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HomeMy WebLinkAbout05-2287 F:IFlLES\DA T AFILEIGeneral\Currenl\7022-5complaim/ajl Created: 9/20/04006PM Revised: 4/26/05 422PM 7022.5 . George B. Faller, Jr., Esquire MARTS ON DEARDORFF WILLIAMS & OTTO I.D. 49813 10 East High Street Carlisle, P A 17013 (717) 243-3341 Attorneys for Plaintiffs IN THE COURT OF COMMON PLEAS 0 CUMBERLAND COUNTY, PENNSYLVl NIA RONALD M. LEITZEL AND BARBARA D. LEITZEL, his wife, on Behalf of Themselves and All Persons, Organizations and Entities Similarly Situated, 2750 Spring Hill Lane Eno]a, P A ] 7025, Plaintiffs, NO. {J!: - c}:),n CIVIL ACTION -"" CLASS ACTION v. MERCHANTS INSURANCE COMPANY OF NEW HAMPSHIRE, INC. AND MERCHANTS INSURANCE GROUP, 250 Main Street Buffalo, NY ]4202, Defendants. JURY TRIAL DEMANDED NOTICE You have been sued in court. If you wish to defend against the claims set forth' the following pages, you must take action within twenty (20) days after this Complaint and Noti e are served, by entering a written appearance personally or by attorney and filing in writing with the ourt 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 may be entered against you by the ourt without further notice for any money claimed in the Complaint or for any other claim or elief requested by the Plaintiffs. 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, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. HIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABL TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LI GAL SERVICES TO ELIGIBLE PERSONS AT A REDUCE FEE OR NO FEE: Cwnber]and County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone (717) 249-3166 George B. Faller, Jr., Esquire MARTSON DEARDORFF WILLIAMS & OTTO !.D. 49813 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiffs RONALD M. LEITZEL AND BARBARA D. LEITZEL, his wife, on Behalf of Themselves and All Persons, Organizations and Entities Similarly Situated, 2750 Spring Hill Lane Enola, PA 17025, IN THE COURT OF COMMON PLEAS 0 CUMBERLAND COUNTY, PENNSYLV NIA Plaintiffs, NO. CIVIL ACTION - EQUI Y v. CLASS ACTION MERCHANTS INSURANCE COMPANY OF NEW HAMPSHIRE, INe. AND MERCHANTS INSURANCE GROUP, 250 Main Street Buffalo, NY 14202, Defendants. JURY TRIAL DEMANDED COMPLAINT AND NOW, come the Plaintiffs, Ronald M. Leitzel and Barbara A. Leitzel, his wife, d all other persons and entities similarly situated, by their attorneys, MARTSON DEARDO F WILLIAMS & OTTO, and aver as follows: I. PARTIES 1. The Plaintiffs, Ronald M. Leitzel and Barbara D. Leitzel, husband and wife, are dult individuals residing at 2750 Spring Hill Lane, Enola, Cumberland County, Pennsylvania, 170 3. 2. The Defendants, Merchants Insurance Company of New Hampshire, Inc. and Merchants Insurance Group ["Merchants Insurance"], are insurance companies licensed to tran act business throughout the United States, with a principal business address of250 Main Street, Buf la, New York, 14202. II. FACTUAL BACKGROUND 3. The Defendants, Merchants Insurance, are in the business of selling prope yand casualty insurance coverage to businesses and individuals throughout the northeastern, mid-a lantic and midwestem United States. 4. The Plaintiffs are the named insureds under a Personal Auto Insurance Polic ,with Policy number PAP 2664949 ["the Policy"] issued by Merchants Insurance. A copy of the olicy is attached as Exhibit "A." 5. On June 29, 2004, Plaintiff Barbara D. Leitzel was involved in an auto accident in which she suffered serious and permanent bodily injuries. 6. At the time ofthe accident, Plaintiff Barbara Leitzel was covered under the Mer Insurance Policy. 7. The Policy has Bodily Injury liability limits of one million (1,000,000.00) d llars. A Copy of the Policy Declaration Page is attached as Exhibit "B." 8. On April 26, 2004, Plaintiff Ronald M. Leitzel executed and signed a Supplem nt to the Policy. 9. The Supplement contained, inter alia, prOVlSlons for I) the Rejectio of Uninsured/Underinsured Motorist Protection ["UM/UIM"]; 2) the Rejection of Stacked UM Coverage Limits; 3) a Lower Limits Request Authorization. 10. Each of the three provisions - Rejection ofUM/UIM Coverage, Rejection ofSta ked UM/UIM Coverage and Authorization of Lower Limits ofUM/UIM coverage - were contain don the same page. See Exhibit "C." 11. Additionally, the Policy explicitly required Plaintiff Ronald Leitzel to first reje tall UM/UIM coverage before being able to select lower limits ofUM/UIM coverage. See Exhibit 'C." 12. Plaintiff Ronald Leitzel signed the provisions rejecting UM/UIM Motorist Cove age and rejecting Stacking ofUM/UIM Motorist Coverage. 13. Plaintiff Ronald Leitzel also initialed the provision selecting Lower Limit of UM/UIM Coverage. Mr. Leitzel selected UM/UIM limits of fifteen thousand (15,000.00) do lars per person and thirty thousand dollars (30,000.00) per accident. The Policy identified this selec ion as "Basic" coverage. 14. Defendants Merchants Insurance have taken the position that the Plaintiffs ar limited to fifteen thousand dollars (15,000.00) in UMlUlM benefits. 15. Plaintiffs aver that they, and all other similarly situated Merchants In urance policyholders, are entitled to receive UMIUIM benefits equal to the Policy's Bodily Injury iability limits due to the Policy's failure to comply with the requirements of Pennsylvania's Motor ehicle Financial Responsibility Law relating to the rejection and/or limitation of UMlUlM cover ge. COUNT I: REFORMATION 16. The allegations contained in paragraphs I through 15 above are incorpor ted by reference as though fully set forth herein. 17. Pennsylvania's Motor Vehicle Financial Responsibility Law 75 Pa.C.S. 91701 etseq. ["MVFRL"] contains strict requirements relating to an insured's rejection and/or limita ion of UMlUlM benefits. 18. Specifically, Section 1731 ofthe MVFRL provides: (c. I) Form ofwaiver.--Insurers shall print the rejection forms required by subsections ( ) and (c) on separate sheets in prominent type and location. The forms must be signed by t e first named insured and dated to be valid. The signatures on the forms may be witnessed by an insurance agent or broker. Any rejection form that does not specifically comply wit this section is void. If the insurer fails to produce a valid rejection form, uninsur d or underinsured coverage, or both, as the case may be, under that policy shall be equal 0 the bodily injury liability limits. On policies in which either uninsured or underinsured cov rage has been rejected, the policy renewals must contain notice in prominent type that the licy does not provide protection against damages caused by uninsured or underinsured mot . sts. Any person who executes a waiver under subsection (b) or (c) shall be precluded rom claiming liability of any person based upon inadequate information. 75 Pa.C.S. 9173l(c.l) (Emphasis added) 19. Defendants Merchants Insurance's Policy fails to complywith the strict require of the MVFRL in several key respects, including: a. the Policy's rejection/waiver forms for UMlUlM coverage and 1M stacking appear on the same page, and not on separate sheets as require by the statute; b. the Policy's rejection/waiver forms for UM/UIM coverage are on th same page as the authorization for lower limits of coverage, which is ambi uous, confusing, inherently contradictory and violative of the statute; c. the Policy requires an insured to first reject UMIUIM coverage efore selecting lower limits of UMIUIM coverage; this requireme t of simultaneous rejection/acceptance of UMIUIM coverage is ambi uous, confusing, inherently contradictory and violative of the statute; and d. the Policy's rejection/waiver forms do not follow the language and rmat requirements of Section 1731 of the MVFRL. 20. Based on the foregoing, the Policy's UMIUIM rejection/waiver forms do no meet the strict requirements of the MVFRL relating to waivers ofUMIUIM coverage or to reque ts for lower limits ofUMIUIM coverage. 21. The Policy's rejection/waiver forms are invalid as a matter oflaw. 22. The Policy's rejection/waiver forms are void as a matter oflaw. 23. Pursuant to Section 1731 of the MVFRL, the Plaintiffs' UMIUIM coverage "sh 11 be equal to the Policy's bodily injury liability limits." 24. Plaintiffs, and all other similarly situated Merchants Insurance policyholders who signed non-complying UMIUIM rejection/waiver forms, are entitled to have their Policy refo ed so that they have UMlUIM benefits equal to the Policy's Bodily Injury liability limits. 25. Representative Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel are entitl d to have their Policy reformed so that they have one million dollars in UMIUIM coverage - an aunt equal to their Policy's bodily injury liability limits. WHEREFORE, Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel respectfullyreques that this Honorable Court enter Judgment in their favor by reforming the Policy so that the UM IM coverage is equal to the bodily injury liability limits, together with costs, attorney's fees, and all ther such relief that the Court deems just and appropriate. CLASS ACTION ALLEGATIONS 26. Paragraphs 1 through 25 above are incorporated by reference as though fully set rth herein. 27. The class of Plaintiffs include all policyholders of Defendants Merchants surance who signed Rejection/Waiver ofUM/UIM coverage forms that fail to comply with the M FRL in the following key respects: a. the Policy's rejection/waiver forms for UM/UIM coverage and IUIM stacking appear on the same page, and not on separate sheets as req ired by the statute; b. the Policy's rejection/waiver forms for UMIUIM coverage are on t e same page as the authorization for lower limits of coverage, which is amb guous, confusing, inherently contradictory and violative of the statute; c. the Policy requires an insured to first reject UMIUIM coverage before selecting lower limits of UMlUIM coverage; this requirem nt of simultaneous rejection/acceptance of UM/UIM coverage is ambi uous, confusing, inherently contradictory and violative of the statute; and d. the Policy's rejection/waiver forms do not follow the language and ormat requirements of Section 173] of the MVFRL. 28. Plaintiffs aver that the total number of all class members is so numerous tha their joinder would be impractical. 29. Plaintiffs also aver that many ofthe members ofthe class are unaware of their due to their lack offamiliarity with the statutory requirements of the MVFRL that strictly gove language, format, content and ultimate validity of automobile insurance contracts. 30. The questions of law and fact raised in the present case are common to all me of the class. 31. The claims ofthe representative Plaintiffs are typical, if not identical, to the cI ims of the other class members. 32. The representative Plaintiffs, together with their undersigned counsel, will fair! and adequately represent the class, have no potential or actual conflict of interest with other membe s of the class and can acquire sufficient financial resources to ensure that the interests of the class ill not be harmed. WHEREFORE, Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel, on behalf ofth selves and the class which they represent, respectfully request that this Honorable Court grant jud ent in their favor and against the Defendants as follows: a) Reformation of the Policy so that the UMfUIM coverage limits are equ to the Policy's bodily injury liability limits; and b) Require the Defendants to pay for the counsel fees incurred in pursuing the resent action. Respectfully Submitted, TO By or . Faller, Jr., Esquir I. D. Number 49813 10 East High Street Carlisle, P A 17013 (717) 243-3341 Date: 5 \ 3\ 0'5 Attorneys for Plaintiffs VERIFICATION The foregoing Complaint is based upon information which has been gathered by my ounsel in the preparation ofthe lawsuit. The language of the document is that of counsel and not yown. I have read the document and to the extent that it is based upon information which I have iven to my counsel, it is true and correctto the best of my knowledge, information and belief. To th extent that the content of the document is that of counsel, I have relied upon counsel in maId verification. This statement and verification are made subject to the penalties of 18 Pa. C.S. Secti 4904 relating to lillswom falsification to <1uthorities, which provides that if I make knowingl false averments, I may be subject to criminal penalties. (/~,ht B<rrbara D. Leitzel F:\FlLES\DA T AFILE\GeneraIICuITent\ 7022_5 complaint ~.'"'''' \.... ,,".C'.