Forms

This page provides numerous forms, most of which require Adobe Acrobat to view and print.

• Agent Letter Example
  (This letter extends liability coverage to agents of the University who are acting within their scope of duties.)

• Agent Liability Coverage Request (PDF)
  (Requests that University professional liability coverage by extended to a named individual, performing specific services on behalf of the University.)

• Art Loan Agreement (PDF)
  (Contract which sets the terms and limitations of insurance coverage for art work loaned to the University.)

• Art Loss Report (PDF)
  (Claim documentation specifically for loss of art works.)

• Assumption of Risk, Release, and Indemnification (PDF)
  (A document signed by persons participating in special events, programs or field trips which releases the University from any liability resulting from injury to the person or property of the participant.)

• Camps and Clinics Forms

  • Camps and Clinics Accident Claim Form (PDF)
    (Completed by the parent or guardian of a camp or clinic participant in case of accident or injury.)

  • Consent for Medication/Consent for Medical Treatment (PDF)
    (Required for all camp/clinic participants under the age of 18 years; used for day and overnight camps.)

  • Health History Questionnaire (PDF)
    (Required for all camp/clinic participants under the age of 18 years; used for overnight camps only.)

• Driver's Authorization Form (PDF)
  (Establishes agency and driving record status of persons seeking to use State-owned vehicles.)

• General Incident Form (PDF)
  (Used to document and describe any type of personal injury or property damage incurred by non-employees.)

• Insured Packages (PDF)
  (Used to document and insure full value of University owned property in transit.)

• Mitchell Hall Indemnification & Liability Statement (DOC)

• Notarized Statement of Driving Record (PDF)
  (Verification of good driving by out-of-state license holders.)

• Property Loss Report (PDF)
  (Claim documentation for a property loss.)

• Release of all Claims (PDF)
  (Agreement which waives a claimant's rights to further legal action in exchange for a monetary settlement.)

• Request for Coverage-borrowed Items (PDF)
  (Requests coverage for property loaned to the University.)

• Special Events Insurance Application (PDF)
  (Purchases liability protection for organizations that host activities that are not included in the University's insurance program.)

• Van Driver Program - Training Exemption (PDF)
  (Provides instructions for requesting exemption from Van Driver Program.  Unless exempted, every UW-La Crosse employee, student and volunteer who uses a State-owned, leased or rental van capable of carrying 12 or more passengers for University business must complete a hands-on driving assessment.)

• Van Driver Program - Training Registration (PDF)
  (Provides instructions for scheduling Van Driver Program.  Unless exempted, every UW-La Crosse employee, student and volunteer who uses a State-owned, leased or rental van capable of carrying 12 or more passengers for University business must complete a hands-on driving assessment.)

• Waiver of Liability (PDF)
  (Acknowledgement of risks associated with participating in proscribed activities.)

• Worker's Compensation Forms
  (A link to University of Wisconsin System Administration OSLP Worker's Compensation home page.)

Back to top

Copyright 2008
University of Wisconsin-La Crosse
1725 State St. La Crosse, WI 54601
(608) 785-8000