.
The bodily injury or property damage must be caused
by an accident arising out of the ownership, maintenance, or use of an uninsured
motor vehicle or underinsured motor vehicle. This coverage
does not apply to the first $500 of the total amount of all property damage
as the result of any one accident.
c. We will pay any amount due: (1) to the insured;
(2) to a parent or guardian if the insured is a minor;
(3) to the surviving spouse by marriage;
(4) to the surviving domestic partner by civil union;
(5) at our option, to a person authorized by law to receive such payment.
21
d. We are not bound by any judgment against any person or organization
resulting from any suit brought without
our written consent.
e. Any amount payable under this coverage shall be reduced by any outstanding premium that is owed by you to
us for this policy.
3. Who Is An Insured
The following are insureds:
a. you;
b. your relatives;
c. any other person while occupying your private passenger auto, a
temporary substitute private passenger auto, a newly acquired
private passenger auto or a trailer attached to such
auto. Such vehicle has to be used with your consent.
d. Any person entitled to recover damages because of bodily injury
to an insured under paragraphs a. through c. above.
4. Determining Liability and Damages
a. Two questions must be decided by agreement between the insured and us:
(1) Is the insured legally entitled to collect damages from the owner or driver
of the uninsured motor vehicle or
underinsured motor vehicle? (2) If so, in what amount?
b. If there is no agreement, these questions shall be decided by arbitration
upon written request of the insured or us. Each party shall select
a competent and impartial arbitrator. These two shall select a third arbitrator.
If unable to agree on the third one within 30 days either party may request a judge
of a court of record in the county in which the arbitration is pending to select
a third one.
c. The cost of the arbitrator and any expert witness shall be paid by the party
who hired them. The cost of the third arbitrator and other expenses of arbitration
shall be shared equally by both parties.
d. The arbitration shall take place in the county in which the insured resides unless
the parties agree to another place. Local rules of law as to procedure and evidence
will apply.
e. The written decision of any two arbitrators as to the questions specified in
paragraph 4.a. above shall be binding on each party unless the amount of damages
awarded exceeds the minimum limit of liability specified
by the financial responsibility law of New Jersey. If the amount of damages exceeds
that limit, either party may, within 60 days of the arbitrators’ decision, demand
a trial. If the demand is not made, the decision of the arbitrators is binding on
each party.
5. Limits of Liability
a. Bodily Injury
The limit shown on the policy declarations under Uninsured and Underinsured Motorist
Coverage for bodily injury Each Person is the maximum amount of coverage
for all damages due to bodily injury to one person in any one accident.
Bodily Injury to one person includes all injuries and damages to others
resulting from this bodily injury. The limit shown under Uninsured
and Underinsured Motorist Coverage for Each Accident is the maximum amount of coverage
subject to the amount shown under Each Person, for all damages due to bodily
injury to two or more persons in the same accident.
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b. Property Damage
The limit shown on the policy declarations under Uninsured and Underinsured Motorist
Coverage for Property Damage, Each Accident is the maximum amount of coverage for
all property damage sustained by all insureds as the result of an
accident.
c. However, subject to our maximum limit of liability for this coverage,
for an insured other than you that is insured as a named insured,
spouse, domestic partner, or relative under one or more policies providing
Uninsured and Underinsured Motorist Coverage at a limit of liability less than
our limit of liability, our limit of liability shall
not exceed the highest applicable limit under any policy providing Uninsured and
Underinsured Motorist Coverage to that insured as a named insured,
spouse, domestic partner, or relative. For an insured other than
you or your relative, who is not insured as a
named insured, spouse, domestic partner or relative under
a policy providing Uninsured and Underinsured Motorists Coverage, our
limit of liability is $15,000 for all damages due to bodily injury
to one person in any one accident and $30,000 for all damages to two or more
persons in the same accident.
d. Any amount payable for economic loss under this coverage shall be reduced by
the amount of any: (1) Personal Injury Protection benefits;
(2) additional Personal Injury Protection benefits;
paid or payable under this or any other motor vehicle insurance policy.
e. Any amount payable under this coverage as the result of an accident involving
an uninsured motor vehicle
shall be reduced by any amount paid to or for the insured:
(1) by or for any person or organization who is or may be legally liable for the
bodily injury or property damage; or
(2) under any Comprehensive or Collision Coverage of this policy.
f. Any payment made to a person under this coverage as the result of an accident
involving an uninsured motor vehicle shall reduce any amount payable
to that person under Liability Coverage.
