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    Kuesioner Pelaut: Merchant Marine Questionnaire

    Uploaded by

    Habib Aqeel Abdullah
    This document is a merchant marine questionnaire from PT Prudential Life Assurance used to collect information from individuals applying for life insurance who work in maritime occupations. It asks for the applicant's name and occupation code, whether their work involves time at sea, the type of vessel they work on, the physical demands of their duties, and whether they have experienced any accidents or illnesses related to their work. The applicant signs to agree that their responses are truthful and complete and that withholding any material information could invalidate their insurance contract.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Kuesioner Pelaut: Merchant Marine Questionnaire

    Uploaded by

    Habib Aqeel Abdullah
    101 views3 pages
    This document is a merchant marine questionnaire from PT Prudential Life Assurance used to collect information from individuals applying for life insurance who work in maritime occupations. It asks for the applicant's name and occupation code, whether their work involves time at sea, the type of vessel they work on, the physical demands of their duties, and whether they have experienced any accidents or illnesses related to their work. The applicant signs to agree that their responses are truthful and complete and that withholding any material information could invalidate their insurance contract.

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    Laporan

    Original Title

    [000481]

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    This document is a merchant marine questionnaire from PT Prudential Life Assurance used to collect information from individuals applying for life insurance who work in maritime occupations. It asks for the applicant's name and occupation code, whether their work involves time at sea, the type of vessel they work on, the physical demands of their duties, and whether they have experienced any accidents or illnesses related to their work. The applicant signs to agree that their responses are truthful and complete and that withholding any material information could invalidate their insurance contract.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    101 views3 pages

    Kuesioner Pelaut: Merchant Marine Questionnaire

    Uploaded by

    Habib Aqeel Abdullah
    This document is a merchant marine questionnaire from PT Prudential Life Assurance used to collect information from individuals applying for life insurance who work in maritime occupations. It asks for the applicant's name and occupation code, whether their work involves time at sea, the type of vessel they work on, the physical demands of their duties, and whether they have experienced any accidents or illnesses related to their work. The applicant signs to agree that their responses are truthful and complete and that withholding any material information could invalidate their insurance contract.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    No.

    SPAJ/Polis:
    SPAJ/Policy No.

    KUESIONER PELAUT
    MERCHANT MARINE QUESTIONNAIRE

    UNTUK DIISI OLEH (CALON) TERTANGGUNG/PESERTA


    TO BE COMPLETED BY (PROPOSED) INSURED/PARTICIPANT

    Nama (Calon) Tertanggung/Peserta: :


    Life To Be Assured Name

    Jenis pekerjaan : ( Mohon tuliskan kode sesuai daftar di bawah ini)


    Type of Job (Please write down code as per below list)

    KODE DAFTAR PEKERJAAN / OCCUPATION LIST CODE


    1 Attendant - hydrofoil or Attendant - jetfoil 21 Lighterman
    2 Bargeman 22 Lighthouse keeper
    3 Baggage master 23 Light keeper - docks and harbours
    4 Boatswain 24 Navigator
    5 Captain (includes Chief Officer, Deck Officer, 25 Passenger Officer - hovercraft
    Master, Mate dan Skipper)
    6 Captain - hovercraft or Commander 26 Pilot
    7 Car lasher 27 Pilot - hydrofoil or Pilot - jetfoil
    Catering staff (includes Catering officer, Chef Cook,
    8 28 Survey Sounder
    Galley Hand)
    9 Dredger driver 29 Tugboatman
    10 Dredgerman 30 Tugman
    11 Dredgermaster 31 Watchman - inland waterways
    12 Dredging superintendent 32 Pilot superintendent
    Engineer (includes Chief Engineer, Electrical
    13 Engineer, Engineer officer, Refrigeration’s Engineer, 33 Purser
    Ship’s Engineer)
    14 Engineer - hovercraft (includes First Officer) 34 Quartmaster
    Engine-room Worker (includes Donkeyman, Engine-
    15 room rating, Engine-room storekeeper, Fireman, 35 Radio Officer
    Greaser, Leading Hand, Mechanic, Oiler, Pumpman,
    Stoker, Winchman)
    16 Entertainments Officer 36 Seaman (includes Deck Hand-boy and
    rating, Cable Hand
    17 Ferryman 37 Steerer
    18 Foreman lighterman 38 Steward (includes Chief and Second steward
    Lainnya, jelaskan:/Others, please specify:
    19 Junk boat worker or Sampan worker
    39 ………………………………………..........
    ………………………………………..........
    20 Leadsman ………………………………………..........
    ………………………………………..........

    Tanda tangan (Calon) Pemegang Polis sesuai Tanda tangan (Calon) Tertanggung/Peserta
    kartu identitas diri yang dilampirkan sesuai kartu identitas diri yang dilampirkan
    Signature of (Proposed) Policy Holder as per attached ID Card Signature of (Proposed) Insured/Participant as per attached ID Card

    Mohon lembar Kuesioner ini tidak ditandatangani dalam keadaan kosong dan pastikan semua informasi yang diminta
    telah diisi dengan benar sebelum ditandatangani./Please do not sign the form in blank and make sure all the required information have been
    filled appropriately prior to signing.

