PSI Personal Service Insurance Company

Transcription

1 PSI Personal Service Insurance Company 1000 River Road Suite 300 Conshohocken, PA New Jersey Standard Personal Auto Policy PSIC NJ SPOL (12/11)

2 POLICY GUIDELINE Section I. Definitions...1 Section II. Insuring Agreement...2 Section III. When and Where Coverage Applies...3 A. When Coverage Applies...3 B. Where Coverage Applies...3 Section IV. Coverages...3 A. Liability Coverage...3 B. Personal Injury Protection Coverage...6 C. Uninsured and Underinsured Motorist Coverage...17 D. Comprehensive and Collision Coverages Damage to Your Auto...21 Section V. Duties After An Accident or Loss...27 Section VI. Conditions...28 A. Policy Changes...28 B. Cancellation...28 C. Renewal/Nonrenewal...29 D. Our Right to Recover Payments...29 E. Suit Against Us...30 F. Change of Interest...30 G. Bankruptcy or Insolvency...30 H. Past Premium Payment Obligations...30 I. Limitation on Lawsuit Option...30 J. Concealment or Fraud...31 K. Loss Payable Clause...31 L. Joint Ownership...31 M. Additional Insured-Lessor...31 i

3 NEW JERSEY STANDARD PERSONAL AUTO INSURANCE POLICY SECTION I. Definitions Applicable to All Sections. We define some words and phrases to shorten the policy. This makes it easier to read and understand. Defined words and phrases are printed in boldface italics. YOU can pick them out easily. A. Additional Private Passenger Auto means a private passenger auto newly owned by or leased to you in addition to any shown on the policy declarations, if: 1. We insure all autos you own, or lease, for a term of at least 6 months; 2. No other insurance policy provides coverage for that auto; 3. You pay us any additional premium required when due; and 4. The additional private passenger auto is an acceptable risk to us under our underwriting guidelines. Comprehensive and Collision Coverages for an additional private passenger auto shall not become effective until you notify us and request coverage for the additional private passenger auto. For coverages other than Part D, we will provide the broadest coverage we now provide for any auto shown in the declarations to an additional private passenger auto for period of fourteen (14) days after you become the owner. We will not provide coverage after this fourteen (14) day period, unless within this period you ask us to insure the additional private passenger auto. If you ask us to insure an additional private passenger auto after the fourteen (14) day period, any coverage we provide for an additional private passenger auto will begin at the time you request coverage. If you request coverage not already provided for any auto shown in the declarations for the additional private passenger auto or increase your limits, these changes to your policy will not become effective until after you ask us to add the coverage or increase your limits. B. Auto means a land motor vehicle with four or more wheels. It does not include: 1. Any vehicle while located for use as a dwelling or other premises; or 2. A truck-tractor designed to pull a semi-trailer. C. Named Insured means the person named as the insured on the policy declarations, and if an individual, named insured includes his or her spouse by marriage or domestic partner by civil union, if the spouse by marriage or domestic partner by civil union, is a resident of the household of the named insured. If the spouse by marriage or domestic partner by civil union ceases to be a resident of the named insured s household, liability coverage will continue for the spouse by marriage or domestic partner by civil union, but only until the earlier of: 1. The effective date of another policy listing the spouse or domestic partner as a named insured; or 2. The end of the policy period in effect at the time he or she ceased to be a resident of such household. D. Newly acquired private passenger auto means a replacement private passenger auto or an additional private passenger auto for which Comprehensive and Collision Coverage is subject to the New Jersey Mandatory Inspection Provision at Section IV, Coverage D(2) of this policy. E. Non-owned Auto means an auto not owned by, registered to, leased to, or available or furnished for the regular use of: 1. You; 2. Any other person residing in the same household as you; 3. Any relative. However, an auto owned by, registered to, leased to, or available or furnished for the regular use of a relative will be considered a non-owned auto for liability arising from your maintenance or use of such auto. A non-owned auto must be an auto in the lawful possession of the person operating it. F. Occupying means in, on, entering into, or alighting from. 1

4 G. Private Passenger Auto means a self-propelled auto designed for use principally on public roads and that is one of the following types: 1. A private passenger or station wagon type automobile; or 2. A private passenger pick up or private passenger van that: a. Has a Gross Vehicle Weight Rating of 10,000 lbs. or less; and b. Is not used for the delivery or transportation of persons or goods and materials unless such use is: (1) Incidental to your business of installing, maintaining or repairing furnishings or equipment; or (2) For farming or ranching. A private passenger auto does not include a motorcycle. H. Relative means a person who resides with you in your household, and is related to you by blood, marriage, civil union, adoption, or is a ward or foster child. I. Replacement Private Passenger Auto means a private passenger auto you become the owner of, if: 1. You acquire the auto during the policy period shown on the declarations page; 2. The auto that you acquire replaces one shown on the declarations page; 3. No other insurance policy provides coverage for that auto; 4. You pay us any additional premium required when due; and 5. The replacement auto is an acceptable risk to us under our underwriting guidelines. We will provide the replacement auto with the same coverage as the auto it replaces. You must ask us to insure a replacement auto within three (3) days after you become the owner if you want to continue coverage under Part D - Comprehensive and Collision Coverages. The three (3) day period includes the day on which the replacement auto is acquired and shall be extended by one day for each Saturday, Sunday, or New Jersey State holiday falling within the three (3) day period. If you ask us to insure a replacement auto after this three day period, any coverage we provide under Part D for a replacement auto will begin at the time you request coverage. If you request coverage not already provided for any auto shown in the declarations for the replacement auto or increase your limits, it will not become effective until after you ask us to add the coverage or increase your limits. J. Temporary Substitute Private Passenger Auto means a private passenger auto not owned by you if it replaces your private passenger auto. Its use has to be with the consent of the owner. Your private passenger auto has to be out of use due to its breakdown, repair, servicing, damage, or loss. A temporary substitute private passenger auto is not considered a non-owned auto. K. Trailer means a trailer of the utility type or a trailer of the house, or camping type equipped or used as living quarters. Trailer is limited to a trailer designed for use with a private passenger auto. Farm implements and farm wagons are considered trailers while pulled by an auto we insure for liability. L. We, Us, or Our means the company providing this insurance as shown on the policy declarations. M. You or Your means the person or persons named as the insured on the policy declaration and if an individual, includes his or her spouse by marriage or domestic partner by civil union if the spouse or domestic partner resides primarily in the same household. N. The term Your Private Passenger Auto, when it appears in this policy, means a private passenger auto that: 1. Is owned by you or is leased for six months or longer to you; 2. Is described on the policy declarations. SECTION II. Insuring Agreement This policy is a legal contract between you and us. We agree to insure you according to the terms of this policy based on your payment of premium for the coverages you chose. You agree, by the acceptance of this policy that: A. Any statements made in conjunction with an application, renewal, or endorsement are your representations and are true; B. This policy is issued in reliance upon the truth of those representations; 2

