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Filing # 99697718 E-Filed 12/03/2019 11:46:58 AM
IN THE CIRCUIT COURT OF THE 15TH
JUDICIAL CIRCUIT IN AND FOR PALM
BEACH COUNTY, FLORIDA
TREVOR RICHARDS
and NOVLAT RICHARDS,
Plaintiffs,
vs. Case No: 50-2017-CA-012343-XXXX-MB
ACE AMERICAN INSURANCE
COMPANY,
Defendant.
/
ACE AMERICAN INSURANCE COMPANY’S MOTION FOR
FINAL SUMMARY JUDGMENT AND INCORPORATED
MEMORANDUM OF LAW
ACE AMERICAN INSURANCE COMPANY (“ACE”), pursuant to Fla.
R. Civ. P. 1.510(b), moves for final summary judgment against TREVOR
RICHARDS (“Richards”), and states:
INTRODUCTION
This action is simple. ACE issued a national, commercial auto insurance
policy to Chubb, as the first Named Insured. Chubb rejected UM/UIM coverage
in Florida. There is simply no UM/UIM coverage available to Richards as a matter
of law.
Richards’s claim for Medical Payments also fails. The Medical Payments
coverage applies only to “covered autos,” which is defined as autos owned by
*** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 12/03/2019 11:46:58 AM ***Chubb. At the time of the accident, Richards was in an auto that was not owned
by Chubb. Consequently, there is no Medical Payments coverage available to
Richards as a matter of law.
ACE respectfully submits this entire action is wholly without merit, and that
the Court should enter final summary judgment for ACE.
STATEMENT OF UNDISPUTED FACTS
THE ACE POLICY
lL. ACE issued a multi-state, commercial automobile insurance policy to
Chubb Group Holdings, Inc. (“Chubb”), as the first Named Insured. The policy is
attached as Exhibit “A.”!
2. As the first Named Insured, Chubb was authorized to act and did act
on behalf of all other insureds under the policy. (/d.)
REJECTION OF UM/UIM COVERAGE IN FLORIDA
3. Chubb is a holding company. (Dep. of J. Canavan, Pg. 27:21-28:1,
attached as Exhibit “B.”).
4. Chubb’s structure consists of a number of majority-owned
subsidiaries. For example, ACE and Combined Insurance Company of America
(“Combined”) are indirect subsidiaries of Chubb. (Ex. B, Pg. 26:1-4.)
' For ease of reference, the policy is numbered Pgs. A001 - A510.
Page 2 of 105. Chubb appointed ACE to perform its risk management functions. (Ex.
B, Pgs. 9:8-14, 13:3-11, 33:4-7.)
6. To that end, on 10/27/2016, ACE employee John “Jake” Canavan
rejected UM/UIM coverage in Florida by executing a Florida Uninsured Motorist
Selection Form (“UIM Rejection Form”). (Ex. B, Pgs. 15:10-13, 24:14-25:2, 40:8-
14.)
7. A copy of the UIM Rejection Form is attached as Exhibit “C.”
8. In pertinent part, the UIM Rejection Form provides:
YOU ARE ELECTING NOT TO PURCHASE CERTAIN
VALUABLE COVERAGE WHICH PROTECTS YOU AND
YOUR FAMILY OR YOU ARE PURCHASING UNINSURED
MOTORIST LIMITS LESS THAN YOUR BODILY INJURY
LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE
READ CAREFULLY. ...
I reject Uninsured Motorists Coverage entirely.
(Ex. C, Pgs. 2-3.)
9. The UIM Rejection Form was signed by Jake Canavan. (Aff., J.
Canavan dated 4/9/2019, 93, attached as Exhibit “D.”)
10. The UIM Rejection Form is valid under Florida law. (Aff., S. Starnes,
Florida Office of Insurance Regulation, attached as Exhibit “E.”)°
11. The UIM Rejection Form was signed knowingly. (Ex. D.)
12. The UIM Rejection Form was signed intentionally. (/d.)
? This language precisely tracks the specific language in Fla. Stat. § 627.727(1).
Page 3 of 1013. The UIM Rejection Form was signed under authority from Chubb.
(Id.)
14. The UIM Rejection Form was signed on behalf of all insureds,
including Combined. (/d.)
RICHARDS’S CLAIM:
15. On 4/25/2017, Richards was involved in an automobile accident with
an underinsured vehicle in Florida. (Am. Compl., §98-9, attached as Exhibit “F.”
See also Florida Traffic Crash Report, attached as Exhibit “G.”)
16. At the time of the accident, Richards was employed by Combined.
(Ex. B, Pg. 25:13-16.)
17. At the time of the accident, Richards was in a vehicle that was owned
by his co-worker, Alvaro Planchart. (ACE’s First Req. for Adm. to Richards,
No. 2, attached as Exhibit “H.” See also, Ex. G, Pg. 5.)
18. The vehicle Richards was occupying was not owned by Chubb. (Ex.
H, Nos. 3,4.)
19. Following the accident, Richards demanded ACE pay him UIM
coverage and Medical Payments coverage. (Ex. F, 412.)
Page 4 of 1020. ACE disclaimed UIM coverage because there is no UIM coverage in
Florida under the policy.’
21. ACE disclaimed Medical Payments coverage because the vehicle
Richards was occupying is not a “‘covered auto.”
RICHARDS’S LAWSUIT
22. On 11/18/2017, Trevor Richards and Novlat Richards filed this action
against ACE and the underinsured driver.
23. The operative complaint includes three counts: Count I seeks UIM
benefits for Trevor Richards; Count II seeks UIM benefits for loss of consortium
for Novlat Richards:* and Count III seeks Medical Payments coverage for Trevor
Richards.
ARGUMENT AND CITATION OF AUTHORITY
Standards of Inquiry
Summary judgment is appropriate in coverage disputes where the material
facts are not in dispute because policy interpretation is a question of law for the
court. Jones v. Utica Mut. Ins., 463 So. 2d 1153, 1157 (Fla. 1985).
> Had UIM coverage been purchased by Chubb, the ACE policy would have a
Florida UIM policy endorsement. For example, the policy provided UIM coverage
in Nebraska, as reflected by Policy Form CA 21 70 10 13. (See Ex. A, Pgs. A260-
64.)
* Count II was dismissed with prejudice.
Page 5 of 10For choice of law, Florida follows the lex loci contractus doctrine to
interpret an insurance policy. State Farm Mut. v. Roach, 945 So. 2d 1160, 1163,
1164 (Fla. 2006). The policy is decided by the law of the state where it was issued
and delivered. In this case, the ACE policy was issued and delivered to Chubb in
Pennsylvania. Accordingly, the policy must be interpreted under Pennsylvania law.
Any question regarding § 627.727, a Florida statute, will be decided under Florida
law. See Bedoya v. Travelers Prop., 773 F. Supp. 2d 1326, 1328 (M.D. Fla. 2011).
I. IT_ IS UNDISPUTED THAT UM/UIM WAS FULLY REJECTED IN
FLORIDA. ACE IS ENTITLED TO SUMMARY JUDGMENT.
Section 627.727 of Florida Statutes requires that all auto insurance policies
that provide liability coverage for bodily injury in Florida offer UIM coverage.
An insured may reject that coverage. That rejection creates a “conclusive
presumption” that the policy does not provide UIM coverage. Jackson v. State
Farm Fire & Cas., 469 So. 2d 191, 193 (Fla. 2d DCA 1985) (holding that “[u]nder
this statutory plan we believe that an insurer, by presenting evidence of such
a written rejection, prima facie establish that no uninsured motorist coverage
applies”).
In this case, it is undisputed UIM coverage in Florida was rejected by
the UIM Rejection Form. This fact is uncontroverted. ACE is accordingly entitled
to the “conclusive presumption” that there is no UIM coverage in Florida.
Page 6 of 10Every case that has considered this simple proposition has reached the same
conclusion: there is no UIM coverage. See Mitleider v. Brier Grieves Agency, Inc.,
53 So. 3d 410, 412 (Fla. 4th DCA 2011) (“The conclusive presumption of the
statute forestalls appellant’s claim that he was not offered or informed of uninsured
motorist coverage.”); Larusso v. Garner, 888 So. 2d 712, 718 (Fla. 4th DCA
2004) (“as a matter of law, [the insurer] was entitled to the statutory conclusive
presumption that [the insured]’s rejection of stacked coverage was knowingly
made”); Liberty Mut. Ins. Co. v. Ledford, 729 So. 2d 426, 428 (Fla. 2d DCA 1999)
(automobile insurer was entitled to conclusive statutory presumption arising from
the named insured’s signature on a form rejecting UIM coverage); Continental Ins.
Co. v. Roth, 388 So. 2d 617, 618 (father’s rejection of uninsured motorist coverage
was binding on insured son, even though son was also included as a named insured
on the policy).
The decision in Bessman v. Travelers Prop. Cas. Co., 773 F. Supp. 2d 1270
(N.D. Fla. 2011) is particularly instructive because it is factually similar. The first
named insured appointed a risk manager that was responsible for managing its
insurance. The risk manager rejected UIM coverage on the named insured’s
behalf. Since the risk manager had authority to execute the UIM rejection,
there was a knowing rejection that eliminated UIM coverage under the policy for
all insureds. In clear language, the district court held:
Page 7 of 10Because [the risk manager] plainly had authority to act on [the
named insured]’s behalf in signing the UM/UIM selection form, a
presumption arises that [the named insured] made an informed,
knowing rejection of UM/UIM coverage. ... As a result, the court
finds that there is no genuine issue of material fact and that [the
insurer] is entitled to summary judgment as a matter of law.
Td. at 1272.
Like Bessman and dozens of other cases enforcing the Legislature’s intent
under § 627.727, the UIM Rejection Form establishes UIM coverage was rejected
in Florida. Richards does not, and cannot, offer any evidence to the contrary. ACE
is entitled to judgment in its favor as a matter of law. See, e.g., Maxwell v. U.S.
Fid. & Guar., 399 So. 2d 1051, 1056-57 (Fla. Ist DCA 1981) (Ervin, J., specially
concurring) (“Florida cases ... construing Section 627.727, have uniformly held
that if the named insured rejects UM coverage at the inception of the policy period,
the additional insured must be considered bound by such rejection.”).
II. THERE IS NO MEDICAL PAYMENTS COVERAGE BECAUSE
RICHARDS WAS NOT RIDING IN A COVERED AUTO.
In Count III, Richards seeks Medical Payments coverage. For that coverage
0
to apply, however, the vehicle must be a “covered ‘auto’” as defined in the policy.
In pertinent part, the policy provides:
SECTION I—- COVERED AUTOS
Items Two of the Declarations shows the “autos” that are covered
“autos” for reach of your coverages. The following numerical symbols
describe the “autos” that may be covered “autos”. The symbols
Page 8 of 10entered next to a coverage on the Declarations designate the only
“autos” that are covered “autos”.
