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Home My WebLink About03-0492IN THE COURT Of COMMON PLEAS OF CUMBERLAND COUNTY, PA CIVIL DIVISION -LAW MAXIM DEMCHAK, Plaintiff VS. LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendant TYPE OF CASE: Civil TYPE OF PLEADING: Complaint FILED ON BEHALF OF: Plaintiff COUNSEL OF RECORD FOR THIS PARTY: David R. Thompson, Esquire Attorney at Law Supreme Court I.D. 73053 308 Walton Street, Suite 4 P.O. Box 587 Philipsburg PA 16866 (814) 342-4100 IN THE COURT OF COMMON MAXIM DEMCHAK, Plaintiff VS. LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendant PLEAS OF CUMBERLAND COUNTY CIVIL DIVISION * No. - 02- NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Courthouse Carlisle PA 17013 ~7)ld ~~~~h~o'0m~'0~so~, E sq uire IN THE COURT OF COMMON MAXIM DEMCHAK, Plaintiff VS, LIBER-rY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendant PLEAS OF CUMBERLAND COUNTY CIVIL DIVISION No.- ¢OAI,oUIJ'NI' AND NOW, comes the Defendant, Maxim Demchak, by and through his attorney, David R. Thompson, Esquire, and files the following Complaint against Defendants to which the following is averred: 1. Plaintiff is Maxim Demchak, an adult individual, with a residential address of 125 Clay Road, Carlisle, Cumberland County, Pennsylvania, 17013. 2. Defendant Liberty Mutual Group is believed to be a business corporation, incorporated under the Laws of the Commonwealth of Massachusetts, with a corporate headquarters located at 175 Berkeley Street, Boston, Massachusetts, 02117. 3. Defendant Liberty Mutual is believed to be a business corporation, incorporated under the Laws of the Commonwealth of Massachusetts, with a corporate headquarters located at 175 Berkeley Street, Boston, Massachusetts, 02117. 4. Defendant Liberty Mutual Insurance Group is believed to be a business corporation, incorporated under the Laws of the Commonwealth of Massachusetts, with a corporate headquarters located at 175 Berkeley Street, Boston, Hassachusetts, 02! 17. 5. Defendant Liberty Mutual Fire Insurance Company is believed to be a business corporation, incorporated under the Laws of the Commonwealth of Massachusetts, with a corporate headquarters located at 175 Berkeley Street, Boston, Massachusetts, 021!7. 6. Plaintiff purchased a policy of automobile insurance, written by Liberty Mutual Insurance Group in the early 1980's. By way of further pleading, Plaintiff maintained said policy during all relevant times contained herein. Said policy number is A02-281-473850- 809-8. 7. This policy was issued to provide insurance coverage pursuant to the Motor Vehicle Financial Responsibility Law (MVFRL) of the Commonwealth of Pennsylvania. 8. On or about May 11, !999, Plaintiff received from Liberty Mutual Fire Insurance Company a renewal notice regarding coverage limits for said policy. 9. Subsequent to receiving said renewal notice, Plaintiff had questions regarding the renewal notice he received from Liberty Mutual. Plaintiff attempted on three separate occasions to contact his insurance agent, R. W. Christ. His calls were not taken and he received no return call. 10. Since time was running out regarding the renewal notice he received, Plaintiff contacted a Liberty Mutual Processing Office in Nechanicsburg, Pennsylvania and spoke with an individual there regarding this policy. By way of further pleading, Plaintiff indicated that the liability limits were insufficient for his needs. Additionally, the individual at Liberty Mutual Processing Office indicated that they had not received Plaintiff's uninsured and forms. By way of further pleading, the pages on these documents read respectfully Page 2 of 4, 3 of ,~, and z[ of ~,. By way of further pleading, Plaintiff did not receive Page I of 4 at the time these forms were mailed to him, and did not receive the same until on or about the Fall of 2001, as stated in Paragraph 16 herein. 16. Several months prior to filing this Complaint, the Plaintiff visited Liberty Mutual Processing Office and questioned the numbering of the forms he had received back in 1999. By way of further pleading, it was at this time that Plaintiff received Page I of 4 of the Pennsylvania Uninsured Motorist Coverage and Underinsured Motorist Coverage Option Form. (A true and correct copy of that said page is attached hereto and marked as Plaintiff's Exhibit "D'% 17. As instructed, Plaintiff signed the uninsured and underinsured motorist coverage amount selection form on or about May 30, 1999 and returned the same to Liberty Mutual. Some time after May 30, 1999, the Plaintiff received the three page Endorsement, the uncompleted split underinsured motorist limits/Pennsylvania/non-stacked form, the uncompleted split uninsured motorist limits/Pennsylvania/non-stacked form, the document indicating this Endorsement changes the policy regarding uninsured motorist coverage, the document indicating this Endorsement changes the policy regarding underinsured motorist coverage, all which included an issue date of May 24, 1999. (A true and correct copy of the entire packet is attached hereto and marked as Plaintiff's Exhibit "E). 18. It is submitted that Plaintiff did not have this instructional information available to him at the time that he entered into the contract due to the fact that Liberty Mutual failed to send these document to him in the desired and required sequence. 19. Plaintiff desired to explore the meaning of the documents by contacting his agent on different occasions, but never received a contact back from said agent. 20. Plaintiff has discussed his insurance agent's conduct with individuals within Liberty Mutual, who responded that he does not return telephone calls to existing Liberty Mutual customers for the purpose of answering questions, due to the fact that he is a salesman. 21. Pursuant to the language of the MVFRL, the statute was amended to provide for certain required coverage and certain permissive coverage. 22. Pursuant to the MVFRL, the Plaintiff was required to be offered protection for uninsured motorist coverage and underinsured motorist coverage, and for the option of stacking the same. Title 75 P.S. § 1738, requires that certain rejection forms or waiver forms of said stacking of coverage be in form, language, and content provided by the MVFRL legislation, and that the same must be signed and dated prior to delivering the policy to the insured. 23. Pursuant to the MVFRL, Title 75 P.S. § 1738, stacking of underinsured coverage is provided, unless specifically waived by the named insured. 24. Title 75 P.S. § 1791 requires that a Notice of Available Benefits and Limits must be submitted to an insured by the insurer prior to entering into any policy or change thereof. 25. The information page (Page i of 4) of the Pennsylvania Uninsured Motorist Coverage and Underinsured Motorist Coverage Option form was not mailed to Plaintiff to afford him the benefit of an informed decision. 26. Plaintiff additionally sought information and advice from his agent, but did not receive contract from him. 27. The Plaintiff specifically had questions regarding the renewal of his insurance, as well as the changes being made by the Endorsement thereto, but was unable to have those questions answered prior to the time limit expiring for completing said insurance policy issuance. 28. The policy and procedure regarding the stacking of uninsured and underinsured motorist coverage is inherently confusing, as there exists no form to be signed by an insured opting to select such stacking coverage, nor is it clearly stated that stacking coverage exists if it is not waived. 29. On or about November 7, 1999, Plaintiffwas involved in an automobile accident that occurred in Decatur Township, Clearfield County, Pennsylvania. 30. An action has been filed by the Plaintiff against the Tort Feasor of that action, Dolores Shook, docketed in the Clearfield County Court of Common Pleas to No. 01-1800- CD. 31. As a direct and proximate result of the automobile accident, Plaintiff sustained serious, permanent bodily injury. 32. Pursuant to the said claim made in the Court of Common Pleas of Clearfield County, it is believed that the third party carrier will agree to pay the policy limits under the automobile liability insurance policy of Dolores Shook. 33. The amount of the policy limits provided by the third party carrier is insufficient and inadequate to compensate for all of the damage and injuries which Plaintiff and his passengers sustained, nor all of the economic Joss which was suffered. 34. Pursuant to the provisions of the MVFRL, the insurer in this case has failed to produce sufficient evidence of compliance with the provisions of the MVFRL with regard to the issuance of uninsured motorist coverage, underinsured motorist coverage and the stacking thereof. At the time of the said accident, Plaintiff had three motor vehicles insured under said policy. 35. Under the policy and based upon the negligent and reckless behavior of Defendants, Plaintiff had uninsured/underinsured motorist coverage only in the amount of $100,000/$300,000. 36. Plaintiff's uninsured/underinsured protection coverage should be $300,000 each person and $900,000 each accident pursuant to Title 75 P.S. § 1738, Stacking of Underinsured Motorist Coverage. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter a Decree declaring: a. That the Defendant Liberty Mutual Insurance Company has failed to adhere to the strict provisions of the MVFRL with regard to assuring that the voluntary and knowing decision is made for the issuances of coverage for Plaintiff's automobile insurance policy; b. That the Plaintiff had three automobiles insured under policy No. A02-281- 473850-8098; c. That the Plaintiff is entitled in underinsured motorist coverage in the amount of $300,000 per person and $900,000 per accident; d. Attorney fees, interest and costs of suit as permitted by law; e. Such further relief as the Court deems proper and just. Respectfully submitted, David R. Thompson, Esquire Attorney for Plaintiff Plaintiff verifies that the statements made in this COMl~l..4IIIfl'are true and correct. ! understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. Maxir~ Demchak LIBERTY MUTUAL FIRE INSURANCE COMPi~NY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS ~OLICY NUMBER AO2-281-473850-809 8 I THESEDECLARATIONSEFFECTIVEI 06/15/99 J NAMEDINSUREDAND MAILING ADDRESS MAXIM DEMCHAK 591 1 GENEVA DR MECHANI CSBURG PA 17055 RENEWAL ~1,,1~ ~,.~,~ ~-/~.¥{~? FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 POLICY PERIOD: 06/15/99 TO 06/15/00 12:01AM STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED IN THE POLICY. THIS POLICY SHALL EXPIRE ON THE DATE SHOWN EXCEPT THAT IT MAY BE CONTINUED IN FORCE FOR SUCCESSIVE POLICY PERIODS BY THE PAYMENT OF THE REQUIRED RENEWAL PREMIUM. EACH SUCH POLICY PERIOD SHALL Bk FOR THE PERIOD SPECIFIED IN THE RENEWAL DECLARATIONS. MATURE DRIVER DISCOUNT APPLIED FOR PRINCIPAL OPERATORS AGED 40-64 COVERAGES AND LIMITS UNDER YOUR AUTO POLICY: PART A.LIABILITY BODILY INJURY PROPERTY DAMAGE C.UNINSURED MOTORISTS BODILY INJURY UNDERINSURED MOTORISTS BODILY INJURY COVERAGE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE $ 100,000 EACH PERSON $ 300,000 EACH ACCIDENT $ 50,000 EACH ACCIDENT $ 100,000 EACH PERSON $ 300,000 EACH ACCIDENT $ 100,000 EACH PERSON $ 300,000 EACH ACCIDENT VEH 1 VEH 2 VEH 3 $ 161 164 147 VEH 4 $ 31 31 31 $ 90 90 90 FULL TORT OPTION SELECTED FIRST PARTY BENEFITS 10,000 MEDICAL EXPENSE 2,500 FUNERAL EXPENSE 5,000 INCOME LOSS 0 ACCIDENTAL DEATH D.COVERAGE FOR DAMAGE TO YOUR AUTO OTHER THAN COLLISION ACTUAL CASH VALUE LESS DEDUCTIBLE SHOWN: VEH 1 $ 100 VEH 2 $ 100 VEH 3 $ 100 VEH 4 $ 50 COLLISION ACTUAL CASH VALUE LESS DEDUCTIBLE SHOWN: VEH 1 $ 500 VEH 2 $ 500 VEH 3 $ 500 VEH 4 $ 100 THIS POLICY COVERS COLLISION DAMAGE TO RENTAL VEHICLES. 65 3116 2 79 "~0 JACKET 3075 1289 RESTRAINT EXHIBIT $ 40 49 44 $ 26 25 141 22 $ 80 71 197 34 ' 000 4 YY]~ 8 001 00 N 00014 IYY~8 100111 000 4 IN0q5 100111 000 0 XXi~ 0 O0 1 O0 N LIBERTY MUTUAL FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETT~ . ~OLICYNUMBER AO2-281-473850-809 ~1 THESEDEC~RATIONSEFFECTIVEI 06/15/99 J '-NAMEDINSUREDANDMAILINGADD~ESS MAXIM DEMCHAK 591 1 GENEVA DR MECIiANICSBURG PA 17055 RENEWAL PAGE 02 FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 (CONTINUED FROM PREVIOUS PAGE) OPTIONAL COVERAGE TOWING AND LABOR COST - $50 EACH DISABLEMENT $ EXTENDED TRANSPORTATION EXPENSES $15/$450 $ 6 6 6 12 12 12 ANNUAL PREMIUM PER VEHICLE: $ 446 448 668 56 SAFE DRIVER INSURANCE PLAN CREDIT: AS A RESULT OF: VIOLATION SC0 NO SURCHARGE ACCIDENT SC0 NO SURCHARGE TOTAL ANNUAL POLICY PREMIUM:' $ 1618.00 ENDORSEMENTS ATTACHED TO YOUR POLICY: 2330 2323 PP 05 51 11 92 PP 04 22 07 90 AS2049 02 96 AS2067 08 97 PP 04 18 07 90 AS2051 12 98 PP 03 03 04 86 PP 03 09 04 86 AS1046 12 89 PP 03 02 12 89 PP 03 08 04 86 CHANGE OF FACSIMILE SIGNATURE ANNUAL MEETING DATE CHANGE PENNSYLVANIA FIRST PARTY BENEFITS COVERAGE ENDORSEMENT SPLIT UNINSURED MOTORISTS LIMITS PENNSYLVANIA (STACKED) UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (STACKED) AMENDMENT OF POLICY PROVISIONS - PENNSYLVDRNIA SPLIT UNDERINSURED MOTORISTS LIMITS PENNSYLVANIA (STACKED) UNDERINSURED MOTORIST COVER3tGE(STACKED)-PENNSYLVANIA TOWING AND LABOR COST COVERAGE SPLIT LIABILITY LIMITS AUTOMATIC TERMINATION ENDORSEMENT EXTENDED TR3tNS~ORTATION EXPENSES COVERAGE COVERAGE FOR D .A!~AGE TO YOUR AUTO VEHICLES COVERED BY YOUR POLICY: VEH YR MAKE 1 90 VOLV 2 85 CHEV 3 83 MRBZ 4 79 BOLE RATING RATING MODEL IDENTIFICATION # CLASS STATE TERRITORY SYMBOL 240 YV1AA8857L1858445 07 PA 37 027 05 CAV TYP 1G1JE67W4F7214338 27 PA 37 027 10 380 WDBBA45A7DB026246 48 PA 37 027 21 725153 00 PA 37 00 YOUR PREMIUM REFLECTS THE FOLLOWING. IF INCORRECT, CONTACT YOUR SERVICE OFFICE. CLASS 00 VEHICLE TYPE INELIGIBLE FOR CLASS ASSIGNMENT. 1 01 0000 000 4 YY' 8 0C 1 00 N 2 01 0000 000 4 YY] 8 0£ 1 00 N 3 01 0000 000 4 N0£ 5 0C 1 00 N 4 05 000C 000 0 XX~ 0 0C 1 00 N ~ACKET 3075 1289 RESTRAINT 2555 LIBERTY MUTUAL FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS °OLIC¥ NUMBER AO2-281-473850-809 8 I THESEDECLARATIONSEFFECTiYEI 06/15/99 I ~'NAMED INSUREDAND MAILING ADDRESS MAXIM DEMCHAK 591 1 GENEVA DR MECHANI CSBURG PA 17055 RENEWAL PAGE 03 FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 CLASS CLASS CLASS (CONTINUED FROM PREVIOUS PAGE) 07 PREFERRED'RATE - PLEASURE USE - NO YOUTHFUL OPER3tTORS - COMMUTING LESS THAN 3 MILES ONE WAY - PRINCIPAL OPERATOR AGE 40-64. 27 PREFERRED RATE - NO YOUTHFUL OPERATORS COMMUTING LESS TH_AN 3 MILES ONE WAY - USES AUTO LESS THAN 7500 MILES ANNUALLY - NO PRINCIPAL OPERATOR AGE 40 OR OVER. 48 PREFERRED RATE - NO YOUTHFUL OPERATORS - COMMUTING LESS THAN 3 MILES ONE WAY - USES AUTO LESS THAN 7500 MILES ANNUALLY - PRINCIPAL OPERATOR AGE 40-64. VEH 1,2,3,4 GARAGED AT NAMED.INSURED,S ADDRESS THE FOLLOWING DISCOUNTS DISPLAYED WITH "YES" HAVE BEEN APPLIED TO YOUR POLICY. THE DISCOUNTS INDICATED AS "NO" HAVE NOT BEEN APPLIED TO YOUR POLICY. IF YOU BELIEVE THAT YOU MAy BE ELIGIBLE FOR ANY DISCOUNT(S) LISTED AS "NO", PLEASE CONTACT YOUR LOCAL SALES OR SERVICE REPRESENTATIVE SHOWN ON THE FIRST PAGE OF YOUR POLICY DECLARATIONS. DISCOUNTS: VEH 1 VEH 2 VEH 3 VEH 4 ANTI-LOCK BRAKES NO NO NO NO ANTI-THEFT DEVICE(S) NO NO NO NO DEFENSIVE DRIVER COURSE NO NO NO NO DRIVER TRAINING NO NO NO NO GOOD STUDENT NO NO NO NO MULTI-CAR YES YES YES NO PASSIVE RESTRAINT YES NO NO NO (AUTOMATIC SEAT BELT AND/OR AIR BAGS) OPERATOR INFORMATION: NO. NAME 1 M;ExlIM DEMCHAK SPECIAL STATE PROVISIONS: DATE OF BIRTH 06/21/36 ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANy MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANy FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. '65 -- 0 05-~1 9 RY 1 o~ 0~00 000 4 ¥Y£ 8__ o~c~ O__ON 2 01 000( 000 4 YY~ 8 0C 1 00 N 3 01 0000 000 4 N01 5 0C 1 00 N 4 05 000C 000 0 XX~ 0 0G 1 00 N ~ACKET 3075 1289 RESTRAINT 2555 The following Sections of this form are for your ~election of the available Uninsured Motorists Coverage and Underinsured Motorists Coverage options. Your premium charge will vary depending on your Tort Option Selection and whether you have selected the stacked or non-stacked limit option. Your Liberty Mutuai Sales/Service Representative will provide you with the Uninsured Motorists Coverage and Underinsured Motorists Coverage premium charges for the coverage amount, Emits and options you select. Please indicate your choices by checking the appropriate box. UNINSURED AND UNDERINSURED MOTORISTS COVERAGE AMOUNT SELECTION I have checked the amount of Uninsured Motorists Coverage I wish to have: SEPARATE LIlvI1T POLICIES SINGLE LIMIT POLICIES (per person/per accident) (per accident) [] $ 15,000/ 30,000 [] $ 15,000/30,000 [] 25,000/ 50,000 ?~50,0001100,000 [] 35,000 [] 50.000 ~ 100,000/300,000 --- [] 100,000 [] 250,0001500,000 [] 300,000 [] 500.0001500,000 [] 500,000 [] 1,000,o00 I have checked the mnount of Underinsured Motorists Coverage I wi~h to have: SEPARATE LIMIT POLICIES SINGLE LIMIT POLICIES (per person/per accident) (per accident) [] $ 15.000/ 30,000 [] $ 15.000/30.000 [] 25,000~ 50,000 [] 35,000 50,000/100,000 [] 50,000 100.000/300,000 [] 100,000 [] 250,000/500,000 [] 300,000 [] 500,000/500,000 IZ] 500,000 [] 1,ooo, oo0 The Uninsured Motorists Coverage and Underinsured Motorists Coverage mnounts selected may not exceed your Bodily Injury Liability linfit. REMINDER: THE PREMIIJM CHARGE FOR THE UNINSURED MOTORISTS COVERAGE AND/OR LrNDERINSURED MOTORISTS COVERAGE LIMIT YOU SELECT WILL REI~ECT TORT OPTION AND STACKED OR NON-STACKED LIMIT OPTION YOU FiAVE CHOSEN. "I am aware that my selections apply to myself and all family membem residing in my household. I am also aware that my selections apply throughout the policy period regardless of any change such as the replacement or addition of vehicles or drivers, and my s~lection also applies to all future renewals or reinstatements of this policy unless I indicate otherwise Liberty Mutual in writing." NAME AND ADDRESS: (Please Print) POLICY NUMBER: ~..'"( _n.~,~ .