QUOTATION SLIP
TCH.LO-014.05.19
Type of Insurance
The Insured
Addresss
Contract No.
Kind of Project
Location of Risk
Period of Insurance
Coverage
Limit of Liability
Jurisdiction
Deductible
Conditions/ Clauses
catatan : penawaran ini merupakan cetakan sistem dan tidak memerlukan tanda tangan
PT. Asuransi Takaful Umum
Graha Kospin Jasa
Jl. Jend. Gatot Subroto Kav. 1
Jakarta Selatan 12870
: Comprehensive General Liability
: TBA as Principal and/or TBA as Main Contractors and/or sub contractors
and/or Consultant and/or other parties with an Insurable Interest.
: TBA
: 4710002796
: TSC for Integrated QA QC Services PHE ONWJ PBAS
: PHE ONWJ (detail location of risk)
: Maximum 18 Months (Capacity ATU)
: To indemnity all sums which the Insured becomes legally liable to third
party in respect of:
- Accidental bodily injury (including death) to any person
- Accidental Loss of Damage to Property
Happening in relating to claim first made during the period of insurance in
the geographical limits of this policy and caused in connection with the
business.
: Bodily Injury :
- USD. 50,000.00 any one person
- USD. 250,000.00 any one occurrence
Property Damage
USD. 500,000.00 any one occurence
USD. 1,000,000.00 Combined Single Limit in respect of bodily injury and
property damage for anyone occurrence and in aggregate for the whole
period of insurance.
: Republic of Indonesia
: 10% of Claim, minimum USD. 2,500.00 any one accident
for Third Party Property Damage Only
: 1. Absolute Asbestos Exclusion Clause
2. Absolute Pollution Exclusion Clause
3. Arbitration Endorsement
4. Claim Made Basis (Subject To Retroactive Date As From Inception Date)
5. Electronic Date Recognation Clause B
6. Exclude Blow Out Risk
7. Exclude Faulty Work
8. Exclude Financial And/Or Performance/Production Guarantees/Bonding
9. Exclude Occupational Disease
10. Exclude Product Liability
11. Exclude Professional Liability
Telp.: (021) 285-43111 / 285-43222
Customer Service Email :
takafulumum.solution@takafulumum.co.id
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 12. Indonesia Jurisdiction Clause
13. Industries, Seepage, Pollution and Contamination Clause - NMA 1685
(Sudden & Accidental)
14. Loss Notification Clause (30 Days)
15. Nuclear Energy Risks Exclusion Clause 1994
16. Sharia Clause – Implementation of Wakalah of Bil Ujrah and Tabarru’
17. Takaful Contribution Clause (30 Days)
18. Termination of Takaful Policy Clause
19. War and Civil War Exclusion Clause - NMA 464

Subjectivity : - Applying safety management system in working area

- Subject to no claim (STNC) as per confirmation date received by Takaful Umum

Rate : 0.25 %

Contribution Calculation : USD. 1,000,000,000.00 x 0.25 % x 1,5 = IDR. 3,750.00

Policy Cost & Stamp Duty = IDR. 5.00
TOTAL = IDR. 3,755.00

Jakarta, May 29, 2019

Signed for and on behalf of
PT Asuransi Takaful Umum

APPROVAL CONFIRMATION

We hereby confirm our approval to be one of the Takaful participants based on the principles of Islamic Insurance
bear one another, protect each other and help each other among fellow participants and approve insurance
management handed over to PT Asuransi Takaful Umum based on the above terms and conditions

Date Company Name & Position Signature & Co. stamp

catatan : penawaran ini merupakan cetakan sistem dan tidak memerlukan tanda tangan
PT. Asuransi Takaful Umum Telp.: (021) 285-43111 / 285-43222
Graha Kospin Jasa Customer Service Email :
Jl. Jend. Gatot Subroto Kav. 1 takafulumum.solution@takafulumum.co.id
Jakarta Selatan 12870
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