CONTOH STUDI KELAYAKAN BISNIS STU

(1)

PLACING SLIP

Reff No : 00/AIAIAJM- PSA/A00/A

Kepada : Divisi Tehnik KP

Dari : KP Janjarmasin

Tanggal : 0A Oktober 00/A

Perihal : Permohonan Persetujuan Ikseptasi PSKIA

In. Tn.Tegak Sukma Judiman

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan akseptasi atas penutupan dengan data sebagai berikut :

Nama Tertanggung : Tn.Tegak Sukma Judiman

Ilamat : Ml. Pegadaian No./9 RT 0I Janjarmasin Kalsel

Letak Risiko : Ml. Pegadaian No./9 RT 0I Janjarmasin Kalsel

Okupasi : Gudang Pribadi ( 0937/)

Periode : / Tahun

Nilai Pertanggungan : Jangunan : Rp. 700.000.000,

Stok Jarang : Rp. 4.000.000.000,

(Stok barang berupa : kelontong kosmetika,produk baby cusson, bambi,fambo,sofe,karpet

plastik,ITK, payung)

Kelas Kontruksi : Kelas 3

Risiko Sendiri : /0 % of TSA for Flexas

Tarif premi : 0,040 %o

Out Go : /A %

Underwriting Anfo : LAR : Nil untuk A tahun terakhir

Subject to survey

Existing di Is. Jerdikari (copy polis terlampir) House keeping yang baik

Demikian kami sampaikan atas perhatian dan kerjasamanya kami ucapkan terima kasih.

Hormat kami,

Parlin.S A -aisarah

(2)

PLACING SLIP

Reff No : 004AIAIAJM- PSA/A00/A

Tanggal : 06 Oktober 00/A

Perihal : Permohonan Persetujuan Ikseptasi -achinery Jreakdown

(-J) dan Loss

of Profits (JA) Following -achinery Jreakdown

In. PT.Idiquatro Elektrikindo Perkasa

Dengan hormat,

Type OF Cover : -achinery Jreakdown (-J) and Jusiness Anteruption

(JA) following

-achinery Jreakdown

Name of Ansured : PT.Idiquatro Elektrikindo Perkasa

Iddress of Ansured : Ml. Lambung -angkurat No.7 Janjarmasin – Kalimantan Selatan 70///

Plant A Risk Iddress : Terlampir

Period of Ansured : /0 -onths

From November 0A, 00/A to November 0A, 00/6

Sum Ansured : Terlampir

Plant name : PT.Idiquatro Elektrikindo Perkasa

Occupation : Power Plant

Anterest Ansured : Section I – MACHINERY BREAKDOWN

The sum insured must be represent the new replacement value of the

machinery to the maintenance and overhaul plus the contractor’s fee.

Section II – BUSINESS INTERUPTION

Loss of gross profit and increase in cost of working from interruption and

interference in the business arising from any cause indemnified under

section A.

Andemnity Period : 06 -onths

Deductible : Section I – MACHINERY BREAKDOWN

/0 % each and every loss, minimum ADR. /00.000.000,

Section II – BUSINESS INTERUPTION

Time excess for JA following -J 30 days minimum ADR./00.000.000, a.o.a

and a.o.l

(3)

Rate : -achinery Jreakdown : 0,30 % Jusiness Anteruption : 0,00 %

Out Go : 0A %

Clauses :

/. Ippraisement Clause 0. Iverage Relief Clause 3. Jankers Clause

4. Capital Idditions Clause A. Currency Clause

6. Cyber Non Iggregation Cluase N-I 09/A 7. Deferred Premium Clause

8. Dispute Clause (IIUA No./6AIIUAA00/0)

9. Electronic Date Recognition Exclusion (Edre) Clause /0.Endorsement 00/ Cover For Loss or Damage Due to

Strike, Riot and Civil Commotion (SRCC) //.Errors Ind Omissions Clause

/0.Fire Jrigade Charges

/3.Fire Extinguishing Costs Clause

/4.General Exclusion of Software and year 0000 – Problems

/A.Loss Notification Clause

/6.Nominated Loss Idjusters Clause /7.Payment of Premium Warranty /8.Payment on Iccount Clause /9.Reinstatement Value Clause 00.Removal Of Debris Clause 0/.Waiver Clause

00.Cover For Extra Charge For Overtime,Night Work,Work On Public Holidays,Express Freight Prorata Cancellation Clause

03.Anstallment Clause

Underwriting Anfo : LAR : Nil untuk A tahun terakhir; Subject to survey;

House keeping yang baik;

Pembayaran Anstallment 6 termin; Existing di Is.Wahana Tata;

TAC disesuaikan dengan existing dari Iswata; Potensi premi dari perusahaan tsb diatas sekitar 0,A -Atahun.

Hormat kami,

Parlindungan S A -aisarah

(4)

PLACING SLIP

Reff No : 00AAIAIAJM- PSA/A00/A

Tanggal : /3 Oktober 00/A

Perihal : Permohonan Persetujuan Ikseptasi -otor Vehicle

In. Dewi Indreana

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan Kantor Pusat untuk akseptasi atas penutupan -otor Vehicle dengan data sebagai berikut :

Nama : Dewi Indreana

Ilamat : Ml.Jelitung darat No.78 Rt.0/0, Kel.Jelitung Utara,

Kec.Janjarmasin Jarat,

Kota Janjarmasin.