~ SIGNATURE(S): Pg. 2of4 REJECTION OF UNINSURED MOTORISTS PROTECTION By signing this waiver, I am rejecting Uninsured Motor]sm Coverage under th.is policy, for myself and all relatives residing in my household. Uninsured coverage protects me and relatives living ia my household for losse,~ and damages suffered if iujury is caused by the negligence of a d~iver who does not have any insurance to pay for losses and damages. I knowingly and voluntarily reject this coverage. Signature of First Named Insured* Date UNINSURED COVERAGE LEM. ITS qy signing this waiver. I am rejecting stacked limits of Uninsured Motorists Coverage under the policy for myself and .embers of my household under which the I[mits of coverage available would be the sum of limits for each motor vehicle insured under the policy. Instead the limits of coverage that ! am purchasing shall be reduced to the IJn~ts stated in the policy. ~ knowingly and voluntarily reject the stacked lireits of coverage. I under~tand that my prer~iums will be reduced if I reject this coverage. '-Signature of First .Named Insured* Date *The First Named Insured listed on the policy must sign and date the waiver for it to be valid. PMKT 100 R2 Pg. 3 al4 REJECTION OF UNDERINSURED MOTORISTS PROTECTION By signing this waiver, I am rejecting Underinsured Motorists Coverage under this policy, for myself and ail relatives residing in my household. Underinsured coverage protects me and relatives living in my household for losses and damages suffered if injury is caused by the negligence of a driver who does not have enough insurance to pay for all losses and damages. I knowingly and voluntarily reject this coverage. Signature of First Named Insured* Date UNDERINSURED COVERAGE LIMITS :ning this waiver, I am rejecting stacked limits of Underinsured Motorists Coverage under the policy for myself and ~ oers of my household under which the limits of coverage available would be the sum of limits for each motor vehicle insured under the policy. Instead the limits of coverage that I am purchasing shall be reduced to the limits stated in the policy. I knowingly and voluntarily reject the stacked limits of coverage. I understand that my premiums will be reduced if I reject this coverage. Sigr~atu~e of First Named Insured* Date *The First Named Insured listed on the policy must sign and date the waiver for it to be valid. PMICr 100 112 Pg. 4 of 4 LIBERTY MUTU~J~ FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON., MASSACHUSETTS ~oucY NUMBER ~"' A02-281-473850-809 8 I NAMED INSURED AND IL4JLING ADDRESS MAXIM DEMCHAK 591 i GENEVA DR MECHANICSBURG PA 17055 THESE DECUMMTIONS EFFECTIVE FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 POLICY PERIOD: 06/15/99 TO 06/15/00 12:01AM STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED IN THE POLICY. CHANGES MADE: ADD NON-STACKED VEH 1,2,3 CHANGE LIABILITY*VEH 1,2,3 CHANGE CLASS*VEH 2 PREMIUM ADJUSTMENT FROM 06/15/99 TO 06/15/00: VEH 1 VEH 2 VEH 3 $ 13CR 47CR 15CR TOTAL ADJUSTMENT: $ 75.00CR VEH 4 COVERAGES AND LIMITS UNDER YOUR AUTO POLICY: PART A.LIABILITY BODILY INJURY PROPERTY DAMAGE C.UNINSURED MOTORISTS BODILY INJURY UNDERINSURED MOTORISTS BODILY INJURY COVERAGE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE VEH 1 VEH 2 VEH 3 VEH 4 $ 184 168 168 250,000 EACH PERSON 500,000 EACH ACCIDENT 100,000 EACH ACCIDENT $ 100,000 EACH PERSON 300,000 EACH ACCIDENT 100,000 EACH PERSON 300,000 EACH ACCIDENT 27 27 27 58 58 58 FULL TORT OPTION SELECTED FIRST PARTY BENEFITS 10,000 MEDICAL EXPENSE 2,500 FUNERAL EXPENSE 5,000 INCOME LOSS 0 ACCIDENTAL'DEATH D.COVERAGE FOR DAMAGE TO YOUR AUTO OTHER THAN COLLISION ACTUAL CASH VALUE LESS DEDUCTIBLE SHOWN: VEH 1 $ 100 VEH 2 $ 100 VEH 3 $ 100 VEH 4 $ 50 COLLISION $ 40 44 44 $ 26 22 141 22 $ 80 64 197 34 Including all endorsements attached Is countersigned by: AUTHORIZED REPRESENTATIVE POLICY NUMBER LIBERTY MUTUAL FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS I A02-281-473850-809 81 NAMED INSURED AND MAIUNG ADDRESS MAXIM DEMCHAK 591 1 GENEVA DR MECHANICSBURG PA 17055 THESE DECLARATIONS EFFECTIVE PAGE 03 FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800'362-5698 (CONTINUED FROM PREVIOUS PAGE) YOUR PREMIUM REFLECTS THE FOLLOWING. IF INCORRECT, CONTACT YOUR SERVICE OFFICE. CLASS 00 VEHICLE TYPE INELIGIBLE FOR CLASS ASSIGNMENT. CLASS 07 PREFERRED RATE - PLEASURE USE - NO YOUTHFUL OPERATORS - COY~3TING LESt THAN 3 MILES ONE WAY - PRINCIPAL OPERATOR AGE 40-64. CLASS ONE WAY - USES AUTO LESS : 00 MILES iU .' ALL -'PRINCIPAL AGE 40-64. VEH 1,2,3,4 GARAGED AT NAMED INSURED'S ADDRESS THE FOLLOWING DISCOUNTS DISPLAYED WITH "YES" HAVE BEEN APPLIED TO YOUR POLICY. THE DISCOUNTS INDICATED AS "NO" HAVE NOT BEEN APPLIED TO YOUR POLICY. IF YOU BELIEVE TEAT YOU MAY BE ELIGIBLE FOR ANY DISCOUNT(S) LISTED AS "NO", PLEASE CONTACT YOUR LOCAL SALES OR SERVICE REPRESENTATIVE SHOWN ON THE FIRST PAGE OFYoUR POLICY DECLARATIONSi DISCOUNTS: VEH 1 VEH 2 VEH 3 VEH 4 ANTI-LOCK BRAKES NO ANTI-THEFT DEVICE(S) NO DEFENSIVE DRIVER' COURSE NO DRIVER TRAINING NO GOOD STUDENT NO MULTi-CAR · YES PASSIVE RESTRAINT YES (AUTOMATIC SEAT BELT AND/OR AIR BAGS) ' NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO YES .: YES NO i NO. NO NO OPERATOR INFORMATION: NO. NAME 1 MAXIM DEMCHAK DATE OF BIRTH 06/21/36 SPECIAL STATE PROVISIONS: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COI~4ITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. This policy, Including all endorsements attached Is countersigned by: PERSONAL AUTO PP 04 16 07 g0 SPLIT UNDERINSURED MOTORI$T$ LIMITS -PENN$YLVANIA (NON-STACKED) SCHEDULE UNDERINSURED MOTORISTS COVERAGE each person each accident Paragraph A. of the Limit of Liability provision in the Underlnsured Motorists Coverage - Pennsylva- nia (Non-Stacked) endorsement is replaced by the following: LIMIT OF LIABILITY A. The limit of liability shown in the Schedule or In the Declarations for each person for Underin- sured Motorists Coverage is our maximum limit of liability for all damages, Including damages for care, loss of services or death, arising out of 'bodily Injury' sustained by any one person in any one accident. Subject to this limit for each person, the limit of liability shown in the Schedule or in the Declarations for each acci- dent for Underinsured Motorists Coverage is our maximum limit of liability for all damages for 'bodily injury' resulting from any one accident. This is the most we will pay regardless of the number of: 1. 'lnsureds'; 2. Claims made; 3. Vehicles or premiums shown in the Declara- tions; or 4. Vehicles involved in the accident. This endorsement must be attached to the Change Endorsement when issued alter the policy is written. PP 04 16 07 90 Copyright, Insurance Services Office, Inc., 1990 Page 1 of 1 PERSONAL AUTO PP 04 20 07 90 SPLIT UNINSURED MOTORIST8 LIMIT8 - PENN8YLVANIA (NON-8TACKED) SCHEDULE UNINSURED MUiURISTS COVERAGE $ each person each accident Paragraph A, of the Limit of Liability provision in the Uninsured Motorists Coverage - Pennsylvania (Non-Stacked) endorsement is replaced by the following: LIMIT OF LIABILITY A. The limit of liability shown in the Schedule or in the Declarations for each person for Uninsured Motorists Coverage is our maximum limit of li- ability for all damages, including damages for care, loss of services or death, arising out of 'bodily injury' sustained by any one person in any one accident. Subject to this limit for each person, the limit of liability shown in the Schedule or in the Declarations for each acci- dent for Uninsured Motorists Coverage is our maximum limit of liability for all damages for "bodily injury' resulting from any one accident. This is the most we will pay regardless of the num- ber of: 1. 'lnsureds'; 2. Claims made; 3. Vehicles or premiums shown in the Declara- tions; or 4. Vehicles involved in the accident. This endorsement must be attached to the Change Endorsement when issued after the policy is written. PP 04 20 07 90 Copyright, Insurance Services Office, Inc., 1990 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) AS 2048 02 96 (PP 04 21 06 95) Part C - Uninsured Motorists Coverage is replaced by the following: SCHEDULE UNINSURED MOTORISTS COVERAGE Descril~[ion Limit of of Vehicle Uabllity Premium $ $ $ $ $ INSURING AGREEMENT A. We will pay compensatory damages which an 'insured' is legally entitled to recover from the owner or operator of an 'uninsured motor ye- hicle' because of 'bodily injury': 1. Sustained by an 'insured'; and 2. Caused by an accident. The owner's or operator's liability for these damages must arise out of the ownership, maintenance or use of the 'uninsured motor vehicle'. No judgment for damages arising out of'a suit brought against the owner or operator of an 'uninsured motor vehicle' is binding on us unless we: 1. Received reasonable notice of the pen- dency of the suit resulting In the judgment; and 2. Had a reasonable opportunity to protect our interests in the suit. B. 'Insured' as used in this endorsement means: 1. You or any 'family member'. 2. Any other person 'occupying' 'your cov- ered auto'. 3. Any person for damages that person is entitled to recover because of 'bodily in- jury' to which this coverage applies sus- tained by a person described in 1. or 2. above. C. "Uninsured motor vehicle' means a land motor vehicle or trailer of any type: 1. To which no bodily injury liability bond or policy applies at the time of the accident. 2. Which is a hit-and-run vehtcle whose operator or owner cannot be identified and which hits or which causes an accident re- sulting in 'bodily injury' without hitting: a. You or any 'family member'; b. A vehicle which you or any "family member' are 'occupying'; or c. 'Your covered auto'. If there is no contact with the hit-and-run vehicle, the facts of the accident must be proved. :~. To which a bodily Injury liability bond or policy applies at the time of the accident but the bonding or insuring company: a. Denies coverage; or b. Is or becomes: (1) Insolvent; or (2) Involved in insolvency proceedings. However, 'uninsured motor vehicle' does not include any vehicle or equipment: 1. Owned by or furnished for the regular use of you or any 'family member". 2. Owned or operated by a self-insurer under any applicable motor vehicle law, except a self-insurer which is or becomes insolvent. 3. Owned by any governmental unit or agency. 4. Operated on rails or crawler treads. 5. Designed mainly for use off public roads while not on public roads. 6. While located for use as a residence or premises. EXCLUSIONS A. We do not provide Uninsured Motorists Cover- age for 'bodily injury' sustained: 1. By you while 'occupying', or when struck by, any motor vehicle you own which is not insured for this coverage under this policy. This includes a trailer of any type used with that vehicle. 2. By a 'family member': e. Who owns an auto, while 'occupying', or when struck by, any motor vehicle owned by you or any 'family member" which is not insured for this coverage under this policy, This includes a trailer of any type used with that vehicle. b. Who does not own an auto, while 'occupying', or when struck by, any motor vehicle you own which is Insured for this coverage on a primary basis un- der any other policy. B. We do not provide Uninsured Motorists Cover- age for 'bodily injury' sustained by any person: Page I of 3 PF (PP 04 2~ 06 951 If two or more policies have equal priority, the insurer against whom the claim is first made shall process and pay the claim as if wholly responsible for all Insurers with equal priority. The insurer is thereafter entitled to recover contribution pro rata from any other insurer for the benefits paid and the costs of processing the claim. If we are the insurer against whom the claim is first made, we will pay, subject to the limit of li- ability shown in the Schedule or in the Declara- tions for Uninsured Motorists Coverage, after we and all other contributing insurers agree: 1. Whether the 'insured' is legally entitled to recover· damages, from the owner or opera- -~. tor of an '.uninsured motor vehicle' and · 2:' As*to'the amoUnt of damages. ARBITRATION A~ if we and an 'insured' dO 'not agree: 1. Whether that 'insured' is legally entitled to recover damages; or 2. As to the amount of damages which are recoverable by that 'insured'; From the owner or operator of an 'uninsured motor vehicte' then the matter may be arbi- trated. Either party may make a written demand for arbitration. Arbitration shall be conducted in accordance with the provisions of the Pennsyl- vania Uniform Arbitration Act. Each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction. Arbitration shall not, however, be a means of settlement should the dispute involve: 1. Any form of inter- or Intra-policy stacking, or 2. Selection of a coverage option, or a waiver of such coverage, or 3. Determination of residency Iff defining who · is~0r is not an' insUred'under this coverage, Or ~' .:~ ". . · " 4. Statutes of limitation, Or: 5. Determination of whether a claimant is an insured under these coverages. Each party will: 1, Pay the expenses it Incurs; and 2. Bear the expenses of the third arbitrator equally. Unless both parties agree otherwise, arbi- tration will take place in the county in which the 'insured' lives. Local rules of laW as to procedure and evidence will apply. A deci- sion agreed to by two of the arbitrators will be binding. This endorsement must be attached to the Change Endorsement when issued after the Policy.is written. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1994 Page 3 of 3 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAR_~ UNDERINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-$TACKEI~ With respect to the coverage provided by this endorsement, the provisions of the policy ai~t the endorsement. SCHEDULE UNDERINSURED MOTORISTS COVERAGE Description Limit of of Vehicle Liability Premium $ $ INSURING AGREEMENT A. We will pay compeusato~y damages which an "insured" is legally entitled to recover from the owner or operator of an "underinsured motor vehi- cie" because of "bodily injury": 1. Sustained by an "insured"; and 2. Caused by an accident. The owners or operator's liability for these dam- ages must arise out of the ownership, maintenance or use of the "underinsured motor vehicle". We will pay under this coverage only if 1. or 2. below applies: 1. The limits of liability under any applicable bodily injury liability bends or policies have been exhausted by payment of judgments or settlements; or 2. A tentative settlement has been made between an "insured" and the insurer of the "underinsored motor vehicle" and we: a. Have been given prompt written notice of such tentative settlement; and b. Advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. No jud~i~ent for damages arising out of a suit brought against the owner or operator of an "underinsured motor vehicle" is binding on us un- less we: 1. Received reasonable notice of the pendency of the suit resulting in the j~_!Ogment; and 2. Had a reasonable opportunity to protect our interests in the suit. B. "Insured" as used in this endorsement means: 1. You or any "£amily member". 2. Any other person "occupying" "your covered auto" . 3. Any person for damages that person is entitled to recover because of "bodily injmT" to which this coverage applies sustained by a person de- scribed in 1. or 2. above. C. "Underinsured motor vehi~ vehicle or trailer of any ty~ ju~y liability bond or poli¢- the accident but the emounl under that bond or policy'- enough to pay the full amm gaily entitled to recover as. However, ~underinsured m include any vehicle or equi_- 1. For which liability cow. Part A of this policy. 2. Owned by any governs. 3. Operated on rails or cra~ 4. Designed mainly for um not on public roads. 5. While located for use ises. EXCLUSIONS A. We do not provide Under- age for "bodily injmy" sus= 1. While "occupying" a you or a "family mca_ deriusured Motorists m icy; nor to "bodily inj~ such motor vehicle. 2. By a "family member" a. Who owns an ant- when struck by, an- you or any "famill insured for this c,-~ This includes a tra_ that vehicle. b. Who does not "occupying", or ~v- vehicle you own coverage on a prim policy. B. We do not provide Unde~ age for "bodily injury" sc= THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. UNI}ERINSURED MOTORISTS COVERAGE - PENNSI'LV IA (NON-STACKED) AS 2050 12 98 0'P 04 oa 95) With respect to the coverage provided by this ~ndors~ment, the provisions of the policy apply unless modified by the endorsement. SCHEDULE UNDERINSURED MOTORISTS COVERAGE Description Limit of of Vehicle Liability Premium $ $ $ $ INSURING AGREEMENT C. "Underinsured motor vehicle" means a laud motor A. We will I?Y compensator/ damages which an 'insured" is legally entitled to recover from the owner or operator of an "underinsured motor vehi- cle'' because of ~bodily injury": I. Sustained by an 'insured"; end 2. Caused by en accident. The owner's or operator's liability for these dam- ages must arise out of the ownership, maintenance or use of the 'underinsured motor vehicle'. We will pay under this coverage only if I. or 2. below applies: I. The limits of liability under any applicable bodily injury liability bends or policies have been exhausted by payment of judgments or settlements; or 2. A tentative settlement has been made between an "insured" and the insurer of the "underinsured motor vehicle" end we: a. Have been given prompt written notice of such tentative settlement; and b. Advence payment to the 'insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. No judgment for damages arising out of a suit brought against the owner or operator of au "underinsured motor vehicle" is binding on us un- less we: 1. Received reasonable notice of the pendency of the suit resulting in the judgment; and 2. Had a reasonable opportunity to protect our interests in the suit. B. "Insured" as used in this endorsement means: 1. You or any 'family member". 2. Any other person "occupying' "your covered auto#. 3. Any person for damages that person is entitled to recover because of "bodily injury' to which this coverage applies sustained by a person de- scribed in I. or 2. above. vehicle or trailer of any type to which a bodily in- jury liability bond or policy applies at the time of the accident but the amount paid for "bodily injm3t" under that bond or policy to an "insured" is not enough to pay the full amount the "insured" is le- gally entitled to recover as damages. However, #underinsured motor vehicle" does not include any vehicle or equipment: 1. For which liability coverage is provided under Part A of this policy. 2. Owned by any governmental unit or agency. 3. Operated on rails or crawler treads. 4. Designed mainly for use off public roads while not on public roads. 5. While located for use as a residence or prem- ises. EXCLUSIONS A. We do not provide Underinsured Motorists Cover- age for "bodily injury" sustained: 1. While "occupying" a motor vehicle owned by you or a "family member" not insured for Un- derinsured Motorists Coverage under this pol- icy; nor to 'bodily injuryH from being hit by any such motor vehicle. 2. By a ,family member": a. Who owns an auto, while 'occupying", or when struck by, eny motor vehicle owned by you or eny *family member' which is not insured for this coverage under this policy. This includes a trailer of eny type used with that vehicle. b. Who does not own any auto, while "occupying", or when struck by, any motor vehicle you own which is insured for this coverage on a prima~y basis under any other policy. B. We do not provide Underinsured Motorists Cover- age for "bodily inju~" sustained by any person: Page 1 of 3 PF If we are the insurer against whom the claim is first AS 20S0 12 98 (PP O4 X? 06 95) C. Unless both parties agree othenvise, arbitration made, we will pay, subject to the limit of liability shown in the Schedule or in the Declarations for Un- derinsured Motorists Coverage, after we and all other contributing insurers agree: 1. Whether the "insured" is legally entitled to re- cover damages from the owner or operator of an "undefinsured motor vehicle"; and 2. As to the amount of damages. ARBITRATION A. If we and an "insured" do not agree: 1. Whether that "insured" is legally entitled to re- cover damages; or 2. As to the amount of damages which are recover- able by that. "insured"; ~ . From the owner or operator of an "underinsured . motor vehicle,' then the matter may.be :arbitrated. Either party may make a written demand 'for arbi- tration. Arbitration shall be conducted in accor- dance with the provisions of the Pennsylvania Uni- form Arbitration Act. Each party will Select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may re- quest that selection be made by a judge of a court having jurisdiction. Arbitration shall not, however, be a means of set- tlement should the dispute involve: 1. Any form of inter- or intra-policy stacking, or 2. Selection of a coverage option, or a waiver of such coverage, or 3. Determination of residency in defining who is or is not an insured under this coverage, or 4. Statutes of limitation, or 5. Determination of whether a claimant is an in- sured under these coverages. B. Each party will: 1. Pay the expenses it incurs; and 2. Bear the expenses of the third arbitrator equally. will take place in the county in which the "insured" lives. Local rules of law as to procedure and evi- dence will apply. A decision agreed to by two of the arbitrators will be binding. ADDITIONAL DUTIES A persou seeking Underinsured Motorists Coverage must also promptly: 1. Send us copies of the legal papers if a suit is brought; and 2. Noti~t us in writing of a tentative settlement between the "insured" and the insurer of the "underinsured motor vehicle" and allow us 30 days to advance payment to that "insured" in au amount equal to the tentative settlement to preserve our rights against the insurer, owner or operator of such "underinsured motor vehi- cleS. · pART F. GENERAL PROVISIONS' ~ ' The following is added to the Our Right To Recover Payment provision of part F: OUR RIGHT TO RECOVER PAYMENT Our rights do not apply under paragraph A, with respect to Underinsured Motorists Coverage if we: 1, Have been given prompt written notice of a tentative settlement between an "insured" and the insurer of an "underinsured motor vehi- cle''; and. 2, Fail to advance payment to the ~in~ured" in an amount equal to the tentative settlement within 30 days after receipt of notification. If we advance payment to the "insured" in an amount equal to the tentative s~le~en~ within 30 days after receipt of notification: 1, That payment, will be s~arate Dom any amount the "insured" is entitled to recover un- der the provisions of Underinsured Motorists Coverage; and · ~ · 2, We also have a right to recover tbe advanced payment. ~ This endorsement must be attached to the Change Endorsement when issued after the policy is written. