N.J. Admin. Code § Tit. 11, ch. 3, subch. 15, app APPENDIX
EXHIBIT 1
STANDARD POLICY COVERAGE SELECTION FORM
Name: _______________________
This Coverage Selection Form is for a STANDARD POLICY, see Buyer's Guide, page insert page #here. A BASIC POLICY with the minimum of required coverages is also available for a lower premium. A SPECIAL POLICY with a very low premium is also available for persons enrolled in Medicaid. Contact your insurer or producer for more information.
BODILY INJURY LIABILITY--Buyer's Guide page insert page #here
Choose the Bodily Injury Liability Limits that you want:
_______________________
_______________________
_______________________
_______________________
At least four of the most popular coverage limits shall be listed, including the lowest limit offered. If a complete list is not provided, state that other coverage limits are available.
PROPERTY DAMAGE LIABILITY--Buyer's Guide page insert page #here
Choose the Property Damage Limits you want:
_______________________
_______________________
_______________________
_______________________
At least four of the most popular coverage limits shall be listed, including the lowest limit offered. If a complete list is not provided, state that other coverage limits are available. For insurers offering combined single limits, substitute at least four of the most popular combined single limits, including the lowest offered.
PERSONAL INJURY PROTECTION (PIP)--Buyer's Guide page insert page #here
[] I choose the standard PIP Medical Expense Limit of $ 250,000. Include higher limit if offered.
[] I choose one of the lower PIP Medical Expense Limits below.
WARNING: Prior to insert effective date of P.L. 1998, c. 21, all auto insurance policies had PIP Medical Expense Benefit limits of $ 250,000. The limits below provide you with less coverage. Warning must be in at least 12 point type.
[ ] $ 150,000* for a __% to __%, or a $___ to $___, reduction in the PIP premium
[ ] $ 75,000* for a __% to __%, or a $___ to $___, reduction in the PIP premium
[ ] $ 50,000* for a __% to __%, or a $___ to $___, reduction in the PIP premium
[ ] $ 15,000* delete for a __% to __%, or a $___ to $___, reduction in the PIP premium
Include both the range of percentage reduction and corresponding dollar amounts based upon your average Statewide premium.
*Even if you choose one of the amounts above, all medically necessary treatment over the policy limit up to $ 250,000 will be paid for permanent or significant brain injury, spinal cord injury or disfigurement or treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until a doctor says that you no longer require critical care.
Choose the PIP Medical Expenses Deductible you want:
[ ] $ 250 deductible, minimum required by law.
[ ] $ 500 deductible, for a __% to __%, or a $___ to $___, reduction in the PIP premium.
[ ] $ 1,000 deductible, for a __% to __%, or a $___ to $___, reduction in the PIP premium.
[ ] $ 2,000 deductible, for a __% to __%, or a $___ to $___, reduction in the PIP premium.
[ ] $ 2,500 deductible, for a __% to __%, or a $___ to $___, reduction in the PIP premium.
Include both the range of percentage reduction and corresponding dollar amounts based upon your average Statewide premium.
Health Insurer for PIP Option
[ ] I choose the health insurer for PIP option--Buyer's Guide, page insert page #here.
The name of my health insurer(s) is (are):
1. ______________________________________________
Policy/Group#/Certificate# ___________________________
2. ______________________________________________
Policy/Group#/Certificate# ___________________________
Extra PIP Package Coverage Options
The Extra PIP Package benefits include income continuation, essential services, death benefits and funeral expense benefits--Buyer's Guide page insert page #here
You may choose not to have the Extra PIP Package benefits for a __% to __%, or a $___ to $___, reduction in the __ PIP premium. Include both the range of percentage reduction and the corresponding dollar amounts in comparison to your average Statewide base PIP premium
I choose PIP Medical Expense Only
Insert a chart listing options and choices
UNINSURED/UNDERINSURED MOTORIST COVERAGE --Buyer's Guide, Page insert page #here
You may choose one of the following higher limits of Uninsured/Underinsured Motorist Coverage, up to your Bodily Injury Liability Insurance Limit.
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
List the same options available for bodily injury liability coverage above. Other options may also be listed.
COLLISION COVERAGE--Buyer's Guide, page insert page #here
[] No, I choose not to be covered for collision damage.
[] Yes, I choose to be covered for collision damage with the default $ 750 deductible.
[] Yes, I choose to be covered for collision damage with the deductible circled here: $ 1,000, $ 1,500 or $ 2,000. This premium will be less than the premium with the default $ 750 deductible. Details available from company or insurance producer (that is, agent or broker).