    PT Prudential Life Assurance


    Prudential Tower – Jl. Jend. Sudirman Kav. 79, Jakarta 12910, Indonesia
    Tel: (62 21) 2995 8888 Fax: (62 21) 2995 8800
    Prudential Customer Line: 500085
    E-mail: [email protected] Website: www.prudential.co.id
    Q.C.6/Merchant Marine Quest/Underwriting Dept/150611
    *12010601* 1 2 0 1 0 6 0
    1/3
    1
    No. SPAJ/Polis:
    SPAJ/Policy No.

    1. Apakah Anda melakukan pekerjaan di laut (atau di masa mendatang akan melakukan pekerjaan di laut )?/Does your
    occupation involve going to sea (or is it likely to be so in the future?)
    □ Ya/Yes □ Tidak/No
    Jika YA, mohon melengkapi kuesioner ini dengan lengkap./If YES, please complete the rest of this questionnaire.

    2. Anda melakukan pekerjaan pada jenis kapal yang mana?/Which of the following types of vessel do you work on?
    □ Ocean liner
    □ Barge, dredger, lighter, lightship, tug or weathership
    □ Cable and pipe-laying vessel, factory ship, oil rig barge or supply ship
    □ Passenger vessel/ferry
    □ Cargo vessel
    □ Lainnya, mohon jelaskan:/Other, please explain:………………………………………

    3. Berapa persen dari pekerjaan Anda menyangkut pekerjaan manual atau fisik?/What percentage of your duties are of
    a manual or physical nature?

    4. Pernahkah Anda mengalami kecelakaan atau sakit sehubungan dengan pekerjaan Anda?/Have you had any
    accidents or illnesses associated with your duties?
    □ Ya/Yes □ Tidak/No
    Jika YA, jelaskan kapan dan jenis kecelakaan/sakitnya./If YES, please explain when and type of accidents/ailments.

    Tanda tangan (Calon) Pemegang Polis sesuai Tanda tangan (Calon) Tertanggung/Peserta
    kartu identitas diri yang dilampirkan sesuai kartu identitas diri yang dilampirkan
    Signature of (Proposed) Policy Holder as per attached ID Card Signature of (Proposed) Insured/Participant as per attached ID Card

    Mohon lembar Kuesioner ini tidak ditandatangani dalam keadaan kosong dan pastikan semua informasi yang diminta
    telah diisi dengan benar sebelum ditandatangani./Please do not sign the form in blank and make sure all the required information have been
    filled appropriately prior to signing.

    PT Prudential Life Assurance


    Prudential Tower – Jl. Jend. Sudirman Kav. 79, Jakarta 12910, Indonesia
    Tel: (62 21) 2995 8888 Fax: (62 21) 2995 8800
    Prudential Customer Line: 500085
    E-mail: [email protected] Website: www.prudential.co.id
    Q.C.6/Merchant Marine Quest/Underwriting Dept/150611
    2/3
    No. SPAJ/Polis:
    SPAJ/Policy No.

    Dengan ini saya telah memberikan jawaban dan keterangan dalam Kuesioner Pelaut ini dengan sejelas-jelasnya dan
    sebenar-benarnya. Saya tidak menyembunyikan informasi apa pun yang dapat memengaruhi penerimaan Surat
    Pengajuan Asuransi Jiwa (SPAJ) saya. Saya menyetujui Kuesioner ini akan menjadi bagian dari SPAJ saya pada PT
    Prudential Life Assurance dan bahwa penyembunyian informasi material apa pun dapat mengakibatkan batalnya
    kontrak asuransi jiwa sebagaimana diatur dalam SPAJ dimaksud.

    I declare that the answers I have given in this Merchant Marine Questionnaire, to the best of my knowledge, are true
    and that I have not withheld any material information that may influence the assessment or acceptance of my Life
    Insurance Policy Application Form. I agree that this Questionnaire will constitute part of my Application Form with
    PT Prudential Life Assurance and that failure to disclose any material fact known to me may invalidate the contract as
    stipulated in the respective Application Form.

    di ……………………….tanggal ……………. bulan ……………..……. 20 ………


    Signed at on month of

    …..………………………………………….......... …..…………………………………………..
    Nama & Tanda Tangan Disaksikan oleh: Nama & Tanda Tangan Tenaga Pemasaran
    (Calon) Tertanggung/Peserta Witnessed by Name & Signature of Sales Representative
    Name & Signature of (Proposed) Insured/Participant (Sales Representative’s No: )

    PERHATIAN: Mohon tanda tangan sesuai kartu identitas diri yang dilampirkan
    ATTENTION: Please note that the signature must be the same with the one shown in the ID card

    Tanda tangan (Calon) Pemegang Polis sesuai Tanda tangan (Calon) Tertanggung/Peserta
    kartu identitas diri yang dilampirkan sesuai kartu identitas diri yang dilampirkan
    Signature of (Proposed) Policy Holder as per attached ID Card Signature of (Proposed) Insured/Participant as per attached ID Card

    Mohon lembar Kuesioner ini tidak ditandatangani dalam keadaan kosong dan pastikan semua informasi yang diminta
    telah diisi dengan benar sebelum ditandatangani./Please do not sign the form in blank and make sure all the required information have been
    filled appropriately prior to signing.

    PT Prudential Life Assurance


    Prudential Tower – Jl. Jend. Sudirman Kav. 79, Jakarta 12910, Indonesia
    Tel: (62 21) 2995 8888 Fax: (62 21) 2995 8800
    Prudential Customer Line: 500085
    E-mail: [email protected] Website: www.prudential.co.id
    Q.C.6/Merchant Marine Quest/Underwriting Dept/150611
    3/3

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