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COURT OF COMMON .). ,I.:AS
DAUPHIN COUNTY CIVil, ACTION
SUITS 1994
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Wrll or Exccullon IlISutd:
Apptlrlnct For:
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March 9. 1994 - Upon consideration of the within PetiLJol!La.Ji~~le is hereby issued UpOI1 Re-
lIpondent State Farm lnsllranc,e Company to Show CaUBe Wl~;......
1. Petitioner Lenora M. Skivlnl:ton' s wUlllluraru.;,lUDQlor iSl~~~.Lll!.l9u1.\U!..o..Lll!!~Jlit teu
2. ReslJOndent Stat!LIillJJLlilllUrlUlce (;anoollY SllOulJlJl!).t~..I:1~1,~Hr(Lt_<).Ji~jg~;JlLlllliUra1QG.._
3. Peti t loner Lenora H. Ski v inl!tQI..U!!m.lliUlo1...m.J!wi!.r.rlr~Lg<!llQtl!ll>l~_(;owJ~!,'L(~IlLl)[!<Lf:.o.l.l.t~_
ll1curred in proceessing and presenting llle foregoing Pelition; and
. _____!!.-._.~et itioneE...Leno@.. t..l..,-~.~i v !,nr.t.on. S!t(~I1..t<l.II(~t_L~ .!!warcl.r:'.1.1_1!I!L(~t III''' "1'.'. Ip f.l.hat. t hi ~ .,
Court d(~ems eqllltab1~~!."-jllOJ.!:.c'_'_'H___..m u u__ ..__._ . . ".....,. n. .._. ....
Rule returnable within :W dap_oj aerv 1~1.:.-__/~Jo~l!!Lll"..f..t0!1[cH.~r L,JI.ldliC'_.~c~.lllJLr,~_[J1E'1.1 '... _._
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Adm, Fee. Cu~',ody
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Arr't. 01 Ma11er
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Ca1h Bond
tn Arhitrntinnj
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Herch 2.~L.1.~.?4. :-,. A Rule is herehy fRRUl'd upon flC!RI'Olldl'lIt to Show CaURI! why the
....!bo_~e.cllptioned action Rhollld not he trllnRferr<>d to CUlllh..rllllld Coullty Court of
Common. PI.eBs , Carlisle, CUllluerllllld Coullty, PI!/lIl/1ylvlIlIllI.
.___n~~II!_ ReturnAble 20 dnys nftl'r Rervl<:... IIlI ./o/ll'l'h II. KI.>Jllfl'1ter, JlJllRe
See RULE TO SIIOW CAUSE, fUed.
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une 2, 1994 - As the petition of Lenora ~l. Skivington to transfer the above-
Btioneel case to CumberlA'Il'dc~;~~tYi-;' un,opi)~;~-;;cJ-I,Y--St-;-t~' F~r;,~ I~;~;~~c~--~__
I Company, thAt petition is grnnted, anel the Prothonotlary of Dauphin County is
, di!:ected to prepare nnel trnnsfe'r tl~~-fll~-:-/sT~-~;;~;i~~T~;rgeon, Judg~~---
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June. 8 , 994 - The. above. ac.Hon .(~._ t"-an.~6.!:H,~~~.__~~~__C.'1,u.':~__oJ_Co!"mon Ptea~ 06
Cumbe.,,-tand County.
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LENORA M. SKIVINGTON, l IN THE COURT OF COMMON PLEAS
Petitioner l DAUPHIN COUNTY, PENNSYLVANIA
l
v. l CIVIL ACTION - LAW
l
STATE FARM INSURANCE COMPANY, . NO. 681-S-1994
.
Respondent I
ORDIIR
AND NOW, this
day of
, 1994, it 1&
hereby ORDERED that Plaintiff's Petition to Make the Rule Ab80lute
be qranted and b. made final and absolute.
BY THE COURTI
J.
"......
LENORA M. SlUVINGTON, : IN THE COURT OF COMMON PLEAS
Petitioner : DAUPHIN COUNTY, PENNSYLVANIA
:
v. CIVIL ACTION - LAW
:
STATE FARM INSURANCE COMPANY, : NO. 681-S-1994
Respondent :
V_TITION TO MAIB THB ROLB ABSOLOTB
1. On February 24, 1994, Plaintiff Lenora M. Skivington
petitioned the Dauphin County Court of Common Pleas to compel
uninsurance arbitration.
2. On March 11, 1994, Plaintiff Lenora M. Skivington
petitioned the Dauphin County Court of Common Pleas to transfer
venue to the Cumberland County Court of Common Pleas. A copy of
the Petition is attached hereto as Exhibit "A".
3. Defendant state Farm, through their attorney, agreed to
the transfer of venue.
4. Both parties to this matter agree that the proper venue of
this case would be the Cumberland County Court of Common Pleas.
5. On March 22, 1994, Judge Kleinfelter issued a Rule upon
Respondent to show cause why the above-captioned action should not
be tl."ansferred to Cumberland County.
attached hereto as Exhibit "B".
A copy of the Order is
6. After more than twenty (20) days, no response was filed
with the Court.
46064/DMR
.'
LENORA M. SKIVINGTON,
Petitioner
I IN THE COURT OF COMMON PLEAS
I DAUPHIN COUNTY, PENNSYLVANIA
I
I CIVIL ACTION - LAW
v.
STATE FARM INSURANCE COMPANY,
Respondent
NO. 681 - S - 1994
PETITION TO TRANSFER VENUE
AND NOW, Petitioner Lenora M. skivington, by and through her
attorneys, Angino & Rovner, P.C., hereby requests this Honorable
Court to transfer the venue in the above-captioned action trom
Dauphin County Court of Common Pleas to Cumberland County Court of
Common Pleas, Carlisle, Cumberland County, Pennsylvania, as
suggested by the Order which was filed with the Court on March 10,
1994.
ANGINO & ROVNER, P.C.
""" \~
Lawrence F\ Barone, Esquire
I. D. No. 68921
4503 North Front street
Harrisburg, PA 17110-1799
(717) 238-6791
Dated: 3/11 /q'l
Counsel tor Petitioner
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IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. b J 1- s - 7 $I'
LENORA M. SKIVINGTON,
Petitioner
STATE FARM INSURANCE COMPANY,
Respondent
'!TITIO. TO COM'IL UNINSURANCB ARBITRATION
AND NOW, come the Petitioner Lenora M. Skivington, by her
attorneys Angino , Rovner, P. C. and respoctfully requests this
Honorable Court to:
1. Compel Respondent State Farm to arbitrate Petitioner's
uninsurance motorist's claim;
2. Order Respondent to select a second Arbitrator; and
3. Compel Respondent to pay Petitioner's counsel fees.
In support, Petitioner respectfully represents the following:
1. Petitioner Lenora M. Skivington is an adult individual
residing in Camp Hill, Cumberland County, Pennsylvania.
2. Respondent State Farm is an insurance company licensed to
do busine.. in the Commonwealth of Pennsylvania with offices
located in New Cumberland, Cumberland County, Pennsylvania.
3. On August 12, 1993, Petitioner Lenora M. Skivington was
injured in an automobile accident at Maclay Street, Dauphin County,
Pennsylvania.
4. On August 12, 1993, Petitioner Lenora M. Skivington was a
39513/LAIf
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na.ed inaured on an automobile insurance policy issued by state
Fan.
5. said policy was in full force and effect on August 12,
1993.
6. The aUbject automobile accident was caused by the
negli~ence ot Randy Fulp. At the time of the subject accident,
Randy Fulp was uninsured.
7. By letter, dated December 22, 1993, counsel for Petitioner
Lenora M. Skivington named Attorney Gerald C. Kramer as her
arbitrator. Counsel's letter is attached hereto as Exhibit "A".
8. To date, state Farm has not appointed an arbitrator.
WHEREFORE, Petitioner Lenora M. Skivington respectfully
requeate this Honorable Court to issue a Rule upon Respondent state
Fan Inaurance Company to show cause why Petitioner's uninsurance
motoriat'a claim should not be submitted to Arbitration, that
Reapondent be compalled to select an Arbitrator, and that
Respondent pay Plaintiff'S counsel fees.
ANGINO
Counsel for Petitioner
Dated: d./J.. 'I/tH
~
.
"\
IlOLI' I. DOLL, lSOUIRI
,.. Supreme Court 1.0. No. 47243
rouLIUIOD, IIIYNOLDI " HAVAI
101 'lne StrHt
'oat Offlce lOx 932
Harrlabur;, Pannaylvanla 17108-0932
Telephone I (717) 236-3200
'axl(717) 236-6863
LENORA M. SKIVINGTON, .
.
Petitioner .
.
:
v. :
:
STATE FARM INSURANCE COMPANY, .
.
Respondent
"
...:Ji-;.iii..-..,,
Attorney for Defendantl
STATI I'IUUI MUTUAL AUTOHOIILI
IN8uaA11CI COMPANY
IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 681-S-1994
_OTIC. '1'0 PLOD
TO: LENORA M. SKIVINGTON
c/o I.awrence F. Barone, Esquire
4503 North Front Street
Harrisburg, PA 17110-1799
You are hereby notified to file a written respon.e to
the enclosed New Matter within twenty (20) days from service
hereof or a default judgment may be entered against you.
DATE:S// /f'/
By:
FOULKROD, REYNOLDS & HAVAS
A Professional Corporation
Attorneys for Respondent,
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
101 Pine Street
Post Office Box 932
Harrisburg, PA 17108-0932
(717) 236-3200
.
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IlOL' .. JlJU)LL, -.sQUID
'a. 'up~... cou~t I.D. Mo. 47243
rouLIUlOD, DYHOLDS 5 HAVIUS
101 'lne .t~..t
.oat Off1ce lox 932
Ha~~1abu~9, 'ennaylvan1a 171C8-0932
Telephone.
'ax 1
(7171 236-3200
(717) 236-6863
Atto~ney fo~ Defendant.
ITAU 'AM IlU'l'UAL AlI'l'OIIOln..
IMSUJWICI COIIPAIfY
v.
IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
LENORA M. SKIVINGTON,
petitioner
.
.
STATE FARM INSURANCE COMPANY,
Respondent
NO. 681-8-1994
....... OP ...l'OlIDD'l', .TAT. PAD I..n...c. COUOY,
TO PftITIO...'. PftITIOM TO COU.L UIII.8D2A11C. ....ITIlATIO.
AND NOW, come. Respondent, State Farm Mutual Automobile
Insurance Company ("State Farm"), by and through its counsel,
Foulkrod, Reynolds , Havas, a Profe.sional Corporation, to answer
the Petition to Compel Uninsurance Arbitration of Petitioner,
Lenora M. Skivington ("Petitioner"), as follows:
1. Admitted.
2. Admitted.
3. Admitted in part and denied in part. It is
admitted that on Auqust 12, 1993, Petitioner, Lenora M.
Skivington claims to have been involved in a motor vehicle
accident. After reasonable investigation however, state Farm is
without knowledge or information 8ufficient to form a belief as
to whether she was injured in this accident and accordingly, no
further responsive pleading thereto is required.
4. Admitted.
.
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5. Denied ae stated. It is admitted that the
underlying policy was in torce and ettect on August 12, 1993. It
is specitically denied however, that plaintiff had any uninsured
or under insured motorist coverage in effect and accordingly, this
Petition is impr~perly betore this Honorable Court.
6. Admitted.
7. Denied. This allegation ot the Petition reters to
a writing which is the best evidence of all it contains and
accordingly no responsive pleading thereto is required. By way
of further answer, the undersigned did not receive a copy of any
document purportedly attached as Exhibit "A" to the petition.
8. Admitted in part and denied in part. It is
admitted that state Farm has not appointed an arbitrator in this
case. It is denied that Petitioner has standing to select an
arbitrator as there was no uninsured motorist policy in force or
effect on August 12, 1993, providing such coverage to Plaintitf.
Accordingly, no arbitration clause was in force or ettect that
would give rise to an arbitration.
9. In view of the foregoing, contemporaneously
herewith, state Farm has tiled a declaratory judgment action with
the Court ot Common Pleas of Cumberland County requesting that
the Petition be stricken and that her rejection of uninsured
motorist coverages be enforced thereby precluding an arbitration
in this matter.
2
,
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WHEREFORE, Respondent, state Farm requests that this
Ilonorable Court dismiss the instant petition with prejudice.
... D'l'TD
10. Petitioner is an adult individual who currently
re.ides at 2206-H Cedar Run Drive, Camp Hill, Cumberland County,
Pennsylvania.
11. Petitioner was born on September 6, 1975.
12. On or about September 30, 1991, Petitioner
executed an Assigned Rillk Application ("Application") for a
private passenger automobile insurance policy which was
ultimately iesued by State Farm. The Policy is identified by
Policy No. B20-1007-F21-38 ("Policy"). A true and correct copy
of the Application is attached hereto as Exhibit "A". True and
correct copies of the pertinent Policy provisions are attached
hereto collectively as Exhibit "B".
13. On June 21, 1993, pursuant to the requirements of
Act 6 of 1990, Petitioner elected the limited tort option of her
liability coverage by executing the Pennsylvania Assigned Risk
Plan Selection of Tort Options form. A true and correct copy of
the executed Pennsylvania Assigned Risk Plan Selection of Tort
Options form is attached hereto as Exhibit "C".
14. On June 15, 1993, Petitioner executed a Rejection
of Underinsured Motorist Protection form under the Policy. A
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true and correct copy of thi. form evidencinq her rejection of
underin.ured .otori.t protection i. attached hereto ae Exhibit
"D".
15. On June 21, 1993, Petitioner executed a Rejection
of unin.ured Motori.t protection form under the Policy. A true
and correct copy of thi. form evidencing her rejection of
unin.ured .otori.t protection ie attached hereto aa Exhibit "E".
16. On August 12, 1993, Petitioner was involved in an
accident with an unin.ured motorist ("accident"). Deapite her
rejection of unin.ured motoriat protection, Petitioner haa
petitioned thi. Honorable Court to compel state Farm to proceed
with an unin.ured motorist arbitration. A true and correct copy
of Petition ia attached hereto as Exhibit "F".
17. By virtue of Petitioner's rejection of uninsured
motori.t coverage, no contractual provision exists requiring
state Farm to arbitrate thi. matter. Accordingly, state Farm is
entitled to declaratory judqment freeing it from any and all
re.pon.ibility to provide uninsured motorist benefits for any
injurie. allegedly .u.tained in the accident.
18. In view of the foregoing, contemporaneously with
the filing of thi. Answer, state Farm has filed, in Cumberland
County, a Complaint for Declaratory Judqment seeking the
enforcement ot Defendant's rejection ot uninaured motoriat
coverage and dismis.ing Petitioner's Petition to Compel Uninaured
4
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Motorist Arbitration. A true and correct copy of this Complaint
is attached hereto as Exhibit "G".
WHEREFORE, state Farm requests that this Honorable
Court dismi.s the instant Petition to Compel Un insurance
Arbitration with prejudice.
... IlATTD J. TB. IlATUIt. 01' Jl)..LIKJDltY ON.CTJO..
.UR.D~ ~ PA. a.c... .0. 1G2.,.tfll
[Improper Venue]
19. Paragraphs 10 through 18 hereof are incorporated
herein by reference as if set forth in full.
20. In the unlikely event this Honorable Court
determines that Plaintiff'S rejection of ooverage may be voidable
and that there may be uninsured motorist coverage in effect, it
is respectfully submitted that venue in this matter is improper
and that cumberland County i. the proper forum to resolve this
dispute.
21. The Uninsured Arbitration Clause found at Page 10
of the Policy provide. as follow.:
Unless both parties agree otherwise,
arbitration will take place in the county in
which the insured lives.
bJl Exhibit "B".
In this instance, the insured Petitioner lives in CUmberland
county and accordingly, the appropriate reviewing court is the
CUmberland County Court of Common Pleas.
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PINNSVLYANIA
ASSIGNED RISK PLAN APPLICATION
. P*OX e510, PROVIDENCE, RI 029~0.6510
Thll .,p11 n mUll be PRINUD IN INK OR TVPID AND
SIGfIIID HI APPLICANT AND PRODUCIR, (For 111m.
wh.re lpeclll.'nlu~lcl."I'"lCh "'""1 Ihlll.)
I dQ h,rebv (,rlllV 11'l1l1 I.m ,'.c,nlld broker/.g.nl. 0' thl 51,1, 01 Pennlvlvlnl...rIlJ
Cltlll..d by IIHt P.nn.."t....m. fJhm I hllVI ,.lI.Ilh. PI"n.ylv.tH. ."IQ"'~ RIIII. Pl,n,
1'1,.... uplameo lhe ptuvlIIO"IIO Ih, .ppllel"l. and h,v'lnCIUd.d In It'uI .pphc.llun
all "l.IlJlfelJ mlorm.llon give" 10 m. bV th, .ppllc.nl In Ih, .~~. puUCy II
cancIIl.d or. chlnge II mlcJ' 'tlulHf1g In' "Iurn premium to Ih'~, I 'D'" 10
"Ium Ihl lJIlII"'ltJ comnlllllQ/l po,lIon 01 luen "turn pflmllJm
ANTI '''AUD .TATlM.NT
"",..... WHO ..........., AND WI'" INn"' TO IN.MJR. OR DI,..AUD lUff ..""'." ''''1 AN AMtCAnoH OR CWII CONTAlNINO MY 'AUI. HtCOWUTl
. ....'fIOM....... OOMVlCnotre. II .....CT TO ",Rll4ru,.""OIt... TO linN nMe" 'ArMUn' Of A" '" TO ItMa
, . '.........""" ...... c::o.. .................. ' ,....... _. lot. ... .... .
pI' )., 'f 'If' 007S-II0 ~s, I) If. '1/1' .,. J,
iff, 'if' '" ,.~.y " IfJr.J ~~:~IJI,tt".1 0"1e ~ llo""'" I'''''.
"""'.......""'...111l1... PIOd- complollng..d IilIn'"l Ih,upphClllon dl"'" ',om the no..." Iho P,_ 01 _In Ilec, '''''''' oppIicol/On, _lIIe nome 0'
1nCll1ociII....,.. numDlr for lh. prOducer c:ompl.llnu ,nd algning lh..pplIClUon mUll be provlded below. .
...... 11.1,1" ,..1:" IA8ISoc SIc.' .
LIllI NIMlt '"1' H.",. ... I
......
... No
,No
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-
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ITI 'OA ALL OPEAATOIlS IN
SIHOLD. U.I Nlm.. AI
A
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lJMIIII_....
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"NtIOtllhlp 'U.. of Ilrth OIl1 ... MIl' DI1*'1 UoInM Nt.IIlCf.....
10 AppIICMI YIh_ I Yell I Mo, 0..,." ..., ell '* ,......,......."......
A'~ICANT
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Zip Code
1;11-- 0 - 0 eo.-' 0 ,....
.....#Olft1ftMlilf1l'U'JOMl
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,USE.VEH,2 0- D-
. ApptIcIItI .,.,.,. fof motorcy.s. UMd fOr 00fNMr06II ..........
'rine'PlI "ICI 0' O.raOlng
o Com",'
0''''
T.rntor,
S1mbOl
IAO.GIOUP
T""0101)1
'_10_'"
T_...
Addr... 01 Appllcanl II Ap...rs on ""ollfrallon
, .,
. ~,Aol' J(1. .1;411-' i ..~~:1t ..
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MtleltoWoftt,or
~I ..'",.- T,..-:t/II
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ai.'.llItQ.".'.d ,,;-
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[j CLIAN "ilK RAn
.v,1I
AS PROVIDED BY THE RUL.ES OF THE PLAN ISAME LIMITS OF LIABILITY MUST BE PURCHASED FOA AOTH VEHICI.ES)
THE APPLICANT ELECTS THE ,OLLOWING TORT OPTION U I.lmlltd Tort U Full Tort Option
__,. TOIIT 0"'"* lI~cmON N<)TICI 'OAII PA.l000 (1/1OIIIUIT'1 I'ONID IT ntl A_ICANT AND ATTACHID TO THII A_'CAnON,
L1A.~ Pr.miums V.hicl. . 1 Premium. V.tUe...2
[!ItIS,ClOIIII3O,ooo _Iy Injury '5,000 P~ Dam.....
o 12II.CIOOINO,ooo ~ '"Jury "0,000 "'- Dama;.
o NO,CIOOI'loo,ooo _Iy 'njury 125,000 Proporly Damao.
o 'loo,OOO/l3OO,ooo BOdily Injury '50,000 P''1''rty Dlma;. "", , " , " , " " , " .. " " , " , , " " , " " " , "
MIDICAL IlCPINIIIINIPlT (AOQUlrOCl) ~5,000 rJ "0,000 n 125,000 0 '50,000 01100,000"",
INCOM& LOSS IINIPlT IO~11 ~ 0 11,IlOOil5.ooo 011,0001115,000 rJ ",5001125,000 0 12,!lOOI'~,000
'PUNuW.IlCPI_ _IT (o,lIonal)~"" 'n .1.1100 0 12,500 "',' , , , ' , , , , '
ACCIDENTAL DEATH IINIPlT (Optl...I) ~O.. 0 '5,000 0 "5,000 0 125,000""", , "
COMllNATION P1AST PAIITY "NIPlTS i'I77,5OO1 0 V.a ePlo """"""',""""""
~ID MOTOIlIIT C:OVIMGI (OpIlOna') INoIIO .._ "a""1y IIm'lt,
!!I'No". 0 "5,~,OOO 0 '25,OOOINO,OOO 0 Wl,OOOI"OC,ooo 0 "00,000'1300,000"", ,.,.
................ ............... ~~..."..,._ "'''''..,.1fI1eWon'' iJl'onfI ''',mII1't'IOI1DtllI'lIl!lIlCItIO'' .
DoH 1M .ppt~IIOOIPI"'''.llml'' 0' Un,nlured Molorl,' COver.g. 0 v.. [J No
tI "'NO. II""" ................."LItIIIIIuIIlIIMoIanII ~ ........lolIftflll.....~'on\'l ,,.,2OOD171101ID N IP(IilCIllOrl
UNJlfAINSUIIID MOTOII'IT COVIMGIIO"I..aIIINol'o.._ 'Ie&IIIIy IImlle'
[i"l-, 0 "'.-t30,OOO 0 125,000IS5O,000 0 '5O,000IS'00,000 0 'HlO,OOOI'300,OOO"""".
1I"Nonl1',1I _..Jo -:r-................\JIldIrInWId......,.lltICtlDfI s...m1Ou1ld," $er:llOfI.Ii Ql'DnTI ,...DIOt111111Io___1aft
Doft.N........ __ .......lImi'. 0' Und.nn.u,ed Molorllr Cower.g. 0 Y.. [J No
r'.NQ.lIdl1c................ ~ ~ UlldIl1l1tUrtd Motonll "ot<<,1Oft !I......."r lor.!IIlf III !<<'IOII. 01 'OImIllA'XIIIll !71101 '0 tll.IIII9Hc.allon
IXTAAOfIOINA"V UIOICAL 'INIPIT COVI"AGIIIMBCI ,..
UNLISS THI APPLICANT INITIALS THI STA TlMINT PROVIDID BILOW NO'EXTRAORDINARY
MIDICAL 'INIPlTS C:OVI"AGI WILL BI PAOVIDID .
'AlQUIST IXTAAOIlOINA"V MIDICAL BINI PIT COVIAAGI
tv
l-J..,
PHYSICAL DAMAGI
COmp,_....~ 0 "00 [] 1200 ['11250 [J I~ [111.000,
COlli..... __ 0 'UlO 01200 fl1250 [] l500 r I" 000,
Louo'U.. b Ua O,No."",
,I NAAWAM.'THAT.M II'\JIIlJCHASI 0' A DEDUCtlBL.E'OR COLLISION COVIRAOI lOWl... THAN
.....HMIIIU... AND THAT THERIl 1$ AN ADDITIONAL COST 011 PUAC!-tA5INO A OlOUCTlBLf
'0'- COLLISION COVIIllIAOI LOWER THAN I~ AND I AGAf!: TO ACCEPT If
~"....''',.
.... ,
~'-'IU'"
,'. ~ .'
ISTIMATlO P~(MIUM
,',
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TorALIST'IIIA1IDPAIIIIIUMVIHICLII.a .
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TelIlphone l\/Mi."" Code.
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Apt,No
ell
.....
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--
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A CANT
ETI 'OR ALL OPERATORS IN
....IIDnlhip 'Ill U.. of Ilrth 011.
to ApplIClllI V.,.. t VIh r Yo 01, V,
lHOLD " Lilt NlmM AI
A
ronO
aiD,.' Ltc.n...
OperI'orl
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AI'PlICANT
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Dw,.,', UcenM No. IlI\d s....
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HII..,.....~...~ TAA~IHGCIIIDIT qu.lllltd? 0 VH 0 No II"VtI".eubmlllChOOlc:anl'luII ''''''''''''lallSlahM IHI,...._~....
""_~ ....._,_""'_~_.___~_,I_-.."" W._,....._1Il J-
of IN Clrtlflcall 01 c:ou.- c:ompItIlOft 10_........
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'~WI ontr tor motDtCyCtM..... rot DOIfl..._'-'~.
'nftClpel "IC. 01 Qlrlfll'lg
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MI"'to WOft, Of
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Tr"IlnIPONllOn
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caItt.. AppMr1I I)f'I "~II".llon
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hmlOf)
l"'o.Oroue
rllllllOr.,
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o CLIAN RISK RAn
"',N
THER THAN CLIAN RISK RATE
AS PROVIDED BY THE RUI.ES OF THE PLAN ISAME liMITS OF LIABILlTV MUST BE PljRCHASED FOA 80TH VEHICLES)
THE APPLICANT ELECTS THE FOLL.OWING TORT OPTION U llmlltd Tort U Full Tort Option
A__ft TORT 01'TlON I,LaCTIOH NOTICI 'ORM 'A-lllOO (7/101 MUIT IIIIONID IY nil A'....ICANT AND AnACHID TO THII "'""-'CAnON,
LIAB~
rYlIS,ClOll/I3O,OOO _Iy Inlu,., '",000 Properly DamlQa
o '25,OOOIUO,OOO -.y InJurY "0,000 '- Damago
o 150,0001"00,000 Bodll, InJulY 121,000 ProporTy Olm.go
0"00,000/1300,000 Bodll, Inlu,., $110,000 Pr~.n, Oomlgo " , """ '.,."", """"."" """",.,.,
MIDICAL IXPENSE SENEflT (ROQulrldl C!l"r1,000 0 "0,000 0 $25,000 0 $110,000 0 $100,000.""
INCOMELOSSBENlfIT(OpIlonIll ~ 0 II,000Il5.0000 $1,0001111,000 0 11,5001125,000 0 U,5OOI11IO,000
. _J.' ,......,'
F1JH_IXPENII MNUIT (OptIonaIl ~...." '0 ",100 0 12,110O "'''','' , , , , " " " , , , , , , .
ACCIOIHTAL DEATH BINEFIT (O,lIonll) ~ono 0 15,000 0 "5,000 0 125,000",
COMBINATION 'IRST PARTY '~NEII'ITS (It77,SOO) 0 Yea ~l(l. ,. , .... ,...,.... ., " ,..", .,.".
UfIIHSUAID MOTORIST COVERAGE (Optlonlll (NOI to '1l0Md liability IImllll
I!!l"Jono 0 III,~,OOO 0 121,000I~,OOO 0 llIO,000I11OC,000 0 1100,000/1300,000" ".".,
II "'NoM" "......tftIOIl;.....""'*'" aflJnlNurtd MOlOnIIPtOlICIOft S&I""*,,llWnd III s.ctIon "'<<foun P....2OOI) 11110110 IllllappllCellOll
Doell.... IpplW-an1 eccepllllCkild limit, (,I' Unm.urld Molonl' COv"'g.: 0 v., 0 No
I''''''' " dltdId. ..... .....~_UnIIttutld MoIonIt~ ~ Ioundlll SIctalIOlFoml P....2OJ01711O) 1011'MllWltlrlOtl
UN,-RINSURID MOTOIUST CoVERAGE 10,lIon.l) (HOllo .._IIOblll., 11m ,,,)
li'NOM OIIl,OOCtII3O,OOO 0121,00011110,000 01110,0001I100,000 n l100,oooil3OO,OOO",..,."
II"Nlll'l(.--~''''''~OI~MoIon11PtOlKlIOfl $tMImIIItIO\ln(llll5k1I011AOi'l)t'I'IlPA.3lIlIOI1iWllolflll_lCIllOfl .
DoeI........~ __ 1t8CUd IImll. 01 Undl"nlured Motorll' Cowerage: 0 Vel 0 No
II ~o. it tNckfd............lIlajIctIon at UI\dtnnaurld MOlonl' PTotlCllOII Stlltmllll found ,n 5Kt10ll 8 01 'OIm P.,3OOO 1111Oll0 Illlt .pphctllOll
EXTRAORDINARY MEDICAL IIINUIT COVERAGE IE..BC) ',.
UNLISS THE APPLICANT INITIALS THE STATEMENT PROVIDEO BElOW, HO'EXTRAOROIHARY
MIDICAL BENE'ITS COVIRAGE WILL BE PROVIDEO
I REOUIST EXTRAORDINARY MIDICAL BENEfiT COVERAGE
Pr.mluml Vehlcl.. ,
Prlmlum, Vente" -2
tv
,,~
...".loItlflS;gNIU,.
PHYSICA'. DAMAGI
Compro.onlIYODoducti_ 01100 01200 012W 01110O 0 ",000 ,,""",","",",,"
CoillllonOeclUGll_ 0'100 01200 012110 01llOO 0."000""",,,,,,,.,,,,,,,,,,,..,,
LOll 01 U.. b V.. Q,No""""""""",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,..,,,,,,...,,,,,,,,,
"All AW_.'llIAT'DtI PURCHASE 0' A DEOUCTISlE fOR COLLISION COVERAGE LOWER THAN
150018 """'lISAit'll AND THAT THERE IS AN ADDITIONAL COST OF PURCHASiNG A DEDUCTIBLE
,OR COLLISION COVERAGE LOWER THAN 1110O, AHO I AGREE TO ACCEPT IT
.-
~,"""'tu...
,,10 1,...
.L ..
TOTAll8TIMATlD PREMIUM VIHICLlI '2 1
'f~
(AI ApplICable)
~UII AnnUlf ,,.,.,Ium .
pilon 1 - Adv,nce Premium "ym.nt of~.. p'o.,ld~ I)y tn. Rul.. 0' tn, Plln. 18lIaraol.....INfM,IIftID..Plld.lt/'lln30dlVI.,..ftlCIICIIaf.....,__0I~...)
OpllOtl 2 - In.IIMmenI ~rtMtUm .lym'1'I1 (I' 3O'lll1l prOV!tMd I)y tn. Ru'" of I"'. Plan, lllllneeoflnnull,,"""um to DePlld In rtwe 15) montItfyl.~t......~tolMcomptIttd III (I)
"...,...... DOtICr....... _, A ... 00 lnaumtnl Cl\irtrl mUll De !>lId WItrI eedlltllflllmtnl
".... .....~ ..._.............-- - - ..t.A......... "'..."..... 1M.... Oftfy Ie............."..,. ........................,___."'_4. r . MIa
-- ..-- ---..............-, ., .. -
Amounl sub mIned WIth U,., application S " t 4/ .
_N.~O'III"'c.a1rl" A/,.vc.-.-
,lner.. IIIemunblllnce duel pr.vIOu, "meO I'.J V" l-J No
N.,~~Plan? n Ve. rl No WUJ-yearltSlll;tnr'l'lfll'fCOmPlftlftd?
POlICy No.
Termm_non OIM
, ; '1'''$ (.j NO If "No" Fl..!on fermln.htd _
\1' an'l ol".r ""ltl" o.ned by In" m.mDtr 0' nf)u!l~-h~id'?IT-';;;---N~ ---,.~---._.- ~.._-------
II "VftS" qlv. n.n1. of Inlur.,
,''''l.l~'''l'''''',/.'\I
_ PnllCY No _
Nll re ~r')r oIemPJ wner,. ~c_ 'I,".ull,c,_nl .tlokn WIlII'I"_ sn...
NIl",. 01 VlOlll1Ol'l
'ow.
.....
II Ipplle'nl 01 O~" '1IGlbll OPlII'Ol lequlred 10 'III ,wldlnCI QI IInlnC111 I,.ponllbllllv? 0 Yo ~
SOCIII SlcuIUy . AI'luon.''lIp to AppllC.nt
"I 0 Y.. 0 No C... 01 'III Numbel AI,.on 11)1 filinG 51111 Whl" FIling AeqUlfed
T' PI O' 'IlIn "1 110 IlIow for opellllon 0' ownld wlhlelll. Ope"IO"1 110 IlIow tOl opellllon of non-own," w.hlel" 101"
'~Ha. 1ft, appllClnVoprafltol or ."01'11'" Ih, houllnClld, or 'nvon._~h~ ........IIV dllwet tn"ppllc.nl'. molar WlhlCI'I.11 Men InYOtved, IIther.1 o*"" 01
,vol Ill.... \fINClIICC'llInl dUllnflll1e _,THIIITV-6IX monl..' lJ VII l......."V.., , .omplolOlhe'.'Iow,.U' III n-...y, - _-,I
... ..' ..... Of ...... _ ,,104It; I " -;;. ci.i,;, ~
Name 01 0tMrt'0I AccMtInI 0111
own
...
"
I
.
I
VIIS
o
o
o
. -...--."HI._Ml"dri...'.""_-"*'IO""'''''wtlhln2..oulllromllm.oIdctllMll '....."":",,, ,., ,.. ...."", ,., C3
\ O_lypIoI...ldInl- non-cn.ruoobleu_IIf..'......oI,he P1.n.. .....,...,.....,...,...,....,,,....,.... .......:..:;;\.....~,f
1111I_1011110"'.",_1111I_1<1111100_1111_, .,~':O-: "";'.. '
.HII I". 'PPUc~nVopt"IOf 01 .nvan. In ",' hOuMftOkI, 01 .nvonl_~hg UIU.IIV CIrlWI. I.,. I ".., .'
, IITIO IAIL ...'" time during the l.,meclIIIIIV PllClCllng THIRTV.SI)C manU'l.? 0 VII [;il'Io, I' "VII," comptelt ttWfOtt..._I,.,,~ (I'
NO": A paid Ilck,l or tlnl " .n admilllan 01 gulll .nd Ihll.'O,. conllllull' I conwlctlon.
,',
.; 1hI.~" tp In~ 01 th, lollOWlnlll,. "V.," 10 .1It. end glw, d.tI 0' ICCld"'''
1 ~ft'tOtOlwehlellllw1uIIVPlllled..."..,......."."....."............... .........,. ........... ..... ,..,..... .....
J, AH'anl Nlmbullld ttv or on ttlt\aU 01 PlrIOt\ r,lponllbll 'or th, ,ecld.nl 01 hlljudglmenl ....IJ4' ~h VfIIOn . . , . . . . . . , . . . , . , . . , ., ,
J OtttIr..,.on In~'ll'M In .celdlnl WII conYlcttd. Appllcanl 01 opel.IOI WII nOl eOf"l\rlclld ........,........"..........,.........."
0111 01 Ace_I
-..-
Do....
CbnWlctlQft
PlK' of eo.mcuon
, OptlllOl'&lIclnM 01 ''IlllIllIon 01 .ppUc.nl, 01 anyone who Ulullly dflWII lhl .pplu=.nl'l molor v.hlCII b..n IUIPlnd,d 01 r,wollld?
] YII [jIIlJlf; II "VII". Ol~ dltllll
Anlwtl bllow I' .ppllelllon II fOl I non"ow"" polrcy
"1 TYIM 0' Vlhlc~ IPpttClnl Will OPllltl: 0 "''11'''1 '....nger 0 Comrnlf'Cl.1 0 T..I 01 Bu. 0 Other (d.ICIIM)
! bl Vtfllcfe will be opellled In .ppllclnr, OCCUptlllon 01 bUllnl": 0 VII 0 No
lclll ve"lel, ownld by. mlmOll 01 Ih, hOUMhold? 0 VII 0 NQ
I' lb) 01 Ie) il .n...1Id "VII". glw, ".ml 01 I"lUral'CI eompl"V plowidlng hlblhlV cowII.g.
I. ~....~? 0 Vft 0 N.
-
It. 1 _'~\',^'_~r ,~.'..'
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;q~" At'. '"
..,;.... .,,.
.., ,'1'.....
I '. II , f " '. I . , I j 'I I I . I I' r, I I I". I j ~ ,~ I
Tn.. apphClllon I"Ilwlng O..n campl'"dlno dul"1' '.'Cule<J I".n be. "0m 1"1 ,Uecllwld,I,
Ind tlm. Ihown b,low, ''''Id,nc. or InlurlnC,1M t'" hmllland cover.g" I"KIIIIO, subllCI to I"e 101l0Wlng contJlllon3
~ IMMEDIATE BINDING COVERAGE AEOUESTEO'J CJ VII 0 No
, Cower.gll' ,fflCllv. II thl tlml .nd on 1"1 dll. Ihown O,low. provldlld 11"11 EleclronlC Mill B.nl1lnq Ptoc.dura aul"oIl.lO~ bV Subaecllon A 01 StellOn 1201 It'le P,nnlvlwl",1
AIIIl;l"ld Rllk Plan has beln ulillllO Vou musl make propII paymenlln Accordance WII" Item 6 01 7 ')11"'5 appllCAllon Tne Appucant IlalJvl~~d 10 Slqn It... appllclllon.n lha
pr...nc. 01 It-I prOdu(:er 01 r~cord tI EIIClronl(: Mad OIMCllng II ulllllIH'l. conlltmatlon 01 "'1' .lIltl,ve .jJll:! t!5laouahelJ by'''' EleclronlC Mad Retarence Numb't ....n.cn I'"
prCXluc" of r'cold IS reQUited 10 pllCI on Ihls appllcallon
II ElectlonlC Mill Binding II ulllllld. COW"IIOI w.1I nOI b, ,ffectlw, on I'" 11m. Ind d.11 Ihown belOw unl... the EllctronlC M.'I Alt"lne. Number prOWlded 101 In
Pennlvlw.nl' Pie" Section 12 "It bltn "llonn 1M I"e lip'" provldld
1t9/J I () 7
ELECTRONIC ......IL REFERENCE NU...eER
':ltctlonlC Tllnlmllt,l -lM.J I'
v ", '(1." .:,~'....
:lftchwe 0.1' ,"d Time ~ ~ ~~ ~ "Y'
'.4,)/'111'1 Oay yea, H<:lur ~
II ,mm.olll. 0lf1111"9 CO\l.raq~'5 not "QUlflO 'hen It,.! ellect.ve (llle 01 Plan cov'tlge Will be as given oelow In accoroance \,\1111'1 In, provllIlons 01 Pennsylvln'l Plan Sect.on 12 A I
:llectlVI O.te ana Tlml
'-:14 M
MOl'lln o.y 'ur Hour --= P M
2 A premium cl"larg. WIll be mad. lor Ih"e covtraqtall tn. policy, wnen lIntJ as 'ssued. 'S nOI Ice.pl.d by Ine Insure"
r".lnlullne. ,ttOldlO t'ltr.undtr S"III be IvbllCt 10 aU Intllrml ,"cJ condlllo" at I", POtlCV torm p'",nOtO for USlln accordl"" w.Il"llh. rullS at tn, P,nn,vlwlnI. AIIIQnld RIIII PI.n
I ' I ~ I ~.' I I r, I I! !, II ~,11 r l fI. ! II I' j
I und,rlt.nd tl"llt lhl pr.mlum snown on Ii'll. Ippl.e.llon I' an I",mllld premIum Tne company r"IIV" tn, rlghllo .dlult lhl pllmlum
Illhit' PliOI' 10 or ,hll tl'll 1"1,1'"" 0' Ii'll poliCY, whlnlwlIl"ollc.bl, a, ""m.ttld bV 1"1 Rul"lnd R"..IPOrovtd bV fheP,nn"ylwlnlllnlu"nc. OIp,"mtnt In aCCOld.nC'Wllh
Pt""IVlw'''11 l"lur.nce OIP.rtmenl regulatIons, cun cannol bl accepled by'''. Producer 01 Record, Pr.m.um monln 10 Itllt PrOduc.r 0' Record ,1'1111 be onlV In H'I.'orm 01 a
b.nkl .1 mo y order, caSI"II'" l"IecM. I .t,ed cI"I,ck, prem,um Ilnance cneCk or p,rlonal cneCM m.~. payable '0 tr'ia Io'ennS\llvanlll Ass.gntld AIsk Plan
'1: ~ J / ." . ...
BV I n tur. 0.". t. , f ' Hour J' I ~ J '~
IN NO NNT SHAI,L COVER...Gf, eE EFFECTIVE PAIOII TO THE OA TE
"IINO HOUA OF COMPl.nlON 0' THIS ...PPLIC...TION
MV lignltul'l h.reon IIpI..."I. Clrtlfle.llon of Ih. $Iatemlnl 01 tn, PlocJUCII 01 AlCord on Inl fe" 0' Ihll .ppllUllon ANO I Clrtlfy ",,' IppUc:.tlon I. lubmiUld pUl'lu.nllO I".
effecl..,. d81.Z9~~r~n~1d lh~1 A Ignld" Plan 0' Ihl. .1Ile and .,comp.nild bV.1I COWII'Ql/lee.pllnc. r'llCllon fOlml m.nd:l~ ~y AclS
ev, __'~)_.__ _ 0... ~/C,I'J_Hour 3', 0''''-
.' 'O,.tUFII __ ' 1!i"'II.
Inauranca Companies operating in the Commonweelth of Pennaylvanie are required by law to make available 'or purchasea the
following benefits lor you, your spouae or other rllletive or minors In your custody 0' in the custody 0' your relatives, residing In your
household, occupants of your motor vehicle or persons stnick by your motor vehicle:
(1) Mldlcal benefits, up to alleast $100,000,
(1.1) Extraordinary medical benefits, from $100,000 10 1,100,000, which may be offered in increments of $100,000,
(2) Income loss benefits, up to et le8lt $2,500 per month up to a maximum benetit of at least $50,000,
(3) Acclcflll..1 death benefits, up to at teast $25,000,
(4) Funeral beneflll. $2,500.
(5) Aa an allernatlve 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 f,om the date of thllccident, which ever occurs f'"t, subject to a limit on
accidental death benelit of $25,000 and a limit on funeral benefit of $2,500, provldBcf that nothing contalnld In this
subsection .hall be construed to limit, reduce, mOdify 0' change the prOVisions of section 171 5(d) (relating to availability
of 11m I"'.
(6) Unlnaured, underinsured and bodily injury liability coverage up to at least S 100,000 because of Injury to one person In any
one accidenland up to at least S3OO,OOO because of Injury to two or more persl)ns In anyone acoldant or. at the option of
the Insurer, up tostleast $300,000 in a single limit fo, these cove,eges, accept fo, policies Issued underthe AsslgnBcf Risk
" , P.Jan..~Jso. lit lelst $5,000 for damage to p,operly of others in anyone accident.
',.r., ~crdfilOnally, Insurers may o"e', hIgh., benefit revel than those enumerited above as well i. additional beneflll, However,
an Insured may elect to purchase lower benehllevels than Ihose enumerated ebove, Your Signature on this notice 0' your
payment of any renewal premium evidencel you, aclual knowledge and understanding of the availability of the.e
llenefl.. andlimll' a. well as the benefits and Iim.ts you have selected
If you have any questions or you do not understand all of the Villous opllons avaIlable to you, contacl your agent 0'
company, If you do nOI understand any ofthe provisions conta. e in thIS nollce, contact youragen.orcompany before
you aign.
". .......
""m.uf05*.lct
'hhJ'IIJ"" .,,, ,I
lQ"'"
!jlll'
_...... oper.lor'a UC'M" ot ,,,lllt.llon ol.pplk;.nl, or .nyon. who 1J.1J.lly drlv" Ihl .ppli.C.,,1'1 molor v.hlCI. b"" IUlp,,,d.d ot t.voktd?
J 'tM (jlfC II "Yo", glV, d.I.II. - -
1. r.' iI. ""tit H
~nlw" bllow II .ppllc.1I0" t, 'Ot I "on-ow",' poliCy
I.) TWpeof vehlc~,pplU:.nl will operll.: 0 Prlv'l. PI...nget 0 Commercl,l 0 Tilt' or Bu.
Ib) YIfI~w,1I be ope"ttd In .ppIlC'"'''' occup.IlO" Ot bUll"",: 0 V.. 0 No
leI II vehlcl. o.nR by. m.mber 01 I'" noullnold? 0 VII 0 No
illb) Ot leI " ,nlw.rK "VII", gt.... ",m, 01 t"lurlnu comp."y ph)vld'n" lI.bllll., CO"',,,,.
IlIppIlCI/ll...ludOd? 0 YH 0 No
-
,
, '.\~~'~,
,,,t,, ~'" ,,; ..
. '
/rl....
r,l Oln., /tJllcubel
,:t,/,'
. .
'.
,.,l'. ~
.,
'f,',
I Villi . I I ",' L 'I. AnI t , fill t . II I r I'.' I l^ II 'JI I I J',/ 111\1./
TM.. ,pplltll.on n'\llml b..n eoll1pl.llIlJ 11111 .jlJlYl'Il'I:ul,() ,1'1,11 be. Itl.1m Ih' .lIttlll/fIJ.t,
llld 11m' Ihown tlllOw, '"'d,,,nCI 1)1 Inlu,.nCI In 11'1, 11"'111 I"d eO"l'",guIIP.ClllltJ $IJblltclll) thll1ollOwl.Hj ~'J"(lll"ll'~
:i IMMEDIATE BINDING COVER.AGE REOUESTEO" I'; v.. [J No
, Co"".g"1 .IItell"l" .llh.llm, '''12 on In. 1211. IIhOl/fn bIlow, pro"l'lrjltO Ihe Elecl,onlC M,118Irtl.llnq PrOCltl'Urlt IIIJlhlHllltlJ bV 5vb'ltCllon P. 01 5.cIIOO 12 Ollh. P,nnlvl"l"""
AIIlgntd R'lk PI"n h81 tllten ullllzed You musl ma~e prope' Doym."l In IIC(O"'""C(I Wllh Il~m t) I)r' ,:1 It-Ill iliJC!l(ftlIC)" ft,lt il~plll:lInl IS ;1'Jv'~~"IQ luqn IhllllpplleallC'n In 11'11'
prll"ncl 01 Ih, ptorJucr, 1,)1 rllco,d II EllIel/onle MII,I blnd.ng Il:!lJlllllitlJ, ';uJllltlrlll\IlJIl 'Jllhe enllCII~1J ').lIe +,~I/lbI15h~11 t~ I"'" t 11!t;ltUPIl: M,lll ""lItt.ne. Numtllr l/fhlch ""lit
prOduc.t 01 rICOtd lIS t'QUlttd 10 plIC' on II'IIIS appllClllon I
If Electton,c M.II Blnd,ng II ullHnd, CO"l',tlg. w,lI nol bl .!teCh"e on Ihe 11m. Ind dlle Ihown ~IOlLllL UllI.U lht lil.cltonlC Mill Aet,,,ne. Number provided rOt 1M
P,nnlylv.nl. PI,." S,ellon , 2 h.. bean ..llof1h 1M Ihe oP'c' prO"llJ'd
"'1.96 I D 7
ELECTRONIC MAIL REFERENCE NUMeER
~1.cltonIC Tr.nlmllt'I~'; '9
~ _" I . ,.~ · :,d 'AM
:lIlcl,,,, DIU' 11M T,r"" '" _~ ~ ... M..,.;"
'.I'lllrn Oily "'JIf H'l";- ~
II ,mml<!l,11t blt1llmq (O~.tlqf 'b nI,)l r.QulleCl lh,,, IhE' ,rlf('tl~' tJ.:tte 01 Pllln Covlltrllqt \11111 bit all glvln blt.c)..... ill ilCC1Jr'lolnc,lt \111/1'1 IhE' IlHJ~I&ll,)nlS lj\ P(l"nsyl~"nl' PI"n 5ltellQn 12 A I
ill'CII,,1 O.I'lInd Tim. ' : '" tvl
~onlh Dlv 1~1t Hour P tvl
:. A Ot.mll"m cherq. Will b. mol.l' 101 11'1.., CO",'lqllll' !hlt POliCY \III1It" onl,] 011 IUueiJ, II not 8((Op'.0 by ''''Il'llsurltc;J
1 Th' Inlu"ne. .Ilordld "",unci" 111'1.11 be lubltK110 III IhtlermllInd conClII.on olIn, POIICV lo,m IHItICllb.d !O' 1;11 tn accon:lBnct Wllh lh. tullS Ollh. P~~~I~~I~~I.Ig.n~ Rllk Pl,n
1'1l1 r,~I( Ir,' III 11 Hr,1Ifli\! II Hl
I uncltr'llnd Ihlllh. prlmlum ,hown on th'l .pphelllon II In ,lIImll'd pt,m't,lm rt1. comp.ny ,...tvUlh, tl"hllO 'ClIU,llh' pttmlum
"".."prIOt toor,h'tth'IIIUlnc, olll'l'POlicV. wh.ntVI' .p~hC'bl' "ptrmlll.d by Ih. Rul..."d R'l" Ipp,ov.d by Ihe p,nnllv'v,nl.lnIU"nct Dlp.rtm.nl," .ceotC.ne_ WII~
P.n"lylvlnlllnIUrl1nC' Oeparlmenl "QulllIOnS, CUh connol be oceeplpd bV Ihe Producer 01 A.corl,], Premium mo"..~!lo !MI!' PriJduClr 01 ~ecord IIhall tie on IV In I~. lorm 01 a
blnkl .1 mo y ordtr, cash I'''' hiCk, t .11110 cheCk, pfl!mlUm Ilnance eher,1I or perlonlll CMCIl mlOft ~IIVllble 10 the l-'enn!yl~Bnlll AUlgn"C1 R'lk Plan
ey n I :' '.,\ /It-,- _ 0". t'4 J l, J f t _ Hou' :J, 6"
ntur. ~ ' ,
IN NO UNT SH~LL COVER~GE eE EFFECTIVE PRIOR TO THE O~TE
"'NO HOUR 0' COMPlETION OF ?'HIS ~PPlIC~TION
My Ilg"'tu,.. ",~ reprnenlt ctnlllelUon of It'I, SI.tlm.n. ollnl Producer of RlCord on 11'1, "C' ollnll 'JlPuc.tiO" AND I clnify ttlll'PPUClllon II Iubmitttd pUrlu,nllO It'I.
.".."" da"~~r~n~td. In~. ~ "gnod l' Plan ollhia ..... end .<companied by .".o'.r.g.I....PI.n.. "I.."on forma m.nd:l:d:; ~., e
ey,_ '>(_. J_.__ 0... ~/c,I', Hour:r. D.""
..~~~ ~ ' ~.
Insurance Companies operating In the Commonwealth of Pennsylvania are required by law to make available for purchases the
following benefits for you, your spoule or other relative 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:
11) Medical beneflte, up to et leest $100,000,
(1.1) Extraordinary medical benefits, from $100,000 to 1,100,000, which may be offered In Increments of $100,000,
(2~ Income loss benefits, up to at least $2,500 per month up to a maximum benefit of alleast $50,000.
