Holder Identifier : 7777777707070700077763616065553330743516777305577507453115562735021073660777146321120772627133247031007766075114032576075026331706723100730401571223471007166035772276110077727252025773110777777707000707007 6666666606060600062606466204446200622202406004020006202004062260022062200042400620020622200404224220206220026240262202062220242602600000622200406206202006222044002460042066646062240664440666666606000606006 Certificate No : 570092897878
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
04/29/2022
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
PRODUCER
Aon Risk Insurance Services West, Inc.
San Francisco CA Office
425 Market Street
Suite 2800
San Francisco CA 94105 USA
PHONE
(A/C. No. Ext):
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
(866) 283-7122
INSURED INSURER A: StarNet Insurance Company 40045
INSURER B: Berkley National Insurance Company 38911
INSURER C: National Fire & Marine Ins Co 20079
INSURER D: Endurance American Specialty Ins Co. 41718
INSURER E:
INSURER F:
FAX
(A/C. No.): (800) 363-0105
CONTACT
NAME:
DocuSign, Inc.
221 Main Street,
Suite 1000
San Francisco CA 941051925 USA
COVERAGES CERTIFICATE NUMBER: 570092897878 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
(MM/DD/YYYY)
SUBR
WVD
INSR
LTR
ADDL TYPE OF INSURANCE INSD POLICY NUMBER LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
POLICY LOC
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
X
X
X
GEN'L AGGREGATE LIMIT APPLIES PER:
$1,000,000
$1,000,000
$15,000
$1,000,000
$3,000,000
$3,000,000
A TCP700795716 04/27/2022 04/27/2023
PROJECT
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
SCHEDULED
AUTOS
HIRED AUTOS
ONLY
NON-OWNED
AUTOS ONLY
BODILY INJURY ( Per person)
PROPERTY DAMAGE
X X (Per accident)
BODILY INJURY (Per accident)
$1,000,000 A 04/27/2022 04/27/2023 COMBINED SINGLE LIMIT (Ea accident)
TCP700795716
EXCESS LIAB
X OCCUR
CLAIMS-MADE AGGREGATE
EACH OCCURRENCE
DED
$5,000,000
$5,000,000
04/27/2022 UMBRELLA LIAB A TCP700795716 04/27/2023
RETENTION
X
E.L. DISEASE-EA EMPLOYEE
E.L. DISEASE-POLICY LIMIT
E.L. EACH ACCIDENT $1,000,000
X
OTHER
B 04/27/2022 04/27/2023 PER STATUTE
$1,000,000
Y / N
(Mandatory in NH)
ANY PROPRIETOR / PARTNER / EXECUTIVE
OFFICER/MEMBER EXCLUDED? N N / A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
If yes, describe under
DESCRIPTION OF OPERATIONS below
$1,000,000
TWC700795518
NRO30006187401 04/27/2022 04/27/2023 Policy Aggregate
Claims-Made
D E&O-PL-Primary
SIR applies per policy terms & conditions
$5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance. Professional Liability policy includes Network Security, Privacy Protection and Cyber Liability policy.
CERTIFICATE HOLDER CANCELLATION
DocuSign, Inc. AUTHORIZED REPRESENTATIVE
221 Main Street, Suite 1000
San Francisco CA 94105-1925 USA
ACORD 25 (2016/03)
©1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
Additional Coverage
AGENCY CUSTOMER ID:
ADDITIONAL REMARKS SCHEDULE
LOC #:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance EFFECTIVE DATE:
CARRIER NAIC CODE
POLICY NUMBER
AGENCY NAMED INSURED
See Certificate Number:
See Certificate Number:
Aon Risk Insurance Services West, Inc.
570000064250
570092897878
570092897878
Page _ of _
DocuSign, Inc.
Coverage: E&O XS 5Mxs5M
Policy No.: EOC727719401
Policy Term: 04/27/21-04/27/22
Underwriting Company: Steadfast Insurance Company
Limits: $5,000,000
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD