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HEAVY VEHICLE & EQUIPMENT QUESTIONNAIRE (Colonial General Insurance Agency, Inc)

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GAR-SUP129-0918 Page 1 of 2
This Questionnaire is supplemental to and part of the Colony Specialty Garage Application or the Colony
Specialty Garage Renewal Application.
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.
Business Trade Name: _______________________________________________________________________
1. What percentage of applicant’s operations involve. (Must total 100%)
Boom Trucks/Bucket Trucks %
Logging Trucks/Equipment %
Buses %
Military Vehicles %
Construction Equipment %
Mining Equipment * %
Municipal Vehicles %
Oilfield Equipment * %
Cranes %
Refrigerated Vans/Trailers %
Farm Equipment %
Semi-Trailers %
Farm Implements %
Tank Trailers/Tankers %
Forklifts %
Truck Tractors %
Lawn/Tree Service Equipment % Other * %
*Describe “Other” and type of equipment:
2. Where are applicant’s operations performed? (Must total 100%)
Your Shop %
Truck & Travel Center %
Customer’s Yard %
Roadside %
3. Type and Percentage of applicant’s work. (Must total 100%)
Body & Paint %
Repair Tank Trlrs (External) %
Blades/Cutting Equip/Chippers %
Snowplow Repair/Installation –
GVW of Vehicles: ___________
%
Brakes %
Subcontracted out to others %
Brakes - Logging Truck/Equipment %
Structural/Frame Modifications
Do you cut frames between the axles?
Yes No
%
Engine Overhaul %
Suspension/Frame Repairs %
Fabrication (Answer Question 7) %
Suspension - Logging Truck/Equipment %
FMCSA Safety Inspection
(Answer Question 8)
%
Tank Clean/Repair - Internal %
Hydraulics - General %
Tank Repair - External %
Hydraulics – Lifting Apparatus % Tire Repair or Replacement %
Lube & Oil % Tune Up %
Power Train %
Wash & Detail %
Radiator %
Other * %
Refrigeration Unit (Cargo Area) %
*Describe “Other” work in detail:
HEAVY VEHICLE & EQUIPMENT
QUESTIONNAIRE
GAR-SUP129-0918 Page 2 of 2
4. Does applicant install, service or repair 5
th
Wheels? Yes No
If “Yes”, what are the qualifications of the employees doing this work?
5. Are you and/or your mechanics ASE Certified? Yes No
If “No”, how many years of training and experience do you require? _____________________
6. Do you test drive extra-heavy trucks or truck tractors away from garage premises
Yes No
on public roadways?
If “Yes”, is at least one driver appropriately licensed with a CDL?
Yes No
7. What parts, equipment, and accessories do you fabricate?
8. If applicant does FMCSA annual vehicle safety inspections, answer the following:
a] Does Inspector understand the FMCSA inspection criteria?
Yes No
b] Has Inspector mastered the methods, procedures, tools and
Yes No
equipment used when performing an inspection?
c] Has Inspector successfully completed a State or Federal training program
Yes No
which qualifies him to perform commercial vehicle safety inspections?
d] Does Inspector have at least one (1) year of training and/or experience consisting of:
• participation in a manufacturer sponsored training program; or
• experience as a mechanic or inspector:
1] in a motor carrier maintenance program; or
Yes No
2] in a commercial garage; or
Yes No
3] for a State or Federal government?
Yes No
THIS SUPPLEMENTAL APPLICATION IS INCORPORATED BY REFERENCE INTO THE PRIMARY APPLICATION
APPLICANT’S SIGNATURE DATE
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HEAVY VEHICLE & EQUIPMENT QUESTIONNAIRE (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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