II COPY 1 1

POLICY SCHEDULE
PA - EXTENDED SCALE
POLICY NO.

THE INSURED : PT. HOTEL INDONESIA NATOUR (PERSERO)

THE BUSINESS : Hotel

I - DETAILS OF THE SUBJECT MATTER INSURED -

PERIOD OF INSURANCE : commencing from September 3, 2020 to September 3, 2021 both days at
12 o'clock noon, local time at the location of the insured property.

CATEGORY : Any One Group

INTEREST INSURED . -.
Employee of the Policyholder
Basis : Unnamed basis
AdditionlDeletion of lnsured Person: automatic with annual premium
adjustment
at the end of insurance periid.

1. Accidental Death Limit IDR 100,000,000

To pay a lump sum amount if injury occurs to lnsured Person which
results in death.
2. Accidental Permanent Disablement
To pay a lump sum amount if injury occurs to lnsured Person which
results in Permanent
Total Disablement or Permanent Partial Disablement.
Sum Insured: 100% of Accidental Death Sum lnsured
3. Accident Medical Reimbursement (AMR)
To reimburse lnsured Person based on actual and reasonable medical
costs, for necessary medical or surgical treatments including
hospitalization as a result of an accident occurred during policy period.
Sum Insured: 10% of ADD
Treatment by traditional physician: Sub-limit: 20% of AMR Limit or IDR
50,000,000 whichever is lower

PT. Asuransi FPG Indonesia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 21
Jakarta 12920, Indonesia
This page is a forming part of Policy No. FPG.16.1014.20.00553
TOTAL SUM INSURED
- Accidental Death IDR 10,000,000,000.00
100 orang Staf
- Accident Medical Reimbursement IDR 1,000,000,000.00
100 orang Staf

DEDUCTIBLE (S) : None

- THE CLAUSES - h

CLAUSE (S) Any sport activities including dangerous sport (except sport activities as
in General Exclusion)
Assault And Murder Clause
Automatic addition and deletion (annual adjustment)
Bomb Threat And Hijack Clause
Communicable Disease Exclusion Clause
Cover for Chartered & Other Non-schedule Flights Excluding Helicopter
Flight
Disappearance Clause
Dispute Clause
Exposure Clause
Food and drink poisoning due to death and disablement
Industries Seepage, Pollution and Contamination Exclusion Clause
(NMA 1685) "Sudden and Accidental"
IT Clarification Clause
Motorboat and motorcycling risk (except racing as in General Exclusion)
Nuclear, Chemical, Biological Terrorism Extension Clause
Strike, Riot And Civil Commotion Clause
Suffocation by smoke, poisonous fumes, gas and drowning
Terrorism And Sabotage
Waiver to the Article 1266 and 1267 of the Indonesian Civil Code Clause
War and Civil War Exclusion (NMA 464)

PT. Asuransi FPG lndonesia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 2 1
Jakarta 12920, Indonesia
This page is a forming part of Policy No. FPG.16.1014.20.00553
EXCLUSION : - General Exclusions : Insurer will not pay for any loss resulting directly
or indirectly, wholly or partly, from:
a) War.
b) Nuclear, biological, or chemical terrorism.
c) Flying as an operator or crew member.
d) Suicide, self-harm or attempted suicide while sane or insane.
e) Participation in any criminal act or in riot, strike, civil commotion, or
any
demonstration.
f) Participation in any professional sport or any sport in which Insured
Person
would or could earn financial rewards of any kind.
g) Driving or riding in any kind of race involving motorized vehicle.
h) Serving in the armed forces of any country or international authority,
whether
in peace or war.
i) The use and effects of alcohol or drugs.
j) Pregnancy, childbirth, miscarriage, or any complications related
thereto.
k) Sickness or disease, any gradually operating cause, naturally
occurring
condition or degenerative process;

I -THE PREMIUM -
I
PREMIUM RATE : Personal Accident + Medex : 0.050000 %
PREMIUM CALCULATION
- Personal Accident + Medex IDR 10,000,000,000.00 x 0.050000% IDR 5,000,000.0C
September 03,2020 - September 03,2021
Policy Administration Fee IDR 40,000.0C
Stamp Duty IDR 6,000.00
TOTAL IDR 5,046,000.00

MO1JP00012
NOTE : In witness whereof the Undersigned being duly authorized by the Insurers and on behalf of the lnsurers
has (have) hereunto set his (their) hand@).

