COVERAGE REQUEST OF BORROWED ITEMS UNIVERSITY OF WISCONSIN –

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COVERAGE REQUEST OF BORROWED ITEMS

COVERAGE REQUEST OF BORROWED ITEMS


UNIVERSITY OF WISCONSIN – WHITEWATER


Department Requesting Coverage:      


Department Head:      


Name of Program or Project:      


Dates of Coverage:   /  /   to   /  /   Coverage Requested: [] General [] Movable


List of Items Borrowed (list below or attach list):


DESCRIPTION OF ITEM ____ NAME/ADDRESS/PHONE OF OWNER____ EST. VALUE


     _____________________      _______________________________      _____


     _____________________      _______________________________      _____


     _____________________      _______________________________      _____


TOTAL:      _____


Location of Item During Loan Period:      


Security Arrangements Made:      


Person Responsible for Security of Item (s):


_______________________________________ _____________________________________

(Name) (Title)


_______________________________________ _____________________________________

(Address) (Phone)


Coverage on the borrowed items is the same as the University has for similar items that are owned by the University. It is insured for its replacement value at time of loss, less the deductible. The dollar amount shown after each item on the list of items to be insured is the maximum amount that would be paid out for a total loss, less the deductible. This does not mean the maximum is paid out automatically.


It is in order to consider opinions of experts, general availability, intrinsic value and any other relevant information to determine the value at the time of loss. It would be wise to have a professional appraisal of any items that are extremely rare or even irreplaceable before these items are turned over to the University.


Coverage is effective when request form is received and approved by Risk Management and Safety, University of Wisconsin-Whitewater, Hyer Hall Room 330.


______________________________________ _____________________________________

(Owner’s Signature) (Department Head’s Signature)


______________________________________ _____________________________________

(Date) (Risk Management & Safety Director)


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