PT Asuransi Allianz Utama Indonesia

SURAT PENAWARAN DAN RINGKASAN PENGAJUAN ASURANSI PENGANGKUTAN BARANG

MARINE CARGO QUOTATION AND INSURANCE APPLICATION SUMMARY

Insured Name : PT. GISTEX including any subsidiary and/or related company exists at the commencement
of this insurance, or formed, purchased or otherwise acquired during the currency of the
policy for their respective rights and interests.

It is also agreed and declared that the named Insured includes the interest of any joint PT.
GISTEX accepted obligation to insured.

Address : Jl. Hegarmanah No.05 Rt. 002 Rw.003 Kel. Hegarmanah, Kec.Cidadap, Kota Bandung Jawa
Barat 40141 Indonesia

Period of Insurance / : 23 September 2024 – 23 September 2025

Interest Insured :
All kind of finished product produced PT. GISTEX and/or Brand New/Used Machinery
and/or Spare parts and/or supporting equipments and/or Raw Materials and/or other
goods related to insured’s business.

Excluding:
Mining Products (such as Coal, Nickel and the like), Blood stock, Container Insurance, Space
Risk, Military Equipment, Fuel and other Energy Business (Oil and Gas) , Luxury Items :
(Antiques, objects of art, valuable paintings and the like, gold, jewelry and the like, luxurious
vehicle and clothing), Alcohol, Tobacco Products, Gadgets (Handphone, Laptop, Tablet,
Video Game, Computer and the like), Fragile Items (ceramics, glass and the like), Liquid Bulk
Cargoes, Log, Cement, Fertilizers, Vehicles, Heavy Equipments, Livestock, Plants,
Documents (including Deeds and Bonds of any kind or nature (including but not limited to
Customs Bonds or Bankers´ Blanket Bonds)), notwithstanding Carnet business, Rejection
cargo and Dangerous / Flammable /Explosive Goods.

Type of Packing : Warranty: Goods should be packed properly follow nature of the goods and proper for
transport purposes

Limit of Liability : USD 500,000 or equivalent in other currency maximum limit of liability per any one
conveyance

Sub Limit for LCT

Max. USD 100.000,00 or equivalent in other currency maximum limit of liability per any one
conveyance

Estimated Annual : USD 49,000,000 (Please re-check, the last 5 years are far from the estimate)
Turnover

Basis of Valuation : Export-Import :

Invoice Value (all trading terms) and/or Invoice Value (all trading terms) + max. 10% and/or
as declared by the insured

Domestic/Local Sending :
Invoice value and/or Invoice value + max. 10% and/or as declared by the insured
 PT Asuransi Allianz Utama Indonesia

Voyage : Land Transit & Inter Island

From Insured’s Factories and/or premises in Indonesia to Warehouses and/or sites and then
continued to sub warehouses and/or to buyer’s warehouses within Indonesia. Including
Canvassing and import shipments on CIF Basis.

Export/Import
From/to port or airports or places anywhere in the world to/from airports/ ports/ places
anywhere in Indonesia. (warehouse to warehouse).

Excluding hot/war area/country

Any shipment to one of the sanction countries and sensitive countries are subject to be
reviewed and approved by the underwriters prior shipment
Excluding shipments to and from Russia, Ukraine, Black Sea and Sea of Azov Region
Excluding shipments not touching the ground of Indonesia

Excluding War, Strikes, Riots and Civil Commotion Perils coverage under the Institute War
Clauses (Cargo) and Institute Strikes Clauses (Cargo) only in respect of shipments to, from
or within the Red Sea, Gulf of Aden and Indian Ocean defined as:
• On the northwest, by the Red Sea, south of Latitude 18°N
• On the northeast, from the Yemen border at 16°38.5’N, 53°6.5’E to high seas point
14°55’N, 53°50’E
• On the east, by a line from high seas point 14°55’N, 53°50’E to high seas point
10°48’N, 60°15’E, thence to high seas point 6°45’S, 48°45’E
• And on the southwest, by the Somalia border at 1°40’S, 41°34’E, to high seas
point 6°45’S, 48°45’E
• Excepting coastal waters of adjoining territories up to 12 nautical miles offshore
unless otherwise provided.

Conveyance : Sea
By Registered Steel vessel as per Inst. Classification Clause 01/01/01 amended to include
BKI class max. 25 years old (for others), 20 years old (for LCT) and min. 1000GRT.

