QUOTATON SLIP

No. 295/MKT/AMP/VIII/2018

CLASS OF BUSINESS : Comprehensive General Liability

Workmen’s Compensation Insurance

THE INSURED : The Principal and/or Company PT. ……………and/or Associated

and/or Subsidiary and/or Affiliated Companies for their respective
rights and interests

ADDRESS : Jl. Majapahit Blok C No.109, Harmoni - Jakarta Pusat

TITLE PROJECT : ……………………………….

CONTRACT NO. : 18141355-OC

RISK LOCATION : NATUNA SEA BLOCK “A” or any other place within which the
services are to be conducted

CONTRACT VALUE : USD. ………………………………

POLICY PERIOD : 05 June 2018 - 24 June 2023 (5 years + 20 days)

YEARLY ESTIMATED
PAYROLL : To be advised (15 person local employees)

LIMIT OF LIABILITY : I. Comprehensive General Liability (CGL)

Rp. 10,000,000,000.- any one accident
Rp. 50,000,000,000.- in aggregate for the whole
period of insurance (Combined Single Limit for
Property Damage & Bodily Injury).

II. Workman Compensation (WCA)

Pertamina Benefit in excess of BPJS
Ketenagakerjaan or Rp. 10,000,000,000.- in
aggregate for the whole period of insurance

DEDUCTIBLES : I. 10 % of claim or minimum Rp. 50,000,000.- any one

accident
II. WCA/Employer Liability (EL) : N I L

TERMS / CONDITIONS : Clauses/warranties as may be agreed each declaration and

subject to be agreed by Underwriters.

- Warranted satisfactory loss record of the Insured and any

risks with previous losses or claims in the last three years to
be declared and separately agreed each declaration.
- Claim Made Basis Indemnity
- Additional Insured Clauses
- Waiver Rights of Subrogation Clauses
- Indonesian Jurisdiction Clauses
- Arbitration Clauses
- Electronic Date Recognition Exclusion Clause
 - Product Liability Exclusion
- Pollution Liability Exclusion
- Excluding Liability for Loss or Damage to property under
care, custody and control of the Insured(s) Clauses
- Marine & Offshore Liability Exclusion Clauses
- Loading & Unloading Clauses
- Absolute Pollution Exclusion Clauses
- Absolute Asbestos Exclusion Clauses
- Warranted validity of supporting documents, certificates,
schedule, contracts, etc are maintained
- Warranted that all local Government Requirements &
Regulations are complied with throughout the currency of
this insurance.
- Warranted Safe working load of everything connected
therewith not exceeded.
- Loss Notification (7 days)
- WPC (45 days)

WARRANTY : - Detail Employee & Salary must be informed to PT. Asuransi

Mega Pratama within 14 days after Policy issued

INDICATIVE PREMIUM RATE : 0.25% (for 1 year)

SUBJECT TO : The quotation slip above is for illustration only. The final
terms and conditions will be confirmed to the insured soon
when the insurer have an approval from reinsurer.

Jakarta, 20 Agustus 2018 Agreed & Accepted,

PT. ASURANSI MEGA PRATAMA PT.

Elvi Yunita (……………………………..)

Area Manager