KWITANSI PREMI

Terima dari : PT. BORNEO GUNA ENERGI

JL. GARUDA NO. 85 KEL.KOMET KOTA BANJARBARU KALIMANTAN SELATAN
Uang Sejumlah : ENAM JUTA DELAPAN RATUS SEMBILAN PULUH SATU RIBU TUJUH RATUS DUA
PULUH LIMA RUPIAH
Cover Note No : 11.9000.0000.550781
Untuk Pembayaran : Marin Cargo
Jumlah Pertangungan : IDR 4.904.803.843
Masa Pertangungan : 10 September 2019

Premi : IDR 6.866.725,00

Biaya Admin : IDR 25.000,00
Total : IDR 6.891.725,00

INFORMASI PENTING Banjarmasin,10 September 2019

- Pembayaran premi wajib dibayarkan langsung ke rekening atas nama PT. ASURANSI SINAR MAS
- Tertanggung dilarang membayar premi melalui PERORANGAN/INDIVIDU(termasuk agen/karyawan PT ASURANSI SINAR MAS
ASM) dalam bentukapapun (baik secara tunai,transfer, Bilyet Giro, Cek dan lain lain)
- ASM hanya mengakui pembayaran premi yang nyata-nyata telah diterima.di rekening atas nama ASM

Alce Herry Christian

 MARINE CARGO COVER NOTE POLICY

Cover Note Policy No. : 11.9000.0000.550781

Assured(s), etc : PT. BORNEO GUNA ENERGI
Address : JL. GARUDA NO. 85 KEL.KOMET KOTA BANJARBARU
KALIMANTAN SELATAN
Total Amount : IDR 4.904.803.843
Interest : COAL IN BULK 7.353,529 MT x USD 48 X IDR.14.500 (1 USD to IDR )
Condition / Cover : - INSTITUTE CARGO CLAUSES ( ICC “C” )
- EXCLUDING LOSS AND OR DAMAGE IF OVERWEIGHT OF CARGO
- EXCLUDING EMBEZZLEMENT BY THE DRIVER OF THE TRANSPORTER CARRYING THE
GOODS
- EXCLUDING SHORTAGE OR LOSS OF WEIGHT OR VOLUME
- EXCLUDING OXIDATION AND CONTAMINATION WHATSOEVER CAUSED
- EXCLUDING DISCOLORATION AND LOSS OR DAMAGE CAUSED BY INHERENT VICE OR
NATURE OF THE SUBJECT MATTER OF INSURANCE
- SUBJECT TO PROVIDE SURAT IJIN BERLAYAR FROM ADPEL (APPROVAL BEING
OBTAINED FROM THE PORT AUTHORITY HARBOUR MASTER/SYAHBANDAR IN
RELATION TO THE SUITABILITY OF WEATHER CONDITIONS FOR THE INTENDED
VOYAGE)
- SAILING PERMIT FROM PORT AUTHORITY
- CARGOES ARE SHIPPED BY STEEL MECHANICAL SELF-PROPELLED VESSEL, NOT
MORE THAN 25 YEARS OLD MIN. 1000 GRT
Deductible : - 2% OF TOTAL SUM INSURED MIN USD 250.00 ANY ONE ACCIDENT
Clauses : - IMPORTANT CLAUSE
- TERMINATION OF TRANSIT CLAUSE (TERRORISM) JC2001/56
- INSTITUTE RADIOACTIVE CONTAMINATION, CHEMICALS, BIOLOGICAL,
BIO-CHEMICAL AND ELECTROMAGNETIC WEAPONS EXCLUSION CLAUSE 10/11/03 (CL
370)
- INSTITUTE CYBER ATTACK EXCLUSION CLAUSE (CL.380)
- COMPUTER MILLENIUM CLAUSE (CARGO)
- TERRORISM EXCLUSION CLAUSE
- SANCTION AND LIMITATION EXCLUSION CLAUSE
- CARGO ISM ENDORSEMENT
- ELECTRONIC DATE RECOGNITION CLAUSE
- INSTITUTE RADIOACTIVE CONTAMINATION EXCLUSION CLAUSE 1/10/90
- NEREC (0.1.01.89) WITH JAPANESE AMENDMENT, (01.04.89) INCLUSION OF NUCLEAR
FUELS IN TRANSIT
- PARAMOUNT WAR CLAUSE 5/10/1977
- SEEPAGE POLLUTION EXCLUSION CLAUSE (01.01.87)
- TERRORISM WRITE BACK EXCLUSION CLAUSE
Date of sailing : SEPTEMBER, 10 2019
Invoice No : At and From : JETTY R, HASNUR JAYA UTAMA,
L/C No : SUNGAI PUTTING, KALIMANTAN
Bank (L/C issued) : Transhipment at : TANJUNG KAMPEH ANCHORAGE,
Vessel : SOUTH SUMATRA, INDONESIA
BL : TB. MICHELLE III To : KAMPONG SAOM, CAMBODIA
BG. BENAMI III

In the event of damage arising under this policy no We Hereby Agree, in Consideration of the
claim will be Committed unless a survey has been held payment to us by or on behalf of the
with the approval. Assured of the premium as arranged, to insure
Premi calculation : 0,14 % = IDR 6.866.725,00 against loss damage liability
Admin Fee : IDR 25.000,00
In witness whereof, this policy has been signed
Total : IDR 6.891.725,00
by duty authorized representative of this
Survey Agent : HUATAI SURVEYORS &
ADJUSTERS COMPANY,AS AGENTS OF W K WEBSTER company at:

- SINGAPORE,
ROOM 1703, STAR WORLD BUILDING,
178 QIXING WEST ROAD, SIMING
DISTRICT, XIAMEN 361012, P.R. CHINA
TELP: +86 592268 1230, 268 1231, 212
3226 FAX: +86 592 2681235 MOBILE: +86
13306054789MAIL:AGENCY.XM@HUAT
AI-SERV.COM, XIAMEN ,CHINA
TELP: +86 592 268 1230, 268 1231, 212
3226 FAX: +86 592 2681235
MOBILE: +8613306054789 EMAIL:
AGENCY.XM@HUATAI-SERV.COM
Jakarta, September 10 2019
PT. ASURANSI SINAR MAS
Alce Herry Christian
NB: Gunakan aplikasi QRCode Reader melalui
smartphone QR Code ini dan melihat keabsahan
polis. The insured agress and is willing to be
contacted by any staff member of PT. Asuransi Sinar
Mas and/or its agents and/orassociates
through personal communication devices such as
telephone, short message system, email, et