5 C. This policy contains all of the agreements between you and us relating to these coverages; D. You will register and principally garage in New Jersey any auto covered by this policy. SECTION III. When and Where Coverage Applies A. When Coverage Applies. The coverage you chose applies to accidents and losses that take place during the policy period. The policy period is shown on the policy declarations. The policy period begins and ends at 12:01 A.M. standard time, or the time at which the policy is issued, whichever is later, at the address shown on the policy declarations. B. Where Coverage Applies. The coverage you chose applies: 1. In the United States of America, its territories or possessions, Puerto Rico, or Canada; or 2. While the insured auto is being shipped between their ports. SECTION IV. Coverages A. Liability Coverage 1. Additional Definitions Applicable to Liability Coverage a. Bodily Injury means bodily injury, sickness or disease, including death resulting therefrom. b. Property Damage means damage to, or destruction of, tangible property including its loss of use. 2. Coverage a. You have this coverage only if a premium for it appears on the policy declarations. b. We will: (1) Pay damages that an insured becomes legally liable to pay because of bodily injury to others and property damage caused by an accident resulting from the ownership, maintenance, or use of your private passenger auto; (2) Defend any suit against an insured for such damages with attorneys hired and paid by us. We will not defend any suit after we have paid the applicable limit of liability for the accident that is the basis of the lawsuit; (3) Have the right to investigate, negotiate, and settle any claim or suit. c. In addition to the limits of liability, we will pay for an insured the costs listed below resulting from such accident: (1) All defense costs we incur; (2) Interest accruing after a judgment is entered in any suit we defend on behalf of an insured. Our duty to pay interest ends when we pay, offer, or deposit in court the amount due under this coverage; (3) The premiums or costs of bonds: (a) Necessary to secure the release of an insured s property attached under a court order in any other suit that we defend on behalf of an insured. The amount of the bond we pay for shall not be more than our limit of liability; (b) Required to appeal a decision in a suit for damages that we defend on behalf of an insured if we have not paid our limit of liability that applies to the suit; (c) Up to $250 for each bail bond needed because of an accident resulting in liability covered under this policy or a traffic violation related to such accident. We have no duty to furnish or apply for any bonds. (4) Expenses incurred by an insured, at our request, for loss of wages or salary up to $50 per day if we ask the insured to attend the trial of a civil suit. We will not pay for loss of other income. 3

6 d. Other Autos. The Liability Coverage extends to the use, by an insured, of a newly acquired private passenger auto, a temporary substitute private passenger auto, or a non-owned auto. e. Trailer Coverage. The Liability Coverage extends to a trailer while owned by, leased to, or used by you or your relative. 3. Who Is an Insured a. For your private passenger auto, a newly acquired private passenger auto, or a temporary substitute private passenger auto, including any trailers attached to such auto, insured means: (1) You; (2) Your relatives; (3) Any other person while using such an auto if its use is with your consent. b. For a non-owned auto, insured means: (1) You; (2) Your relatives. 4. Limits of Liability a. The amount of Bodily Injury Liability Coverage is shown on the policy declarations under Limits of Liability-Bodily Injury, Each Person, Each Accident. The limit stated for Each Person is the maximum amount of coverage for all damages due to bodily injury to one person in any one auto accident. Bodily injury to one person includes all injury and damages to others, including but not limited to damages for care, loss of services, or death resulting from this bodily injury. The limit stated for Each Accident is the total amount of coverage, subject to the amount shown under Each Person, for all damages due to bodily injury to two or more persons in the same accident. The amount of Property Damage Liability Coverage is shown on the policy declarations under Limits of Liability Property Damage, Each Accident. The limit stated for Property Damage, Each Accident is the maximum amount of coverage for all property damage resulting from any one auto accident, regardless of the number of property damage claims presented. We will pay damages for which an insured is legally liable up to these bodily injury and property damage limits. b. The limit of liability is not increased because more than one person or organization may be insured. c. An auto and attached trailer are considered one vehicle. Therefore, the limit is not increased. 5. Exclusions-What Is Not Covered There is no Liability Coverage for: a. Any person for liability arising out of the ownership or operation of any auto while being used as a public or livery conveyance. This exclusion (5.a.) does not apply to shared-expense carpools; b. Any person who intentionally causes property damage or bodily injury; c. Any person while using a vehicle without reasonable belief that he or she has the right to do so; d. Any person for property damage to property owned by or being transported by that person; e. Any person for property damage to property rented to, used by, or in the care or custody of that person. However, coverage applies to a residence or private garage damaged by an auto we insure; f. Any person while employed or engaged in any way in the selling, leasing, repairing, servicing, transporting, storing, or parking of land motor vehicles or trailers. This includes road testing and delivery. For your private passenger auto, a newly acquired private passenger auto, or a temporary private passenger substitute auto, this exclusion (5.f.) does not apply to: (1) You or your relatives; (2) Any partner, agent, or employee of you or any relative. g. Any person maintaining or using a non-owned auto in any business, occupation, or profession other than farming or ranching and not described in exclusion 5.f. This exclusion (5.g.) does not apply to a private passenger auto or a trailer used with a private passenger auto driven or occupied by you or your relatives; h. Any person for bodily injury to any employee of that person arising out of his or her employment. This exclusion (5.h.) does not apply to a household employee who is not covered or required to be covered under any workers compensation insurance; 4

