Blanket Accident Insurance Program

Chubb Group of Insurance Companies
15 Mountain View Road, P.O. Box 1615
Warren, New Jersey 07061-1615

Policyholder’s Name and Mailing Address

State of Wisconsin/University of Wisconsin
101 E. Wilson, 8th Floor
Madison, WI 53702

Policy Number: 9906-76-12

Effective Date: September 15, 2015

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, 2015

To: September 15, 2018
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)