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1994 Page 3 of 3 PF LIBERTY'- PENNSYLVANIA UNINSURED MOTORISTS COVERAGE AND UNDERINSURED MOTORISTS COVERAGE OPTION FORM Pennsylvania law requires that we offer you Uninsured Motorists Coverage and Underinsured Motorists Coverage in limits equal to the Bodily Injury Liability limits carried on your policy. You may select lower available lirnits. You may reject Uninsured Motorists Coverage, Underinsured Motorists Coverage or both of these coverages. This form briefly describes the benefits offered and your options. Please read this form carefully as you are the best person to determine the coverage and limits that fulfill your insurance needs. UNINSURED MOTORISTS COVERAGE AND UNDERINSURED MOTORISTS COVERAGE APPLIES TO: · Motor Vehicles COVERS: BENEFITS: · You · Resident family members · You and resident family members as pedestrians · Other people in your car UNINSURED MOTORISTS COVERAGE provides coverage for bodily injury, sickness, disease, or death, which you are legally entitled to recover from the owner or operator of: · an uninsured motor vehicle · a motor vehicle for which coverage is provided by a liability policy or bond, if the company issuing the coverage for the at-fault party denies coverage or is or becomes insolvent. · a hit-and-run vehicle whose owner or operator cannot be identified. LIMITS: UNDERINSURED MOTORISTS COVERAGE provides coverage for damages you are legally entitled to recover from the owner or operator of an underinsured motor vehicle because of bodily injury, sickness, disease, or death caused by an accident involving the underinsured motor vehicle. An underinsured motor vehicle is one to which a bod~y injury liability policy or bond applies at the time of the accident but the amount paid for bodily injury under that bond or policy is not enough to pay the full amount the insured is legally entitled to recover as damages. Your Uninsured Motorists Coverage and Underinsured Motorists Coverage limit will equal your Bodily Injury Liability limit unless you reject in writing Uninsured Motorists Coverage and/or Underinsured Motorists Coverage or select a lower available coverage limit. When Uninsured Motorists Coverage and/or Underinsured Motorists Coverage applies, the limit of liability for these coverages applicable to you and resident family members will be the sum of the stated coverage limits applicable to each vehicle on your policy. This is known as the "stacked" coverage limit. You may elect to waive the stacked coverage limit and carry limits on a "non- stacked" basis. When the non-stacked limit option is selected, your coverage limit will be that stated in the policy for each vehicle. You will save on your coverage premium if the non-stacked limit option is selected. Please be aware that any summary of coverage on these pages is necessarily general in nature. Your policy contains specific descriptions, exclusions, and conditions. In case of any conflict, your policy language will control the resolution of all coverage questions. ~~ EX~..~HIBIT [ 7:~ii, , PMKT 100 R2 LI ........ -~ Pg. 1 of 4 ~OLICYNUMBER LIBERTY MUTUAL FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS AO2-281-473850-809 81 NAMEDINSUREDAND MAILING ADDRESS MAXIM DEMCHAK 591 1 GENEVA DR MECHANICSBURG PA 17055 THESEDECLARATIONSEFFECTIVE ] 06 / 15 / 99 [ ENDORSEMENT 01 FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 POLICY PERIOD: 06/15/99 TO 06/15/00 12:01AM STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED IN THE POLICY. CHANGES MADE: ADD NON-STACKED VEH 1,2,3 CHANGE LIABILITY*VEH .1,2,3 CHANGE CLASS*VEH 2 PREMIUM ADJUSTMENT FROM 06/15/99 TO 06/15/00: TOTAL ADJUSTMENT: $ 75.00CR COVERAGES AND LIMITS UNDER YOUR AUTO POLICY: PART A.LIABILITY BODILY INJURY PROPERTY DAMAGE C.UNINSURED MOTORISTS BODILY INJURY UNDERINSURED MOTORISTS BODILY INJURY VEH 1 VEH 2 VEH 3 VEH 4 $ 13CR 47CR 15CR covER3tGE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE VEH 1 VEH 2 VEH 3 VEH 4 $ 184 168 168 $ 250,000 EACH PERSON $ 500,000 EACH ACCIDENT $ 100,000 EACH ACCIDENT $ 100,000 EACH PERSON $ 300,000 EACH ACCIDENT $ 100,000 EACH PERSON $ 300,000 EACH ACCIDENT FULL TORT OPTION SELECTED $ 27 27 27 $ 58 58 58 FIRST PARTY BENEFITS 10,000 MEDICAL EXPENSE 2,500 FI/NERAL EXPENSE 5,000 INCOME LOSS 0 ACCIDENTAL DEATH D.COVERAGE FOR DAMAGE TQ YOUR AUTO OTHER THAN COLLISION ACTUAL CASH VALUE LESS DEDUCTIBLE SHOWN: VEH 1 $ 100 VEH 2 $ 100 VEH 3 $ 100 VEH 4 $ 50 COLLISION $ 40 44 44 $ 26 22 141 22 $ 80 64 197 34 ~65 JACKET 3075 1289 X357B62DUNN**/ / EXHIBIT RESTRAINT 255 000 4 YY~ 8 001 00 N oool4 ]YY~8 100il1001NI 000 4 N0q5 00/~ 00IN 000 0 XX~0 0011 00IN '"OLICY NUMBER ~ AO2-281-473850-809 ~ ] NAMED INSUREDAND MAILING ADDRESS MAXIM DEMCHAK 591 1 GENEVA DR MECHANICSBURG PA 17055 LIBERTY MUTUAL FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS THESEDEC~RATIONSEFFECIIVE I 0 6 / 1 5 / 9 9 I FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 ENDORSEMENT 01 PAGE 02 (CONTINUED FROM PREVIOUS PAGE) ACTUAL cAsH VALUE'LESS DEDUCTIBLE SHOWN: VEH 1 $ 500 VEH 2 $ 500 VEH 3 $ 500 VEH 4 $ 100 THIS POLICY COVERS COLLISION DAM3~GE TO RENTAL VEHICLES. OPTIONAL COVERAGE TOWING AND LABOR COST - $50 EACH.DISABLEMENT $ EXTENDED TRD~NSPORTATION EXPENSES $15/$450 $ 6 6 6 12 12 12 ANNUAL PREMIUM PER VEHICLE: $ 433 401 653 56 SAFE DRIVER INSURANCE PLkN CREDIT: AS A RESULT OF: VIOLATION SC0 NO SURCFLARGE ACCIDENT SC0 NO SURCIqARGE TOTAL ANNUAL POLICY PREMIUM: $ 1543.00 ENDORSEMENTS ATTACHED TO YOUR POLICY: 2330 2323 PP 05 51 11 92 PP 04 20 07 90 AS2048 02 96 AS2067 08 97 PP 04 16 07 90 AS2050 12 98 PP 03 03 04 86 PP 03 09 04 86 AS1046 12 89 PP 03 02 12 89 PP 03 08 04 86 CI4_ANGE OF FACSIMILE SIGNATURE ANNUAL MEETING DATE CHANGE PENNSYLVANIA FIRST PARTY BENEFITS COVERAGE ENDORSEMENT SPLIT UNINSURED MOTORISTS LIMITS PENNSYLVANIA (NON-STACKED) UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) · ~MENDMENT OF POLICY PROVISIONS - PENNSYLVANIA SPLIT UNDERINSURED MOTORISTS LIMITS PENNSYLVANIA (NON-STACKED) UNDERINSURED MOTORIST COVERAGE(NON-STACKED)-PENNSYLVANIA TOWING AND LABOR COST COVER~GE SPLIT LIABILITY LIMITS AUTOMATIC TERMINATION ENDORSEMENT EXTENDED TRANSPORTATION EXPENSES COVERAGE COVERAGE FOR Di~d~AGE TO YOUR AUTO VEHICLES COVERED BY YOUR POLICY: VEH YR MAKE 1 90 VOLV 2 85 CHEV 3 83 MRBZ 4 79 BOLE RATING RATING MODEL IDENTIFICATION # CLASS STATE TERRITORY SYMBOL 240 YV1AA8857L1858445 07 PA 37 027 05 CAV TYP 10 1G1JE67W4F7214338 48 PA 37 027 10 380 WDBBA45A7DB026246 48 PA 37 027 21 725153 00 PA 37 00 .... 10 0 05 24 9 oo oo 6 2 RY 1 01 0000 000 4 YY~ 8 001 001N JACKET 3075 1289 2 01 0000 000 4 YY~- 8 001 00 N K357B62DUNN**/ / 3 01 0000 000 4 N0( 5 00 1 00 N 4 05 0000 000 0 XX) 0 00 1 00 N RESTRAINT 2555 LIBERTY MUTUAL FIRE INSURAaNCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS ~OLICYNUMBER AO2-281-473850-809 8] THESEDEC~RATIONSEFFECTiVEI 06/15/99 I NAMEDINSUREDANDMAILINGADDRESS MAXIM DEMCHAK 591 1 GENEVA DR MECHA=NICSBURG PA 17055 ENDORSEMENT 01 PAGE 03 FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LINGLESTOWN RD UNIT 150 HARRISBURG PA 17110 717-545-4528/800-872-2568 CLAIMS: 800-362-5698 YOUR PREMIUM REFLECTS THE FOLLOWING. CLASS CLASS CLASS (CONTINUED FROM PREVIOUS PAGE) IF INCORRECT, CONTACT YOUR SERVICE OFFICE. 00 VEHICLE TYPE INELIGIBLE FOR CLASS ASSIGNMENT. 07 PREFERRED RATE - PLEASURE USE - NO YOUTHFUL OPERATORS - COMMUTING LESS THAN 3 MILES ONE WAY - PRINCIPAL OPERATOR AGE 40-64. 48. PREFERRED RATE - NO YOUTHFUL OPERATORS - COMMUTING LESS THAN 3 MILES ONE WAY - USES AUTO LESS THA~N 7500 MILES ANNUALLY - PRINCIPAL OPERATOR AGE 40-64. VEH 1,2,3,4 GARAGED AT NA]V~ED INSURED'S AiDDRESS THE FOLLOWING DISCOUNTS DISPLAYED WITH "YES" HAVE BEEN APPLIED TO YOUR POLICY. THE DISCOUNTS INDICATED AS "NO" HAVE NOT BEEN APPLIED TO YOUR POLICY. IF YOU BELIEVE THAT YOU MAY BE ELIGIBLE FOR ANY DISCOUNT(S) LISTED AS "NO", PLEASE CONTACT YOUR LOCAL SALES OR SERVICE REPRESENTATIVE SHOWN ON THE FIRST PAGE OF YOUR POLICY DECLARATIONS. DISCOUNTS: VEH 1 VEH 2 VEH 3 VEH 4 A/UTI-LOCK BRAKES NO NO NO NO ANTI-THEFT DEVICE(S) NO NO NO NO DEFENSIVE DRIVER COURSE NO NO NO NO DRIVER TRAINING ~. NO NO NO NO GOOD STUDENT NO NO NO NO MULTI-CAR YES YES YES NO PASSIVE RESTRAINT YES NO NO NO (AUTOMATIC SEAT BELT AND/OR AIR BAGS) OPERATOR INFORMATION: NO. NAME 1 MAXIM DEMCHAK SPECIAL STATE PROVISIONS: DATE OF BIRTH 06/21/36 ANY PERSON WHO KNOWINGLY, A_ND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES D/q APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANy MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FHAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. 2 10 RY 1 01 0000 000 4 YYY 8 00 1 00 N -~ACKET 3075 1289 2 01 0000 000 4 YYY 8 00 1 00 N K357B62DUNN**/ / 3 01 0000 000 4 NO( 5 00 1 00 N 4 05 0000 000 0 XX~ 0 00 1 00 N PERSONAL AUTO PP 04 16 07 90 SPLIT UNDERINSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-STACKED) SCHEDULE UNDERINSURED MOTORISTS COVERAGE $ each person $ each accident Paragraph A. of the Limit of Liability provision in the Underinsured Motorists Coverage - Pennsylva- nia (Non-Stacked) endorsement is replaced by the following: LIMIT OF LIABILITY A. The limit of liability shown in the Schedule or in the Declarations for each person for Underin- sured Motorists Coverage is our maximum limit of liability for all damages, including damages for care, loss of services or death, arising out of "bodily injury" sustained by any one person in any one accident. Subject to this limit for each person, the limit of liability shown in the Schedule or in the Declarations for each acci- dent for Underinsured Motorists Coverage is.our maximum limit of liability for all damages for #bodily injury' resulting from any one accident. This is the most we will pay regardless of the number of: 1. "lnsureds"; 2. Claims made; 3. Vehicles or premiums shown in the Declara- tions; or 4. Vehicles involved in the accident. This endorsement must be attached to the Change Endorsement when issued alter the policy is written. PP 04 16 07 90 Copyright, Insurance Services Office, Inc,, 19gO Page 1 o! 1 PERSONAL AUTO PP 04 20 07' g0 SPLIT UNINSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-STACKED) SCHEDULE UNINSURED MOTORistS COVERAGE each person each accident Paragraph A. of the Limit of Liability provision in the Uninsured Motorists Coverage - Pennsylvania (Non-Stacked) endorsement is replaced by the following: LIMIT OF LIABILITY A. The limit of liability shown in the Schedule or in the Declarations for each person for Uninsured Motorists Coverage is our maximum limit of li- ability for all damages, including damages for care, loss of services or death, arising out of 'bodily injury* sustained by any one person in any one accident. Subject to this limit for each person, the limit of liability shown in the Schedule or in the Declarations for each acci- dent for Uninsured Motorists Coverage is our maximum limit of liability for all damages for "bodily injury' resulting from any one accident. This is the most we will pay regardless of the num- ber of: 1. "lnsureds"; 2. Claims made; 3. Vehicles or premiums shown in the Declara- tions; or 4. Vehicles involved in the accident. This endorsement must be attached to the Change Endorsement when issued alter the policy is written. PP 04 20 07' 90 Copyright, Insurance Services Office, Inc., 'lgg0 Page 1 of I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) AS 2048 02 96 (PP 04 21 06 95) art C - Uninsured Motorists Coverage is replaced by the following: SCHEDULE UNINSURED MOTORISTS COVERAGE Description Limit of of Vehicle Liability Premium $ $ INSURING AGREEMENT A. We will pay compensatory damages which an 'insured' is legally entitled to recover from the owner or operator of an 'uninsured motor ve- hicle" because of "bodily injury": 1, Sustained by an "insured"; and 2, Caused by an accident. The owner's or operator's liability for these damages must arise out of the ownership, maintenance or use of the "uninsured motor vehicle". No judgment for damages arising out of'a suit brought against the owner or operator of an 'uninsured motor vehicle" is binding on us unless we: 1, Received reasonable notice of the pen- dency of the suit resulting in the judgment; and 2, Had a reasonable opportunity to protect our interests in the suit. B, 'Insured' as used in this endorsement means: 1, You or any "family member'. 2, Any other person 'occupying" "your cov- ered auto', 3, Any person for damages that person is entitled to recover because of 'bodily in- jury' to which this coverage applies sus- tained by a person described in 1, or 2, above, C, "Uninsured motor vehicle" means a land motor vehicle or trailer of any type: 1, To which no bodily injury liability bond or policy applies at the time of the accident. 2, Which is a hit-and-run vehicle whose operator or owner cannot be identified and which hits or which causes an accident re- sulting in "bodily injury" without hitting: a, You or any 'family member"; b, A vehicle which you or any "family member" are 'occupying"; or c, "Your covered auto". If there is no contact with the hit-and-run vehicle, the facts of the accident must be proved, 3. To which a bodily injury liability bond or policy applies at the time of the accident but the bonding or insuring company: a. Denies coverage; or b. Is or becomes: (1) Insolvent; or (2) involved in insolvency proceedings. However, "uninsured motor vehicle" does not include any vehicle or equipment: 1. Owned by or furnished for the regular use of you or any "family member". 2. Owned or operated by a self-insurer under any applicable motor vehicle law, except a self-insurer which is or becomes insolvent. 3. Owned by any governmental unit or agency. 4. Operated on rails or crawler treads. 5. Designed mainly for use oft' public roads while not on public roads. 6. While located for use as a residence or premises. EXCLUSIONS A. We do not provide Uninsured Motorists Cover- age for "bodily injury" sustained: 1. By you while 'occupying', or when struck by, any motor vehicle you own which is not insured for this coverage under this policy. This includes a trailer of any type used with that vehicle. 2. By a "family member": a. Who owns an auto, while "occupying", or when struck by, any motor vehicle owned by you or any "family member" which is not insured for this coverage under this policy. This includes a trailer of any type used with that vehicle. b. Who does not own an auto, while "occupying", or when struck by, any motor vehicle you own which is insured for this coverage on a primary basis un- der any other policy. B. We do not provide Uninsured Motorists Cover- age for "bodily injury" sustained by any person: Page 1 of 3 PF 1. If that person or the legal representative settles the bodily injury claim without our consent. However, this exclusion (B.1.) does not apply if such settlement does not ad- versely affect our rights. 2. While "occupying" "your covered auto" when it is being used as a public or livery conveyance. This exclusion (B.2.) does not apply to a share-the-expense car pool. 3. Using a vehicle without a reasonable belief that that "insured" is entitled to do so. C. We do not provide Uninsured Motorists Cover- age for "noneconomic loss" sustained by any person to whom the limited tort alternative applies, resulting from "bodily injury" caused by an accident involving an "uninsured motor vehicle", unless the "bodily injury" sustained is a "serious injury,. This exclusion (C.) does not apply: 1. If the owner or operator of the "uninsured motor vehicle": a. Is convicted, or accepts Accelerated Rehabilitative Disposition, for driving un- der the influence of alcohol or a con- trolled substance in that accident; b. Is operating a motor vehicle registered in another state; or c. Intends to injure himself or another person, provided that the individual does not intentionally injure himself or another person merely because his act or failure to act is intentional or done with his re- alization that it creates a grave risk of causing injury if the act or omission causing the injury is for the purpose of averting bodily harm to himseff or an- other person. 2. If that person is injured while "occupying" a motor vehicle insured under a commercial motor vehicle insurance policy. D. This coverage shall not apply directly or indirectly to benefit any insurer or self-insurer under any of the following or similar law: 1. Workers' compensation law; or 2. Disability i~enefits law. E. We do'not provide Uninsured Motorists Cover- age for punitive or exemplary damages. LIMIT OF LIABILITY A. The limit of liability shown in the Schedule or in the Declarations for Uninsured Motorists Cov- erage is our maximum limit of liability for all damages resulting from any one accident. This is the most we will pay regardless of the .num- ber of: 1. "lnsureds"; 2. Claims made; AS 2048 02 96 {PP 04 21 06 95) 3. Vehicles or premiums shown in the Sched- ule or in the Declarations; or 4. Vehicles involved in the accident. B. No one will be entitled to receive duplicate payments for the same elements of loss under this coverage and: 1. Part A or Part B of this policy; or 2. Any Underinsured Motorists Coverage provided by this policy. C. We will not make a duplicate payment under this coverage for any element of loss for which · payment has been made by or on behalf ol~ persons or organizations who may be legally responsible. This includes all payments made to an #insured's~ attorney either directly or as part of the payment made to the ~insured". D. We will not pay for any element of loss if a person is entitled to receive payment for the same element of loss under any of the follow- ing or similar law: 1. Workers' compensation law; or 2. Disability benefits law. OTHER INSURANCE I!' there is other applicable similar insurance avail- able under more than one policy or provision of coverage: The following First priorities of recovery apply: The Uninsured Motorists Coverage applicable to the vehicle the "insured" was 'occupying" at the time of the accident. Second The policy affording Uninsured Mo- torists Coverage to the "insured" as a named insured or family member. 