7 i. Any person for bodily injury or property damage for which that person would also be covered under nuclear energy liability insurance issued by American Nuclear Insurers, Mutual Atomic Energy Liability Underwriters, Nuclear Insurance Association of Canada, or their successors. This exclusion (5.i.) applies even if the limits of that insurance are exhausted; j. Any person who is a named insured under the terms of a Basic Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3.1. This exclusion (5.j.) does not apply to you if you are occupying your private passenger auto, a newly acquired private passenger auto, a temporary substitute private passenger auto, or a non-owned auto. k. Any person for bodily injury or property damage caused by any auto, located inside a facility designed for racing, or for the purpose of practicing, participating in, or preparing for any race, speed contest, or performance contest. l. Any person for bodily injury or property damage resulting from the use of your private passenger auto for snow removal for compensation or a fee. m. Any person for bodily injury or property damage sustained by an insured while occupying any vehicle located for use or being used as a residence or premises. n. Any person for any trailer used for business, occupational, or professional purposes with other than a private passenger auto; o. Any person for any trailer used with an auto that: (1) Is owned by or hired by you; and (2) We do not insure for Liability Coverage. p. Any person or company which assumes liability under a bailment or other agreement; q. Any person or company with respect to demands for punitive or exemplary damages. 6. If There Is Other Liability Coverage a. Basic Automobile Insurance Policies This policy provides no Liability Coverage for any person other than you who is a named insured under a Basic Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3. b. Other Liability Coverage Available from Other Sources If other motor vehicle Liability Coverage applies, we are liable only for our share of the damages. Our share is the percent that the limit of liability of this policy bears to the total of all motor vehicle Liability Coverage applicable to the accident. c. Other Liability Coverage Including Temporary Substitute Private Passenger Auto, Non-owned Auto, or Trailer If a temporary substitute private passenger auto, a non-owned auto, or a trailer designed for use with a private passenger auto: (1) Has other vehicle Liability Coverage on it; or (2) Is self-insured under any motor vehicle financial responsibility law, motor carrier law, or any similar law; then Liability Coverage under this policy is excess over such insurance or self-insurance. d. Newly Acquired Private Passenger Auto This coverage does not apply if there is other auto Liability Coverage on a newly acquired private passenger auto that is a pickup, panel truck, van, delivery sedan, or utility automobile. 7. Motor Vehicle Compulsory Insurance Law or Financial Responsibility Law a. Out-of-State-Coverage If an insured under the Liability Coverage is in another state or Canada and, as a nonresident, becomes subject to higher limits of liability coverage than are shown on the policy declarations as a result of motor vehicle compulsory insurance, financial responsibility, or similar law: (1) This policy will be interpreted to give the liability coverage required by the law; and (2) The liability coverage so given replaces any liability coverage in this policy to the extent required by the law for the insured s operation, maintenance, or use of an auto insured under this policy. Any coverage so extended shall be reduced to the extent other coverage applies to the accident. 5

8 In no event shall a person collect for the same elements of loss more than once. b. Financial Responsibility Law When certified under any law as proof of future financial responsibility and while required during the policy period, this policy shall comply with such law to the extent required. B. Personal Injury Protection Coverage 1. Personal Injury Protection Coverage a. Additional Definitions Applicable to Personal Injury Protection Coverage (1) Actual Benefits means those benefits determined to be payable for allowable expenses. (2) Allowable Expenses means medically necessary, reasonable, and customary items of expense covered by the named insured s or relative s health insurance benefit plan(s) or by Personal Injury Protection Coverage as an eligible charge. The reasonable monetary value of benefits provided in the form of services shall be considered as both an allowable expense and a paid benefit. (3) Bodily Injury means bodily injury, sickness or disease, including an identified injury or death resulting therefrom. (4) Catastrophic Injury Treatment means medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement, or other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the eligible injured person is stable, no longer requires critical care, and can be safely discharged or transferred to another facility in the judgment of the attending physician. (5) Clinically Supported means that a health care provider, prior to selecting, performing or ordering the administration of a treatment or diagnostic test, has satisfied all of the following requirements: (a) Personally examined the eligible injured person to ensure that the proper medical indications exist to justify ordering the treatment or test; (b) Physically examined the eligible injured person including making an assessment of any current and/or historical subjective complaints, observations, objective findings, neurologic indications, and physical tests; (c) Considered any and all previously performed tests that relate to the injury and the results, and which are relevant to the proposed treatment or test; (d) Recorded and documented these observations, positive and negative findings, and conclusions on the patient s medical records. (6) Death benefits means the amount or amounts payable in the event of the death of an eligible injured person as determined in subdivision (a) or (b) hereof, as appropriate: (a) If the eligible injured person was an income producer at the time of the accident, an amount equal to the difference between $5,200 and all income continuation benefits paid for any loss of income resulting from his or her injury prior to his or her death; (b) If the eligible injured person ordinarily performed essential services for the care and maintenance of himself or herself, his or her family, or family household, an amount not to exceed the difference between $4,380 and all essential services benefits paid with respect to his or her injury prior to death. (7) Diagnostic Test means a medical service or procedure utilizing biomechanical, neurological, neurodiagnostic, radiological, vascular or any means, other than bioanalysis, intended to assist in establishing a medical, dental, physical therapy, chiropractic or psychological diagnosis, for the purpose of recommending or developing a course of treatment for the tested patient to be implemented by the treating practitioner or by the consultant. (8) Eligible Charges means that portion of the medical expenses incurred for treatment of bodily injury that, without considering any deductible or copayment, does not exceed: (a) The percent or dollar amounts specified on the medical fee schedules promulgated by the New Jersey Department of Banking and Insurance, or the treating health care provider s usual, customary and reasonable charge, whichever is less; or 6

9 (b) The reasonable amount, as determined by us, considering the medical fee schedules promulgated by the New Jersey Department of Banking and Insurance for similar services or equipment in the region where the service or equipment was provided, when an incurred medical expense is not included on the medical fee schedules promulgated by the New Jersey Department of Banking and Insurance. (9) Eligible Injured Person means: (a) The named insured or any relative of the named insured, if the named insured or relative sustains bodily injury: (1) As a result of any accident while occupying, using, entering into, or alighting from a private passenger auto; or (2) While a pedestrian, caused by a private passenger auto or by an object propelled by or from a private passenger auto; or (b) Any other person who sustains bodily injury while, with the permission of the named insured, occupying, using, entering into, or alighting from the insured automobile. (10)Emergency Care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in death, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part. Emergency Care shall include all medically necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency Care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Emergency Care shall be presumed when medical care is initiated at a hospital within 120 hours of the accident. (11) Essential Services Benefits means an amount not exceeding a limit of $12 per day and a total limit of $4,380 payable to an eligible injured person as reimbursement for payments made to others for substitute essential services of the type actually rendered during his or her lifetime and that he or she would ordinarily have performed not for income but for the care and maintenance of himself or herself and his or her relatives. (12)Funeral Expense Benefits means an amount not exceeding $1,000 for reasonable funeral, burial, and cremation expenses incurred. (13)Health Care Provider means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to: (a) A hospital or health care facility that is maintained by a state or any political subdivision; (b) A hospital or health care facility licensed by the Department of Health and Senior Services; (c) Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiological and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers; (d) A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital; (e) Hospitals or other health care facilities or treatment centers located in other states or nations; (f) Physicians licensed to practice medicine and surgery; (g) Licensed chiropractors; (h) Licensed dentists; (i) Licensed optometrists; (j) Licensed pharmacists; (k) Licensed chiropodists (podiatrists); (l) Registered bio-analytical laboratories; (m) Licensed psychologists; (n) Licensed physical therapists; (o) Certified nurse midwives; (p) Certified nurse practitioners/clinical nurse-specialists; 7