\H" I M PERSONAL AUTO POLICY DECLARATIONS t '6'"'(o~ Merchants Insurance Company of New Hampshire, Inc. Buffalo, NY 14202 Policy Period: From 02/15/04 To 08/15/04 Date Prepared: OS/22/04 01 :11 DIRECT BILL Change E f f ec t i ve : .e41T47O-4'--"- Your Agent: 00391/W;'~- TOWN & VILLAGE AGENCY - PA PARK W. LEITZEL 3100 TREMONT ROAD P.O. BOX 218904 COLUMBUS, OH 43221 For Information, call your agent: (57) 758 - 9222 12:01 A.M. Standard Time at the address f Named Insured. Transaction Type: POL ICY CHANGE Policy Number: PAP2664949 Named Insured and Mailing Address RONALD M LEITZEL 153 N HANOVER ST CARLISLE, PA 17013 Reason For Change: FORM PP0319 IS ELIMINATED ~~~:gt~ 881 ~~y~~~F5:~gE COVERAGE IS ~AhG~ E D MA 2 62004 VEHICLE 001 LOSS PAYEE 001 !LOSS PAYEE) NAME CHANGED VEHICLE 001 LOSS PAYEE 001 LOSS PAYEE) ADDRESS CHANGED VEHICLE 001 LOSS PAYEE 002 ADDL INSUR~D) IS ELIMINATED The current status of your pol icy is as fol lows: Veh 001 002 Year Make/Model Identification No St 2004 CADI SRX 1GYDE63AX40118616 PA 2002 JEEP GR CHKOVRL 1J8GW68J92C252062 PA Terr Class Sym COST/Stat d Amt 007 885120 22 007 885820 15 Coverage is provided where a premium or I imit of I iabi I ity is shown for the co erage. COVERAGES LIMITS AND/OR DEDUCTIBLE Ful I Tort Threshold Appl ies Liabi I i ty Bodi Iy Injury P EMIUMS C. Property Damage Uninsured Motorists Bodi Iy Injury Each Person Each Accident Each Accident (Non Stacked) Each Person Each Accident 500,000 1,000,000 1,000,000 VEH 1 64.00 56.00 VEH 2 96.00 84.00 A. 15,000 30,000 8.00 8.00 Under insured Motorists (Non Stacked) Bodi Iy Injury Each Person Each Accident Fi rst Party Benefits Coverage - See Schedule Damage To Your Vehicle - Actual Cash Value Less Other Than Col I ision Co I lis i on 15,000 30,000 1.00 52.00 1.00 59.00 Deductible Shown VEH 1 VEH 2 100 DED 100 DED 500 DED 500 DED 101.00 281.00 79.00 273.00 THIS IS A SUMMARY OF THE COVERAGE PROVIDED BY YOUR POLICY FOR COLLISION DAMAGE TO RENTAL VEHICLES, NO COVERAGE IS PROVIDED BY THIS SUMMARY AND IT DOES NOT REPLACE ANY OVISIONS OF YOUR POll CY . YOU SHOULD READ YOUR POll CY AND REV I EW YOUR DECLARA T I ONS PAGE FOR COMPLETE I NFORMA T ION ON THE COVERAGE YOU ARE PROV I DED . I F THERE I S ANY CONFL I BETWEEN THE POll CY AND TH I S SlMtARY, THE PROV I S I ON OF THE POL I CY APPLY. I F YOUR POll CY PROV I DES COLL I S I ON COVERAGE FOR ANY AUTO YOU OWN, WE WILL PROV I E COLLI S I ON COVERAGE, UNDER PART D AND SUBJECT TO ALL THE PROVISIONS CONTAINED THEREIN, F A PRIVATE PASSENGER VEHICLE, PICK-UP OR VAN RENTED BY YOU OR ANY "FAMILY MEMBER", SUBJEC TO THE LOWEST DEDUCTIBLE PROVIDED ANY AUTO YOU OWN AS SHOWN IN THE DECLARATIONS PROVI ED BY THE TERMS OF YOUR POLICY. (CONT NUED) ,.<.,~ Countersigned: Authorized Representative: This policy is not valid unless countersigned by our authorized agent or representative. Page 1 Exhibit A MU 7150 (10/98) M PERSONAL AUTO POLICY DECLARATIONS -Named Insured: RONALD M LE ITZEL Policy Period: 02/15/04 to Policy Number: PAP2664949 08/15/04 ***************************** Total Per Vehicle Return Premium For This Change ?'" (96;'110_1. o~~~;oO DRIVER INFORMATION Driver(s) Name RONALD M LEITZEL BARBARA 0 LEITZEL License Number 14078649 15017099 Bi th Date 05 19/1950 08 27/1950 Garage Address Veh 001 2750 SPRINGHILL LANE ENOLA PA 17025 Garage Address Veh 002 2750 SPRINGHILL LANE ENOLA PA 17025 PREMIUM REDUCTIONS Vehicle #1 Ant i Thef t Passive Restraint Anti Lock Brakes Vehicle #2 Ant i Thef t Passive Restraint Anti Lock Brakes To al Discount 7.00 0.00 5.00 Total Discount 14.00 4.00 8.00 PENNSYLVANIA ADDED FIRST PARTY BENEFITS COVERAGE Medical Expense Benefit Work Loss Benefit Monthly/Total Funeral Expense Benefit Accidental Death Benefit 100,000 2,500 50,000 o 10,000 LOSS PAYEE - VEH 001 GMAC PO BOX 2525 HUDSON, OH 44236 FORMS AND ENDORSEMENTS: In consideration of the premium shown on this Declarations page, the numbered endorsed as of the effective date shown, subject to all the terms and condit; pol icy including forms and endorsements unless otherwise specified. Any newl endorsements are attached. po I icy is ns of the added IL0910 MSIU05 MU0775 MU0844 0702 1199 0185 0790 PENNSYLVANIA NOTICE FRAUD TIP LINE IMPORTANT NOTICE REGARDING YOUR FINANCIAL RESP INSURANCE 10 CARD - PA PENNSYLVANIA COVERAGE SELECTION FORM - TORT OPTION MU 7150 (10198) Page 2 (COnINUED) M PERSONAL AUTO POLICY DECLARATIONS Policy Period: 02/1 5/04 t Policy Number: PAP2664949 08/15/04 Named Insured: RONALD M LE I TZEL FORMS AND ENDORSEMENTS CONTINUED: MU3033 MU7040 MU7150 MU7151 MU7820 MU7838 PP0001 PP0151 PP0305 PP0309 PP0416 PP0417 PP0420 PP0421 PP0551 PP1301 1098 0790 1098 0694 0702 0601 0694 0897 0886 0486 0790 0802 0790 0802 0694 1299 POll CY COVER NOTICE TO NAMED INSUREDS DECLARATIONS QUICK REFERENCE PENNSYLVANIA SURCHARGE DISCLOSURE STATEMENT-MINH NOTICE OF PRIVACY POLICY PERSONAL AUTO POLICY AMENDMENT OF POLICY PROVISIONS - PENNSYLVANIA LOSS PAYABLE CLAUSE SPLIT LIABILITY LIMITS SPLIT UNDER INSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-S ACKED) UNDER INSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACK D) SPLIT UNINSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-STAC ED) UNINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) FIRST PARTY BENEFITS COVERAGE - PENNSYLVANIA COVERAGE FOR DAMAGE TO YOUR AUTO EXCLUSION ENDORSEMENT Any person who knowingly and with intent to injure or defraud any insurer fi I s an appl icat iOI or claim containing any false, incomplete or misleading information shal I, up n conviction, bl subject to imprisonment for up to seven years and payment of a fine up to $15 000. MU 7150 (10/98) Page 3 (LAS PAGE) M 1 PERSONAL ~TO P~L1r~&fi~tJME ~~QUEST FORM MERC TS IN 0 SH R Buffalo, NY 14202 Effective Dale of Endorsement: Date Prepared: Policy Number: PAP2664949 DIRECT BILL Named Insured and Mailing Address Your Agent: 00391/WSBC9/049 RONALD M LEITZEL TOWN & VILLAGE AGENCY - PA 153 N HANOVER ST 1580 FISHINGER ROAD CARL ISLE, PA 17013 P.O. BOX 218904 COLUMBUS, OH 43221 Policy Period: From 02/15/04 To 08/15/04 12:01 a.m. Standard Time at the Resid nee Premises. Change of Named Insured and/or Mailing Address: Change Billing To: Name Direct Bill Street City Agency Bill County State Zip Type of change code : (A)dd (C)hange, (O)elete. ( )ransfer VEHICLE DESCRIPTION/USE Chng Veh Year Make, Model & Body Type Vin/Registered State Date New/ Cost Sym Terr Type II Prehsd Used New Class Per- Mil way #Days #Wks Car Veh Parked Annual Dvr Use Dvr Use Dvr Use Seail Belts form WkjSehl Week Month Pool Use Garage Street Drvwy Miles # % II % # % Dvr/Both Airbag Anti-Theft Anti-Lock Running Acet Cred GARAGED LOCATION (If different than mailing addr ss) Dvr/Both Devices Brakes Lights HO Pol. II Chng Veh Type II GENERAL INFORMATION (Explain all "yes" responses In remarks) IF A VEHICLE IS BEING ADDEO, ANSWER QUESTIONS 1-5 YES NO IF A DRIVER IS BEING ADDED, ANSWER QUESTIONS 6-10 YES NO 1, WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES 6. ANY HOUSEHOLD MEMBER IN THE MILITARY SERVICE? (Drivel numbel') NOT SOLELY OWNED BY AND REGISTERED TO THE AF'PUCANT? 7. ANY DRIVERS LICENSE BEEN SUSPENDED/REVOKED? 2. ANY CAR MQDIFIEDfSPECIAL EQUIPMENT? {Include customized vans/pickups} 6, ANY DRIVER HAVE PHYs\CAWMEN:TAl IMPAIR.MENT? 3. ANY EXISTING DAMAGE TO VEHICLE? (1r1Clude damaged glass) 9. ANY FINANCIAL RESPONSIBILITY FILING? (Driver number and d aeofflling) 4. ANY CAR KEPT AT SCHOOL? 10. ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWE D DURING THE 5. ANY CAR PARKED ON STREET? LAST 3 YEARS? NOT APPliCABLE IN MO REMARKS INSURED'S I I DAlE (MWDDfY)') PRODUCER'S I SIGNATURE SIGNATURE MU 71521098 Page 1 of 2 VEHICLE COVERAGES Coverages Chng Veh# Chng Veh# Type Type SINGLE LIMIT L1AB (CSL) $ EA ACCIDENT . EA ACCIDENT BODILY INJURY L1AB $ EA PERSON $ EA ACCIDENT $ EA PEASON , EA ACCIDENT PROPERTY DAMAGE L1AB $ EA ACCIDENT $ DEDUCTIBLE $ EA ACCIDENT $ DEDUCTIBLE BASIC PIP/FBP $ OED $ OED ADD'L PIP/FBP $ EMS OBEl $ EMS OSEL MEDICAL PAYMENTS $ EA PERSON $ EA PERSON UNINSURED CSL/BI $ EA PEASON $ EA ACCIDENT $ EA PEASON $ fA ACCIDENT MOTORISTS PO $ EA ACCIDENT $ EA ACCIDENT UNDERINSURED CSL/BI $ EA PERSON $ EA ACCIDENT S fA PERSON $ EA ACCIDENT MOTORISTS PD $ EA ACCIDENT . EA ACCIDENT COMPREHENSIVE OED $ FULL GLASS . FULL GLASS COLLISION OED , FULL GLASS , FULL GLASS POP $ , TOWING & LABOR , , TRANS EXP/RENTAL RE , , s , $ $ DRIVER INFORMATION Chg Name Sex Mar. DOB Date STDT Good Orvr Ace Prey Llcense#/State Soc. Sec # Typ # Stat Lie >100 Stdt Train CSE Date ACCIDENT/CONVICTION - IF DRIVER ADDED (Note: Driving record is verified with the state MV Dept.) Has any driver shown above had an accident regardless of fault, DYes 0 No If yes, indicate below or been convicted of a moving violation within the last 5 years? Drv Date of Describe Accident or Conviction License Speeding Cony BII Death Amount of # Ace/Conv Susp/Rev Charged Limit Yes No Property Damage BI PO Call ADDITIONAL INTEREST: o Loss Payee o Additional Lessor o Joint Ownership o Third Party Chng Veh Name & Address Loan Number Type # REMARKS: MU 71521098 Page 2 of 2 kI PERSONAL AUTO PNOLlCY ECHANGE REQUEST FORM MERCHANTS I ~ O~ N W HAMPSHfRE Buffalo, NY 14202 Effective Date of Endorsement: 4/14/2004 Policy Number: PAP2664949 Named Insured and Mailing Address RONALD M LE I TZEL 153 N HANOVER ST CARLI SLE, PA 17013 Dale Prepared: 5/4/2004 DIRECT BILL S HIP P E 0 rAY 1 0 2004 Your Agent: 00391/WSBC9/04~ TOWN & VILLAGE AGENCY - PA 1580 FISHINGER ROAD P.O. BOX 218904 COLUMBUS, OH 43221 Policy Period: From 02/15/04 To 08/15/04 12:01 a.m. Standard Time at the Res dence Premises. Change of Named Insured andlor Mailing Address: Name State Zip Change BillIng To: Direct Bill Agency BiI Type of change co es: (A)dd (C)hange, (D)elele, (T)ransfer Street County City VEH)Cl:EbESGRIPTlotyUSE "chng Veh Year Make, Model & Body Type ( Type # "T 1 2004 lA:'adi 11 ac SRX '- 4-dr. UTL Vin/Registered State Date Newl Cost Sym Terr Prchsd Used New N 22 007 lGYDE63AX40118616 PA Class Per- form Mil way #Days # Wks Car Veh Parked WkfSchl Week Month Pool Use Garage Street ~.~~ual Dvr Use Dvr D~ IvJioes # % # _::: '///1/1 Z.. " Use I 0; rUse % 0/0 ~ J. A Sealt Belts Dvr/Both ---- ~rbag / Dvr/Both Both '-- Anti-Theft Devices Yes -.... Anti-Lock 'flunning Brakes J-ights Yes " ------ Acct Gred HO Pol. # GARAGED LOCATION (If different than mailing ad Chng Veh Type # ess) GENERAL INFORMATION (Explain all "yes" responses in remarks) IF A. VEHICLE IS BEING ADDED, ANSWER QUESTIONS 1-5 1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES NOT SOlELY OWNED BY AND REGISTERED TO THE APPLICANT? YES NO IF P. DRIVER is BEING ADDED, ANSWER QUESTIONS 6-10 6. ANY HOUSEHOLD MEMBER IN THE MILITARY SERVICE? (Dri Elf number) 7. ANY DRIVERS LICENSE BEEN SUSPENDED/REVOKED? 6, ANY DRIVER HAVE PHYSICAUMENTAL IMPAIRMENT? YES NO 2. ANY CAR MODIFIED/SPECIAL EQUIPMENT? (Include customized vansfplckups) 3. ANY EXISTING DAMAGE TO VEHICLE? (Include damaged glass) 4. ANY CAR KEPT AT SCHOOl? 5. ~AR~KEDONSTREET? I/EM~ransfer Vehicle #1 to a 2004 Cadillac SRX. Change Loss Payee for Vehi le #1 and remove Financial Services Vehicle Trust as Lessor. GMAC should be the nly Loss Payee listed on policy. Change Other Than Collision and Collision deductibles to Collision. SIGNED PA COVERAGE SELECTOR FORMS ARE ATT 9, ANY ANANCIAL RESPONSIBILITY FILING? (Driver number and ale of filing) 10. ANY COVERAGE DECLINED, CANCELLED OR NON-RENEW 0 DURING THE LAST 3 YEARS? NOT APPLICABLE IN MO INSURED'S I SIGNATURE $100.00 OTC an .,) $500.00 I DATE (MMIOOfYY) I' ..-,,-,:;, r--? " L 5/4/2004 ::;'~~~~~s --- ~'7V LV v' - ') r'v J p~"p 1 nf? MU7152109S VEHICLE COVERAGES ------~ ~' .~ Coverages ~t Veh# ~ Ch~( Veh# 2 ) ; T pe Typ SINGLE LIMIT L1AB (CSLl $ EA ACCIDENT $ EA ACCIDENT BOOIL Y INJURY L1AB $ EA PERSON . EA ACCIDENT $ EA PERSON $ EA ACCJDfNT PROPERTY DAMAGE LIAS $ / A EA 1CCIDENT $ DEDUCTIBLE $ I EA ACCIDENT $ DEDUCTIBLE BASIC PIP/FBP $~ilIV OEO $ / /l11/JL- OeD ADD'L PIPtrBP , ' ' EMB OBEL $ 7ft/' EMB OBEL MEDICAL PAYMENTS .r' fA PERSON $/ EA PERSON UNINSUREO CSL/BI $ EA PERSON $ EA ACCIDENT . EA PERSON . EA ACCIDENT MOTORISTS PD $ EA ACCIDENT $ EA ACCIDENT UNOERINSUREO CSL/BI .....- t:A P~ON . EA ACCIDENT .........."$ EAPsiSON $ EA ACCIDEm- MOTORISTS PD /' $ fA ACCID~ NT /' $ EA ACCI~ T COMPREHENSIVE o{o C $ 100.00 FULL GLASS / C $ 100.00 FULL GLASS COLLISION OEO C $ 500.00 I FULL GLASS I C . 500.00 FULL GLASS POP l . / "- $ / TOWING & LABOR '-...... $ ~ "- ..... $ ~ TRANS EXPIRENTAL RE . _.~.,. -_~(' <'. \~ b ,'.-'~};.:...'~!) '~~;':_" . . r~'\ \ ,f"V r~.li:' I, ,.y, '~J.i ',;;\1 ':",,\ 1 ,';',~.,~:_, ,,-, f; \' $ $ '0( "f" '.':''.}\ " $ , i ,i . ,'r" \t~; ""'-'\1 "-.~-w VER INFORMATION , ., '-Ic~;i ;. ~ '/ 'r'.1 ~ DRI Name 'If." - Sex Mar. 'OOB Stat '." .. ....\.. ~ Chg Typ 11 Drvr Ace Prey Train CSE Date Llcense#/State Soc. See #I ACCIDENT/CONVICTION - IF DRIVER ADDED (Note: Driving record is verified with the state MV Dept.) Has any driver shown above had an accident regardless of fault, or been convicted of a moving violation within the last 5 years? DYes o No If yes, indicate below Drv 11 Date of Acc/Conv Describe Accident or Conviction License Speeding Cony BII Death Susp/Rev Charged Limit Yes No Amount 01 Property Damage BI PO Coli v---- -~._--- I ADDITIONAL INTEREST: ~ Loss Payee ~ Chng Veh N~. ~ress .,~. [Xl Additional Lessor o Joint Ownership o Third Party Loan Number C 1 GMAC, PO Box 2525, Hudson, OH 44236 (LOSS PAYEE ONLY) n 1 Fin;mrial Services Vehicle Trust Insurance Service Center, PO Box 390902, Minneapolis, MN 55439-0902 (AODITIONAL INSURE[ - LESSOR) REMARKS: MU 71 52 1098 Page 2 of 2 ACORQ. PENNSYLVANIA AUTO SUPPLEMENT PRODUCER Park W. Leitzel R. R. #1, Box 860 Herndon, PA 17830 SUB CODE: APPL.JCANTINAMEP INSURED Ale CODE: CODE: Ronald M. Leitzel COMPANY, Merchants Ins. POLICY'"' PAP 2664949 Co. of NH, I nc. EFfEcnVE OJ 2/l5/20C 391 IMPORTANT NOTICE Insurance companies operating in the Commonwealth of Pennsylvania are requi ed by law to make available for purchase the following benefits for you, your spouse or oth r relatives or minors in your custody or in the custody of your relatives residing in your househ Id, occupants of your motor vehicle or persons struck by your motor vehicle: (1) Medical benefits, up to at least $100,000. (1.1) Extraordinary medical benefits, from $100,000 to $1,100,000, which m in increments of $100,000. Extraordinary medical benefits are those m which have exceeded the $100,000 limit of medical benefits described ab (2) Income loss benefits, up to at least $2,500 per month up to a maximum ben fit of at least $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 combination benefit, p to at least $177,500 of benefits in the aggregate or benefits payable up to three years om 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 $2,500, provided that nothing con ained in this subsection shall be construed to limit, reduce, modify or change the provislo s of section 1715(d) of Pennsylvania law relating to availability of adequate limits. (6) Uninsured, underinsured and bodily injury liability coverage up to at Ie st $100,000 because of injury to one person in anyone accident and up to at least $300, 00 because of injury to two or more persons In anyone accident or, at the option of the i surer, up to at least $300,000 in a single limit for these coverages, except for policies i sued under the Assigned Risk Plan. Also, at least $5,000 for damage to property of other in anyone accident. y be offered Ical benefits ve. Additionally, insurers may offer higher benefit levels than those enumerated abov as well as additional benefits. However, an insured may elect to purchase lower benefit level 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. If you have any questions or you do not understand all of the various options avail ble to you, contact your agent or company. not understand any of the provisions contained in this notice, contact yo r agent or If~t Date t)~ I ~C.9RD 61 PA (5/96\ First Party Benefits Coverage First Party Benefits Coverage pays you, the policyholder, and others covered by the policy in the event of Injury. regardless of who caused the accident. Medical expense benefit insurance pays your medical bills regardless of fault. This coverage is mandatory by Pennsylvania law with a required minimum of $5,000, Other optional First Party Benefits Coverages include work loss insurance, funeral benefit insurance, and accidental death. Work loss coverage provides reimbursement for lost wages due to an auto accident. The funeral benefit provides money to pay for a funeral where the death is the result of an auto accident. Accidental death pays when you or a family member dies in a car crash. These benefits may be purchased separately or as a combination of benefits. The First Party Benefits Coverage options and available limits are shown below. Please indicate the coverage(s) and Iimit(s) you want by placing an "X" in the appropriate box and then sign and date this form and give it to your agent. Basic First Party Benefits Coverage Limits Options Medical Work Loss Benefit Benefit Monthly/Maximum $ 5,000 (BASIC) None 10,000 1,000/ 5,000 25,000 1.000/15,000 50.000 1,500/25,000 '!sfgnature of Fir~ Funeral Expense Benefit ~ None 1,500 2.500 J"~l-- y> cJ Y I Date Accidental Death Benefit ~ None 5.000 X 10,000 25,000 Combination First Party Benefits Coverage Option This coverage is a combination of benefits. Do not complete this section if you have elected to purchase any of the above options. Option ~ Total Benefit Limit $ 50,000 100,000 177,500 Funeral Expense Benefit 2,500 2,500 2,500 Signature of First Named Insured Date Accidental Death Benefit 10,000 10,000 25.000 Extraordinary Medical Benefits Coverage Limits Option Extraordinary Medical Benefits Coverage is an optional coverage. It pays the medical expenses of eligible persons for accidents covered under your policy. Payments under this coverage begin only when covered medical expenses exceed $100.000 and are capped atthe lifetime limit of $1,000,000. Please "X" the appropriate box. ~ Include Extraordinary Medical Benefits Coverage of $100,000 on my policy. Include Extraordinary Medical Benefits Coverage of $300,000 on my policy. Include Extraordinary Medical Benefits Coverage of $500,000 on my policy. Include Extraordinary Medical Benefits Coverage of $1 ,000,000 on my policy. X Do not include Extraordinary Medical Benefits Coverage. The first $100,000 of medical expenses are not covered by this coverage. If you select the Extraordinary Medicai Benefits Coverage and yo First Party Medical Benefits limit is iess than $100,000 you will be responsible for the di r nee. ~: ~ ' ~ ( ate ~ ignature of First Ai""nan 1;.1 D4 1!=l/Q6\ Tort Option Selection. Notice to Named Insureds A. "Limited Tort" Option - The laws 01 the Commonwealth 01 Pennsylvania give you the right to c oose a form 01 insurance that iimits your right and the right 01 the members of your household to seek financ! I compensation for injuries caused by other drivers. Under this form of insurance, you and other household m mbers covered under this poiicy may seek recovery for all medical and other out-ai-pocket expenses, but n lor pain and suffering or other nonmonetary damages unless the injuries suffered lall within the delinition 01 "serious injury" as set forth in the policy, or unless one of the several other exceptions noted in the policy ap lies (ask your agent, broker or company for a description 01 "serious injury" and the exceptions). The annu I premium for basic coverage as required by law under this "Limited Tort" option is $ . Addit nal coverage under this option is available at additional cost. B. "Full Tort" Option - The laws of the Commonwealth of Pennsylvania also give you the right to of insurance under which you maintain an unrestricted right lor you and the members 01 your hou linancial compensation lor injuries caused by other drivers. Under this lorm 01 insurance, you members covered under this policy may seek recovery for all medical and other out-ol-pocket may also seek linancial compensation for pain and suffering and other nonmonetary damages injuries caused by other drivers. The annual premium for basic coverage as required by law under option is $ . Additional coverage under this option is available at additional cost. hoose a form ehold to seek nd household xpenses and s a result of his J'Full Tortll C. You may contact your insurance agent, broker or company to discuss the cost of other coverage. D. If you wish to choose the "Limited Tort" option described in paragraph A, you may sign this indicated below and return it. However, il you do not sign and return this notice, you will be consi chosen the "Full Tort" coverage as described in Paragraph B, and you will be charged the "Full notice where ered to have rt" premium. I WISH TO CHOOSE THE "LIMITED TORT" OPTION DESCRIBED IN PARAGRAPH A. Signature 01 First Named Insured Date E. If you wish to choose the "Full Tort" option described in paragraph B, you may sign this otice where indicated below and return it. However, il you do not sign and return this notice, you will be consid red to have chosen the "Full Tort" coverage as described in Paragraph B, and you will be charged the "Full T rt" premium. TORT" OPTION DESCRIBED IN PARAGRAPH B. ~~ Date Collision Deductible Option Pennsylvania law requires that all automobile poiicies which include collision coverage provide a $50 deductible. You have the option 01 purchasing a lower deductible, lor an additional premium charge. II you wis to carry a collision deductible lower than $500, please indicate your selection below: D $100 0 $250 Other: $ ;;::-- ~ --or Date ~ Ignature 01 First Nam d Insured (Insured wishes to have a $500.00 Collision deductible rather than the pr sent $100.00 Collision deductible. This applies to all vehicles insured under this pol icy). ACORD 61 PA(5/96} Driver Improvement Course Credit If a named insured age 55 or older has successfully completed a driver improvement course approved by Penn- DOT, a 5 percent premium credit may be applied to your policy. To receive this credit: a certificate of successful completion from an approved course must be provided; and - the course must have been completed within the last three years. Passive Restraint Discount If your vehicle is equipped with passive seatbelts or alrbags, you are entitled to a discount on the first party benefits coverage portion of your policy. Passive seatbelts are those which automatically fasten without any action by the driver or front seat passenger. Indicate all options that apply for each applicable vehicle listed below: Vehicle 1: 2004 Cadi 11 ac SRX' o Passive seatbelts [] Driver side alrbag [Xl Passenger side alrbag Vehicle 2: 2002 Jee o Passive seatbelts X Grand Cherokee Driver side alrbag Overland OJ Passenger side alrbag Vehicle 3: o Passive seatbelts o Driver side airbag o Passenger side airbag Anti-Theft Discount If you have an antHheft device In your vehicle, It may be one that qualifies for a discount on the comprehensive coverage portion of your policy. Indicate all options that apply for each applicable vehicle listed below and provide evidence of installation: Vehicle 1: 2004 Cad ill ac SRX ~ Alarm system that can be heard at least 300 feet away for at least three minutes Device that you manually set that makes the fuel, ignition or starting system inoperative X Device that automatically makes the fuel. Ignition or starting system inoperative when lhe ignition is turned off Vehicle 2: 2002 Jeep Grand Cherokee Overl and ~ Alarm system that can be heard at least 300 feet away for at least three minutes Device that you manually set that makes the fuel, Ignition or starting system Inoperative X Device that automatically makes the fuel, Ignition or starting system inoperative when the ignition is turned off Vehicle 3: B Alarm system that can be heard at least 300 feet away for at least three minutes Device lhat you manually set that makes the fuel, ignition or starting system Inoperative Device that automatically makes the fuel, ignition or starting system inoperative when lhe Ignition Is turned off Coverage Is generally described here, 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 all future policy renewals, continuations and changes unle notify you otherwise in writing. Date v- Z64/ Applicant's Signature ACORD 61 PA (5/96) .. .. REJECTION OF U:tONSURED M().TORlST PROTECTION 'A. By signin~ this waiver I am rejecting uninsured motorist coverage under th s policy for myself and fqr my relativesr~siding in my. household. Uninsured c()y~rage rQtec.t$ me ,and relatives, in. my lJousellOl(! for losses ~\lI(!,dama&,es suffered if 'i!ljqry;j:;;c U$edbythe negligence of a drivel' w/)ooOe$ll()t, haveJln "rance to pay f<>rJ()~es ,acl' oam~(\'es. I knowingly ano voluntarily rejectthis coveI:1I.1 PAP 2664949 Policy Number ~ D te REJECTION OF STA.CKED U:tONSURED COVERAGE LlMJ.TS' ;':';-;"'-'''.1 x PAP 2664949 . .. .. ..... ...." . Policy Number rst Named InsUre . . r,zz- .-." '. .-' '. .:.... -"." LOWER tIMrrs REQUEST AlJ1'HORlZATION C. -_-,.-:i::':_.-. . :.'-,,--:;-' .. If you wish to select a limit of Uninsured M<>torists Coverage lower than limit of liability for Bodily Injury, you are required to first reject the coverall' paragraph A above and then select the desir~.d limit beloW:- ' ,~ Split Limit (Per Persan/Per Accident) ur pOlicy's , by, signing Ini tial X~ 0;'+ $1$,000/ 30,000 (Basic) 20,000/ 40,000 25,000/ 50,000 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR U:tONSURED MOTORISTS COVERAGE LIMIT SELECTION WlLL BE ROCESSED ONLY IF yOU HAVE ALSO SIGNED PARAGRAPH A ABOVE. Page 7 REJEC'IiON "OF UNDERINS{ffiED MOTORIST PROTECTION A. By signing this waiver I am rejecting underinsured motorist coverage under this policy, for myself and all relatives residing in my hOUliehold. , Underinsured coverage, protects me and relatives living in my hOUliehold for losses, and damages sufteredif injury is caused by the negligence of a driver who does not V enough insurance to pay for all losses and damages. I knowingly and voluntarily reje is coverag . ~ Signature of P" st Named Insured PAP 2664949 Policy Num.ber t2 /--r6 '" dl/ I Date REJECTION OF STACKED UNDElllNSURElJ COVERAGHLlMrI'S l;l. By signing this waiver, I am rejecting stacked, limits' of underinsured' motorist' coverage under the policy for myself and members of my hoUliehold.undetl whiclHhe limits'of coverage available would be the sum of limits for each rnotorvehicle lnst.!red under the policy. Instead the. limits of coyerage that I am pl-'rchas},~g sl1~1 qe rrquO!!?i~O':~M'H!lli\s,stated in the policy. I knowmgly and voluntarIly Jeet the eRed" bhlltsof. coverage. I understand that my premium will be reduced ' I eject this 0 e ge. i< PAP 26l'i4949 , Policy Number ..: :"'. .