ORIGINAL

To Be a Good Company
Semarang Branch Office
Wisma HSBC 6th Floor
Jl. Gajah Mada N0. 135, Semarang 50134
Phone : (024) 845 4191 -2
Fax : (024) 845 4190

SCHEDULE
PERSONAL ACCIDENT INSURANCE

NEW BUSINESS

Policy Number : SMD/PACC/17-09768

Name of Insured : PT. NEW MARCH QQ EMPLOYEE

00078499
00189190

Address of Insured : CANDI INDUTRIAL ESTATE

JL. GATOT SUBROTO BLOK A1
NO. 31 -33 KEL. NGALIYAN
KEC. NGALIYAN SEMARANG

: Mulai dari 01 Februari 2021 s/d 01 Februari 2022 365 hari

Period f Insurance From to
(both dates inclusive at 12. 00 o’clock moon local time)

Risk Number :0001 Risk Currency : IDR

Insured Number : CHANG SHIH CHIEH

Age / Gender : 40/ M

Occupation : MARKETING MANAGER

Teritorial Limit : WORLDWIDE

Benef Name/ Relation : PT. NEW MARCH

Coverages & Limit of Indemnity :

Coverage Limit of Indemnity Annual Premium

D / PD INCLUDING MOTORCYCLING 100, 000, 000. 00 100, 000. 00

MEDICAL EXP. FOR INCL. MOTORCYCL 10, 000, 000. 00 100, 000. 00

TOTAL 200, 000. 00

Additional Clauses:

1. Strike, Riot, Civil Commotion, Bomb Threat, Hijack,

2. Exposure and Disappearance Clause
3. Food Posioning Clause
4. Motorcycling Risk other than racing any kind A member of the
Tokio Marine Group
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