University of Wisconsin – Stout

                                                                           AGENT LIABILITY REQUEST

On

Campus

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) 

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 ?    Yes_______No_________

6. Are the services or training performed entirely on campus? Yes_______No_________  

(explain off campus activities)__________________________________________________

7. Are the services being performed by the student/volunteer under the supervision of a University employee? Yes ____ No_____        If the answer is yes, does the University:  

    Appoint the student/volunteer? Yes ___ No ___ 

    Provide supervision similar to that provided to an employee ? Yes ___ No ___

    Schedule when the student/volunteer will perform the duties? Yes ___ No ___

    Evaluate student/volunteer performances?     Yes ___ No ___ 

    Dismiss unsatisfactory performers?    Yes ___ No ___

8. Describe the program:______________________________________________________

_________________________________________________________________________

9. For the program described above, state clearly the duties and responsibilities of the individuals for whom agent liability protection is being requested:_____________________________________

____________________________________________________________________________________________________________________________________10. Describe the qualifications of the individual to perform the above duties and responsibilities: ___________________________________________________________________________________________________________

____________________________________________________________________________________________________________

11. Explain the direct and substantial benefits to the University from this particular program:______________________________________________________________________________________________________________________

Submitted by:________________________________ ___________________ ___________