INSURED ______

CLAIM # ______

POLICY # ______

DATE OF ACCIDENT__

Dear Insured:

We have been unable, after negotiating in good faith, to reach an agreed price with you, your Designated Representative and/or your repairer ______, the repairer of your choice. Pursuant

to Insurance Regulation 64 of the New York State Department of Financial Services, we are supplying you with the following information and optional waiver.

Our offer of $ _ plus your deductible of $ _ and $ _ of betterment or previous damage deduction is sufficient to repair your vehicle to its pre-accident condition at a repair shop located reasonably convenient to you. We are able to provide you with the identity of the repair shop that will repair your vehicle at our estimate, but under the Insurance Law we may not recommend a repairer unless you expressly request such information. Unless you have already asked us to recommend a repair shop, you must sign the attached Section 2610 of the Insurance Law Disclosure Statement in order to enable us to make such recommendation.

If your vehicle is repaired at a repair shop recommended by us, the repair shop must issue a written guarantee that any work performed in repairing your vehicle meets generally accepted standards for safe and proper repairs. If our recommended repairer does not honor its written guarantee, we will restore your vehicle to its pre-accident condition within a reasonable time at no additional cost to you.

Your policy covers you for reasonable expenses that you incur in order to protect your motor vehicle from further damage after a loss. Contact us immediately for information as to what extent such expenses are covered. NYS APD 1

Section 2610 of the New York State Insurance Law provides that the insurance carrier shall not require that repairs be made in a particular place or shop or by a particular concern.

The Law further provides that the Insurance Company shall not recommend or suggest repairs be made in a particular place or shop or by a particular concern, unless expressly requested by you.

I acknowledge receipt of a copy of this notice.

I have read the above notice and understand the Insurance Company cannot require or recommend that repairs be made in a particular place or by a particular person unless I expressly request such recommendation. I hereby, of my own volition, request that the Insurance Company or its representative recommend a repair shop.

NYS APD 1-a

Section 3411(i) of the NEW YORK INSURANCE LAW (NYIL) and Article 12-A of the Vehicle and Traffic Law (V&TL) require that the following certification be completed and signed by both the insured and the automobile repairer. These laws also require submission of the repair invoice (Paid Bill) by the automobile repairer or the insured to the insurer whenever any repairs are made. The NYIL does not require an insured to repair the automobile as a condition of payment of a loss. This form must be completed and returned to the insurer within 45 days. A postage-paid return envelope has been furnished for your convenience.

ANY PERSON WHO, KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUD ULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.

I, __ certify, under penalties of perjury, that:

(print your name)

Check A or B

_ A. I have not made any repairs to my automobile as a result of this loss.

_ B. I have made repairs to my automobile and I have attached a copy of my invoice for repairs to my automobile as a result of the captioned loss.

IF THIS CERTIFICATION IS NOT COMPLETED AND RETURNED, TOGETHER WITH A COPY OF THE ITEMIZED PAID BILL, IT WILL BE ASSUMED THAT YOU DID NOT REPAIR YOUR MOTOR VEHICLE. IF YOU HAVE A SUBSEQUENT LOSS, THE COMPANY MUST, TO THE EXTENT RELEVANT, DEDUCT SUCH UNREPAIRED ITEMS AS PREVIOUS DAMAGE IN SETTLING A FUTURE LOSS. IF YOU DO NOT REPAIR ALL THE DAMAGES ALLOWED BY THE INSURER, SUCH REPAIRS NOT PERFORMED MAY REDUCE YOUR SETTLEMENT OF ANY FUTURE LOSS. THEREFORE, IF AFTER SIGNING THIS CERTIFICATION, YOU REPAIR ANY DAMAGE CAUSED BY THIS ACCIDENT, YOU SHOULD NOTIFY THE COMPANY IMMEDIATELY. THE COMPANY MAY AT THAT TIME ELECT TO INSPECT YOUR AUTOMOBILE.

I, (print your name) owner or officer of (print name of auto repair) shop

Auto Repair Shop Registration Number __ _, located at ______ certify, under penalties of perjury, that I have made the repairs to the automobile owned by (print name of insured),

as shown on the attached itemized invoice. I further certify that:

Check A or B

_ A. I have repaired all the items allowed by the insurer, or, if not,

_ B. I have repaired the automobile as described on the attached itemized invoice.

(Owner or Officer)

NYS APD 2