LCT for domestic shipments only.

Excluding Tug/Barge, PLM/KLM, Wooden and Unclassed Vessel.

Land Transit
By Trailer, Trucks, Truck Box and other registered land conveyances in respect of Land
Transit.

Warranty for open truck : should be covered with water resistant tarpaulin at the top.

Warranted vehicles are not left unattended and guarded at all times.

Excluding Public Transportation, such as bus, trains and taxi and also motorcycle.

Air
By registered and scheduled flight
Excluding Chartered Airfreight
 PT Asuransi Allianz Utama Indonesia

Conditions : - Institute Cargo Clause ‘A’ 1/1/82

- Institute Cargo Clauses “Air” 1/1/82
- Institute War Clauses (Cargo) 1/1/82
- Institute Strikes Clauses (Cargo) 1/1/82
- Institute War Clauses (Air Cargo) 1/1/82
- Institute Strikes Clauses (Air Cargo) 1/1/82
- Warehouse to Warehouse
- Including Hijacking
- Cargo ISM Endorsement Clause
- Cargo ISM Forwarding Charges Clause
- Concealed Damage Clause (30 days)
- Cancellation Clause (30 Days)
- Information Technology Hazard Clarification Exclusion Clause
- Institute Classification Clause 1/1/01 amended to include BKI Class max. 25 years old
and min. 1000 GRT
- Institute Cyber Attack Exclusion Clause LMA5403
- Institute Radioactive Contamination, Chemical, Biological, Bio- Chemical and
Electromagnetic Weapons Exclusion Clause 10/11/03 CL. 370
- Institute Replacement Clause 1.1.34
- Loss Notification Clause (30 days)
- Sanction Limitation and Exclusion Clause Jc2010/14
- Second Hand Replacement Clause (for second hand machinery)
- Premium Payment Warranty (30 Days)
- Waiver Clause
- Dispute Clause
- Nuclear Energy Risks NMA 1975a (10/3/94)
- Termination of Transit Clause (Terrorism)
- Cargo Termination of Storage in Transit Clause
- Coronavirus Exclusion LMA 5395
- Electronic Data Exclusion Clause – NMA 2915
- Including Loading Unloading
- Institute Theft, Pilferage, And Non-Delivery 1.12.82.
- Bill of Lading Clause
- Containers Clause
- Error & Omission Clause in declaration only
- Buyer’s Interest Clause
- Seller’s Interest Clause
- Packing Clause
- Label & Salvage Clause
- Pair and Sets Clause
- Nominated Adjuster Clause(as per Allianz’s list) :
1. PT. Radita Hutama Internusa
2. PT. Axis International Indonesia
3. PT. Global Internusa Adjusting
4. PT. Atlas Adjusting Indonesia
5. and other as mutually agreed between insured and insurer
- Removal of Debris Clause (2.5% of Total Sum Insured)
 PT Asuransi Allianz Utama Indonesia

- Replacement Clause (By Air & duty) 2.5% of TSI max. USD. 5,000
- Shipping Expenses Clause – Max. 2.5% of TSI
- Strike Cancellation Clause
- Waiver of Subrogation if the Conveyance Owned by the Insured and/or PT. GISTEX
- War Cancellation
- Excluding Pre-existing Damage(s)
- Excluding Rust, Oxidation, Scratching, Denting, Bending, Breaking, Twisting, Chipping,
Electrical & Mechanical Derangement unless caused by insured perils
- Excluding Rust, Oxidation, Scratching, Denting, Bending, Breaking, Twisting, Chipping,
Electrical & Mechanical Derangement unless caused by insured perils but absolute for
secondhand goods.
- Excluding any damage cause by dismantling, assembling, testing and commissioning
process (if any)

Rate :
0.075%
Minimum Premium USD 10

Deductible : 0.5% of Total Sum Insured

(each and every loss)

Declaration : Declaration (based on monthly declaration) containing particulars of goods to be shipped,

should be forwarded to PT. ASURANSI ALLIANZ UTAMA INDONESIA through the Agent
Consisting of:
• Description, quantities and insured value of the shipped goods.
• Number of Invoice, Bill of Lading (B/L) and Airway Bill (AWB)
• Name of Place or Port of Loading and Discharge (voyage).
• Name and ETD of carrying vessel, Aircraft and/or other conveyance.

