"Colony Specialty Automobile Vehicle Inspection Form"

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Colony Specialty Automobile Vehicle Inspection Form
Named Insured________________________________________ Policy Number: ________________________________ 
Address ___________________________________________________________________________________________ 
Vehicle Description (use a separate inspection form for each vehicle inspected):
Year 
Make 
Model 
GVW or Seating 
Serial Number
Odometer Reading
Capacity 
 
 
 
 
 
 
 
Select the appropriate Yes or No box for the Power Unit or Trailer to indicate if the following items are in good or 
acceptable working order or condition.   A comment is required for all No responses.  
Power unit:
Yes
No 
Yes
No 
1. Brakes (front & rear)      
9. Speedometer 
Yes
No   
Yes
No 
2. Brake Lights 
 
10. Steering 
Yes
No 
Yes
No 
3. Exhaust Pipe & Muffler 
11. Suspension 
Yes
No 
Yes
No 
4. Headlights 
 
12. Tail Lights 
Yes
No 
Yes
No 
5. Horn   
 
13. Turn Signals 
Yes
No 
Yes
No 
6. Mirror   
 
14. Windows 
Yes
No 
Yes
No
7. Odometer 
 
15. Wipers   
Yes
No 
8. Seat Belts 
 
Trailer:
Yes
No
Yes
No
1. Brakes   
 
 
4. Tail Lights 
 
 
Yes
No
Yes
No
2. Brake Lights 
 
 
5.  Connection w/tractor 
 
Yes
No
6. Turn Signals 
Yes
No
3. Suspension 
 
 
 
 
Provide comments for all No responses (indicate Power Unit or Trailer, numeric number of item and provide details). 
Use page 3 of the inspection form for any additional comments.  If problem has been repaired or corrected, attach 
copy of repair receipt or invoice to this inspection form. 
__________________________________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
Vehicle Inspection (Ed. 6/11)  
Page 1 
 
Colony Specialty Automobile Vehicle Inspection Form
Named Insured________________________________________ Policy Number: ________________________________ 
Address ___________________________________________________________________________________________ 
Vehicle Description (use a separate inspection form for each vehicle inspected):
Year 
Make 
Model 
GVW or Seating 
Serial Number
Odometer Reading
Capacity 
 
 
 
 
 
 
 
Select the appropriate Yes or No box for the Power Unit or Trailer to indicate if the following items are in good or 
acceptable working order or condition.   A comment is required for all No responses.  
Power unit:
Yes
No 
Yes
No 
1. Brakes (front & rear)      
9. Speedometer 
Yes
No   
Yes
No 
2. Brake Lights 
 
10. Steering 
Yes
No 
Yes
No 
3. Exhaust Pipe & Muffler 
11. Suspension 
Yes
No 
Yes
No 
4. Headlights 
 
12. Tail Lights 
Yes
No 
Yes
No 
5. Horn   
 
13. Turn Signals 
Yes
No 
Yes
No 
6. Mirror   
 
14. Windows 
Yes
No 
Yes
No
7. Odometer 
 
15. Wipers   
Yes
No 
8. Seat Belts 
 
Trailer:
Yes
No
Yes
No
1. Brakes   
 
 
4. Tail Lights 
 
 
Yes
No
Yes
No
2. Brake Lights 
 
 
5.  Connection w/tractor 
 
Yes
No
6. Turn Signals 
Yes
No
3. Suspension 
 
 
 
 
Provide comments for all No responses (indicate Power Unit or Trailer, numeric number of item and provide details). 
Use page 3 of the inspection form for any additional comments.  If problem has been repaired or corrected, attach 
copy of repair receipt or invoice to this inspection form. 
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Vehicle Inspection (Ed. 6/11)  
Page 1 
 
Tires (power unit or trailer):
                       
Condition: 
New  
Used  
Retreads; # of retreads_______      
 
Tread Depth:
 
Good 8/32 to 7/32 
 
Fair  6/32 to 5/32 
Poor  4/32 or less         
Comments (required if retreads or the tread depth is fair or poor): 
_________________________________________________________________________________________________ 
____________________________________________________________________________
Overall mechanical condition of the vehicle:
Excellent
Good
Fair
Poor
  
Comments (required if mechanical condition is Fair or Poor): 
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
Vehicle Alterations:
Yes
No
Comments (required if answer is Yes): 
__________________________________________________________________________________________________
__________________________________________________________________________________________________ 
General Appearance of Vehicle:
Excellent
Good
Fair
Poor
Comments (required if appearance is Fair or Poor): 
__________________________________________________________________________________________________
__________________________________________________________________________________________________ 
Important Note to insured: All necessary repairs must be completed within 30 days of the inspection or a
written explanation must be provided to your insurance carrier giving the reason for any delay to the repair of
the vehicle. A copy of the repair receipt or invoice must be provided to your insurance carrier within 30 days
of the repair to the vehicle. Failure to comply with these conditions may result in cancellation of your
insurance policy.
Inspection Facility:
By signing this inspection form you certify that you are an independent mechanic and not an employee of the
insured. You further verify that the answers and statements provided in this form are a result of your physical
inspection of the vehicle identified in the Vehicle Description section and are correct to the best of your
knowledge.
__________________
____________________________________
_______________________
Name of Garage
Address
State Inspection # (if applicable)
______________________
____________________________________________
____________________________
Date Inspected
Name of Inspecting Mechanic (please print)
Signature of Mechanic or Proprietor
Vehicle Inspection (Ed. 6/11)  
Page 2 
 
Additional comments (if any) related to items listed on pages 1 and 2 of this inspection form:
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Vehicle Inspection (Ed. 6/11)  
Page 3 
 
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