13! Accidental death benefits, up to at least $25,000,
(4 Funeral benefits, $2,500,
(5 As an alternative to peragraphs (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 datil of the accident, which ever occurs flrsl. subject to allmlt on
accldenlal death benefit of $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) (relating to availability
of limits),
(6) Uninsured, underlnsured and bodily Injury liability coverage up to at least $1 00,000 because of injury to one persun in any
one accident and up to at least $300,000 because of Injury to two or more persons in anyone accident or, atthe option ot
the Insurer, up to at least $300,000 in a single limit for these coverages, accept for pOlicies issued under the Assigned Risk
~", Plan 'Also,.t I88St $5,000 for damage to property of others In anyone accident.
,J.'.,.. " AddrtlOrially, Insurers may offer higher benefit level than those enume;aled 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 renewa' premium evidences your actual knowledge and understanding of the availability of these
benafllland 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 avellable to you, contact your agent Dr
company, If you do not understand any of the provisions conta! e In this notice, contact )'our agen\or company before
you sign.
..: ........
..... ,;;, '
I DICl.AIII AND CIIITln THAT: lIll HAVI TIIIID AND 'AILlD TODeTAIN AUTDMoeu-.,IIC8.' THla ITATI WITHIN THI
, DATlIaTUTllNOT IllClIDIHG'THOM APftJCAIIo8 UNDIIl THI NHHIYLVANIAAI8IQNID 11111I-. (2) To""_oI mv ._.....ncl....leflll.,
.....I"'**eon......IrI""' Ippfk:luon ",Irvet (3.' cert~ Ih., f dO not owel"ymlut.ncecompany any .ulOmobU.premtum..... Of' coni_led dun", 11'11 Pllt '2 monU"
(4) I dealt"..... ProcIUCtrol Atcotd lor 1l'lllln'Urlnc,lhe prO<Jucer n.mld In 'hll .ppllcltion Ind I "ndellland he 'I not .eljng II an Iger" of the P",nlYh."la AII,,,"':!"'I" PI,"
Ot In., COfftPMW 10' the PurpoH of Il'IlllnlUtll'lCI. (&~ l.gtNII'l.. 1'000....,.01.111 be ,"ectiv_lt my pNmtunl'lWnitlAnCI, whiCh lCOOmpAntel tN.. J "1"~ and 1I1orwarded to
lhe....... OItfW, 6IjutlllllOly dllPlOnOttd by In. tI"lnCI.II".tlIullon.
The""" ~........... ........1.oQ!>laln qpver.g. lor you IhtOuQn 11'1, I/olun'try m.rllll, Tnll apPhClllon '1 lor cov.rl;_ ,"'OU;" I"' ',nnlylv.".. AI'iOned Ai'" PII"
. ..........01 .ppl U n, "OIJ_~ rtq,*l~wr~,,"Q tntl'ltM Inturlnel CMpartm.nt.......tMretton.-"yyouw.,.u.-b..'oobt.lncOVWrapll'lrougf\
_ 0.,. I~ It, I, J Hour 3: .' 0 A....,
, , ~
In Cjlllon 10 rouhM VerlllCallon 01 ,nlormallon perlln.nllo ",. Insuranr.' IIpph.d lor, II Ih. IIppllc.llon 1$ tly In IndlVtdu.llor
~tl""tlIyIO'pef'IOnll or 'Im,Iy purpO"I, In.lnllurer 10 which 1111 11119"'<2 may have !I" Irt"estlqll.ve consumer rttpOrl mAr:t,lnCludlng ."Iotmllllon b..tlng on ChltlCltr, g"n.,1I
"PIJ111Ion, ptrlO,'11 cn.tlCl"t'lIc.ormodlolll~ln9 InCl, upon Ihllndl"ldutl'! wrlllen rIQUIII, will dIsclose In wtltlng Ihtf111lut. iI"lJ scop. of Ih'ln".atlg.tlon tequllled, I' such I
report IS proc.,ecI
NOTtel TO A~PUCAN' AND '''ODUCI'': In ~n, ,v_nl .clcnowl.dg.m'"1 01 cov,r.g_ II nOI t'C'IVed wlltun 30 dlys, nOllly lh. PI'n OffIC', P 0 80)( &610, PrOVlde"C_. AI
o:l94O-6610 Pi.... 0'" IppIIC.tIO" number
'"
IElllllblt 8
I.. .'. q'."'l"'" ,..OJf" II
r'
"
I
i
. .' 't
"'"'
'"':."-
, ,".0, Oortl'<'I> "'5'.... ~'CP
l', pick~p 01\':Ll: tl:3t yo~ 0..11; or 1 ru.n..' ..-~ L
c, rraU., IUcd ",illl ~ ..hJcle dcscribed Cd
~. or b. abo.., -. ':c
9, C&<!ltd by or au cOlllCqueo~e of:. :
Q, dlllCharse of a Duclcar weapoll (even If
~ecidClllal);
b, war (decl~.rtd or Wldecilled);
c, cili! war,
d, wurrKlioll; or
e, rebellioll or revolulioll.
lO. From or au conscquccce of we rouo,..fnr,
whether controlled or Ullcontrolled or
however C3 used:
L nuclcu reactioll;
b. ~diatioll; or
c, radioactive cODuuniMtion,
-
, .
UMlT OF LIABIL1TY
A. ~ limit of liability $nowt! in thc DccluatiO,D$
for this covcraCt i$ o~r [llJJl.imWl1 limII of li.
ability forcach penoll icj=d in allY OIlUq:i.
dell\. Thi$ i$ the mOlt we will pay rc~ardJas
'of the lIumber of: ' '
1. !1I.11I"D;
2. C1~s made;
3. VchJclcs or prc:niucssnowtlin 1M DccJa.
",aons, or
4, Vehicln iavolvcd in ilie accideat. '
8, AllY :u:lOlJ1lts othe",i$( p.l~'.lblc for exp=
~1Id'er !hi$ cover"g. s!l.lU be redueed by any
amoWlts p.ud or payable for the ~ cx'
pen>n WIder Put A or Part C,
C. t';o p~ymCllI will bc madc uclC'>. thc injured
pcr,oD or that petsOD'S I.S,u reprC$clltativc C.
aio\tcc> in "rinDI that "-"y p..ymcut ltl.'lll be
Jprlicd ['Jwaro any ~.ttJe::!!cct or judgr.:teD:
th~t person :eccives unde~ p"~[ A or Part C,
, \ 0 0_ , II' I I ~ ~
...,
-.
t{ therc IS ower .1ppUcablc aUIo medIcal paymel1Ll
illlurLll~e we will pay 0111)' our swe of the 10$$,
Our share is the proportioll th.1t our li:nlt of U.
~btlity bclt:-$ to tile lOW of all applialblc limil.l,
Ho..e"r, any insurancc we provide with rcspect
to 3 vehiclc you do 1I0t Owtl .b.tJJ be ex.c.e5S over
nn) other collectible 3UIO WuraJlce providina
paymell~' for medical or funernleltPClISdl
PART C - li~lN5lrRED MOTORISts COV.
ERAGE - C
C'iSl:tmiG AGREEML'1'
>
A, We will p.l~' dam.1Ce5 which all btsu"d is Ie.
gally etltitled to recover Crom the oWller or op-
enuor of llJl 1I/I;1U"",d milro, ,,1IId6 'b.:catI5C
of bodily lnJu,y: '.
L Su.staioed by aD iMa,ct; alld
2, CauJed by lU1l1ccidC'tlL
The owaer's or opera lor's liabiliry for thllle
danlages mU$t arise out of the OWl!Cf'1hip,
maintelWlce or use of the 1IIIi_,d milUJ, .,-
hiti, ,
Any j~d8llleat for ila.m.1gci arlsin~ out of a
, suit brought ..ithout our written co~nt is
DOt bindiag on us.
B, -/",,,,,II'.ll used in this Pert mt:1cs:
L y oJ~ orallY flJmiJy f'IlII/fbn.
, Any other per10n occupying >'0", co.",d
IUIto,
3 .~~' pmon for damaics Wt persoll is co.
titlcd to recover bccaU$t ofbodlJ>'j1ljll7y to
whJcll this coJveraic applies 5u.s~illcd by 11
pcr;OD d.""ribcd it! I. or 2. above,
"
,
-C,,;,,'u,~d _'0' .,laieu" mr.lllslllllCd alotor
,oriel. or tnlilcr ota.llY type:
!, ToJ" hl~h DoJ boJily iojury lillbiil~ boad oJr
poitcy ;.tppHt.. at ~e tim~ ort!:~ ;!~r:tden:.
~
JOQ;P
rDctud,~ .;"p~ntt-~lC"d O.1t~n:1: C": r~.j~"'1ac~" S~:"\'ICes O:'!ke, '~~il". it; p~rmjSSt\."lC. Co;t~!h:.
[n~ur..1:'':-: "'~r-.:t.:4f, Of!i\.'c [:..: !,)~.(
--_._~ "----.----
-------
--~-_..
I- ~ .: '1,1..
.1
,......
w
.'. -'"=-,....... .-,
',2. To w!lich 4 bodJ.!y Injury liabllily oon.:i or
.i~ policy appllri al the time of the llc':ldecl
If: ' Lu thhc~ ICslimit fllr bocllly injul)' lIabii.
"t II)' mUll be Ic:lJ than the m.in.imWllllmit fe'r
~ blldll> injur, liabilily' speti1ied by the fl.
D4ntilll rtllponsibiU~' 131> of the llltte u;
., which yllu, ell.n,d tlUfll is principall,' ~3'
l'a!ed.
,J. Which is:1 hit an..J nu: vehicle l"holl! ope"
'.' ator or owner ClUlnOI b. id,nnJJ.d and
~'hicl1 !lits:
:::".'
II.. you. 01' any fmd/y _mbn:
, ,,'. b a v,hiel. wb,kb you or any' family
Q~. m,mbn an: IIccupying; or
r," e, ,lIur tlo,#wllUltll.
~.~. To which a bodily injury liability be:d 0:
:~,'" poUey applies at the time of the ao;idcCI
; " ' bu.t lb. boDding or illsLlring company:
",7 ..~. denJeseov.rag.; or' '. ' '~'
b, is or ~omu insolvent.
.)'! ; . , . , .." " .
, Ho~'ever.llllinsuntl m,;tll~ ,#1rkU doq DOl in.
clud. any vehlel. or .quipmeut: ..' .. " ,
1. OWlled by or fumisb.td aravailable for tile
reauLu' use of YOll or any ftlltlil, tMmbn,
~ "I' .
_ 2, Owned or operaled by 3 self.ll3:I=r llrlde~
. any appllc:a ble motor vehlc:le'.1a w: :
. 3. Owned by any gove~t3.l unit or
ageuc:y.
4. Operaled 00 ..ws or CT:lwler troIds,
S. DesilD.d lll.1iniy for use of! public road!
w1ll1. not OD public road$,
6. While localCd for use i$ a lnideu.;. 0,
pmni.ses.
EXCLL'SIONS
,... W. do nOI pro,ide U~.d MotorislS Co',,,
=sc for 1I1111iJ;p11r}ury 5U$wocd by an} per.
SOll:
~lucLcs copyn!lhted /:l4teri41 of [=cc
~WUllc:e Services Office.. ine.. 1955
":'.,-------_.- -
',.L 1\,", Ill.'
-
ft;1. Wbl!~ IIc~uI'YIIl,t(, or I>ben s!nl.:k by'. an~
,~, a~tllr \cluek 01> ned b~ ~oJ~ or any f/lmilF
mtmbt' "we: i! Dot in.ur.d for lhis co,.
~ ~ .ru,~ \lcde: this policy. This inelud~s ~
,,: Inlller or.ny type ~.<I with th.r vehicle,
"~2, If lbat perlon or tit. le~:lL r~ptl:~ntl!tive
.ml.s the bodil}' 'If Jill?' elallll "ithllut our
~on$cc.t.
3 While o~(up.lill!l ,I'OU' (O,t,ttl ""to wheo it
is bc:i n~ LlUd to =ry penon$ or property'
for a fee, nus e~ellt$ion (A.3,) doJes Dot
apply to a !lure.the-expensc ell' pool.
4, Usin, a v~!liele withom a n:a$onablc boelief
tb.at that penon is entitled to do so,
B. Th. COVetltie sball nOI apply djrtl:uy vr iodj.
reelly to bc:nefil any iosll!er Or ,,,,If.inS\l~er un.
der 3.!ly of the following or similar la",
I. worker's eompraillUoo law; or
2 djsabllity bcnelil$law.
Lt\1lf OF LJABlLrry ,
A. The limit 'Or'liability shown io lbe DeelualioJ1.j
for .'ltell person for Uninsured Motvrisl$ Cov-
era!:, is oW' tDaxj.m~ limit of liabilil)' for all
d3fr,asn. includin, damait:! for are, loss of
services Or death. arising out of blldIJ, iIIjray
I' stl.StUlltd by any on. pet10n in any on. ac:ci.
d.n:. Subject to this limit for each pe~on. the
limi: of liabllilY sho"u in the Declarations for
t.3c); acc:idect for U oh.sured MotorislS Cover.
: 3ge is 0'" m3:<imwn limit of liability for all
~. ~.g.s for bodily /lIjr1ry resulting from any
" ' ODc accident. This is the cost we will p<1y re.
;. aardlt:!s of the number of:
I, /ruIl,rlb;
2. ClaiJr..s Clade:
3, V.llieles a: ~re:nitc=lS IbllWU i.o. the OKla.
" nbo~. 0:-
4, \'cillelcs In,olved ic the aec:i<lcnt.
9
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effie" wi:.;. i:s pCl'llIJ:LSlon. Copyn~t,
t.' "'.
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1.\it. t ,,~'j Nb',
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- -....... -.----=.....'
8. Any umOUOIS otherwisc p,,~"b:. for ~WJ1l~!~
lIQder thb coverll~e sboll bc reduced by Q~
5u.a1O:
I, Puid b.~uUle of the boJJly Injury b~ or on
behalf of person~ or or!aointioo. who
Oltly be legally re,poulible, Till. lIIc1,!dQ
WI sum" pllid WIder Put A:;JJId '
2, Paid or !,uyable bccall$C 01' thc bodily In.
Jury uDder aoy of the folloYoing or sunilAr
IIlW:
Q, workers' compcn:lo1tilllllaw: 0'
b. disability benefits 13w,
C, MY payment under this cover:1ge will red=
any .mouDt th,lt person'" entitlCll !O recover
: for the 5lLQle damagcs WIder Put A, :E
OTlIER INSt,,'RA.:"!=E
J
If there i" other appUcable 11I:tlil~ inll,,",u..e 9/e
will pay ollly our shue of the loss. Our sbare i:tll!t
prllporlion Wt our limil of liabiUry be:J.IS to'lhe
lo~l of lI,llapplicable \imlts. l{.:lwcver, any ll1Sllf'
ance we provide with respect 10 a vehicle you do
Inol own shall be CJ(ce$S 0'.1' anY,othcr cIlU~li.~
IlS\l!3IlCC, " '
AltBrrRATION
.~ .
. '; ~
A. If we ll.lId 3JI itIsIIIcd do 1I01'eree:
L Whether that persoD is I~~o.lly entilled to
recover damages WIder this part; or
2, ~ 10 the a.mOUXII of cl4m.ges:
either part)' lII3Y JD&ke a wotteO delll3nd' for
arbiUlldoll- ill this even:. each put)' will lelcct
an arbitrator, The tv..o arbiUlllors v.;U seltelS
thir<.1. If they ...wIot agree within 30 days, ei.
ther may ~uest wt selectioll be Clade by a
judge of a court 9vin!Juri"diction.
8, Each party will:
1. PllY tbe e~peDses it incurs: and
1. BC'U:he e~pellsel of the thl:d ;!!bltr.ltur
.q u:01ly.
(. uu"~s, both purtlc:l "!ru otherwise. arbi.
!l'1ltion will wke pl~.e in the count) in "l1ich
me lIuurtJ \l.es LQ''11 rules of law os to pro-
cedure ~nd e,idco~ ",m appl~, ^ decl :11011
~lP'!ed 10 b~ t"'O of the arbicrutors ....,11 be
bln,iinll "" to:
l. Whether the iMuftd i, legu.lly entitled to
,..:o.er dUlll1lln; and
2, The=llulltofdllm"~es. Tl1iuppll\\5olll~
if the amount don not exc-ccd the m~ni.
mwn limit for bodil)' LIljllT}' liabiliry speci.
fied by the financi.u reSpopsibility law of
the $to\te ill which your' (ortfl/J au,ro i.
prillcipally garlSe<.1. If the &mOUXIt exceeds
that lic:U1, either. party D;l..y.demand the
diht to '1 trilll, Tru~ demand llIUSl be made
within 60 days of the ubitiiilois' decision.
If thls dcmi.lld illlOt made. the amount 01'
da.maits aiecd to by the'irliitr:llOrs will
be bin<lillS.' , :' ' '\ ':",
.
. . .' ,~." -:
PAJH D - COVERAGE FOR D,\.\fAGE TO
YOl,JUIJTO - '0, .~ ..,;~
- . ...-'
INSlJlWiG AGREEMEI\i" '". ..
..' ... ~ .
A, We 'will PllY for direct aDd' a~~dentallo$$ to
,l'our (o,,,,d I1MlO or O!1y M/I~"Md /DIf.O, in.
dueling their equiplllelll. mlnllS allY applicable
deductible sbo\';u in the DeclaratiotlS. We will
pay for 1015 to your (0.",4 /IIlfD caused by:
l, Other wn ,.IUsto" oo1v if the Dedara-
lions indicate that Other Th.an Collision
Co.er-Jlle is Ilro\'ided for that auto,
2 Collision only if the Oeclaratiolls indicau:
that Collision CovcJ:"J.lle is provided for
that aulO,
II' there is a 10:15 to a """>4"/I6d auro, we will
provide the broade:ll ~()veralle applicable to
any yo," (o""d aulO :ihown in me Oeclora-
ooQ.$.
10
JOO4P
Ulclud... copyti~ted m~ltri:!l of lJ1.snl'':1llCe ,Se,vkCl Office, 1IIi:ll its pcrmi$Sion. CopynPI.
!.c~u.r.:.'::~ ~~r,iC'tS OffiCII;, lL":.. t93~
..-. - ----~.._..- -~---~--
---
;! o..".d by any go,.,nmenw unit or
~~er.cy ,
:;, Opel:l~d on r:uh or .;to! wier m,,,,ds.
~ De-.ig.ned :n:lln!~ for"'" off p~blic roads
while not on pubuc rotid.:;, ,
, Wb.lle iOc-.lt.ed fo~ use a, a m,dC'!:<" or
p:cmis~,
EXCLl;SIO:'\S
,\, We do not provide 1! ninsured,'L' n~t.ri.nm....d
MotorislS Cove!".1gc ror bodily inj!D'Y ,'\l>I.alllec
bv ony' pc~on; ,
l U wt ~on (lr.u;" 1<:)l3.1 ~p=t.lnv.
s<x<:$ the bodily IqurY c!;uw \\1thO~t QU!
con",nr.
" V,1ille oC<lIpy/il1 yolD cor~"il1J/lo when l\
i~ beUlg used to C:W;' pcnoO$ Ot property
f(lr d fee, Thi; e~clusion doeS not appl~ to
a shaIe.tbt-cxp.en5e car pooL
3. l.">in~ a vehicle ",ithom:l. re.1solUhle belief
th3.r m:,.t pc[~nls .ntitle';! to do so" ,.
B. This covetaie $bai.! oot'apply directly.or indi.
rectly [0 benefit any ins=r or sclf.jllSurer un.
der any of the foUoWlog or simil:tr iaw
\, wotken' compensation l.1..~, ,or
2. disability be1lefit;fla~. '. '" ' '
-
U'\lIT 0 F LlABIl.ITY
,:....! ~ ,.' . -~.' ..;.
. :.~t;~ ~ ~'. .::". .... ..,......~...,,;
ScbJeet to the tllWUmum limit for ca<:h
pt"I"Jon delCribed in Labove, 0\:1' rnui.
tnuID IL'1:Ut of Ua.bility f(lr all damaics <U:l5'
in'. .JUt of boud)' injury r~uJllD; frOlL any
0;'. J",-tdenr is the S\Ull (If lbe lIIllirs of Ii.
abUil)' sbown III the Schtdme or in the
D""lllr.llJoCS for eael, accident for
tJ!litl:iuredIUndennsured :\1ol0n5'..s COy.
=ae,
. Subleel to the 1Il:o.'li:nnm limiu of liability
set CorJ! in L and 2, above. tbt most we
"ill pay for bo4i/y i1IJur7 Su.mlned i.n sw:h
JeCldent bv ;w insJIrer/ other' th.ul you (';
3..~y farrriJ; rrann/J1i' is the'each. penon or
t~~It a~cident limit of UabiTI,t)I shoyro "'- the
Sclt.:dule Or l!l thr. De.::ltlr.1IJOO$ ~pplicable
tv tbe vehicle that the /tuIIrtll was tKt:>>py.
ing ~l the llIllt of the Rcci~tnt,
The ~'<imum limit of llilbility is the most we
will pay regardl~$ of the number of:
1. 1.1IIUdr;
, O:li.rm made:
, Vehicles ot premitmlS sho..n in the Sched.
ule Ot in the Declantioll5; or
>I Vehicle-; involv.:d La the arnd.:nt.
8, U bodily injuy is sustaia~d b~ any Dwuld
othtr th,a,n you or ou>y fanril1 mI1fIl>/tr 1Il;ul a.c.
Cldent La which neither YIlU not any family
/IlirMer' ~ "'odUy~i1fJrirF the liinit (WU.
abilirv sh(lWO in the Sc!lJ:dll1e or in th.:. Dec12,
r~ooCs fot .;a,h' peison ,for U~d'
c', Undt'rinsmed 'Motorists.:Covera&"~is :';'ur
1ll.1.'ClmLllJ1l1m1t of liabili tv fot:ill daml"'l~. tn.
eludiog dalllDges: for'.car~ les>, of services or
death. ..osin:l o,ut of botJily injray ~ b,
'any ooe pel'500 in any oneaccid<1lt. Subject to
this limit for e~,h pe~on;;the limit of .jjabilitv
sbvW!l u, the Scbedule or in the De<:larations
lor, ea.e!:; 'J,cid~t, . for' : tJ~
;, Undennsumi Motorise- '.co.e~e ,..is~nr
, w:OOmuID liniit'ofliabiIJtifoi:8lt~ for
bud:!,'inj!D'Y=1ting'frooUlll'00. dO lknt.
A. If bodiJ, brfta1lS sustained tn an acrid.etlt by
yOU 0: any jGnfily tutrt/Jttr: ,.'. .
. . _._ . "." I' I,
; 1. Olll tiiammnn lImit ~f li:lbiliry",:j'Ot' all
, dama&es. inc!udtng d.UD~ii:S' f'!j- ~Jpss , "
of sctvices or dcath;'';,.;<itig 6utof:bodily
:u;-o ,,~Jur1,~!ly.llflY"~JlC~Jt!J1l~
.~:, S\lCh=;iAem1-S the,~9,r,th"~_I$.,Qf,1is
. '. :: . ability ~hown '? the Sctiedul<c~~ ~:,Ule
:::::, . ,.' ~ dedarauons, tor tnch _person fot
~-~~U - -. ~~" r_ ,~_~....\~.:.;;;,;;j"",O;"" 1 .
. _ _~_. mUSUIWUL.U.ll......,.,'lUl...UU;;;lro,J .:Y'IV4'oI'I...-.>' ".l)V
~- ..- - . - .
.~...:. ~_-":4 '.u:ra8e";-::-~. _:. ~ ":'",7":r:~~
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inclUdes cO'Pyri~ m:1teI\;ll Clt';lu.<onr.uP"1~et'Vic..~ O~Tl\A. ....it.o. Its. pern:l.>s!lJo. uCvpy:"1~h~.
!n,;UI:lllC1: ~!VIce'I' omco. ~c. 19M:' I Q~~ ..:..
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~""'~"'!'i.,""n""'l "HI.,,""" 1<1" 1",1'-'111 (i)
exhibit 0
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Exhibit E
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Exhibit F
f
,-..
LENORA H. SKIVINGTON,
Petitioner
: IN THE COURT OF COMMON PLEAS
: DAOPIiIN COUNTY, PENNSYLVANIA
I
: CIVIL ACTION - LAW
v.
STATE FARK INSURANCE COMPANY,
Raeponclent
NO. ~BJ.5-q'l
.
.
i
I
I
'I
II
'ftITIOIf 10 COMJIIlt. tnrnfSUltANCIl ARBITR1TION
11
i
,\
II
I
AND NOW, come the Petitioner Lenora M. Skivinqt:on, by her
attorneys lnqino , Rovner, P.C. ancl respectfully requests this
Honorable court to:
1. ColIIPel Respondent State Fan to arbitrate Petitioner's
uninsuranc:e motorist's claim;
2. Ord.er Respondent to select a second Arbitrator; and
3. Compel Responclent to pay Petitioner's counsel fees.
Xn support, Petitioner respectfully represents the followinq:
1. Petitioner Lenora M. Skivinqton is an adult inctividual
residinq in Camp Hill, cumberland County, PennsYlvania.
2. Respondent State F~rm is an insurance comp-any licensed to
do business in the Commonwealth of Pennsylvania with otfice.
locate4 1n New CWDl:lerland, cumberland County, Pennsylvania.
3. On Auqust .2, 1993, Petitioner Lenora M. Skivinqton was
injurecl 1n an automobile accident ~.t MaClay street, Dauphin county,
Pennsylvania.