PT. Asuransi FPG lndonesia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 21
Jakarta 12920, Indonesia
This page is a forming part of Policy No. FPG.16.1014.20.00553

Jakarta, September 8,2020

PT. ASURANSI FPG INDONESIA

PT. Asuransi FPG lndonesia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 21
Jakarta 12920, lndonesia
 @ FPC insurance

PA - EXTENDED SCALE INSURANCE

Attaching to and forming part of Policy No. FPG.16.1014.20.00553

I CLAUSES
i
Any sport activities including dangerous sport (except sport activities as in
General Exclusion)
It is hereby declared and agreed that this Policy is extended to indemnify the lnsured in respect of the Insured's legal
liability for bodily injuly and property damage as within defined in this policy caused by or arising out of an in connection
with any social recreational or welfare activities organized supervised and managed by the lnsured for its invited
participants including employees their families and friends anywhere in Indonesia.

The word " lnsured " wherever appearing includes as an lnsured any person who is a member of the organizing or
management committee for ~ c social
h recreational or welfare activities but only while acting within the scope of their
duties as such.

It is further declared and agreed that the indemnity granted under this policy is also extended to apply to occurrences
during the policy period caused by arising out of and in connection with drinks beverages or food served by the lnsured
during such social recreational or welfare activities.

In the event of a claim the Company will not raise the defence that such participants and employees are not third parties.

Provided that if the claim so submitted is covered by any other more specific insurance then this policy shall not insure the
same except only as regards to any excess beyond the limit of liability covered by more specified insurance.

Subject otherwise to the terms exceptions and conditions of this Policy

Assault And Murder Clause
Notwithstandingof anything in Policy to the contrary, this Policy is extended to cover accidental death and/or disablement
and/or injuries caused by assault andlor murder
Automatic addition and deletion (annual adjustment)
It is hereby declared and agreed that additions and deletion to the schedule will be automatically held covered without prior
notice subject to the insu&.submitting such additions and deletions within period as specified above of the following
month. Sum insured not to be exceed the amount as specified above per person, subject to prorate additional premium
Bomb Threat And Hijack Clause
It is herewith noted and agreed that this policy extended with cover the loss which is because of bomb threat and hijack

Communicable Disease Exclusion Clause

1. ~otwithstanding any pr&ision to the contraiy within this insurance agreement, this reinsurance agreement excludes
any loss, damage, liab~lity, claim, cost or expense of whatsoever nature, directly or indirectly caused by,
contributed to by, resulting from, arising out of, or in connection with a Communicable Disease or the fear or threat
(whether actual or perceived) of a Communicable Disease regardless of any other cause or event contributing
concurrently or in any other sequence thereto.

2. As used herein, a Communicable Disease means any disease which can be transmitted by means of any substance
or agent from any organism to another organism where:

2.1. the substance or agent includes, but is not limited to, a v i ~ s , bacterium, parasite or other organism or any
variation thereof, whether deemed living or not, and
2.2. the method of transmission, whether direct or indirect, includes but is not limited to, airborne transmission ,
bodily Ruid transmission, transmission from or to any surface or object, solid, liquid or gas or between
organisms, and

PT. Asuransi FPG lndorksia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 21
Jakarta 12920, Indonesia
 @ FPG insurance

2.3. the disease, substance or agent can cause or threaten damage to human health or human welfare or can
cause or threaten damage to, deterioration of, loss of value of, marketability of or loss of use of properly.
Cover for Chartered & Other Non-schedule Flights Excluding Helicopter
Flight
Its is hereby noted and agreed that notwithstandingany Exclusionwithin the Pdicy to the contrary, this insurance also
cover against loss resulting directly and independentlyof all other causes from bodily injuries caused by accident
However, coverage as respects of flying is limited to loss occurring while the lnsured Person is riding solely as
passenger, not as a operator or crew member, in boarding or alighting from:

- Any aircraR having a current and valid airworthiness certificate (the terms "ailworthiness certificate" is defined
as a certificate issued by the civil aeronautics administration of the United States of America or any equivalent
certificate issued by Lhe jurisdictional agency or authoiity of the recognizedgovernment of any nation anywhere
in the world)
Any transport type aircraft operated by the Military Air Transport Service (MATS) of the United States of America, or by the
similar air transport servce of any duly constituted governmental authority of the recognized government of any nation
anywhere in the world
Disappearance Clause
Notwithstandinganything contained herein to the contrary it is agreed that if after a period of ONE YEAR has elapsed and
the Underwriters having examined all evidence available shall have no reason to suppose other than that an accident has
occurred, the disappearance of a Life lnsured shall be considered to constitute a claim under this Certificate.

It is further agreed that if at any time after payment has been made a Life Insured if found to be living, any sums paid by
the Underwriters in settlement of claim shall be refunded to them.
Dispute Clause
1. In the event of any dispute arising between the lnsurer and the lnsured as consequence of the interpretation of liability
or amount of indemnity of this Policy, the dispute shall be settled amicably within 60 (sixty) calendar days from the
dispute arose. The dispute arises since the lnsured has expressed in writing his disagreement on the subject matter
of the dispute

2. If the dispute could not be settled amicably as provided in item 1 above, the lnsured may request the Indonesian
Insurance Mediation Board (BMAI) to act as a mediator in order to settle the dispute subject to the terms and conditions
applied by BMAI.

3. If the dispute could not be settled amicably as provided in item 1 above, the lnsured does not want to approach BMAI
or after approaching BMAI the lnsured does not want to accept the decision of BMAI then the lnsurer shall give the
option to the Insured to select either one of the following dispute settlement stated below:

It is hereby declared and agreed that the lnsured and the lnsurer shall settle the dispute through Arbitration Ad Hoc
as follows :

a.1. The Ad Hoc Arbiition consists of 3 (three) Arbitrators. The lnsured and the lnsurer shall each appoint one
Arbitrator within 30 (thirty) calendar days from the date of the receipt of the written notification, then the two
Arbitrators shall choose and appoint the third Arbitrator within 14 (fourteen) calendar days from the data of
appointment of the second Arbitrator. The third Arbitrator shall act as Umpire of the Arbltration Ad Hoc.

a.2. Should there be any failure as to the appointment of the third Arbitrator, the lnsured and or the lnsurer could
request the Chairman of the court (Ketua Pengadilan Negeri) where the defendant domiciles to appoint the
Umpire.

a.3. The examination of the dispute shall be settled within 180 (one hundred and eighty) calendar days from the
date of the formation of the Arbiition Ad Hoc. The period of examination of the case could be extended.
Upon the agreement of both parties and if it is deemed necessary by the Arbitration Ad Hoc , the period of

PT. Asuransi FPG Indonesia

Chase Plaza Tower 4th Floor, ~1.7end.Sudirrnan Kav. 21
Jakarta 12920, Indonesia
 Q FPC insurance

examination of the dispute could be extended.

a.4. The Arbitration award is final and enforceable at law and binding the lnsured and the Insurer. Should the
lnsured and or the Insurer fail to comply with the arbitration award, then the award shall be executed under
the order of the Chairman of the competent court (Ketua Pengadilan Negeri yang berwenang) at the request
of the other party in dispute.

a.5. Other matters which are not provided under this clause shall be subject to the provisions of laws on
arbitration, which currently be the Act of the Republic of Indonesia Nr. 30 year 1QQQ dated August 12, IQQD
regardingArbitration and Alternative Dispute Resolution.

B. Court

It is hereby declared and agreed that the lnsured and the Insurer shall settle the dispute through the Court
(Pengadilan Negeri) within the territory of the Republic of Indonesia.

4. In case of the decision of adjudication of BMAl is declined by the insured, but the insured does not take the case to
arbitration or court within 180 (one hundred eighty) calendar days from the date of the adjudication's decision made
by BMAl in writing, then the rights of the lnsured to indemnification will be automatically forfeited.

