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GARAGE RENEWAL PPLICATION ALL APPLICANTS (EXCEPT VIRGINIA): BY (Colonial General Insurance Agency, Inc)

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GAR-APP122-0918 Page 1 of 6
ALL APPLICANTS (EXCEPT VIRGINIA): BY COMPLETING THIS APPLICATION, THE APPLICANT IS APPLYING FOR COVERAGE WITH
EITHER COLONY INSURANCE COMPANY, AN AUTHORIZED SURPLUS LINES INSURER OR ARGONAUT INSURANCE COMPANY OR
ARGONAUT MIDWEST INSURANCE COMPANY, A LICENSED INSURER.
VIRGINIA APPLICANTS: BY COMPLETING THIS APPLICATION, THE APPLICANT IS APPLYING FOR COVERAGE WITH COLONY
SPECIALTY INSURANCE COMPANY, AN AUTHORIZED SURPLUS LINES INSURER.
NOTE: Colony Garage Division reserves the right to request a completed Colony Garage Application for
additional information if there are any significant changes in the operation.
APPLICANT INFORMATION
Named Insured ___________________________________________________________________________________
Renewal of Policy Number _____________________ Renewal Term: From ______________ To ______________
Complete the following in full:
1. Indicate if any changes to be made at renewal:
Coverages
Yes No
Limits Yes No
Deductibles
Yes No
Vehicles Yes No
Location
Yes No If “Yes”, new address: ____________________________________________________
Plates Yes No If “Yes”, how many current: Dealer: __________ Transporter/Repairer: __________
2. Describe any changes in operation or exposure:
3. Please provide your percentage of operations. Must total 100%. (*complete additional Questionnaire.)
Repair Sales
Private Passenger Autos, SUVs, Pick-ups and Vans Service (122100) or Sales (122000)
%%
Antique/Classic Autos Service (122015) or Sales (122005)
%%
Auction (122739) *
%
Boat Service (122016) or Sales (122006)
%%
Commercial Trucks and Trailers Service (122101) and Sales (122001) *
%%
Emergency Vehicle Service (122011) or Sales (122003) *
%%
Farming & Construction Equipment Service (122017) or Sales (122007) *
%%
Mobility Service (122108) with Dealer Operations (122109)
%%
Motorcycle – Franchised Sales (122742) or Service (122748) *
%%
Motorcycle – Non-franchised Sales (122742) or Service (122748) *
%%
Parking Lots/Structures (122113)
%
Repossessors (Storage Lot Only)(122114)
%
RV Service – Motorhome and Camping Trailers (122010) or Sales (122009) *
%%
Salvage Yard Service (122115) with Dealer Operations (122113) *
%%
Storage Facilities/Lots (122102) *
%
Towing Operators (122104)
%
Valet (122103) *
%
Wholesale Dealer (122740) *
%
Other:
%%
GARAGE RENEWAL
A
PPLICATION
GAR-APP122-0918 Page 2 of 6
4. List all current Owners, Employees and Drivers (including all family members licensed to drive) and any 1099 Contractors who are
not required to carry their own insurance.
This must be fully completed. If you attach a separate employee list, include all of this information for each person listed.
Name
Date of
Birth
Driver
License
Number
State
of
L
icense
CDL?
Y/N
Furnished
Auto?
Y/N
Personal
Auto
Policy in
force?
Y/N
Violations &
Accidents Past
Three (3) Years
Full or
Part
Time
Job Title/Duties
Attach Additional Employee Extension if additional space is needed.
