Holder Identifier : 7777777707070700077763616065553330743516777305577507453115562735021073660777146321120772627133247031007726431510036132071062731306323100734005575227475007566435736276550077727252025773110777777707000707007 6666666606060600062606466204446200622222426204200206222006240042202062222042400600220622000424226022006220204042240002062222060420422000622020626206220006000066020662262066646062240664440666666606000606006 Certificate No : 570092957924
CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
05/03/2022
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: 570092957924 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 WVDINSR LTRADDL
INSD TYPE OF INSURANCE 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
PRO- JECT 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
OTH
- 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 / A N 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.
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:
570092957924
570092957924
Aon Risk Insurance Services West, Inc.
570000064250
ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.
INSURER
INSURER
INSURER
INSURER
INSURER(S) AFFORDING COVERAGE
Page _ of _
NAIC #
DocuSign, Inc.
TYPE OF INSURANCE
POLICY NUMBER LIMITS OTHER
C E&O-PL-XS 42EPP31498102 04/27/2022 04/27/2023 Limits $5,000,000 E&O XS 5Mxs5M
ADDL INSD
INSR LTR
SUBR WVD
POLICY EFFECTIVE DATE (MM/DD/YYYY) POLICY EXPIRATION DATE (MM/DD/YYYY) ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD