FINAL SLIP

SGS/FS/MVI/05/2024/053

TYPE OF INSURANCE : Polis Standar Asuransi Kendaraan Bermotor Indonesia (PSAKBI)

INSURED NAME : KUTAI ENERGI, PT

ADDRESS : SOPO DEL OFFICE TOWERS & LIFESTYLE CENTER, TOWER A LT 23 ( UNIT E DAN F ) JL.
MEGA KUNINGAN BARAT III, LOT 10 1-6, KAWASAN MEGA KUNINGAN, KUNINGAN
TIMUR,JAKARTA SELATAN

PERIOD : 25-Jun-2024 until 25-Jun-2025

both dates inclusive at 12 o'clock noon

SUM INSURED : IDR 650,040,909.00

VEHICLE DATA : Police No. : KT 8510 OS

Brand : Mitsubishi
Type : Colt Diesel FE74HD K (4X2) M/T
Model : Truck/Pickup
Year : 2019
Color : Red
Engine No. : 4D34TTX1580
Chassis No. : MHMFE74PPK212105

COVERAGE : Comprehensive

EXTENDED COVERAGE : 1. Typhoon, Storm, Flood, and Water Damage (TSFWD)

2. Earthquake, Volcanic Eruption and Tsunami (EQVET)
3. Strike, Riot and Civil Commotion (SRCC)
4. Terrorism and Sabotage (TS)
5. Authorized Workshop
6. Third Party Liability (TPL) max. IDR 100,000,000.00
7. Personal Accident (PA) for Driver max. IDR 100,000,000.00
8. Personal Accident (PA) for Passenger max. IDR 100,000,000.00 /Person, max. 2 Persons
9. Medical Expenses (MEDEX) max. 10% of Personal Accident Limit

DEDUCTIBLE : 1. IDR 300,000.00 if loss or damage of the vehicle happens partially/occurrence

2. IDR 300,000.00 of Total sum Insured if theft or damage of vehicle happens entirely/occurrence
3. Typhoon, Storm, Flood, and Water Damage (TSFWD): 10% of the Claim Value agreed,
minimum IDR 500,000.00 /occurrence
4. Earthquake, Volcanic Eruption and Tsunami (EQVET): 10% of the Claim Value agreed,
minimum IDR 500,000.00 /occurrence
5. Strike, Riot and Civil Commotion (SRCC): 10% of the Claim Value agreed, minimum IDR
500,000.00 /occurrence
6. Terrorism and Sabotage (TS): 10% of the Claim Value agreed, minimum IDR 500,000.00
/occurrence
7. Others: NIL any one occurrence

CLAUSES : 1. Ambulance Fee Clause (max. IDR. 2,000,000.00 anyone accident)

2. Authorized Workshop Clause (max. age of vehicle 7 years old)
3. Automatic addition and deletion (30 days of notice and Pro-rate premium)
4. Broad Pair And Set Clause
5. Cancellation Clause (30 Days)
6. Constructive Total Loss Clause (75%)
7. Fitted Non-Standard Accessories Clause
8. Garansi Cat dan Suku Cadang Clause

PT SOCIETO GENERAL SINERGI

Prepared by: Syafta Virgianita
Date: June 20th, 2024
 9. It is hereby noted and agreed that all Third Party Liability claims not exceeding IDR
3,000,000.00 anyone occurrence can be settled on the spot subject to all document duty
provided. Maximum of 10 such occurrence per vehicle during the policy period.
10. It is hereby noted and agreed that policy is extended to cover partial and total loss or damage
to insured vehicles consequences of absconding and/or theft by driver
11. KADITSERSE/POLDA waiver clause due to total loss by any kind of theft, Subject to
completion for Police Report and Police Block Letter for the Car Ownership: BPKB and Car
registration: STNK - with deductible 10% of claim
12. Loss notification clause (30 days)
13. Pro-rata Refund Premium upon policy cancellation (subject to no claim)
14. Sister Car Clause
15. Taxi Fare Allowance IDR 300,000.00 per day with max. 5 (five) working days when repair is
done in the Insurance affiliated workshop/agreed workshop (non-authorized workshop
16. Towing Service Clause (0.5% of each Sum Insured as per PSAKBI)
17. Transit Extension (including by vessels between the clients' sites/premises located anywhere
in Indonesia (as per PSAKBI)
18. Waiver of Subrogation Clause
19. Water Hammer Extension Clause
20. Wheels and Tire Clause due to accident (with deductible 10% of loss)
21. Workshop: Insurance service center and Approved Garage

PREMIUM CALCULATION : - Comprehensive IDR 650,040,909.00 2.2300% IDR 14,495,912.27

- TSFWD IDR 650,040,909.00 0.0750% IDR 487,530.68
- EQVET IDR 650,040,909.00 0.0750% IDR 487,530.68
- SRCC IDR 650,040,909.00 0.0500% IDR 325,020.45
- TS IDR 650,040,909.00 0.0500% IDR 325,020.45
- Authorize Workshop IDR 650,040,909.00 0.1000% IDR 650,040.91
- TPL IDR 25,000,000.00 1.5000% IDR 375,000.00
IDR 25,000,000.00 0.7500% IDR 187,500.00
IDR 50,000,000.00 0.3750% IDR 187,500.00
- PA Driver IDR 100,000,000.00 0.5000% IDR 500,000.00
- PA Passenger IDR 200,000,000.00 0.1000% IDR 200,000.00
Total Premium IDR 18,221,055.45
(Excl. policy cost & stamp duty)

BROKERAGE : 25% (Excl. VAT)

UW INFO : - Include Tangki (IDR 250,950,000.00)

- Accessories (IDR 29,090,909.00)
1. Pompa Tohatsu
2. Slang Kain
3. Safety Cone
4. Ban Lokasi (Trade In)
5. Whell Cox
6. Rotari Panjang
7. Pemutus Arus
8. Lampu-lampu Kerja
9. Water Cannon Model Spary + Jet
- Existing Policy PT. Sunday Indonesia Insurance *1MY02252300469

Jakarta, June 20th, 2024

Signed and on behalf of,
PT SOCIETO GENERAL SINERGI

Computer signed

Syafta Virgianita

PT SOCIETO GENERAL SINERGI

Prepared by: Syafta Virgianita
Date: June 20th, 2024