QUOTATION SLIP

PT. ADHI KARYA (persero), Tbk.

No. Proyek : 020/EPCC/INKA/2018

Type Of Insurance : Contractor All Risk

Insured : PT. KAI Cabang Banyuwangi
Address : Desa Ketapang Kec. Kalipuro Kab. Banyuwangi
Period : 16 (Sixteen) Months from
Contractor Type : EPCC (Engineering, Procurement, Contructions and Commissioning)
Project Name : Pembangunan Workshop INKA di Banyuwangi
Project Location / Site : Desa Ketapang Kec. Kalipuro Kab. Banyuwangi
Period of Insurance : 02/06/2020 s/d 02/10/2021
Maintenance Period : 90 days ( 3 Months)
Interest & Sum Insured : Section I : Material Damage
MAIN
- Contract Work IDR 400,000,000,000
TOTAL Sum Insured IDR 400,000,000,000
Section I : Material Damage
ADDITIONAL
- For Bodily Injury : IDR. 50.000.000,- any one IDR 500,000,000
- person
Property & Damage
IDR. 500.000.000,- any one accident
: IDR. 250.000.000,- any one
IDR 250,000,000
accident
- Combine single limit max. IDR. 500.000.000,- for IDR 500,000,000
the whole period
TOTAL Sum Insured of insurance IDR 1,250,000,000
Deductible : - RSCC : 10 % of Claim minimum : IDR 10.000.000,00 for any one accident
Section I
- Act Of God (Earthquake, Volcanic Eruption, and Tsunami, Storm, Flood, Water

Damage) : 10 % of Claim minimum : IDR 25.000.000,00 for any one accident

- Others : IDR 5.000.000.00 for any one accident
Section II
- TPL (Property Damage) : 10 % of Claim minimum : IDR 5.000.000,00 for any one
accident
- TPL (Bodily Injury) : NIL
Clauses : - SANCTION LIMITATION AND EXCLUSION CLAUSE LMA 3100
- ENDORSEMENT 002 COVER FOR CROSS LIABILITY
- ENDORSEMENT 001 COVER FOR LOSS OR DAMAGE DUE TO STRIKE, RIOT AND
CIVIL COMMOTION (SRCC)
- TOTAL ASBESTOS EXCLUSION
- TRANSMISSION AND DISTRIBUTION LINES EXCLUSION CLAUSE
- ENDORSEMENT 004 EXTENDED MAINTENANCE COVER
- SEEPAGE AND POLLUTION EXCLUSION CLAUSE - NMA 1685
- ENDORSEMENT 005 SPECIAL CONDITIONS CONCERNING THE CONSTRUCTION
AND/OR ERECTION TIME SCHEDULE
- NUCLEAR ENERGY RISKS EXCLUSION CLAUSE 1994
- INFORMATION TECHNOLOGY HAZARD CLARIFICATION CLAUSE (NMA 2912)
- EXTRA CONTRACTUAL OBLIGATION EXCLUSION CLAUSE
- ELECTRONIC DATE RECOGNITION CLAUSE (A)
- DISPUTE CLAUSE
 - CYBER RISK EXCLUSION CLAUSE (NMA 2915) ELECTRONIC DATA ENDORSEMENT
B
- TERRORISM AND SABOTAGE EXCLUSION ENDORSEMENT NMA 2920
- ENDORSEMENT 110 SPECIAL CONDITIONS CONCERNING SAFETY MEASURES
WITH RESPECT TO PRECIPITATION, FLOOD AND INUNDATION
- WAR AND CIVIL WAR EXCLUSION CLAUSE
- WAIVER CLAUSE
- WARRANTY PAYMENT CLAUSE (30 DAYS)
- ENDORSEMENT 121 SPECIAL CONDITIONS CONCERNING PILING FOUNDATION
AND RETAINING WALL WORKS
- ENDORSEMENT 120 VIBRATION, REMOVAL OR WEAKENING OF SUPPORT
- ENDORSEMENT 003 MAINTENANCE VISITS COVER
- ENDORSEMENT 111 SPECIAL CONDITIONS CONCERNING REMOVAL OF DEBRIS
- FROM LANDSLIDES
ENDORSEMENT 103 EXCLUSION OF LOSS OR DAMAGE TO CROPS, FORESTS AND
CULTURES
- ENDORSEMENT 102 SPECIAL, CONDITIONS CONCERNING UNDERGROUND
CABLES, PIPES AND OTHER FACILITIES
- ENDORSEMENT 013 PROPERTY IN OFF-SITE STORAGE
- ENDORSEMENT 008 WARRANTY CONCERNING STRUCTURES IN EARTHQUAKE
ZONES
- ENDORSEMENT 007 COVER OF EXTRA CHARGES FOR AIRFREIGHT
- ENDORSEMENT 006 COVER OF EXTRA CHARGES FOR OVERTIME, NIGHT WORK,
WORK ON PUBLIC HOLIDAYS, EXPRESS FREIGHT
- ENDORSEMENT 116 COVER FOR INSURED CONTRACT WORKS TAKEN OVER OR
PUT INTO SERVICE
- ADDITIONAL TERMS AND CONDITION
Rate : - Third Party Liability 0.0000 %
- Contractor All Risk as per Munich Re 0.1000 %
Premium :
Main Premium Calculation Premium
- Contractor All Risk as per Munich Re : IDR 400,000,000,000.00 x 0,10000 % : IDR 400,000,000
Biaya Polis : IDR 75,000
Biaya Materai : IDR 24,000
IDR 400,099,000

Surabaya, Juny 02, 2020

Signed for and on brhalf of
PT. ASURANSI JASARAHARJA PUTRA

ANDREAS GONDO WARDONO

AGENCY MARKETING
HP. 081331857978, WA. 08123576979, 081259209458
e-mail : andreasgondo1011@gmail.com,
wandreasgondo@gmail.com
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