4. On lu9wIt 12, 1993, Petitioner Lenora M. Skivinqton... A
;9!l:!/tAW
,
r-
~
ROL' E. KROLL, ESQUIRE
PI, Supr_ Court I,D, No. 47243
HlULKROD. REYNOLDS & HAVAS
A Profl.atonll Corporation
101 Pin. Str..t
Poat Ollie. lox 932
Harrlaburg, Plnnaylvlnll 1710"0932
Ttl.phone:
'UI
[7171 236.3200
[717] 236'6163
AttornlY lor Plllntl",
STATE 'ARM INSURANCE
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
: NO.
LENORA M. SKIVINGTON,
Defendant
CIVIL ACTION - LAW
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 pe~sonally 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 Plaintiff. You may lose money
or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU 00 NOT
HAVE A LAWYER OR CANNOT AFFORD ONE. GO TO OR TELEPHONE THE OFFICE
SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Lawyer Referral Service
Court Administrator
Cumberland County Courthouse
carlisle, Pennsylvania 17013
(717) 240-6200
IDnKIA
Le han demandado a usted en la corte. Si usted quiere
defenderse de estas demandas expuestas en las paginas siguientes,
usted tiene viento (20) dias de plazo al partir de le fecha de la
demanda y la notificacion. Usted debe presentar una apariencia
~
3. Derendant was born on September 6, 1975.
OCctJRlmNC2
4. On or about September 30, 1991, Defendant executed an
A..igned Risk Plan Application ("Application"), for a private
passenge.r automobile insurance policy which was ultimately issued
by State Farm Mutual Automobile Insurance Company, Policy No.
B20 1007-F21-38 ("Policy"). A true and correct copy of the
Application J.IB attached hereto and identified as Exhibit "A".
True and correct copies or the pertinent Policy provisions are
attached hereto and identified as Exhibit "B".
5. On June 21, 1993, pursuant to the requirements of Act 6
of 1990, Defendant elected the limited tort option of her
liability coverage by executing the Pennsylvania Assigned Risk
Plan Selection of Tort Options form. A true and correct copy of
the form evidencing Defendant's tort option selection is attached
hereto and identified as Exhibit "C".
6. On June 15, 1993, DefendAnt executed a Rejection of
Under insured Motorist Protection under the Policy. A true and
correct copy of the form eVidencing Defendant's rejection of
under insured motorist protection is attached hereto and
identified as Exhibit "0".
7. On June 21, 1993, Defendant executed a Rejection of
Uninsured Motorist Protection under the policy. A true and
correct copy of this form evidencing Defendant's rejection of
- 2 -
~
,'-.
uninsured motorist protection is attached hereto and identified
as Exhibit "E".
8. On August 12, 1993, Defendant was involved in an
accident with an uninsured motorist. ("Accident")
9. Despite her rejection of uninsured motorist coverage,
Defendant has Petitioned the Court of Common Pleas of Dauphin
county to compel state Farm to proceed with an uninsured motorist
arbitration. A true and correct copy of Defendant's petition is
attached hereto as Exhibit "F".
10. By virtue of Defendant'. rejection of uninsured
motorist coverage, no contractual provision exists requiring
state Farm to arbitrate this matter and accordingly, state Farm
is entitled to a Declaratory Judgment freeing it from any and all
responsibility to provide uninsured motorist benefits for any
injuries allegedly sustained in the Accident.
11, Defendant, through communications of her counsel,
apparently asserts that her clear and unambiguous rejection of
uninsured motorist coverage may be voided because she was a minor
at the time of said rejection.
12. Defendant's argument is fatally flawed because the
policy of inaurance with State Farm WAS a contract for
necessaries and is therefore, DQt voidable by Defendant.
13. If Defendant's interpretation of Pennsylvania law is
correct, then every minor may alter his or her automobile
- 3 -
~
r
insurance coverage to suit their needs after an accident takes
place. Such a construction of pennsylvania law is inequitable
and cannot be countenanced by this Honorable Court.
\4. There are no material facts in dispute.
15. The sole issue before the Court is whether a minor may
utilize his or her minol'ity status to void a rejection of
coverage under an automobile insurance policy after an accidont
has occurred for the purpose of obtaining insurance coverage for
the accident.
16. In view of the foregoing, this issue is uniquely suited
for declaratory review.
WHEREFORE, Plaintiff, State Farm, requests declaratory
judgment in its favor enforcing the clear terms of Defendant's
rejection of uninsured motorist coverage thereby discharging
State Farm from any and all responsibility to provide Defendant
with uninsured motorist benefits and dismissing Plaintiff's
Petition to Compel UninBurance Arbitration.
Respectfully submitted,
POULKROD, REYNOLDS & HAVAS
A Professional Corporation
DATED: 3/1/1t(
Attorneys for Plaintiff,
STATE FAllM MtJ'I'UAL AUTOMOBILE
INSURANCE CO.
- 4 -
.
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AI HlOVICID'V THIIlIULIS 0' 1)041 ~AN ISAM. LIMITS 0_ L'....tL.n Mun I. "UIllCI1A510 'Dill 1011'4 VI""CUSI
'iii N'fJ\.~T nleT, THI 'OLLOWIHQ TOfIll O"ION: 0 L,m.11MI 'onO 'wll Tori OptIOn
_. If tura""" Of'nolIIm.I:l"* NCmCI~. ,.,.",...n........n TMI.....ICANT AND AnACHID 1'0 1MII AflftJCA"OII.
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INCOIiI&LOIIIlHUIT t~.1JIIA-e a .1........0 It,OClOillUOO 0 'l.....lIDII 0 12.m11O.000
'..........___'.,......,,'d....-' OU,IOO """"",,'"','''''''''
ACCIDlHTAL OUTH .IHI'lf lo,tloMl. ~ 0 1a.000 0 ',IUloo 0 18,000 .
COlleffMTION'IMT'Mn'INI'tT'!lln,~ 0"'. ~IO .,.
.......... MOTClftI'T COVIMOI f~l,,..................,....... .
(!"No... 0 11..0CIGff"""- 0 m.OOMIO.ooo q UO.ODlIfIIOC.aoo n lu)O.(lOO(L1OO,OOO.........
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MlDfC,tL IIH""I COVIMOI WILL .. ~vIDlO
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_.,.r~.,",MD fHAT T....I". II,t,N .000TIONA&. COST 011I "'-IIICMAIlHO A OIOUCfl....
'0fI' COLLII!ON COWf'AQI LOWI_ fl'tAN POO. .NO 1 AGMI TO ACel'" IT
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Aijllut.1Il """/1..,..., DW '11 ,;" IlIn." III ~'..,n .lIpo,II,.1l11t ItH II', "_~'Il."1 ~. ".. ,..~q''''.''' 1101"011 I\AIl 1"""""
..".. c:..W" "'.n...... ," .' ~"llnl .,. (I)",'CI'" ~llIj"y,'1 ~., "IJ>I'II'I' ..... "U' ~"..." ""
0."'.... '" "".I"O'~II ."...., '''0 ,m.,..,I.-.oolll>O'O llQIIU.'III'"'" "11"" 'Ill'" "'''It''' ,uilljIIM
1,...t.,peIlIIH,Q."". "",,,,.,."'1"/11''''''4''11'0''.'11''111''''''''''/1
1,"1."'0101'1 '..' ,,",,"'-IOItllJI/llonllDllI".,..,e
u
. H., t,.. IIIDlIU"1I0MrtI0,.H ."wo", ," '''It f1oljNMto "' I"W"'" ."'J ""11'1, '1"'" '''1 IIU,lIc&1'r. ""*'"
''''"'11 10..'1. ,1'"" h"'l 11,,"11' '''1.1'1',*,'"11, 1I1...,1ttf ~~ ""<>fl'"'' I ~ U. '~II 1f. .11l""'llIlNlIIlfI"'"9' ,It
NOn! A IN'" lit'" 01 It". II .n 10",,11101'I II' '"III.nol".,..llHl tonll,I..,... to"W'tllll"
~1 e:.~-:..!
""-"~
---
..."II....V..."_
'-
....
. ...,.Ionl~" 01' ",""'lIOn 1M .,pllCInl. OI.,,~.p,o 11....11., 41'Wft th. 'POl"'"'' "'0'0' ,,'"CII/III" '10'0<1"0" 0' ~...,
: ,.. (jIIC II "Y,,' i'" o"ltll -
Ari..., DlI" " .1JOI1t'uon "'0' ,"011-0."'" poll""
I. r.,..otytftltll'~'M"OPl"": a,...,...'....,.., 0 Coml'/lllftNt I::; tUIO"II' C OI"trlOHC,IDI)
01 Vllftlctlwlll......... I" IHfIC:...r. OCCIIOlIIOll or bu.."... 0 Y.. a No
(J II ,,'OIcll owned b,. ",.",DI' 01 tfI.IlOl.lMholCl' 0 V.. 0"'0
Ilbl or leI.' ant""" 'YM", il'" fI''''' oIlnt\1'~lompttl., PfOlIdInf Itlbtll.., tO~I'"
1,~'JCI\IlaN' lJ v. 0 No
... .
j.'" 't: ..
............. ~.I ,..'.
,'~*/" ....,oJ
..'-~ . ......
TIl,. 'lloltC.Illon IItWIII, DHfI to"'o....O .nd d..', ..ec:II'IO. 1Nt1l1M, I,."". ,,.. .IIl1ef... all.
"'4 ,,"'. 1/'10." 0110. ....'4.nC. 01 ,n'II""(1 ," 1""IIM'"lnO CO""19II'0IIC''''0. .~DI.tl.O .,.. IOllo.,nq tOnl1l.."n.
OJ 1....lmATI.INOING COVlfIIAGI "IOUIITIO' c: ,. l] No
, Co....'''' I' ."_ltWI II 1111 II"'. In4t on IF'I 4.11 aIlO." DIIOW, .,0.1410 IlIllllCtrOlllt Mill '1"0'''4 fllOCeolll' ...lnOIl,/KI 0, 15lo1/1hCj,on" ollSolC'lOI'Il~ 01 In. "'"".,,....,,,.
""IQII<IO ",.,IJ1," ".. 01111 ",1111'" YOIl "",II "'I.' "'0"" 11.,,,,,"1 ,n .tCO''''''CI .,'n Ill"" or,.,1 1111' '"~lIttt'OIl TII. 'OIlIlCl"'" '0""110 10 "QII 1111' 'Olllltll'OIl ," III'
1l,,""'(I 0' II" 01011\1(1' ,)1 "to'O It II.tllOIl't "..,1 0'''0'''9'' ..11"'10. (",,'I,mIlIO" 01 '''1 ,UIlU'" ,''" ""011'11'0 llW .", "'lCuo",e "",'. PI.,.,.,.,,, Nllm", .II'Cn In'
1l1001lC., 01 'KIl'O '. '1tO,,'Nd '0 III.tl on Inl' '"IlIICII'OII
It lIIIetrOllIC W"I 11"0'"9 .. ..llllltd. tOYIIIQ' .,II,.of Oil .ltlCllvl Oil 1111 II""'M alii ,''"" 11I10. II".... "" tleclron,e M'II JlII.,.nce NumW "0.1011O 101111
Pert".',...."'. Pl'" llecllo" 12 1111 """ H'lo"" ,n III' 1PK'"'0",'01d
1t.f/lJllJ"1
Il.ICTfIIONIC MAIL,IU,....NCI NUMIp
~11C"onlG T",,,mlllll ~.; I'
~.u ~ I ,.... r, ".._~-".
"'ICII....O...."oT,"'. ~.....k.!....-:...!.L6.- olI..l
'~I)nl" ::., 'II' "'IN'
1 <"',""I.t.1)'""'''Cl CI),,"q_ '. 1'101 110,,"11I th." 11I1.lIte"'" d," 01 PIIII to,IIIO' .11. bill q"'" belO. ,II ItCO'O'''C' .,VIIIII Plovll/ontol ,.lIney.....",. Pl'" 5t'thort 12/4 I
U'IC'I....O.II.M',M.
-::"""
0" '''' "'111I1 ':"""
A 0"""11'" t""~. ."101 mlOI la, 1""1 cl)Ytllon II In, OOllt,. ."1" .no.. '"uW," "1)1 .tUIlI.,., D, In. ''''101"
Th"III\I'IIICI."or"!'lll'~~O'~'llbl"'.Il!Kl~.~II''''IIf'''''f\dtOllllllIOllOII'''OOIIC"lIOl"'"tIK"IlIOIOI~",n.tCO'oJ'f\CI.'I"I"'f\llnO'I~~~~,f11l~~~
~
I 1I1I..,.1IfI41l'111 tilt .....mlllm '110"" on 11111 'pflletllon '. In .lIl1nllM ....."'..,'" 'fl. to"'""' ........."".,.,,110 1ll.1I.lltIl.,.,nNtl
"""""1001"'" ...~.IM IMDOIICy. ............"'ICIl>>I... IMn"lnlllDy"" "''''lftlnll fII... .,.,-lWtClDy .". '.1I111Y1Ylnlllll.".,.OI4IeftlMll' '" ICCOfo.nc,.ltF
"-,,,,,,,,,",, 11I'\I..nc, O'Il'M""n' "01111110"'. CIIII CI,,"OI De.tUII'1O 0, I", P'OOIlCl' 01 IIl1C00ct. '"11'I'11''' ",on,.. 10 .... P'OO\l,,' Ollll'Cord .",11 ~ Ollt, ," I", 101'" 01
oanl! .1 mo ,010". tll"llI. nK_, ,h.o t"ec_.II"""II"" Ii".nt. tll.t. or ",rton'l Cn.U 11'I,0' Oh,OI' 10 tI'If Il,nlll,lv.n,. A"IOIlI4 FI". PI.n
B" " I .: 0.1. t. j 1. j ~ , 1"10\11 7. ~.> - "...
hit. . . ~ ~
IN NO ~T &HAL.!. COVPAOI II ",.CTIVI,..IOR TO THI OA TI
\oMo HOU" ~ COW\rnoN M nttl ,,""'tCAT1ON
..., lIItftltI\l"I\II"IOn,."...n"~lfIcIIlOllofllll"""""IIM 1M~1OO~0l'1Il1CON '"' 111I 1101 01 UlI' UOllClllon AND I e'"',.,""'..............tullmln.t~IIOlfl
__, ..."Jt--:I'r'JIrw:' f 1M rING 1'''''' 011 mI' '''''' tn41UO/'1'111M1ICt 1ty.11 ~ICC~"t' f"KIIO" lonnt"'~""" Actl
BY' ~~....~_ 01. ~/c'I'J HOIl' 7,'-' ~
. ............-..-..... . ,
Inlurlnce Campani.1 op"a'lng In the Commonwellth of P'nnlylYlnia Ir. requir.d by law 10 ml)l:, IVlllabl. for purch.... th.
tollOWlrlO blne"'a for you. your IpOUHorotn,rrel.Uv.or m,norl In yourcullody ortn the cUltOdy o'your r.I.II"'I, r~liding In you
household, occupantl of your motor v'hlcl. or perlonl I'nlck by your molar v,nlcl,;
(1) MoeIlCllbenotlll, up 10 1111"1'100,000,
(1.1) extraordinary medical ben,fltl. from 1100,000 to 1,100,000, wnicn may be offered in Incr.manta of "00,000.
(2... Income 101I bentm" up lo.t 1..1' $2,500 per monlh up to I maxImum b,n,llt of al Ifllt $SO,OOO.
(3. Accldtn'" dOllh benotlll, up 10 1110111'25,000,
(4) Fun""lbenollll, '2,~,
(~) A. In alt.rn.tlve to p"lgrapnl (1), (2). (3) and loti), I combinatIon benellt. up to at l'III"77.~OO of beneml in tl"lf
logreg..e or b.n.fit. payabl. up 10 ,nr.. y..rl trom tn. d.tt Of lh. aCCident, wn,ch .v" 0CCIIr8 flra., .UOlIC.IO. limit or
I..idonlll Oolth bonolll 01 '25,000 Ind I limn on luno..1 bOnll,l 01 '2,~, p,o"doelllloil_lIIng conlolnoelln Ihi.
sub..CIIO" .naU btcOnltru'd to limit. reduCt, mOdltyor cnlng.ln. provlllonaoll"tlon 1715(d) ("IIUnO 10 IVllllbilll\
at Jjmlll~,
(6) UninJured. I.Ind,r1nlur.d Ind bOdily injUry liabIlity cov.rage up 10 It I...t 1100.000 b.eaullot "Iury 10 on. peraon In In\
on. lcardent and up to II Ifill 1300,000 blCIUI. of injury 10 two Q' more ~"Or\l,n Iny on. accident or, It th. OPtion 0
tnelnlur". uP to ..,..It 1300.000 in I Ilngltllml. for th... cov.rIO", ICC.pt lor POIiCl" i..uad und.r th. AIIlgned RII~
l'o." PJan.;~IIO. ..... $5,000 'ordlmlge to pr..,ryotactwraln Iny on. Iccld.nt.
J-~I', AldfD6n.lly. lnlur.,. mlY offir hfOh" btMfIt ....iI_.. &I""';' 'num.;ited Ibov.., well iIlddWklnl1 ttenentl. How.v.r
~n insured ml.y tlee' fo pure"".It)w.r ben.flt '''''' "'an .holl .num.rlled IbOiol'. Your Ilonl'blN on ttltI nollc. or you
p.ymtnt of any ran.wI. premium ,vld.nc.. your Ictual knowl'dg. Ind und.nranolng of Int IWlllblllty ot Inll_
.......nd&Nllill. well II In. b,n.fltalnd Ilmltlyou nlll' Mltcted,
If you hlv. Iny qu..liOn. or you do nOI und.,.tlnd III of th, Vlrlou' optiOnl IVllllbl.IO you, contlcl your 19.nl 0
company. If you do not understand Iny 0' tn. provlllons contll In thll nollCl. conllet your .n'orcompany bI'or,
fOU SIgn. , d. alJ...
-:.. ~~&ur\~~
I alCUlllAHO Cllnl,Y THAr. I III H.....I TIlIIO AHD'A."'O TOO'T,,'M"U'OMOIILl~ ,.,TMII "ATI WIn4INTtoIl
II1IIICIDIII .0""'''' un. NOT IlellolNO 'tolD" ....."'lCA....W.OIIl THI "NNI'" V"HI" "UIQIIIIO Ill'" f'LYI. I ~l hthl ~Of"'v '''o.'lGq..f\O DIl'" I".
~1f",,~'_I'''.'''IfII''''''Ollh.:;IIK>'' ."t,.,., j,l _..,,""1"'" ,kl n." 't_.n.'n."'....C.r.O""OI"'."... 'ulflm"o,"c"''''~'lI'Iltlll.'''~QftI''tlliOn"",''q ''''0'" ''J'''O''I''~
I, I '1"'~"'I'UI"'''''lJt'' 'I' 1-1":<1'0) ,," 1,.""""lInll"'II',;'I,,, II' '.1"....' ," ,,.,, .ou"';"Uj" ""1' ..IIII"'IUI",I"'" ",'I J',''''', U ''''<l"",.o'lfll "'''"h...n,.A.'UIQnlG I-l.u ""11'
'11"1 COII'IO"'" IOf 1"10\1'110"01 In,. "',,,,.nr.' ,~<, .C:'" 1"'1 "'l~"""'lll .',. o,.tllt<:;lIw"I "'v o,.mlum~,"'nc' ..".11 .cCOll'ltlolru.""'IID1C111Oll.'noJ "'ON"Ot<l I,
-,,_;nIOU"'" "'LlIII"'O''''''''"'lI''ll''''Cv'"I',nlr~,~I''..t'I.,I,'l''
~,.. p,~""-.nAlQII""'W._l>l"bl""'.'''''I' 'oj, ."LI ,,.,.,,,'1" ,,.. "'","I,rt "'~'''I . '1'.4Ull",,'Io,.n I', " ',..'..'1' i"rllu~n I'" "'''"hl..".,AU<Qnt<J I-l,U 1".1"
HltttIri~""""""OI i'OOl'cfll'/I. "'oj"""', ""-l,_I'" .""l'\tJ l"II""""'U""'c' U'IIl,,,,,,,,,~_'''''''!lf1l''."'''111U.'''U",''''109ft'''''CO''''lqll''r,,ull'
....,"'r,""..JI;II1r......,..,. \~_'{'f/,J......- "1:'"
_____IIf'"___. __"
._-----._~.,.-'..._-.._.- ~
.
~
('..'
exhibit B
,-.
.,
,.. ~i~j.;\IP Qr ":1:l t!1at yo~ o;"'n; Qr ,":,
~, "aa., used "lth 3 ,'.hidc d<::>c:ibed rn
a. Qr b. above, " '~'c
9, c...lJ.lo!d by or u ~ .o[ue~~ct:~e of:. .'
., discharge of a llu~ltar ..'npon (e.en if
ac:ciden(31):
b, war (.leclued or Ullde.iar.dl.
c, .-(viI war;
d. wunKtioll; or
e, r.bellioll or revolutJon,
10, !'rom or as a .0l1Stquec~e of we (oUo";"J,
whether cOlluoU.d or un.octrolled or
however Clu.s.ld:
L llu.cleu rea~tioll;
b, radiatioll: or
~, radioactiv. .ontamin~tiol1.
LJMlT OF LlA8fLm'
A. The limil of liability shoWt! io t!1e Declaration~
fo'r this coverac. i's our maximum limit odj.
ability for each pmoo injl.:ml ia any ollea~'
deol. This is the mOSl we will pay re~ardlC$S
'Ofthcllumber 0(:
L lIurnoib,'
~. C13i.ms macic:
.. Vebidc:s or pre:niUl:ls sho"'C i.::l ~ Dtci..
tallOo.s, or
4, Vehicln icvolvcd ie :1::e a"id.ce. '
8, Any =o=ts oth.",isc payable (or c,'pto.'t5
und.r this i:over~gc ,h.111 be r.duced by any
amou.ct5 pllid or payable for the s.tmt ex.
pen.... undcr Put A or P~tt C,
C, ~o paytctl1t will be cad. "clcr.. t!:.e lcjur.d
persoll or th~t person's i.g;j repr~ent.llve C.
.1".... ic '" ri:illJ :lm ""'y p.ya:eut siuil be
:iprlifd t.,w:t:Q uny ~ttti~ra~::t vr j\.:.d~~[i:
:.h::tc p~:sut1 :~cci\':~ lIode:- P:.!.:,! A 0:' 1':':1 C.
'.
j
3(l1)':P
/
.,
OTHER L'iSl.jIUSCE
:r there 15 othcr appUcable auto medical pAya:lCCt.I
iesurao~c we will pay only' our swc of the 10$5.
Our shllre is the proportion wt our li:nit of [j.
~bLlity bU,l'$ to the lOW of all applic:ablc limlts.
Ho...c,cr, ZJly ill.s=cc we provide .,ith respect
to a vehi,l. you do aot OWll sh.all be ex.c:as ov.r
:n) otb~. ,ollo:ctiblc auto Wunncc J:'roviding
paymellt5 {or mediall or {uo.craJ elqlCascs,
PART C - liMNSURED MOTORISTS COV.
ERACE - l'
r-;Sl;JIDiC ACREEMLYf
A, w~ 101m pay dll'Uges which aa tMu,od is Ie.
gally e!lulled 10 ~,over from thc oW'Oer or op-
er.1tor of an rurillSln~d """0' "Ail:U 'becaast
of 60dJIy UrJI"Y: -:
I. SllSl.'\ioed by an iIIsIi7,ti; and
2. CalJ.lo!d by dIl aceidcrce.
The oWllcr's or opcrator's liability for th_
damages mllSt aris. out of thc o"'Ilenhip,
mainreoancc or use of the UllilUlll'od """." .,.
Ir/c'o,
Any judgmcnt for (l.1m.1.So::i arisilli out of a
suit brou!lht ..ithoul our writtCIl cons.:nt is
OOt oUldillg 011 us,
B, -[.lSIUltI'.1S used ill tbJs P~tt r::eo.::s:
t, You or aey/amJJy mnnbn.
, AllY othe. persOll occupy;", )'0"' co.",J
IlJJro.
3 .-\n~' persoll for damascs that persoD is en.
titled 10 reco..r because ot' lJodU)' ;1Ij1lry ro
which this coverai. :lpplit.i ,ustained by a
..rSOll d.scnbcd in [, or 2, ..bovc,
~LtJiJuu"d molO, ,'olrick" lDt:1nS 3 iacd moto~
\I:~icle or t-'1ulcr of a.:ly tlP~:
!, To" ruch 00 oo,jlly icjury llabiilt:- bocd or
~olic~, Jppti.:):1t =1:~ ~~ orr.=.: .!;:~ci~c.:.
le~tu<ie~ .op'r1~"'led C::lt.n~' ~:' r~.:ll..":1ac<" 5'''''1." OtTIce, ,.,:;, ils ~e~ssloc. Co;:>yngh:.
rr.~lJt'J.:'':~ ~~f"\-:t.::~ om\,.,/, i=.' :-)s5
-- .. ---,._-_.~---.......- --....---.
--
'W
.. ..-.:-,.... ,..
',2, To ""!lid: ~ bolll!~' leJury ~abl~t) oon.; <1r
,,~ policy Jpplln 3t tP. time of Lb. QC~ldect
":' !n tbis c:I$lt5lirttit flJr bodily Injury lJab.;'
, , it" mu~t ~ i.$i :han th4 miD.imllD1 limit f.:r
, b~.w) iJ:jut) liabilit) fPeritled by ilie fl.
114n<:ial responlibility 13\\ of the ~lJ/.t. U:
., which )'OU' CD,n," IlUfD IS prindpaH;, ~~.
raged.
J' Whjcb" 3 hit an~ nu: vewcle \\'ho~ Opt,.
" ator or O\'intr ClUlnot be identified and
I\'hich hits:
.;r"
II- you or :lny fllllli/y _mb,,;
". ,b a vehicle wwch you or an)' family
::~. m,mb" ane DCCllpyillg; or
f, C, 'DIU CDrt,.1l AlllII.
