Exhibitor

Name:

Phone:

Full Address: _________________________________________________________

_________________________________________________________

(Street)

(City) (State)

Exhibit

Information

Title:

Location:

Exhibit Dates:

Art Work

Identification

Title:

ATTACH A COPY OF INSURANCE DOCUMENTS IF NOT UNIVERSITY-OWNED

Description

Was this item for sale? _____ Yes _____ No

of Loss

Date of loss/incident: _______ Time: ______________ AM / PM

How was item secured in exhibit? _______________________________________

__________________________________________________________

If stolen, to which enforcement agency was this reported?

____________________________
When? __________________________

ATTACH A COPY OF THE POLICE REPORT FOR VANDALISM OR THEFT

Full description of loss (if stolen, also state time and place item was last seen before

discovered missing.)

_________________________________________________________

_________________________________________________________

_________________________________________________________

General

Provide proof of awards, prizes, or previous sales the artist has received to substantiate value of item lost: _________________________________________

Information

_________________________________________________________

_________________________________________________________

Signatures:

Exhibitor (if available): _______________________________________________

Exhibit Director: ____________________________________________________

___________

__________________________________________________________

Date of Report Signature

Department

EXHIBITOR Send to:

CAMPUS Send to:

UW-_________________________

UW System Risk Management

Office of Risk Management

780 Regent Street

Attn: __________

Madison, WI 53715