Formulir Aplikasi Individual Asuransi Kendaraan Bermotor · Tujuan Asuransi Insurance Purpose ......
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Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y 1/5 Formulir Aplikasi Individual Asuransi Kendaraan Bermotor (April 2015) Formulir Aplikasi Individual Asuransi Kendaraan Bermotor Informasi Pemegang Polis / Policy Holder Information* Hasil Usaha Business Income Lain-Lain Others: ................. Sumber Dana Sources of Fund Wirausaha Entrepreneurship Gaji Salary Tabungan / Deposito Saving / Deposit ≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million Penghasilan Kotor per Bulan (Rp) Monthly Gross Income (IDR) > 25-50 Juta / million > 10-25 Juta / million Informasi rekening ini akan digunakan untuk pembayaran manfaat atau transaksi pembayaran lainnya dari PT AIG Insurance Indonesia ("AIG Indonesia") apabila ada. Nama Bank termasuk Cabang / Bank Name incl Branch ................................................................................................................................................................... Nama Pemilik Rekening / Account Name .................................................................................................................................................................................................... Nomor Rekening / Account Number ............................................................................................................................................................................................................... This account information will be used by PT AIG Insurance Indonesia ("AIG Indonesia") for benefit or others payment transaction, if any. Pejabat/Pegawai Pemerintah, BUMN, Polisi, Tentara Official or Employee of Government or State-owned Entity, Police, Military Pekerjaan Occupation Karyawan Swasta Private Employee Nama Perusahaan / Company Name .................................................................................................................................................................................................... Lain-lain Others: ................ Wirausaha Entrepreneur Pengurus Partai Politik atau Anggota Legislatif Political Party Officials or Legislators Alamat Saat ini / Current Address (Jika berbeda dengan Kartu Identitas) (If different with Identity Card) No. Telepon Rumah Home Phone No. No. Ponsel Mobile No. Email .............................................................................................................................................................................................................................................................. Jabatan / Title ............................................................................................................................................................................................................................................ Pensiun Retirement Profesional (Pengacara, Dokter, dll) Professional (Lawyer, Doctor, etc): ............................... Kota / City ..................................................................... Provinsi / Province ........................................................................... Kecamatan / District ................................................................................................................................................................... Kelurahan / Sub District .............................................................................................................................................................. .................................................................................................................................................................. RT/RW ....... / ....... Kode Pos / Postal Code ............................................... Negara / Country ........................................................................... PT AIG Insurance Indonesia Indonesia Stock Exchange Building Tower 2, Floor 3A Jl. Jend. Sudirman Kav. 52-53 Jakarta 12190, Indonesia AIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id PT AIG Insurance Indonesia Indonesia Stock Exchange Building Tower 2, Floor 3A Jl. Jend. Sudirman Kav. 52-53 Jakarta 12190, Indonesia AIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id Nama Pertama / First Name Nama Tengah / Middle Name Nama Akhir / Last Name ....................................................................................... ................................................................................. .................................................................................... WNI / Indonesian WNA / Foreigner .............................................................................................................................. Kewarganegaraan / Citizenship Jenis Kelamin / Gender Laki-Laki / Male Perempuan / Female Alamat Sesuai Kartu Identitas ....................................................................................................................................................................................................... Address refer to Identity Card Kota / City ..................................................................... Provinsi / Province ........................................................................... Kecamatan / District ................................................................................................................................................................... Kelurahan / Sub District .............................................................................................................................................................. .................................................................................................................................................................. RT/RW ....... / ....... Kode Pos / Postal Code ............................................... Negara / Country ........................................................................... ........................................................................................................................................................................................................ ....................................................................................................................................................................................................... Tempat Lahir / Place of Birth .............................................................................. Based on PMK No.30/PMK.010/2010 regarding Know Your Customer Principle, please complete below form and give check mark (v) in the box provided. *Sesuai dengan Kartu Identitas / refer to Identity Card Wajib diisi dengan lengkap sesuai ketentuan PMK No.30/PMK.010/2010 tentang Prinsip Mengenal Nasabah dan beri tanda cek (v) pada kotak yang tersedia. ........................................................................................................................................................................................................ Kode Negara / Country Code Kode Area / Area Code No. Telepon / Phone No. Kode Negara / Country Code No. Telepon / Phone No. + +
Transcript of Formulir Aplikasi Individual Asuransi Kendaraan Bermotor · Tujuan Asuransi Insurance Purpose ......
Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y
1/5Formulir Aplikasi Individual Asuransi Kendaraan Bermotor (April 2015)
Formulir Aplikasi Individual Asuransi Kendaraan Bermotor
Informasi Pemegang Polis / Policy Holder Information*
Hasil UsahaBusiness Income
Lain-LainOthers: .................
Sumber DanaSources of Fund
WirausahaEntrepreneurship
GajiSalary
Tabungan / DepositoSaving / Deposit
≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million Penghasilan Kotorper Bulan (Rp)Monthly Gross Income (IDR)
> 25-50 Juta / million > 10-25 Juta / million
Informasi rekening ini akan digunakan untuk pembayaran manfaat atau transaksi pembayaran lainnya dari PT AIG Insurance Indonesia ("AIG Indonesia") apabila ada.
Nama Bank termasuk Cabang / Bank Name incl Branch ...................................................................................................................................................................
Nama Pemilik Rekening / Account Name ....................................................................................................................................................................................................
Nomor Rekening / Account Number ...............................................................................................................................................................................................................
This account information will be used by PT AIG Insurance Indonesia ("AIG Indonesia") for benefit or others payment transaction, if any.
Pejabat/Pegawai Pemerintah, BUMN, Polisi, TentaraOfficial or Employee of Government or State-owned Entity, Police, Military
PekerjaanOccupation
Karyawan SwastaPrivate Employee
Nama Perusahaan / Company Name ....................................................................................................................................................................................................
Lain-lainOthers: ................
WirausahaEntrepreneur
Pengurus Partai Politik atau Anggota LegislatifPolitical Party Officials or Legislators
Alamat Saat ini / Current Address (Jika berbeda dengan Kartu Identitas)(If different with Identity Card)
No. Telepon RumahHome Phone No.
No. PonselMobile No.
Email ..............................................................................................................................................................................................................................................................
Jabatan / Title ............................................................................................................................................................................................................................................
PensiunRetirement
Profesional (Pengacara, Dokter, dll)Professional (Lawyer, Doctor, etc): ...............................
Kota / City ..................................................................... Provinsi / Province ...........................................................................
Kecamatan / District ...................................................................................................................................................................
Kelurahan / Sub District ..............................................................................................................................................................
.................................................................................................................................................................. RT/RW ....... / .......
Kode Pos / Postal Code ............................................... Negara / Country ...........................................................................
PT AIG Insurance IndonesiaIndonesia Stock Exchange Building Tower 2, Floor 3AJl. Jend. Sudirman Kav. 52-53 Jakarta 12190, IndonesiaAIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id
PT AIG Insurance IndonesiaIndonesia Stock Exchange Building Tower 2, Floor 3AJl. Jend. Sudirman Kav. 52-53 Jakarta 12190, IndonesiaAIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id
Nama Pertama / First Name Nama Tengah / Middle Name Nama Akhir / Last Name
....................................................................................... ................................................................................. ....................................................................................
WNI / Indonesian WNA / Foreigner ..............................................................................................................................Kewarganegaraan / Citizenship
Jenis Kelamin / Gender Laki-Laki / Male Perempuan / Female
Alamat Sesuai Kartu Identitas .......................................................................................................................................................................................................Address refer to Identity Card
Kota / City ..................................................................... Provinsi / Province ...........................................................................
Kecamatan / District ...................................................................................................................................................................
Kelurahan / Sub District ..............................................................................................................................................................
.................................................................................................................................................................. RT/RW ....... / .......
Kode Pos / Postal Code ............................................... Negara / Country ...........................................................................
........................................................................................................................................................................................................
.......................................................................................................................................................................................................
Tempat Lahir / Place of Birth ..............................................................................
Based on PMK No.30/PMK.010/2010 regarding Know Your Customer Principle, please complete below form and give check mark (v) in the box provided.
*Sesuai dengan Kartu Identitas / refer to Identity Card
Wajib diisi dengan lengkap sesuai ketentuan PMK No.30/PMK.010/2010 tentang Prinsip Mengenal Nasabah dan beri tanda cek (v) pada kotak yang tersedia.
........................................................................................................................................................................................................
Kode Negara / Country Code Kode Area / Area Code No. Telepon / Phone No.
Kode Negara / Country Code No. Telepon / Phone No.
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Tujuan AsuransiInsurance Purpose
Perlindungan terhadap Harta Kekayaan / Aset PerusahaanPersonal / Company Asset Protection
Lain-lain: ...............................................................................................Others
Apakah Anda memiliki polis asuransi lain di AIG Indonesia atau di perusahaan lain?Do you have other insurance policy owned in AIG Indonesia or other company?