Exposure Clause
When by reason of any injury covered by this Policy an lnsured Person is exposed to the elements and as the result of
such exposure suffers an Event for which compensation is otherwise payable hereunder, such Event will be covered
under the terms of this Policy. If the body of an lnsured Person has not been found within one year after the date of the
disappearanw, sinking or wrecking of the aircraft or vessel in which he was traveling at the time of the accident and
under such circumstances as would othewise be covered hereunder, it will be presumedthat the lnsured Person
suffered loss of life resulting from lnjury at the time of such disappearance, sinking orwrecking. If the lnsured Person is
found to be alive after the payment of the compensation covered hereunder, the Insurers is entitled to recover the amount
of compensation so paid to the lnsured Person
Food and drink poisoning due to death and disablement
It is noted and agreed that ihis Policy is extended to apply to an event which is directly or indirectly caused by or which
results from food and drink poisoning or arising from poisoning of any kind of foreign or deleterious matter in food and drink
consumed.
Industries Seepage, Pollution and Contamination Exclusion Clause (NMA 1685) "Sudden and
Accidental"
This Policy does not cover any liability for:
1. Personal Injury or Bodily Injury or loss of, damage to, or loss of use of property directly or indirectly caused by
seepage, pollution or contamination, provided always this paragraph (1) shall not apply to liability for Personal lnjury or
Bodily lnjury or loss of or physical damage to or destruction of tangible property, or loss of use of such property
damaged or destroyed, where such seepage, pollution or contamination is caused by a sudden, unintended and
unexpected happening during the period of this Insurance.
2. The cost of removing, nullifying or cleaning up seeping, polluting or contaminating substances unless the seepage,
pollution or contamination Is sudden, unintended and unexpected happening during the period of this insurance.
3. Fines, penalties, punitive or exemplary damages.
This Clause shall not extend this Policy to cover any liability which would not have been covered under this Policy had this
Clause not been attached.
IT Clarification Clause
it is hereby agreed that the property damage covered under this insurance shall mean physical damage to the substance
of property, which is not include damage to the data or software, in particular any detrimental change in data, software or
computer programs that cclivsedby a deletion, a corruption or deformation of the original structure.
Consequently, the following gre excluded from this insurance:
1. Loss or damage to data or soflware, in particular any detrimental change in data, software or computer programs that
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PT. Asuransi FPG lndonesia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 21
Jakarta 12920, lndonesia
 Q FPG insurance

- - --

caused by a deletion, a corruption or deformation of h e original structure and any business interruption losses resulting
from such loss or damage.
Notwithstanding this exclusion, loss of or damage to data or software which is the direct consequence of insured
physical damage to the substance of property shall be covered.
2 Loss or damage resulting from an impairment in the function, availability, range of use or accsssibility of data, soflware
or computer programs and any business interruptionlosses resulting from such loss or damage
Motorboat and motorcycling risk (except racing as in General Exclusion)
Notwithstanding anything contained in the Policy to the contrary, it is hereby declared and agreed that the insurance
provided by this Policy applies to bodily injury as therein defined sustained in connection with the use of a motorcycle or
motor scooter other than whilst the lnsured is engaged in speed trials, competitions, peacemaking or racing of any kind.
Nuclear, Chemical, Biological Terrorism Extension Clause
Notwithstanding any provision to the contrary within the Policy or any endorsement thereto, it is understood and agreed
that this insurance is extended to cover loss or damage caused by any act of Nuclear, Chemical, BiologicalTerrorism.

For the purpose of this extension

Nuclear, chemical, biological terrorism shall mean the use of any nuclear weapon or device or the emission, discharge,
dispersal, release or escape of any solid, liquid or gaseous Chemical agent and/or Biological agent during the period of this
insurance by any person or group(s) of persons, whether acting alone or on behalf of or in connection with any
organization(s) or government(s), committed for political, religious or ideological purposes or reasons includingthe intention
to influence any government and/or to put the public, or any section of the public, in fear.

"Chemical" agent shall mean any compound which, when suitably disseminated, produces incapacitating, damaging or
lethal effects on people, animals, plants or material properly.