(Ex. A at Pg. A053.) The symbol next to the “Medical Payments” coverage is “2”
which is defined as:
Only those “autos” you own (and for Covered Autos Liability
Coverage any “trailers” you don’t own while attached to power units
you own). This includes those “autos” you acquire ownership of after
the policy begins.
(Ud. at Pgs. A039, A053.) The term “you” is defined as “the Named Insured shown
in the Declarations.” (/d. at Pg. A053.) The Named Insured in the Declarations is
“Chubb Group Holdings, Inc.” (/d. at Pg. A038.)
Pennsylvania law, Florida law, and every other state’s law is clear that, with
regard to “covered auto” policies, there is only Medical Payments coverage if the
insured is in a covered auto. See, e.g., Royal Indem. Co. v. Adams, 455 A.2d 135,
139 (Sup. Ct. Pa. 1983) (holding medical payments coverage “is dependent on
occupancy of the covered auto); Govt. Employees Ins. Co. v. Sweet, 186 So. 2d 95,
96-97 (Fla. 4th DCA 1966) (holding medical payments coverage is dependent on
occupancy of covered auto).
Richards was injured in a 2015 Toyota Prius. The vehicle was owned by
Alvaro Planchart. (Ex. G, Pg. 5; Ex. H, No. 2.) It was not owned by Chubb. (Ex. H,
No. 3.) Because the vehicle was not owned by “the Named Insured shown in the
Declarations” (i.e., Chubb), the vehicle is not a “covered auto” for Medical
Page 9 of 10Payments coverage. ACE is accordingly entitled to judgment in its favor on Count
IIT as a matter of law.°
CONCLUSION
This action should not have ever been filed. Richards’s claim is completely
meritless. ACE is entitled to final summary judgment as a matter of law.
Respectfully submitted,
/s/SINA BAHADORAN
SINA BAHADORAN
Florida Bar No. 523364
sina.bahadoran@clydeco.us
AARON L. WARREN
Florida Bar No. 96162
aaron.warren@clydeco.us
Clyde & Co US LLP
1221 Brickell Avenue, Suite 1600
Miami, Florida 33131
T: 305.446.2646
CERTIFICATE OF SERVICE
I CERTIFY that on December 3, 2019 this document was electronically
served via the Florida Courts E-Filings portal to all parties.
/s/AARON WARREN
Aaron L. Warren
> For this same reason, Richards does not qualify as an “insured” under the
Medical Payments coverage. Since it is undisputed that Richards was not
occupying a “covered auto,” he is not an “insured” for purposes of Medical
Payments coverage. (See Ex. A, Pg. A086.)
Page 10 of 10EXHIBIT
ACHUBE
LEAD SHEET
FOR:
LOCKTON COMPANIES LLC
RUN DATE: 11/10/2016
POLICY NUMBER: ISA H09052082
ID: ZO2COLS1
RUN BY: ACEINA\STCOLE
PAGES OF THIS COPY: 0510
INSURED'S NAME
Chubb Group Holdings Inc.
AOOlPOLICY NUMBER: ISA H09052082
CHUBB
Policyholder Notice
Commercial Lines Deregulation
New York
NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE
EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK
INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND
RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK
INSURANCE LAW AND REGULATIONS.
CLASS CODE 2-14057
ALL-23445b (07/13) Page 1 of 1
A002POLICY NUMBER: ISA H09052082
CHUBB Arkansas
Notice To Policyholders
QUESTIONS ABOUT YOUR INSURANCE?
If you have questions about your insurance, need coverage information, or require assistance in resolving complaints, do
not hesitate to contact either your insurance agent, or Chubb, Customer Service Department, 436 Walnut Street,
Philadelphia, PA 19106-3703, telephone 1-800-352-4462.
If we fail to provide you with reasonable and adequate service, you should feel free to contact:
Arkansas Insurance Department
1200 West Third Street
Little Rock, AR 72201
(501) 371-2640 or 800-852-5494
ALL-2Y31b (11/09) Page 1 of 1
A003POLICY NUMBER: ISA H09052082
ILN 119 1015
CALIFORNIA AUTO BODY REPAIR CONSUMER BILL OF
RIGHTS
(This form was developed by the California Department of Insurance.)
ACONSUMER IS ENTITLED TO:
4. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE
INSURANCE COMPANY. AN INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE
DONE AT A SPECIFIC AUTO BODY REPAIR SHOP.
2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF
REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED
LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE
ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET,
RECONDITIONED, OR REBUILT.
3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES.
4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL
VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED.
5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND
CONCERNS ABOUT AUTO BODY REPAIRS.
6. SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED AUTO
BODY REPAIR SHOP FOR REPAIR OF A DAMAGED VEHICLE, EVEN WHEN PURSUING AN
INSURANCE CLAIM FOR REPAIR OF THE VEHICLE.
COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR
Complaints concerning the repair of a vehicle by an auto body repair shop should be directed to:
Toll Free (866) 799-3811
Bureau of Automotive Repair
10949 North Mather Blvd.
Rancho Cordova, CA 95670
The Bureau of Automotive Repair can also accept complaints over its web site at: www.autorepair.ca.gov.
COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER
Any concerns regarding how an auto insurance claim is being handled should be submitted to the California
Department of Insurance at:
(800) 927-4357 or (213) 897-8921
California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
The California Department of Insurance can also accept complaints over its web site at: www. insurance.ca.gov.
IL N 119 10 15 © Insurance Services Office, Inc., 2015 Page 1 of 1
A004POLICY NUMBER: ISA H09052082 ILN 118 01 10
CALIFORNIA AUTOMOTIVE REPAIR DEALER
RECOMMENDATION NOTICE
Claimant:
Company:
WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE
REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE
COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR
DAMAGED VEHICLE. WE RECOMMEND YOU CONTACT ANY OTHER AUTOMOTIVE REPAIR DEALER YOU
ARE CONSIDERING TO CLARIFY ANY QUESTIONS YOU MAY HAVE REGARDING SERVICES AND
BENEFITS. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE
THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL
COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY
LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US
IMMEDIATELY FOR ASSISTANCE.
IL N 118 01 10 © Insurance Services Office, Inc., 2009 Page 1 of 1
A005POLICY NUMBER: ISA H09052082
CHUBB
Chubb Producer Compensation
Practices & Policies
Chubb believes that policyholders should have access to information about Chubb's practices and policies
related to the payment of compensation to brokers and independent agents. You can obtain that information
by accessing our website at http://www.chubbproducercompensation.com or by calling the following toll-free
telephone number: 1-866-512-2862.
ALL-20887 (10/06) Page 1 of 1
A006POLICY NUMBER: ISA H09052082
COLORADO FRAUD STATEMENT
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to
defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado division of insurance within the department of regulatory agencies.
ALL-22368 (06/07) © ISO Properties, Inc., 2004 Page 1 of 1
A007POLICY NUMBER: ISA H09052082
CHUBE
Georgia Notice
The laws of the State of Georgia prohibit insurers from unfairly discriminating against any
person based upon his or her status as a victim of family violence.
ALL-8Z41 (7/2000)
A008
Page 1 of 1POLICY NUMBER: ISA H09052082 ILN 175 11 11
ILLINOIS NOTICE TO POLICYHOLDERS
REGARDING THE RELIGIOUS FREEDOM
PROTECTION AND CIVIL UNION ACT
Dear Policyholder:
This is to provide notice that, pursuant to Illinois Department of Insurance Company Bulletin 2011-06 (CB 2011-06), this
policy is in compliance with the Illinois Religious Freedom Protection and Civil Union Act (“the Act”, 750 ILL. COMP.
STAT. 75/1). The Act, which became effective on June 1, 2011, creates a legal relationship between two persons of either
the same or opposite sex who establish a civil union.
The Act provides that parties to a civil union are entitled to the same legal obligations, responsibilities, protections and
benefits that are afforded or recognized by the law of Illinois to spouses, whether they are derived from statute,
administrative rule, policy, common law or any source of civil or criminal law. In addition, this law requires recognition of a
same-sex civil union, marriage, or other substantially similar legal relationship, except for common law marriage, legally
entered into in other jurisdictions. The Act further provides that “party to a civil union” shall be included in any definition or
use of the terms “spouse”, “family”, “immediate family”, “dependent”, “next of kin” and other terms descriptive of spousal
relationships as those terms are used throughout the law. According to CB 2011-06, this includes the terms “marriage” or
“married” or any variations thereof. CB 2011-06 also states that if policies of insurance provide coverage for children, the
children of civil unions must also be provided coverage.
ILN 175 11 11 © Insurance Services Office, Inc., 2011 Page 1 of 1
A009POLICY NUMBER: ISA H09052082
CHUBE
Important Information to
Idaho Policyholders
Regarding Your Insurance
In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was
involved in the sale of this insurance, or if you have additional questions you may contact the insurance company issuing
this insurance at the following address and telephone number
If you have been unable to contact or
Department of Insurance at:
Chubb Companies
Customer Support Service Department
436 Walnut Street
PO Box 1000
Philadelphia, PA 19106-3703
1-800-352-4462
obtain satisfaction from the company or the agent, you may contact the Idaho
Idaho Department of Insurance
Consumer Affairs
700 W. State Street, 3'¢ Floor
PO Box 83720
Boise, ID 83720-0043
1-800-721-3272 or www.DOI.Idaho.gov
Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company
or the Idaho Department of Insurance, have your policy number available.
ALL-30152 (07/10) Printed in U.S.A.
Page 1 of 1
A010POLICY NUMBER: ISA H09052082
CHUBE’ Important Information to
Virginia Policyholders
Regarding Your Insurance
In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was
involved in the sale of this insurance, or if you have additional questions you may contact the insurance company issuing
this insurance at the following address and telephone number
Chubb Companies
Customer Support Service Department
436 Walnut Street
PO Box 1000
Philadelphia, PA 19106-3703
1-800-352-4462
If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia
State Corporation Commission's Bureau of Insurance at:
1300 East Main Street
Tyler Building
Richmond, VA 23219
Consumer Hot Line: 1-800-552-7945
Bureau of Insurance: 804-371-9185
Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company
or the Bureau of Insurance, have your policy number available.
ALL-7X47a (2/08) Printed in U.S.A. Page 1 of 1
AOIPOLICY NUMBER: ISA H09052082
CHUBE Important Message to Our
Pennsylvania Auto Insurance
Policyholders
NOTICE APPLIES TO AUTOS REGISTERED OR PRINCIPALLY GARAGED IN PA.
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any
false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and
payment of a fine of up to $15,000.
DA-1K19 Ptd. in U.S.A. Page 1 of 1
A012POLICY NUMBER: ISA H09052082
CHUBR
Important Notice - Wisconsin
Wisconsin law requires us to notify you that, if you cancel this policy prior to its expiration date, the terms and
conditions of your policy may require that you pay a substantial penalty.
ALL-38969 (08/12) Page 1 of 1
A013POLICY NUMBER: ISA H09052082
CHUBRE Important Notice To
Our Connecticut Policyholders
This is a description of coverage provided in your policy for damage to a rental vehicle. No coverage is provided by this
description, and it does not replace any provisions of your policy. You should read your policy and review your
Declarations page for complete information on the coverage you are provided. If there is any conflict between the policy
and this description, the provisions of the policy apply.
Under Section Il -- LIABILITY COVERAGE of the Commercial Auto Coverage Forms (CACF), there is no coverage for
damage to a rental vehicle.
Under the Commercial Auto Coverage Forms (CACF), physical damage coverage can be provided for rental vehicles
through an entry in the Schedule of Hired or Borrowed Covered Autos Coverage and Premiums of the CACF
Declarations. This will designate any hired or borrowed car to be a "covered auto."
Endorsement CA 20 01 (Additional Insured - Lessor), which should be used when an auto is leased or rented from a
standard leasing concern, can provide physical damage coverage by changing any leased autos designated in the
schedule of the form "covered autos you own" (while also providing physical damage coverage for the leasing concern).
In addition, Endorsement CA 99 10 (Drive Other Car Coverage - Broadened Coverage For Named Individuals) provides
that any private passenger type auto rented by an employee named in the endorsement will be considered a covered auto
for physical damage coverage.
The limit of liability for this coverage, subject to any applicable deductible shown in the declarations, will be the lesser of:
4. The actual cash value of the vehicle; or
2. The amount necessary to repair or replace the rental vehicle.
DA-3E53a (Ed. 8/02) Ptd. in U.S.A. Page 1 of 1
A014POLICY NUMBER: ISA H09052082
CHUBRE Important Notice To Our
Oregon Policyholders
Oregon law requires we advise policyholders of the RIGHTS AND RESPONSIBILITIES of the insured when submitting a
claim covered by the policy for damage to the insured's vehicle.
The insured must give the company or one of our agents written notice of the accident or loss as soon as reasonably
possible.
When there is a loss covered by the policy, the insured shall:
= make a prompt report to the police when the loss is the result of theft or larceny.
"= protect the damaged vehicle -- we will pay any reasonable expense to do so.
= Show us the damage if we ask.
The insured shall cooperate with the company.
The insured has the right to receive the reasonable cost of repairs for claims covered by the policy.
Oregon law states:
An insurer shall not require that a particular person make the repairs to the insured's motor vehicle as a condition for
recovery by the insured under a motor vehicle liability insurance policy.
The policy contract contains the complete statement of rights and responsibilities of both the insured and the company.
DA-9T21 (Ed. 7/93) Ptd. in U.S.A. Page 1 of 1
AOI5POLICY NUMBER: ISA H09052082
CHUBB Indiana
Notice to Policyholders
We are here to serve you....
As our policyholder, your satisfaction is very important to us. If you have a
question about your policy, if you need assistance with a problem, or if you
have a claim, you should first contact your insurance agent.
If you are unable to reach your agent, or if you wish to contact us directly,
please call our Customer Services Department at 1-800-352-4462. Should
you have a valid claim, we fully expect to provide a fair settlement in a
timely fashion.
Should you feel you are not being treated fairly with respect to a claim, you
may also contact the Indiana Department of Insurance with your complaint.
To contact the Department, write or call:
Consumer Services Division
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis, IN 46204-2787
317-232-2395 or 1-800-622-4461
Complaints can be filed electronically at www.in.gov/idoi
ALL-2Y81 (05/14) Page 1 of 1
A016POLICY NUMBER: ISA H09052082
ILN 043 01 16
KANSAS FRAUD STATEMENT
Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines
and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and
with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be
presented to or by an insurer, purported insurer or insurance agent or broker, any written, electronic, electronic
impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an
application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an
insurance policy, which such person knows to contain materially false information concerning any material fact
thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.
IL N 043 01 16 © Insurance Services Office, Inc., 2015 Page 1 of 1
AOI7POLICY NUMBER: ISA H09052082
CHUBE MARYLAND
NOTICE OF UNDERWRITING PERIOD
We are notifying you that the binder or policy you have just agreed to purchase may provide
you with only temporary coverage, since Maryland law provides the company with a 45 day
period, from the effective date of your coverage, to confirm that you are eligible for coverage
under this policy.
Should the company find that you are not eligible for this coverage, we will send you a written
Notice of Cancellation advising you of the reason(s) that you do not qualify for coverage and
the date on which your policy will be cancelled.
ALL-38711 (08/12) Page 1 of 1
A018MASSACHUSETTS COMPULSORY PREMIUM POLICYHOLDER NOTICE
Named Insured Chubb Group Holdings Inc. Endorsement Number
Policy Symbol | Policy Number Policy Period Effective Date of Endorsement
ISA 09052082 41/02/2016 To 11/02/2017
issued By (Name of Insurance Company)
ACE American Insurance Company
insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
The premium for your compulsory coverage is included in the premium shown on the
Declarations page of your policy. In addition, the limits of insurance for your compulsory
coverages are included in, and not in addition to, the limits of insurance shown on the
Declarations page of your policy.
All other terms and conditions remain unchanged.
Authorized Agent
DA-18607 07/2005 Page 1 of 1
A019POLICY NUMBER: ISA H09052082
: Minnesota Policyholder
CHUBB Notice Of Election To Have Two
Or More Autos Added Together
Pursuant to Section 65B.47, subdivision 7, of the Minnesota statutes, you may make a specific election to have
the limits of liability for basic economic loss benefits added together for two or more motor vehicles under your
automobile insurance policy to determine the limit of insurance coverage available to an injured person for any
one accident. Unless you make such an election, the limit of liability for basic economic loss benefits for two or
more motor vehicles may not be added together to determine the limit of insurance coverage available to an
injured person for any one accident.
If you wish to elect to have the limits of liability for basic economic loss benefits for two or more motor vehicles
added together, please notify your insurance representative. You may be charged an additional premium for such
additional coverage.
DA-410714 (09/13) Page 1 of 1
A020POLICY NUMBER: ISA H09052082 ILN 002 11 10
NEW YORK RENTAL REIMBURSEMENT COVERAGE
DISCLOSURE
YOU HAVE THE RIGHT, PURSUANT TO N.Y. INS. LAW § 2610-A, TO CHOOSE ANY RENTAL VEHICLE COMPANY,
RENTAL VEHICLE COMPANY LOCATION OR A PARTICULAR CONCERN IN THE EVENT YOU UTILIZE RENTAL
REIMBURSEMENT COVERAGE.
IL N 002 11 10 © Insurance Services Office, Inc., 2010 Page 1 of 1
A021POLICY NUMBER: ISA H09052082
NOTICE TO ALL OKLAHOMA POLICYHOLDERS
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false, incomplete or
misleading information is guilty of a felony.
You are insured by the Company listed on the Signature page which is named on the first page of the
Declarations of this policy. It is a Chubb company and has its principal office at 436 Walnut Street, PO Box
1000, Philadelphia, PA 19106-3703.
ALL-2U78b (2/06) Ptd. in U.S. A. Page 1 of 1
A022POLICY NUMBER: ISA H09052082
CHUBB’ Notice To Our Florida
Property And Casualty Policyholders
Guidelines For Loss Control Plans
Florida law requires us to inform you that we have developed guidelines for risk management plan which are available to
you at no cost. The guidelines consist of the following:
A. A booklet entitled “Establishing an Effective Loss Control Program.” This booklet describes various loss control
procedures that can help you in your selection and implementation of actions that eliminate or reduce the frequency
and severity of your losses.
B. A self inspection checklist that is tailored for your business and when used in inspections it may be of assistance to
you in the identification of conditions which could be responsible for losses.
Should you require further help in developing and implementing an effective loss control program, other loss control
services are also available to you for an additional charge. The following services are available from Chubb Loss Control
Services:
A. Loss control management consultation. Through a visit to your facility we will assist you in identifying loss causing
conditions, evaluating your loss prevention methods, and recommending loss control enhancements.
B. Training loss control management techniques. This training supports our consulting and is intended to assist you in
the implementation of your loss control procedures. The training can be provided to you or your employees.
To obtain either the free guidelines for loss control plans or information on additional loss control services, please
complete the section below and send it to:
National Manager, Jurisdictional Services
Chubb Risk Control Services
P.O. Box 1000
Philadelphia, PA 19105-1000
Tel: 866-357-3797
ALL-39822 (04/13) Page 1 of 2
A023| Send me the free guidelines for the loss control plans
LO Send me information on how | can obtain additional loss control services
Business Operation:
Company Name:
Street Address:
City: State: Zip Code:
Telephone: Policy No:
Person to contact: Title:
Signature
ALL-39822 (04/13)
A024
Page 2 of 2POLICY NUMBER: 1SA H09052082
CHUBE Notice To Our New York
Policyholders Optional Basic
Economic Loss Coverage
Dear Policyholder or Applicant:
Optional Basic Economic Loss (OBEL) coverage is being offered to you as an enhancement of the Basic No-
Fault coverage you are presently required to purchase. But before we describe this coverage, we would like to
advise you what benefits Basic No-Fault coverage does and does not provide.
No-Fault coverage, otherwise known as Personal Injury Protection or “PIP” coverage, pays for expenses
incurred by persons injured in a motor vehicle accident. This coverage does not pay to repair damages to your
automobile.
Basic No-Fault, which you are required by law to purchase, provides coverage of up to $50,000 per person in
benefits for:
1. all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee
schedules established or adopted by the New York State Department of Financial Services; and
2. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date
of accident; and
3. up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary
expenses the injured person may have incurred because of an injury resulting from the accident, such as
the cost of hiring a housekeeper or necessary transportation expenses to and from a health service
provider; and
4. a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for
economic loss described above.
No-Fault benefits will be reduced by other benefits that are payable under Workers’ Compensation, Social
Security Disability, New York State Disability, and certain employer “wage continuation” plans where an
employee does not lose any future sick leave benefits.
OPTIONAL COVERAGE AVAILABLE
In addition to Basic No-Fault Coverage, you may also purchase OBEL coverage that will pay certain expenses,
up to $25,000, above the Basic No-Fault limit of $50,000. OBEL coverage is different from other coverages in
that a claimant can select the kinds of benefits to be paid under OBEL.
If you purchase OBEL coverage and if it appears likely that a claimant will use up the Basic No-Fault coverage,
your insurer will send the claimant a form for the claimant to choose what expenses the $25,000 in OBEL
coverage will be used to pay. Under No-Fault, a claimant could include you, family members, passengers in
your car, or pedestrians, if injured in an auto accident.
