Designated Representative Authorisation

SHOP NAME                                                        R #
ADDRESS
CITY, STATE, ZIP CODE
PHONE
FAX

DESIGNATED REPRESENTATIVE AUTHORIZATION
FOR A COLLISION LOSS

_______________________Date

I, ______________________________, owner of a______________Year and Make

license number___________________appoint______________________________
Name

as my Designated Representative, as provided for in Regulation 64 of the
Insurance Department, State of New York, only as to my motor vehicle damage.

This is not an authorization to repair

_________________________________________
Signature