Blanket Accident Insurance Program

Chubb Group of Insurance Companies
202B Hall’s Mill Road, P.O. Box 1650
Whitehouse Station, New Jersey 08889-1650

Policyholder’s Name and Mailing Address

State of Wisconsin/University of Wisconsin
101 E. Wilson
Madison, WI 53702

Policy Number: 9906-76-12

Effective Date: September 15, 2012

Issued by the stock insurance company indicated below.

Federal Insurance Company
Incorporated under the laws of

Producer Number: 0039202

Producer: Aon Risk Services, Inc. of Wisconsin
10700 Research Drive, Suite 450
Milwaukee, WI 53226

Company and Policy Period

Insurance is issued by the Company in consideration of payment of the required premium.

This policy begins and ends at 12:01 A.M. Standard Time at the Policyholder’s address on the dates shown below:

From: September 15, 2018

To: September 15, 2021

The Policyholder’s acceptance of this policy terminates any prior policy of the same number issued to the Policyholder by the Company, effective with the inception of this policy.

This Insuring Agreement, together with the Premium Summary, Schedule of Forms, Declarations, Contract, Hazards, Common Policy Conditions and Endorsements comprise this policy. If this policy is a renewal, we have only reissued to you those policy documents containing changes from your previous policy period coverages and any new additional coverages or policy provisions. All other policy documents continue in effect.

The Company issuing this policy has caused this policy to be signed by its authorized officers, but this policy shall not be valid unless also signed by a duly authorized representative of the Company.

FEDERAL INSURANCE COMPANY (Incorporated under the laws of Indiana)


This insurance document is furnished to you as a matter of information for your convenience. It only
summarizes the listed policy(ies) and is not intended to reflect all the terms and conditions or
exclusions of such policy(ies). Moreover, the information contained in this document reflects coverage
as of the effective date(s) of the policy(ies) and does not include subsequent changes. This document
is not an insurance policy and does not amend, alter or extend the coverage afforded by the listed
policy(ies). The insurance afforded by the listed policy(ies) is subject to all the terms, exclusions and
conditions of such policy(ies).