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REVISION

CLIENT COPY

PLACING SLIP / COVER NOTE No. 0019


ENDORSEMENT I
TYPE : COMBINED PROPERTY ALL RISK + RIOT, STRIKES,
MALICIOUS DAMAGE, CIVIL COMMOTION +
EARTHQUAKE, FIRE AND EXPLOSION
FOLLOWING EARTHQUAKE, VOLCANIC
ERUPTION AND TSUNAMI INSURANCE

INSURED’S NAME : MR. BUDI MARGONO SALIM including any subsidiary and/or
related company existing at the commencement of this Insurance or
formed purchased or otherwise acquired during the currency of the
Policy for their respective rights and interest.

PERIOD : January 31st, 2019 to December 31st, 2019


At 12.00 noon local time (Both days inclusive)

POLICY NO. : TBA

It is hereby noted and agreed that with effect from Inception date, the following Period should be
amended in the Policy, as follow:

PERIOD : January 31st, 2019 to December 31st, 2019

Instead of

PERIOD : January 31st, 2019 to January 31st, 2020

As a consequence thereof, there is a refund premium amounted to USD. 332.60 due to the Insured,
calculated as follow :

USD. 250,000.00 x 1.5965% x 1/12 = USD. 332.60

All other terms and conditions remain unaltered.

Jakarta, February 19th, 2019


Sign in and on behalf of
PT TRIDHARMA PROTEKSI

Fera Indah S. / Nurhasanah


Client Service Division

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REVISION
CLIENT COPY

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Placing Slip/Cove Note No. 0019 (End. I)
Ifo Mr. Budi Margono Salim

AGREED AND ACCEPTED BY:


SECURITY :

 PT. ASURANSI WAHANA TATA (35%  PT. MERITZ KORINDO INSURANCE (30%)
Leader)

 PT. KSK INSURANCE INDONESIA (15%)  PT. ASURANSI FPG INDONESIA (10%)

 ASURANSI MULTI ARTHA GUNA –


A FAIRFAX COMPANY (10%)

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