-erk & Type : Kijang Annova G

Tahun Pembuatan : 00/0

Nomor Polisi : DI 80/A DO

Nomor Rangka : -HF/W40G4C003008A

Nomor -esin : /TR7349473

Menis Kendaraan : -inibus

Luas Maminan : Gabungan + TMH Pihak AAA Rp.00jt

Harga Pertanggungan : Rp.0/0.000.000,

Penggunaan Kendaraan : Pribadi

Periode : /3 Oktober 00/A sAd /3 Oktober 00/6

Rate : Gabungan : /,40 %

TMH sAd 00 jt : / %

Out Go : 0A %

Resiko Sendiri : Rp.300.000, per kejadian

Underwriting Anfo : Penggunaan mobil dengan supir pribadi

Subject to survey ( Foto terlampir )

Penempatan mobil dimasukkan ke garasi Irea penggunaan mobil di kota Janjarmasin

Demikian kami sampaikan, atas perhatian dan kerjasamanya kami ucapkan terima kasih.

Hormat Kami,

(5)

Parlindungan.SA-aisarah

PLACING SLIP

Reff No : 006AIAIAJM- PSA/A00/A

Tanggal : /6 Oktober 00/A

Perihal : Permohonan Persetujuan Ikseptasi Public Liability

In. PT.Panca Pastika -andiri

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan Kantor Pusat untuk akseptasi atas penutupan Public Liability dengan data sebagai berikut :

CLISS OF ANSURINCE : PUJLAC LAIJALATY POLACY

ANSURED : PT.Panca Pastika -andiri

IDDRESS : Ml.Prof.Dr.Soepomo No./AI Tebet

Makarta Selatan

SCOPE OF WORK : Iccess System -aintenance (at Cikarang site)

PERAOD OF COVER : / Mune, 00/A – 3/ -ay, 00/6

both dates inclusive at /0.00 o’clock local time

COVERIGE : To Andemnify the Ansured against all sums which the Ansured

shall

become legally Liable to pay in respect of :

Iccidental Jodily Anjury to Third Party andAor Iccidental Loss or Damage to Third Party Property Happening in connection with the business or occurring within the territorial limits during the period of insurance, subject to Standard Policy Exclusion

TERRATORAIL LA-AT : Andonesian Territory

LA-AT OF LAIJALATY : Jodily Anjury : ADR 0A,000,000 any one

person

ADR 0A0,000,000 any one accident

Property Damage : ADR 0A0,000,000 any one

accident

Combined single limit : ADR /,000,000,000 any one accident

and in aggregate for the hole period of insurance

DEDUCTAJLE : An respect of Jodily Anjury : NAL

An respect of Property Damage : ADR

0A,000,000 a.o.a

CLIUSES : Andonesia Murisdiction Clause

Ibsolute Isbestos Exclusion Clause Ibsolute Pollution Exclusion Clause Notice Cancellation Clause

Loss Notification Clause

RITE PRE-AU- : 0,0A %

OUT GO : 3A %

(6)

UNDERWRATANG ANFO : Perusahaan sudah berpengalaman Hubungan yang baik dengan sumber bisnis Demikian kami sampaikan, atas perhatian dan kerjasamanya kami ucapkan terima kasih.

Hormat kami,

Parlindungan.SA-aisarah

PLACING SLIP

Reff No : 0/0AIAIAJM- PSA/A00/A

Tanggal : 04 November 00/A

In. Tn.Herman Susilo

Dengan hormat,

Nama Tertanggung : Tn.Herman Susilo

Ilamat : Ml. Soetoyo.S GG. Taruna AAA No.0A RT /8

Janjarmasin Kalsel

Letak Risiko : Ml. Soetoyo.S GG. Taruna AAA No.0A RT /8 Janjarmasin

Kalsel

Okupasi : Gudang Pribadi ( 0937/)

Periode : / Tahun

Nilai Pertanggungan : Jangunan : Rp. 7A.000.000,

Stok Jarang : Rp. 700.000.000,

(Stok barang berupa : Jarang Elektronik Dan Spare Part Elektronik)

Kelas Kontruksi : Kelas 3 (Kayu Papan ulin, lantai Ulin, Itap

Seng)

Tarif premi : 0,040 %o

Out Go : /A %

Subject to survey

(7)

Hormat kami,

Parlin.S A Faisal Rachman

PLACING SLIP

Reff No : 0//AIAIAJM- PSA/A00/A

In. Abu Hajjah -uslihah

Dengan hormat,

Nama Tertanggung : Abu Hajjah -uslihah

Ilamat : Ml. Galuh Sari No.06 RT /3 Janjarmasin Kalsel

Letak Risiko : Ml. Galuh Sari No.06 RT /3 Janjarmasin Kalsel

Okupasi : Rumah Tinggal ( 0976)

Periode : / Tahun

Nilai Pertanggungan : Jangunan : Rp. 3A0.000.000,

Anventaris : Rp. /00.000.000,

Kelas Kontruksi : Kelas 3 ( Kayu Papan UlinAPlesteran, Lantai

Keramik, Itap Seng)

Tarif premi : 0,AA80 %o

Out Go : /A %

Subject to survey

(8)

Hormat kami,

Parlin.S A Faisal Rachman

PLACING SLIP

Tanggal : /8 November 00/A

Perihal : Permohonan Persetujuan Ikseptasi Heavy Equipment

In. PT.Cipta Sarana -akmur

Dengan hormat,

Type OF Cover : Heavy Equipment Ansurance

Name of Ansured : PT. Cipta Sarana -akmur

Iddress of Ansured : Ml. I. Yani, K-. // Janjarmasin

Plant A Risk Iddress : Kalimantan selatan & Kalimantan Tengah

Period of Ansured : 03 -onths

From November 03, 00/A to Februari 03, 00/6

Plant name : PT. Cipta Sarana -akmur

Occupation : -ining, Driling etc, untuk pembukaan Lahan Sawit

(Reclearing Hutan untuk

Lahan Sawit) dan Konstruksi MalanAJangunan

Anterest Ansured :

/. Jrand : Komatsu

Type : Wheel Loader WIA00 3

Year Juilt : 00/4

Serial No : A4006

Colour : Kuning

0. Jrand : Hitachi Hyadraulic Excavator

Type : Z/0/0F AG

Year Juilt : 00/3

Engine No : DCDF0C00060876

3. Jrand : Hitachi Hyadraulic Excavator

Type : Z/0/0F AG

Year Juilt : 00/3

Engine No : DCDF0C00060877

Klausula : /. Iverage relief clause 8A%

0. New Replacement Value

(9)

3. Exclude off Shore & underground Construction andAor activies 4. EDRC “I”

A. Cover on site project only 6. Excluding third party liability

Warranted that the insured object shall not used on bargeApontoon or other water vehicle.

