New Jersey Administrative Code

Each group shall establish an administrative account for each fund year which shall be utilized for payment of the group's general operating expenses, including, but not limited to, loss prevention activities, data processing services and general legal expenses. A group shall not…

(a) Each participating member of a risk management group shall appropriate and pay to the group its assessments as required by the risk management group. During the first year of operation of a risk management group these contributions shall be paid in two equal installments, the…

(a) Each group shall levy upon its members an additional assessment whenever needed or so ordered by the Commissioner, to supplement the group's claim or loss retention or administrative accounts to assure payment of the group's obligations, including payment of benefits under th…

Should any member of a group fail or refuse to pay as directed its assessment(s) to the group or to pay as directed any supplemental assessment(s), or should the trustees fail to assess funds required to meet the obligations of the group, the chairman of the board of trustees, if…

(a) Whenever the risk management program of a group requires any members of the group to retain individually a specified amount of risk, potential liability, or incurred losses, the participant shall provide for such liability, or incurred losses: 1. As a deductible to be charged…

Prior to any commitment or agreement requiring the expenditure of funds by the risk management group, the custodian of the group's assets shall certify the availability of sufficient unencumbered funds in the account to fully pay all charges or commitments to be accepted. Notes N…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Actuary" means a person who is a Fellow in good standing of the Casualty Actuarial Society with three years recent experience in loss res…

(a) The free balance of any account maintained by a risk management group, whether for claim or loss retention, administrative, or contingency, shall be invested to obtain the maximum interest return practicable. All investments shall be made in accordance with the group's cash m…

(a) Any monies for a fund year in excess of the amount necessary to fund all obligations for that fund year as certified by an actuary may be declared to be refundable by the group not less than 24 months after the end of the fund year. (b) The group may seek approval from the Co…

(a) All disbursements, payment of claims settlements or other expenditure of funds of the risk management group whether for administrative expenses or for claims purposes must be approved by a majority of the board of trustees, unless approved pursuant to (b) below. (b) To allow …

(a) Consistent with N.J.A.C. 11:15-7.6(a)6, each group providing primary or underlying coverage on a self-insured or commercially insured basis shall secure excess insurance or reinsurance in a form, in an amount and by an insurer, or other entity authorized to provide such cover…

(a) An annual certified report in a form acceptable to the Commissioner shall be prepared by each group, filed with the Department, and made available to each group member on or before December 31 of each year. The report shall include: 1. An annual audited statement of the finan…

(a) In addition to any examination conducted pursuant to N.J.A.C. 11:15-7.6(g), the Commissioner may conduct an examination of any group as he or she deems necessary, or at any time the Commissioner has reasonable cause to believe the group may be insolvent or in a financial cond…

(a) No servicing organization of a fund or producer appointed pursuant to N.J.A.C. 11:15-7.6(d)10, or their employees, officers or directors shall have either a direct or indirect financial interest in the administrator of that group, or be an employee, officer or director of the…

(a) The Commissioner shall give prior written notice of any proposed suspension, revocation of authority, cease and desist order, or other enforcement action to the trustees or member as the case may be, or to any person to whom the proposed enforcement action applies specificall…

(a) After notice and opportunity for a hearing, as provided in N.J.A.C. 11:15-7.2 7, the Commissioner may issue an order revoking or suspending a group's authority or requiring a person or fund to cease and desist from engaging in an act or practice found to be in violation of an…

Unless otherwise provided by this subchapter, all information and documents and any amendments thereto required by this subchapter shall be filed within 30 days from the date such information or document is issued or such change or amendment has occurred. Notes N.J. Admin. Code §…

(a) Any two or more State colleges may form or become members of a State college risk management group. A State college may take this action by resolution of the board of trustees of the State college. (b) The resolution shall provide for execution of a written agreement with the…

The rules contained in this subchapter and any of the provisions thereof shall be severable, and if any of its provisions shall be held to be unconstitutional or otherwise invalid, the decision of the court shall not affect the validity of the remaining rules and regulations or a…

(a) Every risk management group shall be subject to and operate in compliance with the provisions of any applicable law governing contracts by State colleges and the applicable regulations of the State Investment Council governing the investment of surplus public monies of the St…

(a) Each risk management group shall file with the Department for approval by the Commissioner, as provided in N.J.S.A. 18A:64-91, its bylaws and risk management program and any amendments thereto. In addition, in order to ensure that the joint liability funds of State college gr…

(a) The trustees shall prepare and, after the approval by resolution of the governing body of each participating member, shall adopt bylaws for the risk management group. The bylaws shall:1. Set forth a statement of purposes of the group; 2. Set forth provisions for organization …

If the Commissioner determines that the bylaws or risk management program of the group or any subsequent amendments thereto do not contain all of the information set forth in N.J.A.C. 11:15-7.6, are not submitted in the proper format set forth in N.J.A.C. 11:15-7.5, or otherwise …

(a) After notice and opportunity for a hearing, the Commissioner may suspend or terminate the authority of any group, or direct or take any action deemed necessary for good cause, to enable a group to meet its obligations, cover its expected losses, or to liquidate, rehabilitate …

(a) Prospective new members of the group shall submit an application for membership to the group's board of trustees on a form acceptable to the Commissioner. The application shall include a copy of the resolution of participation and executed indemnity and trust agreement. The t…

(a) This subchapter applies to all insurers in the State of New Jersey. (b) For the purpose of this subchapter: "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Insurer" means any person, corporation, association, partnership, company,…

