CERTIFICATE OF INSURANCE

Certificate Number : JR064264 Plan : Return-Trip

Issuance Date : 24 November 2014 Route : Domestic
Effective Date : 30 April 2015 Length of Trip : 4 Days
Expiry Date : 03 May 2015 Premium : IDR 38,000.00

INSURED DETAILS

Name Date of Birth

Leonardi Leonardi 01 January 1995

Address:

BENEFIT SCHEDULE

Benefit Sum Insured

24-Hour Personal Accident* Rp300,000,000
Emergency Medical Evacuation* Rp250,000,000
Repatriation Expenses* Rp250,000,000
Medical Expenses* Rp150,000,000
Trip Cancellation Up to the total original flight cost
Flight Delay Rp450,000 per 6-hour delay period, up to Rp6,750,000
Trip Interruption Up to the total original flight cost
Personal Baggage Rp5,500,000
Loss of Travel Documents Rp1,250,000
24-Hour Emergency Assistance Included
Trip Postponement Rp2,000,000
*due to Accident only

For 24-hour emergency medical assistance, please contact +62 21 5739686

To view or download the full Policy Wordings, please visit us online at www.citilink.co.id/insurance

This Certificate of Insurance issued by PT AIG Insurance Indonesia is forming part of Citilink Shield and subject to
terms, conditions and provisions of the Policy.
Citilink Shield is underwritten by PT AIG Insurance Indonesia.