QUOTATION SLIP

TYPE OF COVER : Public Liability Insurance

FORM :  Liability
THE INSURED : Holiday Inn Jakarta Kemayoran and/or its subsidary and/or
other company owned, operated, managed, controlled by,
affiliated with the company for ther respective rights, interests
and liabilities
ADDRESS OF INSURED : Jl. Prof. DR. Latumenten No.336
Grogol – Jakarta Barat 11460
PERIOD OF INSURANCE : 1 (one) Year
(both date are inclusive at 12:00 noon local time)
CONSTRUCTION CLASS : I (Satu)

RISK OCCUPATION : 29412 – Hotel

RISK LOCATION : Jl. Griya Utama Blok B No. 1 Kemayoran
Jakarta 14340
PERILS INSURED : The Insured legal liability to pay for compensation respect of :
a. Bodily Injury (including death, illness or disease)
b. Property damage : arising from any claim being first made
against the insured during the period of insurance in
connection with the insureds business and occurring within the
territorial limit
LIMIT LIABILITY : Total limit of Liability (Combined Bodily Injury and Property
Damage) IDR 5,000,000,000,- any one occurrence in
aggregate during the whole periode of Insurance (legal cost
inclusive)
DEDUCTIBLES :  Nil for Bodily Injurt
 ■ IDR 1,000,000,- anyone loss of or
damage in respect of third party property damage only
 ■ Car Park
 10% of loss min IDR 2.500.000,-
anyone loss of or damage in respect theft/loss on vehicle
TERRITORY LIMIT : Indonesia
JURISDICTION : Indonesia
CLAUSES : 1. Car Park Clause (Including theft/losses on motor vehicle)
Sub limit USD 50.000,00 anyone accident and in the
aggregate
2. Cancellation Notice (30 Days)
3. Claim made basis
4. Cross Liability (sub limit USD 25.000,00 anyone accident
and in the aggregate)
5. Defective Sanitation Clause
6. Defense and Recourse (within in the limit of liability)
7. WPC 30 days
8. Demonstration/ Exhibition/ Promotion Clause (3 Days)
9. Dispute clause (AAUI No. 16/AAUI/2012)
10. Employee/ Guest Personal Effects Clause (sub limit USD
25.000,00 in aggregate)
11. Error and omission clause
12. Emergency medical expenses clause
13. Electronic Date Recognition clause
14. Fire and Full Explosion (sub limit USD 100.000,00 anyone
accident and in the aggregate)
15. Firs aid facilities clause
16. First Aid Facilities
17. Information technology hazards clarification clause
18. Loss Notification (30 Days)(after receiving third party
claim/Complain)
19. Nominated Loss Adjuster Clause (PT. Prima Adjusterindo
Mandiri, PT. Radita Hutama Internesia, PT. ATLAS
Adjusting Indonesia)
20. Overseas Visit Clause (Excluding USA and Canada)
21. Prorata Return Premium Clause (Subject To Clean Loss
Record)
22. Subject To No Claim As Per Confirmation
23. Waiver of Subrogation Clause (againts subsidiries only)
EXCLUSION : 1. Radiation, or Contamination by Radioactive, Nuclear,
Weapons
2. War, Civil War Rebellion, Revolution, or Civil Commotion
3. Injury to Employee Of The Insured
4. Professional Liability and complete operation
5. Deliberate Activities
6. Absolute Asbestos, Silica and Lead
7. War and Terrorism
8. Marine Liability
9. Underground Works
10. Diving / Under Water Activities / Works
11. Water Sport Activities
12. Amusement Park or Ride Other Than Coin – Operated
Game Machines
13. Consequential Loss / Financial Loss
14. Professional Liability / Error and Omission
 15. Completed Operation and Product Liability Insurance
Exclusion
16. CAR / EAR Risk
17. USA / CANADA Domicile Entities
18. SARS, HIV / AIDS
19. Act of God Exclusion
20. Warehouse Legal Liability
21. Car Park Liability
22. Contractual liability exclusion
23. Cyber risk exclusion clause (NMA 2915)
24. Delay, lack of performance exclusion clause
25. Extra contract obligation exclusion clause
26. Fine, penalties or punitive damage exclusion
27. Care custody and control by the Insured
RATE : Public Liability : 1.50 %o
PREMIUM CALCULATION : Public Liability
IDR.5,000,000,000.00 x 1.50 %o = IDR.7,500,000.00
Biaya Polis & Materai = IDR. 62,000.00
TOTAL = IDR.7,562,000.00
SECURITY : PT. Asuransi Ramayana Tbk 100%

Jakarta, 29 Juli 2019

PT. Asuransi Ramayana Tbk Noted and agreed
Cabang Jakarta Pondok Indah

Adhitya Pradikto ………………………