Safety & Loss Prevention
EVENT INFORMATION QUESTIONNAIRE
University of Wisconsin TULIP Program
EVENT INFORMATION QUESTIONNAIRE
Event Title/User Name _____________________________________
Mailing Address _____________________________________
_____________________________________
Contact Person _____________________________________
Telephone/Fax No. _____________________________________
(Refer to hazard schedule)
Location of Event
Date(s) of Event _____________________________________
Attendance/Day _______________ Total Attendance __________________
(Refer to rate list)
Premium ____________
Campus RM Contact
Events are not bound until approved.
Premium checks are to be
made payable to
Send to: OSLP, Attn. Pam Buchen, 780 Regent Street, Madison, WI 53715-2635.
Coverage
provided by Gales Creek Insurance Services
Fax questionnaire to 503/227-0927