"Biological" agent shall mean any pathogenic (disease producing) microorganism(s)and/or biologically produced toxin(s)
(including genetically modified organisms and chemically synthesized toxins) which cause illness and/or death in humans.
animals or plants.
Strike, Riot And Civil Commotion Clause
It is agreed and understood that otherwise subject to terms, exclusions, provisions and conditions contained in the policy
or endorsed thereon and subject to the insured having paid the agreed extra premium, this policy shall be extended to
cover death or disablement due to Strike, Riot and Civil Commotion which for the purpose of this Endorsement defined as
follows:
Riot is an act of group of at least 12 (twelve) persons, who in the execution of their common purpose cause public
disturbance tumultuously with violence and damage to the properly of others.
Strike is a deliberate act of damage, by a group of workers of at least 12 (twelve) persons or one of the entire
workforce (if the number of the workforce isles than 12 persons) to protest against the termination or
suspension of a fellow employee by the employer.
Civil Commotion is an act of a large number of people acting together disrupting public peace and disturbance
tumultuously with violence and a chain of destruction of a large number of properties, indicated by the cessation
of more than one half of the normal activity of commerciallshopping or business areas or schools or public
transportation In one city for at least 24 (twenty four) hours consecutively immediate before, during or after the
event.
Subject othelwise to the terms, rate and conditions of the Policy
Suffocation by smoke, poisonous fumes, gas and drowning
In the event of an lnsured Person suffers death or disablement as a result of suffocation by smoke, poisonous fumes, gas
or drowning, provided that such event does not arise as a result of an lnsured Person's wilful and intentional act or if
such act could reasonably have been avoided by such lnsured Person, the Company will pay such lnsured Person the
relevant Benefit subject to the terms and conditions of this Policy
Terrorism And Sabotage
Notwithstanding of anything in Policy to the contrary, this Policy is extended to cover accidental death andlor disablement
and/or injuries to lnsured Persons as a result of an act of terrorism provided that such event does not arise as a result Of
or in connection with an insured person's collaboration or provocation of such act or if such act could reasonably have

PT. Asuransi FPG lndonesia

Chase Plaza Tower 4th Floor, JI. Jend. Sudirman Kav. 21
Jakarta 12920, Indonesia
 @ FPC insurance

been avoided by such Insured Person

It is however agreed that regardless of any contributory cause(s) this endorsement does not cover any claim(s) in any
way caused or contributed to by an act of terrorism involving the use or release or the threat thereof of any nuclear
weapon or device or chemical or biological agent. If the Insurer alleges that by reason of this exclusion any claim Is not
covered then the burden of proving to the contrary shall be upon the insured.

For the purpose of this endorsement, an act of terrorism means an act, including but not limited to the use of force or
violence andlor the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in
connection with any organization(s) or government(s) committed for political, religious, ideologicalor ethnic purposes or
similar reasons including h e intention to influence any government and/or to put the public, or any section of the public, in
fear
Waiver to the Article 1266 and 1267 of the lndonesian Civil Code Clause
It is hereby declared that in the event of the Insured or the insurer terminates this insurance, then both parties agree to
waive articles 1266 and 1267 of the Indonesian Civil Code and such termination shall be made without requiring any
consent of the Court (Pengadilan Negeri) within the territory of the Republic of Indonesia.

War and Civil War Exclusion (NMA 464)

Notwithstanding anything to the contrary contained herein this Agreement does not cover Loss or Damage directly or
indirectly occasioned by, happening through or in consequence of war, invasion, acts of foreign enemies, hostilities
(whether war be declared or not), civil war, rebellion, revolution, insurrection, military or usurped power or confiscationor
nationalisationor requisition or destruction of or damage to property by or under the order of any government or public or
local authority, but this exclusion shall not apply to business written in accordance with the Market War and Civil War Risks
Exclusion Agreement nor to busir9ss outside the scope of such Agreement.

PT. Asuransi FPG lndonesia

JI. Jend. Sudirman Kav. 21
Chase Plaza Tower 4 t h Floor,
Jakarta 12920, Indonesia