1. When there is applicable insurance avail- able under the First priority: a. The limit of liability applicable to the vehicle the "insured" was "occupying", under the policy in the First priority, shall first be exhausted; and b. The maximum recovery under all policies in the Second priority shall not exceed the amount by which the highest limit for any one vehicle under any one policy in the Second priority exceeds the limit applicable under the policy in the First priority. 2. When there is no applicable insurance available under the First priority, the maxi- mum recovery under all policies in the Sec- ond priority shall not exceed the highest applicable limit for any one vehicle under any one policy. Page 2 of 3 AS 2048 02 96 (PP 04 21 06 95) It' two or more policies have equal priority, the insurer against whom the claim is first made shall process and pay the claim as if wholly responsible for all insurers with equal priority. The insurer is thereafter entitled to recover contribution pro rata from any other insurer for the benefits paid and the costs of processing the claim. If we are the insurer against whom the claim is first made, we will pay, subject to the limit of li- ability shown in the Schedule or in the Declara- tions for Uninsured Motorists Coverage, alter we and all other contributing insurers agree: 1. Whether the "insured" is legally entitled to recover damages from the owner or opera- tor of an "uninsured motor vehicle"; and 2. As to the amount of damages. ARB ITRATION A. If we and an "insured" do not agree: 1. Whether that "insured" is legally entitled to recover damages; or 2. As to the amount of damages which are recoverable by that "insured'; From the owner or operator of an "uninsured motor vehicle" then the matter may be arbi- trated. Co Either party may make a written demand for arbitration. Arbitration shall be conducted in accordance with the provisions of the Pennsyl- vania Uniform Arbitration Act. Each party will select an arbitrator. The two arbitrators will select a third, If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction. Arbitration shall not, however, be a means of settlement should the dispute involve: 1. Any form of inter- or intra-policy stacking, or 2. Selection of a coverage option, or a waiver of such coverage, or 3. Determination of residency in defining who is or is not an insured under this coverage, or 4. Statutes of limitation, or 5. Determination of whether a claimant is an insured under these coverages. Each party will: 1. Pay the expenses it incurs; and 2. Bear the expenses of the third arbitrator equally. Unless both parties agree otherwise, arbi- tration will take place in the county in which the "insured" lives. Local rules of law as to procedure and evidence will apply. A deci- sion agreed to by two of the arbitrators will be binding. This endorsement must be attached to the Change Endorsement when issued after the policy is written. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1994 Page 3 of 3 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. UNDERINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) AS 2050 12 98 (PP 04 17 06 95) "4ith respect to the coverage provided by this endorsement, tile provisions of tile policy apply unless modified by endorsement. SCHEDULE UNDERINSURED MOTORISTS COVERAGE Description Limit of of Vehicle Liability Premium INSURING AGREEMENT C. "Underinsured motor vehicle" means a land motor A. We will pay compensatory damages which an "insured" is legally entitled to recover from the owner or operator of an "underinsured motor vehi- cle'' became of "bodily injury": 1. Sustained by an "insured"; and 2. Caused by an accident. The owner's or operator's liability for these dam- ages must arise out of the ownership, maintenance or use of the "underinsured motor vehicle". We will pay under this coverage only if 1. or 2. below applies: 1. The limits of liability under any applicable bodily injury liability bonds or policies have been exhausted by payment of judgments or settlements; or 2. A tentative settlement has been made between an "insured" and the insurer of the "underinsured motor vehicle" and we: a. Have been given prompt written notice of such tentative settlement; and b. Advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. No 'judgment for damages arising out of a suit brought against the owner or operator of an "underinsured motor vehicle" is binding on us un- less we: 1. Received reasonable notice of the pendency of the suit resulting in the judgment; and 2. Had a reasonable opportunity to protect our interests in the suit. B. "Insured" as used in this endorsement means: 1. You or any "family member". 2. Any other person "occupying" "your covered auto". 3. Any person for damages that person is entitled to recover became of "bodily injury" to which this coverage applies sustained by a person de- scribed in 1. or 2. above. vehicle or trailer of any type to which a bodily in- jury liability bond or policy applies at tile time of the accident but the amount paid for "bodily injury" under that bond or policy to an "insured" is not enough to pay the full amount the "insured" is le- gally entitled to recover as damages. However, "underinsured motor vehicle" does not include any vehicle or equipment: 1. For which liability coverage is provided under Part A of this policy. 2. Owned by any governmental unit or agency. 3. Operated on rails or crawler treads. 4. Designed mainly for we off public roads while not on public roads. 5. While located for we as a residence or prem- ises. EXCLUSIONS A. We do not provide Underinsured Motorists Cover- age for "bodily injury" sustained: 1. While "occupying" a motor vehicle owned by you or a "family member" not insured for Un- derinsured Motorists Coverage under this pol- icy; nor to "bodily injury" from being hit by any such motor vehicle. 2. By a "family member": a. Who owns an auto, while "occupying", or when struck by, any motor vehicle owned by you or any "family member" which is not insured for this coverage under this policy. This includes a trailer of any type used with that vehicle. b. Who does not own any auto, while "occupying", or when struck by, any motor vehicle you own which is insured for this coverage on a primary basis under any other policy. B. We do not provide Underinsured Motorists Cover- age for "bodily injury" sustained by any person: Page 1 of 3 PF AS 2050 12,98 (PP 04 17 06 95) 1. While "occnpymg" "your covered auto" when it is being used as a public or livery conveyance. This exclusion (BAd does not apply to a share- the-expense car pool. 2. Using a vehicle without a reasonable belief lhat that person is entitled to do so. C. We do not provide Underinsured Motorists Cover- age for "noneconomic loss" sustained by any per- son to whom the limited tort alternative applies, re- sulting from "bodily injnry" caused by an accident involving an "underinsured motor vehicle", unless the "bodily injury" sustained is a "serious injury". This exchision (C.) does not apply: 1. If the owner or operator of the "underinsured motor vehicle": a. Is convicted, or accepts Accelerated Reha- bihtative Disposition, for driving under the influence of alcohol or a controlled sub- stance in that accident; b. Is operating a motor vehicle registered in another state; or e. Intends to injure himself or another person, provided that the individnal does not inten- tionally injure himself or another person merely because his act or failure to act is intentional or done with his realization that it creates a grave risk of causing injm3t if the act or omission causing the injury is for the purpose of averting bodily harm to himself or another person. 2. If lhat person is injured while "occupying" a motor vehicle insured under a commercial mo- tor vehicle insurance policy. D. This coverage shall not apply directly or indirectly to benefit any insurer or self-insurer under any of the following or similar law: 1. Workers! compensation law; or 2. Disability benefits law. E. We do not provide Underinsured Motorists Cover- age for punitive or exemplary damages. LIMIT OF LIABILITY A. The limit of liability shown in the Schedule or in the Declarations for Underinsured Motorists Cov- erage is our maximum limit of liability for all dam- ages resulting from any one accident. This is the most we will pay regardless of the number of: 1. "Insureds"; 2. Claims made; 3. Vehicles or premiums sho~vn in the Schedole or in the Declarations; or 4. Vehicles involved in the accident. B. The damages payable under this coverage shall be redtlced by all sums paid becanse of the "bodily injury" by or on behalf of persons or organizations who may be legally responsible. This includes all sums paid for an "insured's" attorney either directly or as part of the amount paid to the "insured". It also includes all sums paid under Part A of this policy. C. No one will be entitled to receive dnplicate pay- ments for the same elements of loss under this cov- erage and Part A, Part B or Part C of this policy. D. We will not make a dnplicate payment tinder this coverage for any element of loss for which pay- ment has been made by or on behalf of persons or organizations who may be legally responsible. E. We will not pay for any element of loss ifa person is entitled to receive payment for lhe same element of loss under any of the following or similar law: 1. Workers' compensation law; or 2. Disability benefits law. OTtlER INSURANCE If there is other applicable similar insurance available under more than one policy or provision of coverage: The following priorities of recovery apply: First The Underinsured Motorists Coverage applicable to the vehicle the "insured" was "occupying" at the time of the acci- deut. Second 'l~e policy affording Underinsured Motorists Coverage to the "insured" as a named insured or family member. 1. When there is applicable insurance available under the First priority: a. The limit of liability applicable to the vehi- cle the "insured" was "occupying", under the policy in the First priority, shall first be ex- hausted; and b. The maximum recovery trader all policies in the Second priority shall not exceed the amount by which the highest limit for any one vehicle tinder any one policy in the Sec- ond priority exceeds the limit applicable un- der the policy in the First priority. 2. When there is no applicable insurance available under the First priority, the maximum recovery under all policies in the Second priority shall not exceed tile highest applicable limit for any one vehicle tinder any one policy· If two or more policies have eqnal priority, the insnrer against whom the claim is first made shall process and pay the claim as if wholly responsible for all insurers with equal priority. The insnrer is thereafter entitled to recover contribution pro rata from any other insurer for the benefits paid and the costs of processing the claim. Page 2 of 3 PF If we are the insurer against whom the claim is first C. AS 2050 12 98 (PP 04 17 06 95) Unless both parties agree otherwise, arbitration made, we will pay, subject to the limit of liability ~hown in the Schedule or in the Declarations for Un- lerinsured Motorists Coverage, after we and all other contributing insurers agree: 1. Whether the "insured" is legally entitled to re- cover damages from the owner or operator of an "underinsured motor vehicle"; and 2. As to the amount of damages. ARBITRATION A. If we and an "insured" do not agree: 1. Whether that "insured" is legally entitled to re- cover damages; or 2. As to the amount of damages which are recover- able by that "insured"; From the owner or operator of an "underinsured motor vehicle" tl~en the matter may be arbitrated. Either party may make a written demand for arbi- tration. Arbitration shall be conducted in accor- dance with the provisions of the Pennsylvania Uni- fonu Arbitration Act. Each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may re- qnest that selection be made by a judge of a court having jurisdiction. Arbitration shall not, however, be a means of set- flement should the dispute involve: 1. Any form of inter- or intra-policy stacking, or 2. Selection of a coverage option, or a waiver of such coverage, or 3. Determination of residency in defining who is or is not an insured under this coverage, or 4. Statutes of limitation, or 5. Determination of whether a claimant is an in- sured under these coverages. B. Each party will: 1. Pay the expenses it incurs; and 2. Bear the expenses ofti~e third arbitrator equally. will take place in the county in which the "insured" lives. Local rules of law as to procedure and evi- dence will apply. A decision agreed to by two of the arbitrators will be binding. ADDITIONAL DUTIES A person seeking Underinsured Motorists Coverage must also promptly: 1. Send us copies of the legal papers if a suit is brought; and 2. Notify us in writing of a tentative settlement between the "insured" and the insurer of the "underinsured motor vehicle" and allow us 30 days to advance payment to that "insured" in an amount equal to the tentative settlement to preserve our rights against the insurer, owner or operator of such "underinsured motor vehi- cle''. PART F - GENERAL PROVISIONS The following is added to the Our Right To Recover Payment provision of Part F: OUR RIGIIT TO RECOVER PAYMENT Our rights do not apply under paragraph A. with respect to Underinsured Motorists Coverage ifwe: 1. Have been given prompt written notice of a tentative settlement between an "insured" and the insurer of an "underinsured motor vehi- cle''; and 2. Fail to advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. If we advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification: 1. That payment will be separate from any amount the "insured" is entitled to recover un- der the provisions of Undarinsured Motorists Coverage; and 2. We also have a right to recover the advanced payment. This endorsement must be attached to the Change Endorsement when issued after the policy is written. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1994 Page 3 of 3 PF NOTICE OF COVERAGE FOR ACTS OF TERRORISM Westport Insurance Corporation DAVID R. THOMPSON. ATTORNEY AT LAW 310 Walton Street. Suite 4 P.O. Box 587 Philipsburg PA 16866-0587 h,,Ihlh,h,h,lh,,Ih,lh,,,hhh,hh,,Ih,hh,,[[,,hl IMPORTANT - THIS LETTER DISCUSSES COVERAGE FOR TERRORISM UNDER YOUR INSURANCE POLICY - PLEASE READ CAREFULLY AND CONSULT YOUR AGENT, BROKER, OR OTHER INSURANCE PROFESSIONAL IF YOU HAVE ANY QUESTIONS. Dear Insured: WHAT HAS HAPPENED? The tragic events of September 11, 2001 have affected our country in many ways. The insurance industry responded immediately to these events, and has provided billions of dollars of payments. However, the possibility of future attacks has created what Congress describes as an "unprecedented financial risk" with a significant impact on the economy. As a result, Congress passed the Terrorism Risk Insurance Act of 2002 (The Act). The Act provides that all property and casualty insurers must offer their policyholders the opportunity to purchase coverage for "acts of terrorism", and that there will be a temporary (through the year 2005) payment from the federal government of 90% of losses from such acts which exceed the statutorily established deductible (an annually increasing percentage of the insurer's earned premium for the commercial lines of business of the previous year). This deductible must first be paid by each insurance company. WHAT IS AN "ACT OF TERRORISM"? · An "act of ten'orism" is defined as: Any act that is certified by the Secretary of the Treasury: (1) To be an act of terrorism; (2) To be a violent act or an act that is dangerous to (a) human life; (b) property; or (c) infrastructure; (3) To have resulted in damage within the United States, or outside the United States in the case of certain aircraft or vessels, or on the premises of a US mission; and (4) To have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest as part of an effort to coerce the civilian populations of the US or to influence the policy or affect the conduct of the US Government by coercion. SP2455 (12/02) No act will be certified as an "act of terrorism" if: (1) It does not meet the above criteria; (2) The act is committed as part of the course of war declared by Congress (other than with respect to Workers' Compensation); (3) Property and casualty losses resulting from the act, in the aggregate, do not exceed $5,000,000. As used in the letter and the attached Notice, the phrases "act of terrorism" and "acts of terrorism", when set out in quotation marks, are to be construed as defined above. HOW DOES THE ACT AFFECT YOUR INSURANCE COVERAGE? You have a policy of insurance issued by Westport Insurance Corporation which has no terrorism exclusion attached to it. Your current policy will remain in effect as written for the remainder of the current policy period. · As required by the Act, this letter constitutes notice to you of the existence of the Act, and the payments, which will be made from the Federal Government if there is a certified "act of terrorism". · The decision not to include a terrorism exclusion to your policy when it was issued or last renewed was based on a number of reasons, and the continuation or importance of these reasons may or may not have been altered by the passage of the Act. · In the time between now and the next renewal we will examine and refine our treatment of terrorism under your policy. This means that you may or may not have the same terms offered to you upon renewal and that the premium charged may or may not reflect alteration based upon the terrorism exposure. Please contact your insurance agent, broker, or other insurance professional if you have any questions, comments or concerns about your coverage. Yours sincerely, A. Louis Parker SP2455 (12/02) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA. CIVIL ACTION - LAW MAXIM DEMCHAK, Plaintiff VS. LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendants No. 03-492 TYPE OF CASE: Civil Division - law TYPE OF PLEADING: Affidavit of Service FILED ON BEHALF'OF: Plaintiff COUNSEL OF RECORD FOR THIS PARTY: David R. ThompsOn, Esquire P.O. Box 587 Philipsburg, PA 16866 (814) 342-4100 I.D. No. 73053 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA. MAXIM DEMCHAK, Plaintiff VS. LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, CIVIL ACTION - LAW No. 03-492 Defendants · AFFIDAVIT OF SERVIC..F I, DAVID R. THOMPSON, Esquire, hereby certify that I have caused to be served upon the Defendant. A certified copy of the COMPLAI:NT, in the above captioned matter. I served the same by depositing in the U.S. Mail, postage prepaid, certified mail, return receipt requested, addressed as follows: Liberty Mutual Fire Insurance Company 175 Berkley Street 8oston, MA 02117 Liberty Mutual 175 Berkley Street Boston, MA 02117 Liberty Mutual Group 175 8erkley Street Boston, MA 02117 Liberty Mutual Insurance Group 175 Berkley Street Boston, MA 02117 DATED: February 10, 2003 I:~a~id R. TKo 'pson, Esquire Attorney for Plaintiff · Complete items 1, 2, and 3. Also complete item 4. if'Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailplece, or on the front if space permits. 1. Article Addressed to: · gA /- PS Form 3811, July 1999 Domestic Return Receipt D. Is delivery addmss different from item 17 If YES, enter delivery address below: [] Agent [] Yes [] No I L:~-~ertifi~f Mail [] Express Mail I I-3 Registered ~3~eturn Receipt for Merchandise t [] Insured Mail [] C.O.D. 14, Restricted Delivery? (Extra Fee) [] Yes 102595-00-M-0952 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Nticle Addressed to: ~De~ery [] Agent [] Addr~-~ _~-~_- t from item 17 []yes If YES, enter delivery address below: [] No 3. Service Type :Certified Mail Registered [] Insured Mail [] Express Mail c etUrn Receipt for Merchandise .O.D. 4. Rsstdcted Delivery? (Extra Fee) 2. A~ticle Number (Copy from service label) ?rr 00 0 09o I' 3- u I-I Yes PS Foii~ 3811, July 1999 D~T,e~tk~ Return Rec~pt 102595-00-M-0952 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Add~ to: [] Agent different from item 17 [] Yes If YES, enter delivery address below: [] No 3. Service Type ~,Certified Mail [] Registered [] Insured Mail [] Express Mail '~Return Receipt for Memhandise C.O.D. 4. Restricted Delivery? (Extra Fee) DYes 2.