Borrowed Property Insurance Request Form

Complete and submit the following form to assure property insurance coverage for non-owned items that are borrowed from external parties. In addition, a final, signed agreement and any pertinent information not included in this form must be emailed to Risk Management at insuranceinventories@bussvc.wisc.edu.

If you plan to borrow an art exhibit from an external party, do not complete this form. Each artist or owner must submit to UW–Madison Risk Management: a signed Art Exhibit Coverage Request Form, an itemized listing of the works to be exhibited by name or description, and an individual value for each item.

Submitter information

Submitter name(Required)

Submitter email(Required)

Submitter phone number

UW–Madison School/College/Division name

Borrowed property details

Has a borrowed loan agreement been reviewed with the UW Capital Equipment team?(Required)

Yes

Proposed loan/borrowed property agreements are to be first submitted to UW–Madison Capital Equipment (at property@bussvc.wisc.edu) for the signature authority process. Capital Equipment will then coordinate review of the agreement with Legal, Risk Management, and Purchasing, as necessary.

The final signed agreement should then be emailed to Risk Management at insuranceinventories@bussvc.wisc.edu to secure insurance coverage as discussed above. Coverage may not be provided unless this is complete.

Borrowed item(s) description(Required)

If necessary, use the plus symbol to the right to add additional items.

Make

Model

Serial number

Replacement dollar value

Lender organization name(Required)

Lender representative name(Required)

Lender representative email address(Required)

Lender organization's business address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Note: For borrowed loan agreements that require multiple loan periods, a new form must be submitted for each loan period.

Start of loan period(Required)

End of loan period(Required)

Will UW-Madison be responsible for transit coverage?(Required)

Yes

UW–Madison is expected to report all shipments (foreign, domestic, and carry-on) valued at $50,000 and greater via the State of Wisconsin Report of Shipment Request for Marine/Cargo Insurance Coverage Form.

This should be done at least 72 hours prior to time of shipping.

Be sure to keep all transit records within the department in case a loss occurs.

Responsible UW employee information

Information about the UW–Madison employee responsible for custody of the asset/property while in UW–Madison possession.

Responsible UW School/College/Division(Required)

Responsible UW School/College/Division employee(Required)

Responsible UW School/College/Division employee email(Required)

Borrowed asset location(Required)

Location of borrowed asset while in UW–Madison possession.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The requesting School/College/Division will be responsible for property claim submissions, deductibles, and will be financially responsible for any property claim not covered by the State of Wisconsin Self-Funded Property Program (SSPP).

Please send a final, signed borrowed loan agreement and any pertinent information not included in this form to Risk Management at insuranceinventories@bussvc.wisc.edu.

This field is for validation purposes and should be left unchanged.