7. Constructive total loss (/00% of ICV)

8. No Cover whils on bargeApontoonALCT (working andAor in transit, including loading and unloading)

9. Excluding third party liability

/0.Equipment shall be operated by experience and skilled program

//.Warranted skilled and lisenced operator /0.Extension IOG Clause

/3.Expressed continuing warranty /4.Expressed sabotage & terrorism /A.Anvoice by authorized dealer

/6.Waranted that the insured object has not police registration number and not use on public road

/7.Tertanggung di wajibkan menginformasikan kepada

penanggung setiap perpindahan alat berat dari satu lokasi ke lokasi lain, paling lambat 3x 04 jam sejak alat berat itu di pindahkan dari lokasi awal.

/8.Theft must be forcible

/9.Provide detail of HE ( engine & chassis)

00.Subject to security guard warranty 04 hours when HE not in use

0/.Loss notification clause /4 days

00.-aintenance standard and good operation 03.Not operated on barge A pontoon andAor vessel 04.Operated by skilled and authorized personel 0A.Cyber risk excluding clause

06.-aksimum jarak inland transit / (satu) kilometer (K-) 07.Premium payment warranty /A hari

08.Cover including inland transit (-ax. A times movement) 09.Terrorism exclusion clause. Kondisi Pertanggungan : Comprehensive+IOG+Anland transit. Objek Pertanggungan : 3 Unit Ilat Jerat

Harga Pertanggungan : Rp. 4.138.000.000,00 terdiri dari :

Komatsu : Rp. /,8A0,000,000,00 Hitachi Hydraulic Excavator : Rp. /./44.000.000,00 Hitachi Hydraulic Excavator : Rp. /./44.000.000,00

Rate : 0,0%

(10)

Jrokerage : 0A%

Underwriting Anfo : LAR : Nil untuk 0 tahun terakhir;

Existing di Is. Ramayana Tbk dan -itra -arpaya Tbk

Di operasikan oleh tenaga berpengalaman, dan berlisensi

Perusahaan tersebut memiliki 08 unit alat berat yang rencananya apabila jatuh tempo dari perusahaan Isuransi lain akan di berikan ke Isuransi Antra Isia serta aset lainnya

Hormat kami,

Parlindungan S A Faisal

PLACING SLIP

Tanggal : /8 November 00/A

In. PT. Panca Pastika mandiri

Dengan hormat,

Nama Tertanggung : PT. Panca Pastika mandiri

Ilamat : Ml. Kalibata Andah Im /4, Ml. Rajawali indah,

jakarta Selatan

Letak Risiko : Ml. Kalibata indah I-./4 RtARw:007A06 jakarta Selatan

Okupasi : Kantor A 097/

Periode : / Tahun

Nilai Pertanggungan : Jangunan Lantai 0 : Rp.

/.000.000.000,

Anventaris kantor : Rp. A00.000.000,

Stok Jarang : Rp. /.A00.000.000,

Jumlah : Rp.

3.000.000.000,-Kelas Kontruksi : Kelas /

Tarif premi : 0,438%

Out Go : /A %

Underwriting Anfo : LAR : Nil;

(11)

Obyek yang dipertanggungkan terletak di kawasan perkantoran.

Hormat kami,

Parlin.S A Faisal

PLACING SLIP

Perihal : Permohonan Persetujuan Ikseptasi PSKIA In. SAKET

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan akseptasi kantor pusat atas penutupan dengan data sebagai berikut :

Nama Tertanggung : Siket

Ilamat : Komp. Ruko No. 0/ 00 03 30 Pasar Jaru

Jarabai Kalimantan

Selatan

Letak Risiko : Komp. Ruko No.0/ 00 03 30 Pasar Jaru Jarabai

Kalimantan

Selatan

Okupasi : Toko A 0934

Periode : 0 Desember 00/A sampai 0 Desember 00/6

Nilai Pertanggungan : Jangunan Ruko : Rp.

/.A00.000.000,

Stok Jarang dagangan : Rp. 3.300.000.000,

Jerupa Kelontongan

Perabot Rumah Tangga : Rp. 000.000.000,

Tarif premi : FLE/IS :/,A0 %o

RS-D :0,A0 %o

Flood :0,A0 %o

(12)

Out Go : /A %

Luas Maminan : FLE/IS + RS-D + Flood

Resiko Sendiri : FLE/IS : Nil

RS-D : /A% of Claim -in Rp./A.000.000, Flood : /0% of Claim -in Rp./0.000.000,

Underwriting Anfo : LAR : Nil (A tahun terakhir)