~Article Number (Copy from service label) PS Form 3811, July 1999 Dome~ic Return Receipt 102595-00-1V · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, .,,,~.o? the front if space_,permits. 1. Article Addressed to: [] Agent [] Addr~__ _~e , address different from item 17 [] Yes If YES, enter delivery address below: [] No 3. Service Type ~.Certified Mail [] Registered [] Insured Mail [] Express Mail r. Return Receipt for Merchandise La C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 2. Article Number (Copy from service label) PS Form 381 1, July 1999 Domestic Return Receipt 102595-00-M-09525 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA CIVIL ACTION - LAW MAXIM DEMCHAK, Plaintiff · VS. , LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, ' * LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendants No. 03-492 TYPE OF PLEADING: Important Notice FILED ON BEHALF OF: Plaintiff COUNSEL OF RECORD FOR THIS PARTY: David R. Thompson, Esquire Attorney at Law Supreme Court I.D. 73053 308 Walton Street, Suite 4 P.O. Box 587 Philipsburg PA 16866 (814) 342-4100 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA MAXIM DEMCHAK, VS. CIVIL ACTION - LAW Plaintiff * :No. 03-492 LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendants TO: Liberty Mutual Fire Insurance Company 175 Berkley Street Boston, MA 02117 IHPORTANT NOTICE YOU ARE IN DEFAULT BEFORE YOU HAVE FAILED TO TAKE ACTION REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. COURT ADMINISTRATOR Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 DaVid R:Th~)mpson, Esquire ?.O. Box 587 'Philipsburg PA 16866 :(814) 342-4100 I.D. No. 73053 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA CIVIL ACTION - LAVV MAXIM DEMCHAK, Plaintiff VS. , LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, , * LIBERTY MUTUAL INSURANCE GROUP, AND ,,. * LIBERTY MUTUAL FIRE INSURANCE * COMPANY, , Defendants · No. 03-492 CERTIFICATE O F SERVICE I, David R. Thompson, Esquire, hereby certify that an original copy of the Plaintiff's 10 Day Default Notice was served upon Defendant, Liberty* Mutual Fire Insurance Company, by First Class U.S. Mail, postage prepaid, this 27m day of February, 2003, at the following address: LIBERTY MUTUAL FIRE INSUP. RNCE COMPANY 175 Berkley Street Boston, MA 02117 DATED: February 27, 2003 David R. Thor~ps~h, Esquire Attorney for Plaihtiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY MAXIM DEMCHAK Plaintiff LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP AND LIBERTY MUTUAL FIRE INSURANCE COMPANY Defendants NO. 03-492 CIVIL DIVISION NOTICE TO THE PROTHONOTARY OF CUMBERLAND COUNTY TO: THE PROTHONOTARY OF THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY Pursuant to 28 U.S.C. § 1446(a) Defendants Liberty Mutual Group, Liberty Mutual, Liberty Mutual Insurance Group and Liberty Mutual Fire Insurance Company files herewith a certified copy of the Notice of' Removal filed in the United States District Court for the Middle District of Pennsylvania on the 12th day of March, 2003. KELLY, MCLAUGHLIN, FOSTER, BRACAGLIA, DALY, TRAB/UCCO & WHITE, LLP k,~..--'/WILI-,iAM ¢. FOSTER, ESQUIRE- Attome_y forkDefendant ~ Liberty Mumhl~Group, Liberty_ Mutual, Liberty Mutugd Insurance Groui~and. L~erty Mutual Fire Insurance Company IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA MAXIM DEMCHAK Plaintiff Ve LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP AND LIBERTY MUTUAL FIRE INSURANCE COMPANY Defendants -03-- 44,3 FILED HARRIEtBURG, PA TO: NOTICE OF REMOVAL UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA MAR per~ Liberty Mutual Insurance Company ("Liberty Mutual") (incorrectly idemified in Plaintiffs Complaint as "Liberty Mutual") and Liberty Mutual Fire Insurance Company ("Liberty Mutual Fire"), Liberty Mutual Group and Liberty Mutual Insurance Group, ltae' Defendants in the above- captioned matter, hereby files this Notice of Removal of this case fi'om the Court of Common Pleas of Cumberland County, Pennsylvania, where it is now pending, to the United States District Court for the Middle District of Pennsylvania and in support thereof avers as follows: 1. This action was commenced by Complaint which wa~s filed on or about January 31, 2003, with the Prothonotary of the Court of Common Pleas of Cumberland County. The action is docketed as No. 03-492. A copy of this Complaint is attached hereto and marked Exhibit "A". 2. Plaintiffs Complaint requests, inter alia, a declaration that Plaintiff is entitled to underinsured motorist coverage in the amount of $300,000 per person and $900,000 per accident. 3. Based upon the allegations of Plaintiff, she is a resident of Carlisle, Cumberland County, Pennsylvania. Upon information and belief, Plaintiffis a citizen of the Commonwealth of Pennsylvania. 4. Defendant Liberty Mutual is a corporation organized and existing under the laws of the Commonwealth of Massachusetts, with its principal place of business located at 175 Berkeley Street, Boston, MA 02117. 5. Defendant Liberty Mutual Fire is a corporation organized and existing under the laws of the Commonwealth of Massachusetts, with its principal place of business located at 175 Berkeley Street, Boston, MA 02117. 6. Liberty Mutual Group is not an organization but is a name used by a number of companies, including Liberty Mutual and Liberty Mutual Fire, a~ad is not subject to suit. 7. Liberty Mutual Insurance Group is not an organiza'tion but is a name used by a number of companies, including Liberty Mutual and Liberty Mutual Fire, and is not subject to suit. 8. Based upon the allegations of the Complaint of Plai[ntiff, the amount in controversy in this action is in excess of $75,000.00, exclusive of interest and costs, as Plalntiffhas demanded underinsured motorist coverage in the amount of $300,000 per person and $900,000 per accident. 9. Jurisdiction of this Court is proper pursuant to the provisions of 28 U.S.C. § 1332. 10. The present lawsuit is removable fi.om the state court to the District Court of the United States pursuant to 28 U.S.C. §1441 and it is hereby also removed pursuant to that statute. 11. Written notice of the filing of this Notice shall be given to all parties as required by 28 U.S.C. §1446(d). 12. Copies of all process, pleadings and other Orders w]hich have been received by Defendants are filed herewith. 13. This Notice is timely, being filed within thirty (30) days fi.om the date of service of the Complaint setting forth the claims for relief upon which this action is based. WHEREFORE, notice is given that this action is removed fi.om the Court of Common Pleas of Cumberland County, Pennsylvania, to the United States District Court for the Middle District of Pennsylvania. KELLY, MCLAUGHLIN,. FOSTER, BRACAGLIA, DAL/Y~,4gRABUCCO & V~q-IITE LLP Attorney f~r Defenqant / Liberty Mural Gro~ap,/Eiberty Mutual, Liberty Mutual Insur'~a~c~r~p and Liberty Mutual Fire Insurance Company EXHIBIT A IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, Pa CiViL DIVISION - LAW Praintiff NAXIIM DEMCHAK, LIBERTY NI.UTUAL GROUP, LIBERTY D4UTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND I~BERTY HUTUAL FIRE 'INSURANCE COMPANY, Defendant TYPE OF CASE: Civil FILED ON BEHALF OF: Plalntiiff COUNSEL OF RECORD FOR THIS PARTY: David R. Thompson, Esquire Attorney at Law Supreme Court I.D. 73053 308 Walton Street, Suite 4 P.O, Bo× 587 P. hilipsburg~ PA 16866 (8~4) 342-4100 TRUE' .COPY FROM 'RECORD Tes~,. ny w~reo*f,, ! here unto set my ham ~ the_ sea~.'of safd Cou~t a .CarfAsM Pa, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY C/ViL D-"~$ION MAXIM DEMCHAK, Plaintiff VS, LIBERTY MUTUAL GROUP, LIBERTY HUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MUTUAL FIRE INSURANCE COMPANY, Defendant No. - 02- You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) day.,; after this Complaint and Notice are served; by entering a written appearance personally or by attorney and filing in wrfting with the Cou~t your defenses or oi~jecfions to the claims set forth against you. You are warned that if you fail to do so the case may proceed further, notice for any money claimed in the Complaint agaihst you by the Court without or for any other claim' or relief requested by the Plaintiff. You may lose money or property or ,other rights important to you. YOU SHOULD TAKE THIS PAPER ' NOT HAVE A L~- TO YOUR LA~ _ INYER OR CAN ._ .WYIER AT ONCE. IF ¥ OFFICE SET FORTH NOT_AFFORD ONE, GO TO OU DO BELOW TO FIND OUT WHERE OR TE.LEpHONE THE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Courthouse CarlJsle PA 17013 IN THE COURT OF COMMON PLEAS OF CUMBEI~LAND COUNTY CML DIVISION MAXIM DEMCHAK, Plaintiff VS. LrBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP, AND LIBERTY MLFFUA]. ~R~ INSURANCE COMPANY, Defendant No. - 02- AND NOW, comes the Defendant, Maxim Demchal~, by and through his attorney, David R. Thompson, Esquire, and files the following Complaint against Defendants to which the following is averred: :[. Plaintiff is Maxim Demchak, an adult individual,, with a residential address of 125 Clay Road, Carlisle, Cumberland County, .Pennsylvania, 17013.. 2. Defendant Liberty Mutual Group is believed to be a business corporation, incorporated under the Laws of the Commonwealth of Hassachusetts, with a corporate headquarters located at 175 Berkeley Street, Boston, Massach~asetts, 02117. 3. Defendant Liberty Mutual is believed to be a business cbrporation; incorporated under the Laws of the Commonwealth of Massachusetts, with a corporate headquarters · located at 175 Berkeley Streetr Boston, Massachusetts, 02117. 4. Defendant Liberb/ JVlutuai Znsurance Group is believed to be a business corporation, incorporated .under the Laws ofti~e Commonwea, lth of Massachusetts, with a corporate headquarters located at 275 Berkeley Street, Boston, Massachusetts, 02117. $. Defendant Liberty Hutual Fire Insurance Company is believed to be a business corporation, incorporated under the Laws of the Commonwealth of Massachusetts, with a corporate headquarters located at 175 Berkeley Street, Boston, Massachusetts, 02117. 6. Plaintiff purchased a policy of automobile insurance,, written by Uberty I~lu~ual insurance Group in the early. 1980% By' way of further pleading, Plaintiff maintained said POliCy during all relevant times contained herein. Said poiicy number is A02-28:L-,t73850- 809-8. 7. This policy was Issued to provide insurance coverage pursuant to the Motor Vehicle Finandal Responsibility Law (MVFRL) of the Commonwealth of I~ennsylvania. 8. On or about May 11, :1999, Plaintiff received from Liberty Mutual Fire l:nsurance Company a renewal notice regarding coverage limits for said policy. 9. Subsequent to receiving said renewal notice, Plaintiff' had questions regarding the renewal notice he received from Liberty Mutual. Plaintiff atl~;mpted on three separate occasions to contact his insurance agent, R. W. Chris~. His calls were not taken and he received no. return call. 10. SinCe time was running out'regarding the renewal no~ice he received, Plaintiff contacted a Liberty Mutual Processing Office in Mechanicsburg, Pennsylvania and spoke with an individual there regarding this policy. By way of further pleading, Plaintiff indicated that the liability limits were insufficient for his needs. Additionally, the individual at Liberty Mutual Processing Office indicated that they. had not received Plaintifffs uninsured and 9~ :39~d u nderinsured motorist coverage amount selection form. (A'l~ue and correct copy of said renewal notice is attached hereto and marked as Exhibit "A"). ll, PlainUff indicated to the individual at the Liberty lVlutuai Processing Office that he had not received that the Uninsured and Underinsumd IVlotorL~ Coverage Amount Selection Form in the iniUal renewal packet, 2.2. The individual at Liberty Mutual Indicated that they must receive the Uninsured and Underinsured Mo~orlst Coverage Amount Selection Form back prior to processing this renewal, By way of further pleading, she further indicated that she would mail the Uninsured and Underinsured Hotodst Coverage Amount Selection Form to him; and that it was extremely necessary that the PlainUff Immediately sign and return said selection form back to Uberty Mutual. (A true and correc~ copy of the Uninsured and Underinsured Motorist Coverage Amount selection form received by the Plain~tifl= is attached hereto and marked as Exhibit 13. On or about May 2~I, 1999, Plaintiff received Endorsement 01, which included the increased liability coverage for bodily injury. (A. true and correct of said Endorsement is attached hereto and marked as Exhibit ~C"). lZ,. As shown in Exhibit "B; the individual with the Uberty Mutual Processing Olfice had hand written notes informing the Plaintiff where to ~ign, and had in fact completed all aspects of this form with the exception of Plaintiff's signaturE; and the date. 15. Plaintiff's Exhibit "El' attached hereto reflects the exact document received by Plaintiff from Uber[y Mutual regarding his uninsured and underinsured motodst coverage amount selection, as well as rejection of uninsured and underinsLired motodst Protection -I~N.I. NN A-L~3~I9 BBLS-PL~-LT9 T~; :§T forms. By way of further pleading, the pages on these documents read respectfully Page 2 of 4, 3 of= 4, and ~, of 4. By way of further pleading, Plaintiff did not receive Page 1 of 4 at the time these forms were mailed to him, and did not receive th..= same until on or about the Fall of 2001, as stated in Paragraph :t6 herein. 16. Several months prior to filing this Complaint, the Plaintifl=visiited Liberty Mutual =rocessing O~ce and quesUoned the numbering bf the forms he had received back in L999. By way of further pleading, it was at this time that PiainUl~ received Page 1 of 4 of he Pennsylvania Uninsured Motorist Coverage and Underinsured Motorist Coverage Option "orm. (A true and correct copy of bSat sa)d page is attached here~ and marked, as lainfiff's Exhibit "D"). . . 17. As instructed, Plaintiff signed the uninsured and underinsured motorist coverage mount selection form on or about May 30, 1999 and returned the same to Liberty Mutual, ~me time al~er Hay 30, 1999, ~he Plaintiff received the three page Endorsemenl:, the lcompleted split underinsured motorist lirnits/PennsyJvania/non-sta~cked form, the lc0. mpleted split uninsured motorist limits/Pen nsylvania/non-stacked form, the document :licaUng this Endorsement changes the policy regarding ur~insured motori~ coverage, the cument indicating this Endorsement changes the policy regarding under'insured motOrist verage, all which included an Issue date of Play 24, :1999. (A true and correct copy of : entire packet is attached hereto and marked as Plaintiff's Exhibit"E). 18. rt is submitted that PlainUff did not have this instructional infon~aUon available him at the time that he entered into the contract due to the fact that Liberty Mutual ~d to send these document to him in the desired and required sequence. :[9. Plaintiff desired to explore the meaning of the docum,ants by con~acting his agent on different occasions, but never received a contact back fror~ said agent. 20. Plaintiff has discussed his insurance agent's conduct with individuals within Liberty Mutual, who responded that he does not return telephone calls to existing liberty Mutual customers for the purpose of answering questions, due to. the fact that he is a salesman. 23. Pursuant to the language of the MVFRL, the statute was amended to provide for certain required coverage and certain permissive coverage. 22. Pursuant to the IVlVFRL, the Plaintiff was requi~ed to be offered protection for uninsured motorist coverage and underinsured motorist coverage, and for the option of stacking the same. Title 7~; P.S. § :[738, requires ~hat certain rejection forms or waiver forms of said stacking of boverage be in form, language, and content provided by the MVi=RL legislaUon, and that the same must be signed and dated prior to delivering the policy to the insured. 23. Pursuant to the MVFRL, 'lTcle 75 P.S. § 1738, stacking of underinsured coverage is provided, unless specifically waived by the named insured. 24. Title 75 P.S. § :t791 requires that a Notice of Available Benefits and Umits mu~ be submitted to an insured by the insurer p~'ior to entering into any policy or change thereof. 25. The information page (Page :[ of 4) of the Pennsylvania Uninsured Motorist Coverage and Undednsured Motorist Coverage Option form was not mailed to Plaintiff to afford him the benefit of an informed decision. 26. Plaintiff additionally sought Information and advice from J~is agent,, but did not receive contract from him. 27. The Plaintiff specifically had questions regarding ne renewal of his insurance, as well as ~he changes being made by the Endorsement thereto, but was unable to have those questions answered prior to the time limit: expiring, for completing said insurance policy issuance. 28. The policy and procedure regarding the stacking of uninsured and undednsured 'motorist coverage is inherently confusing, as there exists no form to be signed by an insured opting to select such stacking coverage, nor is it clearly stated that stacking coverage exists if it is not waived. 29. On or about November 7, :t999, Plaintiff was involved in an automobile accident that occurred in Decatur Township, Clearfield County~ Pennsylvania. 30. An action has been filed by the Plaintiff against the Tor~ Feasor of that action, Dolores Shook, docketed in the Clearr~ld County Court of Common Pleas b3 No. 0Z-1800- CD. 31. As a direc~ and proximate result of the automobile accident;, Plaintiff sustained serious, permanent bodily injury. 32. Pursuant to the said claim made in the Court of Common Pleas of Clearfield County, it is believed that the third party carrier will agree to pay the policy limits under :he automobile liability insurance policy ol~ Dolores Shook. 33. The amount of the policy limits provided by thethlrd party carrier is insufficient md inadequate to .compensate for all of the damage and injuries which Plaintiff and his ;2158142222 passengers sustained, nor all of the economic loss which was suffered. 34. Pumuant to the provisions of the hlVFRL¢ the insurer in this case has failed to produce suf~dent evidence of compliance with the provisions of U~e MVFRL with regard to the issuance of uninsured motorist coverage, undednsured motorist coverage and the stacking thereof. At the time of f-he said accident, Plaintiff had three motor vehicles insured under said policy. 35. Under the policy and based upon the negligent and reckless behavior of Defendants, Plaintiff had uninsured/underinsured motorist coven~ge only in the amount of $100,000/$300,000. 36. Plaintiff's uninsured/undednsured protection coverage should be $300,000 each person and $900,000 each accident pursuant to Title 75 P.S. § 1738, Stacking of Underinsured Notorist Coverage. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter a Decree declaring: a. That the Defendant Liberty Mutual Insurance Company. has failed to adhere to the stdct provisions of the MVFRL with regard to assuring that the voluntary and knowing decision is made for the issuances of coverage for Plainti~s automobile insurance policy; b. That the PlainUff had three automobiles insured und~-r policy No. A02-281- 473850-8098; c. That the PlainUff is entitled in undednsured motorist coverage in the amount of $300,000 per person and $900,000 per accident; d. Attorney fees, interest and costs of suit as permitted by law; Such further relief as the Cour~ deems proper and just. Respectfully submitted, , David R. Thompson, Esquire Attorney for Plaintiff Plaintiff verifies that the st3tements made in this COMPI.4~ilfX'are true and correct. understand that false stab~men~s herein are made subjec~ to fl3e penaJtles of 18 Pa. C.S. 4904 relating ~o unsworn falsification to authorities. Ha)a~ Demchak ' -~nznN AI~3~tI] 88Zq-t~LS-lI9 IE :qI LI~ERTYGUARD AUTO POLICY DECLA/~%TIONS ~OLIC¥ NUMBER "AO2-2~1-473 $ 50-8.09 a~ NAME D ! NSUPJED AND ~1~ NG ADD~s ~IM DEMC~ 591 1 GENEVA DR RENEWAL ~1,,I?~ BOSTON, MASSACHUSETTS ~ ~,fm~-~,,~ THESEDEC~TJON~FEC~E ~0 ~ / ~ 5~ 9 9 ~ FOR ~E~'ICE ~L OR WRITE: CHRIST ~ W 21~ LI~GL;S~O~ ~ UNIT ~50 ~RRISR~ PA 17110 717-545;-4528/800_872_2568 C~IMS: 800-362-5698 POLIC~f PERIOD: 06/1~/99 TO 06/15/00 12:011~4 STA/~DARD TIME AT T/~E A~DDRESS OF T~E N~D INSURED AS STATED IN THE ~OLI~. T~IS POLICY S~L EX~iRE DN T~E DATE SHOWN EXCEPT T~T IT ~ BE CO~I~ED IN FORCE FOR SUCCESSI~ POLICY. PERIODS ~y T~E PAYME~ OF THE REQUIRED REN~ PREMIUM. EACH SUCH POLI~ PERIOD S~LL B~ FOR THE PERIOD ~P~CIFI~D IN ~E ~N~W~ DEC~TIONS. ~TURE DRIVER DISCO~T APPLIED FOR ~RiNCIP~ OPE~TORS AGED 40-64 COVE~GES ~ LIMITS ~ER YO~ A~O POLICY: COVE~,~E IS PROVIDED WHERE A PART A. LIABILITY BODILY I~qJL~y PROPERTY D~A~E C.UNTNSU~D MOTORISTS BODILY INJURY UAIDERINSURED MOTORISTS BODILY INJTJRy PRI~MI~H IS SHOWN FOR THE COVERAGE .VE~ 1 VEH 2 VE~ 3 VEH 4 100,000 ~2~CH PERSON 300,000 EAC~ ACCIDENT $0,000 F~AC~ ACCIDF/qT . 100,000 ~CH ~ERSON $ 31 31 31 300,000 ~A~ ACCIDENT $ ~o ~o 9o 100,000 ~CH PERSON ~00,000 ~ ACCIDE~ FULL TORT OPTION SELECTED FIRST PARTY B~E~ITS 10,000 MEDICAL EXPENSE 2,500 FUNERAL EXP~NSE $,000 INCOME LOgS 0 ACCIDENTAL DP2%TH $ 4~0 ~9 44 D-COVERAGE FOR DAF~OE TO YOUR AUTO OT~ER THA~; COLLISION ACTUAL CAS~ VALUE LEES DEDUCTIBLE SHOWN: VEH ~ $ ~oo VEH 2 $ ~oo VEH 3 $ ~do ' VEH 4 $ so COLLISION $ 26 25 141 22 · $ 80 71 197 34 ACTUAL CASH VALUE LESS DEDUCTIBLE SHOWN: VEH ~ $ 500 VEH 2 $ 5o0 VEH 3 $ 500 VEH 4 $ 100 THIS mOLICY COVERS COLLISION DA~U~GE TO RENT~ VE~ICLES. REST~zN~ o o o ~ ~~ 88Z~-~L~-LI9 T~:~T £88E/&I/ES '~0 UC:Y NUMAR "-A-Q2~28 l- 473 B50 - 809 ~ "NAMED IN..~UI~J~DAND MAILING ADORE.9$ MAXIM Dm. MCHAK 591 1 GENEVA DR ME CF, Ai%TI CSBURG PA 1T055 LIBERmy MSFI~3AL FIRE ZNSURAi~CE COMPAATY PAGe. 02 ...................... THE~E DEC~iONSE FFEC~N~ ~~ FOR S~RVZCE CALL OR WRITE: CHRIST R W 2t51 LINGLESTO~ RD UNIT ~RISBUR~ PA 17110 717- ~45-4528/800-872-2568 CLAIMS: OPTIONAL COVERAGe. TOWING AND LABOR COST - $50 EACI~ D!SABL~,N~NT EXTENDED TRANSPORTATION EXP~.NSES $15/$450 ANNUD25 PREMZUt4 PER IPEHICLE: SAFE DRIVER ~NST3~CE PLAN CI{EDI0}: AS A RESULT OF: VIOLATION SC0 NO SURCFI~U~GE ACCIDENT ,.9 CO NO SURCI4_ARGE TOTAL ANNUAL POLICy PREMIUM:' ENDORSEMENTS ATTACt~ED TO YOUR POLICY r 2330 ' 2323 l°P 04 22 O7 90 AS2049 02 9~ AS2057 08 97 _up 04 18 0V 90 AS2OS1 12. 98 PP 03 0.3 04 86 PP 03 09 04 86 AS1046 12 ~9 PP 03 02 12 89 PP 03 08 04 86 CHANGE OF FACSIMILE SIGNATEIRE (CO5~INUED PROM PREVIOUS PAGE)' $ 6 6 6 $ ~4~ 448 66I~ 56 $ 1618. 00 A1TAK3AjL MEETIN~ DATE CHAN~E P~ATNSYL1r~/qIA ~IRST PARTY' BEATE~ITS COVe-RAGE ENDORSEMENT SPLIT ~I~SURED MOTORISTS LIMITS P~SYLV~IA (STA~D) ~I~S~ED MOTORISTS COVE~GE - P~S~V~IA (STAC~D) ~ENDME~ OF POLI~ PRO~SIONS - PE~qSYLV~IA SPLIT ~DERINS~D M~ORISTS LIMITS PE~SYLV~IA (STAC~D) ~ERINSU~D MOTORIST CO~GE (STACkeD) - PE~SYLV~IA TOWIN~ ~D ~OR COST SPLIT LIA~ILI~ LIMITS AUTO.TIC TE~INATION ENDORSEMENT EXTENDED T~S~ORTATION COVE~ FOR D~E TO YO~ AUTO VEHICLES COVERED BY YOUR POLICY: RATING RATING VEH YR MAKE MODEL IDENTIFICATION ~ CLAS.~; STATE TERRITORY SYMBOL 1 90 VOLV 240 YVIAA8857L18584~45 07 PA 37 027 05 2 8~ 'CBEV CAV TYP l~lJE6$W4F721~8 27 PA 37 027 3 83 MRBZ 380 '.. WDBBA45A7DB026 246 ~S PA 37 027 21 ~ 79 BOLE 725153 O0 PA 37 O0 YOUR PREMIUM REFLECTS THE FOLLOWIlqG. -"LASS IF rATCORRECT, CONTACT YOUR SERVICE OFFICE. O0 VEHICLE TYPE INELIGIBLE FOR CLASS ASSIGNMENT. 88z q-~iS-iI9 IE :SI E88EI6I,/E0 LIBERTY MUTUAL FIRE INSURA/~C~. COMPANy LIBERT~rGUARD AUtO POLICY DEC~TIONS ' AO2-281r473850-SO9 8 ~ ~M DE~ 591 1 ~E~VA DR MEC~C~BURG PA ~J.~..~...~_~ FOR S~'RVZCE CALL OR WRITE: CHRIST R W RENEWAL PAGe. 03 17055' 2151 LINGLESTOWN RD UNIT 150 HARRIS~URG PA 17110 717-545;-4528/800-872-2568 CLA.IM$: 800-352-5698 (CONTINUED FROM PREVIOUS PAGE} CLASS 07 PREFERRED'RATE . PLEASURE USE - PO YOUTHFU'L OPERATORS - COMMUTING LESS T}U%AT 3 MILES ONE WAY - PRINCIPAL OPERATOR AGE 40-64. CLASS 27 PREFERRED RATE - NO YOUT~{FUL OPEP,-~TORS - COMMUTING LESS THAN 3 MILES ONE WAY - USES AUTO LESS THAN 7500 MILES ANNUALLY - NO PRINCIPAL OPERATOR AGE 40 OR OVER. CLASS 48 PREFERRED RATE - NO YOUTHFUL OPERATORS - COMMUTING LESS THAN 3 MILES ONE WAY - USES AUTO LESS THAI~ 7500 MILES ANNUALLY PRINCIPAL OPERATOR AG~ ~0-64. - Lq~H 1,2,3,4 GARAGED AT N~ED.INSUR~D,S ADDRESS THE FOLLOWING DISCOUNTS DISPLAYED WIT~ "YES" I-/AVE BELN APPLIeD.TO YOUR POLICy. T~E DISCOUNTS INDICATED ~ "NO" I-IAVE ~OT BE]'~TAPPLI~D TO YOUR POLICY. IF YOU BELIEVE TEAT YOU ~y BE ELISIBLE FOR A/FY DISCOUNT(S) LISTED AS "MCI,, PLF2%SE. CONTACT YOUR LOCAL SA ~ SHOWN ON THE ~iRST PAGE O~ YO~ ....... LES OR S~RVICE REPRESENTATIVE . ~ r~ DECLARATIONS. DISCOI/NTS: AIqTI- LOCK BRAKES ANTI-THEFT DEVICE (S) DEFENSI%r~ DRIVER COURSE DRIER TRA-I ~ING GOOD S~E~ ~TI - ~ P~S IVE REST~INT (AUTO.TIC SEAT BELT ~/OR AIR BAGS) ~PE~TOR I~O~T~ON: . N~E ~IM DEMC~ VEH I VER 2 V~H 3 VEH 4 NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO YES YES YES NO YES NO NO NO DATE OF BIRTH 06/21/36 ~PECIAL STATE PROVISIONS: ANY PERSON W~O K~OWINGLY, AND WITH INTENT TO .DEF~%UD ANY INSURANCE COMPANy OR OTHER PERSON FILES AN APPLICATION FOR INSUR. ANCE OR STATEMENT OF CLAIM CONTAINING A/~TY MATERIALLY FALSE INFORNL%TION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNIN~ AIq¥ FACT MAT]ERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH ~ERSON' TO CRIMINAL AND CIVIL P~NALTIEE. Thc follow/nE ,q~ct/o~s of this foam ar~ wh~ you hav~ s~e~ ~ ~ o~ no~s~ckcd ~t up,on. Yo~ ~b~ ~1 ~c~ic~ ~ ~e U~d Mut0~ Co~agc coyote ~o~ B~ ~d o~fious you ~1~ ~ in~te yo~: ch~c~ by c~;u~ ~c ~prop~ box. U~S~D ~ ~E~S~D ~OTO~ CO~GE A~OUNT SELECTION have time. eked U%c amount ~t'Uadn.4-inmm. ed A~io~rlsta Cove. rage I wig ~o ha~c: Tho U~insm'ed l~o~oria~ Cove~a~ and Underinst~ed ~o~ ~ve~e mnouu~ ~te~ may not axed ~~S~D ~OTO~ CO~GE L~ YOU S~ ~ ~CT ~RT O~ION AND STA~ O~ NON-~TAC~9 L~ ~N YOU ~ ~O~EN. 'Im aw~ ~al my ~]~tio~ ~p~ m mya~ ~d ~l f~ memb~ res/~g ~ ~ hou~oM. I ~ ~so aw~ ~a: my SIGNa$): L I 39Vd 88LS-~z-q-L I9 IE :SI I~J~CTION OF UNINSUP,~D 1V~OTORI~T$ PROTECTION ~n ~ ~o~d. U~d cov~g~ ~ ~ a~d rela~ves ~i~g ~ ~ hou~l~ for ]~ ~ ~m~ ~d ~ imj~ is ~ed b7 ~ ~Hg~ of a ~ who does ~t ~ ~y i~ to pay fo~ loszez ~d d~. I ~owim~y Si§nature Date *The P/rs~ ~arned Insm~-,d lismd az fl~..~mllcy rm~t alga and date the wa/v~r for it to be valid. Pg. 3 o1'4 REJECTION OF UNDERINSURED MOTORISTS PROTECTION 3y si~ning ~is waiver, I am rejcaing Underinsured Motorists Coverage under litis polic~,, f~ myze~ ~ ~ ~la~v~ r~iding n my ho~eho~ Un~ed ~v~ge prot~ mc ~d re~ves H~ng ~ my househ~old f~ losses ~d d~es s~er~ if nj~ ~ caused by ~e negligence of a ~ver who do~ no~ have enou~ ~s~c~ ~o pay for ~ lo~es ~d ~es. I mowingly ~d volubly reje~ ~ Signature of First N~med Insured* Date UNDER~$~D COVERAGE LI1VIYI'S ping This waiver, I am rejea/ng s~acked limits of Underinsured Motorists Coverage under the policy for myself and ..~c~ of my household m~der which the limits of coverage available would be ~he ,,~Um of limks for each motor vehicle ~ured 'u~der th~ pol/cy. Instead the limits of coverage r-Mt I am purchasi~ shall bt r~duc~d w rl~ l/mi~s staied in the ,llcy. I knowingly and volun~-/ly reject the stacked limits oi covcra~. I und~and ~,~at my premiums will be reduced if I chis coverage, $igr~e of l.'~rst Named Insured* Date he First Named Insured listed on the policy must sign and dace die waiver-for it to be valid. 6I BD~d 9~l'lll'~l ^l~BaI~ BBZS-~ZS-ll9 Ia:SI EOOE/61,/aO NUMI~R 2-281'473850'809. INSLIIiI~ &lID.MAILING · IM D~M~ i i ~A DK ~ICSB~G PA 1705~ LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MAS SACI4U~.TTS T.ESe D£CI,ARATIONS EFFECTIVE FOR S~VICI~ CALL OR WRITE: CHRIST R W 2151 LIN~LESTOWN RD ~IT 150 ~ISB~G PA 17~1D 717-5d5-4528/800-872-2568 C~: 800-362-5698 ,ICY PERIOD: 06/15/99 TO 06/15/00 12:01AM STANDARD TIME AT THE ADDP, ESS OF THE ~D INSURED AS STA~ED IN THE POLICY. I~GES MADE: ADD NON- STACKED VBH 1,9., 3 CHANG~ LIABILITY*VEH 1,2,3 MIUM ADJUSTME~ FROM 06/15/99 TO 06/15/00: AL ADjUSTM'~: ~ 75.00OK VEH I VEH 2 VEH 3 VJIH 4 $ 13CR 47CR 15CK ~RAGES ~ND LIMITS UNDER YOUR AUTO POLICY: IA~ZLITY ODILY INJURY ROPER~"YDAMAGE NINb~JRF~OMOTORIST~ 0DILY INJURY ERINS.%TP~DMOTO~/ST~ ODILY INJURY COVBRAG~ IS PROVIDED WHERE A PRF/~I~IS SHO~qN FOR THE 'CO'VEI~AGE VEH I V~H 2 V~H 3 VE~' 4 ~ 184 168 168 250,000 SOO,G00 ~ ACCZDE~ - 100,000 EA~ AC~E~ - . $. 27 27 27 100,000 $ 58 58 58 $' 100,000 BACH L:'ERSON $ 300,0~0 F. ACH ACCID~ L TORT OPTION SELECTED ST PAKTYBENEFITS 000 MEDICAL EXPENSE 00 FUNBRAL~XPENSB · 00 INCOMB LOSS CCIDENTAL'DEATH OVERA~E. FOR DAMAGE TO YOUK AUTO THER THAN COLLISION CTUAL CASH VALUE LESS DEDUCTIBLE SHOW/q: VEH-1 ~' .100 VF.H 2 ~ 100 V~H 3 $ 100 v~H 4 $ 50 OLLISION ~ 40 44 44 ~; 26 22 141 22 34 cy, In~lu~lll~g all ,en~lorseme~l~ aaached Is ~untemlgrle~ by; 0Z 39~d '-I'¢FllFIIN A.L~JBEI9 BBZS'-PZq-iI9 IZ :SI lUMBER -281.- 47~8~0 ~ 809 ~SURED AND MAILINr3 ADDRESS ~ D~~ 1 ~A DR ~C~BURG p~ 17 05~ -,~.~'r~ ..... ~%RD AUTO. POLICY DECLARATZ~ BOSTON, MASSACHUSETTS T.~ .ECUVu~T~O.. ~FF"Crlvs ~ PAGE 0 3 FOR SEHVICE ~.ALL OR WRIT~: CHRIST R W 2151 LINGL~STO~ ~ ~IT 150 ~RKISBU~G PA 17110 71T -545 - ~5~ B/B00- 872- 2568 C~MS: 800-362-56~8 (CONTINUED I~ROM PREVIOUS PAGE) PREMIUM ~EFLECTS THE FOLLOWINg. IF INCOR~CT, CO,ACT YOUR SER~ OFFI~. 00 VEHICLE ~E I~LIGIBLE FOR CLASS ASSIGn. g 07 P~FERR~D ~TE - PLEAS~ USE - ~O YO~~ OP~R~ -'CO~ING' LESS ~ 3 MILES O~ ~y - PR~CIP~ OP~TOR AGE 40-64. ~ 48 PRE~~ ~ . ....,,/. ~:....,.~ ,....--.., .... ' O~ WAY - USES A~ YO~H~L AGE 40-64. .. . · . ~, 2,3,4 GA~GED AT N~ IN~ED,'S ~DRES~ ~OLLO~ING DISC~ DIS~Y~ W~H "~,, :Y. T~ DI~~S I , ~ BEEN A~PLI~ ~ YO , ~ICAT~ AS ~NO" -Y. IF YOU BELI~ , , T~T YOU ~y BE ....... ,D AS 'NO" , PL ICOUNT~: VEH I VE~: 2 V~H 3 VEH 4 NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y~S, . , YES'..~. YES NO, .. · i/No ' .,z 0 No · ..': ; DATE OF BIRTH o /21/36 %L STATE PROVISIONS: ' ~ER~ON WHO KNOWINgLy, AND WITH I/FUENT TO DEPRAUD ANY ~Nh~KANCE COMPANy ~THER P~.RSO~ FILES AN APPLICATION FO]~ INSURANCE OR STATEM~%%~ OP CLAIM ?AININ~ ANY MATERIALLY FALSE INFORMATION OR CONCh-ALS FO~ TH~ PURPOSE OF ,EADING, INFORMATION CONC]~RNIN~ AATY FACT MATERIAL THEP,~TO COMMITS A ~JLENT INSURANCE ACT, WHICH IS A CRIME AND STS~JECTS BUCH P~SO~ TO [II~A~ AAiD CIVIL ~ENALTI~.S. This policy, inMudlllg all ontlor~emef~ts .~biched ta ~:auntsrslgned by: 88ZS-~L-C;-~I9 I~ :~I £0g~/8I/Eg t 0--03, ; ? : 04P~M: KMF PHI LA OFF [ CE PERSONAL AUTO PP O4 16 07 gO SPLIT UNDERINSURED MOTORI6TS LIMITS - PENNSYLVANIA (NON-STACKED) SCHEDULE UNDERINSURED MOTORIST~ COVERAGE _ each person ,,, each accident · aragraph A. of the Limit of Liability provision in he Underinsured Motorists Coverage - Pennsylva- fla INon-Stacked) endorsement is replaced by the allowing: .IMIT OF LIABILITY ~. The limit of liability shown in the Schedule or in the Declarations for each person for Underin- surecl Motorists Coverage is our maximum limit or liability for afl'damages, Ifldudiflg damages for care, loss of services or death, arising out 'bodily injury~ sustained by any one person in any one accident. Subject to this limit for each person, the limit Df I/ability shown in the Schedule or in the Declarations for each dent for Underinsured M~torists Coverage is our maximum limit of liability [or all damages fei' 'bodily irtjuw' resulting fl'em afl¥ one accident. This is the most w~, will pay regardless of the number oP. 1. "lnsureds'; 2. Claims made: 3. Vehicles or premiums shown in the Declara- tions; or 4. Vehicles involvecll fn the acc[dent. ;his endorsement must be attached to 1he Change Endorsement when issued afl[er the policy is written. lg 39~,=1 -I~'nJ..FIlN ^/kt3El9 BBZq-'l:,/_B-/_'["3 ID :q'[ £00g/'6T/gFj PERSONAL AUTO PP 04 20 07 90 SPLIT UNINSURED MOTORIST8 LIMITS- PENNSYLVANIA (NON-STACKED) SCHEDULE UNINSURED MUTORIS-i'.~ COVERAGE $ ,,, each person $ ,, each accident ~graph A, of the Limit or Uability provision In Uninsured Motorists Coverage- Pennsylvania ,-Stacked) endorsement is replaced by the wing: ~T OF LIABILITY 'he limit of liability shown in the Schedule or in ~e Declarations f,~r each per, on for Uninsured Aotorists Coverage Is our maximum limit of li- ability for all damages. Including damages for are, Joss of serYices or death, arising out of bodily injul~' sustained by any one person in ny one accident. Subject to 1his ;imit for each ~erson, the limit of liability shown in the ;chedule or in the Declarations for each acci- 'ant for Uninsured Motorists Coverage is our laximurn limit of liability fur all damages for bodiJy Injury' resulting from any one accide*nl. This is the most we will pay regardless of the num- ber oP.. 1. 'lnsureds'; 2. Claims made; 3. Vehicles or premiums shown in' the Declare. tigris; ar 4. Vehicles involved in 'the accident. endorsement must be attached to the Change Endorsement when issued a~ter the policy is written. 1 20 O7 9O C~pyright, Insurance Services Ol~ce, inc., 1990 Page 1 ~ I 3:--10--03; 3:04PM;KMF PHILA OFFICE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ, IT CAREFULLY. UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) AS 2048 I]2 g$ (PP. 04 21 06 95) Part C - Uninsure~l Motorists Coverage is replaced by the follo~inii: SCHEDULE · " Um#~URED MOTOKISTS COVEI~GE .... DescriptJ~n .... Limit ........ of* Vehicle Llabil~ty Premium III~URING A~REEMEHT A. We will pay compensatory damages which an 'insured' is legally entitled to recover from the owner or operator o1' an 'uninsured motor hicle' because of 'bodily injury': 1, Sustained by ~n' 'insured'; and 2. Caused by an ~ccident. Th.e.'owner's or operator's liability for these damages must arise out of the ownership. maintenance or use of the 'uninsured motor vehicle', No judgment for damages arising out ol;a suit brought against the o~er or operator of an 'uninsured motor vehicle' is binding on us unless we: 1, Received reasonable notice of the pen- dency of the suit resuitipg in the judgment; and 2, Had a reasonable opportunity to protect our Interests itl the suit. B. 'Insured' as used In this endorsement men;ns: 1, You or any 'family member', :~. Any other pem. on 'occupying' 'your cov- ered auto". 3, 'Any person for damages ~hat person is entitled to recover because ot' 'bodily in- Jury' to which this coverage applies SUs- tained by a' person described In 1, or 2, above. C. 'Uninsured motor vehicle' means a land motor vehicle or trailer of an~ type: 1.' To whicl~ ~to bodily ihjury Ii'ability bad or policy applies at the time of the accident. 2. Which is a hit-and-run vehicle whose operator or owner cannot be Identified and which hits or which causes an accident re- suiting in 'bodily inJur~ without hieing: e. You or any 'family member"; b, A' vehicle wh'ich you or any "family member' are 'occupying'; or · % 'Your covered auto'. If there is no ~ntact with the hit-and-run vehicle, the facts nf the accldent must' be proved. 3. To which a bodily Injury liability bond or policy applies at the time of the accident but the bonding or ins-ring company: '~ Denies coverage; or b. Is o,r becomes: (1) 'llnsoive~; or (2) Involved in Insolvency proceedings. However, 'uninsured motor vehicle~ does not include any vehicle or equipment: 1. Owne~l by ~r furnished for the 'regular use of you or any 'family member'. 2. Owne;I or operated by a self-insurer under any applicable astor vehicle law, except a sellLlm;urer which Is or becomes insolvent. 3. Owned by any go~emmetttal unit or agency. 4. Opera~ed on rails or crawler treads. '5. Designed mainly for use off public r~ad; while not on public roads, G. While located 'for use as a residence or premi..;es. EXCLUSIONS · A.. We do not provide Uninsured Motorists Cover- age for 'bodily injury' sustained: 1. By you while 'occupying'. or when struck by, any motor vehicle you own which is not insured fdr this coverage under this policy. This includes a trailer of any type used with that vehicle. 2. By a "family member~:. a. Who o~ns an auto, while 'occupying', or when struck' by, any. · motor vehicle owned by you or any 'family member' which is not insured for this coverage under this policy.. This includes a trailer of any type used with that vehicle. b. Who does not own &n 'auto, while 'occupying', or when struck by, any motor vehicle you own which i's Insured for this coverage on ~ primary basis un- der ally other policy. B. We do not provide Uninsured Motorists Cover- age for 'bodily injury' sustained by any person: 88L§-PL§-/_~.9 T,~ :q[ :- I O--OS; 3: 04~'M; Ktv'iF PHt LA OFF I CE AS 204g 02 96 (PP 04 2~ O. If two or more policies have equal priority, the Insurer against whom the claim Is flr~ made shall process and pay the claim as if wholly responsible For all fnsurers with equal priority. The insurer Is thereafter entitled to recover contribution pro rata from any other insurer for the benefits paid and the costs of processing the claim. If we are the Insurer against whom the claim is first made, we will pay, subject to the limit of li- ability shown in the Schedule or in the Declara- tions for Uninsured Motorists Coverage, after we and all other contributing insurer.s agree: 1. Whether the 'insured' .is legally entitled to -- recover, damag.es.from the owner or opera- ..., :. ...,ter-.o[ ~11 .'.qnip...sured ~ .otor. vefiiqle'; and :': . 2::'As'to"tl;~e amt~dnt oF'da'mage~, ' ; .. ARBITRATION , ~ ",, ' ' ' '~ ~: If we and an '~ns'~r~d' dj 'not. t. Whether that 'insured' is legally entitled to recover damages: er 2. As to the amount of damaDes which are recoverable by that 'Insured': From the owner or operator of an 'uninsured motor vehicle' then the matter may'be arbi- trated. · Either party may make a written demand for arbitration. Arbitration shall be conducted in accordance with the provisions of the Pennsyl- vania Uniform Arbitration Act, Each party will select an :arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that .selection be made by a judge of a court having jurisdiction. Arbitration shall not, however, be a means of settlement .should the dispute involve: 1, Any form of Inter- or Snips-policy &-tacking, or ~!, Selection of a coverage option, or a waiver Of such COVerage, or O~t. errrtination 'of residency in defining who ' Is'~br 'is' n'~t a~' tns~red':un.de.r th'ia' coverage, 6r-,~" .... ~"" :" ' ' .... 4, Statutes~ of limitation, or S, ~t'~l:mi~btio'n"af~ wl~eth~r ~" ~l~imant is an Insured under these coverages. Each party will: 1, Pay the expenses It incurs; and ~, Bear the expenses of the third arbitrator equally. Unless both parties agree otherwise, arbi- tration will take place in the county in which the "Insured' lives. Local rules of law as' to procedure ar~ evidence will apply. A deci- sion agreed to by two of the arbitrators will be bindinB.. This endorsement mu~t be attached to the Change Endorsement when issued ·after the ~olicy,ls written. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, insurance Services Office, Inc., t9;14 Page 3 of 3 U~I)ERINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKEi~ IN~q~G AGREEMRNT A~ Wc will ply compensatory a~m~ges which an "insured' is l~iy entRl~ to r~.~ver from ~e ~. ~ed by en ~t. The owu~s or opentoffs liability ,for age. s m~ ~sc,. ~t, of ~c o~p, ma~~' ~ of~e ~s~m~ vehicle'. Wo will pay under ibis toreros.