,., .. . . -
:.-.: To whidl a bodily injury liabillly bo::d or
:~:" policy applies al the lime of Lbe a~deCt
; " ' bUI the bolldiD8 or ilIsuriQg c:ompany:
!I~ .,., .
a, denies coverage; or
b. i5 or becomu insolvent.
.j' : '. " .
Ho"cvcr.IllliluIlr,1l mlirll' ,.hkU doq not in.
c1ude llJIy vehicle or equipment: .' :." ,
1, Owutd by or l'urnisbcd or available for ;he
(e,war use of yon or any /tmriI, """,j".
. 2. Owlled or opented by a self.insurer !l-"d.:
. any applicable rnolorveb,ic:le,law.
.3, OWlled by JJl)' go'e~r.3f urut c:
3iCtlC)' .
4, Operated On r.u1s or=wlor [IUds,
5. DnlJIled m.ili:J)' for u.sc: orr public roae;
wIII10 nOI 011 public road:;.
6, WblJo lClClllCd for la. as a rnidCtlce or
pmni.scs.
EXCLt:SIOt'iS
.f\. We do nor pro,ide V="lIfCd MotoriSts Co',.
emge for jotli/, brjury S'.:.swned by any p.r.
son:
Ia.:ludcs copyn!'llltod =tmoJ .or I==ce
wuro.ou Services omc~ L~." 1935
-
il';1. We!:, o,~upyln~, ~r "b.n ltrwk by', an~
~, ::l.'tlJr Hwck lJI>ned b)' ~o~ or anYlllmilF
m~mJ"'r "l:J,~ ,; out ir..und ror tltis co>-
~, erule uc,;e: t!lll poucy. This include~ "
~, !nUlor of an__ type "-led with tht vehicle,
'J~2, If that p.~on 01' the legal reprc.l.nunive
.ettle. the blldi/)'Injur)' claltll \\ [thuur our
.on5cnt,
], While occup,Iing ,1'1111' cou"d ""rll wQ.en ir
IS bcin~ .uc,j to .':ltl')l penon5 or prlJpert)'
ror a fee, This u,lusion IA.3,) d~C$ not
.apply to ~ sb3.r..the..,~llSC c:Lr pool.
4, L'siOlIl a \'ehicle wttilout a reasonable oelier
that that person is entitled to do so,
B. Tb.is .OVOII,C shall not apply directly ~r indi.
reCTly to bencfit any insUler lJr ~elf.in5Uler un.
der ~y or Lbe (ollowill. or similar la...,
!, woner's cOl!lprlllallonlll\lr, or
2. disability bcncli14law.
LL\IJ[ OF L1.um.m '
A, Thc limilofliabllily5hoWll in the Declmtil>lIS
for"llCb. person for UniIlsured MOrl>rilts Cov-
ellf;e il our lJI~;timWII limit 1>( uabilit)' ror all
dao:agn. illcluding dlma,e:s for care. loss of
services 0: deatb.. arisin, out o( iJtJdJI, iJr)lll'y
" su.stlUlCd by lUll' oce person ill ~)' oce 8C";'
deo:. Subject to this limit for uch person. the
um,j; of li;lbility shOIllU in the Occ!lIl3tlocs for
racl: a~cidtt[ for {;nicsured Motoli~u Cover-
~ oge is Ot.:.: lIU.'<Unllm lmut o( tiabilirv (or all
"daa:"gn for jodJ/}'lnjruy re:swtiD, fro", allY
" ' ace acclde~t. Th.i s is the ClOSt ...'. will puy re,
:".udlcSi o(Lbe cumber of:
I, /uu"tlJ;
2. Cbi.m.s ::lade:
1 \'o:!l"jc!tS O~ ~t:l'S shown:.:: th~ Dtcl.1-
ntloc.:i.o:-
4, \'ebJclell~>olvec1le:::e 3CCl~tlt.
9
;0G4~
s.~~ C~=., "':::. 1:S pemuS:llOU, Copyngi:t.
t
~
~
.1
I
l
I
J
,"""'
.,
.. ..~ ----=-.
B, Aay ..mOUDIS otherWise ?...:,::~',: fer o,iWl.gl$
u.n<ler tith eovcl"ol~e sball be reduceel by a~
sum.:
I, P~id be~uuse of the bmlily iIIi"'Y by or on
beMI!" of p.rsons or or!aaintioo. who
::.Illy be I.plly respoa,ible. Ten Lllclttda
a.U ."lDi pu.id WIde! PU1 A;;Uld. '
1 PUld or payable becaUM' 01' the bodily Ill.
j",y uoder (lOY of the follo"" in! or sllTlil4r
law:
u, workers' ~OlDpcfl:lOlUlJfI i~ w: or
b, diSl!bility bcaelits l.1w,
C, AJjy payment under this eo'C~!e will reeluc.o
1nY umouDI th:lt penoo " enur~cd to recover
: for 1M SIUlle ela\'llllge$ Wleler Part A, :t
OTlIER INS\.rRk~~E
J
If there is other appUc:able ,lll1IllU' insurJ.Cee we
will p3Y only oUt share of the loss. OUt sbatei:\.~
prlJporlio.... Wt our Wnit of Uability bears to' the
loml of all appUcab!e \iInIts, f'{~w.vcr, any in.sllf'
3IIce we provide with respect 10 (l vebicle you 40
~ot own shall be (JtCC$S over an~,lJtb.r clJU(>;ti.b~
l1l.S\llaDee, '
AIlBrrRAll0r-;
A, If we :u:<I:1t\ illSfD,d do flot 1~ee:
1. "'-octileI' thl1.t pc,~oa LS Ic~:illy enUlled ta
recover d.:uI1agcs WlUa ttUs p:w.; or
:. As to the a.mOWlt of damages:
either pattY may Ill&kc a wott.o demand ii'll'
:ubitr:1uoo.. lD this even:. C3ch plU'ty' willsel..t
an ubltratar, The rwo arbitI1ltors \>ill select a
tttircl If they <;'J..tl.Qot l1.!f'Cc within 30 day., cl'
wer may request that selectioll be cade by a
Juel~e oi 3 court h:lving jurisdlcrioo"
B, Ele:, p~rty will:
1, P:lY tbe e:<peoses it incurs; aDd
2. BC'QI ;h~ ~:tpcas~s of ~e ~d ~bH...""'ltu.
elllllAllI',
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-
(, l"oh~.. botn punl"" .grlt lJth~rwl", urbi.
lration will w.ke pi~c~ In tile ClJU.tlt'! Ln "bien
the in.""J lhes L0<.-a1 ru~C5 of law 35 ta pro'
c~<lilre acd evid~DCC will appl~, ^ deei:liOfl
uil1'~fd 10 by 1,,"0 of lI',e arbia-.Ltors "'111 be
bill,lioill>ta;
l. Wbether Ulf j/lSurld L> :eglllly ellntled to
r<:.:over d:Ltllagn; and
2 The umoUUI af do1ma~es, Tbiuppues anly
if the alt\OUflt docs 1101 ellC'Ced the miDi.
lDwn limit far bodily Uljury li(lbllity qlCCi.
lied by the filIlllleial reSpoD$ibility law of
the stolte ill wbien y'''" ctJrI,~d lUIltJ i.
pntlc,pallY g:uagecllf the amOWlI eX~
:!Jat UtDi~ either. party lll",y,demand the
Ogbt to a ui:1l. Thi~ delDanl! mlln be rnad~
within 60 r;\ays of the ubitIalors' rjecisioD-
If this clctll&od i. cot mlde. the amoullt 01"
daInal" aiTe~rj ta by the'irliitr.uors will
be bindi1l8, :,' ~ ',"'.
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PARI 0 - COVERAGE FOR DA.'\1AGE TO
YOllllAljTO - DO'."';"'"
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YQU, cO"rld (DlIQ or l1!lY rIo/lo(/MlMd onao, in.
dueling their equiplUeDt. mln\lS any appUcable
deductible 5!:l0"U i.:l tI::~ Dccl~tions, We will
pay far Iou ta YQIII ctJ"rld IIJIftJ cau.:sc<l by:
I, Other than colUsiDtr onlY if tbe Decla[ll.-
tiOIU inelicate thaI Oth':" 'Thl1.n Collisiotl
Caveracc is providecllor tbat acto.
, Co/JJsion anly if the Oecf.ar3tiocs indicate
:holl Collisiall Co,'e~ale is provided for
that alltO,
If dim ~ a loss to ~ ""n.".-lUd lIUIQ, we will
provide Ihe broacle:lt ~ovel'3ie apptic:lble to
any your CO,(rld ""rQ :\iIown 1:1 the Dcclara.-
tlon:;,
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~ctu.;r; cop:ttiilttcd matcn,;, of ills'.l.".UI<I'Sc",;:c; oroce. ..ith iu pcrtDisaion.. Copynpt.
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LENORA III. SlaVINGTON,
Petitioner
IN THE COURT OF COMMON PLEAS
CAOPHIN COUN'l"l, PENNSYLVANIA
/
CrvIL ACTION - LAW
NO. I;Bl.S-q"
.
.
:
v.
.
.
STATE FARK INSURANCE C:OKJilANY,
Raapondent
.
.
.
.
.
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II....I'1'I09 'J'O COKPIlt. tnrnISD1l>>rCIl AQI'PR1'1'IOH
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AND NOW, come the Petitioner Lenora M. Skivinqton, by her
at.torneys Anqino , Rovner, P.C. and respectfully requests this
Honorable Co\U't 1:0:
1. Compel Respondent State Farm to arbitrate Petitioner's
un1nal1l.'anca motorist's claim;
2. Order Re.pondent to select a second Arbitrator; and
3. Compel Respondent to pay Petitioner's coun.el fees.
xn support, Petitioner respectfully represents the tollowinq:
1. Petitioner Lenora M. Skivinqt:on is an adult individual
residinq in Camp Eill, cumberland county, PennsYlvania.
:1
l 2. Re.pondent state F~rm is an insurance comp'any licensed to
II
:1 do busin.s. in the Collllllonwealth of ~enn.ylvania with otfic..
,
I located in New C1.1II1berland, cumberJ.and County, PeMsylvania.
3. On Auqust 12, 1993, Petitioner Lenora M. Skivinqton wa.
injured in an automobile accident r.t Maclay street, Dauphin county,
Pennsylvania.
4. On Auquat 12, 1993, Petitioner Lenora H. SJtivi.zlqton was .
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CIRT%.%CATB O. 8IRV%CB
I, Donna H. Rineer, an employee of the law firm of Anqino ,
Rovner, P.C., do hereby certify that I am this day servinq a true
and correct copy of the ORDBR TO TRAIIS.IR V.NUB upon all counselor
record and interested parties, via postage pre-paid, first-class
United states Mail, addressed as follows:
Mr. Dave Bucher
state Farm Mutual Insurance Company
Harrisburg Service Center
115 Limekiln Road
P. O. Box 257
New cumberland, PA 17070-0257
Rolf E. Kroll, Esquire
FOULKROD, REYNOLDS & HAVAS
P. O. Box 932
101 Pine street
Harrisburg, PA 17108-0932
, & round /'h i0.h1 ~ n
Donna M. Rineer '
Dated: fh~ )~,Iqqt/
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LENORA M. SKIVINGTON, I IN THE COURT OF COMMON PLEAS
Petitioner . DAUPHIN COUNTY, PENNSYLVANIA
.
.
.
v. I CIVIL ACTION - LAW
I
STATE FARM INSURANCE COMPANY, NO. 681 - S - 1994
Respondent .
.
AND NOW, this
ORDIlR
day ot
, 1994, it
is hereby ORDERED and DECREED that venue in the above-captioned
action be transterred to Cumberland County Court ot Common Pleas,
Carlisle, cumberland County, Pennsylvania.
BY THE COURT:
J.
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I IN THE COURT OP COMMON PLEAS
I DAUPHIN COUNTY, PENNSYLVANIA
I
I CIVIL ACTION - LAW
I
I NO. 681-S-1994
I
LENORA M. SKIVINGTON,
Petitioner
STATE FARM INSURANCE COMPANY,
Respondent
'.TITION.R'I AHIW.R TO NBW MATTIR
AND NOW, Petitioner Lenora M. Skivington, by and through her
attorneys, Angino , Rovner, P.C., hereby responds to Rsspondent
state Farm Insurance company's New Matter as follows:
10.
Denied.
Petitioner Lenora M. skivington currently
resides at 208 A Ramsay Place, New cumberland, York county, PA.
11. Admitted.
12. Admitted. It is hereby admitted only to the extent that
on september 30, 1991, Petitioner Lenora M. Skivington was a minor.
13. Admltted.
14. Admitted. It is hereby admitted only to the extent that
Respondent's agent used his superior position to exert undue
influence and control over the minor Plaintiff/Petitioner to
persuade her to sign a rejection of under insured motorist
protection form under the pOlicy.
15. Admitted. It is hereby admitted only to the extent that
Respondent's agent used his superior position to exert undue
influence and control in persuading the minor Plaintiff/Petitioner
41196/DMR
.
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to sign a rejection of uninsured motorist protection form under the
policy.
16. Admitted. This is an arbitrable issue.
17. Denied. As a minor, Petitioner may only be held to
contracts of necessity. In this instance, a signed rejection of
uninsured motorbt protection does not amount to a contract of
necessity and is therefore voidable. state Farm Insurance company
must therefore arbitrate this matter before un uninsured motorist
arbitration panel.
18. The Respondent's allegations set forth in paragraph 18
fail to state factual allegations that require Petitioner to admit
or deny, however, to the extent that a response is required, said
allegations of rejection of uninsured motorist coverage act as an
inoperative waiver.
ANSWER TO NEW MATTER IN THE NATURE OF PRELIMINARY
OBJECTIONS PURSUANT TO PA. R.C.P. NO. 1028lAll11
19. No response is required.
20. Petitioner Lenora M. Skivington has petitioned the
Dauphin County Court of Common Pleas to change the venue of this
action to Cumberland County by agreement of the attorneys and
parties.
21. Admitted.
22.
Admitted.
It is admitted only to the extent that
Cumberland County is the proper Court of review.
It is
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LENORA M. SKIVINGTON,
Petitioner
IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
v.
STATE FARM INSURANCE COMPANY,
Respondent
,
NO. 681-S-1994
PETITIONBR'S AMBNDBD ANSWIR TO NIW MATTIR
AND NOW, Petitioner Lenora M. Skivington, by and through her
attorneys, Angino & Rovner, P.C., hereby responds to Respondent
State Farm Insurance Company's New Matter as follows:
10.
Denied.
Petitioner Lenora M. Skivington currently
resides at 208 A Ramsey Place, New Cumberland, York County, PA.
11. Admitted.
12. Denied. According to Respondent state Farm's Exhibit
"A", Petitioner Lenora M. Skivington executed said Assigned Risk
Application on June 21, 1993, not September 30, 1991 while
Petitioner was a minor.
13. Admitted.
14. Admitted. It is hereby admitted only to the extent that
Respondent's agent used his superior position to exert undue
influence and control over the minor Plaintiff/Petitioner to
persuade her to sign a rejection of under insured motorist
protection form under the policy.
15. Admitted. It is hereby admitted only to the extent that
Respondent's agent used his superior position to exert undue
41796/DMR
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influence and control in persuading the minor plaintiff/Petitioner
to sign a rejection of uninsured motorist protection form under the
policy.
16. Admitted. This is an arbitrable issue.
17.
Denied.
As a minor, Petitioner may only be held to
contracts of necessity. In this instance, a signed rejection of
uninsured motorist protection does not amount to a contract of
necessity and is therefore voidable. stat( Farm Insurance company
must therefore arbitrate this matter befole an uninsured motorist
arbitration panel.
lS. The Respondent's allegations set forth in paragraph is
fail to state factual allegations that require Petitioner to admit
or deny, however, to the extent that a response is required, said
allegations of rejection of uninsured motorist coverage act as an
inoperative waiver.
ANSWER TO NEW MATTER IN THE NATURE OF PRELIMINARY
OBJECTIONS PURSUANT TO PA. R.C.P. NO. 102S(AI(11
19. No response is required.
20. Petitioner Lenora M. Skivington has petitioned the
Dauphin County Court of Common Pleas to change the venue of this
action to Cumberland county by agreement of the attorneys and
parties.
21. Admitted.
, ,
. '
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C..~I'lca~. 0' I..VIC.
I, Donna M. Rineer, an ..ploye. of the law firm of Anqino ,
Rovner, P.C., do hereby certify that I am thi. day .ervinq a true
and correct copy of the ..TITIO...'I ANKID.D ANI... TO ... MATT"
upon all counael or record, via Certified Mail - Return Receipt
Reque.ted, a. follow.1
Rolf E. Kroll, E.quire
rOULKROD, REYNOLDS , HAVAS
P. O. Box 932
101 Pine street;
Harri.burq, PA 17108-0932
t.9~ ~ 7f>--UntY;
Donna . R neer
Dated I VntWCh;Jf, /9'7ij.
.
.
~
ROL' I. KROLL, ISQUIRE
PI. Supr... Court 1.0. No. 47243
'OULKROO, RIYNOLDS & HAVAS
A 'rolllllonel Corporltlon
101 Pine StrHt
poat Olllco lox 932
Hlrrllbur., Pennlvlvlnll 17108'0932
11 I "",one,
'.XE
mn 236.3200
mn 236.6863
Attornev lor R'"~t'
STATE 'ARM INSURANCI
IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
NO. 681 - S - 1994
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
LENORA M. SKIVINGTON,
Petitioner
v.
STATE FARM INSURANCE COMPANY,
Respondent
ANSWER OF RESPONDENT. STATE FARM INSURANCE. COMPANY TO
PETITIONER'S PETITION TO TRANSFER VENUE
AND NOW, comes Respondent, State Farm Insurance Company by
and through its counsel, Foulkrod, Reynolds & Havas, a
professional corporation to respond to Petitioner's Petition To
Transfer Venue as follows:
1. Respondent concurs with Petitioner's Petition To
Transfer Venue for the reasons set forth in the Answer Of
Respondent, State Farm Insurance Company, To Petitioner's
Petition To Compel Uninsurance Arbitration a true and correct
copy of which is attached hereto as Exhibit "A".
Respectfully submitted,
Dated: 7/'l~7fC:/
/
FOULKROD, REYNOLDS & HAVAS
A profess~al Corporation
By, '?~,( MA2(lP
R()tF E'.
Attorneys for Respondent,
STATE FARM INSURANCE
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ROLF ~. KROLL. 2SQUIRE
Pa. supreme Cour1; LO. No. ..7243
rOULKROD, RlYHOLDS , HAVAS
101 Pln. Strut
Poat Offlc. Box 932
Harrlaburq, P.nnay1van1a 1710B-0932
Telephone.
Fax.
[717 J 236-3200
(717) 236-6863
Attorney for Def.ndan~1
STATI FARM MUTUAL AUTOHOBILI
IH.UIWl~ COIIPAHY
LENORA M. SXIVINGTON,
Petitioner
:
IN THE COURT OF COMMON PLEAS
CA'~HIN COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 681-5-1994
v.
:
STATE FARM INSURANCE COMPANY,
Re.pondent
All.... 01' ....011I)..." l'1'a'1'. I'UK I.lnua. aOUAIIY,
TO P~I'1'IO.-R'1 .~I'1'IO. '1'0 aO".L u.I..nua. ...ITRA'l'IO.
AND NOW, come. Re.pondent, State Farm Mutual Automobile
Insurance Company ("State Farm"), by and throuqh it. counsel,
Foulkrod, Reynolds , Hava., a Profe..ional Corporation, to answer
the Petition to Compel Un insurance Arbitration of Petitioner,
Lenora M. Skivinqton ("Petitioner"), liS follow.:
1. Adllli tted.
2. Adlllitted.
3. Adlllitted in part and denied in part. It is
admitted that on Auqust 12, 1993, Petitioner, Lenora M.
Skivinqton claims to have been involved in a motor vehicle
accident. After reasonable inveatiqation however, State Farm is
without knowledqe or information sufficient to form a beliof as
to whether she was injured in this accident and accordinqly, no
further responsive pleadinq thereto is required.
4.
Adlllitted.
-
/-~,
5. Denied as stated. It is admitted that the
underlying policy was in torce and ettect on August 12, 1993. It
is specitically denied however, that plaintitt had any uninsured
or under insured motorist coverage in ettect and accordingly, this
Petition is improperly betore this Honorable Court.
6. Admitted.
7. Denied. This allegation ot the Petition reters to
a writing which is the best evidence ot all it contains and
accordingly no responsive pleading thereto is required. By way
ot turther answer, the undersigned did not receive a copy ot any
document purportedly attached as Exhibit "An to the Petition.
8. Admitted in part and denied in part. It i.
admitted that State Farm has not appointed an arbitrator in this
case. It is denied that Petitioner has standing to select an
arbitrator as there was no uninsured motorist policy in torce or
ettect on August 12, 1993, providing such coverage to Plaintitt.
Accordingly, no arbitration clause was in torce or eftect that
would give rise to an arbitration.
9. In view at the toregoing, contemporaneously
herewith, State Farm has tiled a declaratory judgment action with
the Court at Common Pleas at cumberland County requesting that
the Petition be stricken and that her rejection ot uninsured
motorist coverages be entorced thereby precluding an arbitration
in this matter.
2
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WHEREFORE, Respondent, state Farm requests that this
Honorable Court dismiss the instant Petition with prejudice.
.... IO.T'l'D
10. Petitioner i. an adult individual who currently
reside. at 2206-H Cedar Run Drive, Camp Hill, cumberland County,
Pennsylvania.
11. Petitioner was born on september 6, 1975.
12. On or about September 30, 1991, Petitioner
executed an A.signed Risk Application ("Application") for a
private pa..enger automobile insurance policy which was
ultimately i..ued by state Farm. The policy i. identified by
Policy No. 820-1007-F21-38 ("Policy"). A true and correct copy
of the Application is attached hereto as Exhibit "A". True and
correct copies of the pertinent policy provisions are attached
hereto collectively as Exhibit "B".
13. On 3une 21, 1993, pursuant to the requirements of
Act 6 of 1990, Petitioner elected the limited tort option of her
liability coverage by executing the Pennsylvania Assigned Risk
Plan Selection of Tort options form. A true and correct copy of
the executed Pennsylvania A.signed Risk Plan Selection of Tort
options form is attached hereto as Exhibit "C".
14. On 3une 15, 1993, Petitioner executed a Rejeotion
of Underin.ured Motorist Protection form under the policy. A
.-
3
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true and correct copy ot this torm evidencinq her rejection ot
under insured motorist protection is attached hereto as Exhibit
"0".
15. On June 21, 1993, Petitioner executed a Rejection
ot uninsured Motorist Protection torm under the Policy. A true
and correct copy ot this form evidencinq her rejection ot
uninsured motorist protection is attached hereto as Exhibit "E".
16. On Auqust 12, 1993, Petitioner was involved in an
accident with an uninsured motorist ("accident"). Despite her
rejection ot uninsured motorist protection, Petitioner has
petitioned this Honorable Court to compel state Farm to proceed
with an uninsured motorist arbitration. A true and correct copy
ot petition is attached hereto as Exhibit "F".
17. By virtue ot Petitioner's rejection ot uninsured
motorist coveraqe, no contractual provision exists requirinq
state Farm to arbitrate this matter. Accordinqly, state Farm is
entitled to declaratory judqment treeinq it trom any and all
responsibility to provide uninsured motorist benetits tor any
injuries alleqedly sustained in the accident.
18. In view ot the toreqoinq, contemporaneously with
the filinq of this Answer, state Farm has tiled, in cumberland
County, a Complaint tor Declaratory Judqment seekinq the
entorcement ot Defendant's rejection of uninsured motorist
coveraqe and dismissinq Petitioner'. Petition to Compel Uninsured
4
~
Motori.t Arbitration. A true and correct copy ot this Complaint
i. attached hereto a. Exhibit "G".
WHEREFORE, state Farm reque.ts that this Honorable
Court di..i.. the in.tant Petition to Compel Uninsurance
Arbitration with prejudice.
... 8ftD I. 'l'IUI _TVU O. ..ILlIIIDaY OBJICTJ:O..
.DR.~ ~ PA. a.e... ~. 102.,.tll'
(Improper Venue)
19. Paraqraphs 10 throuqh 18 hereot are incorporated
herein by reterence a. it set forth in full.
20. In the unlikely event this Honorable Court
determine. that Plaintitt's rejection of coveraqe may be voidable
and that there may be uninsured motori.t coveraqe in ettect, it
i. re.pectfully submitted that venue in this matter i. improper
and that CUmberland County i. the proper forum to re.olve this
dispute.
21. The Uninsured Arbitration Clause tound at paqe 10
of the Policy provide. a. follows:
Unle.. both parties aqree othsrwise,
arbitr'ation will take place in the county in
which the insured live..
ial Exhibit "Bft.
In this in.tance, the insured Petitioner live. in cumberland
County and accordinqly, the appropriate reviev1nq court i. the
CUmberland Coun~y Court ot Common Plea..
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tll~__""IlI0t*8""",,,,~"OClI"''''I'''or'U''''''' 0 "'1 1-: 1lI0
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i IM..,OIA" II,..UINQ CaYI""'O' "'OUIITlO": lI. IJ No
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~f""'I' 01 tr. 010411'" 01 ItcOfO 1I11"lronlc ""III 0,nll'"9 "III'lIlltC1. ,onllllUIIO'" 011'" .lIflCllw' 01,,""1111'"'0 0, 1I.,llltlrll"" ~I'I M,..",.." Nllmllll .Ih'/I III'
0,....., 0' '"01'0"'101,11,.10....,. on Inll .1I01lClllon
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PII'IIII,I."'I' PIIII $1C1I0II 12 nil..." 111'0"11 mIll' '*. 1I10.IOM
11.94/67
II.ICTJIlONIC MAIl. "lnJlllHCI NUMIPI
.IMlronll'l'SI'I,""nll '.,.1, " "..
