HomeMy WebLinkAbout01-04453
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NICHOLAS MAVROPOULOS and
PETER MAVROPOULOS,
Plaintiffs,
vs.
ONE BEACON INSURANCE,
formerly known as GENERAL ACCIDENT
INSURANCE COMPANY and
COMMERCIAL UNION INSURANCE
COMPANY,
Defendant.
..
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION -DECLARATORY
JUDGMENT ACTION
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 without you and a judgment maybe entered 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.
CUMBERLAND COUNTY BAR ASSOCIATION
2 Liberty Avenue
Carlisle, PA 17013
Telephone: (717) 249-3166
NICHOLAS MAVROPOULOS and
PETER MAVROPOULOS,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiffs,
vs.
ONE BEACON INSURANCE,
formerly known as GENERAL ACCIDENT
INSURANCE COMPANY and
COMMERCIAL UNION INSURANCE
COMPANY,
Defendant.
CIVIL ACTION -DECLARATORY
JUDGMENT ACTION
COMPLAINT FOR DECLARATORY JUDGMENT
Plaintiffs, Nicholas Mavropoulos and Peter Mauropoulos, are adult individuals
with an address of 1360 Eisenhower Boulevard, Harrisburg, Dauphin County, Pennsylvania,
17111.
2. Defendant, One Beacon Insurance, formerly known as.General Accident Insurance
Company and/or Commercial Union Insurance Company, is incorporated under the laws of the
Commonwealth of Pennsylvania and maintains a place of business located at 100 Corporate
Center Drive, Camp Hill, Cumberland County, Pennsylvania, 17001.
3. This is an action for declaratory judgment and is brought pursuant to 42 Pa.
C.S.A. § 7532 et seq. for the purpose of determining a question in actual controversy between the
parties as described in detail herein.
4. This controversy arises under the provisions of a policy of motor vehicle
insurance which was initially issued by General Accident Insurance Company (hereinafter,
"General Accident") to Plaintiff, Nicholas Mavropoulos, for the period between December 2,
1998 to June 2, 1999 (Policy Nos. BAC 741216400 and/or RPA 13-268-161). Said policy was
later renewed by General Accident's successor -Commercial Union Insurance Company
(hereinafter, "Commercial Union") -for the period between June 2, 1999, to June 2, 2000
(Policy No. CPAM24468J ). A true and correct copy of the Policy presently at issue is attached
hereto as Exhibit "A" and incorporated herein.
6. At all times relevant hereto, the Policy provided bodily injury/liability coverage in
the amount of $300,000.00 per vehicle, and uninsured motorist (hereinafter, "UM") coverage in
the amount of $35,000.00 per vehicle.
7. On August 7, 1999, Plaintiff, Peter Mavropoulos, sustained serious bodily injury
when the 1998 Ford Mustang automobile which he was operating was struck by an uninsured
motorist on Interstate 83 South, at or near Derry Street, in Swatara Township, Dauphin County,
Pennsylvania. At the time of the collision, Plaintiff, Peter Mavropoulos, was an "insured" under
the Policy as that term is defined in Section 1702 of the Motor Vehicle Financial Responsibility
Law, as amended ("MVFRL"), 75 Pa. C.S.A. § 1701, et seq., and the aforesaid 1998 Ford
Mustang was one (1) of at least seven (7) motor vehicles covered under the Policy.
8. Following the collision, counsel for Plaintiff, Peter Mavropoulos, submitted a
claim with Defendant for UM benefits under the Policy.
9. As part of this claim, counsel for Plaintiff, Peter Mavropoulos, requested
documents from Defendant demonstrating that the named insured had, as of August 7, 1999:
(a) Made a written request for the issuance of UM
coverage in amounts less than the limits of liability
for bodily injury as provided by Section 1734 of the
MVFRL; and
-2-
(b) Made a valid rejection of stacked UM coverage as
provided by Section 1738 of the MVFRL.
10. By letter dated June 18, 2001, Defendant responded to counsel's request by
producing the certain documents purportedly executed by the named insured. A true and correct
copy of Defendant's letter dated June 18, 2001, with enclosures, is attached hereto as Exhibit "B"
and incorporated herein.
11. Sections 1731 and 1734 of the MVFRL provide that insurers must offer UM
coverage equal to bodily injury liability coverage except when the named insured requests, in
writing, UM coverage in amounts less than the limits of liability for bodily injury. 75 Pa. C.S.A.
§§ 1731 and 1734. Unless the named insured elects lower UM coverage pursuant to Section
1734, the named insured is presumed to have UM coverage in the same amount as the limits of
liability for bodily injury.
12. Section 1738 of the MVFRL provides, in pertinent part:
Stacking of uninsured and underinsured benefits and option to
waive.
(a) Limit for each vehicle. -When more than one vehicle is
insured under one or more policies providing uninsured or
underinsured motorist coverage, the state limit for uninsured or
underinsured coverage shall apply separately to each vehicle so
insured. The limits of coverage available under this subchapter for
an insured shall be the sum of the limits for each motor vehicle as
to which the injured person is an insured.
(b) Waiver. -Notwithstanding the provisions of subsection (a), a
named insured may waive coverage providing stacking of
uninsured or underinsured coverages in which case the limits of
coverage auailable under the policy for an insured shall be the
stated limits for the motor vehicle as to which the injured person is
an insured.
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(d) Forms. - (1) The named insured shall be informed that he may
exercise the waiver of the stacked limits of uninsured motorist
coverage by signing the following written rejection form:
UNINSURED COVERAGE LIMITS
By signing this waiver, I am rejecting stacked limits
of uninsured motorist coverage under the policy for
myself and members 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.
Signature of First Named Insured
Date
(e) Signature and date. -The forms described in subsection (d)
must be signed by the first named insured and dated to be valid.
Any rejection form that does not comply with this section is void.
75 Pa. C.S.A. § 1738.
13. Plaintiffs maintain and contend that documents relied upon by Defendant to limit
the amount of UM coverage available under the Policy to $35,000.00 are invalid and
unenforceable under 75 Pa. C.S.A. §§ 1731, 1734 and 1791 because there is no evidence that
Plaintiff, Nicholas Mavropoulos, knowingly and voluntarily elected UM coverage in an amount
less than the limits of liability for bodily injury.
14. Plaintiffs maintain and contend that the form relied upon by Defendant to exclude
stacking of UM benefits under the Policy is invalid and unenforceable under 75 Pa. C.S.A. §
-4-
1738 because the form does not contain the precise language required by Section 1738(b) and
because the form is not dated as required by Section 1738(e).
15. Since the forms relied upon by Defendant to limit the amount of UM coverage
available under the Policy are invalid and unenforceable, Plaintiffs maintain and contend that the
Policy should be reformed by this Honorable Court to provide stacked UM coverage in the
amount of $300,000.00 per vehicle.
16. All persons who have any interest which would be affected by the declaratory
relief requested herein have been joined as parties for the purposes of this action.
WHEREFORE, Plaintiffs Nicholas Mavropolous and Peter Mauropolous request that this
Honorable Court enter a declaratory judgment:
(a) That as of August 7, 1999, the Policy provided for
uninsured motorist coverage in the amount of $300,000.00
per vehicle.
(b) That as of August 7, 1999, the Policy provided for stacked uninsured
motorist coverage; and
(c) That the Court provides such other relief as is deemed necessary or
appropriate under the circumstances.
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Respectfully submitted,
TOMASKO & KORANDA, P.C.
219 State Street
Harrisburg, PA 17101
Telephone: (717) 238-1100
By:
MICHA L A. KORANDA
-6-
PA ID #58808
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C I~M® ILE
LT LICY
INSURANCE IDENTIFICATION CARDS ATTACHED
Issued to:
ANGIE'S BROOKSIDE DINER
MAVROPOLOUS, NICHOLAS
1360 EISENHOWER BLVD
HARRISBURG, PA 17111
Prepared by:
AMERICAN INSURANCE ADMINISTRATORS
368 LEWISBERRY ROAD
NEW CUMBERLAND, PA 17070-0000
Insured by:
CONMERCIAL UNION INSURANCE COMPANY
CAMP HILL, PA 17011
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PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
This card must be shown to any Law Enforcement OHlcer upon request
PLEASE DETACH THIS CARD AND KEEP NAME OF INSURER
IT IN YOUR VEHICLE FOR INSURANCE
IDENTIFICATION PURPOSES. COMMERCIAL UNION INSURANCE CO.
NAME OF INSURED
ANGIE'S BROOKSIDE DINER EFFECTNEDATE
MAVROPOLOUS, NICHOLAS D6/02/1999
1360 EISENHOWER BLVD IXPIRATION DATE
HARRISBURG, PA 17111-0000 12/02/1999
POLICY NUMBER
CPAM24468 J
Applicable wgh respect W the following motor vehicle:
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IDENTIFICATION PURPOSES.
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1979 FORD/VAN E14HHEJ5438
Year Make Vehiele ltleMHicatlon NO.
47 6~ O/~// uj' h~~ J (n,
SEE IMPORTANT MESSAGE ON REVERSE SIDE Authorizetl RapreserdatNe
BP-1
PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
This card must be shown to any Law Enforcement Officer upon request
NAME OF INSURER
COMMERCIAL UNION INSURANCE CO.
NAME OF INSURED
ANGIE'S BROOKSIDE DINER EFFECTIVE DATE
MAVROPOLOUS, NICHOLAS 06/02/1999
1360 EISENHOWER BLVD IXPIRATION DATE
HARRISBURG, PA 17111-OD00 12/02/I999
POLICY NUMBER
Applicable wkh respect to the tollaving motor vehicle:
CPAM24468 J
1986 CHEV/AST 1GCCM15Z7GB167727
Year Make Vehicle ItleMgicalien Na.
~~~~/~~,h9~~~/L~n,
BEE IMPORTANT MESSAGE ON REVERSE SIDE Authorketl RepresanhtWe
BP-1
PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
This card must be shown to any Law Enforcement Officer upon request
NAME OF INSURER
COMMERCIAL UNION INSURANCE CO.
NAME OF INSURED
ANGIE'S BROOKSIDE DINER
MAVROPOLOUS, NICHOLAS
1360 EISENHONER BLVD
HARRISBURG, PA 17111-0000
EFFECTIVE DATE
06/02/1499
IXPIRATION DATE
12/02/1999
POLICY NUMBER
CPAM24468 J
Applcable wah respect to the following motor vehicle;
1977 FORD/VAN E38AHZ370069
Yeat Make Vehiele Identgication No.
BEE IMPORTANT MESSAGE ON REVERSE SIDE
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THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or registrant of a motor vehicle who doves or permits a motor vehicle to be
driven in this Commonwealth without the required financial responsibility may have his registration
suspended or revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You areinvolved in an auto accideni.
(Z) You are convicted M a traffic offense other than a parking offense that requires a
court appearance.
(8) Upon request of a police officer when you are stopped for violating any provision
of the Vehicle Code
p5 Pa. C.S.§§101=9970).
You must provide a copy W this card to the Department of Transportation when you request reatore-
tion of your operating privilege or registration prMiege which has been previousy suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responsibility Insurance indemifieation Card.
Your insurance company b requiretl by Pennsylvania law to send you an I.D. card. The card shows
that an insurance policy has been Issued for the vehicle(s) described satisfying the financial respon-
sibility requirements d the law.
If you lose the card, tooted your Insurance company or agent for a replacement.
The I.D. card infornation may be used fa vehiGe registry})on and repWcing license plates. If your
liability insurance polity Is nd In effect, the LD. cab Is no longer valltl.
You are required to malntaln financial responsibiliTy on your vehicle. It Is against Pennsylvania law to
use the I.D. card freudulently such as using the card as proof of financial responsibility after the in-
surence policy is terminated.
G65184-4
THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or realstrant of a mdor vehicle who drives or permits a motor vehicle to be
driven in this Commonwealth without the required financial responsibility may have his registration
suspended or revoked.
NOTE: THIS CARD IS REpUIRED WHEN:
(1) You are involved in an auto accident.
(2) You are cornided of a traffic offense other than a parking offense that requires a
wurt appearance.
(3) Upon request of a police officer when you are stopped for violating any provision
of the Vehicle Code
(75 Pa. GS.§§101=9910).
You must provide a copy of this card to the Department of Transportation when ycu request restore-
tlon of your operating prlNlege nr registretion privilege which has been previousty suspended or
revoked.
IMPORTANT NOTICE: RegarNhg your FlnancWl Responsibility Insurance Inden}Ificetion Card.
Your Insuance company is required by Pennsylvania law to send you an LD. card. The card shows
that an insurance policy has been issued for the vehicle(s) described satisfying the financial respon-
sibility requirements of the law.
If you lose the card, contact your Insurance company or agent for a replacement.
The I.D. card information may be used for vehicle registration and replacing license plates. If your
liability insurance policy is not in effect, the I.D. card is no longer valid.
You are required to malntaln financial responsibility on your vehicle. It is against Pennsylvania law to
use the I.D. card freudulently such as using the card as proof of financial responsibility after the in-
surance policy is terminated.
G65184-4
THIS CARD MUST QE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YGU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or registrent d a motor vehicle who drives or permits a motor vehicle to be
driven in this Commonwealth WRhout the required financial responsibility may have his registration
suspended or revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You are Involved in an auto accident.
(2) You ere convicted of a traffic offense other than a parking offense that requires a
court appearance.
(8) Upon requeat d a police officer when you are stopped far violating any proWslon
of the VehlWe Code
(75 Pa. C.S.§§301=9910).
You must provide a mpy of this card to the Department of Trensportatlon when you request restore•
lion of your opeating privilege or registration privilege which has been previously suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responsibility Insurance Indentificatlon Card.
Your Insurance company is required by Pennsylvania law to send you an I.D. card. The card shows
that an Insurence policy has bean issued for the vehicle(s) described satisfying the financial respon-
sibility requirements of the law.
If you lose the card, contact your Insurance tympany or agent for a replacement.
The I.D. card Information may be used for vehicle reglsiratlon and replacing license plates. M your
liability insurance policy Is not In effect, the I.D. card is no longer valid.
You are required to maintain financial responsibility on your vehicle. It is against Pennsylvania law to
use the I.D. card fraudulently such as using the card as proof of financial responsibility after the In•
surence policy Is terminated.
G65184-4
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IDENTIFICATION PURPOSES.
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PENNSYLVANIA FINANCIAL RESPQNSIBILITY IDENTIFICATION CARD
This card must be shown to any Law Enforcement Officer upon request
NAME OF INSURER
COMMERCIAL UNION INSURANCE CO.
NAME OF INSURED
ANGIE'S BROOKSIDE DINER
MAVROPOLOUS, NICHOLAS
1360 EISENHOWER BLVD
HARRISBURG, PA 17111-0000
EFFECTIVE DATE
06/02/1999
EXPIRATION DATE
12/02/1999
POLICY NUMBEN
Applicable with respect M the following motor vehicle:
CPAM24468 J
1998 FORD/PKU 1FTRX18L1WNC04776
Year Make Vehicle ltlentHicatlon No.
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SEE IMPORTANT MESSAGE ON REVERSE SIDE Au[hor¢etlRepreser:WtNe
BP-1
PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
PLEASE DETACH THIS CARD AND KEEP - This cab must be shown to any Law Enorcement Officer upon request
IT IN YOUR VEHICLE FOR INSURANCE NAME OF INSURER
IDENTIFICanoN PURPOSES• COMMERCIAL UNION INSURANCE CO.
NAME OF INSURED
ANGIE'S BROOKSIDE DINER EFFECTIVE DATE
MAVROPOLOUS, NICHOLAS D6/02/1999
1360 EISENHOWER BLVD E%PIRATION DATE
HARRISBURG, PA 17111-0000 12/02/1999
POLICY NUMBEfl
CPAM24468 J
Applicable wSh respect to the bllaving motor vehlcle:
1994 CADILLAC 1G6KD52B6RU263420
Year Make Vehicle ItleMBicatlon No. ~T(~6/~y7~~~~/(J
SEE IMPORTANT MESSAGE ON REVERSE SIDE Aufhoraed Represenlalive
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N PLEASE DETACH THIS CARD AND KEEP This card must he shown to any taw Enforcement Officer upon request
~ IT IN YOUR VEHICLE FOR INSURANCE NAME OF INSURER
IOENTIFICAr1oN PURPOSES. COMMERCIAL UNION INSURANCE CO.
NAME OF INSURED
ANGIE'S BROOKSIDE DINER
MAVROPOLOUS, NICHOLAS
1360 EISENHOWER BLVD
HARRISBURG, PA 17111-D000
Applicable wtth respec!!o the folowing molar vehkk:
EFFECTIVE DATE
06/02/1999
EXPIRATION DATE
12/D2/1999
POLICY NUMBER
CPAM24468 J
1981 FORD/ESC 1FABP0823BT1$2674
Year Make Vehicle Iderdaicalhn No. ~~Q~j~///~~~Cl.
SEE IMPORTANT MESSAGE ON REVERSE SIDE Aulhorizetl~resentative
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THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or reg~strent of a motor vehicle who drives or permits a motor vehicle to be
driven in this Commonwealth without the required financial responsibiliTy may have his registation
suspended or revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You are involved in an auto accident.
(2I You are convicted of a traffic offense other than a parking offense that requires e
court appearence.
(5) Upon request of a police officer when you are stopped for violating any provision
of the Vehicle Cotle
p5 Pa. C.S.§§101=9910).
You must provide a copy of this card to the Department of Tansportation when you request restore-
ticn of your operating prvilege or registration privilege which has been prevlousty suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responsibility Insurance Indentlfication Card.
Your insuance company Is required by Pennsylvania law to send you an l.D. card. The card shows
that an Insurenca policy has been Issued for the vehicle(s) described satisfying the flnanclal respon-
sihIIITy requirements of the law.
If you lose the card, contact your Insurance company or agent for a replacement.
The I.D. card Information may be used for vehicle registration and replacing license plates. K your
liabllky Insurance policy Is not in effect, the LD. card is no longer valid.