COVERAGE REQUESTED (Must Be Completed In Its Entirety)
Liability Limit: $ ___________________________ each accident, $ _________________ aggregate
Liability Deductible: $500 $1,000 $2,500
Medical Payments Limit: $ __________________ Premises Only Combined
Garagekeepers If this coverage is chosen, please complete the following chart:
Location # Average # of Vehicles on Lot Average Value per Vehicle Maximum Limit per Vehicle Total Lot Limit
1
$ $
2
$ $
3
$ $
4
$ $
Garagekeepers per policy options:
Choose One:
Legal Liability Primary
Per Vehicle Deductible:
$500 $1,000 $2,500 $5,000 $10,000 $25,000 $50,000
Garagekeepers (coverages selected by location):
Location #
Choose One for each location if coverage desired: Check if coverage desired:
Specified Causes of Loss Comprehensive Collision
1
2
3
4
Garagekeepers Wind/Hail/Flood Deductible Options (applies to Comprehensive Primary only):
Location #
Wind/Hail/Flood Exclusion
applies to:
Wind/Hail/Flood Deductible
Wind/Hail/Flood Deductible
applies to:
Wind, Hail
and Flood
Wind/Hail
only
Flood Only Per vehicle: Aggregate:
Wind, Hail
and Flood
Wind/Hail
only
Flood Only
1
$ $
2
$ $
3
$ $
4
$ $
Garagekeepers Earthquake Restriction (applies to comprehensive primary only within building storage)
Location #
Earthquake per vehicle deductible:
1
$
2
$
3
$
4
$
GAR-APP122-0918 Page 3 of 6
Dealers Physical Damage If this coverage is chosen, please complete the following chart:
Location # Average # of Vehicles on Lot Average Value per Vehicle Maximum Limit per Vehicle Total Lot Limit
1
$ $
2
$ $
3
$ $
4
$ $
Per Vehicle Deductible: $500 $1,000 $2,500 $5,000 $10,000 $25,000 $50,000
Dealers Physical Damage (coverages selected by location):
Location #
Choose One for each location if coverage desired: Check if coverage desired:
Specified Causes of Loss Comprehensive Collision
1
2
3
4
Dealers Physical Damage Wind/Hail/Flood Deductible Options (applies to SCOL and Comprehensive):
Location #
Wind/Hail/Flood Exclusion
applies to:
Wind/Hail/Flood Deductible
Wind/Hail/Flood Deductible
applies to:
Wind, Hail
and Flood
Wind/Hail
only
Flood Only Per vehicle: Aggregate:
Wind, Hail
and Flood
Wind/Hail
only
Flood Only
1
$ $
2
$ $
3
$ $
4
$ $
Dealers Physical Damage Earthquake restriction (applies only with in building storage):
Location #
Earthquake per vehicle deductible:
1
$
2
$
3
$
4
$
Type of vehicles: New Used
Interests Covered:
Owner Owner and Creditor Consignment
Loss Payee: ___________________________________________________________________________________
Optional Coverages:
Additional Insured & Relationship ____________________________________________________________
Broad Form Products Liability
Broadened Coverage – Garage
Cyber Suite (Cyber Liability, Data Compromise, Identity Theft Recovery) Cyber Liability SERP
Drive Other Car Coverage (Number of individuals other than spouse: _____)
Errors and Omissions for Auto Dealers
False Pretense – select limit: $25,000 $50,000 $100,000
Fire Legal Liability: $50,000 $ ________________
Hired Auto – Cost of Hire: ___________
Waiver of Subrogation
Watercraft Liability
Commercial Property Coverage Part (attach Garage Property Questionnaire/Accord 140 and TRIA Notice)
Available for Dealers and Scheduled Autos only:
Personal Injury Protection (signed state form selecting or rejecting coverage is required)
Uninsured Motorist $ _________________ (signed state form selecting or rejecting coverage is required)
GAR-APP122-0918 Page 4 of 6
Specifically Described Autos (use ACORD 127 for additional vehicles):
Are all the scheduled units registered and titled in the business name?