Existing Polis dari Is. Josowa Periskop Foto Survey Terlampir

Toko tersebut sebagai Toko grosiran

Daerah tersebut belum pernah mengalami kebanjiran

Lokasi Toko di daerah Komplek pertokoan bukan daerah pasar

Hormat kami,

Parlin.S A Faisal

PLACING SLIP

Reff No : 0/AAIAIAJM- PSA/A00/A

Perihal : Permohonan Persetujuan Ikseptasi -OP Isuransi

Pengangkutan

In. PT. KOJE/ANDO TRICTORS JINMIR-ISAN

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan akseptasi kantor pusat atas penutupan dengan data sebagai berikut :

Menis Isuransi : Polis Standar Isuransi Pengangkutan Jarang

Andonesia

Menis Polis : -arine Cargo Open Policy

Nama Tertanggung : PT. KOJE/ANDO TRICTORS

Ilamat : Ml. I. Yani Km.0/, Landasan Ulin Jarat Kecamatan

Liang Inggang,

Prov. Kalimantan Selatan 70703

Menis Pengangkutan : Pengangkutan LautAudaraAdarat

Rute Pengangkutan : Dari : Janjarmasin

Tujuan : di seluruh daerah di Andonesia (Andonesia Teritorial)

Ilat Ingkut : Kapal JesiAJaja dengan minimum /00 GRT and

maximun 30

(13)

tahun, antended with JKA Classification Kapal Kayu maximum /0 Tahun dengan min /00 GRT (Kapal Kayu khusus untuk angkutan sungai) Pesawat

TruckATrailer

Jarang yang Diangkut : Spare partsA-esin (List of Spare partsAEngine should be declared)

-ax. ADR A.000.000.000, Untuk kapal besiAbajaAPesawat -ax. ADR 7A0.000.000, Untuk kapal berkonstruksi kayu

Harga Pertanggungan : ADR. A.000.000.000, untuk pengangkutan

kapal besiAPesawatATruckATrailer. ADR. 7A0.000.000, Untuk pengangkutan kapal kayu

Luas Maminan : a. Maminan Satu dan Tiga

b. Anstitute Cargo Clause (Iir) /A/A80 for Iir craft c. Total Loss Only (TLO) port to port for wooden vessel

Tarif Premi : 0.00 % untuk pengangkutan kapal

besiAbaja,kondisi :

Maminan satu (Ill Risk)

0,03 % untuk pengangkutan kapal besiAbaja dari 3/ 40 tahun : jaminan satu (Ill Risk)

0,/8 % Untuk pengangkutan kapal besiAbaja,Kondisi : Maminan Tiga

0,0AA % untuk pengangkutan kapal kayu, Kondisi : TLO dari pelabuhan ke pelabuhan

0,00 % Untuk pengangkutan TruckATrailer, Kondisi : jaminan satu (Ill Risk)

Risiko Sendiri : /% of T.S.A

Premium Warranty : The Premium will be paid within 7 days after the date of policy insurance

Klausula : institue Classification Clause 0/A0/A000/

amended JKA

Class as applicable Maminan satu dan Tiga Anstitute Cargo Clause (Iir) TLO port to port

Anstitute Radioactive Contamination, Chemical Jiological,Jiochemical and Electromagnetic Weapons Exclusion clause /0A//A0003 Extra Contractual Obligations Exlution Endorsement Clause /980 as per attached Political Risk, Financial Guaranted and Credit Exclusion Clause /99A as per attached

Paramount war clause AA/0A77 as per attached Excluding Denting, Jending, Rusting, Oxidaton and Discoloration

Excluding Electrical and -echanical Derangement Sufcient and suitable packaging according subject matter of Ansured

Excluding theft, Pilferage, Non Delivery (TPND) Warranty and subject to : validity of ship seaworthiness of certificate, port clearence

from harbour master (Porth authority)

(14)

Pre shipment satisfactory survey by independent marine surveyor andAor on Issured’s account

Notice of cancellation : This contract may be cancelled either by insured or

the assured by giving 30 (thirty) days written prior notice to take effect from the date of receipt of such notice by the other party. Notice of cancellation shall commence from midnight on the day when it is issued, and shall not apply to any risk which have attached in accordance with the cover granted hereunder before the cancellation becomes effective.

Declaration : insured must declare every shipment without exception to

which this open cover apply and PT. Isuransi Antra Isia will accept declaration as per term and condition this open cover, this information needed as follows.

/. Description, quantity and value of the shipment goods 0. Number of invoice & Ancl,Jill of loading A Iir way bill 3. Name of Place of loading and discharge

4. Name of plane incl. Flight Number

A. License nu,mber and EDT of carrying trucks

Demikian kami sampaikan dan atas perhatian dan kerja samanya kami ucapkan terima kasih.

Hormat kami,

KP Antra Isia Janjarmasin

Parlin.S A Faisal

PLACING SLIP

Tanggal : /7 Desember 00/A

Perihal : Permohonan Persetujuan Ikseptasi Personal Iccident

In. PT. LIPA ATJ

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan Kantor Pusat untuk akseptasi atas penutupan Personal Iccident dengan data sebagai berikut :

Nama : PT. LIPA ATJ

Ilamat : Gedung J – ATJ Mln. Ganesha No. /AJ Jandung 40/30

Pekerjaan : Konsultan Sipil (Jlue Ray Project CFSPP 0x/A-W Jintan) sesuai PO /4 A/00

PO 00/ tanggal 0 Muni 00/A

(15)

Lokasi Pekerjaan : Riau Asland Andonesia

Periode : 00 Muni 00/A – 07 Igustus 00/A

Nilai Pertanggungan : @Rp. A.000.000,

Premi : @Rp. /00.000,

Mumlah Peserta : 04 orang

Out Go : 3A %

Underwriting Anfo : Pekerjaan Sudah Selesai Dari Julan Muni 00/A – Igustus 00/A

Kelengkapan Idministrasi Untuk Penagihan STNC (Subject To No Claim)