10 (q) Licensed health maintenance organizations; (r) Licensed orthotists and prosthetists; (s) Licensed professional nurses; (t) Providers of other health care services or supplies including durable medical goods. (14) Identified Injury means those injuries identified by the New Jersey Department of Banking and Insurance as being subject to medical treatment protocols in accordance with N.J.S.A. 39:6A-3.1a and 39:6A-4a. (15) Income means salary, wages, tips, commissions, fees, and other earnings derived from work or employment. (16) Income Continuation Benefits means an amount not exceeding a limit of $100 per week and a total limit of $5,200 payable for the loss of income of an eligible injured person who is an income producer during his or her lifetime, as a result of bodily injury disability. In no case shall income continuation benefits exceed the net income normally earned during the period in which the benefits are payable. (17) Income Producer means a person who, at the time of the accident, was in an occupational status, earning or producing income. The status of an income producer will cease when the recipient is no longer an income producer for reasons other than bodily injury disability. (18) Insured Automobile means an automobile with respect to which the named insured is required to maintain automobile liability insurance coverage under New Jersey statutes, to which the liability insurance of this policy applies and for which a specific premium is charged. (19) Medical Expense Benefits means the reasonable and necessary expenses for: (a) Treatment or services rendered by a provider, including medical, surgical, rehabilitative, and diagnostic services and hospital expenses; (b) Ambulance services or other transportation; (c) Medication; (d) Clinically supported necessary non-medical expenses that are prescribed by a treating medical provider for a permanent or significant brain, spinal cord, or disfiguring injury. Necessary non-medical expense means charges for: (1) Products and devices, not exclusively used for medical purposes or as durable medical equipment, such as any vehicles, durable goods, equipment, appurtenances, improvements to real or personal property, fixtures; (2) Services and activities such as recreational activities, trips, and leisure activities. Medical expense benefits include any non-medical remedial treatment rendered in accordance with a recognized religious method of healing. Medical expense benefits are subject to the limitations set forth in the policy and as approved by the Commissioner of Banking and Insurance. (20)Medically necessary or medical necessity means that the medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis, or indications of the injured person, and: (a) The treatment is the most appropriate standard or level of service that is in accordance with standards of good practice and standard professional treatment protocols, as such protocols may be recognized or designated by the Commissioner of Banking and Insurance; (b) The treatment of the injury is not primarily for the convenience of the injured person or provider; (c) Does not include unnecessary or inappropriate testing or treatment; (d) Does not include testing or treatment that is considered by the medical community to be experimental; and (e) Does not include testing or treatment that is strictly palliative (treating the symptoms of a condition rather than the condition itself). (21)Named insured means the person named as the insured on the policy declarations, and if an individual, named insured includes his or her spouse by marriage or domestic partner by civil union, if the spouse by marriage or domestic partner by civil union, is a resident of the 8

11 household of the named insured. If the spouse by marriage or domestic partner by civil union ceases to be a resident of the named insured s household, Personal Injury Protection will continue for the spouse until the end of the policy period in effect at the time he or she ceased to be a resident of such household. (22)Pedestrian means any person who is not occupying, entering into, or alighting from a vehicle propelled by other than muscular power and designed primarily for use on highways, rails, and tracks. b. Insuring Agreement (1) You have this coverage only if a premium for it appears on the policy declarations. (2) We will pay Personal Injury Protection Coverage Benefits consisting of: (a) Medical expense benefits, (b) Income continuation benefits, (c) Essential services benefits, (d) Death benefits, (e) Funeral expense benefits, with respect to bodily injury sustained by an eligible injured person, caused by an accident and arising out of the ownership, maintenance, or use, including loading or unloading, of a private passenger auto as an automobile. c. Limits of Liability (1) Medical Expense Benefits (a) Limit The following per person, per accident limit of liability for medical expense benefits applies: (1) For the named insured and relatives, who are not named insureds under another policy, the limit is shown on the declarations. However, for catastrophic injury treatment, the available limit of coverage will be an amount not to exceed $250,000. (2) For all other eligible injured persons, the limit is shown on the declarations. However, for catastrophic injury treatment, the available limit of coverage will be an amount not to exceed $250,000. (3) Under no circumstances will more than $250,000 in medical expense benefits be paid for any one person for any accident involving catastrophic injury treatment. (b) Limitation Set by Medical Fee Schedule Payments of medical expense benefits shall not exceed the applicable amount set forth in any medical fee schedule promulgated by the New Jersey Department of Banking and Insurance for specific injuries or services. If a claimed eligible charge is not included on the medical fee schedule, payment will be determined by us, on a reasonable basis, considering the medical fee schedules for similar services or equipment in the region where the service or equipment was provided. (c) Copayment Our payment of medical expense benefits is subject to a per accident copayment of 20% for the amount between the applicable deductible and $5,000. (d) Deductible The amount shown in the medical expense benefits deductible section on the policy declarations is the deductible amount that applies to medical expense benefits payable to the named insured and relatives, who are not named insureds under another policy. (e) Primary Health Insurance Option (1) If the policy declarations indicate that the Primary Health Insurance Option has been elected: a) Any health insurance coverage or benefits applying to the named insured and relatives shall be the primary coverage for medical expense benefits for allowable expenses. Personal Injury Protection Coverage will apply as secondary coverage for medical expense benefits that remain uncovered. An explanation of benefit payment calculations when Personal Injury Protection Coverage is secondary is given below in the Coordination of Benefits provision. 9