g. Subject to the Limits of Liability set forth in a. through c. above, the most
we will pay as the result of an accident involving an underinsured
motor vehicle will be the lesser of:
(1) the difference between the applicable limit of liability of this coverage and
the amount paid to the insured in damages by or for any person or organization who
may be legally liable for the bodily injury or property damage;
or
(2) the amount of damages for bodily injury or property damage
sustained by but not recovered by the insured.
h. The limits of liability are not increased because:
(1) more than one person is insured at the time of the accident;
(2) more than one auto is insured for this coverage under this policy;
(3) more than one underinsured motor vehicle is involved in the same
accident.
i. No injured person will recover duplicate benefits for the same elements of loss
under this or any other uninsured motorists insurance, including approved plans
of self-insurance.
6. Exclusions-What Is Not Covered
There is no coverage:
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a. for any person if that person or the legal representative without our
written consent, settles a claim with the owner or operator of an
uninsured motor vehicle or underinsured motor vehicle who
may be liable for the bodily injury or property damage;
b. for damages for pain, suffering, and non-economic damages resulting from
bodily injury caused by an accident involving an uninsured motor
vehicle, unless the injured person has a legal right to recover damages
for such pain, suffering, and non-economic damages allowed under New Jersey law.
The injured person’s legal right to recover non-economic damages allowed under New
Jersey Law will be determined by the liability tort limitation, if any, applicable
to that person;
c. to the extent it benefits:
(1) any workers’ compensation or disability benefits insurance company;
(2) a self-insurer under any workers’ compensation, disability benefits, or similar
law; (3) directly or indirectly any insurer of property;
d. for property damage arising out of ownership, maintenance, or use
of a hit-and-run vehicle;
e. for any person while using a vehicle without reasonable belief that he or she
has a right to do so;
f. for punitive or exemplary damages;
g. for any person who is a named insured under the terms of a Basic
Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C.11:3-3.
This exclusion (6.g.) does not apply to you if you are
occupying your private passenger auto, a newly acquired private
passenger auto, a temporary substitute private passenger auto,
or a non-owned auto.
h. for any relative who is also insured as a relative
under the terms of a Basic Automobile Insurance Policy issued pursuant to N.J.A.C.
39:6A-3.1 and N.J.S.A. 11:3-3. This exclusion (6.h.) does not apply if your
relative is occupying your private passenger auto, a
newly acquired private passenger auto, or a temporary substitute
private passenger auto.
i. for any person occupying a motor vehicle that he or she owns for
which he or she has failed to maintain required insurance coverage under New Jersey
statutes and regulations;
j. for bodily injury or property damage to any person
occupying an auto while used as a public or livery conveyance.
This exclusion (6.j.) does not apply to shared-expense car pools.
7. If There Is Other Uninsured and/or Underinsured Motorist Coverage
a. If the insured sustains bodily injury and other Uninsured and/or
Underinsured Motorists Coverage applies, the total limits of liability under all
such coverage shall not exceed that of the coverage with the highest limit for any
one vehicle.
b. However, for an insured other than you that is insured as a
named insured, spouse by marriage, domestic partner by civil union, or
relative under one or more policies providing Uninsured and/or Underinsured
Motorist Coverage, the total limits of liability under all such Uninsured and/or
Underinsured Motorist Coverage for that insured shall not exceed the highest applicable
limit under any policy providing Uninsured and/or Underinsured Motorist Coverage
to that insured as a named insured, spouse by marriage, domestic partner
by civil union, or relative.
c. We are liable only for our share. Our
share is that percent of the damages that the limit of liability of this coverage
bears to the total of all Uninsured and/or Underinsured Motorist Coverage applicable
to the accident.
d. For a non-owned auto this coverage is excess over any other collectible
insurance.
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D. Comprehensive and Collision Coverages-Damage To Your Auto
1. Additional Definitions Applicable to Comprehensive and Collision Coverages
a. Camper Body means a body designed for use as temporary living quarters
and constructed as a detachable unit. A camper unit includes caps, toppers, canopies,
and all equipment and accessories built into and forming a permanent part of the
structure.
b. Collision means:
(1) the upset of your private passenger auto or your trailer;
or
(2) your private passenger auto or your trailer hit
a vehicle or other object; or
(3) your private passenger auto or your trailer was
hit by a vehicle or other object.
c. Custom Parts or Equipment means equipment, devices, accessories,
enhancements, and changes, other than those which are original manufacturer installed
which:
(1) are permanently installed or attached; and
(2) alter the appearance or performance of a vehicle.