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I ,"'fMIlII'" o,nO'"O CO,,'lqt', "01 '"II"" 1"'11 I"' ,Iltcl'" Olt' 0' 1'1," eO'''19' .,11 _ II O'~ 0110. ,n Utelll'"'' .,In In, lI'e."'ol'l' D. 1',"11"","1' Pl," StehOIl I ~ ,. I
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: II ,""'111M cnllO' .", 01 "'HI 101 III'" COtl9fIO" ,. '''llIOlIe" w/l'" Ino 'I'"IIIG. 'I nOI'CUIII. 01'''' ,I'I'II,M
'''' '1I1l1f1/lCll.nOf'lMlO II"""",,", '"11I1 M IwIiIICI 10.11 IMlII,,",,ntCOftOUlonO'II'I.1lOl1CY lOfIflIl'WK'IOIO'Ol ~"'IIICCOfO'"ct .,,1111'1"11'"01 t",,,.,.,..,...~IlII'Il"'-'
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,-,,",,'U"I' .nll,ll,nn 0.0,,,,,,./11 "oullI'OIlI, '"t'I CI""OI !II 'C"OIIO Df I'" ",OOllCl' 01 11I.0"" 1'""""", "'0"111 1111", "'001,1'" o.IIHOI'O .,...n DI 0/11. ,n III' '0'''' Of
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.....,...... ""' '(~ ' ., ?-"
INNO~' 1HAU, COYI~'''IJI'ICTIYlHlIOf' TO TMI OA'I
~HCJUIIlI or CQW\.I'T1ONOI" na ~1CA'nON
""'"""'N.... ,..,....",...1... of IN...........ot 1M "rodUClt' 01""" on Nt_Of IhlllllKllallon ,.NO I c.",''' 1ft"........."" ,,*,,1'-' ~""_It
...........~I"f.,..,1M r-711\M1lI ,.'11.,..... antICCOft'lNl''''....1I eowertt'f--'It'ICI 'ltlClIon ,omit ~l" ty.Act', .-
l't: ~)~_ 011I '-I-e,"" HOUI 3',.4J ~
. .....U.II..liI..._fII....4 .'
lneurlne' Companll. oplrlung In tn. Cammonw.lnh or P.nn.yl~.nl' Ire required by law to mlk, IVlilabl. tor purctI.... th
'OUOWlnG NIt.mft tor you. your lpouaa or oth., "Ialiv. or mlno", in your cua.IOdy or ,n tl'l. eu.(~dy 0' your ,.laIIY", r.lldlng In yO\.
hOUHhold. occupantl of your molor Ylnlcl, or p.raonl 'tnlck by your mOlor ViniC I,;
(I) MIdIOlI OIn.lItl. up to 011.... 1100.000.
(1,t) Extraordinary mediCII ben,'lll, 'rom "00,000 la 1,100,000, WhiCh mly bl offered ,n tncrem.ntl a' $100,000,
(2).. Incom' JOII ben.hI~ up to .t IIIII 12,500 per montn up 10 . mllumum Dln'lll of allea,1 '150,000.
(3) .....Idon... d"'ft OIn"I\I. up to .tl.u\ 125.000.
14) FunIJII OIn.t11I. 12.&00.
(&) AI In alternallYI to pI'lgrapn.l1). (2). (3) and (.), . com')lnal10n Den,'il. uP 10 a' t..I' 1177,500 of bln.ttt. In 11"1
10g,,,,I.. 0' blnaml plyabl. up to tn,.. Y'." trom tn, dltl ot In'acCldlnt. wnlctl lVI' ocC&ft fint. lublect to Illmlt 0
aCCldlntl1 d'.th ben,tIt 0' 12&,000 Ind I limit on 'uneral blnlfll 0' 12.500. prOVided ..... "Uung con.llntell" 11I1
lubllctlon anlll blconll,uld to limit, r'duCI, modIfy orcn.ng.thl p,ovlllonlof lS.cllon 111S(d~ ('.'llinO 10 IVIII.bIU,
olUm,lI),
tl) Unlnlu,td. und,'lnsured and bOdily iniury liability cov.,agl up to II t..I' S 1 00,000 b.cau.. o' inlury toon, person In an
on' accld.nt and up to 1'1'.111300,000 blelul. ollnlury 10 two 0' more persona '" any on. accld.nt or, I' thl option (
Ih.lnlurtr, up to III'''' 1300,000 In ..Inol.llmlt 'ortnl.. cov.r.o... Icelpt ,orpolicl"IIIUId undlr Ihl AllIgnld RII
:'t" . ~IIO..' ..... 16.000 for dlmlg. '0 prOCllftY' O. otnIII In Inv ani Iccldlnl,
,...,. UdAl6nllly.ln.urlrom.y olli,hrghor -'"__lIlo...num.;illdlbO.... w," illddlllonll OInlllll, H_
In Inlu,1d may 1lICIIO purcnllllowlr IMnlflll'Vllalnln tnOH ,num"aled IboVI. Your Ilgnlturl on "'II nollCI 0' VOl
paymln. at any IInl.I' premtum ev1l31nCI' your actull knowltclQ' Ind und'rlllndlng of tn, 1~II.bllity 0' tn..
....... and ~ U Will II Ii'll blnlflla and lima you "1'11 llleerad,
11 you hlvl any qUllllone or you do not Undl,.llncJ all o. tnl yanOul optlona IYlllablllo you. conllCI your .glnl ,
company-If you do not undlrsrand any ot InlprOYIIIOn, con'I',,' In tnil nollCI. conllCI you' Igln'orcomPlnv be'or
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" rrllil6, Wied 'Io1t~ ~ "aiele ~e:lC;';:ed Cti
.. or b, .tbove, " '~C
9, ClllUd by' or au ~onleq~ec~e ui: ,
a, dilcharsc oi I nu~lar wnpon (eveD If
aocidcll[lli:
b, war (<.Itcl.ued or u.ndcciaredl;
c, civil war:
d. wllncceon; or
e. !'ebtllioll or revoiulIon.
10. Frolll or .1.'u COll.lellueccc of the (aUo"ill"
wl1tliler cOlllloUed Ot ~ncocU'oUed or
!Iowevu CI u.scd:
L nuclw re.tclion;
b. radialioll; or
c. radiolclive cOIIClllllinlltioo.
>
UMrr OF LWlU.rrY
A. ThtlimilofliabililY ,hoWll ill r.!Ie Declantio.1lI
for this covera,e is our muillllllll limit ocli.
abwry foreach penoll illj=d ill aoy Olle aq;i.
denl. Thls is the most we will pay re;anllC$$
'ot the IIl1Dlbtr 0(:
I. lflll/nu:
2. Clws lllacle;
.. Vetli~ll!S or pt~t:Cs shown u:::h.: D~a.
raDOQS, or
4, Vehicln illvolved ill :!:c a,,;idec~
B, Any at:lOL:l:lU othen.,sc payable (or e.'ptl:..~
und'er tllb ~ove,""gc shall oe reduced o~ iUly
11ll0u.n1l pllid or pl~aole for the WIle c."
pensn "lldC!' Put A or Part C.
C. :>'0 p:l)'tllellt will be cude ucleu t:c lnjured
per$oo or tll~1 1lC11011" leg:<.l rep'<ljClltanve C,
allteC:l ill \loti::::. ,hat :ul~ p"YJr.eot siui1 be
..prlied to\\'~td any moc::e::t 0r ;.dgr.:ec:
:.b:l~ pce:S~!1 :~r:t\'-::i u:d~;" P~:t A lH' ~::t C.
'l
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-
-.
-.
OTHER L'o'Sl:IUSCr
'.f WlC IS orner applicable auto medical pa)'tllcct.l
,0'urall~C \lo'e will pay onl >' our IWC of the loss.
Our wur II tl:e propurtioll th.1t 0l1r li:nJt of l!.
abilitY bears to the lOW .:I( all applicabl. 1imlu.
Ho..e.cr. iUly WUl':UIct w. proVldr troith tUpca
to a vehicle you do not OWll aball be exca& ovu
~n) ot.l:ler coUectible ~Uto i..csu:uJce providina;
PI)'D.IIlIlS for mtdilOll or (UlI.CraJ eJqleIlJe$.
PART C - limNStiIU:D MOTORISTS COY.
ERACE - t!
CIOSl1IDlC AGREE.\IE..I\T
:'
'.
,
.... We will p~>' dlC.1le5 which an M"tI is lc.
SLlly CI1tilled to ~cover Crom lilt OWCl' or op-
ClIItor or lIIIlUIiJu"'ld fIIOr(J' "AicJI'bccaa.se
of lJ(JdJI, Urj/l'Y: "
1. Su.slailltd by all iAM-,d; alld
2. Caused by lIII ac:cidCl1L
The owocr's or Ilptrator's Uabiliry t"r th_
daml!CS mIlS! :lrisc out of !.be oWenllip,
llIWltelWlCC or usc otthc llllillllll',d fIIOliI""
hie/e.
Any judpneDt for ~m1.1111:1 a.tlsia~ OUI of a
'WI brought 'Ioithout our wrirteo. COll.SC1l.t is
0.01 ot!lcilog 00 \:.\.
B. -Insuretf. as used L:l t~s PortlCea:s:
l. Y"u or ICY ftlllliJy ItIIm/In.
, All)' o!.ber persOD "eeupy;,., }'''''' '(J,ned
4I/r".
3 .-'..n>' pe:-;oc (o~ dalllails that periOD is rc-
titled to recover beCllU$c of 6odiJ)' illjury to
which tJ:.is cllvcr::lle o.ppliC:l sllSwaed by II.
pcr~OD d..cnbed io. t. or 1. .bove.
"Cnins/I,etl fNJl'" .ehiek" mnes ~ ;:lcd COlor
I,cr..:e!e or t.."1.Iier o(:1.:1y c:P~:
!. To \A hi~h!lo boJilv icjury ~iabiilt:o bood or
~\)iicy appUt:i Jot ~e ti.:::~ orr.:~ .l;;:td~c~.
lacludu cop,n~"lcd ::IC:-1:' ,,:' rc.j"'~cc:''' Se:V~t$ Or!iec. .,:=. "l ~e=SSlOC. CO;lynT-t:.
':';iurJ:'''~ "~:,,\..;:!" ("I~..:". ::: ,)....-l:
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"Z. To) w!:Jd: J ;011ll\' I:)~;; Jablllty OODC "'
.... polit~ apput'i at tr.~ w~, ~t' t::~ D.~I~':t
.,,' !II tIlll ~ Itl iimlt lllr bodll~ 10lUl)' ~IOI"
. , Ity IllWt De ic.IJ :hac w aW:Jmum llmit ,c~
~ boIllI) i.njut) IilbUit). JPCC\licd by tl:c f:.
aanl:!al rC'lpoDslbility 13" o( W llJ/.tr L.!:
., IIIhich )'all' rarw,,' lIIIra il prieClpAlly ~3'
ra,ed.
.J Whith" a bit aeJ rw:: yehlele v.'ho~ oper.
3tor or OMler GIUloot be idecnficd aed
,,'bleb 1:iC$:
;r"
lL. ~OU or DO~ fllltd/y trIIIlM",'
,,' . b, a vehicle weith you or ae)' fl1mi1y
.:. _mIur arc occ"pyiltg; or
~ .' e. ,_ .a,..ell &IIla.
~..; To wbich a bodily ilIjury liAbility bo:d 0:
:~:,. polie>, tppUCllU the rime o( th~ ao:idcct
~', . bUllbe boadiD. or izlsurillS eomplJlY:
lit' "", .
t. clCIIia coveralle; or
, b. is or becomca jll$OlvCD~ .
,;)'" . .. . ""
., Ho..ever. lIat."-d lIIli'o~ ,dUU. c;1~ 1I0t Ln.
c1ude uy veblcle or equiplllCllt:' ..
I. Ollltled by or furaisbed or'avlilablc (.,r:i:e
rtlUiu use o( YOll or uy /tIIIIiJ, mnnb"..
_ 2. OMled or operated by a ~l(.i.il:lW'C1' !l=der
allY appliCl1blc 1lI0tor vehicle law.
. j. Owulcl by oUly !ovc~w' \;::!l; ~:
3,CtlCY .
4. Opttated 00 r;.ils or =wler treads.
S. DlSlllled lII.1Wy for use 011 public roadi
wlul.1I01 011 public :oacls.
6. WhilI loaued f.,r us, as a rmclRc. or
pl'Clll.i.se:l.
ElO-t:SrONS
..... We do 1I0t pro,ide Uc=ed MOt.,riSlS Co',.
mse for ja~, 11IjIII)' S'.:.5wccd b~ allY pcr.
SOil:
IDcludds cOpyn!tllltcl IlllllllUl o( Il:S"CI:'Z:lCt
WUr:1.OGC SUVlceJ O:tltc. ~c.. 19!~
-
~.1. 'Sbi:. oC~II,,)'illl/, ,)r "crn lc'wk oy. aey
~, c::~t~r \ (llJcje 0" neLl b~ ~.,,, or any itlmi(r
mtIMt, 1\ hie:: ;. ~ot ir..ured for llll, co,.
:';'. '~r( ~:~(: :!:I$ pou_,:" Th.II ineluclCI '"
.", tnlJler of any !)Ipe u.ud wllh th~t "chicle,
't2. If tllat peraon or ltle It;:!l reprncnuuive
..nlu tlle bot/iI,. '"111">' clllta "ithllUI our
~onSlnt.
, J. Wililc occllp.li", .1'''''' rDvtrcd "'D wc.:u it
is heinr: l:.Ud to .-:Ill')! ptnons or prllpert~.
'or t fee. Thil UChllioc. (A.3,) dllf$ not
apl'l~ to a siwe.lhc..lqltllSC CIZ pool.
~. L"sinr a \'eiUdl WIthOUt a l"CI.loD3ble belief
~l that penon is .etitled ro do 10.
B. This covenl.e shall eOI apply mrtetl)' Ilr ineli.
m:tI>, to beDeUI Uly iosllltr Ilr $Cl'.iel\ller UII-
dcr:LaY o( the (ollowilI. or limiIu I&...~
1. worker's comJlllliaclOlllllw; or
2. disability lltaelhal:!lII.
LL'\ID OF Lr.'-Bn.m .
A. The limit o(liabilitv shollltl in tile Dccl:ualilllU
for Il'lleh penoe (or l1nill.sured Mot.,riUI Cov.
erar.e is oW' maximum limil of Ullbw[)' for ll.ll
daa:.,n. ilIcludi.D. damares (or C'UC. 1011 of
ltMees or dCllth. uisi!ll our of jadiJ, iIIftiry
" lu.st:lIJ:ICd by LIly 0111 penoe ill a.ay oee led-
dCJ~ Subject to tbJs limit iorAce penoe. the
Liml: ofliabUit~ lilOlOU in tile Dccilnuooa (or
e.lel: a~C1dct.t 'or t:aillsW'ed Motonlts Covlr.
r 1,e '. Ot.::' ~=W11 limit o( Ii:tbwr... (0: all
~'dLlI:1,n for jDdiJy '''jruy re:sultiar from :tel'
, oae atrldt,,!. This is :he ClOSI we wtlJ pay reo
:. Jlldless o(the !lWllbcr of:
(, 1/lIlUttb;
l. <'1aimJ Clade:
:. \Ofl"jc1_s 0:" ~:'e::J:':=:s :I'O'IJ....1: L: t.bc Otcl.14
nliol:j.o:
4. \"c!:J:its 1c.~ol\'tC1lC. :':'3C::ta.t:lt.
9
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B. AI1Y ..mountS othcrmlt =..:." ~ · for <3l1..'U"Q ,
WlOCr tN' ellvel'll,e IIlGit ::c rcllucell 01 .U
fWD>'
I. Pllld be~IIUIC of the b~d.Uy iII/ury b\ or on
beh~lt' IIf penon' or Or!lIl1intiolls who
alAY be lcplly retpollublc. Tlll. l.Ilell!dea
...u IUlll' paid Wldet Part A:.;I.Ild .
2. Pllid or !,lIyable bec:u.U,IC 01' the bodily in.
Jllry ulldcr ~llY of the CoHo..i.ll, or sl.llliLo.r
Ill"";
~. workers' eompcl\llOlulllll~\V: or
b. d15abiltty bellefits law.
e, NJy paymCl11 W1cler this cOVCr:lle will reeuu
ol1Y .moUIII tb:Lt penol1 CI enullee 10 [ccover
: for 1M same dllllAlcs undct Put A. :E
OTHER Il'lSl.'llA.ll\CE
. "
If \bee. is owr applicable SI.lIIIiar jl1$WUCC we
will pill' ollly our sbJ,rt of the losl. Our sbare ~ ~
proponioll tb:L1 0111' liIJlil of liabililY bun lo.the
10141 of IIIllPplicablc \iml\:l. ~.:lftYer. al1Y il1SW-
UICC w. provldl wiIA RSpcct 10 a ..Iliele YOIl d6
[1101 own sh&l1 be CJCCa.I o.er an~'"other eoUe.:li.bb-
lIS\lr.lDCC. . '
. ~.
.
AJUlrtRAnOl'
.~.lf we o.ad :1II.-,tI do 1I1110srce:
l. W"lletilet thai penoll IS le;:illy e:lutled to
[ceo.a: dAmllcs unQu \llis part; or
:. ~ [0 tile _OWlI of d4.IIlIlS":
eililer pattY llIl\Y m&ke a wOtteD dellll\l1,fjor
:ubluatiOIL III this eycu:. each pL~' will select
&II arbiU'alor. Th. !:Vo'O ubiuaton ~iU sclolCl"
lhir4. II th.y QL%I.l101 &!ftC witbiD 30 d&ys. ei-
th.r mllY rc<lIlCSI thaI selectioD be c1&de by a
jud,e ot' a co un !savini Jurisdiction,
B. Elle~ Pllrty ...uI:
I. P.y tbe .~pell~ it i.r.cun: alld
2. B~ the ,~pec:scs of t!:e =d ;!:bl~'";ltllr
cqlll&ll)"
-
l..ul~s> Ollt:! pur:le:i ..,ru llthef"olse. arCI'
(muon wll! wke pi~ee In u:e CllLl.:l!:. I". II illcit
tile ill.II"" 1I\'cs. Loc-al "'Jin of ill'" as to pro-
CCllure :llld evidtllCA: wiU apply. ^ deCl:llOI\
J~d 10 by t..o of the GrbicrJtor1 ..111 be
blu,1il1i lI;I to:
I. WlIether we i/llll"d i$ lellLiJy el1nued 10
rc:.:o.er dwuasn; Ind
2. Tile :unOUl1t of d4ma~n. Tbi51PPUCS oe.!y
if we a.tnount docs. 1I0t ucccd the mle.!.
mWD li.allt for bodily U1jury UilbililY '1'<<1-
lied by rhc flIlanc:ill! r~oiwDiUty lr.w of
the stille ill wtUen your co""d &IU" i~
pnl1CIPaJ.ly prlled. lIthe _OWlI e~CC'COs
Will li=it. either, pUty llIay.c.tmlJld the
olllt 10 Il trial. Thil demaDd IllllSt be lDACe
witbiD 60 dI.lys of the ubiaators' decisioB.
II ~ dc:milnd i5 aot mad.. th.lUnOI1Dl of
darDllca lamd to by i,li'e > ~!ijlr.1I0rs will
be bhlllilll" .'" .
'. ," .~: ..
PART D - COVERAGE FOR DA-'\tAGE TO
YOlTRAtrrO - D" .: .:...',:~
. . -*'
INSlJIWoiG AGRIL'\tE......,. ". ..
..' -.. "
A. Vie 'wiu pay for direct iIIld i~dellta.llo.. to
.l'our co,,,,d 1IJIt0 or ~y ritJlI~..rutl -. ill.
dudI.Il~ their cqwl'ltIelll. mlnllS any :1tlPlicable
deducQble sklo\VU in tl:c Decl&r.ltiollS, We will
pay for loss to your c"""tI tIIlfO ClIUiCd by:
I. Other UlaI1 co//Isi.olf oaly If the De.:l&f'll,-
tiOllJ tndica~ that Oth~ '!ha::. Collisiol1
Coyerale is proYldedlOe tbat acto.
, Co/JJsi"1I olliy if the Dccl.ar:lUOllS ind.ica~
that Collisioc: CoveC2le is prll'ided for
tl:Iat;LutO.
U' wet1: IS :1 Ill'" 10 :l /IIIIf~If,..tI ...r". we will
provide the broad~t ~o"r.lIC applic:a.blc 10
any your c"""d IUIIO ilIO....D L:l the Declam.
tiOQ.i.
to
JOO4P
ll:clud" cop\'!i~u:d l:lI:llcr.:r.!. of UISI1:.i1:l..,iSc:vi...... ot!Ic:c. ..;th iu ~rmi$&ion. COPY'"Pt.
-:....: ',;~,' .;~.. ('"\,,,,!,", ";'; ::.~. (.~.:
.--,-"".- -_._-.....~'-
.... -. - -- .-.- ----~ ---
rf'"",
'.
tbJ~ pOlley aa:pt (or !be a~emenl ,.,..j!, . ":~
=cd m this provi,uOD.
IlL COVERAGL-FOR'DA.'UGE 1:Q:-'<"OL'Jt;
...t..'1'O
Pan D II LlI1eDded ~~ foUo"'~:
A, Tl:.e (oUOwUlll e~d U510~ ue add~.
We MU ~ot pay (or:
LoS$ to YOIU eo.uid tlllfO ....hiIe.l)ciag op;
mud ill. any prcal'n!llle!i.. or or&amzed
r:lcillll or ~pccd ,ontell' or ill. pt"3~CC' or
prcpar:<uon ior any suciI 'onlC5!- ~: _ -
All' .OSS 10 YD'" eD..". _0 &risfnl out
oC or durill!! its \lSC for the ~or"..atioo
oiaDY: .
l. expLosive :Nb~W1ce;
". n.~""blc !iqwd; or
'3, rimilu b.u:Udous mau:riil!s;
excepl lr.1Il$'pOrtaaOn iIlcidenuU to you:
ardinar)' hoaschold or cum ac;tivitics.
B, Puagrzph A. of the Umit'"of Liability
provisioll is replaced bytte fonowms:
!.lM1T OF u.um.rn
OlIrtil:ait 6fliabwty-forlosl will be the ~
se:roflb.<: .,
w . ~ . - _ ..
.." ....
. - -
. -..., ;;~ , .:..:.. .
'L,' ^c=Lc2.dn-al'ua'Oillle stOrm oiaaa:-
a;e pro~m bUI DOl W uceed S:!:S,QOO.
" -:.. .\!nouAr'~~'iorepm o~ri!ilI&=
:he propct't)' bill DOl 10 uc:mi SlS,QOO.
Ho",."r. r.b.c most we will pay: for Iou 10
JJlY 1I01l"''''1t/"J 4lU0 whk.h 1.5 a rr.u.r Is
5500; , ", . ,..
..' -' . .-
lV. GE."r:RAL PROVlSIONS
Panpph A. .o(tM T etmJ,.tIaQ'1!l. provisio\1 of
Pa~ f i~ repl~ced. ~y tlIe fol!~\70~
ean,l\lbtlOD. Tbi~ poli,;y tziay 0.:- l:IDccUecl
durinll tlIe polley period u foUows;
,l. The cAJnCd iIlJllnd dlDwn in the Dcclanl.
t10D~ mal' C1lICId by;
a. rerurl1l.D1 this policy 10 \IS; or
. b. givin& lIS a.clvanu WltC'l1 notice of Ille
~lC C!llceUation i$ 10 we ctTeel.
2. We =y.=1 by llI&ilLn& 10 tlIc'1Wllccl
insured showu ill. tlIe [)ccI.UaliollS al thc
address ~hoWt1il1. :his policy.
:L at least LO days nDtlCC if """""II1lioll is
..,. " for nOllpaymcn, ofp~u.m; or
'. b' -at: least 20'd.iYS'l10llCC itlalfothcr c;ua.
NOl:: IIi, roUowbll'endorsein~r'appues wi1:1: the ,ovel".1%e d.:sl~tioo 1: a~pezn in tll.c d.cclara.
. 1I0llS. ' .. ,.. . ,,'; :-.' ." . -. , ..." .
,-' ... ," :..-:"':."':". . ,,""':".:" '" . . - . - - ~
~~.e6s9SC2{t:Nm\suREi>{tWERlNSlj'RED MOTORIST COYERAGE -
~"....:^_':"" ..;:.::,-, ,....:.: ~c;c:'~ :PENNSYLVA."1IA ,.., ':,"
..:.:.::,(Co,erqe,L')- .'
':'~ '..' ..': 4::_ ~ _,:':~::M :;.', __._ ..... _
~ c. ~f1cea ~TtliifOn~r..::i:=2
-V"'"..;:' .... - ~.. 1" "". _ _..~'" .... ........ .",.7
~~. ~o~ _whir~ a,~;.~;,iirir":" ar..d ·
~iorthe.c!'~'
,:,.. :.
INsuRisGA~. '
.~;:: :....:....~ ~.-.. .':-'-
- . - .-.-
. - .
We Mil pay ~es whi,o. au ~ is"icplly
c:.titled 10 =over rro:n tll.c o~~or opetlltot of
.24
~,-=
., 1 ..........:...,."I~n!.w..dZri.ll-....' hL~c:es ()ff!c:. a'it::J. r~ ~<ri~ Co~~t.
r~~~.V!:.J.=.~. .~-
....., . ,
T'b.i..llS llI.c alOSI \\Ie ..'ti1 p:1V {e~...<,Uess ot t~e
.W:::bcr 01:
!. btNr.,'
, C'..a.i= lllidc;
:, V.hiel" or P=wns SilOlll1l111 ilie XCtcl-
we or III ilie Dccl.t.raliOllS; <Jf
4. Vehiela illvolved ill the ~deut
However. 110 1.vw6d will be ClIatled to RCelve
duplialte pa)'tllCllts fOf the Slme elctlClltl of
Iou.
