Quote Requested



FORMCHECKBOX Quote Confirmation Requested FORMCHECKBOX Binder/Certificate RequestedEvent Title: FORMTEXT ?????User Name: FORMTEXT ?????Mailing Address: (street) FORMTEXT ?????(city, state and zip) FORMTEXT ?????Event Contact Person: FORMTEXT ?????Contact Email Address: FORMTEXT ?????Contact Phone Number: FORMTEXT ?????Contact Fax Number: FORMTEXT ?????Type of Event: (refer to hazard schedule) FORMTEXT ?????Hazard Class: (choose one) FORMCHECKBOX I FORMCHECKBOX II FORMCHECKBOX IIILocation of Event: FORMTEXT ?????Date(s) of Event: FORMTEXT ?????Attendance Per Day: FORMTEXT ?????Total Attendance: FORMTEXT ?????Premium: (refer to rate list)$ FORMTEXT ?????Campus RM Contact: FORMTEXT ?????Campus RM Email: FORMTEXT ?????Campus RM Phone #: FORMTEXT ?????Campus RM Fax #: FORMTEXT ?????Coverage provided by JD Fulwiler & Company InsuranceEvents are not bound until approved - fax this questionnaire to (503) 977-5856 Attn Special Events OR scan and email to eventsupport@ for confirmation and approvalPremium checks are to be made payable to UW System Administration and sent to:ORM Attn Alisa Kemnitz, 780 Regent Street, Madison, WI 53715 ................
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