This includes any electronic equipment, antennas, and other devices used exclusively
to send or receive audio, visual, or data signals, or to play back recorded media,
other than those which are original manufacturer installed, that are permanently
installed in your private passenger auto using bolts or brackets,
including
slide-out brackets.
d. Loss means each direct and accidental loss of or damage to: (1)
your private passenger auto or your owned trailer;
or
(2) its equipment that is common to the use of your private passenger auto
as a vehicle; or
(3) a camper body attached to or removed from your private passenger
auto for storage.
2. New Jersey Mandatory Inspection Provision
a. We or our authorized representative have the right
to inspect any private passenger auto insured or intended to be insured
under this policy before Comprehensive or Collision Coverage shall be effective,
with the exception of a new private passenger auto purchased from
a franchised automobile dealership when we are provided with the following
documents:
(1) A copy of the bill of sale which contains a full description of the private
passenger auto, including all options and accessories;
(2) A copy of the window sticker or advanced dealer shipping notice (invoice) showing
the itemized options and equipment, the total retail price of the private
passenger auto, and any dealer installed option purchased by the customer;
or
(3) A vehicles buyer’s order (contract) and/or the dealership invoice to the buyer,
including all options and accessories.
b. During the term of this policy, coverage for an additional or
replacement private passenger auto shall not become effective until
you notify us and request coverage for the auto.
However, this provision does not apply to a replacement private passenger
auto for a period of three days, including the day on which the auto
is acquired, if:
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(1) the auto is acquired during the policy period; and
(2) there was Comprehensive or Collision Coverage on the auto replaced
for at least the 12-month period proceeding the replacement date.
The three-day period shall be extended by one day for each Saturday, Sunday, or
New Jersey State holiday falling within the three-day period.
c. When an inspection is required by us, you shall cooperate
and make the auto available for inspection.
d. The mandatory insurance inspection report, completed by the authorized inspection
site representative for your private passenger auto, shall not establish
coverage for any equipment that is excluded by this policy or that should be specifically
insured by an endorsement to this policy.
3. Comprehensive Coverage
a. You have this coverage only for your private passenger auto
or your owned trailer for which a premium for
this coverage appears on the policy declarations. The deductible amount is shown
on the policy declarations for the private passenger auto or
trailer to which it applies.
b. We will pay for loss to your private passenger
auto or your owned trailer except loss
by collision but only for the amount of each loss
in excess of the deductible amount, subject to our Limit of
Liability, and minus any outstanding premium that is owed by you to
us for this policy. Breakage of glass, or loss caused
by missiles, falling objects, fire, theft, larceny, explosion, earthquake, windstorm,
hail, water, flood, malicious mischief or vandalism, riot, or civil commotion is
payable under this coverage. Loss due to hitting or being hit by a
bird or an animal is payable under this coverage. If breakage of glass is caused
by a collision, at your option, we may
cover it under Collision Coverage.
c. We will repay you for transportation costs if
your private passenger auto is stolen. We will pay up to
$15 per day for the period that begins 48 hours after the theft up to a maximum
of $450. The period ends when your private passenger auto is returned
to use or when we offer to pay for its loss. We
will also pay for loss-of-use expenses for which you are legally
responsible due to theft of a non-owned auto or a temporary
substitute private passenger auto. The most we will pay for
loss of use expenses is $15 per day. Payment for these transportation costs and
loss-of-use expenses will not be subject to any deductible. You must
provide us with written proof of your transportation
expenses and loss-of-use expenses.
4. Collision Coverage
a. You have this coverage only for your private passenger auto
or your owned trailer for which a premium for
this coverage appears on the policy declarations. The deductible amount is shown
on the policy declarations for the private passenger auto or
trailer to which it applies.
b. We will pay for loss to your private passenger
auto or your owned trailer caused by collision
but only for the amount of each such loss in excess of the
deductible amount, subject to our Limit of Liability and minus any
outstanding premium that is owed by you to us for this
policy.
5. Coverage for the Use of Other Autos and Owned Trailers
a. The same coverages in this section that you have on your
private passenger auto extend to a newly acquired private passenger
auto, a temporary substitute private passenger auto, or a
non-owned auto. These coverages extend to a non-owned auto
while it is driven by or in the custody of you or your
relatives.