You are requires to malmain financial responsibility on your vehicle. It is against Pennsylvania law to
use the I.D, card freuduleMty such as using the card as proof of financial responsibility after the In-
surenca policy is terminated.
G65184-4
THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: An owner or reggistrent of a motor vehicle who drives or permits a motor vehicle to be
driven in this (ammonwealth without the required financial responsiblliTy may have his registation
suspendetl or revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You are involved in an auto accident.
(2) You are convicted of a traffic offense other than a parking offense that requires a
court appearence.
(8) Upon request of a police officer when you are stopped for violating any provision
of the Vehicle Code
(75 Pa. C.S.§§101=9910).
You must provide a copy of this card to the Department of Transportation when you request restore-
tion of your opereting pdvilege or registreYlon privilege which has been previously suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responsibility Insurenca Indent'rfication Card.
Your Insurance company Is required by Pennsylvania law to send you an I.D. card. The card shows
that an Insurenca policy has been Issued for the vehicle(s) described satisfymg the flnanclal respon-
siblllTy requlremems d the law.
If you lose the Card, rnntaM your Insurenca company or agent for a replacement.
The I.D. card information may be used fpr vehicle registration and replacing license plates. If your
IiabiliTy insurance policy Is not in effect, the LD. card is no longer valid.
You are required to maintain flnanclal responsibility on your vehicle. It is against Pennsylvania law to
use the I.D. card freudulemty such as using the card as proof of financial responsibility after the in-
surence policy Is terminated.
G65184-4
THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or registrent of a motor vehicle who ddves or permits a motor vehicle to be
driven in this Commonwealth without the required financial responsibility may have his registration
suspended ar revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You ere Involved In an auto accident.
(2) You are convicted of a traffic offense other than a parking offense that requires a
court appearence.
(8) Upon request of a police officer when you ere stopped for violating any provision
of the Vehlole Code
05 Pa. C.S.§§101=9910).
You must provide a copy of this card to the Department of Trensporation when you request restore-
tion of your operetmg privilege or registration privilege which has been previously suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responslbiltty Insurenca indent'rfication Card.
Your Insurance company is required by Pennsylvania law to send you an I,D. card. The card shows
that an insurance policy has been Issuetl for the vehicle(s) descdbed satisfying the flnanclal respon-
slbllky requkements of the law.
If you lose the card, contact your insurance company or agent for a replacement.
The I.D. card information may t» used for vehicle registration and replacing license plates. If your
~biliTy insurance policy is not in effect, the I.D. card is no longer valid.
You are requlretl to maintain financial responsibility on your vehicle. It is against Pennsylvania law to
use the I.D. card freudulemly such as using the card as proof of financial responsibility after the in-
surance policy is terminated.
G65184-4
BP~1
PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
This card must 6e shown to any Law Enforcement Officer upon request
PLEASE DETACH THIS CARD AND KEEP NAME OF INSURER
IT IN YOUR VEHICLE FOR INSURANCE
IDENTIFICArioN PURPOSES. COMMERCIAL UNION INSURANCE CO.
NAME OFINSURED
ANGIE'S BROOKSIDE DINER EFFECTIVE DATE
MAVROPOLOUS, NICHOLAS 06/02/1999
1360 EISENHOWER BLVD IXPIRATION DATE
HARRISBURG, PA 17111-0000 12/02/1999
POLICY NUMBER
CPAM24468 J
Applicable wRh respect to iha lellowing motor vehcle:
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~ IDENTIFICATION PURPOSES.
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IDENTIFICATION PURPOSES.
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1998 FORD/MUS 1FAFP45X3WF123337
Year Make Vehicle lderddication No.
~~~~/j/7W~~.J /L~n,
SEE IMPORTANT MESSAGE ON REVERSE SIDE Authorized RepreserrtatNa
BP~1
PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
This card must be shown to any Law Enforcement Officer upon request
NAME OFINSURER
NAME OF INSURED
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX EFFECTIVE DATE
xXxxxXxxxxxxxxxXxXXXxxXXXxxXxxxxxxxxX xxxxxxxxXx
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX IXPIRATION DATE
xxxxxXxxxxXXxXxxxxxXxxxXXXXXxxXXxxxxX
XxxXXXxxXx
POLICY NUMBER
Applicable with respect to the tollawing motor vehicle:
xxxxxxxxx x
XXxx XXxXxXXx XXXXxxXXXxxxxXXXXXXXX
Year Make Vehicle ltlentHication No. ~~4~fO///~~~~~J/J~
SEE IMPORTANT MESSAGE ON REVERSE SIDE Authorized Representative -
BP~1
PENNSYLVANIA FINANCIAL RESPONSIBILITY IDENTIFICATION CARD
This card must be shown to any Law EnfomemeM Officer upon request
NAME OF INSURER
xxXXxxxXxxxxXXXxxxxxxxxxxxXxxxxxxxxxxXxxxx
NAME OF INSURED
xXXxxxxXxxXXXXxxXxxXXXXxxxXxxXXxxxxxX
XXxxxXXXxXXxxxxXXxxXxxxxxXXxXXXxxxxXX
XXxxXXXxxxXXxxxXxxXXxxxxXXxxXXxxxxXXX
XxxXXxxxxxxxXxxXxXXxxxxXXXxXxXXXXXxXx
POLICY N
Applicable with respect to the following motor vehicle:
EFFECTIVE DATE
xxxxxxxxxx
IXPIRATION DATE
xxxxxxxxxx
UMBER
xxxxxxxxx x
xxXX XXXXxxxX xXXXXXXXXXXXXXXXXXXXX
Year Make Vehicle Itlentekaticn No. ~~~A6/J~z,Y~l~1~~~ /J,~/~t
SEE IMPORTANT MESSAGE ON REVERSE SIDE Authored Representative
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THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or regisirent of a motor vehicle who drives or permits a motor vehicle to be _
driven in this Commonwealth without the required financial responsibility may have his registration
suspended or revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You arelnvolved in an auto accident.
(2) You are convicted of a traffic offense other than a parking offense that requires a
court appearance.
(S) Upon request of a police officer when you are stopped for violating any provision
of the Vehicle Code
(75 Pa. C.S.§§101=9910).
You must provide a copy of this card to the Department of Transportation when you request restore-
tlon of your operating pdvilege or registration privilege which has been previously suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responsibility Insurance Indentificetion Card.
Your insurence company is required by Pennsylvania law to send you an I.D, card. The card shows
that an insurance policy has been Issued for the vehicle(s) described satisfymg the financial respon-
sibility requirements M the law.
If you lose the card, content your Insurance company or agent for a replacement.
The I.C. card information may be used for vehicle registration and replacing license plates. If your
liability insurance policy is not in effect, the I,D. card is no longer valid.
You are required to maintain financial responsibility on your vehicle. It is against Pennsylvania law to
use the I.D. card freudulently such as using the card as proM M financial responsibility after the in-
surence policy is terminated.
G65184.4
THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE.
WARNING: Any owner or reggistrent M a motor vehicle who drives or permits a motor vehicle to be
driven in this Commonweath without the required financial responsibility may have his registation
suspended ar revoked.
NOTE: THIS CARD IS REQUIRED WHEN;
(1) You are involved in an auto accident.
(2) You are convicted of a traffic offense other than a parking offense that requires a
court appearance.
(S) Upon request M a police officer when you are stopped for violating any provision
of the Vehicle Code
(75 Pa. C.S.§§101=9910).
You must provide a copy of this card to the Department of Transportation when you request restore-
tion Myour operating prMlege or registation pdvilege which has been previousy suspended or
revoked.
fMPORTANT NOTICE; Regarding your Financial Responsibility Insurance Indentiflcation Card.
Your insurance company is required by Pennsylvania law to send you an I.D. card. The card shows
that an Insurance policy has been issued for the vehicle(s) descdbed satisfying the financial respon•
slbillty requirements M the law.
If you lose the card, content your insurance company or agent for a replacement.
The I.D. card information may be used for vehicle registration and replacing license plates. If your
liability insurence polity is nM in effect, the LD. card is no longer valid.
You are required to maintain fnancial responsibility on your vehicle. It is against Pennsylvania law to
use the LD, card freudulently such as using the cant as proof of financial responsibility after the in-
surance policy is terminated.
G65184-4
THIS CARD MUST BE CARRIED FOR PRODUCTION UPON DEMAND. IT IS
SUGGESTED THAT YOU CARRY THIS CARD IN THE INSURED VEHICLE,
WARNING: Any owner or registrant M a motor vehicle who drives or permits a motor vehicle to be
driven in this Commonwealth without the required financial responsibility may have his registration
suspended or revoked.
NOTE: THIS CARD IS REQUIRED WHEN:
(1) You areinvolved In en auto accident.
(2) You are convicted M a traffic offense other than a parking offense that requires a
court appearence.
(S) Upon request M a police officer when you are stopped for violating any provision
of the Vehicle Code
05 Pa. C.S.§§101=9910).
You must provide a copy M this card to the Department M Transportation when you request restora-
tion of your operating privilege or registration privilege which has been previously suspended or
revoked.
IMPORTANT NOTICE: Regarding your Financial Responsibility Insurence Indentiflcation Card.
Your Insurance company is required by Pennsylvania law to send you an I.D. card. The card shows
that an Insurance policy has bean issued for the vehicle(s) described satisfying the financial respon-
sibility requirements of the law.
If you lose the card, content your insurance company or agent for areplacement.
The I.D. card Information may be used for vehicle re istretion and replacing license plates. If your
liability Insurence polity is not in effeM, the I.D. cero~Is no longer valid.
You are required to maintain financial responsibility on your vehicle. It is against Pennsylvania law to
use the I.D. card freudulently such as using the card as proof of financial responsibility after the in-
surance policy is terminated.
G65184-4
C~ ~~ IL 09 10 (Ed. Ol 81) /WC 37 06 02
PENNSYLVANIA NOTICE
GU 220b
(1-81)
An Insurance Company, its agents, employees or service furnishing of or the failure to furnish these services.
contractors acting on its behalf, may provide services to The Act does not apply:
reduce the likelihood of injury, death or loss. These services
may include any of the following or related services incident 1. if the injury, death or loss occurred during the actual
to the application for, issuance, renewal or continuation of, performance of the services and was caused by the
a policy of insurance: negligence of the Insurance Company, its agents,
1. surveys; employees or service contractors;
2. consultation or advice; or 2. to consultation services required to be performed under
3. inspections. a written service contract not related to a policy of
insurance; or
The "Insurance Consultation Services Exemption Act" of
Pennsylvania provides that the Insurance Company, its 3. if any acts or omissions of the Insurance Company, its
agents, employeesorservicecontractorsactingon its behalf, agents, employees or service contractors are judicially
is not liable for damages from injury, death or loss occurring determined to constitute a crime, actual malice or gross
as a result of any act or omission by any person in the negligence,
=o'cvn~rneea: CPAN2446H J INSURED COPY
CGV
IMPORTANT NOTICE -- EXTRAORDINARY MEDICAL BENEFITS
Pennsylvania
REFER TO DECLARATIONS AND SCHEDULES.
Annual Cost: $
per vehicle.
A 205
(6-89)
By virtue of recent amendment to the Motor Vehicle Financial Responsibility Law, as of June 1, 1989, the first party benefits
coverage may be extended to provide an extraordinary medical benefit which will pay the medical and rehabilitation costs for
you and your family members residing in your household which are more than $100,000 for each person injured as the result
of an automobile accident, up to a lifetime benefit limit of $1,000,000 for each person. The cost of this extraordinary medical
benefit coverage on an annual basis is referenced above. If you wish to purchase the extraordinary medical benefit coverage,
please notify your agent or insurance company for additional information. If you do not wish to purchase extraordinary medical
benefit coverage, please disregard this notice.
~o:~c~r~ujraca: CPAM24468 J ItlSURED COPY
,.~~
CG~~
NOTICE TO PENNSYLVANIA POLICYHOLDERS
G10890 (9-90)
COLLISION DAMAGE COVERAGE FOR RENTAL VEHICLES
COLLISION DAMAGE COVERAGE FOR RENTAL VEHICLES IS PROVIDED MINUS A DEDUCTIBLE IF A PREMIUM AMOUNT
IS DISPLAYED FOR COLLISION COVERAGE iN ITEM FOUR SCHEDULE OF HIRED OR BORRONED COVERED AUTO
COVERAGE AND PREMIUMS.
~c~icv NuMaE~: CPAM24468 J dNSUltED COPY
CG ~~ P89922 10 94
CU Security for Auto
Protection You Need
Congratulations. With your policy from CU Insurance, you're protected by a company with over 100 years of experience
insuring America's businesses.
After examining your particular needs, as your agency we have determined that your business is better protected by adding the
CU Security for Auto endorsement to your policy. Your enclosed policy includes this endorsement.
CU Security for Auto increases some limits and adds new coverage to give you the extra protection you need. Here are a few
examples:
^ Employees are Insureds-Coverage is provided for employees who use their own auto for your business.
^ Duties after gloss-Timely notice to CU is not required until a key employee or manager knows of the loss. This
protects your coverage in the event an employee does not report an accident promptly.
^ Supplementary payments-If, as a result of an accident, you must testify in court, you will be reimbursed for your
loss of earnings up to $250 per day.
^ Mental anguish*-Claims for mental anguish are covered when It is caused by bodily injury in an accident.
^ Glass repair deductible-The deductible will be waived if the glass is repaired rather than replaced.
^ Stolen vehicle-~If your car is covered for theft, CU will now pay the extra expense to return a stolen vehicle.
^ Substitute transportation-if your car is covered for theft and it is stolen, CU will pay up to $50 per day for
substitute transportation ($1,000 maximum).
^ Rental car/loss of use-if a rental car Is damaged and the lessor holds you responsible for their loss of use of the
car, CU will reimburse you up to $65 per day ($750 maximum).
^ Rental car/foreign coverage*-Liability coverage is extended when an auto is rented outside the U.S. to provide
coverage similar to when rented within the U.S.
^ Purchase of an additional business-Coverage is provided for up to 180 days.
^ Cancellations-If CU cancels your policy for any reason (except non-payment), CU will give you 60 days notice,
rather than 30.
CU Security for Auto protects you above and beyond the standard coverages. For an additional premium of only $50, it's a wise
investment on your part.
If you have any questions about CU Security for Auto, call our agency today.
37-96137
AMERICAN INSURANCE ADMINISTRATORS
368 LEWISBERRY ROAD
NEW CUMBERLAND, PA 17070-OODO
*Not available in AZ, CA, OK, OR, NM, NV, TX, or WA,
Refer to contract for exact coverage descriptions; exclusions and deductibles may apply. Coverages are subject to policy terms
and conditions.
ao?icv~u+nera: CPAM24468 J INSURED COPY
CGt1
COMMERCIAL UNION INSURANCE COMPANY
Boston, Massachusetts 021003100
ITEM ONE
f
BUSINESS AUTO
DECLARATIONS
ttPE OF (CONVERSION RENENAL
DECLARATION:
EFFECTIVE DATE:
POLICY PERIOD
FROM 06/02/1999 TO 06/02/2000
12:01 A.M, Standard Time at tha
Nomad Insured': Address stated belox.
'S BROOKSIDE DINER
~POLWSA NICHOLAS
EISENHONER BLVD
SBUROA PA 17111
PaYMENrPLAN: INSTALLMATIC Q
PoucvTYPE: FLEET
RENUMBER: 1P1ROV
PREVIOUS POLICY CPAM24295
NUMBER:
ICAN INSURANCE ADMINISTRATORS
LENISBERRY ROAD
CUMBERLANDA PA 17070-0000
OFFICE: ~ HARRISBURG
Poucr NumeER: I CPAM24468 J
FILE NUMBER: A9208003 IWSCAAG
'AGENT 37-96137
FORM OF NAMED INSURED'S BUSINESS:
CORPORATION
NAMED INSURED'S BUSINESS
RESTAURANT
IN RETURN FOR THE PAYMENT OF PREMIUM, AND SUBJECT TO ALLTHE TERMS OFTHIS POLICY, WE AGREE WITH YOU T O PROVIUt I Ht INSURANCE
STATED IN THIS POLICY.
ITEM TWO: SCHEDULE OF COVERAGES AND COVERED AUTOS -This policy provides only those coverages where a charge is shown in the premium
column below. Each of these coverages will apply only to those AUTOS shown as covered AUTOS. AUTOS are shown as covered AUTOS for a particular
coverage by the entry of one or more of the symbols from the COVERED AUTOS SECTION of the BUSINESS AUTO COVERAGE FORM_ next to the name of
the coverage.
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LIABILITY 7, 8, 9 $300,000 MINUS
DEDUCTIBLE OF S3A 087
PERSONAL INJURY PROTECTION 7 SEPARATELY STATED IN EACH P.I.P. ENDORSEMENT MINUS DEDUCTIBLE $143
ADDED PERSONAL INJURY PROTECTION 7 SEPARATELY STATED IN EACH ADDED P.I.P. ENDORSEMENT $91
PROPERTY PROTECTION INSURANCE SEPARATELY STATED IN EACH P.I.P. ENDORSEMENT
(MICHIGAN ONLY) MINUS DEDUCTIBLE FOR EALH ACCIDENT
AUTO MEDICAL PAYMENTS INSURANCE SEE SCHEDULE OF AUTOMOBILES ATTACHED
' UNINSURED MOTORISTS 7 SEE SCHEDULE OF AUTOMOBILES ATTACHED $93
' UNDERINSURED MOTORISTS 7 SEE SCHEDULE OF AUTOMOBILES ATTACHED $145
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COMPREHENSIVE COVERAGE a,.,.3 , ?.i>r . 'r
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SEE SCHEDULE OF AUTOMOBILES ATTACHED ...~ n >. i3 °:'.~;a>rx~:u
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SPECIFIED CAUSES OF LOBS COVERAGE SEE SCHEDULE OF AUTOMOBILES gTTACHED
COLLISION COVERAGE 7 SEE SCHEDULE OF AUTOMOBILES ATTACHED S1,4O8
TOWING /ROADSIDE ASSISTANCE SEE SCHEDULE OF AUTOMOBILES ATTACHED
PREMIUM FOR ENDORSEMENTS SSO
ESTIMATED TOTAL PREMIUM S5 A 439
COUNTERSIGNED (STATES):
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TNSURETi CURY AUTHORIZED REPRESENTATIVE ~~~~t t' „l ~ ~~~/
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C ~ L~ DECLARATIONS
COMMERCIAL UNION INSURANCE COMPANY -
Boston, Massachusetts 0210&3100
ANGIE•S BROOKSIDE DINER
ITEM THREE: See attached SCHEDULE OF COVERED AUTOS YOU OWN.
