0007885433

ORIGINAL

SCHEDULE OF TRAVEL INSURANCE

MEGA TRAVEL CARE GROUP TOUR

PT. Asuransi Umum Mega hereby witnessed that subject to the schedule the insurance of the interest from the Insured made in writing for
the purpose of this policy with the terms , exclusions, provisions, and conditions herein or endorsed hereon which is deemed to
be incorporated herein

Policy No. : FP.07.17.000433

Policy Holder : PT. ANTA EXPRESS TOUR & TRAVEL SERVICE
Address : Jl. Hayam Wuruk No 88, Jakarta
Participant Data : Attached
Beneficiary : Legal Heirs

B E N E F I T PLAN
JAMINAN LIMIT OF LIABILITY MAKSIMUM
NON ASIA
1. Personal Accident ( Death and Permanent Disablerrent ) USD 10,000.00
2. Medical Expenses USD 50,000.00
3. Emergendy Medical Evacuation UNLIMITED
4. Emergency Medical Repatriation and Repatriation of Mortal Remains UNLIMITED
5 Compassionate Visit USD 2,500.00
6 Return of Minor Child USD 2,500.00
7 Baggage and Personal Effect USD 300.00
8. Baggage Delay USD 150.00
9. Aircraft Hijacking USD 1,500.00
10 Home Guard USD 200.00

Additional Condition applied for participant ages 71-80 year old

1. Excluding Medical Expenses Bebefit
2. Emergency Medical Evacuation Limit : USD 50,000.00
3. Emergency Medical Repatriation & Repatriation of Mortal Remains Limit : USD 50,000.00

SCHEDULE OF TRAVELLING
1. Destination Country : UNITED KINGDOM + SCHENGEN COUNTRIES
2. Purpose of Travelling : HOLIDAY
3. Date of Departure : As Attached
4. Periode of Journey 1-3 Days 17-23 days
4-6 Days 24- 31days
7-10 Days Others : ____days
11-16 Days
Jakarta , 01 November 2018
For and on behalf of
An AEA Company PT. Asuransi Umum Mega

In Case of Emergency
You Should Call
+ 62-21-751 4522
 Attached By Policy No : FP.07.17.000433
PARTICIPANTS LIST

NO. NAME GENDER DATE OF BIRTH KTP/ VALIDITY

PASSPOR
1 MR FERRY ASKIM MALE 03 January 1972 B7698300 25 December 2018 - 08 January 2019
2 MR BRYAN ASKIM MALE 27 June 2003 B7698303 25 December 2018 - 08 January 2019
3 MRS HILDA WULANDARI AYU FEMALE 26 May 1973 B7698301 25 December 2018 - 08 January 2019
4 MS GRACIA ASKIM FEMALE 11 September 2000 B0883939 25 December 2018 - 08 January 2019
5 MR SUMANTO DJAUHARI MALE 24 October 1970 X078087 25 December 2018 - 08 January 2019
6 MRS JULIANA SETIAWAN FEMALE 06 March 1972 X078086 25 December 2018 - 08 January 2019
7 MR STEFAN MAHATANI MALE 23 March 1993 X199995 25 December 2018 - 08 January 2019
8 MRS AMELIA GEMAN FEMALE 18 March 1961 X237109 25 December 2018 - 08 January 2019
9 MS STELLA LARISSA MAHATANI FEMALE 04 January 1990 X236828 25 December 2018 - 08 January 2019
10 MRS YENTI TANIWAN FEMALE 01 May 1977 X175653 25 December 2018 - 08 January 2019
11 MRS TJING ANG SUAN FEMALE 04 July 1948 B8109186 25 December 2018 - 08 January 2019
12 MR BENEDICT EDWARD CLAYTON MALE 11 February 2004 X175630 25 December 2018 - 08 January 2019
13 MR ANDREW WILLIAM MALE 15 July 2002 X175631 25 December 2018 - 08 January 2019
14 MR AGUSTINUS DJIU MALE 03 August 1976 X591148 25 December 2018 - 08 January 2019

15 MS TASYA REGINA ONG FEMALE 17 August 2001 B1120569 25 December 2018 - 08 January 2019