If you have two or more private passenger autos insured
on this policy, we will provide the broadest coverage applicable to
any of your private passenger autos to an additional private
passenger auto, a temporary private passenger substitute auto,
or a non-owned auto. A replacement private passenger auto
will have the same coverage as the private passenger auto
it replaced. This policy will only provide coverage for the replacement private
passenger auto for a period of three days from its delivery to you,
after which you must satisfy the requirements of the New Jersey Mandatory
Inspection Provision at Section 2 above in order to
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continue Comprehensive and Collision coverage on your replacement private
passenger auto. The three-day period shall be extended by one day for each
Saturday, Sunday, or any New Jersey State legal holiday falling within the three-day
period.
b. If you acquire a trailer during the policy period,
it is covered if you ask us to insure it within 30 days
after you become the owner. If the trailer you acquire
is an additional trailer, we will provide the broadest
coverage applicable to any of your private passenger autos or
trailers. A replacement trailer will have the same coverage
as the trailer it replaced.
6. Coverage for Owned Camper Bodies
Your camper body is covered in accordance with the terms and conditions of paragraphs D.1., D.3., and D.4. above:
a. when it is described on the policy declarations of this policy;
b. for the coverages shown as applying to it;
c. subject to any applicable deductible.
If you acquire a camper body during the policy period,
it is covered if you ask us to insure it within 30 days
after
you become the owner.
7. Coverage for a Non-owned Trailer or Camper Body
a. Any Comprehensive and Collision Coverage in force on your private passenger
auto applies to a non- owned:
(1) trailer, if it is designed for use with a private passenger
auto, or
(2) camper body, used by you or your relatives.
b. A non-owned trailer or camper body is one that is
not owned by or registered in the name of: (1) you or any relative;
(2) any other person residing in the same household as you or any
relative; (3) an employer of you or any relative.
c. The most we will pay under Comprehensive or Collision Coverage
for loss to such non-owned trailer or
camper body is $500.
8. Coverage for Additional Custom Parts or Equipment Coverage
If you pay a premium for Additional Custom Parts or Equipment Coverage,
the Limit of Liability for loss to custom parts or equipment
for this additional coverage will be the lowest of:
a. the actual cash value of such custom parts or equipment;
b. the declared value of such custom parts or equipment; or
c. the amount necessary to repair or replace such custom parts or equipment;
reduced by the applicable deductible.
Coverage for custom parts or equipment shall not cause any Limit of
Liability to be increased to an amount in excess of the actual cash value of any
stolen or damaged vehicle. Any deductible amount will apply separately to each
loss.
9. Coverage for Emergency Towing and Labor
If you pay a premium for Emergency Towing and Labor coverage,
we will pay for towing and labor cost incurred by you as
a result of the disablement of a covered vehicle or non-owned auto,
subject to the Limit of Liability shown on the declarations page, provided that:
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a. the labor is performed at the place of disablement; and b. the disablement does
not occur at your residence.
10. Coverage for Rental Reimbursement
If you pay a premium for Rental Reimbursement Coverage, we
will reimburse you according to the limits stated on the policy
declaration for any one (1) accident for rental charges incurred by you
when you rent a vehicle from a rental agency or vehicle repair
shop due to a loss to a covered vehicle, other than a total theft,
that is payable under this coverage. Rental charges will be reimbursed beginning:
a. when the covered vehicle cannot be driven due to a loss;
b. if the covered vehicle can be driven, when you deliver the covered
vehicle to a vehicle repair shop for repairs due to the loss;
and ending when the covered vehicle has been repaired, replaced, or if the covered
vehicle is deemed by us to be a total loss, forty-eight (48) hours
after we make an offer to pay the actual cash value of the covered
vehicle.
11. Limit of Liability-Comprehensive and Collision Coverages
a. The limit of our liability for loss to property or
any part of it is the lesser of: (1) the actual cash value not to exceed $60,000;
or
(2) the cost of repair or replacement not to exceed $60,000.
b. An adjustment for depreciation and physical condition will be made in determining
actual cash value in the event of a total loss.
12. Settlement of Loss- Comprehensive and Collision Coverages
a. We have the right to settle a loss with you
or the owner of the property in one of the following ways:
(1) pay the agreed upon actual cash value of the property at the time of the
loss in exchange for the damaged property. If the owner and we
cannot agree on the actual cash value, either party may demand appraisal
as described in paragraph 12.b. If the owner keeps the damaged property, we
will deduct its value after the loss from our
payment. The damaged property cannot be abandoned to us.