ITEM FOUR: SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS
OFFICE: HARRISBURG
Poucv NumseR: CPAM24468 J
FILE NUMBER: A92U8U03 IHSCAA6
AGENT NUMBER: 3)-96137.
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ESTIMATED RATE PER EACH ESTIMATED ~ RATE PER EACH
STATE SYMBOL COST OF HIRE $ 100 PREMIUM STATE SYMBOL COST OF HIRE $ 100 PREMIUM
FOR EACH STATE COST OF HIRE FOR EACH STATE COST OF HIRE
PA 8 IF ANY 1.851 $89MP _
TOTAL PREMIUM S89MP
COST OF HIRE means the total amount YOU incur for the hire of AUTOS YOU don't own (not including AUTOS YOU borrow or rent from YOUR partners or
employees or their family members). Cost of Hire does not include charges for services performed by motor carriers of property or passengers.
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COVERAGES LIMIT OF INSURANCE THE MOST WE WILL PAY DEDUCTIBLE ESTIMATED RATE Pgp EACH
$ 100 PREMIUM
ANNUAL COST OF HIRE ANNUAL COBT OF HIRE
COMPREHENSIVE ACTUAL CASH VALUE, COST OF REPAIRS MINUS $ DED. FOR EACH COVERED
AUTO. BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING.
SPECIFIED ACTUAL CASH VALUE, COST OF REPAIRS MINUS $ DED.
CAUSES OF LOSS FOR EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM.
COLLISION ACTUAL CASH VALUE, COST OF REPAIRS MINUS S DEO.
FOR EACH COVERED AUTO
TOTAL PREMIUM
ITEM FIVE
NAMED INSUREb'S BUSINESS
Other than SOCIAL SERVICE AGENCY
RATING BASIS
NUMBER OF EMPLOYEES
NUMBER OF PARTNERB
SYMBOL I NUMBER I PREMIUM
9 ~ 3 ~ 5121
TOTAL PREMIUM ~ $121
0)oJB
INSURED COPY
:»,.
f
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C ~
~ r ,
BUSINESS AUTO
~ DECLARATIONS OFFICE. HARRISBURG
PDLICV NUMBER: CPAM24468 J
COMMERCIAL I;NIOV I\Sl.'RA:VCE COMPAKY FILE NUMBER: A9208003 IWSCAAG
Boston, Mazsa~huse[[s 02108-3100
ANGIE'S BROOKSIDE DINER AGENT NUMBER 37-96137
FORMS AND ENDORSEMENTS APPLYING TO THIS POLICY
Premiums included in PREMIUM FOR ENDORSEMENT, Item Two.
WE WILL NOT BE LIABLE FOR ANY ACCIDENTS OR LOSSES WHILE A COVERED VEHICLE IS DRIVEN DY THE FOLLOWING DRIVERS:
26830694 CU SECURITY AUTO 050
22370395 CA22380395 CA21921198 CA21931198 CA99441293
00010797 IL02460498 IL09100181 A205 A964A G10890 IL00171185
07790588 CA01800997 ILOOD30498 IL00210498
DATE PROCESSED: 07/27/1999 DATE RATED: 06/14/1999
07/37/1.100/1.100/1.100/N/.150/. 000/Y/.ODO/.000/O/371044200 / / /
/ / / / / / /LVL1/FLEET
oD7C Irrcludes CopyrigMad Material of INSURANCE SERVICES OFFICE, used with Rs
permission.
Copyr M, Insurance Services ONios, lnc.
1 N$1~IZE~ ~{)PY 1981, 1985, 1988, 1 93, 1994, 1995, 1997, X998
.~..., .,
C ~ L~ COVERAGE FORM
COMMERCIAL UNION INSURANCE COMPANY
ANGIE•S BRDOKSIDE DINER
SCHEDULE OF LOSS PAYEES
00001
HARRIS SAVINGS
PD 80X 1711
HARRISBURG
00004E
oPPB:E; HARRISBURG
POLICY NUMBER: CPAM2446B J
PILE NUMBER: A92O8003 IWSLAA6
AGENT NUMBER: 37-96137
Except for towing, sll physical damage losses are payable to VOU and the LOSS PAYEES named
below as interests may appear at the time of loss. See ITEM THREE, SCHEDULE OF COVERED
AUTOS YOU OWN Lien Numbers for applicable vehicle.
PA 17105-0000
Po~lcv tiUMESER: CPAM24468 J INSURED COPY
.~ .
C ~ L~ COVERAGE FORM
COMMERCIAL UNION INSURANCE COMPANY
ANGIE'S BROOKSIDE DINER
ITEM THREE: SCHEDULE OF COVERED AUTOS YOU OWN
oFFlCE: HARRISBURG
PoucvNUMBER: CPAH24468 J
FILE NUMBER: A9208003 IWSCAAG
AGENT NUMBER: 37-96137
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VHCL# YEAR/TRADE NAME/MODEL LIMIT EMBC
VIN NUMBER WEIGHT ATD OR PPI DED DED LIMIT LIMIT LIMIT
GARAGE CITY COST NEW RADIUS LUC 300 LIMIT LIMIT LIMIT DED DED DED LIMIT
STATE/TERR/ZONE TYPE CLASS DMP PREM PREM PREM PREM PREM PREM PREM PREM PREM PRE
VHCL# 1979 FORDNAN SERVICE N
00001 E14HHEJ5438 LIGHT 35~ 35N
DUNLANNON 7000 LOCAL
37 053 TRCK 01499 N 5381 811 013 INCLUDED INCLUDED
LIEN: 000 LESSR: 000
ENDT:
VHCL# 1986 CHEY/ASTRO SERVICE N
00002 LGCCMi5Z7G8167727 LIGHT 35~ %~
DUNCANNON 9000 LOCAL
37 053 TRCK 01499 N 5381 O11 513 INCLUDED INCLUDED
LIEN: 000 LESSR: 000
ENDT:
VHCL# 1977 FDRD/VAN SERVICE N
00003 E38AHZ370069 LIGHT 35~ 35~
OUNCANNON 7500 LOCAL
37 053 TRCK 01499 N 0381 811 013 INCLUDED INCLUDED
LIEN: 000 LESSR: 000
ENDT:
VHCL# 1998 FORD/PKUP SERVICE N
00004 1FTRX18L1NNC04776 LIGHT 35x 35•
DUNCANNON 28000 LOCAL Z50 500
37 053 TRCK 03499 N 5381 813 513 INCLUDED INCLUDED 5163 5517
LIEN: 000 LESSR: 000
ENDT:
VHCL# 1994 CADILLAC/DEVILLE N
00005 1G6KD52B6RU263420 35~ 35x
DUNCANNON 18000 100 500
37 053 PPT 7398 N 0451 533 513 INCLUDED INCLUDED 064 0240
LIEN: 000 LESSR: 000
ENDT:
VHCL# 1981 FORD/ESCORT N
00006 1FA8P0823BT182679 35~ 35+
DUNCANNON 10000
37 053 OPT 7398 N 5651 533 513 INCLUDED INCLUDED
LIEN: OOD LESSR: 000
ENDT:
VHCL# 1998 FORD/MUSTANG N
00007 1FAFP45X3NF123337 35~ 35~
DUNCANNON 27500 100 500
37 053 PPT 7398 N 0451 433 513 INCLUDED INCLUDED 5195 0651
LIEN: 003 LESSR: 000
ENDT:
INSURED COPY
_„~,
CG ~~ COV RAGE FORM
COMMERCIAL UNION INSURANCE COMPANY
ANGIE'S BROOKSIDE DINER
ITEM THREE: SCNEDUlE OF COVERED AUTOS YOU OWN
e r
oPPIDE: HARRISBURG
PoucYNUMBER: CPAM24468 J
PILE NUMBER: AA20$OO3 IWSCAAG
AGENT NUMBER: 37-96137
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~P MED PAY UM UIM COMP B.C.L. LOLL TOW
VHCL# YEAR/TRADE NAME/MODEL LI EM
VIN NUMBER WEIGHT ATD OR PPI DED DED LIMIT LIMIT LIMIT
GARAGE CITY COBT NEW RADIUS lUC 300K LIMIT LIMIT LIMIT DED DED DED LIMIT
BTATEI TERR/20NE TYPE CLASS OMP PREM PREM PREM PREM PREM PREM PREM PREM PREM PRE
TOTAL VEHICLE PREMIUM BY COVERAGE 52877 591 SEE DEC 5422 51408
5143 SEE DEC
* (In Thousands) ® 828 Deductible for loss caused by mischief or vantlalism.
INSURED COPY
CGI~
CA 00 O1 07 97
BUSINESS AUTO COVERAGE FORM
Various provisions in this policy restrict coverage. Read the
entire policy carefully to determine rights, duties and what is
and is not covered.
Throughout this policy the words "you" and "your" refer to the
Named Insured shown in the Declarations. The words "we",
"us" and "our" refer to the Company providing this insurance.
Otherwords and phrases that appear in quotation marks have
special meaning. Refer to Section V -Definitions.
SECTION i -COVERED AUTOS
Item Two of the Declarations shows the "autos" that are
covered "autos" for each of your coverages. The following
numerical symbols describe the "autos" that may be covered
"autos". The symbols entered next to a coverage on the
Declarations designate the only "autos" that are covered
"autos".
A. Description Of Covered Auto Designation Symbols
Symbol Description Of Covered Auto Designation Symbols
1 Any "Auto"
2 Owned "Autos" Only Only those "autos" you own (and for Liability Coverage any "trailers" you don't own while
attached to power units you own). This includes those "autos" you acquire ownership of after
the policy begins.
3 Owned Private Passenger Only the private passenger "autos" you own. This includes those private passenger "autos" you
"Autos" Only acquire ownership of after the policy begins.
4 Owned "Autos" Other Than Only those "autos" you own that are not of the private passenger type (and for Liability Coverage
Private Passenger "Autos" Only any "trailers" you don't own while attached to power units you own). This includes those
"autos" not of the private passenger type you acquire ownership of after the policy begins.
5 Owned "Autos" Subject To No- Only those "autos" you own that are required to have No-Fault benefits in the state where they
Fault are licensed or principally garaged. This includes those "autos" you acquire ownership of after
the policy begins provided they are required to have No-Fault benefits in the state where they
are licensed or principally garaged.
6 Owned "Autos" Subject To A Only those "autos" you own that because of the law in the state where they are licensed or
Compulsory Uninsured principally garaged are required to have and cannot reject Uninsured Motorists Coverage. This
Motorists Law includes those "autos" you acquire ownership of after the policy begins provided they are
subject to the same state uninsured motorists requirement.
~ Specifically Described "Autos" Only those "autos" described in Item Three of the Declarations for which a premium charge is
shown (and for Liability Coverage any "trailers" you don't own while attached to any power unit
described in Item Three).
8 Hired "Autos" Only Only those "autos" you lease, hire, rent or borrow. This does not include any "auto" you lease,
hire, rent, or borrow from any of your "employees", partners (if you are a pannership), members
(if you are a limited liability company) or members of their households.
9 Nonowned "Autos" Only Only those "autos" you do not own, lease, hire, rent or borrow that are used in connection with
your business. This includes "autos" owned by your "employees", partners (if you are a
partnership), members (if you are a limited liability company), or members of their households
but only while used in your business or your personal affairs.
B. Owned Autos You Acquire After The Policy Begins
1. If Symbols 1, 2, 3, 4, 5 or 6 are entered next to a
coverage in Item Two of the Declarations, then you
have coverage for "autos" that you acquire of the type
described for the remainder of the policy period.
2. But, if Symbol 7 is entered next to a coverage in Item
Two of the Declarations, an "auto" you acquire will
be a covered "auto" for that coverage only if:
a. Wealreadycoverall"autos"that youownforthat
coverage or it replaces an "auto" you previously
owned that had that coverage; and
b. You telluswithin30daysafteryouacquireitthat
you want us to cover it for that coverage.
C. Certain Trailers, Mobile Equipment And TemporarySub-
stitute Autos
If Liability Coverage is provided by this Coverage Form,
the following types of vehicles are also covered "autos"
for Liability Coverage:
1. "Trailers" with a load capacity of 2,000 pounds or
less designed primarily for travel on public roads.
2. "Mobile equipment" while being carried or towed by
a covered "auto".
3. Any "auto" you do not own while used with the
permission of its owner as a temporary substitute for
po~~cv tiurseee; CPAM2446$ J INSURED COPY
CGU
Form No: CA 00 O1 -
07 97
Page 2 of 9
a covered "auto" you own that is out of service "employees", while moving property to or
because of its: from a covered "auto".
a. Breakdown; (5) A partner (if you are a partnership), or a
b. Repair; member (if you are a limited liability com-
pany) for a covered "auto" owned by him or
c. Servicing; her or a member of his or her household.
d. "Loss"; or c. Anyone liable for the conduct of an "insured"
e. Destruction, described above but only to the extent of that
SECTION II -LIABILITY COVERAGE liability.
A. Coverage 2. Coverage Extensions
We will pay all sums an "insured" legally must pay as a. Supplementary Payments
damages because of "bodily injury" or "property damage" In addition to the Limit of Insurance, we will pay
to which this insurance applies, caused by an "accident" for the "insured":
and resulting from the ownership, maintenance or use of
"
" (1) All expenses we incur.
a covered
auto
.
We will also pay all sums an "insured" legally must pay (2) Up to $2,000 for cost of bail bonds (includ-
as a "covered pollution cost or expense" to which th!s ing bonds for related traffic law violations)
"
insurance applies, caused by an "accident" and resulting required because of an "accident
we cover.
from the ownership, maintenance or use of covered We do not have to furnish these bonds.
"autos". However, we will only pay for the "covered (3) The cost of bonds to release attachments in
pollution cost or expense" if there is either "bodily injury" any "suit" against the "insured" we defend,
or "property damage" to which this insurance appliesthat but only for bond amounts within our Limit
is caused by the same "accident". of Insurance.
We have the right and duty to defend any "insured" (4) All reasonable expenses incurred by the "in-
against a "suit" asking for such damages or a "covered sured" at our request, including actual loss
pollution cost or expense". However, we have no duty to of earning up to $250 a day because of time
defend any "insured" against a "suit" seekingdamages for off from work.
"bodily injury" or "property damage" or a "covered pollu- (5) All costs taxed against the "insured" in any
tion cost or expense" to which this insurance does not "suit" against the "insured" we defend.
apply. We may investigate and settle any claim or "suit"
as we consider appropriate. Our duty to defend or settle (6) All interest on the full amount of any judg-
ends when the Liability Coverage Limit of Insurance has mentthataccruesafterentryofthejudgment
been exhausted by payment of judgments orsettlements. in any "suit" against the "insured" we
1
Who Is An Insured defend, but our duty to pay interest ends
. when we have paid, offered to pay or
The following are "insureds": deposited in court the part of the judgment
a. You for any covered "auto", that is within our Limit of Insurance.
b. Anyone else while using with your permission a b. Out-Of-State Coverage Extensions
covered "auto" you own, hire or borrow except: While a covered "auto" is away from the state
(1) The owner or anyone else from whom you where it is licensed we will:
hire or borrow a covered "auto".This excep- (1) Increase the Limit of Insurance for Liability
tion does not apply if the covered "auto" is a Coverage to meet the limits specified by a
"trailer" connected to a covered "auto" you compulsory or financial responsibility law of
own, the jurisdiction where the covered "auto" is
(2) Your "employee" if the covered "auto" is being used. This extension does not apply to
owned by that "employee" or a member of the limit or limits specified by any law
his or her household, governing motor carriers of passengers or
(3) Someone using a covered "auto" while he or property.
she is working in a business of selling, ser- (2) Provide the minimum amounts and types of
vicing, repairing, parking or storing "autos" other coverages, such as no-fault, required
unless that business is yours. of out-of-state vehicles by the jurisdiction
(4) Anyone other than your "employees", where the covered "auto" is being used,
partners (if you are a partnership), members We will not pay anyone more than once for the
(if you are a limited liability company), or a same elements of loss because of these exten-
lessee or borrower or any of their sions.
aoucv~uMa~R: CPAM24468 J INSURED CDPY
CGt~
B. Exclusions
This insurance does not apply to any of the following:
1. Expected Or Intended Injury
"Bodily injury" or "property damage" expected or
intended from the standpoint of the "insured".
2. Contractual
Liability assumed under any contract or agreement.
But this exclusion does not apply to liability for
damages:
a. Assumed in a contract or agreement that is an
"insured contract" provided the "bodily injury" or
"property damage" occurs subsequent to the
execution of the contract or agreement; or
b. That the "insured" would have in the absence of
the contract or agreement.
3. Workers' Compensation
Any obligation for which the "insured" or the
"insured's" insurer may be held liable under any
workers' compensation, disability benefits or un-
employment compensation law or any similar law,
4. Employee Indemnification And Employer's Liability
"Bodily injury" to:
a. An"employee"of the"insured"arisingoutof and
in the course of:
(1) Employment by the "insured"; or
(2) Performing the duties related to the conduct
of the "insured's" business; or
b. Thespouse,child, parent, brotherorsisterofthat
"employee" as a consequence of Paragraph a.
above.
This exclusion applies:
(1) Whether the "insured" may be liable as an
employer or in any other capacity; and
(2) To any obligation to share damages with or
repay Someone else who must pay damages
because of the injury.
