Collision Masters

Collision Masters
DESIGNATED REPRESENTATIVE FORM

Collision Masters 290 South Park Avenue Buffalo NY 14204
Insurance Company
Claim #
Customer Name
Vin #
I hereby appoint Collision Masters Enterprise 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 Name (Please Print )
Date

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Date
Customer Signature

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Date

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