DA-3H93b (06/13) Page 1 of 2
A025The claimant will be able to choose one of the following four OBEL options and thereby direct the insured to pay
expenses for:
1. basic economic loss, whether health care expenses, loss of earnings from work, or other reasonable and
necessary expenses;
2. loss of earnings from work;
3. psychiatric, physical or occupational therapy and rehabilitation; or
4. acombination of options 2 and 3.
The additional $25,000 of OBEL coverage will be used only for costs incurred under the chosen option, which,
once selected, the claimant cannot change.
If you have any questions, please contact your company or agent.
DA-3H93b (06/13) Page 2 of 2
A026POLICY NUMBER: ISA H09052082
CHUBE Notice To Our Texas Policyholders -
Automobile Theft Prevention
Authority Pass Through Fee
NOTICE: A fee of $ is payable in addition to the policy premium due under this policy.
This fee partially or completely reimburses the insurer, as permitted by 28 TAC 5.205, for the $2.00 fee per motor
vehicle year required to be paid to the Automobile Burglary and Theft Prevention Authority under Vernon's
Annotated Revised civil Statutes of the State of Texas , Article 4413 (37), 10, which became effective on
September 1, 2011 .
DA-8S7 1b (09/13) Page 1 of 1
A027POLICY NUMBER: ISA H09052082
COMPANY: ACE American Insurance Company
NOTICE TO POLICYHOLDER
Named Driver Exclusion- State of Michigan
Warning- when a named excluded person operates a vehicle all liability coverage is void- no one is insured.
Owners of the vehicle and others legally responsible for the acts of the named excluded person remain fully
personally liable.
In addition, a named excluded driver is not entitled to be paid personal protection benefits for accidental bodily
injury if at the time of the accident the named excluded driver was operating a motor vehicle or motorcycle as to
which he or she was named as the excluded driver.
DA-46822 (09/15) Page 1 of 1
A028POLICY NUMBER: ISA H09052082
POLICYHOLDER NOTICE — OHIO
WARNING: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
ALL-SWO06 (7/95) Page 1 of 1
A029POLICY NUMBER: ISA H09052082
CHUBE
QUESTIONS ABOUT YOUR INSURANCE?
Answers to questions about your insurance, coverage information, or assistance in resolving complaints
can be obtained by contacting:
Chubb Customer Support Services Department:
436 Walnut Street
Philadelphia, Pennsylvania 19106-3703
Telephone Number: 1-800-352-4462
Email: ChubbUSCustomerServices@chubb.com
The Illinois Department of Insurance may also be contacted for assistance. Insurance
analysts are available to answer general questions by phone at our toll-free Consumer
Assistance Hotline (866) 445-5364. However, complaints must be submitted in writing.
How to file a complaint with the Insurance Department:
Complaints may be submitted in the following ways:
+ On-line at
https://insurance. illinois.gov/applications/ComplaintF orms/default.aspx
and by following the instructions posted.
«By fax: (217) 558-2083
« By email at consumer_complaints@ins.state.il.us
« By mail: 320 W. Washington St. Springfield, IL 62767 or 122 S. Michigan
Ave., 19th Floor, Chicago, Illinois 60603
ALL-18653d (07/14) Page 1 of 1
A030POLICY NUMBER: ISA H09052082
CHUBE
Questions About Your Insurance?
Answers to questions about your insurance, coverage information, or assistance in resolving
complaints can be obtained by calling Chubb, Customer Support Service Department, at
1-800-352-4462.
ALL-5X45 (11/96) Ptd. in U.S.A.
A031
Page 1 of 1POLICY NUMBER: ISA H09052082
CHUBhRe Chubb Phone: 1.866.357.3797
Risk Control Services Fax: 215.640.5084
436 Walnut Street
Philadelphia, PA 19106-3703 www.chubb.com
National Manager, Jurisdictional Services
RE: RISK CONTROL SERVICES FOR TEXAS POLICYHOLDERS.
Commercial Automobile Liability, General Liability, Professional Liability, and Medical
Professional Liability (other than Hospitals)
The Chubb Companies are required by Texas law and regulations to maintain or provide accident prevention services for
its commercial automobile, general liability and professional liability policyholders. The Chubb Companies offer an array of
accident prevention services in Texas at no additional charge. These services are intended to help prevent and/or
minimize loss.
These services include but are not limited to: individual risk surveys; improvement recommendations; loss investigation;
specific loss problem identification and recommended improvement actions.
Chubb may recommend one or more of these services based upon hazard, experience, and size of your Texas
operations. You have the choice of receiving or declining any of the services offered. If you wish to decline all of the
services or wish to receive only selected risk control service, please indicate that by signing and dating this letter in the
space provided below. Please mail or fax to the captioned address or fax number. If you decline all of Chubb's risk control
services or choose only a support service, such as ergonomics survey,. driving training, or other services and not a
complete risk survey, we still have a responsibility under Texas law and regulation to monitor your losses. In the event you
start to have a loss problem and a trend is established, and/or adverse loss ratio is developed, we will contact you and
offer to assist you in addressing the situation.
Sincerely,
National Manager, Jurisdictional & Regulatory Services
Chubb Risk Control Services
436 Walnut Street, Philadelphia, PA 19106-3703
or call toll free at: 1-866-357-3797
(1) 1am aware of the loss control services offered and decline them. I have made other arrangements for these
services.
[|__| wish to obtain the following offered accident prevention services:
(1 Ihave no risk control services needs now. I reserve the right to request loss control services within the
period.
(Signature) (Phone #) (Date)
Print Name: Policy #
Company Name:
Address:
City, State, Zip:
One of the Chubb Group of Insurance Companies
This Company has undertaken a survey of your premises, equipment, or operations (whichever is pertinent to the type of insurance applied
for or provided) for the purpose of supporting the functions of risk underwriting. Any recommendations or information provided is not
intended as a substitute for advice from a safety expert or legal counsel you may retain for your own purposes. It is not intended to supplant
any legal duty you may have to provide a safe premises, workplace, product or operation.
ALL-11559d (10/07) Page 1 of 1
A032POLICY NUMBER: ISA H09052082
STATE OF NEW HAMPSHIRE
UNINSURED MOTORISTS POLICYHOLDER NOTICE
Notwithstanding any other provision or endorsement of this policy, pursuant to Section 264.15 of the New
Hampshire Revised Statutes, it is understood that in the event of insolvency on the part of the liability insurer
which prevents the insurer from paying the legal liability of its insured within the limits of the coverage provided,
and no other insurance applies, Uninsured Motorists Coverage shall provide for no less than $25,000 coverage
for damage to or destruction of property in any one accident.
DA-39593 (01/13) Page 1 of 1
A033POLICY NUMBER: ISA H09052082
CHUBB
IMPORTANT NOTICE
To obtain information or make a complaint:
You may call the Company's toll-free telephone number
for information or to make a complaint at:
1 (800) 352-4462
You may also write to the Company at:
Chubb
Customer Services
PO Box 1000
Philadelphia, PA 19106-3703
You may contact the Texas Department of Insurance to
obtain information on companies, coverages, rights or
complaints at:
1 (800) 252-3439
You may write the Texas Department of Insurance:
P. O. Box 149104
Austin, TX 78714-9104
Fax: (512) 490-1007
Web: www.tdi.texas.gov
E-mail: ConsumerProtection@tdi.texas.gov
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your premium or
about a claim, you should contact your agent or the
company first. If the dispute is not resolved, you may
contact the Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR POLICY:
This notice is for information only and does not become a
part or condition of the attached document.
ALL-4Y30f (06/15)
Texas Notice —
Information and Complaints
AVISO IMPORTANTE
Para obtener informaci6n o para presentar una queja:
Usted puede llamar al numero de teléfono gratuito de la
Compaiia para obtener informacién o para presentar una
queja al:
1 (800) 352-4462
Usted también puede escribir a la Compafiia:
Chubb
Customer Services
PO Box 1000
Philadelphia, PA 19106-3703
Usted puede comunicarse con el Departamento de
Seguros de Texas para obtener informacion sobre
compafiias, coberturas, derechos, o quejas al:
1 (800) 252-3439
Usted puede escribir al Departamento de Seguros de
Texas a:
P.O. Box 149104
Austin, TX 78714-9104
Fax: (512) 490-1007
Sitio web: www.tdi.texas.gov
E-mail: ConsumerProtection@tdi.texas.gov
DISPUTAS POR PRIMAS DE SEGUROS O
RECLAMACIONES:
Si tiene una disputa relacionada con su prima de seguro 0
con una reclamacion, usted debe comunicarse con el
agente o la compajfiia primero. Si la disputa no es
resuelta, usted puede comunicarse con el Departamento
de Seguros de Texas
ADJUNTE ESTE AVISO A SU POLIZA:
Este aviso es solamente para propésitos informativos y
no se convierte en parte o en condicién del documento
adjunto.
Page 1 of 1
A034POLICY NUMBER: ISA H09052082 IL P 001 01 04
U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN
ASSETS CONTROL ("OFAC")
ADVISORY NOTICE TO POLICYHOLDERS
No coverage is provided by this Policyholder Notice nor can it be construed to replace any provisions of your
policy. You should read your policy and review your Declarations page for complete information on the coverages
you are provided.
This Notice provides information concerning possible impact on your insurance coverage due to directives issued
by OFAC. Please read this Notice carefully.
The Office of Foreign Assets Control (OFAC) administers and enforces sanctions policy, based on Presidential
declarations of "national emergency". OFAC has identified and listed numerous:
@ Foreign agents;
@ Front organizations;
@ Terrorists;
© Terrorist organizations; and
@ Narcotics traffickers;
as "Specially Designated Nationals and Blocked Persons". This list can be located on the United States Treas-
ury's web site — http/Awww.treas.gov/ofac.
In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity
claiming the benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and
Blocked Person, as identified by OFAC, this insurance will be considered a blocked or frozen contract and all
provisions of this insurance are immediately subject to OFAC. When an insurance policy is considered to be such
a blocked or frozen contract, no payments nor premium refunds may be made without authorization from OFAC.
Other limitations on the premiums and payments also apply.
IL P 001 01 04 © ISO Properties, Inc., 2004 Page 1 of 1
A035POLICY NUMBER: ISA H09052082
CHUBB’ UNINSURED MOTORISTS/UNDERINSURED
MOTORIST COVERAGE SUMMARY
The following Limit of Insurance for Uninsured Motorists and Underinsured Motorists (when not included in
Uninsured Motorists Coverage) apply to Item 2 of the Declarations:
4. No Coverage is offered or provided for vehicles principally garaged or registered in the following states:
MI,OH,PR
2. You have rejected coverage in the following states and no Limit of Insurance is provided for vehicles
principally garaged or registered in these states:
AL,AK,AZ,AR,CA,CO,DE,FL,GA,HI,ID,IN,IA,KY,LA,MS,MT,NV,NM,OK,PA,TN,TX,UT,WA,WY
3. Limit of Insurance for vehicles principally garaged or registered in the following states will be the limit of
insurance you selected on the signed Uninsured and/or Underinsured Motorist selection/rejection form on file
with us:
All states not listed in items 1,2 or 4 of this form.
