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