DRAFT

C / I : 2803021500216

POLICY SCHEDULE
MARINE CARGO INSURANCE

TYPE OF INSURANCE
POLICY NO.

: Marine Cargo Import

:

(NEW)

THE INSURED
CORRESPONDENCE ADDRESS

: PT ANAK JAYA BAPAK SEJAHTERA

: JL. RATNA NO.14 BLOK C-2, SURABAYA

DATE OF SAILING

: October 21, 2015

CONSIGNEE

: PT. ANAK JAYA BAPAK SEJAHTERA

JL. RATNA NO.14 BLOK C-2, SURABAYA

VESSEL/CONVEYANCE

: OOCL TOKYO 064W , GRT / THN : 89097 / 2007 - -

VOYAGE

: From
To

:
:
:
:

INVOICE NO
B/L NO.
L/C NO.
ISSUING BANK

SHANGHAI, CHINA
:

TANJUNG PERAK, SURABAYA, INDONESIA

SJFH-150708-1
BSISHA15090598
MI77252084571
PT. BANK MANDIRI (PERSERO) TBK., INDONESIA

TYPE OF COVER

: Institute Cargo Clause A ( 0.07000 % )

PROPERTY INSURED

- 52PCS OF SOFA
QUALITY : EXPORT STANDARTD
COUNTRY OF ORIGIN : CHINA
CONTRACT. NO :SJFH-150708-1
H.S. NO. : 9401
INCOTERMS 2010 FOB ANY PORT IN
SHANGHAI, CHINA

DEDUCTIBLE

- 0,1% of total sum insured min IDR 1,000,000.00 any one loss or series arising
out the same event

PREMIUM CALCULATION

USD

15,632.15

Premium Calculation
: USD

Premium

15,632.15 x 0.07000%

: USD

10.94

Biaya Polis (Policy Cost)

Biaya Materai ( Duty Cost )

: USD
: USD

2.70
0.65

USD

14.29

NOTE : KURS SAAT INI IDR. 14.305

In witness whereof the Undersigned being duly authorized by the Insurers and on behalf of the Insurers has
(have) hereunto set his (their) hand(s).

Surabaya, October 21, 2015

A - M28PM00001/01 - M28PM00001
10/26/15

PSNSI0301E.RPT

Page 1 of 2

DRAFT
C / I : 2803021500216

This page is a forming part of Policy No.

Klausula
(Clauses)

:
1.

INSTITUTE THEFT,PILFERAGE AND NON-DELIVERY CLAUSE (1/12/82)

2.

CANCELLATION CLAUSE ( 30 DAYS )

3.

DISPUTE CLAUSE

4.

WAIVER CLAUSE

5.

INSTITUTE STRIKES CLAUSE

6.

INSTITUTE WAR CLAUSES (A) (AIR CARGO) 1.1.82

7.

TOTAL ASBESTOS EXCLUSION CLAUSE

8.

TERRORISM EXCLUSION CLAUSE (CARGO)

9.

INCLUDING TRANSHIPMENT RISK

10 .

NOMINATED LOSS ADJUSTER :

- PT CUNNINGHAM LINDSAY INDONESIA
- PT RADITA HUTAMA INTERNUSA

11 .

INSTITUTE CARGO CLAUSES (A) 1.1.82

12 .

INSTITUTE CARGO CLAUSES (A) (AIR CARGO) 1.1.82

13 .

ELECTRONIC DATE RECOGNITION EXCLUSION CLAUSE - EDRC ( A ) CARGO

14 .

INFORMATION TECHNOLOGY HAZARD CLAUSE JEL16/11/01

15 .

RIOTS, STRIKES, MALICIOUS DAMAGE, CIVIL COMMOTION FOR ALL TRANSHIPMENT

16 .

LOADING & UNLOADING CLAUSE

17 .

INSTITUTE CLASSIFICATION CLAUSE 1/1/01 AMENDED TO INCLUDE B.K.I CLASSIFICATION AND

AGE OF VESSEL NOT OLDER THAN 35 YEARS OF AGE

18 .

CONCEALED DAMAGE CLAUSE (30 DAYS)

19 .

WAIVER OF SUBROGATION

20 .

INCLUDING HIJACK, ROBBERY AND PIRACY CLAUSE

21 .

MALICIOUS DAMAGE CLAUSE 1/8/82

22 .

INSTITUTE WAR CANCELLATION CLAUSE (CARGO) 1/12/82

23 .

INSTITUTE WAR CLAUSE (A) (CARGO) 1.1.82

24 .

CARGO ISM ENDORSEMENT

25 .

INSTITUTE CYBER ATTACK EXCLUSION CLAUSE

26 .

SEEPAGE & POLLUTION EXCLUSION CLAUSE

27 .

INSTITUTE RADIOACTIVE CONTAMINATION, CHEMICAL, BIOLOGICAL, BIO-CHEMICAL,

ELECTROMAGNETIC WEAPON EXCLUSION CLAUSE