4. The policy limit for liability shall apply for vehicles principally garaged or registered in the state of NH.
DA-40002 (04/13) Page 1 of 1
A036POLICY NUMBER: ISA H09052082
CHUBE
Wisconsin Notice
To Policyholders
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS
PROBLEMS WITH YOUR INSURANCE? -- If you are having problems with your insurance company or agent, do not
hesitate to contact the insurance company or agent to resolve your problem.
Chubb
Customer Support Service Department
436 Walnut Street
PO Box 1000
Philadelphia, PA 19106-3703
1-800-352-4462
You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces
Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF
INSURANCE by contacting:
Office of the Commissioner of Insurance
Complaints Department
P.O. Box 7873
Madison, WI 53707-7873
1-800-236-8517
608-266-0103
ALL-5X51a (2/06) Printed in U.S.A
A037
Page 1 of 1CHUBB Business Auto Declarations)
ACE American Insurance Company
436 Walnut Street
Philadelphia PA 19106
\
POLICY NUMBER: ISA H09052082 EXPIRING POLICY NUMBER: ISA HO886505A
RENEWAL
Named Insured: Chubb Group Holdings Inc.
Address: 510 Walnut Street
Philadelphia PA 19106
Producer Number: 273613
Producer Name: LOCKTON COMPANIES LLC
Producer Address: 3280 PEACHTREE ROAD
SUITE 250
ATLANTA GA 30305
Form of Bus
Preview
Filing # 99697718 E-Filed 12/03/2019 11:46:58 AM IN THE CIRCUIT COURT OF THE 15TH JUDICIAL CIRCUIT IN AND FOR PALM BEACH COUNTY, FLORIDA TREVOR RICHARDS and NOVLAT RICHARDS, Plaintiffs, vs. Case No: 50-2017-CA-012343-XXXX-MB ACE AMERICAN INSURANCE COMPANY, Defendant. / ACE AMERICAN INSURANCE COMPANY’S MOTION FOR FINAL SUMMARY JUDGMENT AND INCORPORATED MEMORANDUM OF LAW ACE AMERICAN INSURANCE COMPANY (“ACE”), pursuant to Fla. R. Civ. P. 1.510(b), moves for final summary judgment against TREVOR RICHARDS (“Richards”), and states: INTRODUCTION This action is simple. ACE issued a national, commercial auto insurance policy to Chubb, as the first Named Insured. Chubb rejected UM/UIM coverage in Florida. There is simply no UM/UIM coverage available to Richards as a matter of law. Richards’s claim for Medical Payments also fails. The Medical Payments coverage applies only to “covered autos,” which is defined as autos owned by *** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 12/03/2019 11:46:58 AM ***Chubb. At the time of the accident, Richards was in an auto that was not owned by Chubb. Consequently, there is no Medical Payments coverage available to Richards as a matter of law. ACE respectfully submits this entire action is wholly without merit, and that the Court should enter final summary judgment for ACE. STATEMENT OF UNDISPUTED FACTS THE ACE POLICY lL. ACE issued a multi-state, commercial automobile insurance policy to Chubb Group Holdings, Inc. (“Chubb”), as the first Named Insured. The policy is attached as Exhibit “A.”! 2. As the first Named Insured, Chubb was authorized to act and did act on behalf of all other insureds under the policy. (/d.) REJECTION OF UM/UIM COVERAGE IN FLORIDA 3. Chubb is a holding company. (Dep. of J. Canavan, Pg. 27:21-28:1, attached as Exhibit “B.”). 4. Chubb’s structure consists of a number of majority-owned subsidiaries. For example, ACE and Combined Insurance Company of America (“Combined”) are indirect subsidiaries of Chubb. (Ex. B, Pg. 26:1-4.) ' For ease of reference, the policy is numbered Pgs. A001 - A510. Page 2 of 105. Chubb appointed ACE to perform its risk management functions. (Ex. B, Pgs. 9:8-14, 13:3-11, 33:4-7.) 6. To that end, on 10/27/2016, ACE employee John “Jake” Canavan rejected UM/UIM coverage in Florida by executing a Florida Uninsured Motorist Selection Form (“UIM Rejection Form”). (Ex. B, Pgs. 15:10-13, 24:14-25:2, 40:8- 14.) 7. A copy of the UIM Rejection Form is attached as Exhibit “C.” 8. In pertinent part, the UIM Rejection Form provides: YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY. ... I reject Uninsured Motorists Coverage entirely. (Ex. C, Pgs. 2-3.) 9. The UIM Rejection Form was signed by Jake Canavan. (Aff., J. Canavan dated 4/9/2019, 93, attached as Exhibit “D.”) 10. The UIM Rejection Form is valid under Florida law. (Aff., S. Starnes, Florida Office of Insurance Regulation, attached as Exhibit “E.”)° 11. The UIM Rejection Form was signed knowingly. (Ex. D.) 12. The UIM Rejection Form was signed intentionally. (/d.) ? This language precisely tracks the specific language in Fla. Stat. § 627.727(1). Page 3 of 1013. The UIM Rejection Form was signed under authority from Chubb. (Id.) 14. The UIM Rejection Form was signed on behalf of all insureds, including Combined. (/d.) RICHARDS’S CLAIM: 15. On 4/25/2017, Richards was involved in an automobile accident with an underinsured vehicle in Florida. (Am. Compl., §98-9, attached as Exhibit “F.” See also Florida Traffic Crash Report, attached as Exhibit “G.”) 16. At the time of the accident, Richards was employed by Combined. (Ex. B, Pg. 25:13-16.) 17. At the time of the accident, Richards was in a vehicle that was owned by his co-worker, Alvaro Planchart. (ACE’s First Req. for Adm. to Richards, No. 2, attached as Exhibit “H.” See also, Ex. G, Pg. 5.) 18. The vehicle Richards was occupying was not owned by Chubb. (Ex. H, Nos. 3,4.) 19. Following the accident, Richards demanded ACE pay him UIM coverage and Medical Payments coverage. (Ex. F, 412.) Page 4 of 1020. ACE disclaimed UIM coverage because there is no UIM coverage in Florida under the policy.’ 21. ACE disclaimed Medical Payments coverage because the vehicle Richards was occupying is not a “‘covered auto.” RICHARDS’S LAWSUIT 22. On 11/18/2017, Trevor Richards and Novlat Richards filed this action against ACE and the underinsured driver. 23. The operative complaint includes three counts: Count I seeks UIM benefits for Trevor Richards; Count II seeks UIM benefits for loss of consortium for Novlat Richards:* and Count III seeks Medical Payments coverage for Trevor Richards. ARGUMENT AND CITATION OF AUTHORITY Standards of Inquiry Summary judgment is appropriate in coverage disputes where the material facts are not in dispute because policy interpretation is a question of law for the court. Jones v. Utica Mut. Ins., 463 So. 2d 1153, 1157 (Fla. 1985). > Had UIM coverage been purchased by Chubb, the ACE policy would have a Florida UIM policy endorsement. For example, the policy provided UIM coverage in Nebraska, as reflected by Policy Form CA 21 70 10 13. (See Ex. A, Pgs. A260- 64.) * Count II was dismissed with prejudice. Page 5 of 10For choice of law, Florida follows the lex loci contractus doctrine to interpret an insurance policy. State Farm Mut. v. Roach, 945 So. 2d 1160, 1163, 1164 (Fla. 2006). The policy is decided by the law of the state where it was issued and delivered. In this case, the ACE policy was issued and delivered to Chubb in Pennsylvania. Accordingly, the policy must be interpreted under Pennsylvania law. Any question regarding § 627.727, a Florida statute, will be decided under Florida law. See Bedoya v. Travelers Prop., 773 F. Supp. 2d 1326, 1328 (M.D. Fla. 2011). I. IT_ IS UNDISPUTED THAT UM/UIM WAS FULLY REJECTED IN FLORIDA. ACE IS ENTITLED TO SUMMARY JUDGMENT. Section 627.727 of Florida Statutes requires that all auto insurance policies that provide liability coverage for bodily injury in Florida offer UIM coverage. An insured may reject that coverage. That rejection creates a “conclusive presumption” that the policy does not provide UIM coverage. Jackson v. State Farm Fire & Cas., 469 So. 2d 191, 193 (Fla. 2d DCA 1985) (holding that “[u]nder this statutory plan we believe that an insurer, by presenting evidence of such a written rejection, prima facie establish that no uninsured motorist coverage applies”). In this case, it is undisputed UIM coverage in Florida was rejected by the UIM Rejection Form. This fact is uncontroverted. ACE is accordingly entitled to the “conclusive presumption” that there is no UIM coverage in Florida. Page 6 of 10Every case that has considered this simple proposition has reached the same conclusion: there is no UIM coverage. See Mitleider v. Brier Grieves Agency, Inc., 53 So. 3d 410, 412 (Fla. 4th DCA 2011) (“The conclusive presumption of the statute forestalls appellant’s claim that he was not offered or informed of uninsured motorist coverage.”); Larusso v. Garner, 888 So. 2d 712, 718 (Fla. 4th DCA 2004) (“as a matter of law, [the insurer] was entitled to the statutory conclusive presumption that [the insured]’s rejection of stacked coverage was knowingly made”); Liberty Mut. Ins. Co. v. Ledford, 729 So. 2d 426, 428 (Fla. 2d DCA 1999) (automobile insurer was entitled to conclusive statutory presumption arising from the named insured’s signature on a form rejecting UIM coverage); Continental Ins. Co. v. Roth, 388 So. 2d 617, 618 (father’s rejection of uninsured motorist coverage was binding on insured son, even though son was also included as a named insured on the policy). The decision in Bessman v. Travelers Prop. Cas. Co., 773 F. Supp. 2d 1270 (N.D. Fla. 2011) is particularly instructive because it is factually similar. The first named insured appointed a risk manager that was responsible for managing its insurance. The risk manager rejected UIM coverage on the named insured’s behalf. Since the risk manager had authority to execute the UIM rejection, there was a knowing rejection that eliminated UIM coverage under the policy for all insureds. In clear language, the district court held: Page 7 of 10Because [the risk manager] plainly had authority to act on [the named insured]’s behalf in signing the UM/UIM selection form, a presumption arises that [the named insured] made an informed, knowing rejection of UM/UIM coverage. ... As a result, the court finds that there is no genuine issue of material fact and that [the insurer] is entitled to summary judgment as a matter of law. Td. at 1272. Like Bessman and dozens of other cases enforcing the Legislature’s intent under § 627.727, the UIM Rejection Form establishes UIM coverage was rejected in Florida. Richards does not, and cannot, offer any evidence to the contrary. ACE is entitled to judgment in its favor as a matter of law. See, e.g., Maxwell v. U.S. Fid. & Guar., 399 So. 2d 1051, 1056-57 (Fla. Ist DCA 1981) (Ervin, J., specially concurring) (“Florida cases ... construing Section 627.727, have uniformly held that if the named insured rejects UM coverage at the inception of the policy period, the additional insured must be considered bound by such rejection.”). II. THERE IS NO MEDICAL PAYMENTS COVERAGE BECAUSE RICHARDS WAS NOT RIDING IN A COVERED AUTO. In Count III, Richards seeks Medical Payments coverage. For that coverage 0 to apply, however, the vehicle must be a “covered ‘auto’” as defined in the policy. In pertinent part, the policy provides: SECTION I—- COVERED AUTOS Items Two of the Declarations shows the “autos” that are covered “autos” for reach of your coverages. The following numerical symbols describe the “autos” that may be covered “autos”. The symbols Page 8 of 10entered next to a coverage on the Declarations designate the only “autos” that are covered “autos”. (Ex. A at Pg. A053.) The symbol next to the “Medical Payments” coverage is “2” which is defined as: Only those “autos” you own (and for Covered Autos Liability Coverage any “trailers” you don’t own while attached to power units you own). This includes those “autos” you acquire ownership of after the policy begins. (Ud. at Pgs. A039, A053.) The term “you” is defined as “the Named Insured shown in the Declarations.” (/d. at Pg. A053.) The Named Insured in the Declarations is “Chubb Group Holdings, Inc.” (/d. at Pg. A038.) Pennsylvania law, Florida law, and every other state’s law is clear that, with regard to “covered auto” policies, there is only Medical Payments coverage if the insured is in a covered auto. See, e.g., Royal Indem. Co. v. Adams, 455 A.2d 135, 139 (Sup. Ct. Pa. 1983) (holding medical payments coverage “is dependent on occupancy of the covered auto); Govt. Employees Ins. Co. v. Sweet, 186 So. 2d 95, 96-97 (Fla. 4th DCA 1966) (holding medical payments coverage is dependent on occupancy of covered auto). Richards was injured in a 2015 Toyota Prius. The vehicle was owned by Alvaro Planchart. (Ex. G, Pg. 5; Ex. H, No. 2.) It was not owned by Chubb. (Ex. H, No. 3.) Because the vehicle was not owned by “the Named Insured shown in the Declarations” (i.e., Chubb), the vehicle is not a “covered auto” for Medical Page 9 of 10Payments coverage. ACE is accordingly entitled to judgment in its favor on Count IIT as a matter of law.