But this exclusion does not apply to °bodily injury" to
domestic "employees" not entitled to workers' com-
pensation benefits or to liability assumed by the
"insured" under an "insured contract". For the pur-
poses of the Coverage Form, a domestic "employee"
is a person engaged in household or domestic work
performed principally in connection with a residence
premises.
5. Fellow Employee
"Bodily injury" to any fellow "employee" of the "in-
sured" arising out of and in the course of the fellow
"employee's" employment orwhile performing duties
related to the conduct of your business.
6. Care, Custody Or Control
"Property damage" to or "covered pollution cost or
expense" involving property owned or transported by
Form No: CA 00 Ol
07 97
Page 3 of 9
the "insured" or in the "insured's" care, custody or
control. But this exclusion does not apply to liability
assumed under a sidetrack agreement,
7. Handling Of Property
"Bodily injury" or "property damage" resulting from
the handling of property:
a. Before it is moved from the place where it is
accepted by the "insured" for movement into or
onto the covered "auto"; or
b. After it is moved from the covered "auto" to the
place where it is finally delivered by the "in-
sured".
8. Movement Of Property By Mechanical Device
"Bodily injury" or "property damage" resulting from
the movement of property by a mechanical device
(other than a hand truck) unless the device is at-
tached to the covered "auto".
9. Operations
"Bodily injury" or "property damage" arising out of the
operation of any equipment listed in Paragraphs 6.b.
and 6.c. of the definition of "mobile equipment".
10. Completed Operations
"Bodily injury" or "property damage" arising out of
your work after that work has been completed or
abandoned.
In this exclusion, your work means:
a. Work or operations performed by you or on your
behalf; and
b. Materials, parts or equipment furnished in con-
nection with such work or operations.
Your work includes warranties or representations
made at any time with respect to the fitness, quality,
durability or performance of any of the items included
in Paragraphs a. orb. above,
Your work will be deemed completed at the earliest
of the following times:
(1) When all of the work called for in your
contract has been completed.
(2) When all of the work to be done at the site
has been completed if your contract calls for
work at more than one site.
(3) When that part of the work done at a job site
has been put to its intended use by any
person or organization other than another
contractor or subcontractor working on the
same project,
Work that may need service, maintenance,
correction, repair or replacement, but which
is otherwise complete, will be treated as
completed.
11. Pollution
"Bodily injury" or "property damage" arising out of the
actual, alleged or threatened discharge, dispersal,
p~,~r~vurseER: CPAM24468 J INSURED COPY
CGt~
seepage, migration, release orescape of "pollutants":
a. That are, or that are contained in any property
that is:
(1) Being transported or towed by, handled, or
handled for movement into, onto orfrom, the
covered "auto";
(2) Otherwise in the course of transit by or on
behalf of the "insured"; or
(3) Being stored, disposed of, treated or
processed in or upon the covered "auto";
b. Before the "pollutants" or any property in which
the "pollutants" are contained are moved from
the place where they are accepted by the "in-
sured" for movement into or onto the covered
"auto"; or
c. After the "pollutants" or any property in which
the "pollutants" are contained are moved from
the covered "auto" to the place where they are
finally delivered, disposed of orabandoned by the
"insured".
Paragraph a. above does not apply to fuels,
lubricants, fluids, exhaust gases or other similar
"pollutants" that are needed for or result from the
normal electrical, hydraulic or mechanical
functioning of the covered "auto" or its parts, if:
(1) The "pollutants" escape, seep, migrate, or
are discharged, dispersed or released directly
from an "auto" part designed by its manufac-
turer tohold, store, receive or dispose of such
"pollutants"; and
(2) The "bodily injury", "property damage" or
"covered pollution cost or expense" does not
arise out of the operation of any equipment
listed in Paragraphs 6.b. and 6.c. of the
definition of "mobile equipment".
Paragraphs b. and c. above of this exclusion do
not apply to "accidents" that occur away from
premises owned by or rented to an "insured" with
respect to "pollutants" not in or upon a covered
"auto" if:
(1) The "pollutants" orany property in which the
"pollutants" are contained are upset, over-
turned or damaged as a result of the main-
tenance or use of a covered "auto": and
(2) The discharge, dispersal, seepage, migra-
tion, release or escape of the "pollutants" is
caused directly by such upset, overturn or
damage.
12. War
"Bodily injury" or "property damage" due to war, whether
or not declared, or any act or condition incident to war,
War includes civil war, insurrection, rebellion or revolu-
tion.This exclusion applies only to liability assumed under
a contract or agreement.
=o,.!CY NuM1naER: CPAM24468
INSURED COPY
Form No: CA 00 Ol
07 97
Page 4 of 9
13. Racing
Covered "autos" while used in any professional or or-
ganized racing or demolition contest or stunting activity,
or while practicing for such contest or activity. This
insurance also does not apply while that covered "auto"
is being prepared for such a contest or activity.
C. Limit Of Insurance
Regardless of the number of covered "autos", "insureds",
premiums paid, claims made or vehicles involved in the
"accident", the most we will pay for the total of all
damages and "covered pollution cost or expense" com-
bined, resulting from any one "accident" is the Limit of
Insurance for Liability Coverage shown in the Declara-
tions.
All "bodily injury", "property damage" and "covered pol-
lution cost or expense" resulting from continuous or
repeated exposure to substantially the same conditions
will be considered as resulting from one "accident".
No one will be entitled to receive duplicate payments for
the same elements of "loss" under this Coverage Form and
any Medical Payments Coverage Endorsement, Uninsured
Motorists Coverage Endorsement or Underinsured
Motorists Coverage Endorsement attached to this
Coverage Part.
SECTION III -PHYSICAL DAMAGE COVERAGE
A. Coverage
1. We will pay for "loss" to a covered "auto" or its
equipment under:
a. Comprehensive Coverage
From any cause except:
(1) The covered "auto's" collision with another
object; or
(2) The covered "auto's" overturn.
b. Specified Causes Of Loss Coverage
Caused by:
(1) Fire, lightning or explosion;
(2) Theft;
(3) Windstorm, hail or earthquake;
(4) Flood;
(5) Mischief or vandalism; or
(6) The sinking, burning, collision or derailment
of any conveyance transporting the covered
"auto".
c. Collision Coverage
Caused by:
(1) The covered "auto's" collision with another
object; or
(2) The covered "auto's" overturn.
2. Towing
We will pay up to the limit shown in the Declarations
for towing and labor costs incurred each time a
covered "auto" of the private passenger type is dis-
x ..,-_. - .._ .
CGU
abled. However, the labor must be performed at the
place of disablement.
3. Glass Breakage - Hitting A Bird Or Animal -
Falling Objects Or Missiles
If you carry Comprehensive Coverage for the damaged
covered "auto", we will pay for the following under
Comprehensive Coverage:
a. Glass breakage;
b. "Loss" caused by hitting a bird or animal; and
c. "Loss" caused by falling objects or missiles.
However, you have the option of having glass
breakage caused by a covered "auto's" collision or
overturn considered a "loss" under Collision
Coverage.
4. Coverage Extension
Wewill pay up to $15 per day to a maximum of $450
for temporary transportation expense incurred by you
because of the total theft of a covered "auto" of the
private passenger type. We will pay only for those
covered "autos" for which you carry either Com-
prehensive orSpecified Causes of Loss Coverage. We
will pay for temporary transportation expenses in-
curredduring the period beginning 48 hours after the
theft and ending, regardless of the policy's expiration,
when the covered "auto" is returned to use or we pay
for its "loss".
B. Exclusions
1. Wewill not pay for "loss" caused by or resulting from
any of the following. Such "loss" is excluded regard-
less of any other cause or event that contributes
concurrently or in any sequence to the "loss".
a. Nuclear Hazard
(1) The explosion of any weapon employing
atomic fission or fusion; or
(2) Nuclear reaction or radiation, or radioactive
contamination, however caused.
b. War Or Military Action
(1) War, including undeclared or civil war;
(2) Warlike action by a military force, including
action in hindering or defending against an
actual or expected attack, by any govern-
ment, sovereign or other authority using
military personnel or other agents; or
(3) Insurrection, rebellion, revolution, usurped
power or action taken by governmental
authority in hindering or defending against
any of these.
2. Wewill not pay for "loss" to any covered "auto" while
used in any professional or organized racing or
demolition contest or stunting activity, or while prac-
ticingfor such contest or activity. Wewill also not pay
for "loss" to any covered "auto" while that covered
Form No: CA 00 O1
07 97
Page 5 of 9
"auto" is being prepared for such a contest or activity.
3. Wewill not pay for "loss" caused by or resulting from
any of the following unless caused by other "loss" that
is covered by this insurance:
a. Wear and tear, freezing, mechanical or electrical
breakdown.
b. Blowouts, punctures or other road damage to
tires,
4. Wewill not pay for "loss" to any of the following:
a. Tapes, records, discs or other similar audio,
visual or data electronic devices designed for use
with audio, visual or data electronic equipment.
b. Any device designed or used to detect speed
measuring equipment such as radar or laser
detectors and any jamming apparatus intended
to elude or disrupt speed measurement equip-
ment.
c. Any electronic equipment, without regard to
whether this equipment is permanently installed,
that receives or transmits audio, visual or data
signals and that is not designed solely for the
reproduction of sound.
d. Any accessories used with the electronic equip-
ment described in Paragraph c, above.
Exclusions 4.c. and 4.d. do not apply to:
a. Equipment designed solely for the reproduction
of sound and accessories used with such equip-
ment, provided such equipment is permanently
installed in the covered "auto" at the time of the
"loss" or such equipment is removable from a
housing unit which is permanently installed in the
covered "auto" at the time of the "loss",and such
equipment is designed to be solely operated by
use of the power from the "auto's" electrical
system, in or upon the covered "auto"; or
b. Any other electronic equipment that is:
(1) Necessary for the normal operation of the
covered "auto" or the monitoring of the
covered "auto's" operating system; or
(2) An integral part of the same unit housing any
sound reproducing equipment described in
a, above and permanently installed in the
opening of the dash or console of the covered
"auto" normally used bythe manufacturerfor
installation of a radio.
C. Limit Of Insurance
The most we will pay for "loss" in any one "accident" is
the lesser of:
1. The actual cash value of the damaged or stolen
property as of the time of the "loss"; or
2. The cost of repairing or replacing the damaged or
stolen property with other property of like kind and
quality.
aoucv ne;r~e~R: CPAN244b8
INSURED COPY
., ,
CGU
D. Deductible
For each covered "auto", our obligation to pay for, repair,
return or replace damaged or stolen property will be
reduced by the applicable deductible shown in the Decla-
rations. Any Comprehensive Coverage deductible shown
in the Declarations does not apply to "loss" caused by fire
or lightning.
SECTION IV -BUSINESS AUTO CONDITIONS
The following conditions apply in addition to the Common
Policy Conditions:
A. Loss Conditions
1. Appraisal For Physical Damage Loss
If you and we disagree on the amount of "loss", either
may demand an appraisal of the "loss". In this event,
each party will select a competent appraiser. The two
appraisers will select a competent and impartial um-
pire. The appraisers will state separately the actual
cash value and amount of "loss". If they fail to agree,
they will submit their differences to the umpire. A
decision agreed to by any two will be binding. Each
party will:
a. Pay its chosen appraiser; and
b. Bear the other expenses of the appraisal and
umpire equally,
If we submit to an appraisal, we will still retain our
right to deny the claim.
2. Duties In The Event Of Accident, Claim, Suit Or Loss
We have no duty to provide coverage under this policy
unless there has been full compliance with the fol-
lowingduties:
a. In the event of "accident", claim, "suit" or "loss",
you must give us or our authorized representative
prompt notice of the "accident" or "loss".Include:
(1) How, when and where the "accident" or
"loss" occurred;
(2) The "insured's" name and address; and
(3) To the extent possible, the names and ad-
dresses of any injured persons and wit-
nesses.
b. Additionally, you and any other involved "in-
sured" must:
(1) Assume no obligation, make no payment or
incur no expense without our consent, except
at the "insured's" own cost.
(2) Immediately send us copies of any request,
demand, order, notice, summons or legal
paper received concerning the claim or
"suit".
(3) Cooperate with us in the investigation or
settlement of the claim or defense against
the "suit",
(4) Authorize us to obtain medical records or
other pertinent information.
Form No: CA 00 Ol
07 97
Page 6 of 9
(5) Submit to examination, at our expense, by
physicians of our choice, as often as we
reasonably require.
c. If there is "loss" to a covered "auto" or its equip-
mentyou must also do the following:
(1) Promptly notify the police if the covered
"auto" or any of its equipment is stolen.
(2) Take all reasonable steps to protect the
covered "auto" from further damage. Also
keep a record of your expenses for considera-
tion in the settlement of the claim.
(3) Permit us to inspect the covered "auto" and
records proving the "loss" before its repair or
disposition.
(4) Agree to examinations under oath at our
request and give us a signed statement of
your answers.
3. Legal Action Against Us
No one may bring a legal action against us under this
Coverage Form until:
a. There has been full compliancewith all the terms
of this Coverage Form; and
b. Under Liability Coverage, we agree in writingthat
the "insured" has an obligation to pay or until the
amount of that obligation has finally been deter-
mined by judgment after trial. No one has the
right under this policy to bring us into an action
to determine the "insured's" liability.
4. Loss Payment -Physical Damage Coverages
At our option we may:
a. Pay for, repair or replace damaged or stolen
property;
b. Return the stolen property, at our expense, We
will pay for any damage that results to the "auto"
from the theft; or
c. Take all or any part of the damaged or stolen
property at an agreed or appraised value.
5. Transfer Of Rights Of Recovery Against Others To
Us
If any person or organization to or for whom we make
payment under this Coverage Form has rights to
recover damages from another, those rights are trans-
ferred to us. That person or organization must do
everything necessary to secure our rights and must do
nothing after "accident" or "loss" to impair them.
B. General Conditions
1. Bankruptcy
Bankruptcy or insolvency of the "insured" or the
"insured's" estatewill not relieve usof any obligations
under this Coverage Form.
2. Concealment, Misrepresentation Or Fraud
This Coverage Form is void in any case of fraud by
you at any time as it relates to this Coverage Form. It
~e!,cv~;:;vsF~: CPAN24468 J ZNSURE- COPY
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is also void if you or any other "insured", at any time,
intentionally conceal or misrepresent a material fact
concerning:
a. This Coverage Form;
b. The covered "auto";
c. Your interest in the covered "auto"; or
d. A claim under this Coverage Form.
3. Liberalization
If we revise this Coverage Form to provide more
coverage without additional premium charge, your
policy will automatically provide the additional
coverage as of the day the revision is effective in your
state.
4. No Benefit To Bailee-Physical Damage Coverages
We will not recognize any assignment or grant any
coverage for the benefit of any person or organization
holding, storing or transporting property for a fee
regardless of any other provision of this Coverage
Form.
5. Other insurance
a. For any covered "auto" you own, this Coverage
Form provides primary insurance. For any
covered "auto" you don't own, the insurance
provided by this Coverage Form is excess over
any other collectible insurance. However, while
a covered "auto" which is a "trailer" is connected
to another vehicle, the Liability Coverage this
Coverage Form provides for the "trailer" is:
(1) Excess while it is connected to a motor
vehicle you do not own.
(2) Primary while it is connected to a covered
"auto" you own.
b. For Hired Auto Physical Damage Coverage, any
covered "auto" you lease, hire, rent or borrow is
deemed to be a covered "auto" you own. How-
ever, any "auto" that is leased, hired, rented or
borrowed with a driver is not a covered "auto".
c. Regardless of the provisions of Paragraph a.
above, this Coverage Form's Liability Coverage is
primary for any liability assumed under an "in-
sured contract".
d. When this Coverage Form and any other
Coverage Form or policy covers on the same
basis, either excess or primary, we will pay only
our share. Our share is the proportion that the
Limit of Insurance of our Coverage Form bears to
the total of the limits of all the Coverage Forms
and policies covering on the same basis.
6. Premium Audit
a. The estimated premium for this Coverage Form
is based on the exposures you told us you would
have when this policy began. We will compute
the final premium due when we determine your
actual exposures. The estimated total premium
Form No: CA 00 01
07 97
Page 7 of 9
will be credited against the final premium due
and the first Named Insured will be billed for the
balance, if any. If the estimated total premium
exceeds the final premium due, the first Named
Insured will get a refund.
b. If this policy is issued for more than one year, the
premium for this Coverage Form will be com-
puted annually based on our rates or premiums
in effect at the beginning of each year of the
policy.
7. Policy Period, Coverage Territory
Under this Coverage Form, we cover "accidents" and
"losses" occurring:
a. During the policy period shown in the Declara-
tions; and
b. Within the coverage territory.
The coverage territory is:
a. The United States of America;
b. The territories and possessions of the United
States of America;
c. Puerto Rico; and
d. Canada.
We also cover "loss" to, or "accidents" involving, a
covered "auto" while being transported between any
of these places.
8. Two Or More Coverage Forms Or Policies Issued By
Us
If this Coverage Form and any other Coverage Form
or policy issued to you by us or any company affiliated
with us apply to the same "accident", the aggregate
maximum Limit of Insurance under all the Coverage
Forms or policies shall not exceed the highest ap-
plicable Limit of Insurance under any one Coverage
Form or policy. This condition does not apply to any
Coverage Form or policy issued by us or an affiliated
company specifically to apply as excess insurance
over this Coverage Form.
SECTION V -DEFINITIONS
A. "Accident" includes continuous or repeated exposure to
the same conditions resulting in "bodily injury" or "proper-
ty damage".
B. "Auto" means a land motor vehicle, "trailer" or semitrailer
designed for travel on public roads but does not include
"mobile equipment".
C. "Bodily injury" means bodily injury, sickness or disease
sustained by a person including death resulting from any
of these.