These declaration should be sent to the Insurer for each and/or every shipment/delivery.
The Insured is bound to declare hereunder each and every shipment without exception and
the Insurer is bound to accept same up to but not exceeding the amount of any one bottom
specified in the contract.

Post-shipping: The Insured and/or their intermediary may declare every shipment to the
underwriter after its occurrence in form of a periodical bordereaux, or maximum 14
(fourteen) days after the shipment.

Any shipments that deviates from the MOP are warranted for approval from
underwriters prior shipment. Without approval from underwriters, PT. Asuransi
Allianz Utama Indonesia will not be liable for the shipment or any claims that may
arise.

Subjectivity : - No deterioration of loss up to renewal date

- No backdated acceptance
- Allianz has the right for immediate review on Pricing and Terms & Condition if the
loss ratio is more than 50%
- Using Merimen
- Validity quotation up to 23 September 2024
 PT Asuransi Allianz Utama Indonesia

Sensitive Countries List:

• Afghanistan
• Cameroon
• Ethiopia
• Congo
• Iraq
• Iran
• North Korea
• Myanmar
• Nigeria
• Pakistan
• Somalia
• South Sudan
• Sudan
• Syria
• Uganda
• Yemen
 PT Asuransi Allianz Utama Indonesia

Jika Anda menyetujui Surat Penawaran d a n R i n g k a s a n P e n g a j u a n A s u r a n s i ini s e r t a semua syarat dan ketentuan
yang terdapat di dalamnya, silakan ( i ) melakukan konfirmasi dengan menghubungi Konsultan Asuransi Anda atau
menghubungi Customer Service Allianz di 1500-136 atau email [email protected]; dan (ii) menyampaikan dokumen
pendukung untuk pengajuan Polis sebelum Polis diterbitkan melalui Konsultan Asuransi Anda, selambat-lambatnya 14 hari
kalender sejak tanggal Surat Penawaran dan Ringkasan Pengajuan Asuransi ini.

If you agree with this Quotation and Insurance Application Summary and all the terms and conditions, please (i)
confirm by contacting your Insurance Consultant or Allianz Customer Service at 1500-136 or email [email protected]; and (ii)
submit supporting documents for Policy issurance before the policy is issued through your Insurance Consultant, no later than
14 calendar days from the date of this Quotation and Insurance Application Summary issued.

Dokumen pendukung untuk pengajuan Polis adalah sebagai berikut:

Supporting documents for Policy submission, as follows:
Jenis Dokumen Nasabah Perorangan Nasabah Korporasi
Type of Documents Individual customer Corporate Customer
Dokumen Identitas salinan Kartu Tanda Penduduk Salinan Akta Pendirian dan/atau Anggaran Dasar, dan Izin
Identity Documents (WNI) atau Paspor dan Kartu Izin usaha atau izin lainnya dari instansi berwenang; atau
Tinggal (WNA) Nomor Induk Berusaha.

Copy of Deed of Establishment and/or Articles of

copy of identity card (Indonesian Association, and business license or other license from
citizen) or Passport and Stay authorized Institution; or Business Registration Number.
Permit (Foreign Citizen)
Dokumen lainnya dokumen wajib pendukung yang berkaitan penilaian resiko lainnya.
Other Documents Other mandatory supporting documents related to risk assessment.

Nama Konsultan Asuransi

Insurance Consultant :
 PT Asuransi Allianz Utama Indonesia

Risiko
Risk

Risiko Kredit
Credit Risk
Risiko yang berkaitan dengan kemampuan PT Asuransi Allianz Utama Indonesia dalam rangka memenuhi
kewajiban pembayaran kepada Tertanggung. PT Asuransi Allianz Utama Indonesia senantiasa mempertahankan
kinerja untuk melebihi minimum kecukupan modal sesuai dengan ketentuan yang berlaku.
Risks related to the ability of PT Asuransi Allianz Utama Indonesia to fulfill payment obligations to the insured. PT
Asuransi Allianz Utama Indonesia always maintains its performance to exceed the minimum capital adequacy in
accordance with applicable regulations.

Risiko Operasional
Operational Risk
Risiko yang berkaitan dengan proses operasional PT Asuransi Allianz Utama Indonesia, termasuk aplikasi system,
maupun peristiwa eksternal yang dapat mempengaruhi kegiatan operasional PT Asuransi Allianz Utama Indonesia.
Risks related to the operational processes of PT Asuransi Allianz Utama Indonesia, including system applications,
as well as external events that may affect the operational activities of PT Asuransi Allianz Utama Indonesia.

