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Enter Keyword:
State of Wisconsin - Report of Shipment
Request for Marine Insurance Coverage
BSRM Ref #:
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x:Invalid Org Codes
Department/Division:
Contact:
Project:
Phone:
Ex. 444-444-4444
State or University Owned Property:
Yes
No
Declared Value:
Total estimates value of shipment of property being shipped.
Shipment Destination:
Property Description:
(Detailed with current values)
Enter each mode of transportation that will be used to transport shipment from start to final destination. ALL FIELDS REQUIRED
1st Conveyance Carrier Information:
Name of Carrier:
Phone:
Ex. International: 011-11-123-456-7890; Domestic: 555-555-5555
Role:
Vendor
Carrier
Broker
Forwarder
Earliest Departure Date:
Format: 06/26/2008
Latest Departure Date:
Format: 06/26/2008
1st Departure Point:
Method of Transport:
Air
Ship
Truck
Rail
Other
2nd Conveyance Carrier Information:
(If 2nd Conveyance Carrier is applicable, then ALL FIELDS REQUIRED)
Name of Carrier:
Phone:
Ex. 444-444-4444
Role:
Vendor
Carrier
Broker
Forwarder
Earliest Departure Date:
Format: 06/26/2008
Latest Departure Date:
Format: 06/26/2008
2nd Departure Point:
Method of Transport:
Air
Ship
Truck
Rail
Other
3rd Conveyance Carrier Information:
(If 3rd Conveyance Carrier is applicable, then ALL FIELDS REQUIRED)
Name of Carrier:
Phone:
Ex. 444-444-4444
Role:
Vendor
Carrier
Broker
Forwarder
Earliest Departure Date:
Format: 06/26/2008
Latest Departure Date:
Format: 06/26/2008
3rd Departure Point:
Method of Transport:
Air
Ship
Truck
Rail
Other
Requesting Property Coverage at Destination?
No
Yes
Coverage Dates:
From:
To:
Format: 06/26/2008
Location
(If different than final destination above):
Who is your Risk Management Contact?
(Select appropriate Contact)
2 YR COLLEGES - Denny Ward
ADMINISTRATION - Dawn Ringelstetter
AGRICULTURE - Tom Putzer
CIRCUS WORLD - Gary Baker
COMMERCE - Barry Wanner
CORRECTIONS - Sharon Wolter
DWD - Deb Stapleton
ECB - Larry Dokken
H&FS - Brenda Clifton
HISTORICAL SOCIETY - David Seligman
JUSTICE - John Martin
MILITARY AFFAIRS - Julie White
NATURAL RESOURCES - Karen Kreger
PUBLIC DEFENDER - Arlene Banoul
PUBLIC INSTRUCTION - Joel Chapiewsky
REVENUE - Blanca Rivera
STATE FAIR PARK - Pat Hedden
TRANSPORTATION - Hal Galbraith
UW EAU CLAIRE - John Baltes
UW EXTENSION - Luis Fernandez
UW GREEN BAY - Jane Rank
UW HOSPITALS - Deb Ankowicz
UW LA CROSSE - Barry Miller
UW MADISON - Margaret Hoffman
UW MILWAUKEE - Angie Ogan
UW OSHKOSH - Jim Johnson
UW PARKSIDE - Steven Carlson
UW PLATTEVILLE - Tom Pritchett
UW RIVER FALLS - Connie Smith
UW STEVENS POINT - Jeff Karcher
UW STOUT - Sheila Forrest-DeSmith
UW SUPERIOR - Jan Hanson
UW WHITEWATER - Ernest Stracener
UW-SYSTEM DIR. - Dave Pulda
VETERANS AFFAIRS - Hope Koprowski
Who Else Should Receive a Copy of this Request?
Add appropriate email addresses separated by a ";"
Verification Text:
Enter the
red
text below into the adjacent form field then press "Submit".
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Enterprise Operations
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Madison, Wisconsin 53703-3405
FAX: 608-267-0600
DOAWebMaster@wi.gov