(2) pay to:
(a) repair the damaged property or part, or
(b) replace the property or part.
If the repair or replacement results in betterment, you must pay for
the amount of betterment; or
(3) return the stolen property and pay for any damage due to the theft.
b. Appraisal under item a.(1) above shall be conducted according to the following
procedure. Each party shall select a competent appraiser. These two shall select
a third appraiser. The written decision of any two appraisers shall be binding.
The cost of the appraiser shall be paid by the party who hired him or her. The cost
of the third appraiser and other appraisal expenses shall be shared equally by both
parties. We do not waive any of our rights by any act
relating to appraisal. If you give us your consent,
we may move the damaged property, at our expense, to
reduce storage costs during the appraisal process. If you do not give
us your consent, we will pay only the storage cost that
would have resulted if we had moved the damaged property.
c. The settlement of loss provision for Comprehensive and Collision
Coverages incorporates the limit of liability stated in paragraph 11. above.
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d. You must provide us written proof of your
rental charges.
Duplicate recovery for identical elements of damages is not permitted under this
policy.
13. Payment of Loss
At our expense, we may return any stolen property to
you or to the address shown on the declarations page, with payment
for any damage resulting from the theft. We may keep all or part of
the property at the agreed or appraised value. We may settle any
loss with you or the owner or lienholder of the property.
14. No Benefit to Bailee
These coverages shall not benefit any carrier or other bailee for hire liable for
loss.
15. Exclusions-What is not Covered
There is no coverage for:
a. any auto or trailer used as a public or livery conveyance.
This exclusion (15.a.) does not apply to shared- expense car-pools;
b. any loss to any auto or trailer arising
out of or during its use for the transportation of any: (1) explosive substance;
(2) flammable liquid;
(3) similar hazardous materials;
except transportation incidental to your ordinary household activities;
c. any customized equipment in or on a pickup, panel truck, van, delivery sedan
or utility automobile. Customized equipment includes but is not limited to:
(1) television antennas;
(2) cooking and plumbing equipment; (3) sleeping facilities;
(4) height-extending roofs;
(5) special carpeting and insulation, furniture, or bars; (6) murals, paintings,
or other decals or graphics;
d. awnings, cabanas, or equipment designed to create additional living facilities;
e. any non-owned auto while being repaired, serviced, or used by any
person while that person is employed or engaged in any way in the selling, leasing,
repairing servicing, transporting or storing, or parking of land motor vehicles
or trailers including road testing and delivery of such vehicle;
f. any person maintaining or using a non-owned auto in any business,
occupation, or profession other than farming or ranching and not described in exclusion
15.e. This exclusion (15.f.) does not apply to a private passenger auto,
or trailer used with a private passenger auto driven,
maintained, or occupied by you or your relatives;
g. any auto or trailer while being operated in any prearranged
or organized racing or speed contest or in practice or preparation for any such
contest;
h. any sound reproduction system including, but not limited to, radios, stereos,
tape decks, or compact disk players. Coverage under this Section also will not apply
to any apparatus or accessories in or on the auto designed for use
with that system. This exclusion (15.h.) does not apply if the sound reproduction
system is permanently installed in the auto;
29
i. any audio, visual, or data receiving and transmitting equipment including, but
not limited to:
(1) citizens band or two-way mobile radios; (2) telephones;
(3) scanning or television monitor receivers; (4) video or audio cassette recorders;
or
(5) personal computers.
This exclusion (15.i.) does not apply if the electronic equipment is necessary for
the normal operation of an auto. Coverage under this Section also
will not apply to any apparatus or accessories designed for use with that equipment;
j. any tapes, records, discs or other media used with equipment described in exclusions
15.h. and 15.i. above for recording or reproducing sound;
k. any laser or radar detector;
l. loss to any vehicle due to war of any kind;
m. loss to any vehicle due to and limited to wear and tear, freezing,
and mechanical or electrical breakdown or failure. This exclusion (15.m.) does not
apply when the loss is the result of a theft covered by this policy;
n. road damage to tires. This exclusion (15.n.) does not apply if the damage results
from the total theft of your private passenger auto, temporary
substitute private passenger auto, newly acquired private passenger
auto, non-owned auto or any trailer;
o. radioactive contamination;
p. any diminution in the value of any auto or trailer
after it has been repaired as compared to its value before it was damaged;
q. damage due to an intentional act caused by you, a relative
or the owner of a non-owned vehicle;
r. damage to a covered vehicle prior to inspection by us or
our representative as required by New Jersey law;
16. If There Is Other Insurance
a. Coverage Available from Other Sources
If other insurance applies to the loss or expenses, we
will pay only our share. Our share is the percent
the limit of liability of this policy bears to the total of all coverage that applies.
b. Temporary Substitute Private Passenger Auto, Non-owned Auto,
or Trailer.