Risiko Perubahan Kondisi Ekonomi dan Politik

Economic and Politic Alteration Risk
Risiko perubahan kondisi ekonomi dan stabilitas politik di dalam dan di luar negeri, atau perubahan undang-
undang, kebijakan dan peraturan pemerintah yang berkaitan dengan dunia usaha serta dapat mempengaruhi
kinerja investasi dan kinerja PT Asuransi Allianz Utama Indonesia.
The risk of changes in economic conditions and political stability at home and abroad, or changes in laws, policies
and government regulations related to the business world and may affect the investment performance and
performance of PT Asuransi Allianz Utama Indonesia.

Catatan Penting
Important Notes
- Surat Penawaran dan Ringkasan Pengajuan Asuransi ini merupakan Ringkasan Informasi Produk dan
Layanan (RIPLAY) Personal dan permohonan asuransi Anda yang memberikan informasi mengenai
pertanggungan, manfaat, biaya, syarat & ketentuan dan risiko secara ringkas sesuai dengan jenis produk
yang akan Anda beli. Anda dapat menghubungi Tenaga Pemasar atau Kami untuk mendapatkan informasi
lebih lengkap mengenai produk asuransi yang akan Anda beli.
This Quotation and Insurance Application Summary is a Personal Product and Service Information Summary
(RIPLAY) and your insurance application which provides information on coverage, benefits, costs, terms &
conditions and risks in a brief manner according to the type of product you are willing to buy. You can contact
our sales force or Us to get more complete information about the insurance product that you are willing to
buy.
- Anda harus memahami informasi pada Surat Penawaran dan Ringkasan Pengajuan Asuransi ini sebelum
Anda menyetujuinya.
You must understand the information in this Quotation and Insurance Application Summary before you accept
it.
- Penjelasan pertanggungan asuransi yang lengkap terdapat pada Polis. Pertanggungan asuransi berlaku
ketentuan Pengecualian yang terdapat pada Polis, yaitu hal-hal yang tidak ditanggung dalam Polis.
A complete explanation of insurance coverage can be found in the Policy. Insurance coverage applies to the
Exception provisions contained in the Policy, namely things that are not covered in the Policy.
 PT Asuransi Allianz Utama Indonesia

- PT Asuransi Allianz Utama Indonesia berizin dan diawasi oleh Otoritas Jasa Keuangan, dan tenaga
pemasarnya telah memegang lisensi dari Asosiasi Asuransi Umum Indonesia.
PT Asuransi Allianz Utama Indonesia is licensed and supervised by the Financial Services Authority, and their
marketing personnel are licensed by the Indonesian General Insurance Association.
- Kami akan menginformasikan kepada Anda apabila terjadi perubahan manfaat, biaya, risiko, syarat, dan
ketentuan sebagaimana tercantum di dalam Polis paling lambat 30 (tiga puluh) hari kerja sebelum berlakunya
perubahan manfaat, biaya, risiko, syarat, dan ketentuan tersebut.
We will inform you if there are any changes in benefits, costs, risks, terms and conditions as stipulated in the
policy wording no later than 30 (thirty) working days before the changes are effective.

Syarat dan Ketentuan

Terms and Conditions

Anda menyatakan dan menyetujui:

You as the insured acknowledge and agree:
1. Mohon periksa kembali informasi dan persyaratan asuransi yang tercantum dalam Surat Penawaran dan
Ringkasan Pengajuan Asuransi ini serta tinjau kembali nilai pertanggungan agar sesuai dengan harga pasar
saat ini dan untuk menghindari pembayaran klaim secara pro rata apabila harga pertanggungan di bawah
harga pasar.
Please re-check the information and terms that stipulated in this Quotation and Insurance Application
Summary and review the sum insured in accordance with the current market value and to avoid claim payment
on pro rata basis if the sum insured is below the market value.
2. Dengan Anda (i) memberikan konfirmasi atau persetujuan atas Surat Penawaran dan Ringkasan Pengajuan
Asuransi ini (melalui media apa pun), (ii) melakukan pembayaran premi asuransi sesuai dengan ketentuan
Surat Penawaran dan Ringkasan Pengajuan Asuransi ini; dan/atau (iii) melakukan tindakan lainnya yang
mengindikasikan persetujuan Anda atas Surat Penawaran dan Ringkasan Pengajuan Asuransi ini, maka
Anda menyetujui dan terikat pada (a) Syarat dan Ketentuan Umum dan Syarat dan Ketentuan Khusus dari
Surat Penawaran dan Ringkasan Pengajuan Asuransi ini; dan (b) Polis asuransi.
By you (i) providing confirmation or approval upon this Quotation and Insurance Application Summary
(through any media), (ii) making insurance premium payments in accordance with the terms of this Quotation
and Insurance Application Summary; and/or (iii) taking other actions that indicate your approval upon this
Quotation and Insurance Application Summary, you agree and are bound to (a) General Terms and Conditions
and Special Terms and Conditions of this Quotation and Insurance Application Summary; and (b) Insurance
Policy.

Syarat dan Ketentuan Khusus

Specific Terms and Conditions
Anda menyatakan dan menyetujui:
You as the insured acknowledge and agree:
1. Semua keterangan yang tercantum dalam Surat 1. All information that stipulated in this
Penawaran dan Ringkasan Pengajuan Asuransi Quotation and Insurance Application
ini dan keterangan lain yang Anda sampaikan Summary and other information that you
kepada Allianz adalah benar dan tidak ada convey to Allianz is true and there are no
keterangan-keterangan dan hal-hal lain yang information or other things undisclosed.
Anda sembunyikan.
 PT Asuransi Allianz Utama Indonesia

2. Pembayaran yang dilakukan oleh Anda untuk 2. Your premium payment based on this Quotation and
pembayaran Premi berdasarkan Surat Penawaran Insurance Application Summary do not originate from
dan Ringkasan Pengajuan Asuransi ini tidak or used for the purpose of money laundering and
berasal dari maupun digunakan untuk tujuan terrorism financing as referred to in constitution “UU
tindak pidana pencucian uang dan pendanaan No. 8 Tahun 2010 tentang Penecegahan dan
terorisme sebagaimana dimaksud UU No. 8 Tahun Pemberantasan Tindk Pindana Pencucian Uang dan
2010 tentang Pencegahan dan Pemberantasan UU No. 9 tahun 2013 tentang Pencegahan dan
Tindak Pidana Pencucian Uang dan UU No. 9 Pemberantasan Tindak Pidana Pendanaan
Tahun 2013 tentang Pencegahan dan Terorisme” (and/or amendments thereto), include not
Pemberantasan Tindak Pidana Pendanaan being involved in and/or being included in the list of
Terorisme (dan/atau perubahannya), termasuk funding for the proliferation or weapons of mass
tidak terlibat dan/atau terdapat dalam daftar destruction. If there are indications of a violation of the
pendanaan proliferasi senjata pemusnah massal. constitutions and the provisions mentioned above,
Apabila ada indikasi pelanggaran atas Undang- Allianz will carry out its obligations in accordance with
Undang dan ketentuan-ketentuan tersebut di atas, applicable regulations or on orders from the
maka Allianz akan melaksanakan kewajiban Authorized Institution, including carrying out reporting
sesuai dengan ketentuan yang berlaku atau atas obligations and providing reports on the suspicious
perintah Lembaga Negara yang berwenang, financial transactions. In order to fulfill the obligations
termasuk melakukan kewajiban pelaporan dan of the Customer Due Diligence, You are willing to
memberikan laporan atas transaksi keuangan provide the requested data in accordance with the
yang mencurigakan. Dalam rangka memenuhi applicable regulations and to update the data if there
kewajiban Uji Tuntas Nasabah, Anda bersedia are any changes to the data in the future.
untuk memberikan data yang diminta sesuai
dengan peraturan yang berlaku dan Anda
bersedia untuk melakukan pengkinian data dalam
hal terdapat perubahan data di kemudian hari.
3. Anda dengan ini memberikan persetujuan dan 3. You hereby give your consent and permission, to
izin, kepada Allianz untuk: Allianz to:
a. menyimpan dan memproses data dan/atau a. store and process your personal data and/or
informasi pribadi Anda (termasuk data dan information (including your health and financial
informasi kesehatan serta finansial Anda) data and information) for and/or for each of the
dalam rangka dan/atau untuk setiap tujuan following purposes:
berikut ini:
(i) proses pengajuan permohonan (i) the insurance application process;
asuransi;
(ii) penerbitan Polis; (ii) issuance of the Policy;
(iii) penilaian risiko asuransi; (iii)insurance risk assessment;
(iv) kegiatan operasional Allianz; (iv) Allianz’s operational activities;
(v) pengajuan dan penanganan setiap (v) filing and handling of any claims (including
klaim (termasuk namun tidak but not limited to the examination and
terbatas pada pemeriksaan dan investigation of claims);
investigasi klaim); (vi) payment of insurance benefits/claims;
(vi) pembayaran manfaat
asuransi/klaim; (vii) the need for co-insurance including the
(vii) keperluan ko-asuransi termasuk handling of claims arising from co-
penanganan klaim yang timbul atas insurance;
ko-asuransi; (viii) customer service including handling
(viii) pelayanan nasabah termasuk complaints/complaints;
penanganan keluhan/komplain; (ix) commission payments;
(ix) pembayaran komisi; (x) cooperation in the detection or prevention
(x) kerja sama dalam rangka penemuan of fraud and financial crimes;
atau pencegahan penipuan dan
kejahatan keuangan; (xi) any legal proceedings involving Allianz
(xi) setiap proses hukum yang and/or its sales force;
melibatkan Allianz dan/atau tenaga
pemasarnya;
 PT Asuransi Allianz Utama Indonesia