Informasi Tambahan / Additional Info
Apakah Anda atau anggota keluarga Anda Pejabat/Pegawai Pemerintah, BUMN, Kepolisian, Militer, Pengurus Partai Politik atau Anggota Legislatif?Do you or your family member is an Official/Employee of Government Institution, State-owned Entity, Police, Military, Political Party Officials or Legislators?
Ya / Yes Tidak / No
No. Nomor Polis / Policy Number Jenis Asuransi / Type of Insurance Perusahaan Asuransi / Insurance Company
TidakNo
Ya, Mohon isi tabel di bawah iniYes, Please complete below table
Pejabat/Pegawai Pemerintah, BUMN, Polisi, TentaraOfficial or Employee of Government or State-owned Entity, Police, Military
PekerjaanOccupation
Karyawan SwastaPrivate Employee
Nama Perusahaan / Company Name .....................................................................................................................................................................................................
Lain-lainOthers: ................
WirausahaEntrepreneur
Pengurus Partai Politik atau Anggota LegislatifPolitical Party Officials or Legislators
Nama Pertama / First Name Nama Tengah / Middle Name Nama Akhir / Last Name
(Jika berbeda dengan kartu identitas)(If different with Identity Card)
No. Telepon RumahHome Phone No.
No. PonselMobile No.
Email .............................................................................................................................................................................................................................................................
Jabatan / Title ............................................................................................................................................................................................................................................
PensiunRetirement
Profesional (Pengacara, Dokter, dll)Professional (Lawyer, Doctor, etc): ...............................
Kota / City ..................................................................... Provinsi / Province ...........................................................................
Kecamatan / District ...................................................................................................................................................................
Kelurahan / Sub District ..............................................................................................................................................................
....................................................................................... ................................................................................. ...................................................................................
.................................................................................................................................................................. RT/RW ....... / .......
Kode Pos / Postal Code ............................................... Negara / Country ...........................................................................
WNI / Indonesian WNA / Foreigner ..............................................................................................................................Kewarganegaraan / Citizenship
Jenis Kelamin / Gender Laki-Laki / Male Perempuan / Female
Alamat Sesuai Kartu Identitas ........................................................................................................................................................................................................Address refer to Identity Card
Kota / City ..................................................................... Provinsi / Province ...........................................................................
Kecamatan / District ...................................................................................................................................................................
Kelurahan / Sub District ..............................................................................................................................................................
.................................................................................................................................................................. RT/RW ....... / .......
Kode Pos / Postal Code ............................................... Negara / Country ...........................................................................
........................................................................................................................................................................................................
........................................................................................................................................................................................................
Tempat Lahir / Place of Birth ..............................................................................
Hubungan dengan Pemegang Polis / Relationship with Policy Holder .......................................................................................................................................
Informasi Tertanggung / Insured Information*
(Diisi jika Nama Tertanggung berbeda dengan Pemegang Polis / To be completed if the Insured name is different with Policy Holder Name)
Alamat Saat ini / Current Address ........................................................................................................................................................................................................
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Kode Negara / Country Code Kode Area / Area Code No. Telepon / Phone No.
Kode Negara / Country Code No. Telepon / Phone No.
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Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y
Beneficial Owner Perorangan / Individual Beneficial Owner*
Apakah nama Beneficial Owner sama dengansalah satu di atas?Is Beneficial Owner name same with one of the above? Pemegang Polis
Policy Holder
Ya / Yes TertanggungInsured
Tidak, Mohon diisi Informasi di bawahNo, Please complete below information
Beneficial Owner adalah setiap orang atau badan hukum yang memiliki dana, mengendalikan transaksi Nasabah, yang memberikan kuasa atas terjadinya suatu transaksi dan/atau yang melakukan pengendalianmelalui badan hukum atau perjanjian.Beneficial Owner is any person or legal entity who has the funds, controls the Customer's transaction, provides power of attorney to a transaction and/or does control through legal entity or agreement.
Hasil UsahaBusiness Income
Lain-LainOthers: .................
Sumber DanaSources of Fund
WirausahaEntrepreneurship
GajiSalary
Tabungan / DepositoSaving / Deposit
≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million > 25-50 Juta / million > 10-25 Juta / million
Pejabat/Pegawai Pemerintah, BUMN, Polisi, TentaraOfficial or Employee of Government or State-owned Entity, Police, Military
PekerjaanOccupation
Karyawan SwastaPrivate Employee
Nama Perusahaan / Company Name .....................................................................................................................................................................................................
Lain-lainOthers: ................
WirausahaEntrepreneur
Pengurus Partai Politik atau Anggota LegislatifPolitical Party Officials or Legislators
Alamat Saat ini / Current Address ........................................................................................................................................................................................................