[] Yes, I choose to be covered for collision damage with the deductible circled here: $ 100, $ 150, $ 200, $ 250 or $ 500. This premium will be more than the premium with the default $ 750 deductible. Details available from insurer or insurance producer.
Insert provision for coverage/no coverage per car if available
COMPREHENSIVE COVERAGE Buyer's Guide page insert page #here If appropriate, use the term "other than collision" coverage throughout this section
[] No, I choose not to be covered for comprehensive damage.
[] Yes, I choose to be covered for comprehensive damage with the default $ 750 deductible.
[] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $ 1,000, $ 1,500 or $ 2,000. This premium will be less than the premium with the default $ 750 deductible. Details available from insurer or insurance producer.
[] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $ 100, $ 150, $ 200, $ 250 or $ 500. This premium will be more than the premium with the default $ 750 deductible. Details available from insurer or insurance producer.
Insert provision for coverage/no coverage per car if available
For both collision and comprehensive, if either the $ 200 deductible or $ 250 deductible is not offered, that option may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate.
WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose not to purchase higher limits of PIP medical expense coverage, higher limits of uninsured/underinsured motorists coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See 17:28-1.9 for more information. Warning must be in at least 12 point type.
LAWSUIT OPTIONS, Buyer's Guide, page insert page #here
[] I want the Limitation on Lawsuit Option.
[] I want the No Limitation on Lawsuit Option. My bodily injury liability premium will be __% to __% higher if I select the No Limitation on Lawsuit option instead of the Limitation on Lawsuit option, depending upon where my car is garaged, my bodily injury liability coverage limit, and other factors. Per vehicle, my bodily injury liability premium at current rates will be $__ to $__ higher on each __ renewal of my policy if I select the No Limitation on Lawsuit option instead of the Lawsuit option. I understand that I can contact my insurer or my insurance producer for specific details.
Insurance companies writing six month policies should insert the word "semi-annual" in the blank space above. Companies writing 12 month policies should insert the word "annual."
Insurance companies writing single limit liability coverage may add a footnote to inform insureds that the policy declaration page will not include a specific premium for "bodily injury liability" coverage.
WARNING: Insurance companies or their producers or representatives shall not be held liable for your choice of lawsuit option (limitation on lawsuit option or no limitation on lawsuit option). Insurers or their producers or representatives also shall not be liable if the limitation on lawsuit option is imposed by law because no choice was made on the coverage selection form. Insurers, their producers or representatives can lose this limitation on liability for failing to act in accordance with the law. See 17:28-1.9 for more information. Warning must be in at least 12 point type.
STATEMENT OF INSURED or APPLICANT:
I have read the Buyer's Guide outlining the coverage options available to me. The limits available for PIP medical expense coverage and uninsured and underinsured motorists coverage have been explained to me. My choices are shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my request that a change be made.
For new policyholders, I understand that:
(a) If I do not make a choice to have the No Limitation on Lawsuit Option, I will receive the Limitation on Lawsuit option;
(b) If I carry collision and/or comprehensive coverage without making a written choice of deductible, I will receive the default $ 750 deductible;
(c) If I do not choose to have my health insurer provide PIP medical expense benefits, my auto insurer will provide PIP medical expense benefits; and
(d) If I do not choose a lower PIP medical expense limit, I will receive the $ 250,000 limit.
I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy. I understand that these choices take effect in the following manner:
(1) For new policies, on the effective date of the policy;
(2) For mid-term policy changes, on the day following the date of postmark or, when personal delivery is made or the postmark is illegible, the day following receipt of this form by the insurer or producer; and
(3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior to the renewal date.
ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL AND CRIMINAL PENALTIES.
Please check the appropriate box to which this form applies:
[ ] New Policy [ ] Mid-Term Change
[ ]Renewal Change
SIGNATURE OF NAMED INSURED
OR APPLICANT_______________________
DATE _______________________
EXHIBIT 2
CERTIFICATION OF COMPLIANCE WITH 11:3-15.6(g)4
I hereby certify that the Lawsuit Option rate differentials in the Standard Policy Coverage Selection Form for ___________ (Name of Insurance Company) were calculated in accordance with 11:3-15.6(g)4.
_______________________
Signature
_______________________
Print Name
_______________________
Title
_______________________
Telephone Number
EXHIBIT 3
BASIC POLICY COVERAGE SELECTION FORM
Name: _______________________
This Coverage Selection Form is for a BASIC POLICY, see Buyer's Guide, page insert page #here. A STANDARD POLICY with more coverages and higher limits is also available for a higher premium. A SPECIAL POLICY with a very low premium is also available for persons enrolled in Medicaid. Contact your insurer or producer for more information.