= only if 1..or 2. below applies: 1. The !i~its of liability uml~r any al~li~able bodily injury lhbfl/t3, ban/is or policies have been exham'ted by lmyment o.f judgments or settlements; or 2. A tentative settlement ires bee~ mad~ between an "insured" and tim insurer of the "undcxinsta~ motor vehiol~" and wo: a. Have b~n given p/ompt wdUen ~otice of b. Advance payment to ti~ "insured" iu an within 30 days afl~ r~pt ofnotifica~iou. No.-judEmcnt for damages arising out of a suit ~/~ought aga/nst 1he o ,w~,cr ? ,ol~,?rawr of an tm .der/muted motor vchlclc" ts bm~lln~ on us un- less wo: 1. Received reasonabl~ notice of &e pendency of the suit resuliinS in the jxatgmcnt; and 2. Had a r~asonablo opportunity to protect o~r interests in 0xc suit. 'Insured" as used in this cndorsemem means: ~. You or miy 'family member'. 2. Any othcr person 'occupying' 'your covered axitou. ~. Any person for damages ,t~..t p.~son is entitled ~o mcowr because of %odily m~UrY? to which this coverage applies sustaiued by a pcrscm de- scribed in 1. or 2. above. C. "Und~rinsmml motor vehi~ vohicle or trailer of any jury liability bond m poli~- ~he accideni bm ~be amoun~ under Ib~*. bo~l or _pg_ licy~ enough t~ pay ~he full .gaily entitl~to recover as However, %ndminmned include any vabicle or equiZ 1. For which liability coy- Part A 0fthis polio3'. Z. Owned bl/~'~lr §overm~ ~. Operated oil, ~ails or ~ 4. Designed mainly for ~. Whil~ looated for use ises. EXCLUSIONS A. We do not pr~r~ide Und~r- a§c for "~odily inju~" you or a "family men-- derlmured Motoris~ nor "s tach mo~ vehide. 2. By a ~.family when struck bY, ~- you or any "famili insured for this cc~ This includes a Ira.. that vehicle. b. Who does not "occupying", or w- vehicle you own covcrage on a ~ policy. B. We do ?t Im~ide Uncle= aa~ for 'bodily injury" st~ BBL c;-t~Z ci-L'[:9 3.--10--03; 3: 04PM; KMF PHILA OFFICE UNI)EIIlNSURED MOTORISl8 COVEI~OE, PENNSYLVANI~ (NON-,~.FACKED) AS 20S0 12'98 Wifla ~espect 1o the coverage l~ravided by this endorsement, tbs provisions of the policy apply unless modified by SCHEDI.~,E IJNDERINSURED MoToRIsTs COVERAGE Description Limt_t ~f. of Vehicle Liabilfty Premium $ $ AGREEMENT Cl. "Underinsurcd motor vehicle" means a laud motor A. We will lmy comlxmS~...lp~, dan~l~cs which an '~insuved'" is legally entitled ~o recover from the owner or operator of an %mtcrinstucd motor vchi- cie" because of"bodil~ injury": 1. Smtainedby an "i~-urcd"; and z. Caused by an accident. The owner's or opcmio~s li~biliv~ for thcse dam- ages must aris~ out of thc o~p, maiur~mance. or usc of ~bc %ndefinsumd moor vehicle". We will Dy unda lbi~ covengc only if 1. or 2. below applies: 1. Thc limit~ of ljabilit~ under any applicable bodily injury liability bonils or ~olicies have bccn exhausted by paym~ of Judgl~aOlll~ ~ 2. A telltatJVo $~ .l~--'memt h~ b~'~l mad~ ~otwccn an "insured' and thc i~surer of the "undc-rins~cd motor vehicle~ ,,,,a w~: ~. Ha.ye bcen given pmmpx written notice of such tentative settl~tu~c; and b. Advance l~kment to thc "insured" in an ~mo~t eqml to the tentative settl.~ment within 30 days after r~ of notific~ion. No..judgment for damages arising out of a suit brought against the owner ,or, operator of an "~od motor vehicle" ~s binding an us un- less We: 1. Received rea.sona, btg notice of ~he pcudengy of thc suit ~sulli~g In the jmil~ncnt; and 2. Had a reasonable olrp~i~ ~o lnO~cct our B. ~lusured" as ~ed in this end_~rsommt means: 1. You or aW "family member% 2. Any other person "occupying' "your covered :3. Any person for damage~ that pc~s. on is ~ntitled to ~ccov~ because of "bodily i~ury~ m which this coverage applies sustained by a person dc- scribed i~ 1. ur~ ~bove. vehicle or ~aRer of any Wi~ to whigh a bodily in- ]u~ lhbility bond ~rpoli~y el~pl/e~ at thc rime of ~xe- accident bm thc ~mount l~id for "bodily in, jmy" under that.bond or policy to .za "insum~t" ~s no~ enough to pay th~ fi~l zmount th~ "inS'ul~l' is lc- gaily entitled to re~ov~r as However~ '~m. dezlnsmed moto~ vehicle" ~bes not i~clnd~ any ~clc ~ ~i~ 1. For which ~b~ c~e~ge is ~i~d uuder · P~ A of~is 2. ~cdb~ ~y gov~mcn~l ~it ~ a~n~. 3. ~ted on rai~ or cmwl~ ~.. 4. Deai~ ~ f~ ~ off pub~ ~ while a~e rot bMily iud' 1. ~i~ "~cu~ng" a mot~ ~clc o~ by you or a "~ily m~b~' n~ ~ for Uu- ~n~od M~ Cov~se ~ ~ pol- ~; ~ ~ ~o~ly ~" t~ b~ h~ by any ~h ~ vehicle. a, Who owns an cmo, while '"oCCUl~ug", or when struck ?,~y, shy motor vehicle owned you or. mff' family m~mbe~' which ,is insured fix this coverage und~ this poli~y. This inchtdes a trailer of ~ type used with tl~t v,hicle. b-Who does not own any auto, while "occupying'*, or when su . Ii. by, any motor vehicle you own which is insured for this coverage on a prima~y basis under any other polio. We do not p,rvide Undexinsured Motorists Cover- are for "bodily injury" sustained by any person: 2-~0--03;; 3:04PM:KMF PHILA OFFICE . If v~ are the insx~r~r a§a, inst whom the claim is first made, we will pay, subject to limit of lia _ t,/ shown in the Schedule or in the De¢la~tiom for deriusared Motorists Coverage, aRer we and ali other con~buting insures agra: 1. Whether the "insured" is legally entilled to re- covc~ damages f~om the 0wll~r or operator cf "un&vinstt~d motor vehicle"; and 2. As to rig amount of damages. AS 2050 12 98 ~PP 04 17 06 95) C. Unless both _l~-~ies egt~ .oth.m~w. is~, arbitration ~l ~ phcc ~a ~ ~ m which ~e '~s~cd" lives. L~al ~l~ o~law ~ ~ ~oc~ and cvi* ~nc~ wi~ ~1~, A deci~on a~ccA to ~ ~o of ~ ~i~t~s roll ~ ~g. A p~son s~g Und~n~d Mo~ ~v~agc m~ also p~y: 1, ARBITRATION A- If we end an "insurcd' do not 1.' Whelher that "insured" is legally entitled to r~- cover dama§c$; or 2.. As to the nmmmt of danmges wl~ich al~ r~cover- ab.lc b~ that .~'.m. surcd,"; , , .., , . , ,. m o~ ,vehicle..: ~en.. th~ ma~e~ may ,1~ ~5itr~ted. Either party may make,&..Wn.'.'tt~n dem.aml'f.o~ arbi- tration. Arbi~x~tion shall be conducted in accor- dance with ~hc provisi6ns'o'f the P~ms',y,l? .an~ Uni- form A~.bitration Act. E~h' l~art~ will g~l?o~, an arbilrato~. The two a~bitra~ors will select Send us col~ies of thc l~gal papers ff a suit is brought; 2, Not/l~ us in ~ of a' ~vc s~l~ be~en ~e "~* "~nsm'M an ~o~t ~[ ~ ~o ~e se~lement to , ~ o~ .of ~h ~'~~ moor v~i- "Cie'. :"' .... .*~ ......f' ".:~- ''~' ' Thc fo, Uowing is ,at~. d to the ..Our...Right. To Recowr Pnym~n~ ~rovlsio~ ;bfP~t'F: ..... *. ', OUR RIGHT 'TO RECOVER PAYMENT they c.snnot ?8t~e. witlgn 30 days, dther may .quest that se.t. ectloll be made by a judge of a court ttaving jm-isdiction. ArbiWation shall nnt, however, be ,, means of set- tlen~n! should the dispute involve: 1. Any form ofi~ter- or intm,l~licy slacldng, or 2. Selection of. a coverage option, or a waive~ of $~h Coverwgo, o~ 3. Determination ofrcsidcucy in defining who is or is not all irksttred under ~lie coverage, or 4. Statutes of limitation, or $. Dcl~,mluation of whether a claimant is an in- suredunder these covera.ses. " 2., Bear the ~cp6hses of the f~ird ~fbi~rator' equally. Out- rights do not apply under paxa~aph A. w~th respect t~ Unde4insm~d Motorists Cov~ge if we: 1. Have be~ g~ pmm~ ~u~ ~ice of a t~tive s~lm~t be~ au '~s~' ~ the insurer of an "underinsured moor vehi- This enck~rscmcnt ihust b~ httnched ~ ~he ~angc F, ndorsemcnl when issued after the policy is written. Includes copyrighted maie~al oflnsurence Services Office, Inc., with it~ permission. Copyright, Insurance Serv/ces Office, Inc., 1!)94 Page 3 of 3 £99a/61/aa 3:-1Q-03.; 3:04PM;KMF PHILA OFFICE ;£158.142222 PENNS~¥~ UNINSUle, ED MOTORISTS COVERAGE AND UNDERENSUR~D MOTORISTS COVERAGE OPTION. Ii'OHM MUTUAL - tvanin law requires tho we offer you Uninsured Motorists Coverage and Und~'insured Mowrists Coverage in limits ) the Bodily Irijury Liability limils canied on your policy. You may select lower available limits, You may reject red Motorists Coverage, Undorinsur~d Motorists Coverage or both of th~se coYerages. tm briefly desewibes the benefits offered and yr, ur opiions. Please read chis form caret~lly as you are the bes~ p~rson mine the cov~age and limits that fulfill your insurance needs. NINSURED MOTORISTS COVERAGE AND UNDERINSUR.ED MOTORISTS COVERAGE ~ES TO: - Motor Yehtcl~ RS: · You · Resident f~ntly member~ . · You and resident family members as pedestrians ' Or. her people in your ear ?ITS: UlqI~SU~.n MOTORI,~TS COVHt~OE provid~s cowragc for bodily injur~, sidmess, disease, or death, which you are legally enfirl~l to recover item ~he owner or operator of: · ~ uninsured motor vehicle a motor vehicle for which coverage is provid=d by a liability policy or bond, if lhe company issuin~ the coverage for the/t-fault party denies co~terage or is or becomes ir~solvent. hit-and-run vehicle whose owner or operator emmet b~ ldcnt//ied_ UNDIil~SURF~ MOTORISTS COV~R~OE provid/s coverage for damages you ~e leg~ly enfifl~ ~ ~cov~ ~om ~e ow~r.or s~rator of ~ ~d~ns~ motor ve~cl~ beca~ of bodity inju~, stress, ~s~se, or d~ ca~ by ~ ~d~t ~nvolv~g ~e ~dedn~ed motor vcMclc. ~ under,ed motor v~de is one w w~ch a bodily ~j~ ~abiliw policy or bond applies ~ ~ ~e of ~e acct~n~ but the ~ou~ p~d for bodily inj~ un~r ~a: bond or policy h not enough pay ~e ~11 ~unt ~e ~s~ed is leg~y en~fl~ m r~over ~ ~i. Your Uninsured Motorists Coverage and Underiusured M~t0rists. Cove. rage limit will equal your Bodily Injury Liability limit unless you reject in writing Ur~hlsu~vd Motorists Coverage and/or Underinsumd Motorists Coverage or select a. lower ~vailable coverage limit, 'When Uninsured Motorists Coverage and/or Underinsured Motorists Covarage applies, the limit of liability for these coverages applicable to you and resident family memberz will be the ~um of r,.h¢ stated coverage lira/ts applicable to each vehicle on your policy. This is known as ihc "smoked" coverage lirait. 'You may dect to waive the stacked coverage lirni.t and carry limits on a "non- stacked" basis. VChen the non-stocked limit option is selected, your coverage limit will be that smr~d in the policy for each veabicle. You will save on your coverage prem./um if the non-stacked limit option is selected. : aware that any ~ummary of coverage on these pages is necessar/ly general in nature.. Your policy contains speaifia )ns, exclusions, and condldons. In case of any conflict, your policy language will control the resolution of all quest'ions. :-~0-C3; 3:04PM;KMF PHILA OFFICE OLIGY NUMBER LIBERTY MUTUAL FIRE INSLIR2%~CE COMPA~-Y L!BERTYGUARD AUTO POLIC"f DECLARATIONS BOSTON, MASSAC/TUSETTS. TH ES E DECLARATIONSEi=FEC'I'IVF.. ENDORSEMENT FOR SERVICE CALL OR WRITE: CHRIST R W 2151 LIN6~ESTOWN RD 'UNIT 150 HARRISBUlq. G PA Z7110 717-545-4528/800-872-2568 CLAIMS: $00-392-Bg98 POLICY. PERIOD: 06/15/99 TO 0g/15/00 12:01A~4 STA/qDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED IN THE POLICY. CF_ANGE$ MADE: ADD NON-STACKED lrsH 1,2,3 CHANGE LIAB~LITY*VEH-1,2,3 CHANGE CLAES*VEH 2 PREMIUM ADJUSTMENT FRON 06/15/99 TO 06/15/00: TOTAL ADJUSTMENT: $ 75.00CR 47CR I~R COVERAGES AND LIMITS UNDER YOUR AUTO POLICY: COV~RAG3: IS PROVIDED W~ERE A PREMIUM IS SHOWN FOR THE COVERAGE PART VEH 1 VE~ 2 VEH 3 ~.LIA~ILITY $ 184 168 168 BODILY INJURY $ 250,000 EACH PERSON $ 500,000 EACH ACCIDENT $ 10~,000 EACH ACCIDENT PROPERTY DAS~AGE 2.UNINSURED ~OTORISTS BODILY INJTJR~ /NDERINSURED MOTORISTS BODILY INJURY $ 100,000 EACH I~E~SON $ 300,000 EACH ACCIDENT 100,000 EAC~ PERSON 300,000 EACH ACCiDEAFE ~ULL TORT OPTION SELECTED VEH 4 $ 27 . 27 27 ~IRST PARTY BENEFITS .0,000 MEDZC2%L EXPENSE :,~00 FUNERAL ~XPENSE ;,000 INCOM~ LOSS t ACCIDENTAL DEATH $ 40 44 44 ,-COVERAGE FOR DAbtAGE TQ YOUR AUTO OTHER THAN CQLLISION ACTUAL CASH VALUE LESS DKDUCTIBLE SHOWN: VEH ~ $ i0o V~K 2 $ VEH 3 $ zoo VEH ~ $ ~o COLLISION $ 26 22 141 22 $ 80 64 197 34 -~KET 307~ 128~ ~ 7562DU1N-N** / RESTRAINT 255 i 01 0000 000 4 Y~Y 8 001 00 N 2-- o__! oooo ooo 4, YYTt 8 oo~ ooN i,,ii o--6V6-6 oooT ooz oo ! oooo ..... ooo o xx~ o ool oo~" ;2158142222 -10--03; 3:04PM;KMF PHILA OFFICE LIBERTY MUTUAL FIRE INSURANCE COMPANY LIBERTYGUARD AUTO POLICY DECLARATIONS BOSTON, MASSACHUSETTS )EMCHAK ;ENEVA DR i CSBURG PA 1705~ ENDORSEMENT PAGE 02 FOR SERVICE CALL OR WRITE: CR~IST R W 2151 LINGLESTOWN RD UNIT 150 '~IARRISBURG PA 1'7110 717-S45-4528/800-872-2568 CLAIMS: 800-362-5698 (CONTINUED FROM PREVIOUS PAGE) CASH VALUE'LESS DEDUCTIBLE SHOWN: VEH 2 $ SOO VEH 2 $ 50O VEH 3 $ 500 VEH 4 $ ~00 ~OLICY COVERS COLLISION DAMAGE TO ~HICLES. COVERAGE ; AND LABOR COST - $50 EACH.DISABLEMENT )ED TRAHSPORTATION EXPENSES $15/$450 'REMIUM ~ER VEHICLE: $ 6 ,~ 6 $ 12 12 12 $ ' 433 401 6S3 56 VER INSURANCE PLAN C~EDIT: ULT OF: VIOLATION SC0 NO ACCIDENT SC0 NO SURC~ARGE SU~C~I~KGE N-UAL POLICY PREMIUM: 1543.00 E~S ATTAC~qED TO YOUI~ POLICY: 07 90 07 m0 04 86 04 86 12 89 O4 86 C~%/~GE OF FACSIMILE SIC~NA~IRE AN1TUALMEETING DATE CHANGE PENI~SYLVANZA FIRST PAR~Y BENRFITS CO~GE ENDORSEM~ SPLIT ~INSURED MOTORISTS LIMITS PE~SYLV~IA (NON-STACKED) ~I~S~ MOTORISTS COVE~GR - PE~YLV~IA (NON-STACKED) ~ENDMENT OF POLI~ PROVISIONS - PE~S~V~IA SPLIT ~DRRINSUR~D MOTORISTS LIMITS ~E~SYLV~IA (NON-STACKED) ~ERINSU~D MOTORIST COVE~GE(NON-STAC~D)-PR~SYLV~IA TOWI~ ~ ~OR COST COVE~GE SPLIT LI~ILITY LIMITS AUTO.TIC ~INATION E~ORSEME~ EXTE~ED ~SPORTATION E~PENSES CO~GE COVE~GE FOR D~E T0 YOUR A~O COVERED BY YOUR POLICY: , RATING RATING MAKE MODEL IDENTIFICATION ~ CLASS STATE TERRITORY SYMBOL VOLV 240 ~'Vli~.8857L18~844~ 07 PA 37 027 05 C~EV CAV TYP 10 1G1JE67W4F721%338 48 PA 37 027 10 MRBZ 380 WDBBA45A7DB026246 ~8 PA 37 027 21 BOLE 725153 00 PA 37 O0 1'; I¢1- I -' .... '" '= '" "'"* ..... S i0 0 05/24/9 00 00 RY Z 0'l 0000 0Co 4 Y¥~ ~ 0aZ "00 N s z2~ ~ oz oooO .... ooo ~ YY~ 8 oo~ oo N N**/ / 3 o~ oooo O'oo 4 NOC $ o0~ oo ~ 4 05 ~060 0~0 0 XX~ 0 001 00 N LIBERTY MUTUAL FIRE ZNSLTRANCE LIBERTYGUARD AUTO POLICY DECLi~D, ATI¢)NS BOSTON, ~SSACHUS~S )uc~ ~281-473B50- 8D9 8 ~ ~MED INmUREDAND ~L~G ~IM DEM~ 5~Z 1 GE~A DR MEC~ICSBURG PA 17055 ENDORSEMENT 01 PAGE 03 ~EDECLARA~ONSEFFECTWE~ FOR S~RVIC~ CALL OR WRITE: CHRIST R W 2151 5INGLESTOWN RD UNIT 150 HAi~RISBLTRG~ PA 17110 717-54~-4528/B00-872-2568 CLAIMS: 800-362-5695 fOLT~ PREMIUM REFLECTS T~E FOLLOWING. ]LASS (CONTINUED FROM PREVIOUS PAGE) ZF INCORRECT, CONTACT YOUR SERVICE OFFICE. 00 VEHICLE TYPE INELIGIBLE ~OR CLASS ASSIGNMENT. 07 PREFERRED RATE - PLEASURE USE - NO YOUThfUL OPERATORS - COMMUTING LESS THAN 3 MILES ONE WAY.- PRINCIPAL OPERATOR AGE: ~S 48 PREFERRED ~TE - ~O YO~MF~ OPE~T~S - CO~TING LESS T~ 3 MILES 'ONE' WAY - USES A~O LESS T~ 7500 MILES ~A~Y - PRINCIP~ OPE~TOR AGE 40-64. '~ 1,2~3,4 GA~GED AT N~ED 'INS~ED'S HE FOLLOWING DISCO--S DISP~YED WI~ "YES" ~VE BEEN APPLIED TO OLICY. ~ DISCO--S I~ICATED AS "NO" ~ NOT B~EN APPLIED TO YOUR OLICY. IF YOU BEL~E T~T YOU ~y BE ELIGIBLE FOR ~ DISCO--(S) ISTED AS "NO", PLEASE CONTACT YOUR LOC~ S~ES OR SERVICE REPRESE~ATI~ HOWN ON ~E FIRST P~E OP YOUR POLICY DECL~TIONS. DISCOUITrS: AI~TI -LOCK BRAKES ANTI-TaEF~ D~IC~ (S) DEFENSIVE DRIVER COURSE DRIVER TRAINING GOOD STUDENT MULTI -CAR PAS S TVS RESTRAINT (AUTOMATIC SEAT BELT A19D/OR AIR BAGS} 'ERATOR INFOR~4ATION: MAXIM DEHCHAK V-EH 1 VEH 2 VEH 3 VEH 4 NO NO NO NO NO ~0 NO NO NO NO NO NO NO NO NO NO NO NO NO NO YES Y~S YES NO' · YES NO NO NO ECIAL STATE PROVISIONS: DATE OF ]BIRTH D~NY PERSON WHO KNOWINGLY, AND WITH INTENT TO I1EFP,~) 3L~Y INSURANCE COMPANY OR OTHER PERSON FILES ~ APPLI~TIO~ FOR INSU~CE OR STATEMENT OF C~IM OONTAINING ~Y ~TERI~LY P~SE 'INFO~TION OR COCCi:ALS FOR THE P~POSE OF ~ISLE~I~G, I~OR~TION CONCERNIN~ ~y FACT ~TERIAL ~ERETO COMMITs A F~ULE~ INSU~CE A~, WHICH IS A CRINE ~D SUBJECTS SUCH PERSO~ TO ~RIMIN~~ C~IL PENALTIES. 3075 1289 'R62DUNN**/ / ' RESTRAINT 2555 EE Bg~d q~slnH Al~2~Iq 88/S-~7S-719 IE :SI PERSONAL. AUTO PP O4 15 O? 90 SPLIT UNDERINSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-STACKED) SCHEDULE UNDERINSURED MOTORJ~¥S COVI~RAGE each person each accident Iph A. of the Limit of Liability provision in lerinsured Motorists C~verage - Pennsylva- n-Stacked) endorsement is replaced by the g: IF LIABILITY limit of liability shown in the Schedule or in Declarations for each person rot Underin- d Motorists C,~verage is our maximum limit' ability for all damages, including damages are, loss of services or death, arising out of ily injury' sustained by any one person In one accident. Subject to this limit for each .~n, the limit of liability shown in the dule or in the Declarations for each eccl. I~or Underinsured Motorists Coverage is.our mum limit of liability for..all damages for i1¥ injury' resulting from any one accident. This is the most we will pay regardless ol~ the number oE 1, 'lnsureds"; 2. Claims made; 3. Vehicles or premiums shown in the Oeclara- 1ions; or 4. Vehicles involved in the accident. lorsement must be attached to the Change Endorsement when issued alter the policy is written. :-10-03.; $:04PM:KMF PHILA OFPlCE PERSONAL AUTO PP 04.20 O7 9O SPLIT UNINSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-STACKED} SCHEDULE UNINSURED MOTORISTS COVERAGE $ each person $ each ac~d~nt Paragraph A. o1' the Limit of Liability provision in the Uninsured Motorists Coverage - Pennsylvania (Non-Stacked) endorsement is replaced by the following: LIMIT OF LIABILITY A, The limit of liability shown in the Schedule or in th.e Declarations [or each person for Uninsured Motorists Coverage is our maximum limit of' Ii~ ability t'or all damages, including damages for care, loss of services or death, arising out of 'bodily injury" sustained by any one person in any one accident. Subject to this limit for each person, the limit el~ liability shown in the Schedule-or in the Declarations for each acci- dent for Uninsured Motorists Coverage is our maximum limit of liability [or all damages for .:' . 'bodily In'jury' resultlrlg Imm any one accident. This is 1he most we will pay regardless of the num- ber of: 1, "lnsureds'; 2. Claims made; :3. Vehicles or premiums shown in the Declara- tions; or 4. Vehicles involved in 1he accident. 'his endorsement must be attached to the Change ~=ndorsement whorl Issued alter the policy is written. ' 04 20 07 90 1~£ 39'¢--I Copyright, Insurance Bervices O~ce. In:. t~*en 3-10--O2:: 3:O4PM:KMF PHILA OFFICE ' THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) AS 204e (}2 9; (PP 04 21 0e 9~ art C - Un Insured Motorists Coverage Is rbplaced by the following: SCH~ - UNINSURED MoToRisTS COVER '"f ',of Vehicle Liability Premium . $ $ II~ISURING AGREEMENT A. We will pay compensatory damages which an 'insured' is legally entitled to recover from the owner or operator of an 'uni~isured motor ve- hicle' because of 'bodily injury': 1. Sustained by an 'insured"; and 2, Caused by an accident. The owner's or operator's liability for these damages must arise out of the ownership, maintenance or use or the 'uninsured mator vehicle'. No judgment for damages arising out of'a suit brough{ against the owner or operator of an 'uninsured motor vehicle' is binding on us unless we: 1, Received reasonable n;3tlce. Of the pen- . _ .dency of the suit resulting in the judgment: and 2. Had a reasonable opportunity to protect our Interests in the suit. B; 'Insured" as 'used in this endorsement means: 1. You or any 'family member'. 2. Any other person 'occupying' 'your cov- ered auto'. 3, Any person for damages that person Is entitled to recover because of 'bodily jury' to which this coverage applies sus- tained by a person described in 1. or 2. a boys. C. "Uninsured motor vehicle' means a land motor vehicle or trailer olr any type.: 1. To which no bddily injury liability bond or policy applies at the time of the accident. 2. Which is a hit-and-run vehicle whose operator or owner cannot be identified and which hits or which causes an accident re- suiting in 'bodily injury" without hitting: a. You or any 'family member"; b. A vehicle which you or any 'family member" are 'occupying"; or c. 