Yes No
If “No”, explain:
Auto
#
Year Make/Model VIN Radius GVW Primary Driver Description of Use
1
2
3
4
5
Auto
#
Stated
Amount
Comp or
SCOL
COMP/SCOL
Deductible
Collision
Collision
Deductible
On-Hook
On-Hook
Limit
Comp or
SCOL
(collision
included)
On-Hook
Deductible
1 $
SCOL
Comp
$500
$1,000
$2,500
$5,000
Yes
No
$500
$1,000
$2,500
$5,000
Yes
No
$
Check to
include Bailees
SCOL
Comp
$500
$1,000
$2,500
2 $
SCOL
Comp
$500
$1,000
$2,500
$5,000
Yes
No
$500
$1,000
$2,500
$5,000
Yes
No
$
Check to
include Bailees
SCOL
Comp
$500
$1,000
$2,500
3 $
SCOL
Comp
$500
$1,000
$2,500
$5,000
Yes
No
$500
$1,000
$2,500
$5,000
Yes
No
$
Check to
include Bailees
SCOL
Comp
$500
$1,000
$2,500
4 $
SCOL
Comp
$500
$1,000
$2,500
$5,000
Yes
No
$500
$1,000
$2,500
$5,000
Yes
No
$
Check to
include Bailees
SCOL
Comp
$500
$1,000
$2,500
5 $
SCOL
Comp
$500
$1,000
$2,500
$5,000
Yes
No
$500
$1,000
$2,500
$5,000
Yes
No
$
Check to
include Bailees
SCOL
Comp
$500
$1,000
$2,500
Optional Scheduled Auto Coverages:
Rental Reimbursement
Maximum Daily Amount $_____________ Number of Days _________
SCOL
Comp
Collision
Auto Loan/Lease Gap
Additional Interest for autos only:
Vehicle #
Names/Address: Interest
1
Loss Payee
Lessor
2
Loss Payee
Lessor
3
Loss Payee
Lessor
FRAUD STATEMENT/SIGNATURES
THE FRAUD STATEMENT APPLICABLE TO YOU APPEARS ON THE FOLLOWING PAGE OF THIS INSURANCE
APPLICATION. PLEASE READ IT CAREFULLY AND SIGN YOUR APPLICATION.
FS-APP001-0618 Page 5 of 6
FRAUD STATEMENTS
FRAUD STATEMENT
(Not applicable in the states mentioned below where a specific warning applies.)
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning
any fact material thereto, may be committing a fraudulent insurance act, and may be subject to a civil penalty or fine.
Alabama
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or
any combination thereof.
Arkansas, District of Columbia, Louisiana, Rhode Island, West Virginia
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within
the Department of Regulatory Agencies.
Florida
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kansas
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that
it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse,
facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of,
or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an
insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning
any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act.
Kentucky
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Maine
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Maryland
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
New Jersey, New Mexico
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
Ohio
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
FS-APP001-0618 Page 6 of 6
Oklahoma
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds
of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application
containing a false statement as to any material fact may be violating state law.
Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Pennsylvania (Auto)
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false,
incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a
fine of up to $15,000.
Tennessee, Virginia, Washington
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
New York
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
New York (Auto)
Any person who knowingly makes or 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 fraudulent 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.
SIGNATURES
DO NOT SIGN UNTIL YOU HAVE READ THE CONTENTS OF THIS APPLICATION AND THE APPLICABLE FRAUD WARNING(S).
I have reviewed the contents of this application and with my signature, I declare to the best of my knowledge that all statements herein are true
and no material facts have been suppressed or misstated. I am also aware that my operation may be inspected by the Insurance Company.
APPLICANT/NAMED INSURED
APPLICANT/NAMED INSURED SIGNATURE DATE
Agent/Broker:
Are you personally familiar with this Applicant’s operations? Yes No
Did your office control this risk in the past year? Yes No
AGENT’S OR BROKER’S NAME AND ADDRESS TELEPHONE NUMBER LICENSE NO.
AGENT’S OR BROKER’S SIGNATURE DATE
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GARAGE RENEWAL PPLICATION ALL APPLICANTS (EXCEPT VIRGINIA): BY (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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