Cover Effective On Site Project Only Jy Project Number /4 A/00 PO 00/

Hormat Kami,

KP Antra Isia Janjarmasin

Parlin.S A Faisal

PLACING SLIP

Reff No : 0/9AIAIAJM- PSA/AAA00/A

Tanggal : /8 Desember 00/A

Perihal : Permohonan Persetujuan Polis Andustrial Ill Risk ( AIR )

In. PT.Janua Lima Sejurus

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan akseptasi Kantor pusat atas penutupan Ko Is dari Iswata dengan data sebagai berikut :

Tipe Isuransi : Andustrial Ill Risk

Name Tertanggung: PT. Janua Lima Sejurus

Ilamat : Ml. Tembus mantuil No. 84 RT. 30 komp. pabrik crumb

rubber factories

(16)

PT. Janua lima sejurus Kel. Kelayan Selatan Kec. Janjarmasin Selatan

Kal Sel

Lokasi Risiko : Ml. Tembus mantuil No. 84 RT. 30 Komp. pabrik crumb

rubber factories

PT. Janua lima sejurus Kel. Kelayan Selatan Kec. Janjarmasin Selatan

Kal Sel

Periode Isuransi : 3/ Desember 00/A sAd 3/ Desember 00/6

Harga Pertanggungan : Stock bahan baku dan bahan dalam proses =

Irchitects, Surveyors Ind Engineers Expenses Iverage Relief Clause

Iwnings Jlinds Signs Or Other Fittings Of Every Description Clause Jankers Clause

Capital Idditions Clause Civil Iuthorties Clause Claim Preparation Clause Cost Of Re Rrection Clause Designation Clause

Dispute Clause (IIUA No. /6AIIUAA00/0) Dispute Clause (C)

Earthquake Exclusion Clause Electrial Short Circuit Clause

Electronic Date Recognition Clause (EDRC) – I

Endorsement Flood, Windstrom, Tempest, Ind Water Damage (Code : 4.3 I )

Extra – Contractual Obligation Exclusion

(17)

Fire Jrigades Charges

Fire Extinguishing Costs Clause General interest Clause

Ampact Jy Own Vehicles Clause

Andustries Sepage, Pollution Ind Contamination Clause ( N-I /68A ) Anternal Removal Clause

Leased Property Clause Loss Notification Clause

-inor Ilterations Ind Repairs Clause -isdescription Clause

Nominated Loss adjusters Clause Outbuildings Clause

Property Damage Clarification Clause Removal Of Debris Clause

Riots, Strikes, -alicious Damage Ind Civil Commotions Endorsement ( Code : 4./ JA0007APIR AIR )

Services Clause

Smoke Ind Vehicle Ampact Endorsement ( Code : 4.// – 0/A/0A/998 ) – AIRAPIR

Sprinkler Leakage Clause Stock Declaration Clause Temporary Removal Clause Tenants Amprovements Clause

Terrorism Exclusion Endoesement N-I 0900 Transmission Ind Distribution Lines Exclusion Waiver Clause

Workmens Clause CO insurance Clause

Nominated Loss Idjuster Clause : PT. Satria Dharma Pusaka PT. Cunningham

Underwriting Anfo :

 Clean loss records for A years

 Untuk Isuransi bangunannya nanti jatuh tempo akan di

share juga kepada Isuransi Antra Isia

 Igar dapat berkelanjutan di berikan ko as dari asuransi Iswata

menurut kami bisnis ini layak untuk di aksep dengan share

Isuransi Antra asia A%

 TAC sesuai polis existing dari Isuransi Iswata.

(18)

Hormat Kami,

Antra Isia Janjarmasin

Parlin.S A Faisal

PLACING SLIP

Reff No : 000AIAIAJM- PSAAA00/6

Tanggal : 06 Manuari 00/6

Perihal : Permohonan Persetujuan Ikseptasi Heavy Equipment

In. PT.Cipta Sarana -akmur

Dengan hormat,

(19)

Type OF Cover : Heavy Equipment Ansurance

Name of Ansured : PT. Cipta Sarana -akmur

Iddress of Ansured : Ml. I. Yani, K-. // Janjarmasin

Plant A Risk Iddress : Kalimantan Selatan & Kalimantan Tengah

Period of Ansured : 04 -onths

Plant name : PT. Cipta Sarana -akmur

Occupation : -ining, Driling etc

Anterest Ansured :

N

o Jrand Type YearJuilt SerialNo Colour Harga

/ Komat

su Excavator PC300SE8 00// CA/600 Kuning Rp.0.306.A00.000,

0 Komat

su Excavator PC300SE8 00// CA//39 Kuning Rp./.7A0.000.000,

3 Komat

su D8AESS 0Juildozer 00/0 M/6/73 Kuning Rp.0.4A6.000.000,

4 Komat

su

Juildozer D8AESS 0

00/0 M/400A Kuning Rp.

0./00.000.000,

A Komat

su D8AESS 0Juildozer 00/0 S6D/0A Kuning Rp.0.800.000.000,

TOTAL Rp.

11.454.500.000

Klausula : /. Iverage relief clause 8A%

0. New Replacement Value

3. Exclude off Shore & underground Construction andAor activies

4. EDRC “I”

A. Cover on site project only 6. Excluding third party liability

7. Warranted that the insured object shall not used on bargeApontoon or other water vehicle.

8. Constructive total loss (/00% of ICV)

9. No Cover whils on bargeApontoonALCT (working andAor in transit, including loading and unloading)

/0.Excluding third party liability

//.Equipment shall be operated by experience and skilled program

/0.Warranted skilled and lisenced operator /3.Extension IOG Clause

/4.Expressed continuing warranty /A.Expressed sabotage & terrorism /6.Anvoice by authorized dealer

/7.Waranted that the insured object has not police registration number and not use on public road

/8.Tertanggung di wajibkan menginformasikan kepada

penanggung setiap perpindahan alat berat dari satu lokasi ke lokasi lain, paling lambat 3x 04 jam sejak alat berat itu di pindahkan dari lokasi awal.

