N.J. Admin. Code § Tit. 11, ch. 3, subch. 33, app B
NOTE: YOU HAVE 90 DAYS FROM THE DATE ON WHICH A WRITTEN DENIAL OF AUTOMOBILE INSURANCE IS MADE TO FILE THIS APPEAL.
NEW JERSEY DEPARTMENT OF BANKING AND INSURANCE
AUTOMOBILE DECLINATION APPEAL
Your Name:
Your Address:
Your Telephone Number: ()
Insurance Company and/or Insurance Producer (agent or broker) that declined your application for automobile insurance coverage in the voluntary market (if producer, please provide the name and address):
Company:
Producer:
YOU MUST ATTACH A COPY OF THE DECLINATION (If you have not received a written declination from the insurance company or producer, you must request one within 90 days from the date you first applied for insurance.)
BASIS FOR YOUR APPEAL (Please indicate with an "X" those statements or reasons that apply and attach a copy of pertinent documentation supporting your appeal. Such documentation should include a certified motor vehicle driver "abstract," where appropriate, available from the Motor Vehicle Commission. To obtain a certified copy of your driving record:
1. Visit a Regional Center or call 888-486-3339 (toll free in New Jersey) or 609-292-6500 and request the Driver History Abstract form.
2. Provide your full name, address, date of birth, driver license number (when available), and reason for making the request.
3. Mail the application, a copy of your driver's license (or other form of acceptable ID) and a check or money order for $ 10.00 payable to the New Jersey Motor Vehicle Commission to:
Motor Vehicle Commission
Abstract Unit
225 East State Street
PO Box 142
Trenton, New Jersey 08666-0142
There is a $ 10.00 fee for each copy of the MVC abstract.)
[ ] I have not been convicted of Driving Under the Influence (N.J.S.A. 39:4-50) or of refusing to submit to a chemical test (N.J.S.A. 39:4-50.4(a)), or for a similar offense in another jurisdiction, or of a crime involving an automobile or theft of a motor vehicle.
[ ] My driver's license is not suspended or revoked, nor has it been for any 12-month period in the preceding three years.
[ ] I have not been convicted of insurance fraud or intent to defraud, or have not had an insurance claim (in excess of $ 1,000) denied because of evidence of fraud within the five-year period immediately preceding application or renewal.
[ ] My auto insurance has not been cancelled for nonpayment of premium within the last two years and I provide proof of payment OR I have had my policy cancelled for nonpayment AND I am able to pay the full annual premium for this policy.
[ ] My auto insurance has not been cancelled for knowingly providing materially false or misleading information in connection with an application for insurance, renewal of insurance, or claim for benefits under an insurance policy during the three-year period immediately preceding the declined application being appealed.
[ ] I am not a named insured or insured under the same policy as a person whose driver's license is suspended or revoked and either: i. The suspended or revoked driver has been convicted of a violation of N.J.S.A. 39:6B-2within the previous three years; or ii. Other evidence exists indicating that the suspended or revoked driver has been operating a vehicle during the period of suspension.
[ ] I am qualified as a member of a group or organization in which membership is required in order to obtain this insurance policy.
[ ] I have fewer eligibility points accumulated than alleged in the declination letter as evidenced by the attached copy of my driving record.
[ ] The accident record indicated in the declination letter is wrong as evidenced by the attached.
[ ] No other person who is a member of the same household and who will drive the subject vehicle for 10 percent or more of the time is an ineligible person.
[ ] Other (Specify and provide proof, if appropriate).
CERTIFICATION OF APPEAL
The information contained in this appeal is true and complete to the best of my knowledge and belief.
I UNDERSTAND THAT FILING THIS APPEAL DOES NOT PROVIDE ME WITH AUTOMOBILE INSURANCE. IF MY AUTO IS REGISTERED IN NEW JERSEY OR IS BEING DRIVEN, I HAVE OBTAINED OTHER AUTO INSURANCE.
Your Signature: Date:
MAIL THIS COMPLETED FORM AND NECESSARY DOCUMENTATION TO:
New Jersey Department of Banking and Insurance
Division of Enforcement and Consumer Protection
PO Box 471
Trenton, New Jersey 08625-0471
Attn: Auto Insurance Denial
N.J. Admin. Code Tit. 11, ch. 3, subch. 33, app B
See: 32 New Jersey Register 3891(a), 33 New Jersey Register 573(a).
Amended by R.2004 d.372, effective 10/4/2004.
See: 36 New Jersey Register 1171(a), 36 New Jersey Register 4470(b).
Rewrote the section.