Any o1lIIOWlU olllft'WIM payable ior d4m.tps
wllich the "'-" ia JepJly ealitl.ecllo ncovtr
Crom the OWII<< or OperatOr o( q ......J
-,." '6,*" or ........ - .Ii __ ,Utid#
becallSt of IINIII, I1V-7 caused by atIaClCidcul,
UaJl be ~ by r.I1_ pU4 becallle of
the 1<<61,., by or OIl beha.U' of pmo~ or
"rJlllizalioaa who mty ~ Jeplly RSpOllSIbJe.
Thi, iIIelad&s all S1IIlU paid WIde: Pan A.
Ally pal'lDCllr WIder this coven.. wtlI re.dIICt
Il:lY atIlOllDC ther penon ia carJed ro =over
(or llI.c __ dama,. WIder Pur A.
OTBER INSURANCE
tbcn is otllcr IppliC1ble similar iIlslll'iLllce
1ftI1&b1. Wlcl.trIDOM lIl.ul OtIC policy Or proVlsioll
otco'enle: -, .... ' ..
I. The fOUOMnr prionties or'recovery aPPT
F" an n. u lliD.sund1U ll.dcriAmted ,;.\(o.
COlUl:l Co"'ra~ :1ppiic:able to the
\',h1ele the buwu ...as DCa,,,, II
the time of the aa:idct
~ -;':-....'..
.'';''.~... ~
~:"':olld The policy .uror~ Ullill..
sunclit.'OldtrUlSllll:id \IOIOrUtI c..v.
~l1Ile to the iMIIr6d .u a ~
i.J:Isurrd or ItII1II1y 1IIftNbn.
, We ..111 pay only oW' lh.a.rw oft.!le fOloS. Our
sb4:c is th.c ptoPOrlloa tlIal our limir of li.
abllIry bnn to the 10L1l of &lJ limns ilppli.
ClIbl. 011 !.be sam. level o( IlDonry.
.WrTaAnoN
UQI, Uld III iat.u do COtler=:
1. Whethtr that pcnou is Icpjly ClIarJecI EO
twCOvcr damara lrom the onu or opna.
tor of l1I1 . .It _r .dtkU or 1IIIiU.
~tt _tM """4;
2. AI 10 W &IIIOlllll o( claJups;
eiWt"JUt)' lIIlIY lIl&b I wnllell d&:maad (or arbi-
llalioD. A.tbiItadoa IIW1 be COlldus:rcd ia aa:ord.
w:c 'IoIirh the proviliolla of tba PtuDsytvaala
Uaifotm ArtrirntiOll Act. &cia plll'ty "'111 select
&l1 arbiUalCr. TIle two arbiuuOn Wl1.l wJll:t a
llIird. If they CI1DIIOllpw 'IoIidlia 30 d.1~s. ntller
lll.\ly requesl WE M1l1Ction be llliclc by. Judcc ot'
I CQUtt ll.a~1 iurildietioD. Each party Will:
I. 1>ay the tlrpCIlSeS il illCUl'S; OUld
. '2. Uear the I'ZpCIISes of llIc third atbirralat
' eqlll..l.ly.
Ullleu botll puties IllRC olllcrwtsc. Ulli tr:l a 011
,.,:n tUt plilcc LI1 the 'Ol:.tlry ill ",!zjc:h rhc covcrc.d
prt$Ol1 lives. LOQJ tuJcs of ra.... :u 10 procedW'C
OlIId c"d.ace Wl1.l apply. A dc::1sioa aerwd to by
two oi t!:c ubirra[QlS...uJ be biadiag.
27-~
3382P'
idus ,opyaclllA:l -.. or Iasun.a.. Senica oroce- Wltll it.! PfllZlJs1i.ol1. COPi'Ili/:u,
at :)em_ omce. ~~ 19&4. 1986
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exhibit c
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Exhibit D
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Exhibit E
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"jII.2000 ...... 7,..,1
III rlrl ),1 Vjl.14Ii\ ,', "llllfJI ,1 J 1,1, I I,,,;j
ATTACH TO APPUCAnoN OR POLICY CHANGERlQUIST fORM
III )1 l \ I rJ ('I I 'r;'r. ,Ill I I) I' \ 1 (1H' I lll, ,II I "
'f I...... lie _ 11/1I ....... ____ ....1 III ..j_...... uniIf .... ,...,. III ..,... ~ II. '
,..._......IIl""....'f '," U,.___,,,,,,~""_"l~-.""'''''Ml I I~"
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.f........IIliI_~'1 ;.;..1I11....~..:~li.~~~i~.:.4i.;::;~ J ~.....,.-...~,.:.~..
lIIfMlI_n_.IMlI"""-" IJlIII!*,.......lIlIlI.......-....,.rr" !~...JIW...-.... ".,
""'Ita "" I. _..... __...,.... ,AU J:Ii' . W........, ......-....-,............ ,':
"'............ ....IImlII'.......1lt II.",,; I ~...__.......IIIIIlIIIilIIInII. of" "
_...... I ..............., "" pqml\IIiII" . ....... ~.; .
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....NI. at Fill' NIIlIId iNured
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Exhibit F
~
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.
.
IN THE COCR~ OF COMMON PLEAS
OAOl'E1:M COUN'l'Y, PENNSYLV'MJIA
I
CIVIL ACTION - LAW
NO. /p8J-5-QIl
!.!:NORA Ill. SKr/'INGTON,
Pe~itioner
.
.
S'rA'R FAllK INSmwrCE COMfANY,
Ra8poDelen~
.
.
Dftrrrml ora COdE tnrnfSnw'tVtlll 'tD~rlJ!lU.'rrOH
II
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'I
I
AND NOW, cOllie the p.tition.r Lenora M. Skivin~on, by her
at'tomeytl ).aqino , Rovner, P.C. anel respectfully requ.sts this
HonoJ:Ulla ColIrt to:
1. eoapal RespondeDt state 'arm to arbitrate Petitioner's
uft4ftauranca motorist's claim,
2. order Respondent to select a seconel A:bitrator; anel
3. COIDPel aespoDdent to pay P.titioner's couns.l f....
~, :In support, P.titioner re.pectfully represents th. !ollowinq:
~ 1. 'etiUoDer Lenora M. Skivinqton is an adult intiividual
r.sidiDq in camp Bill, ~erland count" gennsylvania.
I
_ ,\ 2. aaepoDelent State F!L:r:'IIl is an insurance comp.any licensed to
.I
,I do bWline.. in the COllllllonwealth of ilennsylvania with affice.
located in New CWIl1lerland, cum.I:l.rland County, Pennsylvania.
3. On Auqust .2, 1993, Petitioner Lenora M. Skivinqt~D was
lDjurecl in an autolllobile accident z.t Maclay strHe, oauphin county,
Pennsylvania.
4. GIll ....;J'.t 12, 1993, Petit.ionar Lenora H. SJtivinqtml WIU &
.-
..'"!!:: ':":'W
.~\
r""""
nueci wu:ed on an aU1:olllol:lil8 insurance policy iSll1.led by State
F&r.IIl.
5. said policy was in full forc. and effect on Auqust ~2,
11113.
~I
d. '!:he subject' autCllllol:lile acci<1ent vas caused by the
neqliqenca o:e Randy F\l.lp. At the time of the subject acc1<18nt,
Randy Fulp vae uniMuZ'eci.
7. By letter, dated. 08cember 22, 1993, counsel for Petitioner
Lanon K. skivinpn rwae<1 Attorney Gerald C. Kruer as her
arbitrator. COUDael'. let1:er i. attached hereto as Exh1l:l1t: "A-.
.. To date, State Farm ha. not appointed an arl:litrator.
1fVDWWORE, ,etit10ner Lenora K. Skivinqton re.p~lly
requeaU this Bonorallle Court 1:0 issue a Rule upon ae.pondent state
r&r.lll tn.surance co~any to show cause wby Pe1:itioner's uninsurance
motorist's claim should no~ be sul:lmitted to Arbitration, that
p'.Qonc!eDt be cOlllPellad to select an Arl:litrator, and that:
~.pondellt pay plaintiff'S counsel fe...
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W'r,nC8 . earonet
I. ol No. 6192:1.
4503 North Front street
Bazr.ul:lurq, PA ].7110-17.81
('711) 238-6791
--c:cnznsel tor pet1tionllZ'
.
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("-,
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escrita 0 en persona 0 por abogado y archivar en la corte en
forma escrita sus defensas 0 sus objectiones alas demandas en
contra de au persona. Sea advisado que si usted no se defiende,
la corte tomara medidas y puede entrar una orden contra usted sin
previa adviso 0 notificacion y por cualquier queja 0 alivio que
.. pedido en la peticion de demanda. Usted puede perder dinero 0
e. propiedades 0 otros derechos importantes para usted,
T.T.RVR ESTA DEMANDA A UN ABODAGO INMEDIATAMENTE. 51 NO
TIENE ABOG"DO 0 SI NO TIENE EL DlNERO DUFICIENTE DE PAGAR TAL
SERVICIO. VAYA EN PERSONA 0 T.T.J.1fR POR TELEFONO A LA OFICINA CUYA
DlRECCION BE ENCUENTRA EBCRIT" "BAJO PARA AVERIGUAR CONDE SE
PUEDE CONBEGUIR ASISTENCIA LEGAL.
Cumberland County Lawyer Referral Service
Court Administrator
Cumberland county Courthouse
Carlisle, Pennsylvania 17013
(717) 240-6200
"I,
-
- 2 -
~
~
3. Defendant was born on September 6, 1975.
OCCURRENCE
4. On or about September 30, 1991, Defendant executed an
Assigned Risk Plan Application ("Application"), for a private
passenger automobile insurance policy which was ultimately issued
by State Farm Mutual Automobile Insurance company, Policy No.
820 1007-F21-38 ("Policy"). A true and correct copy of the
Application is attached hereto and identified as Exhibit "A".
True and correct copies of the pertinent policy provisions are
attached hereto and identified as Exhibit "B".
5. On June 21, 1993, pursuant to the requirements of Act 6
of 1990, Defendant elected the limited tort option of her
liability coverage by executing the Pennsylvania Assigned Risk
Plan Selection of Tort Options form. A true and correct copy of
the form evidencing Defendant's tort option selection is attached
hereto and identified as Exhibit "C".
6. On June 15, 1993, Defendant executed a Rejection of
Under insured Motorist Protection under the Policy. A true and
correct copy of the form evidencing Defendant's rejection of
under insured motorist protection is attached hereto and
identified as Exhibit "0".
7. On June 21, 1993, Defendant executed a Rejection of
Uninsured Motorist Protection under the policy. A true and
correct copy of this form evidencing Defendant's rejection of
- 2 -
~
,-,
uninsured motorist protection is attached hereto and identified
as Exhibit "E".
8. On August 12, 1993, Defendant was involved in an
accident with an uninsured motorist. ("Accident")
9. Despite her rejection of uninsured motorist coverage,
Oefendant has Petitioned the Court of Common Pleas of Dauphin
county to compel state Farm to proceed with an uninsured motorist
arbitration. A true and correct copy of Defendant's petition is
attached hereto as Exhibit "F".
10. By virtue of Defendant's rejection of uninsured
motorist coverage, no contractual provision exists requiring
state Farm to arbitrate this matter and accordingly, State Farm
is entitled to a Declaratory Judgment freeing it from any and all
responsibility to provide uninsured motorist benefits for any
injuries allegedly sustained in the Accident.
11. Defendant, through communications of her counsel,
apparently asserts that her clear and unambiguous rejection of
uninsured motorist coverage may be voided because she was a minor
at the time of said rejection.
12. Defendant's argument is fatally flawed because the
policy of insurance with state Farm w.. a contract for
necessaries and is therefore, n2t voidable by Defendant.
13. If Defendant's interpretation of Pennsylvania law is
correct, then every minor may alter his or her automobile
- J -
1"""'\
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insurance coverage to suit their needs after an accident takes
place. such ~ onstruction of pennsylvania law is inequitable
and cannot be countenanced by this Honorable Court.
14. There are no material facts in dispute.
15. The sole issue before the Court is whether a minor may
utilize his or her minority status to void a rejection of
coverage under an automobile ins~rance policy after an accident
has occurred for the purpose of obtaining insurance coverage for
the accident.
16. In view of the foregoing, this issue is uniquely suited
for declaratory review.
WHEREFORE, plaintiff, State Farm, requests declaratory
judgment in its favor enforcing the clear terms of Defendant's
rejection of uninsured motorist coverage thereby discharging
State Farm from any and all responsibility to provide Defendant
with uninsured motorist benefits and dismissing Plaintiff's
Petition to Compel Uninsurance Arbitration.
Respectfully submitted,
FOULKROD, REYNOLDS & HAVAS
A Professional Corporation
"'-'
DATED: 3/11 f t.!
/(~ ( /1_ A/) /;
By: I ' /r~
OLF ~ KROLL"
Attorneys for Plaintiff,
STATE FARM MUTUAL AUTOMOBILE
INSURANCE CO.
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9, C/.u.ud b)' or au cOllleq~.e,( of; ,
Ol. dllchu8C of 2 lIuclnr ...caPOll (.,cD if
~c:adC11t~);
" wu (d<<lu(d or U.lIcirc;ar.dl.
c, cil'ilwar:
c. i.:lSurrccuon; or
e. reb(lIioll orrevolutloll.
10. Froel or 3..$.1 cOC.:lClluecc', of we (o~o..inr.
...~.tiI.r cOlltloUed or ulIco=troU.d c,
!lo....ver CI u.scQ:
L oucleu reaction;
b. radiatioll; or
c. radioactive cOllwninctioll.
a
-,
...
LIMIT OF LLUUUTY
A. The limit of Uabili~ Itlowo ill t!:. DCCluallO.lI$
for this cowral' is our maximum limit of li-
abiliry [or each persoll illJL:r.d ill allY Olle ac:ci.
dellt. This is the 1Il0st we ",ill pay re~anlla.s
'of the llumber 0(:
1. IflSllf'u:
2, C1.1imslllOldc;
.. Vehicles or pt<:niues scowe L.:: :b.e DCCJOl-
r:laotU. or
4. \'dlicln iavol,ed ie :1:. ac<:id.n:. '
B. AllY :U::Ot:nU oUt.",;,. plY.1b!( (or e'p~'($
uccer this ,ov(r.lg. ,hall be reduced 'oy a:l"
alllOC.lH.s pwd or payable for the = e."
p.n.... Wld.r P= A or Part C.
C. '0 p.lyme:lt will be c3de uel... ~. tnjured
ptr;oa or that persoc's i.!.1l r.prcoellraave C.
J.~'~ i: ......n:i.o' ;hit O!.Q~ p..~o:cat stull b~
;tprlicd t.,w:uo i.!r.y ~ttr.i~=-:::t vr j~c~~c:
~~~ t'~:Sva :ecc~\'-::i u:d~:- P:l:'t A C~ P:~ C.
-
-.
'.
:: :::erell other appUcabic aUto medlt:al pl>'Cle:::.s
,:Sut1ll~( "'f ...w pay 0111>' our ,i:I4r~ of the 1055,
0... sure II the proportioa tI:.1t oW' li:nit of (j.
.lowr,r Ofl.rs to til~ lOW of all appliClblc limlLS,
no",.,er. illY WW':LtlC~ ""e proVide ,.,ith respect
to 3 v.!licle you do cot OWII ,ball be e.= over
~~> otl:.r coU<<tibl~ auro L.:!.sura.lICC ~rovi<li.cg
pa)'lIlfllL5 (or mtdlCllI or fwu:mJ elqlCDSCS.
PART C - li~INSURED MOTORJSTS COV.
ERAGE - l'
rssnu~c AGREEME.'1
,
A, w. ...ill Pol)' d3!l:.1ICS ...!lich all iIInmd 11 Ie.
gally euDtled to ~covcr from th~ OWl!ttor op-
t.r:ltor of llI1 wWullud fNJr~, reAid,bcclIlI.lC
of 6~dJJy injury: "
1. SU$aintd by III u..sr.,4f; alld
2, Cawed by llI1 accideut.
Th. owoer's or operator's liabilir,r fJr thCliC
damages mU$t Ilrise out o( the ov.'llen.b.ip,
ms.il1t.lWlce or use of the 1IIIi/lSlll'.d fNJUI, ".
hie/..
Any judpoeat for Cl=gt:l .ui.si..ai out of a
Iwt brou!ht ..ithout our wrirten COll.\tCt is
::Ot OUldJllg Oll us.
a, -lnsIU.i!' 3S used ~ t::JS Part C:e:1:S
You or 3CY {Q/1riJ.v nwmbn.
, Aa>' oth.r perloa "ccup,.,., )'''''' e",n.d
QIIr~.
) .-'..0>' perlO!! :'cr dama~Cl tI:.1t persoc is ec.
rHled to reco'.r bCC':1use ot' bodiJ>' inJIIFY [0
,,"wd tI:l. co"e~ie :lppli", .u.sI.1:.::ea by a
per~oa d.senecd 1:1 t. or 1. ..bo,.,
- L'ninSM"d fNJrc, "NeU" mQCS ~ i,C;! :::oto~
'fer-Jeie oTt!W.lierot':L:Y t)-pe:
.. To \.\hi~~:1L:> boJliy i:jury ~l:Loiil~ ~o:J L):'
:oiic~.' Jpp!i() ~t:.:e ~~ otc.=~ ':':;:C::::.
j
3()f)~P
!QclUcif~ e~p~1't~~t.:d ::::l:e~::: ("I( [~~~"'"1:C::"' S~:"'IC1S O?f!ce. ~I:": its ~":::USSt"r.. C.;);3Yr!~:':'
':-:~urJ.:;':~ ""~ro.':~:~ O~h.''' .=: t.)"'l,'"
-- "-- -----
-..
-
',2. ToJ w!:Jd:" co.:J.:\' 1=:.:-> .ubllJc~ 000'; ~,
'.. poho~ Jj:pu~ ~t tr.e Ur;:e ot" LOe ~o';Ilie:t
.,:, !II tllll Ollj( ItS iirrut t"oJr bodily IDjU!')' !Jabl'.
It''lDUSI be ielJ :J:aa tlI.t m.i.aiclIlIl1 Umit :,,,,
, b~dlI) U1jur) liabwt) JPCcWed by tl:e (:.
D.1nc:ial 'elpoasibiti~. 10" of the Sl;/.tc ~
., "hlc:h ."0'" corem' ""'0 IS pncc:ipaHy ~a.
ra!ed,
J. Whic:h IS ~ hil ac.;! n:.c veiliole who~ ope,.
" uor or O\\''De: CllI:loot be id.cnfied a:c
...hic:lll:ies:
:=-,'
II.. ~ou or aoy flDrliJy _mbn:
,',' ,b ... v.hiele wwdl you or ao) Jizmily
::. _mbnucoccupyilft::or
~ .' o. ,ow CO"N. -.no. .
6,~; To whiei1 a bodily injury tiOlbiIiry bo:d 0:
;::" poUc:y appUes .u the lime of Lb. acdd~c[
:'. . bur lbe boadID. or insuriD! ooDlpany:
''I'" .
. . a. delliCll oovera;e; or
b. is or becomes iasolveat.
'i'H~""enr. ~i "";10' "Jokk d~ Dot in.
dllde lUly vlblc:le orcquipmCIIl: ,. :.- ' .
1. OW'llcd by or furuitb.ed or available ("r ;te
. re,wu use of YOD or ar.y fMJiJ, mnnIIn.
_ 2. Owned or o~lcd by a self.toJurcr :mde:
allY appUC3ble ruOIOr veJ:ijc:le.l.aw.
.3. OWliec;l by .lll)' go"e~la( .01. 0:
~.euC'y .
4. Operaled 00 llLI1s Or = wier treads.
5. OCSllDed aWnl)' for ~ oII publio roaes
while aOI oa pubUo :"acl$.
6. While loallcd ("r u.se 2.S a rnidl:'COc or
pl'C'll1i.ses.
EXCLl'SrONS
.~ We do aOI pro,ide r.:=-und MOloJ<1stS Co',.
=se ror IJodJI, iIrJm'>' S'-'SWD.::l by aay p",
Soa:
-fDclucll:S copyn~t.c lllOltatl:U "i I=oc
Ul.tl1r.UlU SCMca omoo.l!::.. 19'~
...
~.t. '.\ ':L:~ ac,;up)"n::. .;or \\oQrn '~~I\ :)'. 3:~
~, ~,'t<lr '. ~CJd~ "" r.~1l by ."u or ar.y Jizrrul.r
mimJur \\CJ':: ..) ~'.H lr.:.urrc1 for thu CO\.
:':''' t:tZlf ~:c:,: ::.u pcu=y. nul incil.:d-::i ..l
.. UlIJicr o( any rypc "-Scd with th:l.t v.hicle.
""2. rr th:lt perlon or lne le;:11 repmenunvc
.mle. t.~ bodil,. ;"Ju.,' elllOl "ith"ut our
,0nSCOt.
3. While OCCllpy;", .'"011' co~~"i ""'0 wilen il
IS bein! use..i to .-:.rry penons 01 propert)
for a f~~. ThJs uclu.sioc (A.3,) d"cs :lot
ipply tel a share-li1e-c.'l'pCllSC CI.r pooi.
4, t:si;J, a ,'~Qjole WIthout a reuooable ceuof
cUI tOal perlOlllS eaotled to do so.
B. Th.is covcraee sball aOI apply dirC'Cuy "r iodi.
reetlv 10 beoefil &.ov 11Isurcr "r self.iDlIltcr UJ:l-
der.u.y of lbc roilo~in! or silDiJar II'"
1. worker's CODlpelllatiolllOlw; Or
2. disability bcllefiu law.
Lnm OF Llun.m .
A. The Umil 'OfliabiUlv sh"WI1 iD the D~I:mIti<l1l.i
(or ,'lie!!. persoo ior UlIiD.sw:'ed MOI<l<1st:l Cov.
crate is Ollt C1a:Umlll:tllimil "f UlIbwt). ror ;I.!I
dll.ll:l!n. inoludilll ~1S'e:t for care. 101$ of
services or de:lLb. ui:rins OUI or bodily injllJ'y
" s=d by any ODe persoD i:1 :ltIy oce lOci.
de::_ Sllbj= 10 t.b.is ilmit ior each penoe. the
WI:J: o( li:lbiUlv shOWlIlIl Lbe Occlar:l[ioDS fo~
C30t i~c:ld"'t for (JWllSl:.r<<d MOloliluCover.
~ 1se ;5 I)"" D:.1.'tim= l1m:: of U:1bilit). fo: :1J.
,"dan:3!n for bodily i"jruy reosulci.tl, ::rom a::y
, ODe lOClae:!" This is :he cost ..'. "'ill P"~' 'e.
:- Jlldle:ts of tho lIi:mbcr of:
I JIIIU,C..;
2. C:.1U::..s =ade:
.. \',"'.iells 0:' ~~~S ~hl.:l~1: L.::. tCr Dcci.l4
nUo~. 0:
4, \'c!:J::es ::,olve,,":::. :'::c aO::tu:!t.
9
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Se~.;a em:.. llIr.!'.:.s pc=:l.IlOU. Copyn~:.
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B. j-\oy J..'t\OUC(S gr.ncr\\'i5t ::~.'..~':' '= fer 1Jit.....".v.r$
w:Qcr till. CI)'eL"ll~C .ilai~ te re~ucCo;1 e~ .u
!wn.:
I. P;lid bc~I/.U'C of the: b",/./I.' iJIiur~ b\ or en
tch3it' I)f p.nons or of!aointiOIl> who
:ully be l.rally r~poll.ible" TIlI~ IIlcll!da
J.ll s~s pllid IIIldul'art A; I/.1ld .
.' PJld or puyable bec:l..:se: 01' the bodily /11.
Ju,y uDder allY of the foito",ill, or lunilar
lil.W:
~, worle:a' COlllpcllsaU.:l~ i~w: or
e. .iisabihty bellelils L1"',
C. /VJY parcelll IIIldu lhis co'e~,e wUI redur.<:
111Y "moulll tlI31 pcnoll IS enulled to reco\c:t
: for 1M $lI.II1C darllllSCS undCl PW A. :E
OTHER INSlrR...,'i!=E
If there i:l other applicable .llDlilll illSU=CC we
will p3Y oaly OU% shut of the loss. OU% sblle i:\.~
pr.:lponlOIl W~ OU% lilDil of liabilitY bean to,the
lOW of wi applicable limIl>., H.JI>ever. allY illlw-
&lice we provide with RSPCCt to a ,ellicle you 46
~ot OW'll shall be CJtC'C$S o,er an~, .:Ither cI)Ue.:ti.b~
IUI\ll3.lIe:c. . '
. ~.
AllBrTa.,no:-; .
..... If we c~ :l.lI"LSlIrld do IIl)to~ec:
I. ~-"eUlcr thaI penoll II Ic~:illy clluued :0
recover <l:Im&lcs unciU 1o"U5 part; or
. ,~tO the amount of cl.amoges:
CLIne: pUt)' lll3Y m&ke: a wotteo dea1Aod ior
ubiUlttiOll- !.ll this even:. caci'. pa:<ty willlele.:t
a4 arbl~r:lIor, The [Vo'o arbiuuton ....iU SclCCll
:hir~ 1! thev =ot lime w;tbin 30 d.1\I, d.
:!ler IIlI/.Y reClUe5t thaI selCCQOll be cade by c
~ud!e ot:!. court navieS jurildlctioa.
B, Eoc:: party will:
I. roy toe e~pcDses itlr.C\1fI: Illd
~ Bnr ~nc c~pec~C:$ o~. :.:~ :=.:;d ~.:blt.-:.tlJ:'
ellu.;WY.
