BOARD OF REGENTS OF THE UNIVERSITY OF WISCONSIN SYSTEM
As Represented By
University of Wisconsin - Stout
Safety
& Risk Management
Services
Based on the information obtained from the Agent Liability Qualification Statement, I request that consideration be given to extending liability coverage to qualified individuals as agents of the University of Wisconsin (State of Wisconsin) as outlined in the answers supplied for the specific questions noted below. Any additional information I feel would be helpful in your determination as to whether this program and those qualified individuals participating therein appear to meet the intent of Wisconsin Statutes Section 895.46(1) is also enclosed.
1. Specific name of program:__________________________________________________
2. Duration of program: from________________________to_____________________
(month, day, year) (month, day, year)
3. What University office or department supervises the services performed?____________________________________________________________________
4. What is the approximate number of individuals for whom agent liability protection is requested? ___________________________________
5. Is the student/volunteer for which agent liability protection is being requested paid a salary, wage, or stipend for services performed? _____________
6. Does the outside organization demand that liability coverage be extended to the student/volunteer prior to performing the service? ____________________________
NOTE: If the answer is yes and it is not a system wide agreement having already been approved, then attach a copy of the pertinent provisions of the contract or agreement language so that it, too, may be evaluated.
7. For services or training being performed off the University property, who selects the site/organization? ___________________________________________________
_____________________________________________________________________
8. Explain what methods are used in the site/organization selection. _______________
_____________________________________________________________________
_____________________________________________________________________
9. Name(s) of site/organization selected._______________________________________
_____________________________________________________________________
10. Who selects the supervisor at the site/organization to which the student/volunteer is assigned? __________________________________________________________
11. Once the site/organization and supervisor is selected, does the University:
Have direct cooperation with the immediate supervisor of the trainee at the site/organization?
Yes__ No___
Make sure the site/organization supervisor evaluates our trainees? Yes__ No___
Evaluates the site/organization to determine participation in the future? Yes__ No___
Evaluate the site/organization supervisor? Yes__ No___
Evaluate the trainee while at the site/organization? Yes__ No___
12. Describe the program: __________________________________________________
____________________________________________________________________
____________________________________________________________________
13. For the program described above, state clearly the duties and responsibilities of the
individuals for whom agent liability protection is being requested: ______________
___________________________________________________________________
___________________________________________________________________
14. Describe the qualifications of the individual to perform the above duties and
responsibilities: ______________________________________________________
____________________________________________________________________
____________________________________________________________________
15. Explain the direct and substantial benefits to the University from this particular
program: ____________________________________________________________
____________________________________________________________________
____________________________________________________________________
Submitted by:
______________________________________________________ ___________
Signature Job Title Date