~;< '.' ., '{i First 'Named Insured -r~)-c. .4 r Pate LOWER LIMITS REQUEST AU1'HO.R.IZATlON C. If you WiSh to select a limit of Underinsured Motorists CoVel'agelower th!j.llyour policy'S limit of liability for Bodily Injury, you are required to first reject the coverage by signing paragraph A above and then select the desired limit beloW. Initial ...1 ;Z-t ~ I wish a lower limit of Underinsured lVlotorists coverage.. than my policy's ,... ( limit of liability for Bodily Injury as follows: Split Limit (Per PersQnlPer AccicJent) $ 15,000/ 30,000 (Basic) 20,000/ 40,000 25,000/ 50,000 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR UNDERINSURED MOTORISTS COVERAGE LIMIT SELECTION WILL BE PROCESSED ONLY IF YOU HAVE ALSO SIGNED PARAGRAPH A ABOVE. Page 8 /' ----- M PERSONAL AUTO POLICY DECLARATIONS Merchants Insurance Company of New Hampshire, Inc. Buffalo, NY 14202 Policy Number: PAP2664949 Date Prepared: 01/01/04 00:08 Previous Pol icy No: PAP2664949 Your Agent: 00391/WSBC9/049 TOWN & VILLAGE AGENCY - PA PARK W. LEITZEL 3100 TREMONT ROAD P.O. BOX 218904 COLUMBUS, OH 43221 For Information, call your agent: (570 758 - 9222 DIRECT BILL "Transaction Type: RENEWAL CERT IF ICATE Named Insured and Mailing Address RONALD M LEITZEL 153 N HANOVER ST CARLISLE, PA 17013 Policy Period: From 02/15/04 To 08/15/04 12:01 A.M. Standard Time at the address f Named Insured. Veh Year 001 2001 002 2002 Make/Model BMW X5 4.41 JEEP GR CHKOVRL Identification No WBAFB33501LH20704 1J8GW68J92C252062 St Terr Class Sym COST/State Amt PA 007 885120 22 PA 007 885820 15 Coverage is provided where a premium or limit of I iabiljty is shown for the cov rage. PR MIUMS COVERAGES LIMITS AND/OR DEDUCTIBLE Fur r Tort Threshold Appl ies Liabi I i ty Bodi Iy Injury C. Property Damage Uninsured Motorists Bod! Iy Injury Each Person Each Accident Each Accident (Non Stacked) Each Person Each Accident 500,000 1,000,000 1,000,000 VEH 1 VEH 2 64.00 96.00 56.00 84.00 A. 15,000 30,000 8.00 8.00 Under insured Motorists (Non Stacked) Bodi Iy Injury Each Person Each Accident First Party Benefjts Coverage - See Schedule Damage To Your Vehicle - Actual Cash Value Less Other Than CoIl ision Coli ision 15,000 30,000 1.00 52.00 1.00 59.00 Deduc t i b I e Shown VEH 1 VEH 2 50 DED 50 DED 100 DED 100 DED 102.00 278.00 561.00 97.00 320.00 665.00 ***************************************** Total Per Vehicle Total Pol icy Premium $ 1,226.00 Garage Address Veh 001 2750 SPRINGHILL LANE ENOLA PA 17025 Garage Address Veh 002 2750 SPRINGHILL LANE ENOLA PA 17025 TH I S I S A SUMMARY OF THE COVERAGE PROV I DED BY YOUR POL I CY FOR COLL I S ION DAMAGE TO RENTAL VEH I CLES, NO COVERAGE IS PROV I DED BY TH I S StMIARY AND I T DOES NOT REPLACE ANY PRO I S I ONS OF YOUR POLICY. YOU SHOULD READ YOUR POLICY AND REVIEW YOUR DECLARATIONS PAGE F COMPLETE I NFORMA T I ON ON THE COVERAGE YOU ARE PROV I DED. I F THERE I S ANY CONFL I CT ETWEEN THE POLICY AND THIS SUMMARY, THE PROVISION OF THE POLICY APPLY. I F YOUR POll CY PROV I DES COLL I S I ON COVERAGE FOR ANY AUTO YOU OWN, WE WILL PROV I DE LLI S I ON COVERAGE, LtlDER PART D AND SUBJECT TO ALL THE PROVISIONS CONTAINED THEREIN, FOR A PRIVATE PASSENGER VEHICLE, PICK-UP OR VAN RENTED BY YOU OR ANY "FAMILY MEMBER", SUBJECT T THE LOWEST DEDUCT I BLE PROV I OED ANY AUTO YOU OWN AS SHOWN I N THE DECLARA IONS PROV I OED BY THE TERMS OF YOUR POLICY. Countersigned: Authorized Representative: This policy is not valid unless countersigned by our authorized agent or representative. Page 1 INSURED COpy MU 7150 (10/98) Exhibit ------ ...... "",' \\,,\''''\~ \... "",""'" / / I / \ / ./,,/ / / REJECTION OF UNINSURED MOTORIST PROTECTION A. By signing this waiver I am rejecting uninsured motorist coverage under his policy for myself and for my relatives residing in my household. Uninsured coverag protects me ,and r~lativesi\'l my household for, losses anq. damages suffered if injury is caused by the negligence of a driver who does not have any' 'rance to pay for losses and damages. I knowingly and voluntarily reject this covera PAP 2664949 Policy NUlT)ber ::';; .. :-':,:,/'"",--':'" -,- " ",' REJECTION OF STACKED UNINSURED COVERAGE LIMITS .. " .....- ," ,..... .... .... "".' '., .. ....".,.'...'. .......-'>.,..'. ....,....,.'...-;_.....,-........,' "..,.............:....:.,.....;:; ,".. ,,'.... ",.........- B. By signing;thi~ waiver; I am rejecting staclHld~limits' of uninsured, mot~rist c verage under t\1e ,poljcy"for myself and; memberS,' of my,houselJold under which'thelimitof:,coverage available would be the sum of limits ,for' ellch motor vehicle insured under the. p licy" :lnstead the limits of coverage, that I am purchasing shaIibe reduced to "the Jimits fated in'the policy. ,I knowingly and vOlWltarily' ,reje~t t 'stacked limits: of cov'erage.: Iiunderstlind that my premiums will be reduced if I ~eject i,' coverage. ' , ," . , x d PAP 2664949 Policy Number, LOWERLlMITS iiEQUEsTAUTHoiuZA~ON --'-', Ini tial \I.~ R"" - }. $ ,15,000/ 30,000 (Basic) "0- 20,000/ 40,000 25,000/ 50,000 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR UNINSURED MOTORISTS COVERAGE LIMIT SELECTION WILL BE ROCESSED ON'LY IF YOU HAVE ALSO SIGNED PARAGRAPH A ABOVE. Page 7 Exhibit C REJECTION OF UNDERINSURED MOTORIST PROTECTION A. By signing this waiver I am rejecting underinsured motorjst coverage under this policy for myself and all relatives residing in my household. Underinsured coverage protects me and relatives living in my household for losses and damages suffered if injury is caused by the negligenc'il of a driver who does not v enough insurance to pay for all losses and daOlag'ils. I knowingly and voluntatiIy reje is coverag . - Signature of p' st Named Insured PAP 2664949 Policy Number ""..',.....,- . ',;., . .'j'...... /?2. h b ... .rr; f Date 6. By signing thi~ waiVer,"I^ am rejbcting sta,cked, limits ofunderir\SIW'ild motoris.t' coverage under the ,po~icy ,for Olyself.and members'o,! my hOusehold under'which'the'lim.its of coverage "aVaiIabl'il' would ,be the' sum of limits' fw'each'Olotor vehicle insured' under the 'policy. Instead the limits of coverage that I ar(l,purchasing shall be redUced, to' the' limits stated 'in the' policy. I' knowingly anif vo~untariiy ,', ject' the "'~ked limits of coverage. I understand that my premium will be: reduc~d' I, eject this 0 e e. PAP 2664949 , ,'Policy Number "f~~(, -4 r Date '_;',""i c. If YQllWi~h to>select a,limit OfUl1derins4re<:! Motorists COV'ilrag'illow'ilr than your policy's limit of liability forflodiIy InjurY, you are requir'ildto first reject the coverage by signing paragraph A above and then select the desir'ild limit below. Initial ' ,/ ~~ I wish a lower limit of Underinsured Motorists Coverage, than my policy's "I . limit of liability for Bodily Injury as follows: Split Limit (Per Person/Per Accident) () c- N~ ~ '~) :r"~/ nl.= _....:; TJr:"l ;;~.~\? ~~ (.~~ 7J ,"", 'II $ 15,000/ 30,000 (Basic) cr 20,000/ 40,000 l. ~~. ~ ~i'J ~ <l (A 25,000/ 50,000 % ~ ::::-- ~ G 50,000/100,000 '0 ". 'V ), \\.. "- ~ ~ "'" 100,000/200,000 k~, ~ i "',0,"/300,000 ~'-'\ YOUR UNDERlNSURED MOTORISTS COVERAGE LIlT SELECTION PROCESSED ONLY IF YOU HAVE ALSO SIGNED PARAGR~H A ABOVE. I W -::J --; -<c {,.) f"-_, -..l '..' ~S -< NOTE: WILL BE Page 8 // / ~ Pennsylvania Middle District Version 2.4 Page 1 of2 // Civil and Miscellaneous Initial Pleadings 3:02-at-06000-UN Plaintiffv. Defendant ()s- ;),1'61 ~:v;\ U.S. District Court Middle District of Pennsylvania Notice of Electronic Filing The following transaction was received from Fontanella, Mark entered on 5/25/2005 at 4:09 PM EDT and filed on 5/25/2005 Case Name: Plaintiffv. Defendant Case Number: 3:02-at-6000 Filer: Document Number: 337 Docket Text: Notice of Removal Case Title: Ronald M. Leitzel and Barbara D. Leitzel v. Merchants Insurance Company of New Hampshire, Inc. and Merchants Insurance Group; Court Name: Cumberland County of Pennsylvania.. (Attachments: # (1) Civil Cover Sheet # (2) Exhibit(s) Plaintiffs Complaint - Exhibit A to removal# (3) Affidavit)(Fontanella, Mark) The following document(s) are associated with this transaction: Document description:Main Document Original filename:nla Electronic document Stamp: [STAMP dcecfStamp _10=1027698419 [Date=5/25/2005] [FileNumber=825519-0] [llc5dc458f89d204578614061d9dcI2f84c7023d76615562b65c0f315121a44eeb53 bd80f440a9988beOef674eOe020e83c0820fd466da36e 130df9bf53528bb]] Document description:Civil Cover Sheet Original filename:nla Electronic document Stamp: [STAMP dcecfStamp _10=1027698419 [Date=5/25/2005] [FileNumber=825519-1] [Oefdf4a6e2072076bb19534c5c55e97595cf487b3864bed4a67d302a3886dbf78766 6c3 06fbaOc62ac48e2fc2f1 f1 e6956e4d80ge2bOed867 a2d3efOf1 Oa63 3e ]] Document description:Exhibit(s) Plaintiffs Complaint - Exhibit A to removal Original filename:nla Electronic document Stamp: [STAMP dcecfStamp_ID=1027698419 [Date=5/25/2005] [FileNumber=825519-2] [a6e6286c6c4809353c30602efe2f8e85db3da3ac907376b8d94d715981dbbff0658e e4802 793 fc43b68 88089bfd05 23 3 3e54 70dac2b5 92fce8d2f115 27 5 f9aab ]] Document description:Affidavit Original filename:nla Electronic document Stamp: [STAMP dcecfStarnp _10=1027698419 [Date=5/25/2005] [FileNumber=825519-3] [93ae73b26764889bcc48dea86f76febbe8dc92b99711b0231e9c087c7e4ad0762c23 614e90f4d9dI6576ccbfd9be7aa20c66f1 dOab2f1770f76c4bd53183fb58]] https:/lecf.pamd.uscourts.gov/cgi-binlDispatch.pI79387243 795 97487 5/25/2005 Pennsylvania Middle District Version 2.4 Page 2 of2 3:02-at-6000 Notice will be electronically mailed to: 3:02-at-6000 Notice will be delivered by other means to: https://ecf.pamd.uscourts.gov/cgi-bin/Dispatch.pl?9387243 795 97 48 7 5/25/2005 JS-44 CIVIL COVER SHEET (Rev 07/89) -The J5-44 dvil cover sheet and the information contained herein neither replace nor supplement the filing and sel'\lice of pleadings or other papers as required by law, except as provided by local rules of court. this fonT\. approved by the Judldal Conference of the United Stales In September 1974, is required for the use of the Clm of Court for the purpose of Initiating the dvil docket sheet. (SEE INSTRUCTIONS ON THE REVERSE OF THE FORM.) I(a) PLAINTIFFS RONALD M. LEITZEL AND BARBARA D. LEITZEL 2750 SPRING HILL LANE ENOLA, PA 17025 DEFENDANTS MERCHANTS INSURANCE COMPANYOF NEW HAMPSHIRE, INC. and MERCHANTS INSURANCE GROUP 250 MAIN STREET BUFFALO, NY 14202 (b) COUNTY OF RESIDENCE OF FIRST LISTED PLAINTIFF Cumberland, PA (EXCEPT IN U.S. PLAINTIFF CASES) COUNTY OF RESIDENCE OF FIRST LISTED DEFENDANT ~ (EXCEPT IN U.S. PLAINTIFF CASES) NOTE: IN LAND CONDEMNATION CASES. USE THE LOCATION OF THE TRACT OF lAND INVOLVED ATTORNEYS (IF KNOWN) Mark A. Fontanella, Esquire Marshall, Dennehey, Warner, Coleman & Goggin 401 Adams Avenue, Suite 400 Scranton, P A 18510 (e) ATTORNEYS (FIRM NAME, ADDRESS, AND TELEPHONE NUMBER) George 8. Faller, Jr., Esquire 10 East High Street Carlisle, PA 17013 II. BASIS OF JURISDICTION (PLACE ANXIN ONE BOX ONLY) III. CITIZENSHIP OF PRINCIPAL PARTIES (FOR DIVERSITY CASES ONLY) o 1. U.S. Government Plaintiff 02. U.S. Government Defendant [] 3. Federal Question (U.S. Government Not a Party) ~ 4. Dlvenlty (Indicates Citizenship of Parties In Item III) Citizen of This Stat. PTl' ji( o o DEF o o o Incorporated or Principal Place of Business In This State (PLACE AN X IN ONE BOX FOR PlAINTIFF AND ONE BOX FOR DEFENDANT) PTl' o DEF o Citizen of Another State Citizen of Subject Of a Foreign Country Incorporated and Prlntlpal Place of Business In Another State o IlII Forel n Nation 0 [J IV. CAUSE OF ACTION (CITE THE U.S. CIVil STATUTE UNDER WHICH YOU ARE FiliNG AND WRlTE A BRIEF STATEMENT OF CAUSE. 00 NOT CITE JURISDICTIONAL STATUTES UNLESS DNERSITY.) 28 U.S.C. section 2201 V. NATURE OF SUIT (PLACE AN X IN ONE BOX ONLY) CONTRACT TORTS FORFEITURE 1 PENAL TV BANKRUPTCY OTHER STATUTES !! 110 IllSurance PERSONAL INJURY PERSONAL INJURY gl10AgIlCJJJlure ~ 422 Appeal 28 USC 158 ~ 400 State Reapportionment o 120 Manne o 310 Airplane o 312 Personal Injury - Med o 120 Other Food & Drug [J 423 Withdrawal 28 USC 0410 Antitrust D130MiIlerAcl 0315 Airplane Product Malpractice D 625 Drug Related Seizurl) 157 D 430 BankS and Banking o 140 Negollable Instrument tiabfflly o 385 Personal Injury- of Property 21 USC 881 D 450 CommerceIlCC Rates fete. D 150 Recovery of Overpayment & D 320 Assault, Libel & Product Liability o 630 Liquor laws D 460 Deportation Enforcement of Judgement Slander D 368 Asbestos Personal DI40R.R&Truck o 470 Racketeer lnftuenced and 0151 MedkareAct 0330 Federal E~yers' Injury Product UaMlly o ISO Airline Regs Corrupt Organizations D 152 Recover of Defaulted Student Liability D 160 Occupational Safety I o 810 Selective Servlce loallS (ExcI. Veterans) o 340 Marine Health D 850 Secunlles ( Commodilies J o 153 Recovery of Overpayment of o us Matine Product D 1'0 Other """"'noo Veteran's Benefits. liability o 875 Customer Chaflenge 12 o 110 Stockholder's Suits o 350 Motor Vehicle PERSONAL PROPERTY lABOR PROPERTY RIGHTS USC 3410 o 191) Other Contract o 355 Molor Vehlde o 370 Other Fraud o 710 Fair Labor Standards ~ ~20 Copyrights D891AgriculturalActs D 195 Contract Product liability Product liability D 371 Truth in lending Act [J 830 Patent o au Economic StabiNzallon Act [J 310 Other Personal D 380 Other Personal o 720 LaborJMgrrt. Relations o 840 Trademar1< o 893 Environmental Matln In)"", Property Damage D 730 Labor/Mgmt. Reporting SOCIAL SECURITY o 894 Energy Allocation Act D 385 Property Damage & Disclosure Act o St! Freedom of InfonnaUoo Product Liability D 740 Railway labor Act !:;:! 861 HIA (1395ff) Act D 790 Other labor litigation [J 812 Black lung (923) o 900 Appeal of Fee o 791 Emp1. Ret. Inc. Security CJ 863 OllNoorww (405(g)) DeterrrmatiOn Under Equal Ad [J 864 SS\~4~~~o~1 Access to Justice [J 885 RSI 402 o 950 Constitutionality of Slate REAL PROPERTY CIVIL RI HTS PRISONER PETITIONS FEDERAL TAX surrs StaMes o 210 land CondeflYlatlon !::!441 Voting ~ 510 Motions 10 Vacate ~ .870 Taxes (U,S. Plaintiff o 890 Other Statutory Actions o 220 Foreclosure o 442 Employment Sentence or Defendant) D 230 Rent, Lease & Ejectment o 443 Housing J Habeas Corpus: o 871 IRS - Third Party 26 D 240 Torts to Land AcconmodaUons D530General use 7609 D 245 Tor! Product liability o 444 Welfare o 535 Death Penalty D 290 All other Real Property o 440 Other QViI Rights o 540 Mandamus & Other o 550 Other VI. ORIGIN (PLACE AN X IN ONE BOX ONLY) o 1 OrigInal Proceeding xlllr2 Removed from 0 3 Remanded from ~e Court Appellate Court o 4 Reinstated or Reopened o 5 Transferred from Another District (specify) o 8 Multldlstricl litigation [] 7 Appeal to Dlsb1ct Judge from Magistrate Judament Check YES only if demanded In complaint: JURY DEMAND: 0 VES jJt NO VII. REQUESTED IN COMPLAINT: VIII. RELATED CASE(S) (S..'n""'ct,o",) IFANY DATE May 25, 2005 CHECK IF THIS IS A UNDER F.R.C.P.23 CLASS ACTION o DEMAND $-IY JUDGE NIA DOCKET NUMBER NJA UNITED STATES DISTRICT COURT ORD INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET JS-44 Authority For Civil Cover Sheet The J8-44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleadings of other papers as required by law, except as provided by local rule ofeourt. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. Consequently a civil cover sheet is submitted to the Clerk of Court for each civil complaint filed. The attorney filing a case should complete the form as follows: I. <a) Plaintiffs - Defendanu. Enter names (last, First, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, use only the full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and then the official, giving both name and title. (b) County of Residence. For each civil case filed, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at the time of filing. In U.s. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: In land condenmation cases, the county of residence of the "defendant" is the location of the tract of land involved.) (c) Attorneys. Enter firm name, address, telephone number, and attorney or record. [fthere are several attorneys, list them on an attachment, noting in this section "(see attachment)". II. Jurisdiction. The basis of jurisdiction is set forth under Rule 8(a), F.R.C.P., Which requires that jurisdictions be shown in pleadings. Place an "X" in one of the boxes. [fthere is more than one basis of jurisdiction, precedence is given in the order shown below. United States plaintiff. (1) Jurisdiction is based on 28 U.S.C. 1345 and 1348. Suits by agencies and officers of the United States are included here. United States defendant. (2) When the plaintiff is suing the United States, its officers or agencies, place an X in this box. Federal question. (3) This refers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution of the United States, an amendment to the Constitution, an act of Congress ora treaty of the United States. In cases where the U.S. is a party, the U.S. plaintiff or defendant code takes precedence, and box 1 or 2 should be marked. Diversity of citizenship. (4) This refers to suits under 28 U.S.C. 1332, where parties are citizens of different states. When Box 4 is checked, the citizenship of the different parties must be checked. (See Section III below; federal question actions take precedence over diversity cases.) III. Residence (citizenship) of Principal Parties. This section of the 15-44 is to be completed if diversity of citizenship was indicated above. Mark this section for each principal party, IV. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. V. Nature of Suit. Place an "X" in the appropriate box. If the nature of suit cannot be detennined. be sure the cause ofaetian, in Section IV above, is sufficient to enable the deputy clerk or the statistical clerks in the Administrative Office to detennine the nature of suit. If the cause fits more than one suit, select the most definitive. VI. Origin Place an "X" in one of the seven boxes. Original Proceedings. (1) Cases which originate in the United States district courts. Removed from State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.c., Section 1441. When the petition for removal is granted, check this box. Remanded from Appellate Court. (3) Check this box for cases remanded to the district court for further action. Use the date of remand as the filing date. Reinstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date. Transferred from Another District. (5) For cases transferred under Title 28 U.S.c. Section 1404(a). Do not use this for within district transfers or Multidistrict litigation transfers. Multidistrict Litigation. (6) Check this box when a Multidistrict case is transferred into the district under authority of Title 28 U.S.c. Section 1407. When this box is checked, do not check (5) above. Appeal to District Judge from Magistrate Judgment (7) Check this box for an appeal from a magistrate's decision. VII. Requested in Complaint. Class Action. Place an "X" in this box if you are filing a class action under Rule 23, F .R.Cv.P. Demand. In this space, enter the dollar amount (in thousands of dollars) being demanded or indicate other demand such as a preliminary injunction. Jury Demand. Check the appropriate box to indicate whether or not a jury triaJ is being demanded. VIII. Related Cases. This section of the 1544 is used to reference relating pending cases if any. lfthere are related pending cases, insert the docket numbers and the corresponding judge names for such cases. Date and Attorney Signature. Date and sign the civil cover sheet. (rev, 7/89) GPO: 1989-237-312 MARSHALL,DENNEHEY, WARNER COLEMAN & GOGGIN By: Mark A. Fontanella, Esquire Identification Numbers: 84248 401 Adams Avenue, Suite 400 Scranton, PA 18510 (570) 496-4613 Attorney for Defendants, Merchants Insurance Company UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYL VANIA RONALD M. LEITZEL and BARBARA D. LEITZEL, his Wife, on behalf of Themselves and All Persons, Organizations and Entities Similarly Situated, 2750 Spring Hill Lane Enola, P A 17025, Plaintiffs Removed from the Court of Cumberland County, Pennsylvania No. 05-2287 . . CLASS ACTION Civil Action - Law v. MERCHANTS INSURANCE COMPANY OF NEW HAMPSHIRE, INC. and MERCHANTS INSURANCE GROUP, 250 Main Street Buffalo, NY 14202 JURY TRIAL DEMANDED Defendant NOTICE OF REMOVAL TO THE HONORABLE JUDGES OF THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA: Removing party, Defendant, Merchants Insurance Company of New Hampshire, Inc. and Merchants Insurance Group, ("Removing party"), by and 1 through its attorneys, Marshall, Dennehey, Warner, Coleman & Goggin, hereby removes the above-captioned case to this Honorable Court and provides notice of same to Plaintiff s counsel. In support of the removal, Removing party avers as follows: 1. On or about May 3, 2005, Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel, his wife, commenced a civil action by filing a Complaint in the Court of Common Pleas of Cumberland County, Pennsylvania, Civil No. 05-22287 against Removing Defendants. A copy of Plaintiff's Complaint is attached as Exhibit "A." 2. Upon information and belief, Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel are adult individuals that reside at 2750 Spring Hill Lane, Enola, PA 17025. 3. Removing Defendant Merchants Insurance Company of New Hampshire, Inc. and Merchants Insurance Group has its principle place of business located at 250 Main Street, Buffalo, New York and is not otherwise incorporated in the Commonwealth of Pennsylvania. 4. Removing Defendants first received a copy of the Complaint on or about May 6,2005, as Plaintiff's counsel forwarded a copy of the complaint to Merchants' counsel, the undersigned. 5. This Notice of Removal has been filed within thirty (30) days after receipt by the Removing Defendants of the Complaint in accordance with 28 U.S.C. ~ 1446 (b). 2 6. Removing Defendants allege that the value of this matter in controversy exceeds seventy five thousand ($75,000.00), as Plaintiffs seek to reform the applicable insurance policy limits from $15,000 to $1,000,000.00 and plaintiffs further allege a class action claiming all Merchant reduction ofUMIUIM forms are invalid. 7. The above described civil action is one in which this Honorable Court has jurisdiction pursuant to Title 28 U.S. Code S 1332 based upon the fact that there exists diversity of citizenship between the parties and the amount in controversy exceeds the jurisdictional minimum of $75,000 and is, accordingly, one which may be removed to this Honorable Court by Notice pursuant to Title 28 U.S. Code S l441(d). 8. Written notice of the filing of this Notice of Removal has been given to all the parties in accordance with 28 U.S. Code S 1446(d) as noted in the Certificate of Service attached hereto. 9. Promptly after filing with this Court and with the assignment of a civil action number, a Notice of this removal will be filed with the Court of Common Pleas of Cumberland, Pennsylvania in accordance with 28 U.S.C. S 1446(d). 10. Attached hereto as Exhibit "A" is a copy of all the relevant pleadings with regard to the Leitzel v. Merchants Insurance Companv. Court of Common Pleas Cumberland County, Pennsylvania, civil action no., 05-2287. 3 WHEREFORE, the Removing Defendants request that the above action now pending in the Court of Common Pleas for Cumberland County be removed to this Honorable Court. Respectfully submitted, MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN By: ~.1'i. ?~.,eUa. &~ Mark A. Fontanella (pA I.D. No.: 84248) 401 Adams Avenue, Ste. 400 Scranton, P A 18510 (570) 496-4602 Attorneys for Merchants Insurance Co. of New Hampshire, Inc. and Merchants Insurance Group 4 . > F:\FlLES\DATAFILE\Gefleflll\Cum:nt\1022-5.complainllajt Created: 9120104 0:06PM Revised: 4126105 4:22PM 7022.5 , \" i George B. Faller, Jr., Esquire MARTSON DEARDORFF WILLIAMS & OTTO I.D. 49813 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiffs RONALD M. LEITZEL AND BARBARA D. LEITZEL, his wife, on Behalf of Themselves and All Persons, Organizations and Entities Similarly Situated, 2750 Spring Hill Lane Enola, P A 17025, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs, NO. 1),5 -,),).,5-'7 CIVIL ACTION ~~.; '1. ~ -c~ :: ~ (1"! r~' ;po n1:n ;; .-. -< r- . ~: lOrn / I co,? ~.~.~ - (:, ~~~,;': ; ~~ .:,,- en p,~.; 'I} ~ -'" 1:"" ::~~ r"'...) '":0 -< -.J :-<: CLASS ACTION v. MERCHANTS INSURANCE COMPANY OF NEW HAMPSHIRE, INC. AND MERCHANTS INSURANCE GROUP, 250 Main Street Buffalo, NY 14202, " Defendants. JURY TRIAL DEMANDED 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 may be 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 Plaintiffs. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LA WYERAT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELlGffiLE PERSONS AT A REDUCE FEE OR NO FEE: Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone (717) 249-3166 .l~~".;~'" .. '"'' ;'''' , , George B. Faller, Jr., Esquire MARTSON DEARDORFF WilLIAMS & OTTO I.D. 49813 10 East High Street Carlisle, P A 17013 (717) 243-3341 Attorneys for Plaintiffs RONALD M. LEITZEL AND BARBARA D. LEITZEL, his wife, on Behalf of Themselves and All Persons, Organizations and Entities Similarly Situated, 2750 Spring Hill Lane Eno1a, P A 17025, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs, NO. CNIL ACTION - EQUITY v. CLASS ACTION MERCHANTS INSURANCE COMPANY OF NEW HAMPSHIRE, INe. AND MERCHANTS INSURANCE GROUP, 250 Main Street Buffalo, NY 14202, Defendants. JURY TRIAL DEMANDED COMPLAINT AND NOW, come the Plaintiffs, Ronald M. Leitzel and Barbara A. Leitzel, his wife, and all other persons and entities similarly situated, by their attorneys, MARTS ON DEARDORFF WILLIAMS & OTTO, and aver as follows: I. PARTIES 1. The Plaintiffs, Ronald M. Leitzel and Barbara D. Leitzel, husband and wife, are adult individuals residing at 2750 Spring Hill Lane, Eno1a, Cumberland County, Pennsylvania, 17013. 2. The Defendants, Merchants Insurance Company of New Hampshire, Inc. and Merchants Insurance Group ["Merchants Insurance"], are insurance companies licensed to transact business throughout the United States, with a principal business address of250 Main Street, Buffalo, New York, 14202. " ll.FACTUALBACKGROUND 3. The Defendants, Merchants Insurance, are in the business of selling property and casualty insurance coverage to businesses and individuals throughout the northeastern, mid-atlantic and midwestern United States. 4. The Plaintiffs are the named insureds under a Personal Auto Insurance Policy, with Policy number PAP 2664949 ["the Policy"] issued by Merchants Insurance. A copy of the Policy is attached as Exhibit "A." 5. On June 29, 2004, Plaintiff Barbara D. Leitzel was involved in an automobile accident in which she suffered serious and permanent bodily injuries. 6. At the time of the accident, Plaintiff Barbara Leitzel was covered under the Merchants Insurance Policy. 7. The Policy has Bodily Injury liability limits of one million (1,000,000.00) dollars. A Copy of the Policy Declaration Page is attached as Exhibit "B." 8. On April 26, 2004, Plaintiff Ronald M. Leitzel executed and signed a Supplement to the Policy. 9. The Supplement contained, inter alia, provisions for 1) the Rejection of UninsuredlUnderinsured Motorist Protection ["UM!UIM"]; 2) the Rejection of Stacked UM/UIM Coverage Limits; 3) a Lower Limits Request Authorization. 10. Each of the three provisions - Rejection ofUM/UIM Coverage, Rejection of Stacked UM/UIM Coverage and Authorization of Lower Limits ofUMIUIM coverage - were contained on the same page. See Exhibit "C." 11. Additionally, the Policy explicitly required Plaintiff Ronald Leitzel to first reject all UM/UIM coverage before being able to select lower limits ofUMIUIM coverage. See Exhibit "C." 12. Plaintiff Ronald Leitzel signed the provisions rejecting UMIUlM Motorist Coverage and rejecting Stacking ofUM!UIM Motorist Coverage. 13. Plaintiff Ronald Leitzel also initialed the provision selecting Lower Limits of UM/UIM Coverage. Mr. Leitzel selected UMIUIM limits of fifteen thousand (15,000.00) dollars per person and thirty thousand dollars (30,000.00) per accident. The Policy identified this selection as "Basic" coverage. " 14. Defendants Merchants Insurance have taken the position thatthe Plaintiffs are limited to fifteen thousand dolJars (15,000.00) in UMIU1M benefits. 15. Plaintiffs aver that they, and aIJ other similarly situated Merchants Insurance policyholders, are entitled to receive UWU1M benefits equal to the Policy's Bodily Injury liability limits due to the Policy's failure to comply with the requirements of Pennsylvania' s Motor Vehicle Financial Responsibility Law relating to the rejection and/or limitation ofUMlUlM coverage. COUNTI: REFORMATION 16. The aIJegations contained in paragraphs I through 15 above are incorporated by reference as though fuIJy set forth herein. 17. Pennsylvania's Motor Vehicle Financial Responsibility Law 75 Pa.C.S. ~1701 et seq. ["MVFRL"] contains strict requirements relating to an insured's rejection and/or limitation of UMIU1M benefits. 18. SpecificaIJy, Section 1731 of the MVFRL provides: (c.!) Form ofwaiver.