D. "Covered pollution cost or expense" means any cost or
expense arising out of:
1. Any request, demand or order; or
2. Any claim or "suit" by or on behalf of a governmental
authority demanding
that the "insured" or others test for, monitor, clean up,
Poucvn~+nsFq,~ CPAM244b8 J INSURED COPY
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remove, contain, treat, detoxify or neutralize, or in anyway
respond to, or assess the effects of "pollutants".
"Covered pollution cost or expense" does not include any
cost or expense arising out of the actual, alleged or
threatened discharge, dispersal, seepage, migration,
release or escape of "pollutants":
a. That are, or that are contained in any property
that is:
(1) Being transported or towed by, handled, or
handled for movement into, onto orfrom the
covered "auto";
(2) Otherwise in the course of transit by or on
behalf of the "insured";
(3) Being stored, disposed of, treated or
processed in or upon the covered "auto"; or
b. Before the "pollutants" or any property in which
the "pollutants" are contained are moved from
the place where they are accepted by the "in-
sured" for movement into or onto the covered
"auto"; or
c. After the "pollutants" or any property in which
the "pollutants" are contained are moved from
the covered "auto" to the place where they are
finally delivered, disposed of or abandoned by the
"insured".
Paragraph a. above does not apply to fuels,
lubricants, fluids, exhaust gases or other similar
"pollutants" that are needed for or result from the
normal electrical, hydraulic or mechanical
functioning of the covered "auto" or its parts, if:
(1) The "pollutants" escape, seep, migrate, or
are discharged, dispersed or released directly
from an "auto" part designed by its manufac-
turer tohold, store, receive or dispose of such
"pollutants"; and
(2) The "bodily injury", "property damage" or
"covered pollution cost or expense" does not
arise out of the operation of any equipment
listed in Paragraphs 6.b. or 6.c, of the defini-
tion of "mobile equipment".
Paragraphs b, and c. above do not apply to
"accidents" that occur away from premises
owned by or rented to an "insured" with respect
to "pollutants" not in or upon a covered "auto" if:
(1) The "pollutants" orany property inwhich the
"pollutants" are contained are upset, over-
turned or damaged as a result of the main-
tenance or use of a covered "auto"; and
Form No: CA 00 O1
07 97
Page 8 of 9
F. "Insured" means any person or organization qualifying as
an insured in the Who Is An Insured provision of the
applicable coverage. Except with respect to the Limit of
Insurance, the coverage afforded applies separately to
each insured who is seeking coverage or against whom a
claim or "suit" is brought.
G. "Insured contract" means:
1. A lease of premises;
2. A sidetrack agreement;
3. Any easement or license agreement, except in con-
nectionwith construction or demolition operations on
or within 50 feet of a railroad;
4. An obligation, as required by ordinance, to indemnify
a municipality, except in connection with work for a
municipality;
5. That part of any other contract or agreement pertain-
ing to your business (including an indemnification of
a municipality in connection with work performed for
a municipality) under which you assume the tort
liability of another to pay for "bodily injury" or "proper-
ty damage" to a third parry or organization. Tort
liability means a liability that would be imposed by
law in the absence of any contract or agreement;
6. That part of any contract or agreement entered into,
as part of your business, pertaining to the rental or
lease, by you or any of your "employees", of any
"auto". However, such contract or agreement shall
not be considered an "insured contract" to the extent
that it obligates you or any of your "employees" to pay
for "property damage" to any "auto" rented or leased
by you or any of your "employees".
An "insured contract" does not include that pan. of
any contract or agreement:
a. That indemnifies any person or organization for
"bodily injury" or "property damage" arising out
of construction or demolition operations, within
50 feet of any railroad property and affecting any
railroad bridge or trestle, tracks, roadbeds, tun-
nel, underpass or crossing; or
b. That pertains to the loan, lease or rental of an
"auto" to you or any of your "employees", if the
"auto" is loaned, leased or rented with a driver;
or
c. That holds a person or organization engaged in
the business of transporting property by "auto"
for hire harmless foryouruse of acovered "auto"
over a route or territory that person or organiza-
tion is authorized to serve by public authority.
(2) The discharge, dispersal, seepage, migra- H. "Leased worker" means a person leased to you by a labor
tion, release or escape of the "pollutants" is leasing firm under an agreement between you and the
caused directly by such upset, overturn or labor leasingfirm, to perform duties related totheconduct
damage. of your business. "Leased worker" does not include a
E. "Employee" includes a "leased worker". "Employee" does "temporary worker".
not include a "temporary worker". I. "Loss" means direct and accidental loss or damage.
Fc_icv ~u~rJe~?: CPAM24~r68
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"Mobile equipment" means any of the following types of
land vehicles, including any attached machinery or equip-
ment:
1. Bulldozers, farm machinery, forklifts and other
vehicles designed for use principally off public roads;
2. Vehicles maintained for use solely on or next to
premises you own or rent;
3. Vehicles that travel on crawler treads; K.
4. Vehicles, whether self-propelled or not, maintained
primarily to provide mobility to permanently mounted:
a. Power cranes, shovels, loaders, diggers or drills;
or
b. Road construction or resurfacing equipment such
as graders, scrapers or rollers.
5. Vehicles not described in Paragraphs 1., 2., 3., or 4.
above that are not self-propelled and are maintained
primarily to provide mobility to permanently attached
equipment of the following types;
a. Air compressors, pumps and generators, includ-
ing spraying, welding, building cleaning,
geophysical exploration, lighting and well servic-
ing equipment; or
b. Cherry pickers and similar devices used to raise
or lower workers.
6. Vehicles not described in Paragraphs 1., 2., 3. or 4.
above maintained primarily for purposes other than
the transportation of persons or cargo. However,
self-propelled vehicles with the following types of
permanently attached equipment are not "mobile
equipment" but will be considered "autos";
a. Equipment designed primarily for:
(1) Snow removal;
(2) Road maintenance, but not construction or
resurfacing; or
(3) Street cleaning;
Form No: CA 00 Ol
07 97
Page 9 of 9
b. Cherry pickers and similar devices mounted on
automobile or truck chassis and used to raise or
lower workers; and
c. Air compressors, pumps and generators, includ-
ing spraying, welding, building cleaning,
geophysical exploration, lighting Orwell servicing
equipment.
"Pollutants" means any solid, liquid, gaseous or thermal
irritant or contaminant, including smoke, vapor, soot,
fumes, acids, alkalis, chemicals and waste. Waste in-
cludes materials to be recycled, reconditioned or
reclaimed.
L. "Property damage" means damage to or loss of use of
tangible property.
M. "Suit" means a civil proceeding in which:
1. Damages because of "bodily injury" or "property
damage"; or
2. A "covered pollution cost or expense", to which this
insurance applies, are alleged.
"Suit" includes:
a. An arbitration proceeding inwhich such damages
or "covered pollution costs or expenses" are
claimed and to which the "insured" must submit
or does submit with our consent; or
b. Any other alternative dispute resolution proceed-
ing inwhich such damages or "covered pollution
costs or expenses" are claimed and to which the
insured submits with our consent.
N. "Temporary worker" means a person who is furnished to
you for a finite time period to support or supplement your
workforce in special work situations such as "employee"
absences, temporary skill shortages and seasonal
workloads.
0. "Trailer" includes semitrailer.
Foucv,huMat?: CPAM2446S J INSilRED COPY
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IMPORTANT NOTICE
Pennsylvania
A 964a
(6-89)
Insurance companies operating in the Commonwealth of Pennsylvania are required by law to make available for purchase the
following benefits for you, your spquse or other relatives or minors in your custody or in the custody of your relatives, residing
in your household, occupants of your motor vehicle or persons struck by your motor vehicle:
1. Medical benefits, up to at least $100,000.
1.1.Extraordinaryrnedical benefits, from $100,000 to $1,100,000 which may be offered in increments of $100,000.
2. Income loss benefits, up to at least $2500 per month up to a maximum benefit of at least $50,000.
3. Accidental death benefits, up to at least $25,000.
4. Funeral benefits, $2500.
5. As an alternative to paragraphs (1) through (4), a combination benefit, up to at least $277,500 of benefits in the aggregate
or benefits payable up to three years from the date of the accident, whichever occurs first, subject to a limit on accidental
death benefit of up to $25,000 and a limit on funeral benefit of $2500, provided that nothing contained in this subsection
shall be construed to limit, reduce, modify or change the provisions of section 1715(d) (relating to availability of adequate
limits).
6. Uninsured, underinsured and bodily injury liability coverage up to at least $100,000 because of injury to one person in
any one accident and up to at least $300,000 because of injury to two or more persons in any one accident or, at the
option of the insurer, up to at least $300,000 in a single limit for these coverages, except for policies issued under the
Assigned Risk Plan. Also, at least $5000 for damage to property of others in any one accident.
Additionally, insurers may offer higher benefit levels than those enumerated above as well as additional benefits. However,
an insured may elect to purchase lower benefit levels than those enumerated above.
Your signature on this notice or your payment of any renewal premium evidences your actual knowledge and understanding
of the availability of these benefits and limits as well as the benefits and limits you have selected.
ao! icv ~uva_R: CPAM24458 J INSURED COPY
~~~~ CA2237 0395
PENNSYLVANIA BASIC FIRST PARTY BENEFIT
For a covered "auto" licensed or principally garaged in, or "garage operations" conducted in, Pennsylvania, this endorsement
modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the
endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
SCHEDULE
Benefits Limit of Liability
(per insured)
Medical Expense Benefits Up to $5,000
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
A. COVERAGE
We will pay the Basic First Party Benefit in accordance
with the "Act" to or for an insured who sustains bodily
injury caused by an "accident" arising out of the main-
tenance or use of an "auto".
BENEFITS
Subject to the limit shown in the Schedule or Declarations,
the Basic First Party Benefit consists of Medical Expense
Benefits. These benefits consist of reasonable and neces-
sarymedical expenses incurred for an "insured's":
parked in a manner as to create an unreasonable risk
of injury.
C. EXCLUSIONS
We will not pay First Party Benefits for "bodily injury";
1. Care;
2. Recovery; or
9. Rehabilitation.
This includes remedial care and treatment rendered in
accordance with a recognized religious method of healing.
Medical expenseswill be paid if incurredwilhin 18 months
from the date of the "accident" causing "bodily injury", If
within 18 months from the date of the "accident" causing
"bodily injury" it is ascertainable with reasonable medical
probability that further expenses may be incurred as a
result of the "bodily injury", medical expenseswill be paid
without limitation as to the time such further expenses are
incurred.
B. WHO IS AN INSURED
1. You.
2. If you are an individual, any "family member".
3. Any person while "occupying" a "covered auto".
4. Any person while not "occupying" an "auto" if injured
as a result of an "accident" in Pennsylvania involving
a covered "auto".
If a covered "auto" is parked and unoccupied, it is not
an "auto" involved in an "accident" unless it was
1. Sustained by any person injured while intentionally
causing or attempting to cause injury to himself or
herself or any other person.
2. Sustained by any person while committing a felony.
3. Sustained by any person while seeking to elude lawful
apprehension or arrest by a law enforcement official.
4. Sustained by any person while maintaining or using
an "auto" knowingly converted by that person. How-
ever, this exclusion does not apply to:
a. You; or
b. Any "family member".
5. Sustained by any person who, at the time of the
"accident":
a. Is the owner of one or more currently registered
"autos" and none of those autos is covered by the
financial responsibility required by the Act; or
b. Is occupying an auto owned by that person for
which the financial responsibility required by the
Act is not in effect.
6. Sustained by any person maintaining or using an
"auto" while located for use as a residence or prem-
ises.
7. Sustained by a pedestrian if the "accident" occurs
outside of Pennsylvania. This exclusion does not
apply to:
a. You; or
b. Any "family member",
8. Sustained by any person while "occupying":
PouCYrvu+neca: CPAM24458 J INSURED COPY
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a. A recreational vehicle designed for use off public
roads; or
b. A motorcycle, moped or similar type vehicle.
9. Caused by or as a consequence of:
a. Discharge of a nuclear weapon (even if acciden-
tal);
b. War (declared or undeclared);
c. Civil war;
d. Insurrection; or
e. Rebellion or revolution,
10. From or as a consequence of the following whether
controlled or uncontrolled or however caused:
a. Nuclear reaction;
b. Radiation; or
c. Radioactive contamination.
D. LIMIT OF INSURANCE
1. Regardless of the number of covered "autos", prem-
iums paid, claims made, "autos" involved in the
"accident" or insurers providing First Parry Benefits,
the most we will pay to or for an "insured" as the
result of any one "accident" is the limit shown in the
Schedule or in the Declarations.
2. Any amount payable under First Party Benefits shall
be excess over any sums paid, payable or required to
be provided under any workers' compensation law or
similar law.
E. CHANGES IN CONDITIONS
The CONDITIONS are changed for FIRST PARTY BENE-
FITS as follows:
i. TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TO US does not apply.
2. The following CONDITIONS are added:
NON-DUPLICATION OF BENEFITS
No person may recover duplicate benefits for the
same,expenses or loss under this or any other similar
automobile coverage including self-insurance.
PRIORITIES OF POLICIES
We will pay First Party Benefits in accordance with
the order of priority set forth by the "Act". We will not
pay if there is another insurer at a higher level of
priority. The "First" category listed below is the high-
est level of priority and the "Fourth" category listed
below is the lowest level of priority. The priority order
is:
First The insurer providing benefits to the "insured" as
a named insured.
Po~rcY buMeea. CPAM2~+4b8
INSURED COPY
Form No: CA 22 37
03 95
Page 2 of 2
Second The insurer providing benefits to the "insured" as
a family member who is not a named insured
under another policy providing coverage under
the "Act".
Third The insurer of the "auto" which the "insured" is
"occupying" at the time of the "accident",
Fourth The insurer providing benefits on any "auto"
involved in the "accident" if the "insured" is:
a. Not "occupying" an "auto"; and
b. Not provided First Party Benefits under any
other policy.
If two or more policies have equal priority within the
highest applicable number in the priority order:
1. The insurer against whom the claim is first made
shall process and pay the claim as if wholly
responsible;
2. If we are the insurer against whom the claim is
' first made, our payment toorforan"insured"will
not exceed the applicable limit shown in the
Schedule or Declarations;
3. The insurer thereafter is entitled to recover pro
rata contribution from any other insurer for the
benefits paid and the costs of processing the
claim, If contribution is sought among insurers
under the Fourth priority, proration shall be based
on the number of involved motor vehicles; and
4. The maximum recovery under all policies shall
not exceed the amount payable under the policy
with the highest dollar limits of benefits.
F. ADDITIONAL DEFINITIONS
As used in this endorsement:
1. "Auto" means aself-propelled motorvehicle, ortrailer
required to be registered, operated or designed for use
on public roads. However, "auto" does not include a
vehicle operated:
a. By muscular power; or
b. On rails or tracks.
2. The "Act" means the Pennsylvania Motor Vehicle
Financial Responsibility Law.
3. "Family member"meansaresident of your household
who is:
a. Related to you by blood, marriage or adoption; or
b. A minor in your custody or in the custody of any
other "family member".
4. "Occupying" means in, upon, getting in, on, out or off.
CGU
CA2238 03 95
PENNSYLVANIA ADDED AND COMBINATION
FIRST PARTY BENEFITS ENDORSEMENT
This endorsement modifies insurance provided under the following;
PENNSYLVANIA BASIC FIRST PARTY BENEFIT
With respect to coverage provided by this endorsement. The provisions of the Coverage Form apply unless modified by the
endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
BASIC FIRST PARTY BENEFIT is changed as follows:
SCHEDULE
As indicated below, Added First Party Benefits or Combination First Party Benefits apply instead of the Basic First Party Benefit.
The limits of liability shown for the benefits selected below replace the limits of liability shown in the Schedule for the Basic First
Party Benefit.
Benefits Limit of Liability
(per insured)
^ Added First Party Benefits
Medical Expense Benefits Up to $io, o00
Work Loss Benefits Up to $s,ooo
subject to a maximum
of $1,00o per month
Funeral Expense Benefits Up to $i,5oo
Accidental Death Benefits $
^ Combination First Party Benefits
Maximum Total Limit Up to $
for All Benefits
Subject to the following individual limits:
Medical Excpense Benefits No specific dollar amount
Work Loss Benefits No specific dollar amount
Funeral Expense Benefits Up to $2,500
Accidental Death Benefits $
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
A. COVERAGE
We will pay Added First Party Benefits or Combination
First Party Benefits in accordance with the "Act" up to the
limits slated in the Schedule or Declarations to or for an
"insured" who sustains "bodily injury" caused by an "ac-
cident" and arising out of the maintenance or use of an
"auto". We will only pay Combination First Party Benefits
for expenses or loss incurred within 3 years from the date
of the "accident".
In addition to the Medical Expense Benefits described in
the Basic First Party Benefit endorsement, Added First
Party Benefits and Combination First Party Benefits also
consist of:
1. Work Loss Benefits consisting of:
a. Loss of income. Up to 80% of the gross income
actually lost by an "insured".
b. Reasonable expenses actually incurred to reduce
loss of income by hiring:
(1) Special help, thereby enabling the "insured"
to work; or
(2) A substitute to perform the work aself-
employed "insured" would have performed.
However, Work Loss Benefits do not include:
a. Loss of expected income for any period following
the death of an "insured"; or
b. Expenses incurred for services performed follow-
ingthe death of an "insured"; or
aoucvhurneeK: CPAM2k468 J INSURED CDPY
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c. Any loss of income, or expenses incurred for
services performed, during the first 5 working
days the "insured" did not work after the "acci-
dent" because of the "bodily injury",
2. Funeral Expense Benefits. Actual expenses incurred
for an "insured's" funeral or burial if "bodily injury"
resulting from the "accident" causes his or her death
within 24 months from the date of the "accident".
3. Accidental Death Benefits. A death benefit paid if
"bodily injury" resultingfrom an "accident" causesthe
death of you or any "family member" within 24
months from the date of the "accident".
B. EXCLUSIONS
In addition to the exclusions in the Basic First Party
Benefit endorsement, the following exclusion also applies.