(xii) kerja sama reasuransi dan/atau (xii) reinsurance and/or retrocession

retrosesi; cooperation;
(xiii) kepatuhan terhadap perintah (xiii) compliance with court orders, applicable
pengadilan, hukum dan peraturan laws and regulations; and/or
perundang-undangan yang berlaku;
dan/atau
(xiv) proses lainnya yang terkait dengan (xiv) other processes related to the
penyelenggaraan kegiatan asuransi. implementation of insurance activities.
b. menyimpan dan memproses data dan/atau
informasi pribadi Anda (termasuk data dan
informasi kesehatan serta finansial Anda) b. disclose your personal data and/or information
dalam rangka dan/atau untuk setiap tujuan (including your health and financial data and
berikut ini: information) to the following parties:
(i) ahli medis, ahli independen,
dan/atau pihak ketiga lainnya (i) medical professionals and/or other third
(termasuk mereka yang parties (including those who provide you
memberikan perawatan, pelayanan with treatment, health care and/or other
kesehatan dan/atau layanan lainnya services);
kepada Anda);
(ii) setiap perusahaan (termasuk
Perusahaan penyedia layanan, (ii) any company (including service provider
perusahaan asuransi, dan companies, insurance companies, and
perusahaan reasuransi), mitra, reinsurance companies), partners,
orang atau pihak ketiga yang persons or third parties appointed by
ditunjuk dan/atau bekerja sama and/or cooperating with Allianz;
dengan Allianz;
(iii) perusahaan induk Allianz, afiliasi, (iii) Allianz's parent companies, affiliates,
anak perusahaan, agen dan subsidiaries, agents and representatives
perwakilannya dan/atau usaha and/or joint ventures; and/or
patungan; dan/atau (iv) authorities, insurance associations
(iv) otoritas, asosiasi asuransi dan/atau and/or government bodies (regulators).
badan pemerintah (regulator), in connection with and/or for any purpose
dalam rangka dan/atau untuk setiap tujuan mentioned in point 3 (a) above.
sebagaimana yang diuraikan dalam butir 3 (a)
di atas.
c. menyimpan serta memproses data dan/atau c. store and process your personal data and/or
informasi pribadi Anda (termasuk data dan information (including your health and financial
informasi kesehatan serta finansial Anda) dan data and information) and disclose such personal
mengungkapkan data dan/atau informasi data and/or information in response to a court
pribadi tersebut untuk menanggapi perintah order or legal process or request from any
pengadilan atau proses hukum atau regulator or authority or to protect against fraud or
permintaan dari regulator manapun atau other illegal activities or for risk management
pihak berwenang atau untuk melindungi purposes or to enable Allianz to take available
terhadap penipuan atau aktivitas ilegal legal remedies or limit damages that may occur to
lainnya atau untuk tujuan manajemen risiko Allianz, and/or comply with laws and legal
atau untuk memungkinkan Allianz untuk processes including but not limited to regulations
melakukan upaya hukum yang tersedia atau regarding FATCA and CRS (“Exchange Reporting
membatasi kerusakan yang mungkin terjadi Needs Inter-Country Information”). You are also
terhadap Allianz, dan/atau mematuhi hukum willing to provide the necessary information/
dan proses hukum termasuk tetapi tidak documents to fulfill the related needs (“Related
terbatas pada peraturan tentang FATCA dan Information”) and immediately submit the data
CRS (“Kebutuhan Pelaporan Pertukaran entry to Allianz if there are changes to the Related
Informasi Antar Negara”). Anda juga bersedia Information.
untuk memberikan informasi/ dokumen yang
diperlukan guna memenuhi kebutuhan terkait
(“Informasi Terkait”) dan dengan segera
menyampaikan pengikian data kepada Allianz
jika ada perubahan atas Informasi Terkait
tersebut.
 PT Asuransi Allianz Utama Indonesia

