Safety & Loss Prevention

Camp & Clinic Reporting Form

Please complete this form for the specified period and return with the applicable premium amount to:

UW System Risk Management
780 Regent St. Suite 145
Madison, WI 53715-2635
(608) 263-4377

Period Ending		April 10
(circle one)		July 10
		October 10
		January 10

University of Wisconsin-_____________________________________



Total number of campers x weeks			(from back)	__________________
$.39/day/participant for one or two day camps w/no overnight stay $2.20/participant for camps lasting 3-7 days			* .39 or 2.20	__________________
			Total Premium Due	__________________

NOTE:	One rate applies to all camps regardless of the degree of hazard involved.

Make check payable to: UW System Administration