We will not pay:
Accidental Death Benefits on behalf of any person who
intentionally caused or attempted to cause "bodily injury"
to himself, herself or any other person,
C. LIMIT OF INSURANCE
1. Regardless of the number of covered "autos", prem-
iums paid, claims made, "autos" involved in the
"accident" or insurers providing First Party Benefits,
the most we will pay to or for an "insured" as the
result of any one "accident" is the limit shown in the
Form No: CA 22 38
03 95
Page 2 of 2
Schedule orthe Declarations. Combination First Party
Benefits are subject to a maximum total single limit
of liability with individual limits for specific benefits
as shown in the Schedule or Declarations.
2. If Combination First Party Benefits are afforded, we
will make available at least the minimum limit re-
quired by the "Act" for the Basic First Party Benefit.
This provision will not change our total limit of lia-
bility.
D. CHANGES IN CONDITIONS
In addition to the CONDITIONS applicable to the Basic
First Party Benefit endorsement, the following CONDI-
TION also applies.
PAYMENT OF ACCIDENTAL DEATH BENEFITS
The Accidental Death Benefit underthis policywill be paid
to the executor or administrator of the deceased insured's
estate. If there is no executor or administrator, benefits
shall be paid to:
1. The deceased "insured's" surviving spouse; or
2. If there is no surviving spouse, the deceased "in-
sured's" surviving children; or
3. If there is no surviving spouse or surviving children,
the deceased "insured's" estate.
PCUCY NUMBER: CPAM24G6$ J INSURED COPY
C ~ ~~ CA 21 92 11 98
PENNSYLVANIA UNINSURED MOTORISTS COVERAGE - NONSTACKED
For a covered "motor vehicle" licensed or principally garaged in, or "garage operations" conducted in, Pennsylvania, this
endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the
endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below:
SCHEDULE
LIMIT OF INSURANCE $ Each "Accident"
A. Coverage
1. We will pay all sums the "insured" is legally entitled to recover as compensatory damages from the owner or driver of an
"uninsured motor vehicle". The damages must result from "bodily injury" sustained by the "insured" caused by an
"accident". The owner's or driver's liability for these damages must result from the ownership, maintenance or use of an
"uninsured motor vehicle".
2. 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:
a. Received reasonable notice of the pendency of the "suit" resulting in the judgment; and
b. Had a reasonable opportunity to protect our interests in the "suit",
B. Who Is An Insured
1. You,
2. If you are an individual, any "family member".
3. Anyone else "occupying" a covered "motor vehicle" or a temporary substitute for a covered "motor vehicle". The covered
"motor vehicle" must be out of service because of its breakdown, repair, servicing, "loss" or destruction.
4. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another "insured".
C. Exclusions
This insurance does not apply to any of the following:
1. Any claim settled without our consent, However, this exclusion does not apply if such settlement does not adversely affect
our rights of recovery under this coverage.
2. The direct or indirect benefit of any insurer orself-insurer under any workers' compensation, disability benefits or similar
law.
3. Anyone using a vehicle without a reasonable belief that the person is entitled to do so.
4. Punitive or exemplary damages.
5. "Bodily injury" sustained by:
a. You while "occupying" or when struck by any vehicle owned by you thatls not a covered "auto" for Uninsured
Motorists Coverage under this Coverage Form;
b. Any "family member" while "occupying" or when struck by any vehicle owned by that "family member" that is not
a covered "auto" for Uninsured Motorists Coverage under this Coverage Form; or
c. Any "family member" while "occupying" or when struck by any vehicle owned by you that is insured for Uninsured
Motorists Coverage on a primary basis under any other Coverage Form or policy.
D. Limit OFlnsurance
1. Regardless of the number of covered "motor vehicles", "insureds", premiums paid, claims made or vehicles involved in
the "accident", the most we will pay for all damages resulting from any one "accident" is the Limit Of Insurance for
Uninsured Motorists Coverage shown in the Schedule or Declarations.
ac±icv,;un+ata: GPAM24468 J INSi3F.ED COPY
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Form No: CA 21 92
11 98
Page 2 of 3
2. Any amount payable for damages under this coverage shall be reduced by all sums paid by or for anyone who is legally
responsible. This includes all sums paid for the same damages under this Coverage Form's Liability Coverage. This also
includes all sums paid for an "insured's" attorney either directly or as part of the amount paid to the "insured".
3. No one will be entitled to receive duplicate payments for the same elements of "loss" under this Coverage Form and any
Liability Coverage Form, Medical Payments Coverage Endorsement or Underinsured Motorists Coverage Endorsement
attached to this Coverage Part.
We will not make a duplicate payment under this Coverage for any element of "loss" for which payment has been made
by or for anyone who is legally responsible.
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 workers' compensation, disability benefits or similar law.
E. Changes In Conditions
The Conditions are changed for Pennsylvania Uninsured Motorists Coverage - Nonstacked as follows:
1. Duties In The Event Of Accident, Claim, Suit Or Loss is changed by adding the following;
a. Promptly notify the police if ahit-and-run driver is involved, and
b. Promptly send us copies of the legal papers if a "suit" is brought.
2. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the following:
If we make any payment due to an "accident" involving an "uninsured motor vehicle" and the "insured" recovers from
another party in a separate claim or "suit", the "insured" shall hold the proceeds in trust for us and pay us back the
amount we have paid less reasonable attorneys' fees, costs and expenses incurred by the "insured" to the extent such
payment duplicates any amount we have paid under this coverage.
3. Other Insurance in the Business Auto and Garage Coverage Forms and Other Insurance -Primary And Excess Insurance
Provisions in the Truckers and Motor Carrier Coverage Forms are replaced by the following:
a. If there is other applicable similar insurance available under more than one Coverage Form or policy, the following
priorities of recovery apply:
Flrst The Uninsured Motorists Coverage applicable to the vehicle the "insured" was "occupying" at the time of the "accident".
Second The Coverage Form or policy affording Uninsured Motorists Coverage to the "insured" as a named insured or family member.
b. Where there is no applicable insurance available under the first priority, the maximum recovery under all Coverage
Forms or policies in the second priority shall not exceed the highest applicable limit for any one vehicle under any
one Coverage Form or policy.
c. Where there is applicable insurance available under the first priority:
(1) The Limit Of Insurance applicable to the vehicle the "insured" was "occupying" under the Coverage Form or
policy in the first priority, shall first be exhausted; and
(2) The maximum recovery under all Coverage Forms or policies in the second priority shall not exceed the amount
by which the highest limit for any one vehicle under any one Coverage Form or policy in the second priority
exceeds the limit applicable under the Coverage Form or policy in the first priority,
d. If two or more Coverage Forms or policies have equal priority:
(1) 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;
(2) The insurer thereafter is entitled to recover pro rata contribution from any other insurer on the same level of
priority for the benefits paid and the costs of processing the claim; and
(3) If we are the insurer against whom the claim is first made, we will pay, subject to the limit of insurance for
Uninsured Motorists Coverage shown in the Declarations, after all contributing insurers agree as to:
(a) Whether the "insured" is legally entitled to recover damages from the owner or driver of an "uninsured motor
vehicle"; and
(b) The amount of damages.
4. The following condition is added:
ARBITRATION
a. If we and an "insured" disagree whether the "insured" is legally entitled to recover damages from the owner or driver
of an "uninsured motor vehicle" or do not agree as to the amount of damages that are recoverable by that "insured",
then the matter may be arbitrated. However, disputes concerning coverage under this endorsement may not be
~oucv NuN,ee~: CPAM24468 J INSURER CRFY
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Form No: CA 21 92
11 98
Page 3 of 3
arbitrated. Either party may make a written demand for arbitration. In this event, 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. Each party will pay the expenses it incurs and bear the expenses of the third
arbitrator equally.
b. Arbitration shall be conducted in accordance with the Pennsylvania Uniform Arbitration Act. Unless both parties
agree otherwise, arbitration will take place in the county in which the "insured" lives. Local rules of law as to arbitration
procedure and evidence will apply. A decision agreed to by two of the arbitrators will be binding,
F. Addltlonal Deflnltlons
As used in this endorsement:
1. "Family member" means a person related to you by blood, marriage or adoption who is a resident of your household,
including a ward or foster child.
2. "Occupying" means in, upon, getting in, on, out or off.
3. "Uninsured motor vehicle" means a land motor vehicle or trailer:
a. For which no liability bond or policy applies at the time of an "accident".
b. For which an insuring or bonding company:
(1) Denies coverage;
(2) Is or becomes insolvent; or
(3) Is or becomes involved in insolvency proceedings.
c. For which neither the driver nor owner can be identified. The vehicle or trailer must:
(1) Hit an "insured", a covered "motor vehicle" or a vehicle an "insured" is "occupying"; or
(2) Cause an "accident" resulting in "bodily injury" to an "insured" without hitting an "insured", a covered "motor
vehicle" or a vehicle an "insured" is "occupying".
If there is no physical contact with the hit-and-run vehicle, the facts of the "accident" must be proved,
However, an "uninsured motor vehicle" does not include any vehicle:
a. Owned or operated by aself-insurer under any applicable motor vehicle law, except aself-insurer who is or who
becomes insolvent and cannot provide the amounts required by that motor vehicle law;
b. Owned by a governmental unit or agency; or
c. Designed for use mainly off public roads, while not on public roads.
4. "Motorvehicle" means a vehiclewhich isself-propelled except one which is propelled solely by human power or by electric
power obtained from overhead trolley wires, but does not mean a vehicle operated upon rails.
aoucvvuvee~: CPAM24468
INSURED COPY
C ~ ~~ CA 21 93 11 98
PENNSYLVANIA UNDERINSURED MOTORISTS COVERAGE - NONSTACKED
For a covered "motor vehicle" licensed or principally garaged in, or "garage operations" conducted in, Pennsylvania, this
endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the
endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
SCHEDULE
LIMIT OF INSURANCE $ Each "Accident"
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
A. Coverage
1. We will pay all sums the "insured" is legally entitled to recover as compensatory damages from the owner or driver of an
"underinsured motor vehicle". The damages must result from "bodily injury" sustained by the "insured" caused by an
"accident". The owner's or driver's liability for these damages must result from the ownership, maintenance or use of an
"underinsured motor vehicle".
2. We will pay under this coverage only if a. or b. below applies:
a. The limits of any applicable liability bonds or policies have been exhausted by judgments or payments; or
b. A tentative settlement has been made between an "insured" and the insurer of the "underinsured motor vehicle" and
we:
(1) Have been given prompt written notice of such tentative settlement; and
(2) Advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt
of notification.
3. Nojudgmentfordamagesarisingoutofa"suit"brought against the owner or operator of an "underinsuredmotorvehicle"
is binding on us unless we:
a. Received reasonable notice of the pendency of the "suit" resulting in the judgment; and
b. Had a reasonable opportunity to protect our interests in the "suit".
B. Who Is An Insured
1. You.
2. If you are an individual, any "family member",
3. Anyone else "occupying" a covered "motor vehicle" or a temporary substitute for a covered "motor vehicle", The covered
"motor vehicle" must be out of service because of its breakdown, repair, servicing, "loss" or destruction.
4. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another "insured".
C. Exclusions
This insurance does not apply to any of the following:
1. The direct or indirect benefit of any insurer orself-insurer under any workers' compensation, disability benefits or similar
law.
2. Anyone using a vehicle without a reasonable belief that the person is entitled to do so.
3. Punitive or exemplary damages.
4. "Bodily injury" sustained by:
a. You while "occupying" or when struck by any vehicle owned by you that is not a covered "auto" for Underinsured
Motorists Coverage under this Coverage Form;
b. Any "family member" while "occupying" or when struck by any vehicle owned by that "family member" that is not
a covered "auto" for Underinsured Motorists Coverage under this Coverage Form; or
~..^,~_icv;.ua,~eE-: CPAM24468 J INSURED COPY
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Form No: CA 21 93
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Page 2 of 3
c. Any "family member" while "occupying" or when struck by any vehicle owned by you that is insured for Underinsured
Motorists Coverage on a primary basis under any other Coverage Form or policy.
D. Limit Of Insurance
1. Regardless of the number of covered "motor vehicles", "insureds", premiums paid, claims made or vehicles involved in
the "accident", the most we will pay for ail damages resulting from any one "accident" is the Limit Of Insurance for
Underinsured Motorists Coverage shown in the Schedule or Declarations,
2. No one will be entitled to receive duplicate payments for the same elements of "loss" under this Coverage Form and any
Liability Coverage Form, Medical Payments Coverage Endorsement or Uninsured Motorists Coverage Endorsement
attached to this Coverage Part.
We will not make a duplicate payment under this Coverage for any element of "loss" for which payment has been made
by or for anyone who is legally responsible.
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 workers' compensation, disability benefits or similar law.
E. Changes In Conditions
The conditions are changed for Pennsylvania Underinsured Motorists Coverage - Nonstacked as follows:
1. Duties In The Event Of Accident, Claim, Suit Or Loss is changed by adding the following:
a. Promptly send us copies of the legal papers if a "suit" is brought.
b. A person seeking Underinsured Motorists Coverage must also promptly 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 the "insured" in an amount equal to the tentative settlement to preserve our rights against the insurer, owner or
operator of such "underinsured motor vehicle".
2. Transfer Of Rights OF Recovery Against Others To Us is changed by adding the following:
If we make any payment due to an "accident" involving an "underinsured motor vehicle" and the "insured" recovers from
another party in a separate claim or "suit", the "insured" shall hold the proceeds in trust for us and pay us back the
amount we have paid less reasonable attorneys' fees, costs and expenses incurred by the "insured" to the extent such
payment duplicates any amount we have paid under this coverage.
Our rights do not apply under this provision with respect to Underinsured Motorists Coverage if we:
a. Have been given prompt written notice of a tentative settlement between an "insured" and the insurer of an
"underinsured motor vehicle"; and
b. 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:
a. That payment will be separate from any amount the "insured" is entitled to recover under the provisions of
Underinsured Motorists Coverage; and
b. We also have a right to recover the advanced payment.
3. Other Insurance in the Business Auto and Garage Coverage Forms and Other Insurance - PrimaryAnd Excess Insurance
Provisions in the Truckers and Motor Carrier Coverage Forms are replaced by the following;
a. If there is other applicable similar insurance available under more than one Coverage Form or policy, the following
priorities of recovery apply:
___
First The Underinsured Motorists Coverage applicable to the vehicle the "insured" was "occupying" at the time of the "accident".
Second The Coverage Form or policy affording Underinsured Motorists Coverage to the "insured" as a named insured or family
member.
o. wnere tnere Is no applicable insurance available under the first priority, the maximum recovery under all Coverage
Forms or policies in the second priority shall not exceed the highest applicable limit for any one vehicle under any
one Coverage Form or policy,
c. Where there is applicable insurance available under the first priority:
(1) The Limit Of Insurance applicable to the vehicle the "insured" was "occupying" under the Coverage Form or
policy in the first priority, shall first be exhausted; and
Fc!cvn~rre~~, CPAN2G468 J INSURED COPY
CGL1
Farm No: CA 21 93
11 98
Page 3 of 3
(2) The maximum recovery under all Coverage Forms or policies in the second priority shall not exceed the amount
by which the highest limit for any one vehicle under any one Coverage Form or policy in the second priority
exceeds the limit applicable under the Coverage Form or policy in the first priority.
d. If two or more Coverage forms or policies have equal .priority:
(1) 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;
(2) The insurer thereafter is entitled to recover pro rata contribution from any other insurer for the benefits paid and
the costs of processing the claim; and
(3) If we are the insurer against whom the claim is first made, we will pay, subject to the limit of insurance for
Underinsured Motorists Coverage shown in the Declarations, after all contributing insurers agree as to:
(a) Whether the "insured" is legally entitled to recover damages from the owner or driver of an "underinsured
motor vehicle"; and
(b) The amount of damages.
4. The following condition is added:
ARBITRATION
a. If we and an "insured" disagree whether the "insured" is legally entitled to recover damages from the owner or driver
of an "underinsured motorvehicle" or do not agree as to the amount of damages that are recoverable by that "insured",
then the matter may be arbitrated. However, disputes concerning coverage under this endorsement may not be
arbitrated. Either party may make a written demand for arbitration. In this event, 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. Each parry will pay the expenses it incurs and bear the expenses of the third
arbitrator equally.
b. Arbitration shall be conducted in accordance with the Pennsylvania Uniform Arbitration Act. Unless both parties
agree otherwise, arbitration will take place in the county in which the "insured" lives. Local rules of law as to arbitration
procedure and evidence will apply. A decision agreed to by two of the arbitrators will be binding.
F. Additional Definitions
As used in this endorsement:
1. "Family member" means a person related to you by blood, marriage or adoption who is a resident of your household,
including a ward or foster child.
2. "Occupying" means in, upon, getting in, on, out or off,
3. "Underinsured motor vehicle" means a vehicle for which the sum of all liability bonds or policies that apply at the time
of an "accident" do not provide at least the amount an "insured" is legally entitled to recover as damages.
However, an "underinsured motor vehicle" does not include any vehicle;
a. Owned or operated by aself-insurer under any applicable motor vehicle law;
b. Owned by a governmental unit or agency; or
c. Designed for use mainly off public roads while not on public roads,
4. "Motorvehicle" means a vehiclewhich isself-propelled except onewhich is propelled solely by human power or by electric
power obtained from overhead trolley wires, but does not mean a vehicle operated upon rails.
Pc! ice nuhnSER~. CPAN24468 J INS@RED COPY
CG ~~ G12683 06 94
CU SECURITY FOR AUTO
This endorsement modifies insurance provided under the
BUSINESS AUTO COVERAGE FORM
To the extent that the provisions of this endorsement provide broader benefits to the insured than other provisions of the
policy, the provisions of this endorsement control.
A. Broad Form Insured Section II -Liability, B. Exclusions 2 and 6 are changed
The Named Insured shown in the Declarations is
amended to include:
1. Any legally incorporated subsidiary in which you own
more than 50% of the voting stock on the effective
date of the Coverage Form. However, the Named
Insured does not include any subsidiary that is an
"insured"under any otherautomobile policy or would
be an "insured" under such a policy but for its
termination or the exhaustion of its Limit of In-
surance.