4. Bahwa apabila ternyata pernyataan, keterangan, 4. If your statements, information, documents and the
dokumen dan jawaban yang Anda berikan tidak answer that you provide are not true/doubtful, You are
benar/ diragukan kebenarannya, maka Anda fully understand and agree that this Quotation and
memahami serta menyetujui sepenuhnya bahwa Insurance Application Summary and the policy will be
Surat Penawaran dan Ringkasan Pengajuan void and Allianz is released from all obligations to pay
Asuransi dan Polis menjadi batal dan Allianz the sum insured, demands, claims or part of it in any
dibebaskan dari segala kewajibannya membayar form and name, nor to return the premium, either now
Uang Pertanggungan, segala gugatan, tuntutan, or at future.
klaim atau bagian dari itu dalam bentuk dan nama
apapun, maupun mengembalikan Premi, baik saat
ini maupun di kemudian hari.
5. Allianz hanya mengakui pembayaran Premi yang 5. Allianz only recognize the premium payments
dilakukan melalui media pembayaran Premi through the payment media as stipulated in this
sebagaimana tertera dalam Surat Penawaran dan Quotation and Insurance Application Summary. You
Ringkasan Pengajuan Asuransi ini. Anda are fully aware of and responsible for all risks that arise
menyadari dan bertanggung jawab secara penuh if you do not pay the premium based on procedures
atas segala risiko yang timbul bila Anda tidak that stipulated in this Quotation and Insurance
melakukan pembayaran Premi sesuai tata cara Application Summary.
yang diatur dalam Surat Penawaran dan
Ringkasan Pengajuan Asuransi ini.
6. Pertanggungan asuransi akan mulai berlaku 6. The insurance coverage will fully effective if the
penuh apabila hal-hal berikut ini telah terjadi: following events have occurred:
a. Polis atau surat/pernyataan akseptasi telah a. The policy or acceptance letter/statement
diterbitkan Allianz; dan has been issued by Allianz; and
b. Premi telah dibayar lunas dan diterima oleh b. The premium has been fully paid and
Allianz sesuai ketentuan pembayaran premi received by Allianz in accordance with the
yang telah ditetapkan. predetermined premium payment terms.
7. Anda sadar dan sudah mengetahui serta 7. You are aware and already acknowledge and fully
memahami sepenuhnya jenis produk yang akan understand the product that will be purchased and get
dibeli dan mendapatkan penjelasan produk yang the explanation of the product based on this Quotation
akan Anda beli berdasarkan Surat Penawaran dan and Insurance Application Summary.
Ringkasan Pengajuan Asuransi ini.
8. Setiap komunikasi dan korespondensi antara 8. Every communication and correspondence between
Anda dengan Allianz sehubungan dengan Surat you and Allianz regarding the Quotation and Insurance
Penawaran dan Ringkasan Pengajuan Asuransi, Application Summary, Policy, Services form Allianz,
Polis, layanan dari Allianz, dan informasi lainnya and other information (including without limitation the
(termasuk tidak terbatas mengenai syarat-syarat additional terms, endorsements, addendums,
tambahan, endosemen, addendum, perubahan, changes, notifications, reports, data updates, Allianz
pemberitahuan, laporan, pengkinian data, and/or
kampanye yang dilakukan oleh Allianz dan/atau affiliates campaigns, documents and other
afiliasinya, dokumen-dokumen dan transaksi- transactions both from you and Allianz) will be made
transaksi lainnya baik dari Anda maupun Allianz) through digital/ electronic communication media
akan dilakukan melalui media komunikasi (including without limitation to email, telephone, and
digital/elektronik (termasuk tidak terbatas melalui other digital/ electronic communication media that will
email, telepon, dan media komunikasi digital/ be used by Allianz) from time to time in accordance
elektronik lainnya yang akan digunakan oleh with the applicable procedures.
Allianz), dari waktu ke waktu sesuai dengan
prosedur yang berlaku.
9. Anda menyadari sepenuhnya bahwa Allianz 9.You fully acknowledge that Allianz may
memiliki hak untuk menolak/menerima, refuse/accept, cancel/change (in this case including
membatalkan/ mengubah (dalam hal ini termasuk adding/removing) any provisions herein, including
untuk menambahkan/mengurangi) ketentuan among others to decide if the participation of any
dalam perjanjian pertanggungan ini, termasuk Prospective Insured/ Policyholders is refused by
antara lain untuk menentukan bahwa apabila Allianz.
Calon Tertanggung/Calon Pemegang Polis ditolak
kepesertaannya oleh Allianz.
 PT Asuransi Allianz Utama Indonesia