(a) Insurers shall either place on or attach to all claim forms the following warning: "Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties." (b) Pursuant to N.J.S.A. 17:33A-6, all applicati…

This subchapter governs the reporting of motor vehicle theft or salvage and related transactions between insurers and the National Insurance Crime Bureau ("NICB") or its successor, in implementation of N.J.S.A. 17:23-19. This subchapter applies to all insurers transacting motor v…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Insurer" means any corporation, company, partnership, association, society, order, individual or combination of individuals transacting…

(a) By December 20, 1989, every insurer transacting motor vehicle insurance in New Jersey that is not already a member or a service company of the NICB, shall make application to become either a member or a service company of the NICB. An insurer shall pay all assessments for mem…

(a) Insurers shall report to the NICB all motor vehicles involved in losses as follows: 1. All thefts of a motor vehicle, or any of its major component parts, shall be reported within two working days from the receipt of sufficient information from the insured. The NICB shall ack…

Insurers shall cooperate with the NICB and shall release information in their possession to the NICB upon its reasonable request. Notes N.J. Admin. Code § 11:16-2.5 Amended by R.1993 d.48, effective 1/19/1993. See: 24 New Jersey Register 3606(a), 25 New Jersey Register 311(a). Na…

The NICB shall cooperate with insurers in the resolution of errors and the investigation of claims suspected to be fraudulent. Notes N.J. Admin. Code § 11:16-2.6 Amended by R.1993 d.48, effective 1/19/1993. See: 24 New Jersey Register 3606(a), 25 New Jersey Register 311(a). Natio…

(a) Notwithstanding any provision of Title 11 of the New Jersey Administrative Code to the contrary, an insurer shall defer the processing and payment of a claim filed under comprehensive or other coverage in accordance with the following: 1. No insurer shall pay a claim filed by…

Such reports as may be required to be filed with the NICB by an insurer pursuant to P.L. 1989, c.65, this subchapter and the operating procedures of the NICB, shall be maintained by the NICB for at least a period of five years from the date of entry into the NICB system, except t…

Failure of an insurer to abide by the requirements of this subchapter may lead to the imposition of sanctions or penalties as provided by law. Notes N.J. Admin. Code § 11:16-2.9

(a) This subchapter sets forth the standards for a plan for the prevention and detection of fraudulent insurance applications and claims filed for approval pursuant to N.J.S.A. 17:33A-15 by insurers which transact the business of private passenger automobile insurance or health i…

Failure to comply with the provisions of this subchapter shall subject the insurer to penalties as prescribed by law. Notes N.J. Admin. Code § 11:16-6.10

(a) All information and materials in the possession of the OIFP concerning the possibility of the existence or occurrence of insurance fraud or related criminal activities are confidential and privileged against disclosure, and shall not be deemed public records, so as to protect…

Notes N.J. Admin. Code § 11:16-6.12 Recodified to N.J.A.C. 11:16-6.11 by R.2005 d. 159, effective 5/16/2005. See: 37 New Jersey Register 199(a), 37 New Jersey Register 1733(a). Section was "Confidential records and information".

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Anti-fraud prevention and detection plan" means the creation and maintenance of an anti-fraud protection and detection protocol, an anti-…

(a) All insurers shall file for approval a fraud prevention and detection plan ("plan") in accordance with N.J.S.A. 17:33A-15 and this subchapter. No insurer shall use or implement any plan that is not filed and approved. (b) Insurers shall submit their plan on 81/2 by 11-inch pa…

(a) Except for automobile insurers that insure fewer than 2,500 New Jersey automobile policies, and health insurers that insure fewer than 10,000 lives, the plan filed in accordance with N.J.A.C. 11:16-6.3 shall establish a full-time Special Investigations Unit ("SIU"). (b) The S…

(a) The requirements with respect to fraud prevention and detection training programs are set forth in this subsection. Except for automobile insurers that insure fewer than 2,500 New Jersey automobile policies and health insurers that insure fewer than 10,000 lives, the plan sha…

(a) The plan shall provide for underwriting inquiry to verify that the insured satisfies the insurer's acceptance criteria and that the policy is properly rated within 60 days of receipt of the application. These underwriting inquiries shall verify the insured's residency provide…

(a) The plan shall provide that upon completion of its investigation, as described in (d) below, an SIU shall refer cases which meet the standards in (a)1 and 2 below. The SIU shall submit one copy of the appropriate referral form and one copy of any attachments to the address in…

(a) Insurers shall maintain up-to-date and accurate records on their fraud prevention and detection plan, which shall at minimum include those necessary to prepare the report required in (b) below. (b) Insurers shall submit to the Commissioner on or before March 31 of each year a…

(a) An insurer's fraud prevention and detection plan shall be deemed approved by the Commissioner if not affirmatively approved or disapproved by the Commissioner within 90 days of the date of filing. (b) The Commissioner may request such amendments to the plan as he or she deems…

This subchapter sets forth the procedures that govern the conduct of administrative hearings for imposing civil and administrative penalties for violations of the New Jersey Insurance Fraud Prevention Act, as amended, N.J.S.A. 17:33A-1 et seq. These rules are intended to implemen…

If any rule, sentence, paragraph or section of these rules, or the application thereof to any persons or circumstances, shall be adjudged by a court of competent jurisdiction to be invalid, or if by legislative action any rule shall lose its force and effect, such judgment or act…