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Insurance Designation Form
In Accordance With The Laws of The State of New York | NYCARS From #DR-01BSBP
Insurance Company
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Claim Number
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Customer Name
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VIN Number
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Consent
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I agree
I hereby appoint Abushi 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.
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