(Insured’s Letterhead)

LETTER OF DISCHARGE

Insured : PT XXXX
Policy No. : 031212XXXX
Claim No : XXX /XXX
Object : BG AABB under tow TB AACC
Cause of Loss : Third Party Liability
Date of Loss : XXX

I/We, the undersigned and being an Insured under the above policy for our
respective rights and interests, hereby agree to accept the respective sum of
IDR XXXXXX (net of deductible) as the Full and Final Settlement of Marine
Hull Claim and in consideration of the said sums, I/We hereby unconditionally
and irrevocably release and discharge PT Asuransi XXXX and Co Insurer(s), if
any, and any of its employees from and against any and all liabilities, suits,
claims, demands, losses, actions, causes of actions and proceedings
whatsoever nature based upon, resulting from, or arising out of or relating to
and/or any injury to any person or persons and/or any damage to property,
including reasonable attorney’s fees, costs and expenses, which may occur or
be alleged to have occurred in relation to or in any way connected with which
I/We now have or may hereafter have on account of loss or damage described
in the above claim.

I/We further declare that there are no other parties interested in the property
which forms the subject of this claim and that there are no other insurance
policies affected by us or by any other parties upon the said property.

This agreement will be legally binding upon the undersigned, its successors
and assigns.

IN WITNESS WHEREOF, the undersigned has caused this agreement to be

executed under its corporate seal by its officers thereunto authorized this.

location, date month year

materai IDR 6,000.00

signature + company seal

( name )
( position )