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CERTIFICATE OF COVERAGE
STATE OF WISCONSIN

This is to certify that coverage described below is effective per the Statutory authority referenced. This certificate is not a policy or a binder of insurance and does not in any way alter, amend or extend the coverage afforded by any reference herein. The coverage is subject to all terms and conditions of the statutory authority.

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STATE AGENCY: Board of Regents of the University of Wisconsin System 780 Regent Street Madison, WI 53715	CAMPUS NAME:
	DATE ISSUED:

The entry of an XX in this column means that the coverage is afforded per this certificate and the statute referenced.

KIND OF COVERAGE	XX	STATUTORY REFERENCES
Workers' Compensation
Liability
Automobile Liability
Property

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DATES OF COVERAGE:

DESCRIPTION OF COVERAGE:

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ISSUED TO:	|	ISSUED BY:
	|
	|	Signed:__________________________________
	|	Campus Risk Manager