If a temporary substitute private passenger auto, a non-owned
auto, or trailer designed for use with a
private passenger auto has other coverage on it, then this coverage is excess.
17. It is agreed that loss covered under Comprehensive and/or Collision
coverage under your policy shall be paid to you and,
as its interest may appear, to the loss payee shown above or in the policy declarations.
Coverage for the loss payee, shall not terminate because of your fraudulent
acts or misrepresentations. However, if a loss results from
your conversion, secretion or embezzlement of your private passenger
auto, coverage for 98 the loss payee shall be invalid.
If a Named Excluded Driver Endorsement has been issued for this policy, such exclusion
applies to any claim of the loss payee for the specified driver and auto.
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If we initiate termination of this coverage, we will
give the same advance notice of cancellation to the loss payee as we
give to the named insured.
When we pay the loss payee for a loss, we
are entitled to the loss payee’s right of recovery against you
to the extent of our payment.
SECTION V.
Duties After An Accident Or Loss
If you do not fulfill the following responsibilities, we have no duty to provide coverage under this policy. A. Notice to Us of an Accident or Loss
We must be given notice of the accident or loss as soon as reasonably possible. The notice must give us:
1. your name;
2. the names and addresses of all persons involved;
3. the hour, date, place, and facts of the accident or loss;
4. the names and addresses of witnesses. B. Notice to Us of Claim or Suit
We must be given copies of every demand, notice, or claim made and every summons or legal process received in connection with the accident or loss as soon as reasonably possible.
C. Duty to Cooperate with Us
You and any person seeking coverage shall cooperate with us and, when asked, assist us in:
1. investigating;
2. defending;
3. making settlements;
4. securing and giving evidence;
5. attending, and getting witnesses to attend, hearings and trials;
6. taking signed or recorded statements, including statements under oath, and answer
all reasonable questions we
may ask, as often as we may reasonably require;
7. providing any written proof of loss we may reasonably require.
D. Other Duties Under Personal Injury Protection Coverage
The person making claim also shall:
1. give us all the details about the death injury, treatment, and
other information we request;
2. be examined by physicians chosen and paid by us as often as
we reasonably may require. A copy of the report will be sent to the person
upon written request. The person, or his or her legal representative if the person
is dead or unable to act, shall authorize us to obtain all medical
reports and records;
3. answer questions under oath when asked by anyone we name, as often
as we reasonably ask, and sign copies of the answers;
4. submit a proof of loss and PIP Application when required by us;
5. authorize us to obtain medical and other pertinent records.
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E. Other Duties Under Uninsured and Underinsured Motorists Coverage
The person making claim also shall:
1. give us all the details about the death, injury, treatment, and
other information that we request;
2. be examined by physicians chosen and paid by us as often as
we reasonably may require. A copy of the report
will be sent to the person upon written request. The person, or his or her legal
representative if the person is dead or unable to act, shall authorize us
to obtain all medical reports and records;
3. answer questions under oath when asked by anyone we name, as often
as we reasonably ask, and sign copies of the answers;
4. promptly report a hit-and-run accident to us and to the police
or the Commissioner of Motor Vehicles;
5. send us at once a copy of all suit papers if the person sues the
party liable for the accident for damages;
6. if making the claim due to an accident involving an underinsured motor
vehicle:
a. give us prompt notice if a tentative settlement is offered by the
insurer of the underinsured motor vehicle;
and
b. allow us 30 days to advance payment to the insured person in an
amount equal to the tentative settlement;
7. submit a proof of loss when required by us;
8. authorize us to obtain medical and other pertinent records.
F. Other Duties Under Comprehensive and/or Collision Coverages
When there is a loss, you or the owner of the property
also shall:
1. make a prompt report to the police when the loss is the result
of theft or larceny;
2. protect the damaged auto and/or trailer and equipment.
We will pay reasonable expense incurred to do it;
3. allow us to inspect and appraise the damaged property;
4. provide all records, receipts, and invoices and authorize us to obtain pertinent
records;
5. answer questions under oath when asked by anyone we name, as often as we reasonably
ask, and sign copies of the answers;
6. submitted proof of loss when required by us;
7. allow us to inspect and appraise the damaged property prior to
its repair or disposal.
