Transcription of DESIGNATED REPRESENTATIVE FORM - Auto Body …
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DESIGNATED REPRESENTATIVE FORM - Auto Body …
In accordance with the laws of the state of New York NYCARS form # DR-01 BSBP. DESIGNATED REPRESENTATIVE form . Tedesco Auto Body, INC. 320 Main Street New Rochelle, NY 10801. Office: (914) 636-3000. Fax: (914) 636-3075. Email: Tax ID # 133831242. Shop Registration # 7098507. Insurance Company: Claim #. Customer Name: Vin #. I hereby appoint TEDESCO AUTO BODY, INC. as my DESIGNATED REPRESENTATIVE as provided by Regulation 64 of the New York State Insurance Department to negotiate with the intent to settle this claim. This applies only to my motor vehicle damages. Customer Print Name: Customer Sign Name.
In accordance with the laws of the state of New York NYCARS Form # DR-01BSBP DESIGNATED REPRESENTATIVE FORM Tedesco Auto Body, INC. 320 Main Street
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