"
:' LU\t:h otJt:-. pilr:tc:.\ ol'iI'U ~::.ler.~t5C. ~rt:t.
tlUUOn ,V\ll ULKe pi~c~ ,:'. :.::e CI)"'"t:. :'1 "i:lcn
the inJurrd Ih~~ LI1_'" ,"4," oi ,a'"' G5 to pro-
C~IlIHe: aad evidellCC ,viU appl~, ^ d~Cl:llOl\
~1l1'-"Cd 10 by 11'01) ai u-,~ ~rbilTJ.lon ....'Il be
blll,jioi"" 10:
, Wl1elher we ;/lSurtd IS :eg.wy e"\lued to
re.:Ovcr dUJUIgn; :!.lId
2. Tl1c amount of d4mu~el. This appUes only
if the: arnOll1l1 clces nOl ur;ucl the mini.
mwn IlmIl for bodily IIlJury lio.biHtY ,;peel.
fied by the JlIIaIl~i3.i respoll$ibility II"'" of
the l!.oll~ ill \Yiti~n yo," (.",,,d IUUtJ i.
pnllclpally pt'Igec!. If the amount e~c:z:cds
:hat liaUl. e.ther. paJ:ty :!Illy..clcmanci the
Oll1t to :l tri:l!. This dcmalld c\lSt be made
withill60 doLys or the ubitiillOi\' dceisioo.
u this clcmaDCi is 1l0t IIllde. the lLmOUllt oL'
cWllales a;reed 10 ':ly ilie, i:liitrluors will
be biu<llllg. :' . ~ ';'-,
. .~:...
PAAf D - COVERAGE fOR DA-'\1AGE TO
YOlTlu.trfO - n, ,,;. ..~~
INS~G AGRtL.'tL""'.:: .;'
A. We 'will p.y for clircct :!.pd a.:.:iclelltal 10$$ to
.lo'" to,,,ltl aMID Ot" :.=.y 1\011-0..,..11 4IIIf,O, in-
dudlll! their equip:U~!It. ~1l5 an)' applicable
<!eduClIbl.,!1o\'o1l L:l u:e Dcclar:1tI0a$. We "';;,
pay ior loss to yo," co""d IlUfO Cllu.>o:ci by:
Other WI1 co//isiDn oQ!y if tbe: DedaL"ll"
tioes indicate ~t Oth('\' 1"h.a:l ColUsioa
Cover:lic L.s proVld~d L'or WI 0.\:10.
. Co/Ji.sion oely if tl'.~ Decl.ar:1UOOS iedic:ltr.
WL Collisioll Co,crJ.le II ?r~v1ded fOl
that aUIO,
llo there LS :!. i.:l:;S to ~ IItIn-<JlfflAd ""10. we ""ill
provide the broadesl _over3;e o.pplic::lble to
any yo," co",,1I ""fO wown 1:'. the De.:I:L.>;\"
1:10"',
lil
:OO4P
l:C!~d~.. e~p_\'ti.~~~~ calero'" ,~t, U1st:-~CliSe:'\'\:C1 oalft. ",;w itS cc:missioll. CO?~-neht.
..---........--.-----------.... ~_. ------.---..
~
'.
IItbtr I.ll wlitwmJ _, .1Irkk or "Nilri'SfT"d
-, '.IIUU. but a~t boti1. bccanse of Nii1, bt.
"""
l. Sll$u.iaed by aaliutnu::<zld
2. Caa.scd by Ul &(eid.ornt.
The OWller's or operator's liAbili~ for. thew d.1:n.
'In lIlll.St uiIe oUt of tbt oWllenllip. 1Il&Ull.t.
II&DClC or 11M oC th. ~" trIIIlt" ..,dUII or
1IWiI""--' f/II1t., .MIde. W. will p4Y daaulC"
IIIIMr this coverage ariS,qe out .:If an acdd.e'llt
with an lIIIdtrriJumui fNI"" ultUlI .:IlIly wr the
limits of liability lUIder aay applic::lble bodlJ)' ia.
JlItY !.iaQility boads or policie:s bAve bmI Ell.
,ullmd by paymeat of judgments o~ sen1cmnlls.
n. amOlUlt of daauln Q,e ..,11 pay is subject to
,tba prol'isiollS of oW' LiIlIit of Liability,
No ia.eII! far d&ma!C:l uisine OIU of. a SUit
brouilll acaiAn tbe OWller or operator of an 1IIIi1I.
"".d IM,O, "IIUU or 1lIIIiIri1u....d ",.,,,,, ,,1U1I
It iliDdia& on us llllIess "'.:
I, Rccei,'t(j reO=tI2.ble notict of t!:e pen.
dency of the suit ~ultiag In the Ju.dg;a:ent;
.lad
2. P....d a re:uonable oppor:u.nirv '0 pro=
OUT intclCSts lZl r.te SUIt.
r-", ~ u.scd ill this eadonemtllt mum:
Yoa or .lay /mrl7, flWml,.,.
, Any ,olher -penoa ocapyr"Z y"'" ~o'<<I'''/
-_0.
:'J. Any pl:noa for clalna&e:s ~t pct'SCQ is eti.
'. .. titled to RCOVC7 bec1ase. o(6odi1)' ilr/III'7 to
whicl1 this Cover:lle applies sust.1ic~ by a
. ._l?'rsOll~bedi:rl.or;2,.abOV~. ~ .
~1.1:._ . ~ ~ . _ _ _ _
it """0' .dIidil.llleacs" !.:led OJotor
'cle or ",ail" of aay [)llC to "'Ole!:! ~ bodily 1.:;.
. Ua.bility bocci or pol.ic-,o applies at tn= am. af
tmdeut but IlS ti:nlt for bodil) iJ:lJu...,. ~bilJry
, .
.,
-
3JS2P
. ~.. ..,.......
'., . ..
is cot eIIoU,!ll to pay the Fu.II amOll1l1 tbebu,.,.d is
1~ly eJ:cll.d to recover 1$ d.IuIlages. ,
UNJn.Uur",d mtJl., ,,1UdI d<lt$ a01 wdu.de IJ1
lUJUsrrq,d ""'0' ../Uei&.
CfliluvfII'molo, ,,/dell rtl= .11a..cd lIloror vehl.
~J.e or tnilcr or' Il:ly type:
I, To lailtiel1 ao bodily iajury liability baad or
poUcy applies at lhe ti.a!e o( the 'aa:idCIIL
1 Which IS a tII: Uld run v~iucle \l.'bose ope-r.
.1tor c:: owcer OllllJaI be ideatitIcd i..:Id
wtllcl11ul~ or \IIllich C31l>1eS III aci:idetit reo
lultiof u:6<>dily illljIuy \\Iithou.c hitti1le:,
J.. yo~ or :my /"""7y mnnb",
b. a vellicle \IIhlell. you or JOY /4miJ;;
_mlJ" u, oceIlP"",; Or
c, '.1:0/17 eD"'''/ /lIIIO.
, If tbtrc L> 00 ptlv51Cl!1 CllQUlet \\lith th.e hit
. ud run vebcJc' Ute faeu of the: .1cddcnt
lIlu.lt be proved.
. To wbJ,j;, a bodily wjury liabililJl baed or
policy lppUCS Jt the ti:rie of:11.: ac.cidt::t,
but lh~ honding or ia:criDg c~mPany:
.l. d..::tit'$ covers ~~; or
~. IS or :>e-....oalC5:
'I) l.::\.:Ilvecl or
(2) ul'Ioived ill LJ:lOlveccy pro~~dicf!'S,
l./lIiJuuud ""'ta, ,,/lU1I dces aot ltl<:ludc:
. I
,
,-\.ilIUllilnJur.tso,t/ """0. .,/uk; 0 ~ '.
Any, \t!!ide or eqlllpmrn: 9":'tI~d Or opet-
,a~d by a;e!f.insurer tin~r iiiiy;npplicabie
::::Joter velll". 1.1...,
~ ..
Iii additfllD.;' cdther """",,,Id '"."o'.mu:1I oar
tJ/Ilinitutovd _,u ..mcll iIlelude:> &:lV 'vchide or
~pc:et!~'
-... ....
, 1 O"'!Oed~! ," c'~ 01' :!'lZliabllc for lht
:~~ar .;co:':.()uar:1:J.Y/iDffiJ..."""",,,.
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~.J,: IS W reOS! We \\w P\ c~~~CtVe:ss of ~!:=
;w:;oe.:- or:
I. f1r.Nr1l4l:
. C'~ cada;
) Ve!uel", or PN:mlWllS ICOo:.-n III (!:e xc"a.
l:le or III ~~e Dc.:l&ra 0 QIlj. vt
4, Vcl1ielesillvolved ill the !ec1deQ..
Hewever. 110 iIuw"j WL1J be ftI11Uea to receive
o;!uplic:r.e paYlDftllS for the loame cJ==lS or
loss.
Ally .unOUllIS otllnMM payable lor d.1.mares
wbich tile "'-U is lep.Uy ealitlb:l to recover
· Crom tile OWller or opcuor of &Jl """'-red
_fDr ..,.. or .......... __ ..1tU4
becallJe or lUll, I11Jrn7 calUCa by Olll ag:jcleut,
sllaLI be fIlCIlIGId by alll1.lllls paid bec:allJe of
till btHIIJ,,.,, by or on behal( of Pfno'7' or
"1P/UZaliOlll "ho may b.: lcpUy RSpOtISlble.
This ilIcllldes III StIIIIS paid UlIder Part A.
ADy payment lII1der t!lis coveragE will rcdace
&:IIY -OIlllC thac penon is CZllltlcd to =Over
(or tb.e sam. damares llllder Part A.
OTHER INSURANCE
rr !bcn is other IppliC:ble S1IlIJ..Iu inswuc:.e
"lIlable WIder more chan OtIC poUc:y Or plOVlSJOIl
o( COVerag.: _.
I. Tl:.e roUoWit1C "rioolies 01 rec:overy aP\l~
r= The UnillsluM/U~ ,;.\{o.
tollSlS Coverage appiicable co ~
.ebIc!e !be buared wu oct:J/p~ at
the rime orlb.! ac:ddea~
~7.:"'...,."
. .. .~....-
27.~
3332P'
~:":otld The pouey J.tford1:l.4 L'aul.
SU....d,L'::dmn.sun:.:t \fO!OnSlS <:.Jv.
~rase ro t.:e ~tti ,U a !:.1lIIcd
i'lsurea Or fdmily fIIIrIIAIr.
, We alll pay oiUy our sllan oCtae 10>1. Our
sb4.n: IS the propOl'Oon !bat our limit or u.
abwry be3.n co thc !0t.1l of alllimlts appli.
cabl. 011 the same level or Plloncy.
.WllTRAnoN
U"Ill:ld &:II iIIs..ed do not agree:
l. Wbetb.cr th..u pencil is IcpI1:- I:Illtled to
tU:Over damaPs from rlle Otrller or apeq.
:or of llZI .0:1,)....... _Dr '1!ddI or 1IIIIiI.
riJuw,ti _'Dr ulliel4:
2. As to tile a.mOIlllC O( d.unasa;
eirller ':IUty ClIAy lIIUe a wtitlen demAnd (or ubi-
ll'Inoll. MUrat/Oil slWl be c:ond~ in ICl:Crd.
~ lIIitll !be provisions of rlle PClI.I1Sytvenla
tlnj(Otlll Arbilfllion Ac~ ~ch Pl11ly will select
llJl arbiuator. The two arbiUUors lIIill Sodecr a
tlIird. If tbcy c:ulnot acnor lIIithin 30 d.1~s. either
J.aAy rtqUCIt thaI selection be made by. judce of
a courc haVing jurisdictioll. Each party "ill:
I. Pay the eq>etl$es it i.cCW"S; .1J:lQ
. 2. llear tile ~ of tb.e third arbitnllGr
equaJ.ly.
Ullless both pun" agree otll.:rwuc. Ubi:r.tllOIl
will takc place 1.Q the co~ty in w!!ich tlle C<:lvered
penon L:Vl'S. LO<:a1 rules or law as !o procedure
Ollla c\1dcn.oe lIIill appiy. A. do::tsioD acrwct Co by
rIlIO or' tJ:= arbitntors I\'IJl be bind.i.ng.
Ddcs ,opytic!ual .....-.t at lIUUi:U:CI: Scr\1"a:s Ofri,c_.vtt!l i:.s P-'::::i.uion. COPi'Tlihl.
oe ScMCa otIiar. !Il.c~ 19&4. t 9'6
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Exhibit C
PA.3000 (..... ,.to,
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III flrJ lYI \'ArJJ^ I, ,',It.lll I) 1ll'lj~ I.' f,fJ
ATTACH TO APPUCAnON OR POUCY CHANaa It.auaT JlOIUI
! II JI I f i')f l ('I I H 11'1 lllr J d 11 01 I ,. ~ I \ , '
,
A.
IV 111""'9 I/lI ....... , 11ft "11111I. ~ __1Ill._..... ....... ...,. 1Il'... _ II
'f1I_ ......1rI....'lCl'JIlhald. "'*'........ ~.~.........._..""'~ ...,.,.lII.,NuII"*
.. '01 loal" ....................InlUIr. ..-.,1Ii "lL -L _".................
i::.: 'I"IU'::~ 11I1. IOIMI.... .........~~J.~' .. \t~,~......1t ...1lIt~ ...~....:. ,)
....: '.4'" . 'r _L!!!~~_'~ ~( ~ .
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It" .... . '4 ~""'1Y I_ .,' . ' ....~.. .~
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Iv 1.......;.\iw.1'Ii;i' D,:... _ '~~~J.~~ .-:tiJ1;_~_III"""
'ormya"'-IIiiNM.'~~~.lftiii.IllIlIj,._friIIIJat.Ct J..-~'I ........IlltIUlll,
at IImlla ""-lllIIWnllllll.....iNldw._....,:.,..........., I J 1_'...-.....
S~I. be --- .................. i""" pOlICy. 11Inowingt, _ YOIunIIIlIr.,...... _lCIlImnI at
~ ~_....~_...._"_..._-
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LENORA Ill. SXIVINGTON,
Petitioner
m THE: COO'R'l' or COMMON PLEAS
OAt1P~ COUNTY, PENNSn'nN'IA
I
: CIVIL ACTION - LAW
: NO. /;8/-S-QIl
v.
STATE FAllK INSCRANCE COMPANY,
RMpondent
Jftrl'IOIl oro COMlll!lt. mrnrSD1lAHCIl UUlI'r1l1'PIOH
"
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~
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,
AND NOW, cOllIe the Petitioner Lenora M. Skivinqt:on, by her
at.t.orneys lnqino .. Rovner, P.C. and respectfully requests this
Honorable Court: tol
1. compel Respondent State F&1'lIl to arbitrate Petitioner'.
""f"-urance motorist's claim,
2. Order R..pondent to select a second Arbitrator; and
3. Compel Re.pondent to pay Petitioner'. counsel fees.
In .upport, Pet.itioner respectfully represents the followinq:
1. Petitioner Lenora M. Skivinqton is an adult individual
re.idinq in Camp Hill, cumberland County, Pennsylvania.
2. R..poncl.ant state F!!:rlll is an insurance cOIllp"any licensed to
do bus in... in the COllllllonwealth of Pennsylvania with otfic..
located in New cumtlerlancl., cuml:ierland County, penns~'lvania.
3. On Auqust 12, 1993, Petitioner Lenora M. Skivinqton was
injured in an autolllol:lile accident :.t Maclay Street, Dauphin county,
Pennsylvania.
4. On .luqwat 12, 1993, petitioner t....~r& H. Skivinqtcn.... &
.~;;r:
::!~:,~w
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CIDI!UI'J:CA'J!Z ':)1' snvrClIl
I, Donna M. 1tineer, an employee ot the lAW firm ot Anqino ,
~vner, P.C., do hereby certHy that! am this day servinq a t:ue
and con-ect copy ot the .."rUOK TO COIOm. tmnIlU1l.l1 .. UIIJ:'J:D'nOl(
upon all c::ouuel or record and intere.ted parti.., via c:art:1t1ed
Mail - Re~ Receipt Requested, as follows:
~ 0 cave IUcber
stau i'U'IIl ltUt:ual Insurance Company
lIazzoiaWr9 service center
115 L1MJd1ll Rc:lad
'0 O. lOX 217
Kev ~-haPland, PA 17070-0257
ltoU I. Kroll, Esquire
FOot.DOD, REmOLDS' HAVAS
'0 O. !ox '32
101 P!II. lue.t
aarriaburq, PA 17108-0'32
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Donna . near
Dated: .!J'fI.J"UA~ f ~'( /(/(11/
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CERTIFICATE OF SERVICE
I HEREBY CERTIFY that I have served a true and correct
copy of the foreqoinq document upon all counsel and partie. of
record this -I!:it day of M.a.~tV\ , 1994, by placinq
the same in the united states First Class Mail, postaqe prepaid,
at Harrisburg, Pennsylvania, addressed a. follows:
Lawrence F. Barone, Esquire
4503 North Front street
Harrisburq, PA 17110-1799
~A~ ~~ """-
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ROLf I. kROLL, IIOUIRI
PI. lupr_ Court I.D. No. 4n45
'OULkRDO, RIYNOLDI & HAVAI
A Profllltonll Corporltlon
101 PI". Itrllt
POlt OffIcI 10k 932
Hlrrl.burg. Pennlylvlnfl 171D8.0932
Tolophonll
'I.lU
[7171 236.32DD
[7171 236.6863
Attorney for Dlfondlntl
ITATI fARM INSURANCI
v.
IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
NO. 681 - S - 1994
CIVlL ACTION - LAW
JURY TRIAL DEMANDED
LENORA M. SKIVINGTON,
Petitioner
STATE FARM INSURANCE COMPANY,
Respondent
ORDER
AND NOW, this
day of
, 1994, it is
NOW AND HEREBY ORDERED that Plaintiff's Petition To Make Rule
Absolute be granted and the file in this action be transferred to
Cumberland County.
J.
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6.
Denied. The Rule To Show Cause dated March 22,
1994, provided, in pertinent part, that the Rule was "returnable
20 days after service." (Emp\'lasiB added). The Certified Copy of
the Rule was forwarded from the prothonotary's office on March
25, 1994, and was served upon counsel for the Defendant with a
Certificate of Service indicating that service was performed on
March 28, 1994. A true and correct copy of the certified Copy of
the Rule with the certificate of Service is attached hereto as
Exhibit "B". The Answer to this Rule was filed on April 15,
1994, within the 20 days required by the Court's Order.
WHEREFORE, Respondent, state Farm Insurance Company requests
that this Honorable Court make the rule absolute and transfer
this action to Cumberland County.
Respectfully submitted,
Dated:
~;11
Attorneys for Respondent,
STATE FARM INSURANCE COMPANY
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~OLF Z. KROLL, :SQUIRE
Par Supreme Coure 1.0. No. 47.43
FOULKROD, RlYNOLDS , HAVAS
101 Pine street
POlt 011 ice 80x 932
Hlrriabur~, Pennay1vlnLI 17108-0932
Telephone.
Fax,
(717) 236-3200
[717l 236-6863
Attorney lor Defendlnt.
STATI PARM MUTUAL AUTONOIILI
IHStlRANCI ODHPAHY
LENORA M. SKIVINGTON,
Petitioner
v.
IN THE COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 681-S-1994
STATE FARM INSURANCE COMPANY,
Respondent
AIr.... 01' 811..01ll)1DI'1', .TA'1'. I'UII 1..uauC. COXI'UY,
'1'0 .DITIO...'. .DITIO. TO COJOl.L UJlI..uauC. ~.llt'1'JUl.TIO.
AND NOW, comes Respondent, state Farm Mutual Automobile
Insurance Company ("state Farm"), by and through its counsel,
Foulkrod, Reynolds' Havas, a Professional Corporation, to answer
the Petition to Compel UninBurance Arbitration of Petitioner,
Lenora M. Skivington ("Petitioner"), as follows:
1. Admitted.
2. Admitted.
3. Admitted in part and denied in part. It is
admitted that on August 12, 1993, Petitioner, Lenora H.
Skivington claims to have been involved in a motor vehicle
accident. After reasonable investigation however, State Farm is
without knowledge or information sufficient to form a belief as
tc ,...hether !:ho .....as injul ea in this accident ana accoraillyly, .IU
further responsive pleading thereto is required.
4. Admitted.
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,..,.
5. Oenied as stated. It is admitted that the
underlying policy was in force and effect on August 12, 1993. It
is specifically denied however, that plaintiff had any uninsured
or underinsured motorist coverage in effect and accordingly, this
Petition is improperly before this Honorable Court.
6. Admitted.
7. Denied. This allegation of the Petition refers to
a writing which is the best evidence of all it contains and
accordingly no responsive pleading thereto is required. By way
of further answer, the undersigned did not receive a copy of any
document purportedly attached as Exhibit "A" to the Petition.
8. Admitted in part and denied in part. It is
admitted that state Farm has not appointed an arbitrator in this
case. It is denied that Petitioner has standing to select an
arbitrator as there was no uninsured motorist policy in force or
effect on August 12, 1993, providing such coverage to Plaintiff.
Accordingly, no arbitration clause was in force or effect that
would give rise to an arbitration.
9. In view of the foregoing, contemporaneously
herewith, state Farm has filed a declaratory judgment action with
the Court of Common Pleas of Cumberland County requesting that
the Petition be stricken ~nd that her rejection of uninsured
motorist coverages be enforced thereby precluding an arbi'trat.inn
in t~is matter.
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Honorable
WHEREFORE, Respondent, state Farm requests that this
Court dismiss the instant Petition with prejudice.
... IO.'l"1'D
10. Petitioner is an adult individual who currently
re.ide. at 2206-H Cedar Run Drive, Camp Hill, CUmberland County,
Pennsylvania.
11. Petitioner was born on September 6, 1975.
12. On or about September 30, 1991, Petitioner
executed an Assigned Risk Application ("Application") for a
private passenger automobile insurance policy which was
ultimately issued by state Farm. The Policy is identified by
Policy No. B20-1007-F21-38 ("Policy"). A true and correct copy
of the Application is attached hereto as Exhibit "A". True and
correct copies of. the pertinent Policy provisions are attached
hereto collectively as Exhibit "B".
13. On June 21, 1993, pursuant to the requirements of
Act 6 of 1990, Petitioner elected the limited tort option or. her
liability coverage by executing the Pennsylvania Assigned Ri.k
Plan Selection of Tort Options form. A true and correct copy of
the executed Pennsylvania Assigned Risk Plan Selection or. Tort
Options f.orm is attached hereto as Exhibit "C".
14. On June 15, 1993, Petitioner executed a ReJection
of. Underin.ured MotoriGt Protection form under th~ Polioy. A
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true and correct copy of this form evidencinq her rejection Of
under insured motorist protection is attached hereto as EXhibit
nD".
15. On June 21, 1993, Petitioner executed a Rejection
of Uninsured Motorist Protection form under the Policy. A true
and correct copy of this form eVidencing her rejection of
uninsured motorist protection is attached hereto as Exhibit "E".
16. On August 12, 1993, Petitioner was involved in an
accident with an uninsured motorist ("accident"). Despite her
rejection of uninsured motorist protection, Petitioner has
petitioned this Honorable Court to compel state Farm to proceed
with an uninsured motorist arbitration. A true and correct copy
of Petition is attached hereto as EXhibit "F".
17. By virtue of Petitioner's rejection of uninsured
motorist coverage, no contractual provision exists requiring
state Farm to arbitrate this matter. Accordingly, State Farm is
entitled to declaratory jUdgment freeing it from any and all
responSibility to provide uninsured motorist benefits for any
injuries allegedly sustained in the accident.
18. In view of the foregoing, contemporaneously with
the filing of this Answer, State Farm has filed, in Cumberland
County, a Complaint for Dec]ar~tory Judgment seeking the
enforcement of Defendant's reiection ~f .:ninsured motorist
coverage and dismisSing Petitioner's Petition to Compel Uninsured
4
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Motorist Arbitration. A true and oorrect oopy of this Complaint
is attached hereto as Exhibit "G".
WHEREFORE, state Farm request. that this Honorable
Court dismiss the instant Petition to Compel Uninsuranoe
Arbitration with prejudice.
... 1CAT'l''' I. 'I'JI. BTU" 01' ...LIXIDIlY 08".CTIO..
'UR.U~ TO PA. R.C.P. MO. lD211.ill'
(Improper Venue)
19. Paragraphs 10 through 18 hereot are incorporated
herein by reference as if set forth in full.
20. In the unlikely event this Honorable Court
determines that Plaintiff's rejection of coverage may be voidable
and that there may be uninsured motorist coverage in effect, it
is respectfully submitted that venue in this matter is improper
and that cumberland County is the proper forum to resolve this
dispute.
21. The Uninsured Arbitration Clause found at Page 10
of the Policy provides as follows:
Unless both parties agree otherwise,
arbitration will take place in the county in
which the insured lives.
an Exhibi t liB".
In this instance, the insured Petitioner lives in Cumberland
County and accordingly, tho appropriate reviewinq court l~ the
Cumberland County Court of Common Pleas.
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CIRTII'ICAT. 01' .IRVIC.
I, Donna M. Rineer, an employee of the law firm of Anqino ,
Rovner, P.C., do hereby certify that I am this day serving a true
and correct copy of the RULI TO 8HOW CAU81 upon all coun.el or
record, via Certified Mail - Return Receipt Requested, as follows:
Rolf E. Kroll, Esquire
FOULKROD, REYNOLDS , HAVAS
P. O. Box 932
101 pine Street
Harrisburg, PA 17108-0932
..Ijt7>1/YJt2 ~.~ ()IJA~
Donna M. R neer
Dated: YntlA..d, ~ /C)t}'1