12 b) However, if it is determined that the health insurance certified by the named insured, or another comparable plan, was not in effect at the time of the accident then: 1) The terms and conditions applicable if the Primary Health Insurance Option had not been elected on the policy declarations will apply; 2) An additional $750 deductible per accident will apply to the medical expense benefits; 3) We will be entitled to recover as additional premium the total amount of any reduction applied to the premium for the policy period in which the accident occurred, due to the insured s election of the Primary Health Insurance Option. (2) If the policy declarations indicate that the Primary Health Insurance Option has not been elected to provide primary coverage, Personal Injury Protection Coverage shall be the primary coverage for medical expense benefits payable to the named insured and relatives, who are not named insureds under another policy. (3) Health Insurance includes individual, blanket, or group accident insurance; medical or surgical reimbursement plans; health care services provided by a health maintenance organization; a state-sanctioned flexible spending account, or any coverage or benefits provided under any federal or state program. (4) Coordination of Benefits a) When this coverage applies as primary, we will pay medical expense benefits without reduction for amounts collected from health insurance coverage. b) When this coverage applies as secondary, we will pay actual benefits to be calculated as follows: 1) We will first determine the amount of eligible charges which would have been paid under this coverage after application of the deductible and copayment requirements, if this coverage applied as primary. 2) If the allowable expenses that remain unpaid by the health insurance that applies as primary are less than the benefits calculated in 1) above, we will pay actual benefits equal to the allowable expenses that remain unpaid, without reducing the remaining allowable expenses by the deductible or copayment amounts of Personal Injury Protection Coverage. In determining the allowable expenses that remain unpaid, we shall not consider any amount for items of expense which exceed the dollar or percent amounts recognized by the medical fee schedules promulgated by the New Jersey Department of Banking and Insurance. 3) If the allowable expenses that remain unpaid by the health insurance that applies as primary are greater than the amount calculated in 1) above, without reducing the remaining allowable expenses by the deductible or copayment amounts of this coverage, we will pay the amount calculated in 1) above. c) The total amount of medical expense benefits for the named insured or any relative per accident shall not exceed the maximum amount payable for medical expense benefits under this policy. (2) Income Continuation Benefits The applicable limit on income continuation benefits applies separately to each full regular and customary workweek of an eligible injured person. We will prorate the limit of liability shown in the policy declarations for weekly income continuation benefits for any period of bodily injury disability shorter than one week. (3) Medical Expense Benefits Only Option If the policy declarations indicate that the Medical Expense Benefits Only Option has been elected, there is no coverage for the named insured and relatives for any benefit provided by Personal Injury Protection Coverage except medical expense benefits. (4) Reduction of Personal Injury Protection Coverage Benefits 10

13 Any amount payable by us as Personal Injury Protection Coverage benefits with respect to bodily injury shall be reduced by all amounts: (a) Paid, payable, or required to be provided under any workers compensation or employees temporary disability law; or (b) Paid, payable, or required to be provided under Medicare provided under federal law; or (c) Actually paid as benefits provided under federal law to active and retired military personnel. d. Exclusions (1) Personal Injury Protection Coverage does not apply: (a) To bodily injury to a person whose conduct contributed to the injury in any of the following ways: (1) While committing a high misdemeanor or felony or seeking to avoid lawful apprehension or arrest by a police officer; or (2) While acting with specific intent to cause injury or damage to himself or others. (b) To bodily injury to the named insured or any relative of the named insured sustained while occupying, using, entering into or alighting from a private passenger auto which is not an insured automobile under this policy, if he or she is required to maintain automobile liability insurance coverage with respect to that automobile under New Jersey statutes. (c) To bodily injury to any person who at the time of the accident: (1) Was the owner or registrant of a private passenger auto registered or principally garaged in New Jersey that was being operated without Personal Injury Protection Coverage; or (2) Was operating or occupying a private passenger auto without the permission of the owner or other named insured. (d) To bodily injury to any person who is not occupying an insured automobile if the accident occurs outside of New Jersey. This exclusion ((1)(d)) does not apply to: (1) the named insured; or (2) a relative of the named insured; or (3) a resident of New Jersey. (e) To bodily injury arising out of ownership, maintenance, or use, including loading or unloading, of any vehicle while located for use as a residence or premises other than for transitory recreational purposes. (f) To bodily injury due to war, whether or not declared, civil war, insurrection, rebellion, or revolution, or to any act or condition incident to any of the foregoing. (g) To bodily injury resulting from the radioactive, toxic, explosive, or other hazardous properties of nuclear material. (h) To bodily injury to any person who is entitled to New Jersey Personal Injury protection Coverage as a named insured or relative under the terms of any other policy. This exclusion ((1)(h)) does not apply to the named insured under this policy. (i) To bodily injury to any relative who is entitled to New Jersey Personal Injury Protection Coverage as a named insured under the terms of another policy. (j) To bodily injury to any person who is a named insured under the terms of a Standard Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3 and 39:6A-4. (2) We do not provide Personal Injury Protection Coverage with respect to those diagnostic tests prohibited by the New Jersey Department of Banking and Insurance or by statute or regulation. e. Mandated Medical Expense Conditions (1) Voluntary Networks (a) Upon receiving notification of bodily injury covered under this policy, we will make available to the named insured and the treating health care provider information about our approved voluntary network providers. (b) If an eligible injured person does not use a voluntary network provider, we will impose a copayment not to exceed 30% of the eligible charges. (2) Care Paths for Identified Injuries 11