° CONCLUSION This action should not have ever been filed. Richards’s claim is completely meritless. ACE is entitled to final summary judgment as a matter of law. Respectfully submitted, /s/SINA BAHADORAN SINA BAHADORAN Florida Bar No. 523364 sina.bahadoran@clydeco.us AARON L. WARREN Florida Bar No. 96162 aaron.warren@clydeco.us Clyde & Co US LLP 1221 Brickell Avenue, Suite 1600 Miami, Florida 33131 T: 305.446.2646 CERTIFICATE OF SERVICE I CERTIFY that on December 3, 2019 this document was electronically served via the Florida Courts E-Filings portal to all parties. /s/AARON WARREN Aaron L. Warren > For this same reason, Richards does not qualify as an “insured” under the Medical Payments coverage. Since it is undisputed that Richards was not occupying a “covered auto,” he is not an “insured” for purposes of Medical Payments coverage. (See Ex. A, Pg. A086.) Page 10 of 10EXHIBIT ACHUBE LEAD SHEET FOR: LOCKTON COMPANIES LLC RUN DATE: 11/10/2016 POLICY NUMBER: ISA H09052082 ID: ZO2COLS1 RUN BY: ACEINA\STCOLE PAGES OF THIS COPY: 0510 INSURED'S NAME Chubb Group Holdings Inc. AOOlPOLICY NUMBER: ISA H09052082 CHUBB Policyholder Notice Commercial Lines Deregulation New York NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. CLASS CODE 2-14057 ALL-23445b (07/13) Page 1 of 1 A002POLICY NUMBER: ISA H09052082 CHUBB Arkansas Notice To Policyholders QUESTIONS ABOUT YOUR INSURANCE? If you have questions about your insurance, need coverage information, or require assistance in resolving complaints, do not hesitate to contact either your insurance agent, or Chubb, Customer Service Department, 436 Walnut Street, Philadelphia, PA 19106-3703, telephone 1-800-352-4462. If we fail to provide you with reasonable and adequate service, you should feel free to contact: Arkansas Insurance Department 1200 West Third Street Little Rock, AR 72201 (501) 371-2640 or 800-852-5494 ALL-2Y31b (11/09) Page 1 of 1 A003POLICY NUMBER: ISA H09052082 ILN 119 1015 CALIFORNIA AUTO BODY REPAIR CONSUMER BILL OF RIGHTS (This form was developed by the California Department of Insurance.) ACONSUMER IS ENTITLED TO: 4. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP. 2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES. 4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. 5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS. 6. SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED AUTO BODY REPAIR SHOP FOR REPAIR OF A DAMAGED VEHICLE, EVEN WHEN PURSUING AN INSURANCE CLAIM FOR REPAIR OF THE VEHICLE. COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR Complaints concerning the repair of a vehicle by an auto body repair shop should be directed to: Toll Free (866) 799-3811 Bureau of Automotive Repair 10949 North Mather Blvd. Rancho Cordova, CA 95670 The Bureau of Automotive Repair can also accept complaints over its web site at: www.autorepair.ca.gov. COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER Any concerns regarding how an auto insurance claim is being handled should be submitted to the California Department of Insurance at: (800) 927-4357 or (213) 897-8921 California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 The California Department of Insurance can also accept complaints over its web site at: www. insurance.ca.gov. IL N 119 10 15 © Insurance Services Office, Inc., 2015 Page 1 of 1 A004POLICY NUMBER: ISA H09052082 ILN 118 01 10 CALIFORNIA AUTOMOTIVE REPAIR DEALER RECOMMENDATION NOTICE Claimant: Company: WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. WE RECOMMEND YOU CONTACT ANY OTHER AUTOMOTIVE REPAIR DEALER YOU ARE CONSIDERING TO CLARIFY ANY QUESTIONS YOU MAY HAVE REGARDING SERVICES AND BENEFITS. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. IL N 118 01 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 A005POLICY NUMBER: ISA H09052082 CHUBB Chubb Producer Compensation Practices & Policies Chubb believes that policyholders should have access to information about Chubb's practices and policies related to the payment of compensation to brokers and independent agents. You can obtain that information by accessing our website at http://www.chubbproducercompensation.com or by calling the following toll-free telephone number: 1-866-512-2862. ALL-20887 (10/06) Page 1 of 1 A006POLICY NUMBER: ISA H09052082 COLORADO FRAUD STATEMENT It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. ALL-22368 (06/07) © ISO Properties, Inc., 2004 Page 1 of 1 A007POLICY NUMBER: ISA H09052082 CHUBE Georgia Notice The laws of the State of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence. ALL-8Z41 (7/2000) A008 Page 1 of 1POLICY NUMBER: ISA H09052082 ILN 175 11 11 ILLINOIS NOTICE TO POLICYHOLDERS REGARDING THE RELIGIOUS FREEDOM PROTECTION AND CIVIL UNION ACT Dear Policyholder: This is to provide notice that, pursuant to Illinois Department of Insurance Company Bulletin 2011-06 (CB 2011-06), this policy is in compliance with the Illinois Religious Freedom Protection and Civil Union Act (“the Act”, 750 ILL. COMP. STAT. 75/1). The Act, which became effective on June 1, 2011, creates a legal relationship between two persons of either the same or opposite sex who establish a civil union. The Act provides that parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the law of Illinois to spouses, whether they are derived from statute, administrative rule, policy, common law or any source of civil or criminal law. In addition, this law requires recognition of a same-sex civil union, marriage, or other substantially similar legal relationship, except for common law marriage, legally entered into in other jurisdictions. The Act further provides that “party to a civil union” shall be included in any definition or use of the terms “spouse”, “family”, “immediate family”, “dependent”, “next of kin” and other terms descriptive of spousal relationships as those terms are used throughout the law. According to CB 2011-06, this includes the terms “marriage” or “married” or any variations thereof. CB 2011-06 also states that if policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. ILN 175 11 11 © Insurance Services Office, Inc., 2011 Page 1 of 1 A009POLICY NUMBER: ISA H09052082 CHUBE Important Information to Idaho Policyholders Regarding Your Insurance In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was involved in the sale of this insurance, or if you have additional questions you may contact the insurance company issuing this insurance at the following address and telephone number If you have been unable to contact or Department of Insurance at: Chubb Companies Customer Support Service Department 436 Walnut Street PO Box 1000 Philadelphia, PA 19106-3703 1-800-352-4462 obtain satisfaction from the company or the agent, you may contact the Idaho Idaho Department of Insurance Consumer Affairs 700 W. State Street, 3'¢ Floor PO Box 83720 Boise, ID 83720-0043 1-800-721-3272 or www.DOI.Idaho.gov Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or the Idaho Department of Insurance, have your policy number available. ALL-30152 (07/10) Printed in U.S.A. Page 1 of 1 A010POLICY NUMBER: ISA H09052082 CHUBE’ Important Information to Virginia Policyholders Regarding Your Insurance In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was involved in the sale of this insurance, or if you have additional questions you may contact the insurance company issuing this insurance at the following address and telephone number Chubb Companies Customer Support Service Department 436 Walnut Street PO Box 1000 Philadelphia, PA 19106-3703 1-800-352-4462 If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia State Corporation Commission's Bureau of Insurance at: 1300 East Main Street Tyler Building Richmond, VA 23219 Consumer Hot Line: 1-800-552-7945 Bureau of Insurance: 804-371-9185 Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or the Bureau of Insurance, have your policy number available. ALL-7X47a (2/08) Printed in U.S.A. Page 1 of 1 AOIPOLICY NUMBER: ISA H09052082 CHUBE Important Message to Our Pennsylvania Auto Insurance Policyholders NOTICE APPLIES TO AUTOS REGISTERED OR PRINCIPALLY GARAGED IN PA. Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000. DA-1K19 Ptd. in U.S.A. Page 1 of 1 A012POLICY NUMBER: ISA H09052082 CHUBR Important Notice - Wisconsin Wisconsin law requires us to notify you that, if you cancel this policy prior to its expiration date, the terms and conditions of your policy may require that you pay a substantial penalty. ALL-38969 (08/12) Page 1 of 1 A013POLICY NUMBER: ISA H09052082 CHUBRE Important Notice To Our Connecticut Policyholders This is a description of coverage provided in your policy for damage to a rental vehicle. No coverage is provided by this description, and it does not replace any provisions of your policy. You should read your policy and review your Declarations page for complete information on the coverage you are provided. If there is any conflict between the policy and this description, the provisions of the policy apply. Under Section Il -- LIABILITY COVERAGE of the Commercial Auto Coverage Forms (CACF), there is no coverage for damage to a rental vehicle. Under the Commercial Auto Coverage Forms (CACF), physical damage coverage can be provided for rental vehicles through an entry in the Schedule of Hired or Borrowed Covered Autos Coverage and Premiums of the CACF Declarations. This will designate any hired or borrowed car to be a "covered auto." Endorsement CA 20 01 (Additional Insured - Lessor), which should be used when an auto is leased or rented from a standard leasing concern, can provide physical damage coverage by changing any leased autos designated in the schedule of the form "covered autos you own" (while also providing physical damage coverage for the leasing concern). In addition, Endorsement CA 99 10 (Drive Other Car Coverage - Broadened Coverage For Named Individuals) provides that any private passenger type auto rented by an employee named in the endorsement will be considered a covered auto for physical damage coverage. The limit of