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SECTION VI.
Conditions
A. Policy Changes
1. Premium Changes
a. The premium for this policy is based on information we have received
from you or other sources. You agree:
(1) that if any of this information material to the development of the policy premium
is incorrect, incomplete, or changed, we may adjust the premium accordingly
during the policy period;
(2) to cooperate with us in determining if this information is correct
and complete, and to advise us of changes in this information.
b. Any adjustments of your premium will be made using the rules in effect at the
time of the change. c. Premium adjustment may be made as the result of a change
in:
(1) autos insured by the policy, including changes in use;
(2) drivers (including newly licensed relatives) or driver’s marital
status; (3) coverages or coverage limits;
(4) rating territory;
(5) eligibility for discounts or other premium credits.
2. Policy Terms
The terms of this policy may be changed or waived only by:
a. an endorsement issued by us; or
b. the revision of this policy form to give broader coverage without an extra charge.
If any coverage you carry is changed to give broader coverage,
we will give you the broader coverage without the issuance
of a new policy as of the date we make the change effective.
B. Cancellation
1. How You May Cancel
The named insured may cancel this policy by notifying us in writing of the date to cancel, which must be later than the date he or she mails or delivers the notification to us. We may waive these requirements by confirming the date and time of cancellation to the named insured in writing.
2. How and When We May Cancel
a. We may cancel this policy by written notice mailed to the
named insured shown in the declarations at the address shown in this
policy and to the producer of record.
b. We may cancel this policy for fraud or if the insured knowingly
provides materially false or misleading information in connection with any application
for insurance, renewal of insurance, or claim for benefits under an insurance policy.
c. The notice will be mailed to you at least:
(1) 10 days before the cancellation date, if notice is mailed during the first 60
days this policy is in effect and if this is not a renewal policy;
33
(2) 15 days, but no more than 30 days, before the cancellation date if the cancellation
is for nonpayment of premium;
(3) 20 days before the cancellation date for any other reason.
The effective date of cancellation stated in the notice shall become the end of
the policy period.
3. If you get an insurance policy that provides any coverage for
your private passenger auto that is similar to any coverages provided
by this policy, we will cancel the similar coverages on this policy
upon our receipt of proper notice. We will cancel such
coverages effective on the effective date of the other insurance policy.
4. Return of Unearned Premium
If this policy is cancelled, you may be entitled to a refund of unearned
premium. Any premium refund will be computed according to our manuals.
Delay in the return of unearned premium does not effect the cancellation.
C. Renewal/Nonrenewal
1. How and When We May Renew This Policy
a. We will mail an offer to renew this policy at least 45 days,
but not more than 60 days, prior to the expiration date of this policy to the
named insured shown in the declarations at the address shown in this
policy and to the producer of record.
b. The notice will specify the renewal premium and payment options.
c. Failure to pay the required renewal premium when due shall mean that you
have not accepted our offer.
d. If you do not accept our offer, this policy will
automatically terminate at the end of the current policy period.
e. If your renewal payment is justifiably dishonored by a financial
institution, no coverage shall be provided by us
after the expiration of this policy.
2. How and When We May Nonrenew This Policy
We will not renew this policy if you cease to be a qualified applicant as defined in our manuals. We will mail or deliver to the named insured shown in the declarations at the address shown in this policy and to the producer of record a notice of nonrenewal of this policy 60 days prior to the expiration date of this policy.
D. Our Right to Recover Payments
1. Uninsured and Underinsured Motorist Coverage
a. If the bodily injury or property damage results from
an accident involving an uninsured motor vehicle: (1) we
are subrogated to the extent of our payments to the proceeds of
any settlement the injured person
recovers from any party liable for the bodily injury or property
damage;
(2) if the person to or for whom we have made payment has not recovered
from the party at fault, he or she shall:
(a) keep these rights in trust for us;
(b) execute any legal papers we need;
(c) when we ask, take action through our representative
to recover our payments.
We are to be repaid our payments, costs, and fees of collection out of any recovery.
b. If the bodily injury or property damage results from an accident involving an underinsured motor vehicle to the extent of our payment:
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(1) we have subrogation rights;
(2) the insured shall assign to us any judgment obtained by the insured
against the parties liable for the bodily injury or property
damage.