14 (a) The New Jersey Department of Banking and Insurance has established standard courses of medically necessary treatment including diagnostic tests for identified injuries that are reimbursable as medical expense benefits. The standard treatments and practices are based on the diagnosed injury and are known as Care Paths. Care Paths do not apply to treatment administered during emergency care. (b) We will advise an eligible injured person of the Care Path requirements established by the New Jersey Department of Banking and Insurance upon receiving notice of a bodily injury covered under this policy. (c) Within the Care Path, certain treatments and diagnostic tests are subject to the Decision Point Review Plan and pre-certification requirements. The administration of any test listed in N.J.A.C. 11:3-4.5(b) 1-10 also require decision point review, regardless of the diagnosis. (d) Medical care provided to persons injured in auto accidents that is consistent with the Care Paths will be reimbursable by the Personal Injury Protection Coverage medical expense benefits. Medical care that deviates from these Care Paths will not be reimbursable except by reason of specific medical necessity based upon adequate clinically supported findings in the particular case. Medical treatments, diagnostic tests, or durable medical equipment that are not medically necessary will not be reimbursable through Personal Injury Protection Coverage. (3) Decision Point Review Plan and Pre-Certification The following Decision Point Review Plan and pre-certification requirements are applicable only after the tenth day following the accident, and do not apply to treatment administered in emergency care. (a) Upon receipt of notice of bodily injury covered under this policy, we will make available to the eligible injured person our Decision Point Review Plan and pre-certification requirements, if any. (b) If the eligible injured person or an eligible injured person s health care provider requests either: (i) A decision point review; or (ii) Pre-certification of certain diagnostic tests, specific proposed treatment, non-medical expenses, or durable medical equipment; then we will provide a written authorization, denial, or request for more information within 3 business days. (c) We must be provided with the appropriate clinically supported findings, that the administration of a test allowable by the New Jersey Department of Banking and Insurance, proposed treatments, non-medical expenses, or durable medical equipment is medically necessary. (d) During our review of the information required in paragraph (3) (c) above, we may: (1) Approve the proposed treatment, test, non-medical expenses, or durable medical equipment; (2) Request further information; (3) Schedule a physical examination of the injured person in accordance with (g) below where the notice and supporting materials and other medical records, if requested, are not sufficient to authorize or deny reimbursement of further treatment, diagnostic tests or durable medical equipment; and/or (4) Deny reimbursement of further treatment, diagnostic tests, non-medical expense, or durable medical equipment pursuant to N.J.A.C. 11:3-4.7(b). (e) After consideration of the further information and/or physical examination, we will then authorize or deny reimbursement for the treatment, tests, non-medical expense, or durable medical equipment. Our authorization or denial will be based on medical necessity and will not encourage over or under utilization of benefits. (f) Any denial of decision point review or pre-certification requests based on medical necessity will be the determination of a physician. If the treatment is prescribed by a dentist, any denial will be determined by a dentist. 12

15 (g) Physical Examination (1) We will notify the eligible injured person or his or her designee if a physical examination is required for reimbursement of further treatment, diagnostic tests, or durable medical equipment. (2) The medical examination will be: a) Scheduled within seven calendar days of receipt of the notice described above unless the eligible injured person agrees to extend the time period; b) Conducted by a health care provider similar to the treating health care provider; c) Conducted at a location reasonably convenient to the eligible injured person. (3) Upon our request, the treating health care provider or the eligible injured person will provide medical records and other pertinent information to the health care provider conducting the medical examination. The requested records will be provided no later than the time of the examination. (4) We may deny reimbursement of further treatment, testing or use of durable medical equipment for an eligible injured person s repeated unexcused failure to appear for a physical examination required by us in accordance with our plan. (5) We will notify the eligible injured person, his or her designee, and the treating healthcare provider whether reimbursement for further treatment, diagnostic tests, or durable medical equipment is authorized as promptly as possible but no later than three business days after the examination. A copy of the healthcare provider s report, if prepared, is available upon request. (h) Penalty If the eligible injured person or healthcare provider fails to: (1) Request a decision point review or pre-certification where required; or (2) Provide clinically supported findings that support the treatment, diagnostic tests or durable medical equipment; we will impose an additional copayment applicable to eligible charges for medically necessary diagnostic tests, treatments, surgery, durable medical goods, and nonmedical expenses that were provided between the time notification to us was required and the time that proper notification is made and we have an opportunity to respond in accordance with our Decision Point Review Plan. The copayment will be 25% when the request or findings are provided 30 to 59 days after the accident. The copayment will be 50% when the request or findings are provided 60 or more days after the accident. We will not impose the additional copayment where we received the required notice but failed to act in accordance with the Decision Point Review Plan to request further information, to modify or deny reimbursement of further treatment, diagnostic tests, or durable medical equipment. f. Conditions (1) Notice In the event of an accident, written notice containing both particulars sufficient to identify the eligible injured person, and reasonably obtainable information respecting the time, place, and circumstances of the accident shall be given by or on behalf of each eligible injured person to us within 29 days following the accident. If any eligible injured person, his or her legal representative, or survivors shall institute legal action to recover damages for injury against a person or organization who is or may be liable in tort therefore, a copy of the summons and complaint or other process served in connection with such legal action shall be forwarded to us promptly by such eligible injured person, his or her legal representative, or his or her survivors. (2) Medical Reports; Proof of Claim Within 29 days following the accident, the eligible injured person or someone on his or her behalf shall give to us written proof of claim, including full particulars of the nature and extent of the injuries and treatment received and contemplated, and such other information as may 13

16 assist us in determining the amount due and payable. The eligible injured person shall, at our request, submit a timely PIP Application. The eligible injured person shall submit to physical examination by physicians when and as often as we may reasonably require and a copy of the medical report will be forwarded to such eligible injured person if requested. (3) Penalty If an eligible injured person fails to provide us with notice, proof of claim and other reasonably obtainable information regarding an injury or claim, we may impose an additional copayment as a penalty. The additional copayment shall be an amount no greater than: (a) 10 percent when notification is received 21 to 30 days after the commencement of treatment; (b) 25 percent when notification is received 31 to 60 days after the commencement of treatment; (c) 50 percent when notification is received 61 to 120 days after the commencement of treatment; (d) 76 percent when notification is received 121 to 160 days after the commencement of treatment; and (e) 100 percent when notification is received 161 or more days after the commencement of treatment. Such copayment will reduce the amounts reimbursed for eligible charges that are incurred after notification to us is required and until we receive notification. Any reduction in the amount of reimbursement in eligible charges shall be in addition to any other deductible or copayment requirement. (4) Multiple Policies Applicable to One Accident; Non-duplication of Benefits; Priority of Complying Policies This policy provides no Personal Injury Protection Coverage Benefits for a person who is a named insured under a Basic Automobile Insurance Policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3. Regardless of the number of automobiles insured for Personal Injury Protection Coverage pursuant to Section 4 of the New Jersey Automobile Reparation Reform Act, or the number of insurers or policies affording such coverage, there should be no duplication of payment of Personal Injury Protection Coverage benefits and the aggregate maximum amount payable under this and all applicable policies with respect to bodily injury to any one person as the result of any one accident shall not exceed the applicable amount or limits specified in Section 4 of said Act. Personal Injury Protection Coverage applies on a primary basis to bodily injury to the named insured and his or her relative and on a secondary basis to all other eligible injured persons. Similarly, the Personal Injury Protection Coverage provided by other complying policies applies on a primary basis to bodily injury to those persons who are named insureds under such policies and their relatives. If an eligible injured person to whom Personal Injury Protection Coverage applies on a secondary basis has other Personal Injury Protection Coverage under another complying policy applicable to his or her bodily injury on a primary basis, all claims for Personal Injury Protection Coverage benefits shall first be made against the insurer issuing the other complying policy. No Personal Injury Protection Coverage benefits shall be due and payable under Personal Injury Protection Coverage unless the other insurer fails to pay such benefits by reason of insolvency and we have been given written notice by the claimant of such failure. Complying Policy means a policy of automobile liability insurance maintained pursuant to the requirements of Section 3 of the New Jersey Automobile Reparation Reform Act and providing Personal Injury Protection Coverage as approved by the Department of Banking and Insurance. The eligible injured person shall not collect under more than one policy. If an eligible injured person under this policy qualifies for payments under other policies providing Personal Injury Protection Coverage benefits, the insurer paying benefits to such person shall be entitled to 14