2. Any organization that is acquired or formed by you
and over which you maintain majority ownership.
However, the Named Insured does not include any
newly formed or acquired organization:
a. That is a joint venture or partnership, E'
b. That is an "insured" under any other policy,
c. That has exhausted its Limit of Insurance under
any other policy, or
d. 180 days or more after its acquisition or forma-
tion by you, unless you have given us notice of
the acquisition or formation.
Coverage does not apply to "bodily injury" or "proper-
ty damage" that results from an accident that oc-
curred before you formed or acquired the
organization.
B. Employees As Insureds
Paragraph A.1 -WHO IS AN INSURED - of SECTION II
LIABILITY COVERAGE is amended to add:
d. Any employee of yours while using a covered
"auto" you don't own, hire or borrow in your
business or your personal affairs.
Coverage is excess over any other collectible insurance.
C. Coverage Extensions -Supplementary Payments
Supplementary Payments a.(2) and a.(4) in Coverage
Extensions (Section II) are revised as follows:
as follows:
NotwithstandingSection II, Liability, B. Exclusions 2 and
6, we will pay sums which you legally must pay to the
lessor of a covered auto which you have leased without
a driver for 30 days or less for the lessor's loss of use of
the covered auto, provided:
1. This insurance provides comprehensive, specified
causes of loss or collision coverage on the covered
auto and,
2. The loss of use results from the covered auto being
damaged in an accident while you are leasing it.
We will pay up to $65 per day subject to a maximum of
$750.
Duties in the Event of Accident, Claim, Suit or Loss
1. Your obligation in Loss Condition 2.a. (Section IV)
relative to notification requirements applies only
when the "accident" or "loss" is known to:
a. You, if you are an individual;
b. A partner, if you are a partnership; or
c. An executive officer or insurance manager, if
you are a corporation.
2. Your obligation in Loss Condition 2.b (Section IV)
relative to providing us with documents concerning
a claim or "suit" will not be considered breached
unless the breach occurs after such claim or "suit"
is known to:
a. You, if you are an individual;
b. A partner, if you are a partnership; or
c. An executive officer or insurance manager, if
you are a corporation.
F. Bodily Injury -Mental Anguish
The following is added to the definition of "bodily injury"
in Section V Definitions:
1. In a.(2), the limit for the cost of bail bonds is
changed from $250 to $2,000; and
2. In a.(4), the limit for the loss of earnings is changed G'
from $100 a day to $250 a day.
D. Hired Car Physical Damage • Loss of Use
"Bodily injury" also includes mental anguish but only
when the mental anguish arises from other bodily injury,
sickness, or disease.
Hired Car -Worldwide Coverage Territory
Section IV -Business Auto Conditions 6.7. General
Conditions, Policy Period, Coverage Territory is amended
by added the following:
'oucv^,uv~e~n: CPAM244b8 J IN5t1REO COPY
CGI~
e. Coverage Territory -Outside the United States
of America, its territories and possessions, Puer-
to Rico, and Canada.
We will pay all sums an "insured" legally must
pay as damages because of "bodily injury" or
"property damage" to which this insurance ap-
plies, caused by an "accident" which occurs
outside the United States of America, the ter-
ritoriesand possessions of the United States of
America, Puerto Rico, and Canada resulting
from the operation, maintenance, or use of any
covered "auto" of the private passengertype you
lease, hire, rent, or borrow without a driver for
30 days or less.
With respect to any claim made or suit instituted
outside the United States of America, the territories
and possessions of the United States of America,
Puerto Rico, and Canada:
a. You shall undertake the investigation, settle-
ment,and defense of such claims and suits and
keep us advised of all proceedings and actions.
We will have the right and shall be given the
opportunity either to assume complete control
of, or to associate with the insured in the
investigation, defense or settlement of such
claim, suit or proceeding.
b. You will not make any settlement without our
consent.
c. We will reimburse you
Form No: G12683
06 94
Page 2 of 2
1. The insurance provided by this endorsement is ex-
cess over any other collectible insurance available
to you.
Coverage is not applicable if foreign Auto Coverage
is specifically provided under the Business Auto or
Commercial General Liability Coverage forms.
2. You must maintain primary auto insurance for any
such auto at minimum limits of $300,000 Com-
bined Single Limit or $100,000 per per-
son/$300,000 per accident Bodily Injury,
$100,000 Property Damage. If you fail to comply
with the above, this insurance is not invalidated.
However, in the event of a loss, we will pay only to
the extent that we would have paid had you so
complied.
H. Extended Cancellation Condition
Paragraph 2 of the COMMON POLICY CONDITIONS -
CANCELLATION -applies except as follows:
If we cancel for any reason other than nonpayment of
premium, we will mail or deliver to the first Named
Insured written notice of cancellation at least 60 days
before the effective date of cancellation.
Provided this insurance provides comprehensive or Specified
Causes of Loss Coverage, the following coverage extensions
apply.
I. Glass Repair -Waiver of Deductible
Under Paragraph D. -DEDUCTIBLE - of SECTION III
PHYSICAL DAMAGE COVERAGE, the following is added:
(1) for the amount of damages because of
liability imposed upon you by law on ac-
count of "bodily injury" or "property damage" ~
to which this policy applies, and
(2) for all reasonable expenses with our consent
incurred in connection with the investiga-
tion, settlement or defense of such claims
or suits.
d. (1) our reimbursement obligation for the sum
of all damages imposed on and expense
incurred by you shall be limited to the
amount stated in the policy as the ap-
plicable limit of our liability for damages.
Limit of Insurance
With respect to this endorsement, the LIMIT OF IN-
SURANCE provision of LIABILITY COVERAGE is
amended by adding the following:
1. $50 per day, in lieu of $15; subject to
2. $1,000 maximum, in lieu of $450.
No deductible applies to glass damage if the glass is
repaired rather than replaced.
Extra Expense -Broadened Coverage
Under Paragraph A. -COVERAGE - of SECTION III -
PHYSICAL DAMAGE COVERAGE, we will pay for the
expense of returning a stolen covered "auto" to you
subject to Paragraph C. Limit of Insurance.
K. Physical Damage -Transportation Expense
Paragraph A.4., Coverage Extension (Section III) is
revised with respect to transportation expense incurred
by you, to provide:
~oucv~uvarR: CPAM244b8 J YNSURED COPY
C ~ ~~ CA 99 44 12 93
LOSS PAYABLE CLAUSE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM
With respect to coverage provided by this endorsement, the
provisions of the Coverage Form apply unless modified by
the endorsement.
A. We will pay, as interest may appear, you and the loss
payee named in the policy for "loss" to a covered "auto."
B. The insurance coverstheinterestoftheloss payee unless
the "loss" results from conversion, secretion or embez-
zlement on your part.
CA 801
(12-93)
C. We may cancel the policy as allowed by the CANCEL-
LATION Common Policy Condition.
Cancellation ends this agreement as to the loss payee's
interest. If we cancel the policy, we will mail you and
the loss payee the same advance notice.
D. If we make any payments to the loss payee, we will
obtain his or her rights against any other party.
?oucv nuvae4: CPAM24458 J INSURED COPY
CGU
IL 02 46 04 98
PENNSII'L9IANIA CHANGES -CANCELLATION AND NONRENEWAL
This endorsement modifies insurance provided under the following:
BOILER AND MACHINERY COVERAGE PART
BUSINESSOWNERS POLICY
COMMERCIAL AUTOMOBILE COVERAGE PART
COMMERCIAL CRIME COVERAGE PART*
COMMERCIAL GENERA4 LIABILITY COVERAGE PART
COMMERCIAL PROPERTY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
EMPLOYMENT-RELATED PRACTICES LIABILITY COVERAGE PART
FARM COVERAGE PART
LI4UOR LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART
PRODUCTS(COMPLETED OPERATIONS LIABILITY COVERAGE PART
*This endorsement does not apply to coverage provided for employee dishonesty (Coverage Form A) or public employee dishonesty
(Coverage Forms 0 and P).
A. The Cancellation Common Policy Condition is replaced by
the following;
CANCELLATION
1. The first Named Insured shown in the Declarations
may cancel this policy by writing or giving notice of
cancellation,
2. Cancellation Of Policies In Effect For Less Than 60
Days
We may cancel this policy by mailing or delivering to
the first Named Insured written notice of cancellation
at least 30 days before the effective date of cancel-
lation.
3. Cancellation Of Polities In Effect For 60 Days Or
More
If this policy has been in effect for 60 days or more
or if this policy is a renewal of a policy we issued, we
may cancel this policy only for one or more of the
following reasons:
a. You have made a material misrepresentation
which affects the insurability of the risk. Notice
of cancellation will be mailed or delivered at least
15 days before the effective date of cancellation.
b. You have failed to pay a premium when due,
whether the premium is payable directly to us or
our agents or indirectly under a premium finance
plan or extension of credit. Notice of cancellation
will be mailed at least 15 days before the effec-
tivedate of cancellation.
c. A condition, factor or loss experience material to
insurability has changed substantially or a sub-
stantial condition, factor or loss experience
material to insurability has become known during
the policy period. Notice of cancellation will be
mailed or delivered at least 60 days before the
effective date of cancellation.
d. Loss of reinsurance or a substantial decrease in
reinsurance has occurred, which loss or
decrease, at the time of cancellation, shall be
certified to the Insurance Commissioner as direct-
ly affecting in-force policies, Notice of cancella-
tion will be mailed or delivered at least 60 days
before the effective date of cancellation.
e. Material failure to comply with policy terms,
conditions or contractual duties, Notice of can-
cellation will be mailed or delivered at least 60
days before the effective date of cancellation.
f. Other reasons that the Insurance Commissioner
may approve, Notice of cancellation will be
mailed or delivered at least 60 days before the
effective date of cancellation.
This policy may also be cancelled from inception upon
discovery that the policy was obtained through
fraudulent statements, omissions or concealment of
facts material to the acceptance of the risk or to the
hazard assumed by us.
4. We will mail or deliver our notice to the first Named
Insured's last mailing address known to us. Notice of
cancellation will state the specific reasons for cancel-
lation.
5. Notice of cancellation will state the effective date of
cancellation. The policy period will end on that date.
6. If this policy is cancelled, wewill send thefirst Named
Insured any premium refund due, If we cancel, the
refund will be pro rata and will be returned within 10
business days after the effective date of cancellation.
If the first Named Insured cancels, the refund may be
less than pro rata and will be returned within 30 days
after the effective date of cancellation, The cancella-
tion will be effective even if we have not made or
offered a refund.
7. If notice is mailed, it will be by registered or first class
mail. Proof of mailingwill besufficient proof of notice.
B. The following are added and supersede any provisions to
the contrary:
FoL!CY^iuMe'eR~ CPAM244b$ J INSUI?ED COPY
CGU
1. Nonrenewal
If we decide not to renew this policy, we will mail or
deliver written notice of nonrenewal, stating the
specific reasons for nonrenewal, to the first Named
Insured at least 60 days before the expiration date of
the policy,
2. Increase OF Premium
Form No: IL 02 46
04 98
Page 2 or 2
If we increase your renewal premium, we will mail or
deliver to the first Named Insured written notice of
our intent to increase the premium at least 30 days
before the effective date of the premium increase,
Any notice of nonrenewal or renewal premium increase
will be mailed or delivered to the first Named Insured's
last known address. If notice is mailed, it will be by
registered or first class mail. Proof of mailing will be
sufficient proof of notice,
CA O1 80 09 97
PENNSYLVANIA CHANGES
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the
endorsement.
A. Changes In Liability Coverage
2. The following is added to Supplementary Payments:
Prejudgment interest awarded against the "insured"
on the part of the judgment we pay, Any prejudgment
interest awarded against the "insured" is subject to
the applicable Pennsylvania Rules of Civil Procedure.
B. Changes In Conditions
1. The following is added to the Loss Conditions Sec-
tion:
Paragraph A.2.b.(5) of the Duties In The Event Of
An Accident, Claim, Suit Or Loss Condition is
replaced by the following:
After we show good cause, submit to examination at
our expense, by physicians of our choice.
The following is added to the Transfer Of Rights Of
Recovery Aga{nst Others To Us Condition:
If we make any payment due to an "accident" and the
"insured" recovers from another parry in a separate
claim or "suit", the insured shall hold the proceeds in
?oucv ~~u^naea: CPAN244b8
INSURED COPY
trust for us and pay us back the amount we have paid
less reasonable attorneys'fees, costs and expenses
incurred by the "insured" to the extent such payment
duplicates any amount we have paid under this
coverage,
2. The following is added to the General Conditions
Section:
CONSTITUTIONALITY CLAUSE
The premium for, and the coverages of, this Coverage
Form have been established in reliance upon the
provisions of the Pennsylvania Motor Vehicle Finan-
cial Responsibility Law.
In the event a court, from which there is no appeal,
declares or enters a judgment, the effect of which is
to render the provisions of such statute invalid or
unenforceable in whole or in part, we shall have the
right to recompute the premium payable for the
Coverage Form and void or amend the provisions of
the Coverage Form, subject to the approval of the
Insurance Commissioner.
~ „r..
C `+ ~~ I L 00 03 04 98
CALCULATION OF
This endorsement modifies insurance provided under the following:
BOILER AND MACHINERY COVERAGE PART
BUSINESSOWNERS POLICY
COMMERCIAL AUTOMOBILE COVERAGE PART
COMMERCIAL CRIME COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL PROPERTY COVERAGE PART
EMPLOYMENT•RELATED PRACTICES LIABILITY COVERAGE PART
FARM COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
PROFESSIONAL LIABILITY COVERAGE PART
RAILROAD PROTECTIVE LIABILITY COVERAGE PART
SPECIAL PROTECTIVE AND HIGHWAY LIABILITY POLICY -NEW YORK
The following is added:
The premium shown in the Declarations was computed based
on rates in effect at the time the policy was issued. On each
renewal, continuation, or anniversary of the effective date of
this policy, we will compute the premium in accordance with
our rates and rules then in effect.
aoucv~;u+rae,~; CPAM24468 J INSURl=D CDPY
CGU
IL 0021 0498
NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (Broad Form)
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS POLICY
COMMERCIAL AUTO COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
EMPLOYMENT-RELATED PRACTICES LIABILITY COVERAGE PART
FARM COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
PROFESSIONAL LIABILITY COVERAGE PART
RAILROAD PROTECTIVE LIABILITY COVERAGE PART
SPECIAL PROTECTIVE AND HIGHWAY LIABILITY POLICY NEW YORK DEPARTMENT OF TRANSPORTATION
UNDERGROUND STORAGE TANK POLICY
1. The insurance does not apply:
A. Under any Liability Coverage, to "bodily injury" or
"property damage":
(1) With respect to which an "insured" under the
policy is also an insured under a nuclear energy
liability policy issued by Nuclear Energy Liability
Insurance Association, Mutual Atomic Energy
Liability Underwriters, Nuclear Insurance As-
sociation of Canada or any of theirsuccessors, or
would be an insured under any such policy but
for its termination upon exhaustion of its limit of
liability; or
(2) Resulting from the "hazardous properties" of
"nuclear material" and with respect to which (a)
any person ororganization is required to maintain
financial protection pursuant to the Atomic Ener-
gy Act of 1954, or any law amendatory thereof,
or (b) the "insured" is, or had this policy not been
issued would be, entitled to indemnity from the
United States of America, or any agency thereof,
under any agreement entered into by the United
States of America, or any agency thereof, with
any person ororganization.
B. Under any Medical Payments coverage, to expenses
incurred with respect to "bodily injury" resulting from
the "hazardous properties" of "nuclear material" and
arising out of the operation of a "nuclear facility" by
any person ororganization.
C, Under any Liability Coverage, to "bodily injury" or
"property damage" resultingfrom "hazardous proper-
ties" of "nuclear material", if:
(1) The "nuclear material" (a) is at any "nuclear
facility" owned by, or operated by or on behalf of,
an "insured" or (b) has been discharged or dis-
persed therefrom;
(2) The "nuclear material" is contained in "spent
fuel" or "waste" at any time possessed, handled,
used, processed, stored, transported or disposed
of, by or on behalf of an "insured"; or
(3) The "bodily injury" or "property damage" arises
out of the furnishing by an "insured" of services,
materials, parts or equipment in connection with
the planning, construction, maintenance, opera-
tion or use of any "nuclear facility", but if such
facility is located within the United States of
America, its territories or possessions or Canada,
this exclusion (3) applies only to "property
damage" to such "nuclear facility" and any
property thereat.
2. As used in this endorsement:
"Hazardous properties" includes radioactive, toxic or ex-
plosive properties,
"Nuclear material" means "source material", "Special
nuclear material" or "by-product material".
"Source material", "special nuclear material", and "by-
product material" have the meanings given them in the
Atomic Energy Act of 1954 or in any law amendatory
thereof.
"Spent fuel" means any fuel element or fuel component,
solid or liquid, which has been used or exposed to radia-
tion in a "nuclear reactor".
"Waste" means any waste material (a) containing "by-
product material" other than the tailings or wastes
produced by the extraction or concentration of uranium or
thorium from any ore processed primarily for its "source
material" content, and (b) resulting from the operation by
any person or organization of any "nuclear facility" in-
cluded under the first two paragraphs of the definition of
"nuclear facility".
"Nuclear facility" means:
(a) Any "nuclear reactor";
(b) Any equipment or device designed or used
for (1) separating the isotopes of uranium or
plutonium, (2) processing or utilizing "spent
fuel", or (3) handling, processing or packag-
ing "waste";
(c) Any equipment or device used for the
processing, fabricating or aNoying of "special
P~~cvr~u°~aeR: GP~M24458 J INSURED COPY
CGU
nuclear material" if at any time the total
amount of such material in the custody of
the "insured" at the premises where such
equipment or device is located consists of or
contains more than 25 grams of plutonium
or uranium 233 or any combination thereof,
or more than 250 grams of uranium 235;
(d) Any structure, basin, excavation, premises or
place prepared or used for the storage or
disposal of "waste";
Form No: IL 00 21
04 98
Page 2 of 2
and includes the site on which any of the foregoing is
located, all operations conducted on such site and all
premises used for such operations.