If the insured has not recovered from the parties at fault, he or she shall: (1)
keep these rights in trust for us;
(2) execute any legal papers we need;
(3) when we ask, take action through our representative
to recover our payment.
We are to be repaid our payments, costs and fees of collection out of any recovery.
If we are notified of a tentative settlement offer from the insurer
of an underinsured motor vehicle to an insured claimant, we
may advance a payment equal to such settlement offer to the insured claimant.
Such payment will be separate from any payment under Uninsured or Underinsured Motorists
Coverage and will be subject to our rights to recover payments.
We lose our rights to recover payments if we
fail to advance such payment to the insured claimant within 30 days after we
are notified of the settlement offer.
2. All Other Coverages
a. For all other coverages, the right of recovery of any party we
pay passes to us. Such party shall: (1) not hurt our
rights to recover;
(2) help us get our money back.
However, our rights to recover under Comprehensive and Collision Coverages
do not apply to any person while using an auto or trailer
with your consent.
b. We are to be repaid our payments out of the proceeds
of any settlement the injured person recovers from any legally responsible party.
E. Suit Against Us
1. There is no right of action against us under any coverage until
all the terms of this policy have been met. In addition, there is no right of action
against us under the Property Damage Liability Coverage until:
a. we agree in writing that the insured has an obligation to pay;
or
b. the amount of damages an insured is legally liable to pay has been finally determined
by judgment after trial.
2. This policy does not provide any right to a person or organization to bring a
cause of action against us under any coverage to determine an insured’s
liability.
F. Change Of Interest
1. No assignment of interest in this policy is effective unless we
consent in writing. However, if the policyholder named on the policy declarations
dies, for the remainder of the current policy period we will protect
as named insured:
a. the surviving spouse by marriage or domestic partner by civil union, if residing
primarily with the named insured at the time of death;
b. the legal representative of the deceased policyholder while acting within the
scope of his or her duties.
2. Our notice requirements are met by mailing any notices to the deceased
named insured’s last known address.
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G. Bankruptcy Or Insolvency
Bankruptcy or insolvency of the insured or his or her estate shall not relieve
us of our obligations under this policy. H. Past
Premium Payment Obligations
We may deduct from your deposit premium any unpaid premium owed to us by you for a prior policy issued by us. Any deduction from the deposit premium made in accordance with the foregoing may be applied to the unpaid premium balance for such prior policy and you will be billed for any required additional deposit premium or a cancel- lation notice will be issued.
I. Limitation On Lawsuit Option
You and any relatives, who are not named insureds under another policy, may not maintain a suit for tort liability for non-economic loss for an accident arising out of the maintenance, operation, or use, including loading or unloading, of an auto to which N.J.S.A. Section 39:6A-8 applies, unless you or such relative has sustained a bodily injury that results in death; dismemberment; significant disfigurement or significant scarring; displaced fractures; loss of a fetus; or a permanent injury within a reasonable degree of medical probability, other than scarring or disfigurement.
J. Concealment or Fraud
There is no coverage under this policy if you or any other person
insured under this policy has made false statements, with the intent to conceal
or misrepresent any material fact or circumstances in connection with any claim
under this policy.
K. Joint Ownership
If applicable, it is agreed that your policy is changed as follows:
I. Section I. Definitions Applicable To All Sections
The following definition is changed to read as follows:
You or Your means the persons named as insureds on the policy declarations.
II. Section IV. A-Liability Coverage
If the persons named as insureds on the policy declarations do not reside primarily
in the same household, Liability Coverage is changed as follows:
A. Section IV.A.2d is changed to read:
d. Other Autos
The Liability Coverage extends to the use, by an insured, of a newly acquired
private passenger auto, or a
temporary substitute private passenger auto. B. Section A.3. is changed to read:
3. Who Is an Insured
For your private passenger auto, a newly acquired private passenger
auto, or a temporary substitute private passenger auto, insured
means:
a. you;
b. your relatives;
c. any other person while using such an auto if its use is with
your consent;
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L. Additional Insured-Lessor
It is agreed that for the auto specified in the policy declarations
as having an additional insured-lessor, your policy is changed as
follows:
I. Liability Coverage
The lessor identified in the declarations is an insured for the specified auto or a temporary substitute vehicle for such auto furnished by the lessor. However, this coverage only applies for acts and omissions of you, your relatives and any other person, except such lessor and his employees and agents, using such auto with your consent. This endorsement does not increase our Limit of Liability.
II. Cancellation
We will give the same advance notice of cancellation to the lessor as we give to the named insured.