liability for this coverage, subject to any applicable deductible shown in the declarations, will be the lesser of: 4. The actual cash value of the vehicle; or 2. The amount necessary to repair or replace the rental vehicle. DA-3E53a (Ed. 8/02) Ptd. in U.S.A. Page 1 of 1 A014POLICY NUMBER: ISA H09052082 CHUBRE Important Notice To Our Oregon Policyholders Oregon law requires we advise policyholders of the RIGHTS AND RESPONSIBILITIES of the insured when submitting a claim covered by the policy for damage to the insured's vehicle. The insured must give the company or one of our agents written notice of the accident or loss as soon as reasonably possible. When there is a loss covered by the policy, the insured shall: = make a prompt report to the police when the loss is the result of theft or larceny. "= protect the damaged vehicle -- we will pay any reasonable expense to do so. = Show us the damage if we ask. The insured shall cooperate with the company. The insured has the right to receive the reasonable cost of repairs for claims covered by the policy. Oregon law states: An insurer shall not require that a particular person make the repairs to the insured's motor vehicle as a condition for recovery by the insured under a motor vehicle liability insurance policy. The policy contract contains the complete statement of rights and responsibilities of both the insured and the company. DA-9T21 (Ed. 7/93) Ptd. in U.S.A. Page 1 of 1 AOI5POLICY NUMBER: ISA H09052082 CHUBB Indiana Notice to Policyholders We are here to serve you.... As our policyholder, your satisfaction is very important to us. If you have a question about your policy, if you need assistance with a problem, or if you have a claim, you should first contact your insurance agent. If you are unable to reach your agent, or if you wish to contact us directly, please call our Customer Services Department at 1-800-352-4462. Should you have a valid claim, we fully expect to provide a fair settlement in a timely fashion. Should you feel you are not being treated fairly with respect to a claim, you may also contact the Indiana Department of Insurance with your complaint. To contact the Department, write or call: Consumer Services Division Indiana Department of Insurance 311 West Washington Street, Suite 300 Indianapolis, IN 46204-2787 317-232-2395 or 1-800-622-4461 Complaints can be filed electronically at www.in.gov/idoi ALL-2Y81 (05/14) Page 1 of 1 A016POLICY NUMBER: ISA H09052082 ILN 043 01 16 KANSAS FRAUD STATEMENT Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer or insurance agent or broker, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. IL N 043 01 16 © Insurance Services Office, Inc., 2015 Page 1 of 1 AOI7POLICY NUMBER: ISA H09052082 CHUBE MARYLAND NOTICE OF UNDERWRITING PERIOD We are notifying you that the binder or policy you have just agreed to purchase may provide you with only temporary coverage, since Maryland law provides the company with a 45 day period, from the effective date of your coverage, to confirm that you are eligible for coverage under this policy. Should the company find that you are not eligible for this coverage, we will send you a written Notice of Cancellation advising you of the reason(s) that you do not qualify for coverage and the date on which your policy will be cancelled. ALL-38711 (08/12) Page 1 of 1 A018MASSACHUSETTS COMPULSORY PREMIUM POLICYHOLDER NOTICE Named Insured Chubb Group Holdings Inc. Endorsement Number Policy Symbol | Policy Number Policy Period Effective Date of Endorsement ISA 09052082 41/02/2016 To 11/02/2017 issued By (Name of Insurance Company) ACE American Insurance Company insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: The premium for your compulsory coverage is included in the premium shown on the Declarations page of your policy. In addition, the limits of insurance for your compulsory coverages are included in, and not in addition to, the limits of insurance shown on the Declarations page of your policy. All other terms and conditions remain unchanged. Authorized Agent DA-18607 07/2005 Page 1 of 1 A019POLICY NUMBER: ISA H09052082 : Minnesota Policyholder CHUBB Notice Of Election To Have Two Or More Autos Added Together Pursuant to Section 65B.47, subdivision 7, of the Minnesota statutes, you may make a specific election to have the limits of liability for basic economic loss benefits added together for two or more motor vehicles under your automobile insurance policy to determine the limit of insurance coverage available to an injured person for any one accident. Unless you make such an election, the limit of liability for basic economic loss benefits for two or more motor vehicles may not be added together to determine the limit of insurance coverage available to an injured person for any one accident. If you wish to elect to have the limits of liability for basic economic loss benefits for two or more motor vehicles added together, please notify your insurance representative. You may be charged an additional premium for such additional coverage. DA-410714 (09/13) Page 1 of 1 A020POLICY NUMBER: ISA H09052082 ILN 002 11 10 NEW YORK RENTAL REIMBURSEMENT COVERAGE DISCLOSURE YOU HAVE THE RIGHT, PURSUANT TO N.Y. INS. LAW § 2610-A, TO CHOOSE ANY RENTAL VEHICLE COMPANY, RENTAL VEHICLE COMPANY LOCATION OR A PARTICULAR CONCERN IN THE EVENT YOU UTILIZE RENTAL REIMBURSEMENT COVERAGE. IL N 002 11 10 © Insurance Services Office, Inc., 2010 Page 1 of 1 A021POLICY NUMBER: ISA H09052082 NOTICE TO ALL OKLAHOMA POLICYHOLDERS WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. You are insured by the Company listed on the Signature page which is named on the first page of the Declarations of this policy. It is a Chubb company and has its principal office at 436 Walnut Street, PO Box 1000, Philadelphia, PA 19106-3703. ALL-2U78b (2/06) Ptd. in U.S. A. Page 1 of 1 A022POLICY NUMBER: ISA H09052082 CHUBB’ Notice To Our Florida Property And Casualty Policyholders Guidelines For Loss Control Plans Florida law requires us to inform you that we have developed guidelines for risk management plan which are available to you at no cost. The guidelines consist of the following: A. A booklet entitled “Establishing an Effective Loss Control Program.” This booklet describes various loss control procedures that can help you in your selection and implementation of actions that eliminate or reduce the frequency and severity of your losses. B. A self inspection checklist that is tailored for your business and when used in inspections it may be of assistance to you in the identification of conditions which could be responsible for losses. Should you require further help in developing and implementing an effective loss control program, other loss control services are also available to you for an additional charge. The following services are available from Chubb Loss Control Services: A. Loss control management consultation. Through a visit to your facility we will assist you in identifying loss causing conditions, evaluating your loss prevention methods, and recommending loss control enhancements. B. Training loss control management techniques. This training supports our consulting and is intended to assist you in the implementation of your loss control procedures. The training can be provided to you or your employees. To obtain either the free guidelines for loss control plans or information on additional loss control services, please complete the section below and send it to: National Manager, Jurisdictional Services Chubb Risk Control Services P.O. Box 1000 Philadelphia, PA 19105-1000 Tel: 866-357-3797 ALL-39822 (04/13) Page 1 of 2 A023| Send me the free guidelines for the loss control plans LO Send me information on how | can obtain additional loss control services Business Operation: Company Name: Street Address: City: State: Zip Code: Telephone: Policy No: Person to contact: Title: Signature ALL-39822 (04/13) A024 Page 2 of 2POLICY NUMBER: 1SA H09052082 CHUBE Notice To Our New York Policyholders Optional Basic Economic Loss Coverage Dear Policyholder or Applicant: Optional Basic Economic Loss (OBEL) coverage is being offered to you as an enhancement of the Basic No- Fault coverage you are presently required to purchase. But before we describe this coverage, we would like to advise you what benefits Basic No-Fault coverage does and does not provide. No-Fault coverage, otherwise known as Personal Injury Protection or “PIP” coverage, pays for expenses incurred by persons injured in a motor vehicle accident. This coverage does not pay to repair damages to your automobile. Basic No-Fault, which you are required by law to purchase, provides coverage of up to $50,000 per person in benefits for: 1. all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee schedules established or adopted by the New York State Department of Financial Services; and 2. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of accident; and 3. up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary expenses the injured person may have incurred because of an injury resulting from the accident, such as the cost of hiring a housekeeper or necessary transportation expenses to and from a health service provider; and 4. a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for economic loss described above. No-Fault benefits will be reduced by other benefits that are payable under Workers’ Compensation, Social Security Disability, New York State Disability, and certain employer “wage continuation” plans where an employee does not lose any future sick leave benefits. OPTIONAL COVERAGE AVAILABLE In addition to Basic No-Fault Coverage, you may also purchase OBEL coverage that will pay certain expenses, up to $25,000, above the Basic No-Fault limit of $50,000. OBEL coverage is different from other coverages in that a claimant can select the kinds of benefits to be paid under OBEL. If you purchase OBEL coverage and if it appears likely that a claimant will use up the Basic No-Fault coverage, your insurer will send the claimant a form for the claimant to choose what expenses the $25,000 in OBEL coverage will be used to pay. Under No-Fault, a claimant could include you, family members, passengers in your car, or pedestrians, if injured in an auto accident. DA-3H93b (06/13) Page 1 of 2 A025The claimant will be able to choose one of the following four OBEL options and thereby direct the insured to pay expenses for: 1. basic economic loss, whether health care expenses, loss of earnings from work, or other reasonable and necessary expenses; 2. loss of earnings from work; 3. psychiatric, physical or occupational therapy and rehabilitation; or 4. acombination of options 2 and 3. The additional $25,000 of OBEL coverage will be used only for costs incurred under the chosen option, which, once selected, the claimant cannot change. If you have any questions, please contact your company or agent. DA-3H93b (06/13) Page 2 of 2 A026POLICY NUMBER: ISA H09052082 CHUBE Notice To Our Texas Policyholders - Automobile Theft Prevention Authority Pass Through Fee NOTICE: A fee of $ is payable in addition to the policy premium due under this policy. This fee partially or completely reimburses the insurer, as permitted by 28 TAC 5.205, for the $2.00 fee per motor vehicle year required to