17 recover from each of the other insurers an equitable pro rata share of the benefits paid. The pro rata share is the proportion that the insurer s liability bears to the total of all applicable limits. Any deductible amounts applicable shall be taken into consideration in determining each insurer s pro rata share. (5) Reimbursement and Trust Agreement Subject to any applicable limitations set forth In the New Jersey Automobile Reparation Reform Act, in the event of any payment to any person under Personal Injury Protection Coverage: (a) We shall be entitled to the extent of such payment to the proceeds of any settlement or judgment that may result from the exercise of any rights of recovery of such person against any person or organization legally responsible for the bodily injury because of which such payment is made; and we shall have a lien to the extent of such payment. Notice of our lien may be given to the person or organization causing such bodily injury, his or her producer of record, his or her insurer, or a court having jurisdiction in the matter; (b) Such person shall hold in trust for our benefit all rights of recovery that he or she shall have against such other person or organization because of such bodily injury; (c) Such person shall do whatever is proper to secure and shall do nothing after loss to prejudice such rights; (d) Such person shall execute and deliver to us such instruments and papers as may be appropriate to secure the rights and obligations of such person and us established by this provision. (6) Payment of Personal Injury Protection Coverage Benefits Medical expense benefits may be paid at our option to the eligible injured person or the person or organization furnishing the products or services for which such benefits are due. These benefits shall not be assignable except to providers of service benefits who comply with the Care Paths, pre-certification and decision point review requirements of this policy. The first recourse for disputes regarding payment of Personal Injury Protection Coverage for assignees of benefits shall be the procedure specified in paragraph 3 of this Section. In the event of the death of an eligible injured person, any amounts payable, but unpaid prior to death, for medical expense benefits are payable to the eligible injured person s estate. Benefits payable under subdivision (a) of the definition of death benefits are payable to the eligible injured person s surviving spouse by marriage or domestic partner by civil union, or if there is no surviving spouse by marriage or domestic partner by civil union, to his or her surviving children, or if there are no surviving spouse or surviving children, to the eligible injured person s estate. Benefits payable under subdivision (b) of the definition of death benefits are payable to the person who has incurred the expense of providing essential services. Funeral expenses benefits are payable to the eligible injured person s estate. (7) Our Right to Apply for Employee Benefits If an eligible injured person has not applied for workers compensation or employees temporary disability benefits, we may immediately apply directly to the provider of such benefits paid under this coverage. (8) Proof of Health Benefits Plan Coverage If you have elected the Medical Expense Benefits-As-Secondary option, you must provide proof that you and your relatives are insured by health insurance coverage or benefits in a manner and to an extent approved by the New Jersey Department of Banking and Insurance. g. Policy Period; Territory Personal Injury Protection Coverage applies only to accidents that occur during the policy period and anywhere in the world. 2. Extended Medical Expense Benefits Coverage a. Definitions The definitions under Personal Injury Protection Coverage apply to Extended Medical Expenses Benefits Coverage, and under Extended Medical Expense Benefits Coverage. (1) Highway Vehicle means a land motor vehicle or trailer other than: (a) A private passenger auto; 15

18 (b) A farm type tractor or other equipment designed for use principally off public roads, while not upon public roads; (c) A vehicle operated on rails or crawler-treads; or (d) A vehicle while located for use as a residence or premises. (2) Insured Person means: (a) The named insured or any relative of the named insured, if the named insured or relative sustains bodily injury: (1) While occupying, using, entering into, or alighting from a highway vehicle; or (2) While a pedestrian, caused by a highway vehicle; (b) Any other person who sustains bodily injury while occupying a highway vehicle (other than a motorcycle or a vehicle while being used as a public or livery conveyance) if such highway vehicle is being operated by the named insured or a relative of the named insured or any other person using such highway vehicle with the permission of the named insured; b. Insuring Agreement (1) You have this coverage only if a premium for it appears on the policy declarations. (2) We will pay medical expense benefits not to exceed the total aggregate amount stated on the policy declarations with respect to bodily injury sustained by an insured person, caused by an accident occurring during the policy period anywhere in the world and arising out of the ownership, maintenance, or use, including loading and unloading, of an insured automobile or of a highway vehicle not owned by or furnished or available for the regular use of the named insured or any relative of the named insured. c. Limit of Liability The limit of our liability under Extended Medical Expense Benefits for each person entitled to benefits who sustains bodily injury in any one accident shall not exceed the amount shown in the Extended Medical Expense Limit section on the policy declarations. No eligible injured person will recover duplicate benefits for the same elements of loss under Personal Injury Protection Coverage. d. Exclusions (1) Extended Medical Expense Benefits Coverage is subject to all of the exclusions applicable to Personal Injury Protection Coverage except that the word person in exclusion 1.d.(1)(c) is replaced by the word pedestrian. (2) The following exclusions also apply to Extended Medical Expense Benefits Coverage: (a) Extended Medical Expense Benefits Coverage does not apply to any insured who would be entitled to benefits under Personal Injury Protection Coverage except for the application of the medical fee schedule promulgated by the New Jersey Department of Banking and Insurance. (b) Extended Medical Expense Benefits Coverage does not apply to any person, other than the named insured or a relative of the named insured or a resident of New Jersey, if the accident occurs outside of New Jersey. e. Conditions Conditions (1), (2), (5), and (8) of Personal Injury Protection Coverage apply to Extended Medical Expense Benefits Coverage, substituting the term insured person for eligible injured person wherever it appears therein. The following additional condition applies under Extended Medical Expense Benefits Coverage: Other Insurance or Benefits Extended Medical Expense Benefits Coverage does not apply to loss or expense with respect to which an insured person is entitled to benefits under any Medicare provided under federal law, any workers compensation law, or under Section 4 of the New Jersey Reparation Reform Act. Extended Medical Expense Benefits Coverage does not apply to loss or expense to the extent that benefits are payable or are required to be provided therefore under any other automobile no-fault law or under any other automobile medical payments insurance. 16