Nama Pertama / First Name Nama Tengah / Middle Name Nama Akhir / Last Name
(Jika berbeda dengan Kartu Identitas)(If different with Identity Card)
No. Telepon RumahHome Phone No.
No. PonselMobile No.
Email .............................................................................................................................................................................................................................................................
Jabatan / Title ............................................................................................................................................................................................................................................
PensiunRetirement
Profesional (Pengacara, Dokter, dll)Professional (Lawyer, Doctor, etc): ...............................
Kota / City ..................................................................... Provinsi / Province ............................................................................
Kecamatan / District ...................................................................................................................................................................
Kelurahan / Sub District ..............................................................................................................................................................
....................................................................................... ................................................................................. ....................................................................................
.................................................................................................................................................................. RT/RW ....... / .......
Kode Pos / Postal Code ............................................... Negara / Country ............................................................................
WNI / Indonesian WNA / Foreigner ..............................................................................................................................Kewarganegaraan / Citizenship
Jenis Kelamin / Gender Laki-Laki / Male Perempuan / Female
Alamat Sesuai Kartu Identitas ........................................................................................................................................................................................................Address refer to Identity Card
Kota / City ..................................................................... Provinsi / Province ...........................................................................
Kecamatan / District ...................................................................................................................................................................
Kelurahan / Sub District ..............................................................................................................................................................
.................................................................................................................................................................. RT/RW ....... / .......
Kode Pos / Postal Code ............................................... Negara / Country ............................................................................
........................................................................................................................................................................................................
........................................................................................................................................................................................................
Tempat Lahir / Place of Birth ..............................................................................
Hubungan dengan Pemegang Polis / Relationship with Policy Holder ........................................................................................................................................
Penghasilan Kotorper Bulan (Rp)Monthly Gross Income (IDR)
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Kode Negara / Country Code Kode Area / Area Code No. Telepon / Phone No.
Kode Negara / Country Code No. Telepon / Phone No.
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Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y
Informasi Tentang Kendaraan Yang Diasuransikan / Information Regarding Your Insured Automobile
Merek Kendaraan / Brand ..............................................................................
Model .....................................................................................................................
No. Mesin / Machine No .......................................................................................
Rp ............................................................................................................................
Nama pada STNK : ...........................................................................................Name as refer to STNK
Jangka waktu perlindungan asuransi dimulai dari:Proposed periode of insurance to take effect from
.................................................................................. selama 1 tahun / for 1 year
Jaminan Utama / Main Coverage:
Comprehensive Total Loss Only
Perlengkapan non-standard (maks 10% harga kendaraan)Non-standard accessories (max 10% of the vehicle price)
AksesorisAccessories
Merek dan TipeBrand and Type
Harga (Rupiah)Market Value (IDR)
Kaca Film / Window Films
Audio Video
Aksesori tambahan lainnyaAdditional accessory
Ban / Velg Racing
Body Kit
No. Polisi / Plate No. .............................................................................................
No.Rangka / Chassis No. .....................................................................................
Tahun pembuatan / Manufacturing Year .........................................................
Penggunaan Kendaraan Bermotor Vehicle occupation
PribadiPrivate
DinasCommercial
Nilai total pertanggungan(termasuk perlengkapan non-standar)Value of items insured (including non-standard accessories)
Bila nama yang tercantum pada STNK tidak sama dengan nama pemohon, harap lengkapi data-data di bawah ini:If the name in the STNK is not the same with the applicant, please complete the following:
Jaminan Tambahan / Additional Coverage:
Jaminan Perluasan / Extended Cover
Banjir, Angin Topan, Badai, Hujan Es, Tanah Longsor / Flood, Typhoon, Storm, Hail, Landslide
Gempa Bumi, Letusan Gunung Berapi, Tsunami / Earthquake, Volcanic Eruption, Tsunami
Huru Hara, Kerusuhan, termasuk Terorisme Sabotase / Riot, Strike, Civil Commotion, including Terrorism and Sabotage
Jaminan Paket / Package Cover Silver Gold Platinum Diamond
Tanggung Jawab pihak ketiga,batas per kejadianThird Party Liability, limit per occurrence
10.000.000
10.000.000
1.000.000
30.000.000
30.000.000
3.000.000
100.000.000
100.000.000
10.000.000
200.000.000
200.000.000
20.000.000
Kecelakaan Diri, batas per kejadianPersonal Accident, limit per occurrence
Biaya Pengobatan, batas per kejadianMedical Expense, limit per occurrence
Tanggung Jawab Pihak Ketiga Saja,batas per kejadianThird Party Liability Only, limit per occurrence
Limit lain diluar pilihan di atasOther limits aside from above
10.000.000
............................................................................................................................................................................................