--Insurers shaIJ print the rejection forms required by subsections (b) and (c) on separate sheets in prominent type and location. The forms must be signed by the first named insured and dated to be valid. The signatures on the forms may be witnessed by an insurance agent or broker. Any rejection form that does not specifically comply with this section is void. If the insurer fails to produce a valid rejection form, uninsured or underinsured coverage, or both, as the case may be, under that policy shall be equal to the bodily injury liability limits. On policies in which either uninsured orunderinsured coverage has been rejected, the policy renewals must contain notice in prominent type that the policy does not provide protection against damages caused by uninsured or underinsured motorists. Any person who executes a waiver under subsection (b) or (c) shaIJ be precluded from claiming liability of any person based upon inadequate information. 75 Pa.C.S. ~173!(c.!) (Emphasis added) 19. Defendants Merchants Insurance's Policy fails to comply with the strict requirements of the MVFRL in several key respects, including: a. the Policy's rejection/waiver forms for UMIUlM coverage and UMIUIM stacking appear on the same page, and not on separate sheets as required by the statute; '. b. the Policy's rejection/waiver forms for UM/UIM coverage are on the same page as the authorization for lower limits of coverage, which is ambiguous, confusing, inherently contradictory and violative of the statute; c. the Policy requires an insured to first reject UM/UIM coverage before selecting lower limits of UMIUlM coverage; this requirement of simultaneous rejection/acceptance of UM/UIM coverage is ambiguous, confusing, inherently contradictory and violative of the statute; and d. the Policy's rejection/waiver forms do not follow the language and format requirements of Section 1731 of the MVFRL. 20. Based on the foregoing, the Policy's UMIUlM rejection/waiver forms do not meet the strict requirements of the MVFRL relating to waivers ofUMlUlM coverage or to requests for lower limits ofUMlUlM coverage. 21. The Policy's rejection/waiver forms are invalid as a matter of law. 22. The Policy's rejection/waiver forms are void as a matter oflaw. 23. Pursuant to Section 1731 ofthe MVFRL, the Plaintiffs' UMIUIM coverage "shall be equal to the Policy's bodily injury liability limits." 24. Plaintiffs, and all other similarly situated Merchants Insurance policyholders who signed non-complying UMIUlM rejection/waiver forms, are entitled to have their Policy reformed so that they have UMIUlM benefits equal to the Policy's Bodily Injury liability limits. 25. Representative Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel are entitled to have their Policy reformed so that they have one million dollars in UMIUIM coverage - an amount equal to their Policy's bodily injury liability limits. WHEREFORE, Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel respectfully request that thi~ Honorable Court enter Judgment in their favor by reforming the Policy so that the UMIUIM coverage is equal to the bodily injury liability limits, together with costs, attorney's fees, and all other such relief that the Court deems just and appropriate. CLASS ACTION ALLEGATIONS 26. Paragraphs 1 through 25 above are incorporated byreference as though fully set forth herein. 27. The class of Plaintiffs include all policyholders of Defendants Merchants Insurance who signed Rejection/Waiver ofUMIUIM coverage forms that fail to comply with the MVFRL in the following key respects: a. the Policy's rejection/waiver forms for UMIUIM coverage and UM/UIM stacking appear on the same page, and not on separate sheets as required by the statute; b. the Policy's rejection/waiver forms for UMIUIM coverage are on the same page as the authorization for lower limits of coverage, which is ambiguous, confusing, inherently contradictory and violative of the statute; c. the Policy requires an insured to first reject UM/UIM coverage before selecting lower limits of UM/UIM coverage; this requirement of simultaneous rejection/acceptance of UM/UIM coverage is ambiguous, confusing, inherently contradictory and violative of the statute; and d. the Policy's rejection/waiver forms do not follow the language and format requirements of Section 1731 of the MVFRL. 28. Plaintiffs aver that the total number of all class members is so numerous that their joinder would be impractical. 29. Plaintiffs also aver that many of the members of the class are unaware oftheir rights due to their lack of familiarity with the statutory requirements of the MVFRL that strictly govern the language, format, content and ultimate validity of automobile insurance contracts. 30. The questions of law and fact raised in the present case are common to all members of the class. 31. The claims of the representative Plaintiffs are typical, if not identical, to the claims of the Qther class members. 32. The representative Plaintiffs, together with their undersigned counsel, will fairly and adequately represent the class, have no potential or actual conflict of interest with other members of the class and can acquire sufficient financial resources to ensure that the interests of the class will not be harmed. WHEREFORE, Plaintiffs Ronald M. Leitzel and Barbara D. Leitzel, on behalf of themselves and the class which they represent, respectfully request that this Honorable Court grant judgment in their favor and against the Defendants as follows: a) Reformation of the Policy so that the UMIUlM coverage limits are equal to the Policy's bodily injury liability limits; and b) Require the Defendants to pay for the counsel fees incurred in pursuing the present action. Respectfully Submitted, By or . Faller, Jr., Esquir I. D. Number 49813 10 East High Street Carlisle, P A 17013 (717) 243-3341 Date: 5\3\ 05 Attorneys for Plaintiffs VERIFICATION The foregoing Complaint is based upon infonnation which has been gathered by my counsel in the preparation of the lawsuit. The language of the document is that of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to my counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the document is that of counsel, I have relied upon counsel in making this verification. This statement and verification are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to 'illsworn falsification to authorities, which provides that if I make knowingly false averments, I may be subject to criminal ~. Q f'\ r,. . (l, , RonaldM~ --._" I h1.. Bilrbara D. Leitzel P:\FILES\DA T AFILE\Gener'afICuJTt\7022-S,comp\ainl M' : . , ' . PERSONAL AUTO POLICY DECLARATIONS \ % L{o~ Merchants Insurance CQmp~ny of New Hampshire, Inc. , Buffalo, NY 14202 Transaction Type: POll CY CHANGE Date Prepared: OS/22/04 01: 11 DIRECT B I L Change Effective: _ ~~ Your Agent: 00391/WSBC9/04 TOWN & VILLAGE AGENCY - PA PARK W. LEITZEL 3100 TREMONT ROAD P.O. BOX 218904 COLUMBUS. OH 43221 For Information, call your agent: (570) 758 - 9222 02/15/04 To 08/15/04> 12:01 A.M. Standard Time at the address of Named Insur FORM PP0319 IS ELIMINATED ~~Igt~ gg~ - ~~y=F5~~ COVERAGE IS 6.JGJb E D M/1.Y 2 62004 VEHICLE 001 LOSS PAYEE 001 {LOSS PAYEE~NAME CHANGED VEH ICLE 001 LOSS PAYEE 001 LOSS PAYEE ADDRESS CHANGED VEHICLE 001 LOSS PAYEE 002 ADDL INSUR ) IS ELIMINATED Policy Number: PAP2664949 Named Insured and Mailing Address RONALD M LEITZEL 1 53 N HANOVER ST CARLISLE, PA 17013 Policy Period: From Reason For Change: The current status of your policy is as fol laws: Veh Year Make/Model Identification No St Terr Class Sym COST/Stated Amt 001 2004 CADI SRX 1GYDE63AX40118616 PA 007 885120 22 002 2002 JEEP GR CHKOVRL 1J8GW68J92C252062 PA 007 885820 15 coverage Is provided where a premium or limit of I labl I Ity Is shown for the coverage. COVERAGES LIMITS AND/OR DEDUCTIBLE PREMIUMS Ful I Tort Threshold Applies A. Llablll ty Bodily Injury Property Damage Uninsured Motorists Bodily Injury Each Person Each Accident Each Accident (Non stacked) Each Person Each Accident Underlnsured Motorists (Non Stacked) Bodily Injury Each Person Each Accident -: -. 500,000 1,000,000 1,000,000 15,000 30,000 VEH 1 VEH 2 64.00 96.00 56.00 84.00 8.00 8.00 C. 15,000 30,000 1.00 1.00 First Party Benefits Coverage - See Schedule 52.00 59.00 Damage To Your Vehicle - Actual Cash Value Les.s"DedtlCiiblecShown VEH 1 VEH 2 Ot he r Than Co I I I s I on 100 OED 100 OED 101 .00 79 .00 Co III s I on 500 OED 500 DED 281.00 273.00 THIS IS A SlIIMARY OF THE COVERAGE PROVIDED BY YOUR POLICY FOR COLLISION DAMAGE TO RENTAL VEH I CLES, NO COVERAGE IS PROV I OED BY TH IS SUMMARY AND I T DOES NOT REPLACE ANY PROV IS I ONS OF YOUR POLICY. YOU SHOULD READ YOUR POLICY AND REVIEW YOUR DECLARA.T\ONS PAGE FOR COMPLETE I NFORMA T ION ON THE COVERAGE YOU ARE PROV I OED. I F THERE I S ANY CONFL I CT BETWEEN THE POL I CY AND TH I S SUMMARY, THE PROV I S I ON OF, THE POL I CY APPLY. IF YOUR POLICY PROVIDES COLLISION COVERAGE FOR ANY AUTO YOU OWN, WE WILL PROVIDE COLLISION COVERAGE, UIDER PART D AND su:lJECT TO ALL THE PROVISIONS CONTAINED THEREIN, FOR A PRIVATE PASSENGER vetICLE, PICK-UP OR VAN RENTED BY YOU OR ANY "FAMILY MEMBER", SUBJECT TO THE LOWEST DEDUCTIBLE PROVIDED ANY AUTO YOU OWN AS SHOWN IN THE DECl.ARA~IONS PROVIDED BY THE TERMS OF YOUl POLICY. Countersigned: Authorized Representative: '.V '21/. K~ This policy is not valid unless countersigned by our authorized agent or representative. ,/' \AU 7150(10/98) Page 1 Exhibit A (COOT INUED) ~/ .s::: M , PERSONAL AUTO POLICY DECLARATIONS Named Insured: RONALD M LE 1 TZEL PolicyPeri9d: 02/15/04 to Policy Number: PAP2664949 08/15/04 ****************.******...*** Total Per Vehicle Return Premium For This Change ;>- ...0.0__." 600 . 00 "-'- $ 31.00- <:: DRIVER INFORMATION Dr iver(s) Name RONALD M LEITZEL BARBARA 0 LE I TZEL Li cense Numbe r 14078649 15017099 BI rth Date 05/19/1950 08/27/1950 Garage Address - Veh 001 - '2750 SPRIN~ILL LANE ENOLA PA 17025 Garage Address - Veh 002 - 2750 SPRIN~ILL LANE ENOLA PA 17025 PREM IW REDUCT I ONS Veh I c I e #1 Ant I Thef t Passive Restraint Ant I Lock Brakes Vehicle #2 Ant I Theft Passive Restraint Anti Lock Brakes Total Discount 17.00 20.00 5.00 Total Discount 14.00 24.00 8.00 PENNSYLVANIA ADDED FIRST PARTY BENEFITS COVERAGE Mad Ica 1 Expense Benef I t Work Loss Benefit Monthly/Total Funeral Expense Benefit Accidental Death Benefit LOSS PAYEE - VEH 001 GMAC PO BOX 2525 HlDSON, OH 44236 FORMS AND ENDORSEMENTS: 100,000 - 2,500 50,000 o 10,000 In consideration of the premium shown on this Declarations page, the numbered pol Icy Is endorsed as of the effective date shown, subject to al I the terms and conditions of the pol Icy Including forms and endorsements unless otherwise specified. Any newly added endorsements are attached. IL0910 MSIU05 MU0775 MU0844 0702 1199 0185 0790 PENNSYLVANIA NOTICE FRAUD TIP LINE IMPORTANT NOTICE REGARDING YOUR FINANCIAL RESP INSURANCE 10 CARD - PA PENNSYLVANIA COVERAGE SELECTION FORM - TORT OPTION MU 7150 (10/98) Page 2 (CONTINUED) M Named Insured: PERSONAL AUTO POLICY DECLARATIONS RONALD M LE I TZEL Policy Period: 02/1 5/04 Policy Number: PAP2664949 to 08/15/04 - FORMS AND ENDORSEMENTS CONTINUED: MU3033 MU7040 MU7150 MU7151 MU7820 MU7838 PP0001 PP0151 PP0305 PP0309 PP0416 PP0417 PP0420 PP0421 PP0551 PP1301 1098 0790 1098 0694 0702 0601 0694 0897 0886 0486 0790 0802 0790 0802 0694 1299 POll CY COVER NOTICE TO NAMED INSUREDS DECLARA T IONS QUICK REFERENCE PENNSYLVANIA S~CHARGE DISCLOS~E STATEMENT-MINH NOTICE OF PRIVACY POLICY PERSONAL AUTO POLICY AMENDMENT OF POLICY PROVISIONS - PENNSYLVANIA LOSS PAYABLE CLAUSE SPLIT LIABILITY LIMITS SPLIT lJIlDERINSURED MOTORISTS LIMITS - PENNSYLVANIA (NON-STACKED) lNlERINSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) SPLIT lJIllNSURED MOTORISTS LIMITS. PENNSYLVANIA (NON-STACKED) lJIllNSURED MOTORISTS COVERAGE - PENNSYLVANIA (NON-STACKED) FIRST PARTY BENEFITS COVERAGE - PENNSYLVANIA COVERAGE FOR DAMAGE TO YOUR AUTO EXCLUS ION ENDORSEMENT Any person who knowingly and with intent to InjUre or defraud any insurer files an appllca or claim containing any false, Incomplete or m sleadlng information shal I, upon conviction subject to imprisonment for up to seven years and payment of a fine up to $15,000. MU 7150 (10(9B) Page 3 (LAST PAGE) M.. :"1 PERSO~~~lP rN~LJ~\~~M!R ~~QUEST FORM Buffalo, NY 14202 Effective Date of Endorsement: Policy Number: PAP2664949 Named Insured and Mailing Address RONALD M LE ITZEL 153 N HANOVER ST CARLISLE, PA 17013 Date Prepared: DIRECT BILL Your Agent: 00391/WSBC9/049 TOWN & V I LLAGE AGENCY - P A 1580 FISHINGER ROAD P.O. BOX 218904 COLUMBUS, OH 43221 Policy Period: From 02/15/04 To 08/15/04 12:01 a.m. Standard Time at tile Residence Premises. Change of Named Insured and/or Mailing Address: Name Street City County State Change Billing To: Direct Bill Agency Bill Type of change codes: (A)dd (C)hange, (D)elete, (T)ransfer Zip VEHICLE DESCRIPTION/USE Chng Veh Year Make, Model & Body Type Vin/Registered State Date Newt Cost Sym Ten Type it Prchsd Used New Class Per- Mil way itDays itWks Car Veh Parked Annual Dvr Use Dvr Use Dvr Use SeaH Belts form WkfSchl Week Month Pool Use Garage IStreet Drvwy Miles it % it % it % DvrtBoth Alrbag Anti-Theft Anti-Lock Running Acct Cred GARAGED LOCATION (If different than mailing address) Dvr/Both Devices Brakes Ughts HO Pol. it Chng Veh Type it GENERAL INFORMATION (Explain all "yes" responses In remarks) IF A VEHICLE IS BElNQ ADDED, ANSWER QUESTIONS 1-5 YES NO IF A DRrvER IS BElNQ ADDED, ANSWER OOESTIONS 8-10 YES HI 1. WITH THE EXCEPT10N OF ANY ENCUMBRANCES, ARE ANY VEHICLES 6. Nt( HOUSEHOlD MEMBER IN THE MIUTARY SERVICE? (DrIver nun'lbet) NOT SOLELY OWNED BY AND REGISTERED TO "mE APPUCANT? 7. ANy DRIVERS lICENSE BEEN SUSPENDEDlREVOKED? 2. ANY CAR MODIFlED/SPECIAL eCOIPMENT? (lncfude customlzed vans/pickupS) 8. ANY DRIVER HAVE PHVSlCAl/MENTAlIMPAIAMENT? 3. ANY EXlS11NG DAMAGE TO VEHICLE? (Include damaged glass) 9. ANY ANANCIAL RESPONSIBIUTY FlUNG? (Driver number and date offUlng) ~. ANY CAR KEPT AT SCHOOL? 