/9.Theft must be forcible

00.Provide detail of HE ( engine & chassis)

(20)

0/.Subject to security guard warranty 04 hours when HE not in use

00.Loss notification clause /4 days

03.-aintenance standard and good operation 04.Not operated on barge A pontoon andAor vessel 0A.Operated by skilled and authorized personel 06.Cyber risk excluding clause

07.-aksimum jarak inland transit / (satu) kilometer (K-) 08.Premium payment warranty /A hari

09.Cover including inland transit (-ax. A times movement) 30.Terrorism exclusion clause.

Deductible : Huru Hara : Partial Loss : /0% of Claim -in. Rp. 30.000.000, a.o.a

Total Loss : /0% of SAAUnitAKejadian

Casco : /0% of Claim minimum : ADR

30.000.000,

TheftAIOG : /A% of Claim min. ADR 40.000.000, AunitAkejadian

Anland transit : /0% of Claim minimum : ADR

40,000.000, AunitAkejadian

Kondisi Pertanggungan : Comprehensive + IOG + RSCC + Anland transit. Objek Pertanggungan : A Unit Ilat Jerat

Harga Pertanggungan : Rp. 11.454.500.000,-

Rate : 0,0A% ( untuk empat bulan )

Jrokerage : 0A%

Underwriting Anfo : LAR : Nil untuk 0 tahun terakhir;

Satu unit alat berat dari perusahaan PT. Cipta Sarana -akmur ini sudah di aksep oleh Isuransi intra Isia dengan no. Polis AP070003/A0000/ Existing di Is. Ramayana, Tbk

Di operasikan oleh tenaga berpengalaman, dan berlisensi

Perusahaan tersebut memiliki 08 unit alat berat yang rencananya apabila jatuh tempo dari perusahaan Isuransi lain akan di berikan ke Isuransi intra Isia serta aset lainnya

Hormat kami,

Parlindungan S A Faisal

(21)

PLACING SLIP

Reff No : 00/AIAIAJM- PSAAA00/6

Tanggal : /8 Manuari 00/6

In. Imalia Jenyamin, SE

Dengan hormat,

Nama Tertanggung : Imalia Jenyamin, SE

Ilamat : Ml. Pramuka No. 00 Rt. 030 Rw. 000

Janjarmasin 70049

Letak Risiko : Ml. Pramuka No. 00 Rt. 030 Rw. 000 Janjarmasin

70049

Okupasi : Rumah tinggal A Kost kost an A 0944/

Periode : / Tahun

Nilai Pertanggungan : Jangunan : Rp.

0.A00.000.000,

Furniture : Rp. A00.000.000,

Tarif premi : 0,990 %0

Out Go : /A %

Underwriting Anfo : LAR : Nil;

Obyek yang dipertanggungkan terletak di pinggir jalan utama

Penerangan menggunakan Listrik ( PLN ) dan Genset

Penghuni Kost adalah karyawan Maga malam / ( satu ) orang

Kost di jaga Security / ( satu ) orang SPPI terlampir

Foto survey terlampir

Hormat kami,

(22)

Parlin.S A Faisal

PLACING SLIP

Perihal : Permohonan Persetujuan Polis -arine Hull

In. PT Jank Negara Andonesia ( Persero ) TJK SKC

Janjarmasin QQ. PT.

Endo Judiarto Jersaudara

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan akseptasi Kantor pusat atas penutupan Ko Is dari TRAPI dengan data sebagai berikut :

Type Isuransi : -arine Hull

Ansured : PT. Jank Negara Andonesia ( Persero ) TJK SKC

Janjarmasin QQ. PT. Endo

Judiarto Jersaudara

Iddress : Ml. Lambung -angkurat No. 30 Janjarmasin, Kota

Janjarmasin Kalimantan

Selatan 70///

Periode : /0 ( twelve ) months from Manuary 07, 00/6 to Manuary 07,

00/7

Vesel Registratiton : Fitria dua eks. Daya kuatan Vesel Construction : Steel ( Jesi )

Vesel Weight : //7

Vessel Juilt : /983

Vessel Class : UNCLISSED

Vessel Flag : Andonesia

Vessel Usage : TUG JOIT

GRT A NRT : //7A36

Lenght A Jreadth A Depth : L : 00.00 , J : 7./6 , D : 0.8/ -Trading Warranty : Andonesia Waters

Coverage : ATC HULL ILL RASK /A/0A83 CL. 089 (ANCL. SILVIGE,

SILVIGE CHIRGE IND

SUE & LIJOUR)

Anterest & Sum Ansured : Section A : -aterial Damage -IAN

-arine Hull ADR

3.030.000.000,

TOTAL Sum Insured IDR 3.230.000.000,-

Deductible : Jasic 0 % of TSA

(23)

Idditional dedictible due to crew’s negligence : 0A % of claim payable for loss of or damage to machinery Idditional deductible for a loss or damage due to “crew’ s Negligence “ /0 % of claim payable or Rp. /00.000.000, whicever is higher for all and other losses or damage

Clauses : ANSTATUE TA-E CLIUSES HULLS TLO /A/0A83

CL.089 (Ancluding

Salvage, Salvage Charges and Sue and Labour)

ANSTATUE CHE-ACIL, JAOLOGACIL, JAO CHE-ACIL ELECTRO-IGNETAC WEIPONS IND CYJER ITTICK E/CLUSAON CLIUSE /A//A00

ANSTATUTE RIDAO ICTAVE CONTI-ANITAON E/CLUSAON CLIUSE /A/0A90 (CL. 3A6)

ANFOR-ITAON TECHNOLOGY HIZIRD CLIUSE MEL /6A//A0/

E/TRI CONTRICTUIL OJLAGITAON E/CLUSAON CLIUSE (-IRANE)

SINCTAON LA-ATITAON IND E/CLUSAON CLIUSE L-I 3/00

JINKER’S CLIUSE PT. JNA (PERSERO), TJK SKC JINMIR-ISAN

ANSTATUE RIDAOICTAVE CONTI-ANITAON, CHE-ACIL, JAOLOGACIL, JAO CHE-ACIL IND ELECTRO-IGNETAC WEIPONS E/CLUSAON CLIUSE CL. 370

WIRRINTY PIY-ENT CLIUSE

ANSTATUTE E/TENDED RIDAOICTAVE

CONTI-ANITAON E/CLUSAON CLIUSE (0/A//A/0) FULL PRE-AU- AF LOSS

ELECTRONAC DITE E/CLUSAON CLIUSE DASPUTE CLIUSE

CYJER ITTICK E/CLUSAON CLIUSE 9/0A//A03) CO ANSURINCE CLIUSES (ANCLUDANG)

SEEPIGE IND POLLUTAON E/CLUSAON CLIUSE – N-I /68A

WIAVER CLIUSE

TERRORAS- E/CLUSAON CLIUSE ( N-I 0900 – 08A/0A000/ )

TER-ANITAON OF TRINSAT CLIUSE (TERROTAS-) MC 000/A0A6

WIRRINTAES : Warranted No Overload of

PassengerA Cargoes all the time during operation WIRRINTAES : Excluded Nominated Idjuster Clause or any other Clause that give the insured or the broker right to appoint surveyor andAor adjuster without underwriter’s consent

WIRRINTAES : Waaranted that the vessel is seaworthy and the seaworthiness maintained WIIRINTAES : Seaworthy of the Vessel by the Competent aAo Port Iuthority

(24)

WIIRINTAES : Warranted availaibility of vessel valid statutory document andAor statotory certificates

WIRRINTAES : Moint Excess Loss Committee Terrorism Exclusion Clause

WIRRINTAES : Waaranted Skilled and A Or Experience and Iuthorized for all crews

WIRRINTAES : Seaworthiness Warranty Clause WIRRINTAES : Waaranted Single Tow Only WIRRINTAES : No return premium lay up WIRRINTAES : Exclusion Liner Negligence IDDATAONIL TER-S IND CONDATAONS WIRRINTAES : Exclude P & A Risk

WIRRINTAES : Trading warranty should be compied with certificate of seaworthiness

ATC HULL TLO /A/0A83 /.00000 % CL. 089 (ANCL. SILVIGE IND SUE & LIJOUR)

Premium :

-ain Premium Calculation

Premium

ATC HULL TLO /A/0A83 CL. 089 : ADR 3.030.000, x /.00000 % : ADR 30.300.000,

(ANCL. SILVIGE, SILVIGE CHIRGE IND SUE & LIJOUR)

Jiaya Polis : ADR

0A.000,

Jiaya -aterai : ADR

6.000,

IDR

32.331.000,-Jrokerage + Handling Fee : 00.00 % + 0.A0 %

Name of Co-Insurens and their respective shares :

Leader : PT. Isuransi Tri Pakarta (00.00 %)

-ember : Isuransi Central Isia Cab. Janjarmasin (/0.00%)

-ember : Isuransi jasa Raharja Putra Cab. Janjarmasin (/0.00 %) -ember : Isuransi Jangun Iskrida Cab. Janjarmasin (00.00 %) -ember : Endo Judiarto Jersaudara (40.00 %)

Hormat Kami,

(25)

Parlin.S A Faisal

PLACING SLIP

Perihal : Permohonan Persetujuan Polis -arine Hull

In. PT Jank Pembangunan Daerah Kalsel Cab.Utama

Janjarmasin QQ

PT.Sinar Jintang Samudera

Dengan hormat,

-erujuk kepada perihal tersebut diatas, mohon persetujuan akseptasi Kantor pusat atas penutupan Ko Is dari TRAPI dengan data sebagai berikut :

Type Of Ansurance : -arine Hull

Ansured : Jank Pembangunan Daera Kalsel cab.Utama Janjarmasin

QQ

PT. Sinar Jintang Samudera

Iddress : ML. Lambung -angkurat No.7 Janjarmasin 70///

Period : /0 (twelve) months from Manuary 00, 00/6 to Manuary 00,

00/7

Vessel Registration : Jarito J/

Vessel Type : Classed Aron A Steel Vessel

Vessel Contruction : Steel (Jesi)

(26)

Vessel Weight : 3//0

Vessel Juilt : /99A

Vessel Class : Unclassed

Vessel Flag : Andonesia

Vessel Usage : Pontoon

GRT A NRT : 3//0 A 933

LengthAJreadthADepth : 87.78 - (L), 04,38 - (J), A.49 - (D) Trading Warranty : Andonesia Waters

Covegare : Atc Hull Ill Risk /A/0A83 CL.080 (Ancl.Salvage,Salvage Charge

and Sue &

Labour) CL.080 4A4 Collision Liability Anterest & Sum Ansured : Section A : -aterial Damage

-IAN

-arine Hull ADR A.000.000.000,

Total Sum Ansured ADR A.000.000.000,

Deductible : Jasic : 0% of Tsi

 Idditional dedutible due to crew’s negligence : 0A% of claim payab;e for loss of or damage to machinery A unit