be paid to the Automobile Burglary and Theft Prevention Authority under Vernon's Annotated Revised civil Statutes of the State of Texas , Article 4413 (37), 10, which became effective on September 1, 2011 . DA-8S7 1b (09/13) Page 1 of 1 A027POLICY NUMBER: ISA H09052082 COMPANY: ACE American Insurance Company NOTICE TO POLICYHOLDER Named Driver Exclusion- State of Michigan Warning- when a named excluded person operates a vehicle all liability coverage is void- no one is insured. Owners of the vehicle and others legally responsible for the acts of the named excluded person remain fully personally liable. In addition, a named excluded driver is not entitled to be paid personal protection benefits for accidental bodily injury if at the time of the accident the named excluded driver was operating a motor vehicle or motorcycle as to which he or she was named as the excluded driver. DA-46822 (09/15) Page 1 of 1 A028POLICY NUMBER: ISA H09052082 POLICYHOLDER NOTICE — OHIO WARNING: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. ALL-SWO06 (7/95) Page 1 of 1 A029POLICY NUMBER: ISA H09052082 CHUBE QUESTIONS ABOUT YOUR INSURANCE? Answers to questions about your insurance, coverage information, or assistance in resolving complaints can be obtained by contacting: Chubb Customer Support Services Department: 436 Walnut Street Philadelphia, Pennsylvania 19106-3703 Telephone Number: 1-800-352-4462 Email: ChubbUSCustomerServices@chubb.com The Illinois Department of Insurance may also be contacted for assistance. Insurance analysts are available to answer general questions by phone at our toll-free Consumer Assistance Hotline (866) 445-5364. However, complaints must be submitted in writing. How to file a complaint with the Insurance Department: Complaints may be submitted in the following ways: + On-line at https://insurance. illinois.gov/applications/ComplaintF orms/default.aspx and by following the instructions posted. «By fax: (217) 558-2083 « By email at consumer_complaints@ins.state.il.us « By mail: 320 W. Washington St. Springfield, IL 62767 or 122 S. Michigan Ave., 19th Floor, Chicago, Illinois 60603 ALL-18653d (07/14) Page 1 of 1 A030POLICY NUMBER: ISA H09052082 CHUBE Questions About Your Insurance? Answers to questions about your insurance, coverage information, or assistance in resolving complaints can be obtained by calling Chubb, Customer Support Service Department, at 1-800-352-4462. ALL-5X45 (11/96) Ptd. in U.S.A. A031 Page 1 of 1POLICY NUMBER: ISA H09052082 CHUBhRe Chubb Phone: 1.866.357.3797 Risk Control Services Fax: 215.640.5084 436 Walnut Street Philadelphia, PA 19106-3703 www.chubb.com National Manager, Jurisdictional Services RE: RISK CONTROL SERVICES FOR TEXAS POLICYHOLDERS. Commercial Automobile Liability, General Liability, Professional Liability, and Medical Professional Liability (other than Hospitals) The Chubb Companies are required by Texas law and regulations to maintain or provide accident prevention services for its commercial automobile, general liability and professional liability policyholders. The Chubb Companies offer an array of accident prevention services in Texas at no additional charge. These services are intended to help prevent and/or minimize loss. These services include but are not limited to: individual risk surveys; improvement recommendations; loss investigation; specific loss problem identification and recommended improvement actions. Chubb may recommend one or more of these services based upon hazard, experience, and size of your Texas operations. You have the choice of receiving or declining any of the services offered. If you wish to decline all of the services or wish to receive only selected risk control service, please indicate that by signing and dating this letter in the space provided below. Please mail or fax to the captioned address or fax number. If you decline all of Chubb's risk control services or choose only a support service, such as ergonomics survey,. driving training, or other services and not a complete risk survey, we still have a responsibility under Texas law and regulation to monitor your losses. In the event you start to have a loss problem and a trend is established, and/or adverse loss ratio is developed, we will contact you and offer to assist you in addressing the situation. Sincerely, National Manager, Jurisdictional & Regulatory Services Chubb Risk Control Services 436 Walnut Street, Philadelphia, PA 19106-3703 or call toll free at: 1-866-357-3797 (1) 1am aware of the loss control services offered and decline them. I have made other arrangements for these services. [|__| wish to obtain the following offered accident prevention services: (1 Ihave no risk control services needs now. I reserve the right to request loss control services within the period. (Signature) (Phone #) (Date) Print Name: Policy # Company Name: Address: City, State, Zip: One of the Chubb Group of Insurance Companies This Company has undertaken a survey of your premises, equipment, or operations (whichever is pertinent to the type of insurance applied for or provided) for the purpose of supporting the functions of risk underwriting. Any recommendations or information provided is not intended as a substitute for advice from a safety expert or legal counsel you may retain for your own purposes. It is not intended to supplant any legal duty you may have to provide a safe premises, workplace, product or operation. ALL-11559d (10/07) Page 1 of 1 A032POLICY NUMBER: ISA H09052082 STATE OF NEW HAMPSHIRE UNINSURED MOTORISTS POLICYHOLDER NOTICE Notwithstanding any other provision or endorsement of this policy, pursuant to Section 264.15 of the New Hampshire Revised Statutes, it is understood that in the event of insolvency on the part of the liability insurer which prevents the insurer from paying the legal liability of its insured within the limits of the coverage provided, and no other insurance applies, Uninsured Motorists Coverage shall provide for no less than $25,000 coverage for damage to or destruction of property in any one accident. DA-39593 (01/13) Page 1 of 1 A033POLICY NUMBER: ISA H09052082 CHUBB IMPORTANT NOTICE To obtain information or make a complaint: You may call the Company's toll-free telephone number for information or to make a complaint at: 1 (800) 352-4462 You may also write to the Company at: Chubb Customer Services PO Box 1000 Philadelphia, PA 19106-3703 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1 (800) 252-3439 You may write the Texas Department of Insurance: P. O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007 Web: www.tdi.texas.gov E-mail: ConsumerProtection@tdi.texas.gov PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact your agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. ALL-4Y30f (06/15) Texas Notice — Information and Complaints AVISO IMPORTANTE Para obtener informaci6n o para presentar una queja: Usted puede llamar al numero de teléfono gratuito de la Compaiia para obtener informacién o para presentar una queja al: 1 (800) 352-4462 Usted también puede escribir a la Compafiia: Chubb Customer Services PO Box 1000 Philadelphia, PA 19106-3703 Usted puede comunicarse con el Departamento de Seguros de Texas para obtener informacion sobre compafiias, coberturas, derechos, o quejas al: 1 (800) 252-3439 Usted puede escribir al Departamento de Seguros de Texas a: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007 Sitio web: www.tdi.texas.gov E-mail: ConsumerProtection@tdi.texas.gov DISPUTAS POR PRIMAS DE SEGUROS O RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro 0 con una reclamacion, usted debe comunicarse con el agente o la compajfiia primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas ADJUNTE ESTE AVISO A SU POLIZA: Este aviso es solamente para propésitos informativos y no se convierte en parte o en condicién del documento adjunto. Page 1 of 1 A034POLICY NUMBER: ISA H09052082 IL P 001 01 04 U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC") ADVISORY NOTICE TO POLICYHOLDERS No coverage is provided by this Policyholder Notice nor can it be construed to replace any provisions of your policy. You should read your policy and review your Declarations page for complete information on the coverages you are provided. This Notice provides information concerning possible impact on your insurance coverage due to directives issued by OFAC. Please read this Notice carefully. The Office of Foreign Assets Control (OFAC) administers and enforces sanctions policy, based on Presidential declarations of "national emergency". OFAC has identified and listed numerous: @ Foreign agents; @ Front organizations; @ Terrorists; © Terrorist organizations; and @ Narcotics traffickers; as "Specially Designated Nationals and Blocked Persons". This list can be located on the United States Treas- ury's web site — http/Awww.treas.gov/ofac. In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and Blocked Person, as identified by OFAC, this insurance will be considered a blocked or frozen contract and all provisions of this insurance are immediately subject to OFAC. When an insurance policy is considered to be such a blocked or frozen contract, no payments nor premium refunds may be made without authorization from OFAC. Other limitations on the premiums and payments also apply. IL P 001 01 04 © ISO Properties, Inc., 2004 Page 1 of 1 A035POLICY NUMBER: ISA H09052082 CHUBB’ UNINSURED MOTORISTS/UNDERINSURED MOTORIST COVERAGE SUMMARY The following Limit of Insurance for Uninsured Motorists and Underinsured Motorists (when not included in Uninsured Motorists Coverage) apply to Item 2 of the Declarations: 4. No Coverage is offered or provided for vehicles principally garaged or registered in the following states: MI,OH,PR 2. You have rejected coverage in the following states and no Limit of Insurance is provided for vehicles principally garaged or registered in these states: AL,AK,AZ,AR,CA,CO,DE,FL,GA,HI,ID,IN,IA,KY,LA,MS,MT,NV,NM,OK,PA,TN,TX,UT,WA,WY 3. Limit of Insurance for vehicles principally garaged or registered in the following states will be the limit of insurance you selected on the signed Uninsured and/or Underinsured Motorist selection/rejection form on file with us: All states not listed in items 1,2 or 4 of this form. 4. The policy limit for liability shall apply for vehicles principally garaged or registered in the state of NH. DA-40002 (04/13) Page 1 of 1 A036POLICY NUMBER: ISA H09052082 CHUBE Wisconsin Notice To Policyholders KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? -- If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem. Chubb Customer Support Service Department 436 Walnut Street PO Box 1000 Philadelphia, PA 19106-3703 1-800-352-4462 You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting: Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 608-266-0103 ALL-5X51a (2/06) Printed in U.S.A A037 Page 1 of 1CHUBB Business Auto Declarations) ACE American Insurance Company 436 Walnut Street Philadelphia PA 19106 \ POLICY NUMBER: ISA H09052082 EXPIRING POLICY NUMBER: ISA HO886505A RENEWAL Named Insured: Chubb Group Holdings Inc. Address: 510 Walnut Street Philadelphia PA 19106 Producer Number: 273613 Producer Name: LOCKTON COMPANIES LLC Producer Address: 3280 PEACHTREE ROAD SUITE 250 ATLANTA GA 30305 Form of Bus