DESIGNATED REPRESENTATIVE


Insurance Co,. in accordance with NJCA 11:3 - 10:3(1):

Name:
Insurance Co:
Year::
Make:
Model
Serial No:
Claim #:
Notice to:
Insured:
Policy No:
Claimant:
Date of Loss:

 

I, , do hereby make the authorization below with respect to the above referenced claim and damages to my Serial (VIN) Number ; the authority hereby granted is restricted to this claim and this claim only,, and may only be withdrawn by written notice from me to all parties named herein.


I hereby authorize D&M Auto Body Inc. to repair the above vehicle as per the above claim. I hereby designate Employees and Representatives of D&M Auto Body Inc. to be my Designated Representatives in negotiating a settlement with the above named insurance company for the repair of my vehicle. All negotiations from this day forward regarding repairs to my vehicle arising from the above referenced claim must be conducted through my Designated Representative. I specifically authorize my Designated Representative to invoke, at his discretion, the appraisal clause in my policy on my behalf, if applicable. I do not wish to be directed to any repair facility, which may have pre-arranged repair procedures or payment arrangements with the above named insurance company.

Date :

Witness:

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