10, ANY COVERAGE OECUNED. CANCELLED OR NON-AENEWED OUAJNQ THE LAST 3 YEARS? NOT APPUCABLE IN MO 5. ANY OM PARKED ON STREET? REMARKS INSURED'S SIGNATURE DATE (MMJDll/VY) MU71521098 Page 1 of 2 .VEHICLE COVERAGES , . Coverages Chng Vehll Chng Vehll Type Type - SINGLE LIMIT L1AB (CSL) $ EA ACCIDENT $ EA ACCtD~NT BODILY INJURY L1AB $ EA PERSON $ EA ACCIDENT $ EAPERSQN $ . EA ACClOEt PROPERTY DAMAGE L1AB $ EA ACCIDENT $ DEDUCTIBLE $ EA ACCIDENT $ DEDUCTISlI BASIC PIP/FBP $ OED $ OED ADD'L PIP/FBP $ EMB OBEl $ EMB OBEL MEDICAL PAYMENTS $ EA PERSON $ EA PERSON UNINSURED CSL/BI $ EA PERSON $ EA ACCIDENT $ EA PERSON $ EA Aoooe... MOTORISTS PD $ EA ACCIDENT $ EA ACCIDENT . UNDERINSURED CSL/BI , EA PERSON $ EA ACCIDENT $ EA PERSON $ EA ACClDEl'i MOTORISTS PO . EA ACCIOENT , EA ACCIDENT COMPREHENSIVE DED $ FULL GLASS $ FULL GlASS COLLISION DED . FULL GLASS $ FULL GLASS POP . . TOWING & LABOR $ $ TRANS EXP/RENTAL RE . $ $ $ $ . DRIVER INFORMATION Chg Name Sex Mar. DOB Dete STDT Good Drvr Ace Prey L1eense#/Stete Soc. See /I Typ II Stet Lie >100 Stdt Train CSE Date - ACCIDENT/CONVICTION - IF DRIVER ADDED (Note: Driving record is verified with the state MV Dept.) Has any driver shown above had an accident regardless of fault, o Yes I 0 No If yes, indicate below or been convicted of a moving violation within the last 5 years? Drv Date of Describe Accident or Conviction License Speeding Cony BI / Desth Amount of II Ace/Cony Suep/Rey Charged Limit Yes No Property Damage BI PO Coli "DDITIONAL INTEREST: o Loss Payee o Additional Lessor o Joint Ownership o Third Party Chng Veh Name Be Addraas Loan Num ber Type II 'IEMARKS: MU 71521098 Page 2 of 2 PERSO~cfl'.Mt~ rN~LJFt8.fi~~~ ~~QUEST FORM Buffalo. NY 14202 Effective Date of Endorsement: 4/14/2004 Policy Number: PAP2664949 ,Named Insured and Mailing Address RONALD M LEITZEL 153 N HANOVER ST cCARLISLE. PA 17013 bate Prepared: 5/4/2004' DIRECT BILL SHIPPED MAY 1 0 Z004 Your Agent: 00391/WSBC9/049 TOWN & VILLAGE AGENCY - PA 1580 FISHINGER ROAD P.O. BOX 218904 COLUMBUS, OH 43221 Policy Period: From 02/15/04 To 08/15/04 12:01 a.m. Standard Time at the Residence Premises. 'Change of Named Insured snd/or Mailing Address: Change Billing To: Name Direct Bill Street , City Agency Bill County State Zip Type of change codes: (A)dd (C)hange, (D)elete,(T)ransfer VEt!JCl:E15ESCRIPT~USE ,chng Veh Year Make, Model & Body Type Vin/Registered State Date New/ Cost Sym T. Type # Prphsd Used New T 1 2004 ,.cadi 11 ac SRX lGYDEo3AX40118016 PA N 22 O( --- 4-dr. UTL Class Per- Mil way #Days #Wks Car Veh Parked Annual Dvr Use Dvr Use Dvr Use Sealt Be form WktSchl Week Month Pool Use Garage IStreet D~ I~es # % # % # % DvrIBo , .~ ~.A/M Z 1# J - -- /~:rg Anti-Theft Anti-lock ~~nning Acet Cred GARAGED LOCATION (If different than mailing address) Dvr/Both Devices Brakes Ights HO Pol. # Chng Veh Both Yes Yes ./ Type # r--.... ---- GENERAL INFORMATION (Explain all "yes" responses In remarks) IF A VEHICLE IS BEING ADDED, ANSWER QUESTJONB.1..fJ '" WITH 1HE EXCEPTION OF AWl ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY DINNED BY AND REGISTERED TO THE APPLICANT? YES NO .IF A DRNER IS BEING ADDED, ANSWER, QUESTIONS 6-10 YEa 8. ANY HOUSEHOLD MEMBER IN THE MIUTARY SERVtCE? (Ortver numb<<) 7. ANY DRIVERS LICENSE BEEN SUSPENDEDlREVOKED? B. ANV ORrveR HAVE PHYSlCAllMENTAllMPAIRMENT? 9. ANY RNANClAl RESPONS1BlUTY RUNG? (Orlver number and data oftlng) 10. ANY COVERAGE DEClINED, CANCEUED OR NON-RENEWEO DURING THE lAST 3 YEARS? NOT APPLICABLE IN MO 2. ANY CAR MOOIAEDlSPECIAL EOUIPMENT? (InoIude customized vans/ptckups) 3. ANY EXISTING DAMAGE TO VEHiClE? (Inctude damaged gtass) 4. ANY CAR KEPT AT SCHOOl? KED ON STREET? ransfer Vehicle #1 to a 2004 Cadillac SRX. Change Loss Payee for Vehicle #1 and remove Financial Services Vehicle Trust as Lessor. GMAC should be the only Loss Payee listed on policy. Change Other Than Collision and Collision deductibles to $100.00 OTC and $500.00 Collision. SIGNED PA COVERAGE SELECTOR FORMS ARE ATT INSURED'S SION^1'URE DATE (MMJOD/YV) 5/4/2004 t\Alt 711;? 1r\OR VEHICLE COVERAGES ~_-:.... Coverages ~ Veh /I 1/ SING\.E LiMIT L1AB (CSL) BODILY INJURY L1AB PROPERTY DAMAGE L1AB BASIC PIP/FBP ADD'L PIP/FBP MEDICAL PAYMENTS UNINSURED CSlIBI MOTORISTS PO UNDERINSURED MOTORISTS CSlIBI PO D70 IDEO T "'= COMPREHENSIVE COLLISION POP TOWING & LABOR TRANS EXP/RENTAL RE DRIVER INFORMATION Chg Typ II Name - , Ch:{ Vehll 2 ) Typ . EA ACCIDENT EA ACCIDENT . EA PERSON . . $ EA ACClbENT $ EA PERSON $ . I SA APCIOENT . . / II hII:-'" . '-'--J/J/' . ~ EMB r7 SA PERSON DEOUcnBlE OED OBEL \. $ I EA ACClot:NT S · /d/:/J~ ~ . EMB . / SA PERSON EA ACCH oeoiJcn OED OBEL . . k- EA PERSON $ EA ACctDENT . EA PERSON $ SA ACOIC EA ACCIDENT SA~ON. EA ACCIOENT $; EA ACCfDENT ./"' . SA Ps,SON . . SA ACOI~ ~ · 100.00 . 500.00 SA ACClO c c FULJ. GU\SS FULJ. GU\SS v c c . EAACCID NT '" / I , / ~ . 100.00 . 500.00 ) / FULJ. GlASS FULJ.GlASS . . . . . Drvr Ace Prey Train CSE Date Llcensell/State Soc. See . \. "'...... __,"~<'''('.A,1Ij;ili~ -:;Y,' ._~'\' \~,f , :.Ii il1i f?\.', 'i L_ I. it '..1 !",-L\ \",tt .~. '" !'. . \" ~ 0" .,..... .. , .,-,\ ".../ "'" ,'" " ~:' A' ,,,. ,', j} \ \\"' '" ~ ,"'~ ...W II "eM Sex Mar. .....-.rOB ~~!e ~~l' ~ Stat , ,~l~ c:?'..;:s:J J. IlUW ll'il. 'J IL,L I'\"'~ ' ACCIDENT/CONVICTION - IF DRIVER ADDED (Note: Driving record Is verified with the state MV Dept.) . . . . ~ Has any driver shown above had an accident regardless of fault, DYes o No If yes, Indicate below or been convicted of a moving violation within the last 5 years? Drv Date 01 Describe Accident or Conviction License Speeding Conv BI/ Deeth Amount of It Ace/Conv Susp/Rev Charged Limit Ves No Property Oamag BI PO Co L.---- ,- 1/.......- \ ., ADDlnONAL INTEREST: fi Loss Payee !XI Additional Lessor 0 Joint Ownership 0 Third Party Chng Veh Na . ""'dress Loan Number I,. C 1 GMAC, PO Box 2525, Hudson,OH 44236 (LOSS PAYEE ONLY) n 1 C'; ',1 S"'r"ice~ Vehicle Trust Insurance Service Center. PO Box 390902, Minneapolis, MN 55439-0902 (ADDITIONAL INSURE[ - LESSOR) REMARKS: Mil 71 I;? in OR '. ACO"RD~ PENNSYLVANIA AUTO SUPPLEMENT coDE: Park W. Leitzel R. R. #1. Box 860 Herndon, PA 17830 SUB CODE: APPUCANTINAMEDINSURED PRODUCER Ronald M. Leitzel COMPANV, Merchants Ins. Pot.CY~o; PAP 2664949 HAle COPE: Co. of NH, Inc. EF"""'" 2/15/: '~91 IMPORTANT NOTICE ". Insurance companies operating in the Commonwealth of Pennsylvania are required by law to make aVailable for purchase the following benefits for you, your spouse 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) Extraordinary medical benefits, from $100,000 to $1,100,000, which may be offered in Increments of $100,000. Extraordinary medical benefits are those medical benefits which have exceeded the $100,000 IImlt'of medical benefits described above. (2) Income loss benefits, up to at least $2,500 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, $2,500. (5) As an alternative to paragraphs (1), (2), (3) and (4), a combination benefit, up to at least $177,500 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 $2,500, provided that nothing contained In this subsection shall be construed to limit, reduce, modify or change the provisions of section 1715(d) of Pennsylvania law relating to availability of adequate limits. (6) Uninsured, underlnsured and bodily Injury liability coverage up to at least $100,000 because of Injury to one person In anyone accident and up to at least $300,000 because of Injury to two or more persons In anyone 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 $5,000 for damage to property of others In anyone 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. If you have any questions or you do not understand all of the various options available to you, contact your agent or company. not understand any of the provisions contained In this notice, contact your agent or If~t Date 'l>~ f First Party Benefits Coverage First Party Benefits Coverage pays you, the policyholder, and others covered by the policy in the event ofinJurY" regardless of who caused the accident. Medical expense benefit insurance pays your medical bills regardless of' fault. This coverage is mandatory by Pennsylvania law with a required minimum of $5,000. Other optional First Party Benefits Coverages include work loss insurance, funeral benefit Insurance, and "'., accidental death. Work loss coverage provides reimbursement for lost wages due to an auto accident. The funeral benefit provides money to pay for a funeral where the death is the result of an auto accident. Accidental death pays when you or a family member dies in a car crash. These benefits may be purchased separately or as a combination of benefits. The First Party Benefits Coverage options and available limits are shown below. Please indicate the coverage(s) and Iimit(s) you want by placing an "X' in the appropriate box and then sign and date this fonn and give it to your agent. Basic First Party Benefits Coverage Limits Options Medical Work Loss Benefit . Benefit MonthlylMaxlmum ~ $ 5,000 (BASIC) ~ None 10,000 1,000/5.000 25,000 1.000/15,000 50,000 1,500/25,000 ~oo,ooo X 2,500/50,000 -J H~~~~~ "S!bnature of Amt med I sured Funeral Expense Benefit a None 1,500 2,500 j.;~t.- y,.- d Y , Date Accidental Death Benefit ~ None 5,000 X 10,000 25,000 Combination First Party Benefits Coverage Option This coverage Is a combination of benefits. Do not complete this section If you have elected to purchase any of the above options. Option ~ Total Benefit Umil $ 50,000 100,000 1n,500 ' Funeral Expense Benefit 2,500 2,500 2,500 Signature of First Named Insured Date Accidental Death Benefit 10,000 10,000 25,000 Extraordinary Medical Benefits Coverage Limits Option Extraordinary Medical Benefits Coverage Is an optional coverage. It pays. the medical expenses of eligible persons for accidents covered 'under your policy. Payments under this coverage begin only when covered medical expenses exceed $100,000 and are capped at.the lifetime limit of $1 ,000,000. Please 'X" the appropriate box. ~ Include Extraordinary Medical Benefits Coverage of $100,000 on my polley. Include Extraordinary Medical Benefits Coverage of $300,000 on my policy. Include Extraordinary Medical Benefits Coverage of $500,000 on my policy. Include Extraordinary Medical Benefits Coverage of $1,000,000 on my polley. X Do not include Extraordinary Medical Benefits Coverage. The first $100,000 of medical expenses are not covered by this coverage. If you select the Extraordinary Medical Benefits Coverage and yo First Party Medical Benefits limit Is less than $100,000 you will be responslbla for the d nee. Ii; IJ'6 ~ ~ f ate ~ Ignature of First A,.......___~ __ ._.__. Tort Option Selection - Notice to Named Insureds A. "Limited Tori" Option . The laws 01 the Commonweailh 01 Pennsylvania give you the right to choose a flml1 of insurance that limits your right and the righlol,,jhe:m6ll1bers 01 your household to seek fihanclalcompensatloh lor injuries caused by other drivers. Under this lorm 01 insurance, you and other household members covered under this policy may seek recovery for all medical and other out-ol-pocket expenses, but not lor pain and sullering or other nOhmonetary damages unless the injuries suffered fall within the definition 01 "serious Injury" as ,set forth in the policy, or unless one 01 the "everal other exceptions noted in the policy applies (ask your agent, broker or company lor a description 01 "serious injury" and the exceptions). The annual premium lor .baslc coverage as required by law under this "Limited Tort" option Is $ . Additional coverage under this option is available at additional cost. B. "Full Tort" Option . The laws of the Commonwealth of Pennsylvania also give you the right to choose a lorm 01 insurance under which you. maintain an unrestrictlld right for you and the members of your household to seek financial compensation for injuries caused by other drivers. Under this fonn of Insurance, you and household members covered under this policy may seek recovery for all medical and other out'ol-pocket expenses and may also seek financial compensation lor pain and suffering and other nonmonetary damages as Ii result of injuries caused by other drivers. The annual premium lor basic coverage as required by law under this "Full Tort" option Is $ . Additional coverage under this option Is available at additional cost. C. You may contact your Insurance agent, broker or company to discuss the cost 01 other coverage. D. If you wish to choose 'the "limited Tort" option described in paragraph A, you may sign this notice where indicated below and return it. However, it you do not sign and retum this notice, you will be considered to have chosen the "Full Tort" coverage as described In Paragraph B, and you will be charged the "Full Tori" premium. I WISH TO CHOOSE THE "LIMITED TORT" OPTION DESCRIBED IN PARAGRAPH A. Signature 01 First Named Insured Date E. II you wish to choose the "Full Tort" option described in paragraph B, you may sign this notice where indicated below and return it. However, jf you do not sign and return this notice, you will be considered to have chosen the "Full Tort" coverage as described In Paragraph B, and you will be charged the "Full Tort" premium. TORT" OPTION DESCRIBED IN PARAGRAPH B. ~~ Date Collision Deductible Option Pennsylvania law requires that all automobile policies which Include colllsioh coverage provide a $500 deductible. You have the option 01 purchasing a lower deductible, for an additional premium charge. If you wish to carry a collision deductible lower than $500, please indicate your selection below: 0$100 0 $250 Other: $ , f0~~ Date '^ (Insured wishes to have a $500.00 Collision deductible rather than the present $100.00 Collision deductible. This applies to all vehicles insured under this pol icy). " Driver Improvement Course Credit If a named insured age 55 or older has successfully completed a driver improvement course approved by Penn- DOT, a 5 percent premium