19 Extended Medical Expense Benefits Coverage does not apply to amounts not paid under the New Jersey No-Fault Law because of the application of the deductible or the copayment stated in the Limit of Liability provision for Personal Injury Protection Coverage. 3. Dispute Resolution The New Jersey Department of Banking and Insurance established procedures for the resolution of disputes concerning the payment of medical expense and other benefits provided by Personal Injury Protection Coverage. A request for dispute resolution for Personal Injury Protection Coverage may be submitted by the injured party, the insured, a provider of service benefits who is an assignee of Personal Injury Protection Coverage benefits, or the insurer in accordance with New Jersey Law. The request for dispute resolution may include a request for review by a medical review organization. 4. Added Personal Injury Protection Coverage The amount indicated for Income Continuation Benefits, Essential Services Benefits and Funeral Expense Benefits includes the benefits payable under the Personal Injury Protection Coverage. a. The weekly and total limits applicable to income continuation benefits as stated in the policy declarations are amended by substituting therefore, respectively, the amounts shown in the policy declarations for income continuation benefits under Added Personal Injury Protection Coverage. b. The per day and total limits applicable to essential services benefits as stated in the policy declarations are amended by substituting therefore, respectively, the amounts shown in the policy declarations for essential services benefits under Added Personal Injury Protection Coverage. c. The limit applicable to funeral expense benefits as stated in the policy declarations is amended by substituting therefore the amount shown in the policy declarations for funeral expense benefits under Added Personal Injury Protection Coverage. d. The income continuation benefits and essential services benefits shall cease upon the death of the eligible injured person and shall not operate to increase the amount of any death benefits payable under the Section IV.B. Personal Injury Protection Coverage of the policy. e. We will pay an added death benefit of $10,000 to the surviving spouse by marriage or domestic partner by civil union; or if there is no surviving spouse by marriage or domestic partner by civil union, to the surviving children; or if there is no surviving spouse by marriage, domestic partner by civil union or surviving children, to the estate of the person insured for Added Personal Injury Protection Coverage if his or her death results from bodily injury for which Personal Injury Protection Benefit Coverage is payable and occurs within 2 years of the accident. f. Subject to the limits of liability shown in the policy declarations, we shall not be liable for more than 75% of weekly income in excess of $100, provided however, that after $5,200 has been paid as income continuation benefits at the rate specified in the Section IV.B. Personal Injury Protection Coverage of the policy, we shall not be liable for more than 75% of weekly income thereafter. C. Uninsured and Underinsured Motorist Coverage 1. Additional Definitions Applicable to Uninsured and Underinsured Motorist Coverage a. Bodily Injury means bodily injury, sickness or disease, including death resulting therefrom. b. Underinsured Motor Vehicle means: (1) For you and any insured who is not insured as a named insured, spouse by marriage or domestic partner by civil union or relative under any policy providing Uninsured and Underinsured Motorist Coverage: a land motor vehicle or trailer, the ownership, maintenance, or use of which is insured or bonded for bodily injury and property damage liability at the time of the accident, but the limits of liability are less than the limits you carry for Uninsured and Underinsured Motorist Coverage under this policy. (2) For any insured who is insured as a named insured, spouse by marriage, domestic partner by civil union, or relative under any other policy providing Uninsured and Underinsured Motorist Coverage: a land motor vehicle or trailer, the ownership, maintenance, or use of which is insured or 17

20 bonded for bodily injury and property damage liability at the time of the accident, but the limits of liability are less than the highest applicable limit of liability under any other policy providing Uninsured and Underinsured Motorist Coverage to that insured as a named insured, spouse by marriage, domestic partner by civil union, or relative. An underinsured motor vehicle does not include: (1) An uninsured motor vehicle; (2) A land motor vehicle or trailer that is owned by, or leased to, or furnished for the regular use of: (a) You; or (b) Any relative; or (c) A resident of your household; (3) A land motor vehicle or trailer: (a) Owned or operated by a self-insurer under any motor vehicle financial responsibility law, motor carrier law, or any similar law; (b) Owned by any government or any of its political subdivisions or agencies; (c) Designed for use mainly off public roads except while on public roads; (d) Used as a residence or stationary structure; (e) Operated on rails or crawler treads. c. Uninsured Motor Vehicle means: (1) A land motor vehicle or trailer, the ownership, operation, maintenance, or use of which is: (a) Not insured or bonded for bodily injury and property damage liability at the time of the accident; or (b) Insured or bonded for bodily injury and property damage liability at the time of the accident, but the insuring company denies coverage or is or becomes insolvent, or the Commissioner of Banking and Insurance has undertaken control of the insurer for purposes of liquidation; or (2) With respect to bodily injury, a hit-and-run land motor vehicle whose owner and driver remains unknown and: (a) That strikes the insured or the vehicle the insured is occupying and causes bodily injury to an insured; or (b) That causes bodily injury to the insured without striking the insured or the vehicle the insured is occupying. If there is no physical contact with the hit-and run vehicle, the facts of the accident must be corroborated by: (1) An accident report completed by a law enforcement agency; or (2) An affidavit attesting to the truth of the facts of the accident signed by any eyewitness other than the owner or operator of the vehicle which you, an insured driver, or any family member were occupying at the time of the accident. (3) An auto covered by a New Jersey Special Automobile Insurance Policy. An uninsured motor vehicle does not include: (1) An underinsured motor vehicle; (2) A land motor vehicle or trailer that is owned by, or leased to, or furnished for the regular use of: (a) You; or (b) Any relative; or (c) A resident of your household; (3) A land motor vehicle or trailer: (a) Owned or operated by a self-insurer under any motor vehicle financial responsibility law, motor carrier law, or any similar law; (b) Owned by any government or any of its political subdivisions or agencies; (c) Designed for use mainly off public roads except while on public roads; (d) Used as a residence or stationary structure; (e) Operated on rails or treads; (f) Insured under the terms of a Basic Automobile Insurance Policy issued pursuant to N.J.S.A 39:6A-3.1 and N.J.A.C. 11:3-3 18