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This Questionnaire is supplemental to and part of (Colonial General Insurance Agency, Inc)

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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. Describe total operations by percentage including type of vehicles you sell or service
Ambulance __________%
Fire __________%
Police __________%
Other __________% List:_____________________________________________________
2. What percentage of applicant’s work is performed at?
Your Shop _________ %
Customer’s Location _________ %
3. What percentage of applicant’s operation is:
A. General service ___________ %
Brakes _______ %
Electrical _______ %
Engine Repair _______ %
Hydraulics - General _______ %
Maintenance/Preventive _______ %
Oil & Lube _______ %
Radiator _______ %
Suspension/Frame Repairs _______ %
Tire Repair or Replacement _______ %
Transmission _______ %
Tune Up _______ %
Wash & Detail _______ %
Other _______ % List: _________________________________________
B. Emergency Vehicle Specific __________ %
Aerial Ladder Service _______ %
Custom Vehicle Conversions _______ % Do you cut the frame between the axles? Yes No
Fabrication _______ % Answer Question 8
Ground Ladder Service _______ %
Hydraulics – Lifting apparatus _______ %
Ladders & Hoses _______ %
Lights, Sirens, Radios _______ %
Pump Service _______ %
Pump Testing _______ %
Tank Clean/Repair - Internal _______ %
Tank Repair - External _______ %
Other _______ % List: _________________________________________
Total: _______ % (Total of A & B must = 100%)
EMERGENCY VEHICLE &
EQUIPMENT QUESTIONNAIRE
GAR-SUP126-0117 Page 1 of 2
4. If any percentages listed in 3.B. above, provide details of:
Qualifications:
Experience:
Work Performed:
5. Do you install, sell or service medical equipment for ambulances or paramedic vehicles? Yes No
If yes, is this covered elsewhere? Yes No
6. Do you sell or service any durable medical equipment (power chairs, walkers, etc.)? Yes No
If yes, is this covered elsewhere? Yes No
7. Do you test drive extra-heavy vehicles off-premises on public roadways? Yes No
If yes, is at least one driver appropriately licensed with a CDL? Yes No
8. What parts, equipment, and accessories do you fabricate?
FRAUD WARNING
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.
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, declare that 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.
SIGN AND DATE
APPLICANT’S PRINTED NAME
APPLICANT’S SIGNATURE DATE
AGENT OR BROKER’S NAME LICENSE NO.
AGENT OR BROKER’S SIGNATURE DATE
GAR-SUP126-0117 Page 2 of 2
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Completed 22 August 2020

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