26.000.000 51.000.000 100.000.000
dalam Rp
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Kartu Kredit / Credit Card
Nama Pemegang Kartu: ..................................................................Name of Card Holder
No. Visa/Master/BCA Card:
Masa BerlakuExpiry Date
Tanda tangan Pemegang Kartu Signature of Card Holder
Pernyataan atas Cara Pembayaran Premi / Statement of Premium Payment Method
............................................................
No. Rekening Bank:Bank Account Number
Nama Pemilik / Account Name ............................................................
kirim bukti transfer ke kantor pusat AIG Indonesia atau kirim melalui:please send the transfer receipt to AIG Indonesia:fax. : 021 5291 4801/4802e-mail : [email protected]
Bank No. Rek (US$)
Citibank 010 265 001 8 010 265 051 4
BCA 458 300 985 2 458 370 089 0
HSBC 001 016 963 068 001 016 963 115
No. Rek (Rp)
D D / M M / Y Y Y Y
Saya dengan ini menyatakan bahwa pada saat aplikasi Saya disetujui, Saya sepakat untuk melunasi premi secara penuh dengan cara sebagai berikut:I hereby that at the time the application is approved, I agree to fully pay the premium in below method
Transfer dari Nama Bank:Transfer from Bank
*Lampirkan Salinan KTP/SIM/Paspor/KIMS/KITAS/KITAP (Attach Copy of Identity/SIM/Passport/KIMS/KITAS/KITAP)
Setuju / Agree Tidak setuju / Disagree
DENGAN MENCENTANG KOLOM SETUJU / BY CHECKING AGREE COLUMN: 1). Saya/Kami setuju bahwa setiap informasi yang diperoleh atau disimpan oleh AIG Indonesia, baik yang terdapat dalam aplikasi ini atau yang diperoleh dengan cara lain, dapat dipergunakan dan diungkapkan oleh AIG Indonesia kepada individu/perusahaan/pihak ketiga (di dalam atau di luar Indonesia) untuk melakukan segala aktivitas yang berhubungan dengan polis Saya/Kami dan/atau AIG Indonesia. Saya/Kami mengerti bahwa ketidaksetujuan Saya/Kami atas kebijakan tersebut dapat mengakibatkan ditolaknya pengajuan formulir aplikasi ini. I/We agree that every information been obtain or kept by AIG Indonesia, both that contained in this application or being obtain by other means, can be used and disclosed by AIG Indonesia to individuals/entities/any third parties (within or outside Indonesia) to do any activities which related to My/Our Policy and/or AIG Indonesia. I/We understand that our disagreement on this policy may have impact on the rejection of this application form.
2) Saya/Kami menyatakan bahwa semua pernyataan yang diberikan dalam aplikasi ini adalah benar dan Saya/Kami tidak menyembunyikan, salah menyatakan atau salah menuliskan semua fakta yang ada. I/We hereby confirm that the statements contained in this form are correct and I/We have not concealed, misrepresented or misstated any material facts.
3). Saya/Kami telah membaca, memahami dan menyetujui syarat dan ketentuan produk asuransi yang telah dijelaskan baik secara lisan atau melalui Ringkasan Produk. Perlindungan asuransi akan dimulai dengan memperhatikan persetujuan dari AIG Indonesia terhadap aplikasi Saya/Kami dan pembayaran premi atas perlindungan asuransi telah diterima oleh AIG Indonesia. I/We had read, understood, and agreed the terms and conditions of insurance product that been explained by both verbally or using Product Summary. Insurance coverage will be commenced subject to conformity from AIG Indonesia to My/Our application and premium payment of such insurance coverage been received by AIG Indonesia.
Pernyataan Nasabah / Customer Disclaimer
Broker / Agent
Nama / Name: ..............................................................
Kode / Code:
Tanggal / Date: ................ / .................. / .....................D D M M 2 0 Y Y
Formulir aplikasi dan dokumen pendukung harap dikirim ke kantor pusat atau kantor cabang AIG Indonesia terdekat.Please send the application form and supporting documents to AIG Indonesia head office or branches.
PERHATIAN! Jangan menandatangani formulir aplikasi ini dalam keadaan kosong / belum diisi.WARNING! Do not sign this application form if it is still blank / not yet filled out.
Pemohon / Applicant
Tanggal / Date: ................ / .................. / .....................D D M M 2 0 Y Y
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