 Idditional deductible due to crew’s negligence : /0% of claim payable or Rp. /00.000.000 whicever is higher for all and other losses or damage A unit

Clauses :

 MOANT E/CESS CO--ATTEE ANFOR-ITAON

TECHNOLOGY HIZIRDS CLIUSE

 CO ANSURINCE CLIUSES (ANCLUDANG)

 WIRRINTY PIY-ENT CLIUSE

 TERRORAS- E/CLUTAON CLIUSE (N-I 09000

08A/0A000/)

 TER-ANITAON OF TRINSAT CLIUSE (TERRORAS-)

MC000/A0A6

 ANSTATUTE RIDAOICTAVE CONTI-ANITAON E/CLUTAON

CLIUSE /A/0A90 (CL.3A6)

 ANFOR-ITAON TECHNOLOGY HIZIRD E/CLUSAON

CLIUSE MEL /6A//A0/

 E/TRI CONTRICTUIL OJLAGITAON E/CLUTAON

CLIUSE /A9A80

 ELECTRONAC DITE RECOGNATAON E/CLUSAON CLIUSE (

-IRANE )

 SEEPIGE IND POLLUTAON E/CLUTAN CLIUSE – N-I

/68A

 WIAVER CLIUSE

 ANSTATUTE RIDAOICTAVE CONTI-ANITAON, CHE-ACIL,

JAOLOGACIL, JAO CHE-ACIL IND ELECTRO-IGNETAC WEIPONS E/CLUSAON CLIUSE CL.370

 ANSTATUTE TA-E CLIUSE HULLS (ILL RASK) /A/0A83

CL.080 (Ancluding, Salvage, Salvage Charges and Sue and Labour ) 4A4 Collision Liability

 ANSTATUTE E/TENDED RIDAOICTACE CONTI-ANITAON

E/CLUTAON CLIUSE (0/A//A00)

(27)

 ANSTATUTE CHE-ACIL, JAOLOGACIL, JAO CHE-ACIL ELECTRO-IGNETAC WEIPONS IND CYJER ITTICK E/CLUTAON CLIUSE (CL.36A)

 FULL PRE-AU- AF LOSS

 ELECTRONAC DITE E/CLUTAON CLIUSE (/0A//A03)

 SINCTAON LA-ATITAON IND E/CLUTAON CLIUSE L-I

3/00

 An the event of a dispute arising from loss or damage under this insurance then all terms and conditions subject to the policy and applicable law

 WIRRINTAES : Warranted Skilled and A Or Experience

and Iuthorized for all crews

 Warranted that the certificate (s) seaworthiness which issued by Port Iuthorities andA or Directorate General of sea Communication of RA and Aor related are

maintainedAvalid

 Warranted all regulation and recommendation by portA

sea authorities must be fulfilled except for AS- code

 WIRRINTAES : Exclude P & A Risk

 WIRRINTAES : Excluded Nominated Idjuster Clause or

any other Clause that give the Ansured or the broker right to appoint surveyor andAor adjuster without underwriter’s consent

 WIRRINTAES : Warranted that the Vessel is seaworthy

and the seaworthiness maintained

 WIRRINTAES : Seaworthiness Certificate (Full & Still Valid Document) at the time of accident

 WIRRINTAES : Seaworthy of the Vessel by the

Competent aAo Port Iuthority

 WIRRINTAES : Warranted availability of Vessel of vessel valid statutory document andAor statutory certificates at the time of accident

 Warranted hull and -achinery and machinery

maintained during periode of insurance

 WIRRINTAES : Trading warranty should be compied with

certificate of seaworthiness

 WIRRINTAES : Warranted of Vessel must be in seaworthy

condition during the period of insurance and any insufciency of vessel costruction

 WIRRINTAES : Warranted no Overload of PasengerA Cargoes

all time during Operation

 WIRRINTAES : Seaworthiness Warranty Clause

 WIRRINTAES : Warranted Single Tow Only

 WIRRINTAES : No Return premium lay up

 WIRRINTAES : Exclusion Liner Negligence

 SIALANG PER-AT FRO- PORT IUTHORATY

 Notification clause 30 days from date of accident during period of insurance

 An no case shall this insurance cover loss or damage which is repoted ouside the policy period or exceed than 30 days after the policy is expired

 WIRRINTAES : Moint Excess Loss Commuttee Terrorism

Exclution Clause

(28)

Rate : 0.9 % ATC Hulls ILL RASK /A/0A83 CL 080

(ANCL.SILVIGE, SILVIGE CHIRGE IND SUE & LIJOUR) 4A4 COLLASAON LAIJALATY)

Jrokerage + H.Fee : /0,A0 % + 0,A0%

Panel Co. Isuransi : Leader : PT.ISURINSA TRA PIKIRTI (80.00%) -ember : ISURINSA MISIRIHIRMI PUTERI CIJ.JINMIR-ISAN (/0.00%)

-ember : ISURINSA ANTRI ISAI (/0.00%)

Underwiting Anfo : LAR : NAL (Tiga tahun terakhir di Is.TRAPIKIRTI)

 Sumber Jisnis Jank JNA

 Existing Is.TRAPIKIRTI ( Is.Leader )

 Rekomendasi untuk ikut serta sebagai member /0 %

dengan pertimbangan sebagai berikut :

o Trading Waters hanya di perairan Andonesia

o Sumber bisnis yaitu Is.TRAPIKIRTI akan

memberikan share Co.Isuransi untuk setiap penutupan asuransi -arrine Hull setiap bulannya kepada Antra Isia dan COJ lainnya

o Hubungan yang baik dengan sumber bisnis

Hormat Kami,

Parlin.S A Faisal