10. Dalam hal Anda memilih Buku Polis versi 10. In the event you choose the electronic version of
elektronik sebagaimana keterangan yang Anda the Policy Book as mentioned in this Quotation and
berikan dalam Surat Penawaran dan Ringkasan Insurance Application Summary, you represent and
Pengajuan Asuransi ini, maka Anda menyatakan agree that the electronic version of the Policy Book will
dan menyetujui bahwa Buku Polis versi elektronik be sent by e-mail.
akan dikirimkan melalui e-mail.
11. Anda mengerti bahwa untuk mempelajari lebih 11. You understand to learn about Allianz protects your
lanjut tentang bagaimana Allianz melindungi data personal data and rights by accessing the following
Pribadi dan hak-hak Anda dengan mengakses link:
tautan berikut: https://www.allianz.co.id/kebijakan- https://www.allianz.co.id/kebijakan-privasi.html.
privasi.html.
12. Anda harus memastikan dan menjamin kepada 12. You must ensure and guarantee to Allianz that you
Allianz bahwa Anda tidak tunduk pada Qanun No. are not subject to Qanun No. 11 Year 2018 concerning
11 Tahun 2018 tentang Lembaga Keuangan the sharia financial institutions and their implementing
Syari’ah dan peraturan pelaksanaannya regulations (as may be amended, added or replaced
(sebagaimana dapat diubah, ditambah atau from time to time) that there are no prohibition for you
digantikan dari waktu ke waktu) sehingga tidak to purchase non-sharia insurance products.
ada larangan bagi Anda untuk membeli produk
asuransi non-syari’ah.
13. Surat Penawaran dan Ringkasan Pengajuan 13. This Quotation and Insurance Application
Asuransi ini disediakan dalam versi Bahasa Summary is provided in English version and
Indonesia dan Bahasa Inggris. Dalam hal terjadi Indonesian language version. In the event of a
ketidaksesuaian atau inkonsistensi antara versi discrepancy or inconsistency between English version
Bahasa Inggris dan Bahasa Indonesia, maka versi and Indonesian language version, then the Indonesian
dalam Bahasa Indonesia yang berlaku. language version shall prevail.

Kami berkomitmen tinggi untuk memberikan pelayanan terbaik bagi Anda. Kepercayaan Anda pada Allianz adalah
kebanggaan Kami.
We are highly committed to provide the best services for you. Your trust in Allianz Is our pride.

JAKARTA, 19 August 2024

PT Asuransi Allianz Utama Indonesia

Marine Underwriter
Dita Agustina / Neti Setyabudi

Pertanyaan, keluhan terkait produk dan/atau layanan serta prosedur dan syarat dan ketentuan pengajuan klaim,
dapat Anda sampaikan melalui Customer Center Kami:
You can submit the questions, complaint related to product and/or procedures and claims terms and conditions
through our Customer Center:

PT Asuransi Allianz Utama Indonesia

World Trade Centre 6
Jalan Jenderal Sudirman Kav. 29-31
Jakarta Selatan 12920, Indonesia
Allianz Care 1500-136
[email protected] - www.allianz.co.id