BODILY INJURY LIABILITY--Buyer's Guide page--insert page #here
[ ] Yes, I choose the $ 10,000 Bodily Injury Liability Limit.
[ ] No, I do not choose to have Bodily Injury Liability Coverage.
WARNING: If you do not choose to have Bodily Injury Liability Coverage and you are at fault in an accident where people are injured or die, you will be responsible for paying for the pain, suffering and other personal hardships and some economic damages, such as lost wages that you cause. Your insurer will not pay a judgment against you or pay for a lawyer to defend you if you are sued. Your assets will be at risk, including having money deducted from your wages if a judgment is entered against you. Warning must be in at least 12 point type.
WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose to purchase a basic policy instead of a standard policy, or if you choose not to purchase bodily injury liability coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See 17:28-1.9 for more information.
PERSONAL INJURY PROTECTION--Buyer's Guide, page insert page #here
WARNING: For a BASIC POLICY, the limit on PIP Medical Expense Coverage is $ 15,000 but includes up to $ 250,000 for emergency care of certain catastrophic injuries (See Buyer's Guide page insert page #here). Prior to insert effective date of P.L. 1998, c. 21, all automobile insurance policies had PIP Medical Expense limits of $ 250,000. The PIP Medical Expense Coverage for a BASIC POLICY is significantly less than previously required by law. Warning must be in at least 12 point type.
Choose the PIP Medical Expenses Deductible you want:
[ ] $ 250 deductible, minimum required by law.
[ ] $ 500 deductible, for a __% to __%, or a $___ to $____, reduction in the PIP premium.
[ ] $ 1,000 deductible, for a __% to __%, or a $___ to $____, reduction in the PIP premium.
[ ] $ 2,000 deductible, for a __% to __%, or a $___ to $____, reduction in the PIP premium.
[ ] $ 2,500 deductible, for a __% to __%, or a $___ to $____, reduction in the PIP premium.
Include both the range of percentage reduction and corresponding dollar amounts based upon your average Statewide premium.
COLLISION COVERAGE--Buyer's Guide, page insert page #here
[ ] No, I choose not to be covered for collision damage.
[ ] Yes, I choose to be covered for collision damage with the basic deductible.
[ ] Yes, I choose to be covered for collision damage with the deductible circled here: $ 1,000, $ 1,500 or $ 2,000. This premium will be less than the premium with the default $ 750 deductible. Details available from company or insurance producer (i.e., agent or broker).
[ ] Yes, I choose to be covered for collision damage with the deductible circled here: $ 100, $ 150, $ 200, $ 250 or $ 500. This premium will be more than the premium with the default $ 750 deductible. Details available from insurer or insurance producer.
Insert provision for coverage/no coverage per car if available
COMPREHENSIVE COVERAGE Buyer's Guide page insert page #here If appropriate, use the term "other than collision" coverage throughout this section
[ ] No, I choose not to be covered for comprehensive damage.
[ ] Yes, I choose to be covered for comprehensive damage with the default $ 750 deductible.
[ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $ 1,000, $ 1,500 or $ 2,000. This premium will be less than the premium with the default $ 750 deductible. Details available from insurer or insurance producer.
[ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $ 100, $ 150, $ 200, $ 250 or $ 500. This premium will be more than the premium with the $ 750 deductible. Details available from insurer or insurance producer.
Insert provision for coverage/no coverage per car if available.
These sections should be omitted by insurers that do not offer collision and comprehensive coverage in the Basic Policy. For both collision and comprehensive, if either the $ 200 deductible or $ 250 deductible is not offered, that option may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate.
STATEMENT OF INSURED or APPLICANT:
I have read the Buyer's Guide outlining the coverage options available to me. I understand that this is a BASIC POLICY with the minimum coverages required by law and that a Standard Policy with higher limits and additional coverages is available. The option to buy Bodily Liability Coverage has been explained to me. My choices are shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my request that a change be made.
For new policyholders, I understand that:
(a) Unless I choose to have the $ 10,000 Bodily Injury Liability Coverage, I will not receive any Bodily Injury Liability Coverage;
(b) If I choose collision or comprehensive coverage without making a written choice of deductible, I will receive the $ 750 deductible; I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy.
I understand that these choices take effect in the following manner:
(1) For new policies, on the effective date of the policy;
(2) For mid-term policy changes, on the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of this Form by the insurers or by a producer; and
ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL AND CRIMINAL PENALTIES.
Please check the appropriate box to which this form applies:
[ ] New Policy [ ] Mid-Term Change
[ ] Renewal Change
SIGNATURE OF NAMED INSURED
OR APPLICANT _______________________
DATE _______________________
N.J. Admin. Code Tit. 11, ch. 3, subch. 15, app APPENDIX