"Nuclear reactor" means any apparatus designed or
used to sustain nuclear fission in aself-supporting
chain reaction or to contain a critical mass of fis-
sionable material.
"Property damage" includes all forms of radioactive
contamination of property.
?cicv ~u>a~a: CPAM2kk68
INSURED COPY
~~-r.
C ~ ~~ I L 00 17 11 85
COMMON POLICY CONDITIONS
All Coverage Parts included in this policy are subject to the following conditions.
A. CANCELLATION
1. The first Named Insured shown in the Declarations
may cancel this policy by mailing or delivering to us
advance written notice of cancellation.
2. We may cancel this policy by mailing or delivering
to the first Named Insured written notice of cancel-
lation at least:
a. 10 days before the effective date of cancellation
if we cancel for nonpayment of premium; or
b. 30 days before the effective date of cancellation
if we cancel for any other reason.
3. We will mail or deliver our notice to the first Named
Insured's last mailing address known to us.
4. Notice of cancellation will state the effective date of
cancellation. The policy period will end on that date.
5. If this policy is cancelled, we will send the first
Named Insured any premium refund due. If we
cancel, the refund will be pro rata. If the first Named
Insured cancels, the refund may be less than pro
rata. The cancellation will be effective even if we
have not made or offered a refund.
6. If notice is mailed, proof of mailing will be sufficient
proof of notice.
B. CHANGES
This policy contains all the agreements between you and
us concerning the insurance afforded. The first Named
Insured shown in the Declarations is authorized to make
changes in the terms of this policy with our consent. This
policy's terms can be amended or waived only by endor-
sement issued by us and made a part of this policy.
C. EXAMINATION OF YOUR BOOKS AND RECORDS
We may examine and audit your books and records as
they relate to this policy at any time during the policy
period and up to three years afterward.
r~icv Nun4aER: CPAM24468
D. INSPECTIONS AND SURVEYS
GU 267
(i1-85)
We have the right but are not obligated to:
1. Make inspections and surveys at any time;
2. Give you reports on the conditions we find; and
3. Recommend changes.
Any inspections, surveys, reports or recommenda-
tions relate only to insurability and the premiums to
be charged. We do not make safety inspections. We
do not undertake to perform the duty of any person
or organization to provide for the health or safety of
workers or the public. And we do not warrant that
conditions:
1. Are safe or healthful; or
2. Comply with laws, regulations, codes or standards.
This condition applies not only to us, but also to any
rating, advisory, rate service or similar organization
which makes insurance inspections, surveys, reports or
recommendations.
E. PREMIUMS
The first Named Insured shown in the Declarations:
1. Is responsible for the payment of all premiums, and
2. Will be the payee for any return premiums we pay.
F. TRANSFER OF YOUR RIGHTS AND DUTIES UNDER
THIS POLICY
Your rights and duties under this policy may not be
transferred without our written consent except in the
case of death of an individual named insured.
If you die, your rights and duties will be transferred to
your legal representative but only while acting within the
scope of duties as your legal representative. Until your,
legal representative is appointed, anyone having proper
temporary custody of your property will have your rights
and duties but only with respect to that property.
INSURED CUPY
~~
. ,
C~ ~~ G10779 05 88
EXECUTION OF OFFICERS' SIGNATURES
In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not
be valid unless countersigned by our authorized representative.
R.
~ennls Smith, Secretary
~~
Robert Gowdy, President
an.~Cv ~urv3ER. CPAM2446$ J INSURED COPY
one Beacon
t N S U R A N C B
June 18, 2001
Tomasko and Koranda, P.C.
219 State Street
Harrisbwg, Pa. 17101
Inswed: Angie's Diner
Claim: OP202733t
Clmt.: Peter Mavropulous
D/L 8 6 99
Dear Mr. McCall,
Per your request enclosed are the sign down and rejection of stacking forms which yow requested.
It is ow opinion that ow Um coverage is $35,000.
Please contact me at 303 2361 to discuss settlement of this claim.
Very Truly Yows,
Don Dallabrida, SCLA
Sr. Claims Representative
,3,.qq F ^ r.y~.n
OneBeacon Insurance Mid-Atlantic 100 Corporate Center Drive, Camp Hill, PA 17001
Telephone: (717) 763-7331 FAX: (717) 975-4832
www.One9eaeon.eom
~ ,. ... .
_ .,
~~ ~~' Supplernenta~ €,'ommerciaf Auto
_~"- Generafl Accident
Insurance Application ~ PennsYtvania
General Accident Insurance The Camden Fire Pennsylvania General Potomac Insurance Potomac Insuran ce
Company ofAmerica Insurance Association Insurance Company Company of Illinois Company
Name of Applicant CompanylFirs Named Insured Policy Number ~,," / ~ /
/fin it_ S ~fooK.giGl-r' ~2e~L ~lC 7l~•/ losf DD
Na of Company Representative Title f ~.r~..~.,~~
i' Vhav,~t,~lo5 _~u ,~ ~
Notice of available benefits and limits ~ M
IMPORTANT NOTICE
Insurance companies operating in the Commonwealth of Pennsylvania are requiredby law to make available for purchase
the following benefits-for you, your spouse or other relatives or minors in your custtmdy or in the custody of your relatives,
residing in your household, occupants of your motor vehicle or persomsstruck by yronr motor vehicle:
(1) Medical. benefits, up to at (east $100,000
(l.t) Extraordinary medico{.benefits, from $100,000 to $1,1,000 wfiich maybe ~mffered in increments Of $100,000_
(2) Income loss benefits up to of least $2,500 per month up to a maximum beraet5iof at least of $50,000.
(3) Accidental death benefits, up to at least $25,000.
(4) Funeral benefits, $2,500.
(5) As an alternative to paragraphs (1), (2), (3) and (4), a corfrbination of benefit, up to at least $177,500 of benefits in
the aggregate or benefits payable up to three years from the date of the accidl'mt, whichever occurs first, subjecR to
a limit on accidental death benefit of up to $25,000 and a limit an funeral bemefit of $2,500, provided that nothing
contained in this subsection shall be construed to limit, veduce, modify or chamge the provisions of section 1715(d)
(relating to availability of adequate limits).
(6) Uninsured, underinsured and bodily injury liability coverage up to at least $t110,000 because of injury to one
person in any one accident and up to at lest $300,000 because o$ injury to twnoor more persons in any one accident
or, at the option of the insurer, up to at least $300,000 in a single: limit forthe*~ coverages, except for policies issued
underthe Assigned- Risk Plan. Also, at least $5;000 for damage to property of hers in any one accident.
Additionally, insurers may offer higher benefit levels than those enumerated above aswell as additional benefits.
However, an insured may elect to purchase lower benefit levels than those enumerateed above.
Your signature on this notice or your payment of any renewal evidences your actual :hrowledge and
understanding of the availability of these benefits and limits as well as ttte benefits a{nd limits you have selected.
If you have any questions ar you do not understand all of the various options availaE~fe to you, contact your agent or
company.
If you do not understand any of the provisions contained'rn this notice; contact your agent or company before you sign
Signature of Applicant/Firs Named Insured
Name of Company Representative
D
Title
Page 1 of S
Uninsured Motorist Protection Optioi
Uninsured Motorist Protection is insurance coverage you carry on your own policy that protects eligible persons under the
policy if injured by a negligent driver who fails to have any insurance coverage.
Uninsured Motorist Coverage is an optional coverage. However, we are required to include it in your policy unless you take
steps to reject it.
Rejection of Uninsured Motorists Protection
If you do not want Uninsured Motorist Coverage, the first named insured must sign and dastethe Rejection of Uninsured
Motorist Protection form provided.
Selection of Uninsured Motorist Coverage Limits
Uninsured Motorist Coverage is available in amounts equal to or less than the limits of lialmi6ty for bodily injury. However, the
limits may not be less than the minimum bodily injury limits required by Pennsylvania law ($15,000 each personl$30,000 eacFe
accident split limits or $35,000 single limit).
If you want Uninsured Motorist Coverage, please indicate the'edverage limits you want by'piacitig'arf "X" in the appropriate
box and then sign and date where appropriate.
~ 1 want Uninsured Motorist Coverage with limits equal to my Bodily Injury Liability limits.
,~
Signature of First Name Insured Date
I~1 want Uninsured Motorist Coverage with limits lower than my Bodily Injury Liability (imnts as indicated below:
For Single Limit Liability Policy:
35,000 _ $}00,000 _ $350,000 - _ $1,000,000
_ $50;000 _ $250,000 ~ $500,000
For Split Limit Liability Policy:
$15,000/$30,000 _ $50,000/$100,000 _ $ai50,00~9$500,000
_ $25,000/$50,000 _ $700,000/$300,000 _ $SOO,OOOJ$t,000,
Signature of First Named Insure Da
Rejection of Stacked Uninsured Motorist Coverage Limits
If you elect Uninsured Motorist Coverage and you have more than one private passenger tyype vehicle, the coverage you have
on these vehicles will be added together to total the limit of the benefit availabile to you. Thryis"stacking" costs; you extra
premium. Therefore, you may reject stacking to save money.
If you do not want stacking, the first named insured must sign and date'the Rejiection of Stacdced Uninsured fviotorist Coverage
Limits form provided.
Page 3 of S
A-8077 4.97
Underinsured Motorist Protectior, ,
Underinsured Motorist Protection is insurance coverage you carry on your own policy that protectseligible persons under the
policy if injured by a negligent driver who does not have enough bodily injury liability insurance tocover your claims.
Underinsured Motorist Coverage is an optional coverage. However, we are required to include it inyour policy unless you
take steps to reject it.
Rejection of Underinsured Motorists Protection
If you do not want Underinsured Motorist Coverage, the first named insured must sign and date th+eRejection of Underinsured
Motorist Protection form provided.
Selection of Underinsured Motorist Coverage Limits
Underinsured Motorist Coverage is available in amounts equal to or less than the limits of liability faor bodily injury. However,
the limits may not be less than the minimum bodily injury limits required by Pennsylvania law ($15,000 each persond$30,000
each accident split limits or $35,000 single limit).
If you want Underinsured Motorist Coverage, please indicate thecoverage limits you want by placiing an "X" in the ap-
propriate box and then sign and date where appropriate.
^ I want Underinsured Motorist Coverage with limits equal to my Bodily Injury Liability limits.
Signature of First Name Insured
Date
CV31 want Underinsured Motorist Coverage with limits lower than my Bodily Injury Liability limits as; indicated below:
For Single 4imit Liability Policy:
$35,000
_ $50,000
$100,000
$zso,ooo
_ $350,006
$500,000
-$t,6oa,00o
For Split Limit Liability Policy:
$15,000/$30,000
$zs,ooo/$so,ooo
Signature of
T $zso,ooolSSOO,o~
$500,0001$1,000,
'~ q ~
ate
Rejection of Stacked Underinsured Motorist Coverage Limits
If you elect Underinsured Motorist Coverage and you have more than one private passenger type vrehicle, the coverage you
have on these vehicles will be added together to total the limit of the benefit available to you. This "'stacking" costs yow extra
premium. Therefore, you may reject stacking to save money.
If you do not want statc~karrg; first named insured must sign and date the Rejection of Stacked Uniinsured Motorist Coverage
Li mits form provi~(lt ij. I J l'r1,; j b
".
s`,
~`
$50,000/$100,000
- $100,000/$300,000
Page 4 of 5
n-aon a.v~
~_~1
Coverage is generally described in this Application. Only the policy provides a complete description of the coverages and
their limitations.
I understand that the coverage selection and limit choices indicated here will apply to this policy and all future policy
renewals, continuations and changes unless I notify the company in writing that a change be made and the company receives
my written request.
.~:~
Signature of First Named ns 7ed
Signature of Agent
Titf~,~ ,,.
~a
Date
d~~ir q
Date
Any person who knowingly and with intent to injure or defraud any insurer files an appliation or claim containing any
falseTincompipte.oshiis[eadung infocmatioashall,-uponconvistian, b~subjesttaimprisonmentfor up-te-seven years ~
payment of a fine of up to $15,000.
Ir
Page 5 of 5
A-80774.97
~ i ~ 5
~ ~ ~ +
M'
w GENERAL Pennsylvania Automobile:
G/ `\ ACCIDENT
INSURANCE Underinsured Motorist
Rejection Of Underinsured Mo#orist Protection
A. By signing this waiver I am rejecting underinsured motorist coverage under
this policy, for myself and all other eligible insureds. Underinsured motorast
coverage protects me and relatives living in my household for tosses and
damages suffered if injury i~ caused by the negligence of a driver who dines
not have enough insurance to pay for all losses and damages. t knowingl~+
and voluntarily reject this e~verage.
Signature of First Named Irxsured
Date
Rejection Of Stacked Underinsured Coverage Limits
~a
B. By signing this waiver, 1 am rejecting stacked limits of underinsured motorrist
coverage under the pa1icy feor myself and all other eligible insureds under
which the limits of coweragc~ available would be the sum of limits for eael-r
motor vehicle insured underrthe policy. Instead the limits of coverage that. I
am purchasing shall be reduced to the limits stated in the policy. I knowia~g-
ly and voluntarily reject the stacked limits of coverage. I a~ndersttand that rm~y
prgmium will be reduced if i reject this coverage.
of First
Date
VGIE'S BROOKSIDE DINER
Insured's name
A-7913 Rev. 9.93
ARCH P. WERNER gNS. BAC 74121fn4 W6-02-~98
Agent Policy Number Policy Effective Date
i~
. ~ ,
Generac~iccident
°-"`' Insurance
r_
' Application
Supplement
Certain states require that statements be made to the applicant regarding the
application being completed or the policy that the company may issue.
Please read the paragraph relating to your state carefulily before signing this
application.
Applicable In Kentucky -Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance containing any materially false information, or conceals, for
the purpose of misleading, information concerning any fact material thereto, c®mmits a fraudulent insurance
act, which is a crime.
Applicable In Minnesota - A person who submits an application or files a claim with intent to defraud or
helps commit a fraud against an insurer is guilty of a crime.
Apphcdble in New Jersey -The general liability coverage form attached Coo the policy being applied for
excludes coverage for pollution liability.
Applicable in New York -Any person who knowingly and with intent to defraud any insurance company
or other person files an appl'~cation 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 shall also be subject tso a civil penalty not to exceed
five thousand dollars and the stated value of the claim for each such violation.
Applicable in Ohio -Any person who, with intent to defraud or knowing deaf he/she is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or dleceptive statement is guilty of
insurance fraud.
Applicable in Pennsylvania -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 rnnceals for the purpose of misleading, information concerning any fact material d~ereto
commits a fraudulent insurance act, which is a crime, and subjects such person toy criminal and civil penalties.
Applicable in Colorado - It is unlawful to knowingy provide false, incomQlette, or misleading facts or
m ormatian to an insurance company for tfie purpose n defrauding or attemptmg; to defraud the company.
Penalties may include imprisonment, Fines, denial of insurance, and civil damages... Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to
a policy holder or claimant for the purpose of defrauding or attempting to defraud) the polity holder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Departrnent Regulatory Agencies.
ANGLE"S BROOICSIDE DINER - BAC 7412164 ARCH P.. WERNER INSURANCE 427623
r
scant s Signature
Completed as a supplement to the
Date
Application
~v
P-0328 2.97
~ ~A
VERIFICATION OF COUNSEL
..
I, Michael A. Koranda, Esquire, verify that I am the attorney for the Plaintiffs in this
action and that the foregoing COMPLAINT FOR DECLARATORY JUDGMENT is true and
correct to the best of my knowledge, information and belief. I make this verification in lieu of
the Plaintiffs because the Plaintiffs lack sufficient knowledge or information concerning the
averments contained in the above pleading. I understand that false statements herein are made
subject to the penalties of 18 Pa. C.S.A. § 4904 relating to unsworn falsification to authorities.
Dated: ~ ~D -~ l ~'<%~ 1///~.c `_
MICHAEL A. KO~ A DA
SHERIFF'S RETURN - REGULAR
CASE NO: 2001-04453 P
COMMON[„]EALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MAVROPOULOS NICHOLAS ET AL
VS
BEACON INSURANCE
BRIAN BARR
Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to Saw,
says, the within COMPLAINT & NOTI
was served upon
ONE BEACON INSURANCE the
DEFENDANT at 0946:00 HOURS, on the 26th day of July 2001
at 100 CORPORATE CENTER DRIVE
CAMP HILL, PA 17001 by handing to
SUE LEITZEL, ASST CLAIMS MANAGER
a true and attested copy of COMPLAINT & NOTICE together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing 18.00
Service 9.75
Affidavit .00
Surcharge 10.00
.00
37.75
Sworn and Subscribed to before
me this ~ ~ day of
~~ oZyo/ A.D.
rothonotary
So Answers:
~~
R. Thomas Kline
07/27/2001
TOMASKO & KO A
By:
Deputy Sheriff
NICHOLAS MAVROPOULOS and IN THE COURT OF COMMON PLEAS
PETER MAVROPOULOS, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiffs,
vs. N0.01-4453 (CIVIL TERM)
ONE BEACON INSURANCE,
formerly known as GENERAL ACCIDENT
INSURANCE COMPANY and
COMMERCIAL UNION INSURANCE
COMPANY,
CIVIL ACTION -DECLARATORY
Defendant. JUDGMENT ACTION
PRAECIPE
TO THE PROTHONOTARY:
Kindly mark the above-captioned action settled, discontinued and ended as to all
Defendants.
Respectfully submitted,
TOMASKO & KORANDA, P.C.
219 State Street
Harrisburg, PA 17101
Telephone: (717) 238-1100
Dated: 6 /7-CJi By;~~ ~~~
MICHAEL A. KORANDA
PA ID #58808
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