credit may be applied to your policy. To receive this credit: a certificate of successful completion from an approved course must be provided; and - the course must have been Completed within the last three years. Passive Restraint Discount If your vehicle is equipped with passive sealbelts' or airbags, you are entitled to a discount on the fi,rst party benefits coverage portion of your policy. Passive seatbelts are those which automatically fasten without any action by the driver or front seat passenger. Indicate all options that apply for each applicable vehicle listed below: Vehicle 1: 2004 Cadi 11 ac SRX' o Passive seatbelts IKJ Oliver side airbag CXJ Passenger side airbag Vehicle 2: 2002 Jee o Passive sealbelts X Grand Cherokee Driver side airbag Vehicte 3: o Passive sealbelts o Driver side alrbag o Passenger side alrbag Anti-Theft Discount If yoU have an anti-theft device in your vehicle, it may be one that qualifies for a discount on the comprehensive coverage portion of your policy. Indicate all options that apply for each applicable vehicle listed below and provide evidence of Installation: Vehicle 1: 2004 Cadi 11 ac SRX ~ Alann system that can be heard at least 300 feet away for at least three minutes Device that you manually set that makes the fuel, ignition or starting system inoperative X Device that automatically makes the fuel, ignition or starting system inoperative when the ignition is tumed off Vehicle 2: 2002 Jeep Grand Cherokee Overl and ~ Alann system that can be heard at least 300 feet away for at least three minutes Device that you manually set that makes the fuel, ignition or starting systElm inoperative X Device that automatically makes the fuel, ignition or starting system inoperative when the ignition is turned off Vehicle 3: ~ Alann system that can be heard at least 300 feet away for at least three minutes Device that you manually set that makes the fuel, ignition or starting system inoperative Device that automatically makes the fuel, ignition or starting system inoperative when the ignition is turned off Coverage is generally described here. 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 all future policy renewals, continuations and changes unle notify you otherwise in writing. Date lfZ64/ Applicant's Signature ACORD 61 PA 15(96\ k'" " fA.. .~"~.. "".' ''! ,'.: .;~,., .~':"\~': y,<('l',<'" ':" .':, ,,';r,;;',' ,..,;,. :.,.&:', '.' ,. """.." . ,; ~ , c. , b'liUal ,,~ ;,'K", " ' I' ! U,Qgo/ \l0, ,I);, 0.0",' '..' ., .. 69,000/10Q,OOO 100,0001200,000 100,000/300,000 NOTE: YQl1R UNlNf;rolUID MOTOIUSTS COVB,:BA.GE ldMrr SBLECTJO}l wtI.L BE PROCESSED ON,LY IF YOU HA VB ALSO $lONBD PA11AG!tAPB A ABoVE. ' R&mcrtON OF UllDEJt.ll(StJ'RtD MO'l'OR.l$'I' PROTECTION A. ay$t~l~ this waiVer 1 am reje,4ttnlii..ll~~l(\1'~~~~~.~t~tg~lI:~~~~>.\Wd~~tlVIi poU(!y- t. or,'.m..~flt.lif.'.'.'.,.'., 4".!'!-.<I aUl'El1.tive$~Iil.;t,lil.J.,'l'ig.'.. In,,' ..m,...y. '.'.,."n. "~~.'.,.,IJ,~,CI.".~~".'..',.,Utl. ,~e.J.."~,.,... ",....,.IJ~..'.....~,.~,'.,J..[j()V..".d..i'I1..lr,. .',$".. i.'p.rotf. ,ct...s ' ~e'::::~~~t~~~i~rga it~~rtr~~:b:~:<;f~~q~; .~::b~rrr!fL~~:~rr&.!~~~i1jt~~'ltc~'::~,' and dalMges. r knowinglyatld vol\Ultarily rej.. is.,Q9Verag - 8. 'A, Ul'ed /' .,:>': :1'~"',:'~F;;::~:q,~: ~~6" ~ ory I. ' b.ti!l -'.') , e, ,.; ,Ii! , ';..,,~., ",', ,'",jQ '.,..'....><:0: -/ '<"::-"~':'~;~";""":i;":~\" ,',: .: '" ,.\? ':''''-~'-'/''l6a'-,iij~~;'' " '-.,:'," ~ :'- "':.' '.' ..'." '.,' .'. ',' ,,'" '..'.....' '>i,kt!:\ct~g\~JiA';O'~')~';,ll;';~"'F ,L()WmiLIM1Ts~~~V:aS1i ~~~9.JiWM'1QN "':'-,:- ,._.~\'i<, ,,,", "',, . ,'~"':,:< -',~-:,;,;/,_,',_;,~),>,.,:~~:_,.:_~:,:,\,,~:>_:,-)..,.:',:' " _', '.:. '::"_". ", c. 'it YCIl,l wmj)t~ $electa limit Qt'. t1na~l'~}Ir,e~ ~~~q~l~t~~<;IYe~~~t'~9~~",~)1AA"}l9\Jl1' J.i9U~ts' Umito.tliabqity for90dilyfujm.-y, YPul!.l'~rElq\iji!~d~o. t'~lIt l'ej!)ot tliei!!QVE1"ll.!te\'bY/llgrling, pa",agrapli Aabove anClthen select the des~rE!dlimltl;leloW.' ' , .lniti!l1, ' " ", ' . , \./ t,,, J I wish a. lower limit ot' UriclEll'inSurecl .Motorists '" I' limit of liability for Bodily Injury as follows: ", .",--, COVEll'agll,. thlU1 my pOlicy'S sJjt L' it . '. .' (1)~ WeM~er Acelclent> $ 15,000/ :10,000 (Basic) 20,000/ 40,000 25,0001 50,000 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR UNDBRINSURED MOTORISTS COVERAGB LIMIT SBLECTION WILL BE PROCBS,~n ONLY IF YOU HAVE ALSO SIGNlm PARAGRAPH A ABOVE.. M PERSONAL AUTO POLICY DECLARATIONS Merchants Insurance Company of New Hampshire, Inc. _ Buf falo, NY 14202 '.-',,"- Transaction Type: RENEWAL CERn FICA TE Polley Number: PAP2664949 Named Insured and Mailing Address RONALD M LEITZEL 153 N HANOVER ST CARLISLE, PA 17013 Polley Period: From 02/15/04 To 08/15/04 12:01 A.M. Standard Time at the address of Named Insured. Date Prepared: 01/01/04 00:08 Previous Pol Icy No: PAP2664949 Your Agent: 00391/WSBC9/049 TOWN & VILLAGE AGENCY - PA PARK W. LEITZEL 3100 TREMONT ROAD P.O. BOX 218904 COLlJ.lBUS. OH 43221 For Information, call your agent: (570) 758 - 9222 DIRECT BILL Veh 001 002 Year Make/Model 2001 BMW X5 4.41 2002 JEEP GR CHKOVRL Ident I f Icatlon No St Terr Class Sym COST/Stated Amt WBAFB33501LH20704 PA 007 885120 22 1J8GW68J92C252062 PA 007 885820 15 Coverage is provided where a premium or limit of Ilabll ity Is shown for the coverage. COVERAGES LIMITS AND/OR DEDUCTIBLE PREMIUMS Full Tort Threshold Applies First Party Benefits Coverage - See Schedule Damage To Your Vehicle - Actual Cash Value Less Deductible Shown VEH 1 VEH 2 Other Than Co III s I on 50 OED 50 OED Col I islon 100 OED 100 OED Total Per Vehicle A. Liability Bodily Injury Property Damage Uninsured Motorists Bodily Injury C. Each Person Each Accident Each Accident (Non Stacked) Each Person Each Accident Under Insured Motorists (Non Stacked) Bod I Iy Injury Each Person Each Accident .********.*...****************.********** 500,000 1,000,000 1,000,000 15,000 30,000 VEH 1 64.00 56.00 VEH 2 96.00 84.00 8.00 8.00 15,000 30,000 1.00 52.00 1.00 59.00 102.00 278.00 561 .00 97.00 320.00 665.00 Total Pol Icy Premium $ 1,226.00 Garage Address Veh 001 2750 SPRINGHILL LANE,..ENOLA PA 17025 Garage Address Veh 002 2750 SPRINGHILL LANE ENOLA PA 17025 THIS IS A SlHotARY OF THE COVERAGE PROVIDED BY YOUR POliCY FOR COLLISION DAMAGE TO RENTAL VEHICLES, NO COVERAGE IS PROVIDED BY THIS SUMMARY AND IT DOES NOT REPLACE ANY PROVISIONS OF YOUR POLICY. YOU SHOULD READ YOUR POLICY AND REVIEW YOUR DECLARATIONS PAGE FOR COMPLETE I NFORMA TI ON ON THE COVERAGE YOU ARE PROV I DED. I F THERE IS AJN CONFLI CT BETWEEN THE POL I CY AND TH I S SUMMARY, THE PROV I S I ON OF THE POll CY APPLY. I F YOUR POL ICY PROV I DES COLL I S I ON COVERAGE FOR AJN AlITO YOU OWN, WE WILL PROV IDE COLL I S I ON COVERAGE, UNDER PART D AND SUBJECT TO ALL THE PROVISIONS CONTAINED THEREIN, FOR A PRIVATE PASSENGER VEHICLE, PICK-UP OR VAN RENTED BY YOU OR AJN "FAMILY MEMBER", SlI!JECT TO THE ........ PBIUOTIBLE '.ll""'" "" AUI'O YOU .... AS ..- IN 1llE 1lECUIIASl;.. _'''''' BY 1llE TERMS OF YOUR POL I CY . Countersigned: Authorized Representative: A/ ';1/. j(a, This policy Is not valid unless countersigned by our authorized agent or representative. . ~ Page 1 (CONTINUED) Exhibit B MU 7150 (10198) INSURED COPY '. "....,'><'4t.... .......,..-.. JI>"'-, , . .~,. .-..""""" - -"', REJECTION OF. UmifSURED MQlI'ORIST PROTECTlON" , , ,A. By signing, fhisW9,ivet>. r , 9,il)rejeetiilg uniljsured motorist /)overage under this I?O!icyf(jr, myself,9,llP,.tQi)..my.-.l'el9,t11f~s,...~e$idll'\~Jn';.my ,hqYl'lehqld. . Uninf1ur~d'coyet:age '.,,~J;l)t~cts,;rit~<; an, d"" r.",!l.l,.,at..i. V,'. il, $. 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',' , ,,:-,,,, ' , " , iN"" ". i- .:';'" ',~6,0001 ~o,tJOO .,"" , . 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR UNINSURED MOTOR.I8'rS COVEaAGE LIMrr SELECTION WILL BE PROCESSED ONJ,Y IF YOU HAVE ALSO SIGNED PARAGRAPH A ABOVE. ." Page 7 Exhibit C REJBCTION OF UNbBIUNSU'RbD MOTORIST PRd'rllCTION 'A. Bys,igtiiw; tlJ~ wB,iver Ia,m rejeG~ingufH:lel'il)1l\.!J:egrnot()rjs"tcov~ragEj\JnclerC'this polioy, , ''for 'm:ys~t, at'IcI' aUrelati\t~$ r~~i~frig,: In ,tlJY2I.1P~!lh()1c1,;. V'l}<Ierin~l!i'lldcovel'age i protlicts .' 'roEi" 'll.p!:'l'lIl)iatlvesINing in mYli()~Eiltol,d,tor,tQ$seS'E\ncl dam!l.lres'sU,tferediif. injury' is caused " bythen~gUgen\lS!of aclr!vEit' wtj(;it,/qel!\n()~"", v,el1Oughil1stirll.l1\:leto paytotaI110sses and dat.nj;l.ges. IkfiOw,inglY!lndvQlUl1t4tgy~~Ie js oovei'ag , -" -' i ~;';;: ",~4rl",'~ "~\1;~.t:';~~~ ." '... ," "il;, " , ' . :.i4'i . .:,,;t:l<,,;i',,'j,ur!;l '. ',,:,;:,~;,;t<!I"';!il;~~-:f.f,"~~' . :;Z"''.if'~9;'' ;., "i{....'::,..., ,I. 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' . . l1.mitot til1-bUity for Bodily Irfjul'y as follows: ,~t)!it M' It (l'et"1fet$()~er A<:cictend $ 15,000/ 30,000 (Basic) 20,000/ 40,000 25,000/ 50,000 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR UNDERINSURED MOTORISTS COVERAGE LIMIT SELECTION WILL BE PROCESSHD ONLY IF YOU HAVE ALSO SIGNED PARAGRAPH A ABOVE.. PAO''' R / ;' R~CTION OF l1NDBlUKStJ1t:ODMOTOlUS'l' PROTlWTiON '."A. , , JilY$ig.{jfjg 'tilts W iJ,i\lerIll,ril r~~ecting ,und~~i1)$9~,ea; !l\ot()l'j~tCb\f~tagE!~Il<fer~;thispoli(jy .. ,'ti:ll' 'm)'$~ ,~1'!1;F,au'relatiV:er~e~i~(ligi.;lnll'ly;~p9!l.~h~lli( .l!~fJerinlllU!li!d ,<lo1';el'llg,e r~~b~!!!ltllo', 'file 11MrEllllt~\lesU\fing fit myl)6~!l(lld\tOI"1t~esi,',!n<,!dalt1~ges'slt#ered:if l(Ijur~'iscll,lJiled" " byfhe .I)~gUgeMeot ll,4r~YEitiw.ho 't;f(!El~\l\Q1i'i" . tenol1gh'll1Slil'!li:1(JEr',t<) Pll.y'tbl'lill"lossell''';' al1d da~ges~ rkI'UMifilrlY'Ill\I1V.bJAI1t~n~,~~te:;~~.' doverag', - 1 '~;';', "',':' "~~I~i' " .,.. . ,- ,:--'~_. '.~iL~72t:~;~~ii~J~~}'t1-;L; ,,': ':.: -::.'i'~~;~~ "~~n}ll.::,wr1f:$~,j~f, - . ,;' ':- <.(t t}:~J(:'-';J:""[{\q;(~,,:' 01"';'''' ,"', ." ' , i;,)~r.ne;,:;;;,.~~~:.:,. ':,;,,; ;,:':." . ....4".',',. " "',<'",."JIfi, ,-"1\"',,,.,, '...4..)1i1,., . ~,' ':i1;1~.;'- :Y'-:t~t.q:~.\\#t~~,... .-~,rv, '.','." .',' . " """lO''''''''fii!o'''" " ',) ".~,,',.., _,.1'.., '~~~''-~''1!f"'*J:),J ,:"tf.'"....:',..,~.. r'-' . .,~;j~.}l~;>h~ ~ ~," '.'-;{h-~'-'; -~' ,- -~~;'~;:~~:1::;1",;~ _.\:t;.', ~...'::!;t-/.":,'--':-rr:J/ "'H';~ .-, .... _.....-..:"~->',,:::i),:.,: ..>:;.....-..'..,.:,.'....-",.'..:.:,. """,,;,,:,tff' ^,,',"', ..;';9".~ ",I"'C"? 'I"i,!\ ";J.,.;~~jtP:N' ,.",:)',..,.. ,>" dt.~I:~i:iy~~:,~P.ifl",~~~~~ct 'lifU~ij~::_ f;)U>>~~lIHit!~~ \~d~Qtll>~' .09V\'l~.4i~~~ilwer-~~!lttn.yO~, P9i,h~Y'llc . UJl1i't o,t -I.t!W4lty '~Ol' a~d,Uy ~fi !I~yl~tiU~lt!l!it'~q~l\d"''to ~'rej'eot"dle, t\Ov!!r~g'e',I:IY"!llgl"ii1g1 " ,til:!ra(n'llph A a!)ove and t~en$.,. .~~. Uie deS1\-1el1'Ilmit I:l~low. " .' , ,,', ,.'tl'litl!4 . " ;;;,:",'.}.'.,',; " 'I>, ilk~I.*i,fih ,,'~" t~iUwet,!t{ll~otUJiI.'.'..'c:l.~fli!111\1l'~ 'Motol"ists Cciv~~ag~i,:than IlJY Pc:>1!<!Y's' }. 'I' ,,' . " ",li,mJtot lillp' . ty ~or pOdi~;~AAY 1l1l,6...0WSI ,~t, " , 'Wet',' " fir Accident) $ 15,000/ 30.000 (Basic) " 20,000/ 40,000 25,0001 50,000 50,000/100,000 100,000/200,000 100,000/300,000 NOTE: YOUR UNDERINSURED MOTORISTS COVERAGE IJMIT SELECTION WILL BE PROCESSED ONLY IF YOU HAVE ALSO SIGNED PARAGRAPH A ABOVE. Page 8 ./ UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA RONALD M. LEITZEL and BARBARA D. LEITZEL, his Wife, on behalf of Themselves and : All Persons, Organizations and Entities Similarly Situated, Plaintiffs Removed from the Court of Cumberland County, Pennsylvania No. 05-2287 CLASS ACTION Civil Action - Law v MERCHANTS INSURANCE COMPANY OF NEW HAMPSHIRE,INC. and MERCHANTS INSURANCE GROUP, . . . . JURY TRIAL DEMANDED Defendant CERTIFICATE OF SERVICE I hereby certify that I have this 25th day of May 2005, served upon the persons listed below a true and correct copy of Notice of Removal in the above-captioned matter by U.S. First-Class mail, postage prepaid. George B. Faller, Jr., Esquire Martson Deardoff Williams & Otto 10 East High Street Carlisle, PA 17013 MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN By: ?ItM4?t. ?~"etta, ~ MARK A. FONTANELLA 401 Adams Avenue, Ste. 400 Scranton, P A 18510 (570) 496-4613 Attorneys for Merchants Insurance Co., of New Hampshire, Inc. and Merchants Insurance Group 6 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA RONALD M. LEITZEL and Removed from the Court of BARBARA D. LEITZEL, his Cumberland County, Pennsylvania Wife, on behalf of Themselves and No. 05-2287 All Persons, Organizations and Entities Similarly Situated, Plaintiffs CLASS ACTION Civil Action -- Law v MERCHANTS INSURANCE COMPANY OF NEW HAMPSIDRE, INC. and MERCHANTS INSURANCE GROUP, JURY TRIAL DEMANDED Defendant AFFIDAVIT OF SERVICE MARK A. FONTANELLA, being duly sworn according to law, deposes and says that he is filing a true and correct certified copy of the Defendant's Notice of Removal, together with copies of the documents attached hereto with the Prothonotary of Cumberland County, Pennsylvania by first class mail on Mav 25, 2005. MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN DATED 5/25/05 By: ~ rl. ?OHta"etta, &~ MARK A. FONTANELLA 401 Adams Avenue, Ste. 400 Scranton, P A 18510 (570) 496-4613 Attorneys for Merchants Insurance Co. of New Hampshire, Inc. and Merchants Insurance Group 110 _A ILIAB\MXA ILLPG\572774\MXA 113235100287 7 AFFIDA VIT MARK A. FONTANELLA, being duly sworn according to law deposes and says that the facts set forth in the foregoing Notice of Removal are true and correct to the best of his knowledge, information and belief. ~) M A, FONTANELLA SWORN TO AND SUBSCRIBED 7t...->-H--- before me this 0<'..) day ~x !': ~ Notary Pubhc ,2005 COMMONWEA~ TH OF PENNSY~VANIA NotariaIlltlaI Joy E. Lewis, Nolaoy Public aty Of Saantoo. Lad<awanna County My eom_ ExpiJ9s Nov. 22, 2007 Member. Pennsylvania Association Of Notaries 5 r , , " o ..n .-< .r_-:::~ i" ..... j , ) 1 "" -