'Your covered auto% If there is no contact with the hit-and-run vehicle, the facts of the accident must be proved. 3. To which a bodily injury liability bond or policy applies at the time of the accident but the bonding or insuring company: a. Denies coverage; or b. Is or becomes; (1) Insolvent; or (2) Involved in insolvency proceedings. However, 'uninsured motor vehicle', does not include any ~ehicle or equipment: 1, Owned by or furnished for the regular use ol~ you or any "family member'. 2. Owned or operated by a self-insurer under any applicable motor vehicle law, except a self-i~tsurer which is or becomes insolvent, 3. Owned by any governmental unit or agency. 4. Operated on rails or crawler treads. S, Designed mainly for use off public roads while nc~ on public roads. 6, While located [or use' as a residence or premises. EXCLUSIONS A, We do not provide Uninsured Motorists Cover- age for 'bodily injury' sustained: 1. By you while 'occupying', or wher~ struck by,. any motor* vehicle you own which is not insured for this coverage under this policy. This includes a trailer o¢ any type used with that vehlcle. 2. 13y' a 'family nlember": a, Who owns an auto, while 'occupying-, or When struck by, any motor vehicle owned by you or any 'family member" which is not insured for this coverage under this policy. This includes a trailer orany type Used with that vehicle. b. Who does', not own an aulo, while 'occupying', or when struck by, any motor vehicle you own which is insured For this coverage on a primary basis tier any other policy. B. We do not provide Uninsured Motorists Cover- age for "bodily injury~ sustained by any person: GE 39'~d -IMFIIFIN .&J..;b~T-I 88.,' c;-'~/..q-L"l:"=J T~ :~T EB0~;/F,"[,/;~B 3-10-C3; 3:04PM;KMF PHILA OFFICE AS 2o48 02 96 {PP 04 2t, 06 95) 1. If .that person or the legal representative settles the bodily injury claim without our consent, However, this exclusion (B.1,) does not apply if such settlement does not ad- versely affect our rights. 2. While 'occupying' 'your covered auto" when it is being used as a public or livery conveyance. This exclusion lB,2.) does not apply to a share-the-expense car pool. 3. Using a vehicle witho~ a reasonable belief that that 'insured' is entitled to do so. C, We do not provide Uninsured Motorists Cover- age for 'noneconomic less' sustained by any person to whom the limited tort alternative applies, resulting from 'bodily injuw' caused by an accident.involving an "unirtsured motor vehicle*, unless the "bodily injury' sustained, is a "serious ,in. Jury'.. Thi.s. e,,*!., 1. If the owner or operator of the 'uninsured mater yen a. Is convicted, or accepts Accelerated Rehabilitative Disposition, ror driving un- der the Influence of alcohol ar a con- trolled substance In that. accident; b, Is operating a motor vehicle registered in another state; or c. Intends to injure himself or another person, provided that the individual does not intentionally injure himself or another person merely because his act or failure to act..Is intentional or done with his re- alization that it creates a grave risk of causing injury if the act or omission causing the injury is for the purpose averting bodily harm to himself' or other person. 2, If that person is injured while 'occupying" motor vehicle insured under a commercial motor vehicle insurance policy. 13, This coverage shall net apply directly or indirectly to benefit .any insurer or self-insurer under a.ny ef the ~'o)lowing or similar law: 1: Workers- ~-~mpensation law; or 2. Disability benefits law. E. We do' not provide Uninsured Motorists Cover- age for punitive or exemplary damages. LIMIT OF LIABILITY A, ~he limit of liability shown in the Schedule or in the Declarations for Uninsured Motorists Cov- erage is our maximum limit of liability for all damages resulting from any one accident. This is the most we will pay regardless o¢ the .num- ber Of: 1. "lnsureds:; 2. Claims made; 3, Vehicles or premiums shown in the Sched- ule er in the Declarations; or 4, Vehicles involved in the accident. B. No one will be entitled to receive duplicate payments for the same elements of loss under this coverage and: 1. Part A or Part El of thi~ policy; or 2. Any Underinsured Motorists Coverage provided by this policy. C. We will not make a duplicate payment under this coverage for any element of loss for which payment has been made by or or~ behalf of persol~s or erganizatiorts who may be legally responsible. This includes all payments made to an 'insured's'. attorney either directly or as part of the.'.payment made to the '.insured". D, We will Filet pay for any elemer~t ot loss if a person iS entitled to receive payment for the same element of 10ss under any of the lng or similar law: 1. Workers' compensation law; or 2. Dlsa. bility bellefits law. OTHER INSURANCE Il'there is other applicable similar insurance able under mere than one policy or provision of coverage: The following priorities of recovery apply; First The Uninsured Motorists Coverage applicable to the vehicle the 'insured' was 'occupying" at the time of the accident. Second The policy affording Uninsured Mo- torists Coverage to the 'insured" as a named insured or family member. 1, When *there is applicable insurance avail- able under the First priority: a, The limit of liability applicable to the vehicle the 'insured' was "occupying", under the policy in the First priority, shall first be exhausted; and b. The maxln:l. LIm recovery under all policies in the Second priority shall not exceed the amount b~ which 'the highest limit for any one vehicle under any one policy in the Second priority exceeds the limit ai~pllcable under the policy In the First p fierily. 2, When there is no applicable insurance available under the First priority, lhe maxi- mum r~covery under all policies in the Sec- ond priority shall not exceed the highest applicable limit for any one vehicle under any on,a policy. 3,:04PM;KMF PHILA OFFICE AS 2O48 02 96 {PP 04 ;1 05 95) . If two or more policies have e~lual priority, the insurer against whom the clal~ is first made shall process and pay the claim as ii' wholly responsible for all insurers with equal priority. The insurer Is therealtar entitled to recover con'[ribution pro rata from any other insurer [or the benefits paid and the costs of processing the claim. if we are the insurer against whom the claim is I~rst made. we will pay, subject to the limit ot' ability shown in the Schedule or in the Declara- tions for Uhinsured Motorists Coverage, alter we and all ~ther contributing Insurers agree: 1. Whether the 'insured" is legally entitled to recover, damages, from the owner or opera- ..... for of an "uninsured motor vehicle'; and · ' 2; As to the amount of damages. ARBITRATION ' · , : ,. · ',, A: If we and an 'insur:'d' do not agree: 1. Whether that -insured~ is legally entitled to recover damages; or 2. As to the amount of damages which are reooverabre by that "insured'; From the owner or operator of an "uninsured motor vehicle' then the matter may be arbi- trated. Either party may make a written demand for arbitration, Arbitration shall be conducted In accordance with the provisions or the Pennsyl- vania Uniform Arbitration Act, Each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that 'selection be made by a Judge of a court having jurisdiction. Arbitration shall not, .however, be a means settlement should the dispute involve: 1. Any form of inter- or il3tra-policy stacking, or 2, Selection of a coverage option, or a waiver of such coverage, or 3. Determination of residency in defining who · ' is'or is not an insured 'under this coverage, or 4. Statute-=: or limitation, or' 5. Determination of whether a claimant is art insured under these coverages. Each party will; 1. Pay the expenses it incurs; and 2. Bear th,~ expenses of the third arbitrator equally. Unless both parties "agree otherwise, arbi- tration will take place in the county in which tile 'Tnsured' lives. Local rules of law as to procedure and evidence will apply. A deci- sion agreed to by two of the arbitrators will be binding. This endorsement must be attached to the Change En~lorsement when Issued alter the policy is written. Includes copyrighted material o1' Insurer)ce Services O~lice, Inc., with its permission. Copyright, Insurance Services Olfice, Inc.. 1994 Page 3 of 3 :-- I 0--O~"~ ; 3 : 041~M; ~M~ P*M I LA OFF I CE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ lT CAP. FULLY. UNDERINSURED MOTORISTS COVERAGE - PEI~NSYLVANIA (NOPI-~rI'ACKED) 04. 17 o6 p~) 'Vith respect to the coverage provided b~ this eudo~sement, The provisions of the policy apply unless modified by ~ e~lorsement SCHEDULE UNDERI,NSUI1Ki~ MOTORISTS COVERAGE Description Limit of of Vehicle Liability Premium INSUIiIN(I AGREEMENT A. We will pay compensatory dama§~s, which o~r o~ opera,or of ~ "~d~d motor whi- cie" ~ of"b~ly inj~": 1. S~ined by a~ "i~d"; and 2. ~us~by an accid~ ~le o~'s or o~mtoPs l~bili~ for these ages m~t ~ o~ of ~e o~e~hip, or ~o ol~e "~&~d me,or vehi01e". . We will pay ~d~ ibis ~e~ge ~ly if 1. or below appli~; 1. ~e, limit-of lis~W ~ ~ ~lica~e b~fly inj~ liabili~ ~n~ ~ poH~es have be~ e~d by pa~e~t of l~Em~ or s~lem~nts; or 2. A t~ve ~lemmt ~ ~ ~de be~n au "ins~ed" and a. Have been givm prompt ~n ~otice of ~h ten.five ~l~entl ~d b. Advance pa~enl am~t e~l ~ the ~tive se~lemmt wi~in 30 ~ a~ No 'j~gm~t ~ ~a~ ~si~ o~ of a suit brought against ~e ~ or op~r of "~nsw~ motor vehicle" less we; 1. ~eived reamnable ~ofice · e ~ resul~ ~ the ~e~; ~d l. H~ a re.enable ~po~ B. "I~" ~ mod ~ ~ endors~t 1. You or any "family m~b~", 2. ~y o&er p~ou %c~ing" "yo~ co~ered 3. Any person f~ ~ag~ t~t person is entitled w recover ~ca~e of "bodily init" to w~ch this cov~age a~h~ s~ed scgb~ in 1. ~ 2. above. C. "Underinsured motor vehicle' means a land motor vehicle or lrailex' of any ~e to Which a bodily in- {homy liability l~ond or policy applies at the tlme cf accident but the amount paid for "bodily injury" urid~ that bond or policy to a~ "insur~l".is not euot~ io pay the full amount the "insured is le- gally entitled to recover as damages. However, 'rtmderinsu~r~ motor ve. hiolc" dow not includ~ any -,~hicle or. equipment: 1. For which liability ;overal~e is provided under Pan A o£~hls 2. Owned by ai~ gover~menlal unit or agency. 3. Operated ~n :mils or c. aawl~r treads. 4. Designed mainly for use off public roads whiie not on public; roads. 5- While located for use as a r~sidencc or prom- EXCLUSIONS A. 'We do ,rt,,et l~ovide Underinsurea Motorists Cov~r- age for' bodily injury" sust~inea-' 1. While "ocuupy_ing" a motor vehicle nwnexi by you or a 'family member" not insured for derinsut~d Motorists Coverage under this pol- icy; nor to 'bodily injury" flx~m being hit by a~y such motor vehicle. 2. By a "family member": a. Who o~s an auto, while "occupying", or when struck by, any me,or vehicle own~l by you or-any "family m6ml~er" which is ~ot insured for this coverage trader this policy. Thi-~ includes a trail6r of a~y ~pe us~l with that v&hii~k. b. Who does not own any ~uto, while °'occupying", or when struck by, any motor vehiCle you own which is insured for this cowry§,,, on a primary'basis under auy other petit. B. We do 10et provide Underinsured Motorists Cower- al~ for "bodily injury" sustained by any person: BBZS-~ZS-II9 AS 2050 12.98 (?p 04 l?,o~ os) l, While "occupying" 'your covered aulo" when it i5 beil]g tiffed ~ a public or live~ conv~ance, This excJt~ion (B.I .) does not apply to a shar~ Iht-expense cat p~l: 2. Us~n~ a vehicle wRhbut a reasonable bclic~that 1bat ~rso~ Js eDfitle~ ~o do ~, C. We do nm provide Onderin~ed Motoris~ Cover- age for "~onee~omie lo~~ ~stai~ by ~y per- son to whom the limited tod altemat~ ~pplies. suiting from "b~ily inj~" caus~ by an accid~t involving an unclouded motor vehicle., the "b~ily iujt~' su~ain~ is a 'serious ~is e~lxgion (C,) does ~t ~ply: 1. If ~he 0x~gr or op~ator of the g~m~ins~ed motor vehicle": a, Is convi~, or accepts Accel~ated Reha- bilil~fivg DJs~sitioo~ for driving und~ influence 0f' al~hol or a con,oiled st~b- sm~ i~ ~at accid~ng b. Is '0~atiag a motor vehicle regist~ed another ~te; ~ ' ' c. lnteMs m i~jt~ himself or anther person, prodded that, the i~ivid~ml ~es not int~- tiomlly Jnjx~ himself ~ ~nothm person m~ly because his act or t~iltgz to ~t is inIenfional or done with his realiv~fion that it ~eates a grave ~sk of ~using inj~ if the act or omission cau~g the inj~ is for ~be · . pigpose of ~vertJng b~ily h~ lo himself 2. If that person ig iaj~ed while "~u~ving" a motor vehicle instead under ~ commgrci' '&! ~o- . wr ~cle ~s~mice D. ~is gowrage shall not apply direcRy ~ iadir~tly m benefit m~y Jn~r or self-ink, er under any of th~ foll~g.or aimil~ law~ 1. Workers~ compensafon law; 9r 2. Disabili~ benefi~ law. . · - E. We do not p~vide Undafin~ed Metrics Cover- age for puni0w ~.exempl~ damage.. LIMIT' OF L~BIL~ A. ~e limit of lia~li~ sh6~n in the ~hedule or in ~he Declarations .for Unde~ns~w~d Motoflslg Cov- erage is our m~ximum limll of liabiliW ~r all dam- ages resuRing from any ot~e a.ecident. ~is is the mo~ we will pay reg~dless of the numar o~ 1. "Insured~"; 2. ~laims 3. Vehleles or premiums sho~ in the Schedule or in the Deci~mipns; or. 4. Vehi~les.invoJved in the accident. B. The damages payable under tMs coverage shall be re~l, uced by all sums paid l~cause of the "bodily injury" by or on behalf of persons or organizations who ma.y'_ be legally responsible. This includes all sxans paid for an "insured's' atton~ey either directly ox as part of the amount paid to the "insured". It also includes all sums paid under Part A of this policy. C. lqo one will be eutitlgd to ~'e~iw duplicate pay- merits for the same elements of lo~s trader this cov- erage and Part A, Par~ B or Part C oflhis poliey~ D, We will not make a duplicate payment ~mder lhis coverage for any element of ~ss for whi~-h pay- ment has been made by or on behalf of persons or organizations who may be legally responsible. 'E. 'We will not pay for any element oflo~s ifa person is entitled to receive payment for the same element of loss under a[r~ oflhe following or similar law: i. Workers' compensat!on law; or g. Disability benefita law. OTH ER IN~URANC'E If there is olh~r applicable similar insurance available under more.than one Imliey or provision o'l'eoverage: The following priorities ofreeovery apply: The Und~rinsured Motoris~ Coverage applicable to the vehi4e the "insured". was "occupying" at the time of tim neet- Second The policy affo~liQg 'Undefinsttted Morea-tats Coverage to the "insured~ as .-, named insured or family member. 1. When there is applica~ble insuranc~ available under the First priority: a. The limi¥, of liability applieaMe to the vehi- cle the "insured~ was 'occupying", under the c oiie~ in flue First priority, shall first be ex- austed; and b. The mzxiimum r~overy trader ali policies in lhe Second p~iorily shall not exceed amount by '~hich lhe highest limit for any one vehicl~ tinder any one policy'in ti~e Sec- ond priori~ exceeds ~he limit applicable tin- der lh~ pobcy in the First priority. ' 2. When there iis no applicable ins~a'ance available under the First prior/ty, the maximum ~covery ~md~r all policies in the Second priority shall not exceed lhe highest applicable limit for any one vehicle ~mder any one poIicy, If' lwo or fi~ore policies have equal priority, the insurer against whom the claim is first made slmll process and p&y the claim as if wholly ~mspomible for all insurers with equal priority. The in&.trer is thereafter out. tried to recover contribution pm ~ata lmm any otl~er iu~urer for thc benefits paid and (he costs of processing th~ cla ira. Ir we are the insurer against ~hom tb~ claim is first made, we will pay, subj~t to the limit of liability ~hown in lhe Schedule or in the Declarations for Un- __~eriusured Motorists Coverage, after w.e and all other contributing.insures agree: I. Whether the "insured" is legally entitled to re- cover damages from the owner or operator of an "undexinsured motor vohicle"; and C. Unless both ps, tics agree otherwise, ~bi~tion will ~ pl~ in ~e c~aW in which the "ias~6d" liv0s. ~ rul, s of hw ~ to pt0ce~, and ~vi-' d~nce will apply. A decision ag~ed to by ~o of thc ~b~at~s ~R be binding. ~D~IONAL DU~ES A p~son s~k~g Underin~ed Mo~ris~ Coverag~ m~t a~o pr~ptty: 2. As to the mnount ofdamages. ARBITRATION A. If we andan 'insured" do not agree: 1. Whethe~ that "insured" is legally ~ntitled to cover damages; or 2. As to the amount of damages which are r~cover- able by. tlmt "instw~d"; · From the o,Wg,,e.,r or operator of an "m~deriusured motor, vehicle' then the matter may.b~ arbitrated. Either parly may make .a written demand for arbi- tration. Arbitration shall be conducted in accor- dance with the provisions of the Pennsylvania Uni- form Arbitration ,Act. Each party will select an 1, Sgmd us copies of the legal papers if a suit is brought; arid Z. Notify us ia writing of a tentative' settlement between the "insured'' and the insures- of the "underitlsured motor vehicle" and allow us 30 . days to advance payment to that "insured" in 'au amotmt equal to file tentative settlement to preser,~ our rights agairmt the insure~, owner or op~zalor of such "underinsur~l motor vehi- ale". Ir- GENERAL PRO.VISIONS. The following i~ added Io the Our Right To Recover Payment prox4sion of Part F: PART arbitrator. The two axbitratora will select a third- If · lhey cannot agree within 30 days, either may re- quest that selection be made by a judge of a corot having jur/sdiction. Arbitration shall not, howevar~ be a means of set- tlement should th~ dispute involve: 1. Any foma of inter- or intra-poIioy stacking, or 2. Selection of a cove. rage option, or a waiver of such covet'age, or 3. Determination of~sidency in defining who is or is not an immred unde~ this coverage; or 4. ~tatute~ of'lirait~tion, o~ 5. Determination of whether ,, claimant i$ an sured under these coverages. B. Each party will: 1. Pay tile expenses it illours; and 2.-Bear the expenses ofth~ third aibitratot equally. OUR RIGHT TO I-~ECOVER PAYMENT ' Our rights do not apply under paragraph A. with xespect to Underinsured Motorists Coverage if we: l. Have bee~ give~ p~ompt wriHen notice of a lentative settl~ment b~twgen an "insured" aud lhe ias.m'~ of an "mldexiixsured motor vehi- cle''; and 2. Fail to advance payment to tl~ "insult" in au amount equil to the tentative settlement within 30 days aRer receipt ofnotificatiom If we advance payment to the 'insured" in au amount equal to the tentatix~, settlemelit within 30 days after r. ec~ipt of notification: 1. That payment will be separate from any amount the ~insured" is entitled to ~e. cover un- der the provisions of Und~rinsured Motorists Cowrag~, and 2. W~ also have a right to recover the. advanced payment. This endors~-mont must be attached to fl~e Change Endorsement when iss~,ed ariel ~e policy is written. Includes copyrighted material of Insurance S~rvices Office, Inc., with its pennis, sion. Copy~ighh Insurance Services Office, In0., 1994 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA MAXIM DEMCHAK Plaintiff LIBERTY MUTUAL GROUP, LIBERTY MUTUAL, LIBERTY MUTUAL INSURANCE GROUP AND LIBERTY MUTUAL FIRE INSURANCE COMPANY Defendants CERTIFICATE OF SERVICE I hereby certify that a tree and correct copy of the foregoing Notice to the Prothonotary of Cumberland County and the Notice of Removal were mailed this 12th day of March, 2002, via United States Mail, First Class, postage pre-paid, upon the following individual: David R. Thompson, Esquire 308 Walton Street, Ste. 4 P.O. Box 587 Philipsburg, PA 16866 KELLY, MCLAUGHL1N, FOSTER, BRACAGLIA, DALY, TRA.]YO~CO & WHITE, LLP _ ~...~..-/' hq¢l~I/lAM C. ~-'T)STE~, ESQUIRE Attorney for Defenda, rlt Liberbd Mutual Gr/odp, Liberty Mutual, Liberty Mutual Insuran~and Liberty Mutual Fire Insurance Company