a TRIPA -Membertan yang terbalk No. c00686/DN/10/02119 CONTRIBUTION NOTE Ta: 23 Februagi.2019 1001551900002 111001851800001 Nama & Alamat Peserta PT JASA MEDIVEST (M01EJ00018) Name & Address of Participant JL. CICENDO NO.19 BANDUNG Janka Waktu 28/02/2019 - 23/02/2020 denis Asuransi INDUSTRIAL ALL RISK Period Type of Insurance SHARIA - tatan | Notes Perincian / Details {flease pay the amount shown in this Contribution Note immediately o finalize | Kontribusi_ IDR 197,067,986.12 the transaction. Payment should be made with a crossed cheque in the name | Contribution - - Te RRANSITR! PAKARTA or transfered o our current account with one of | origi Nat = IDR | the following bank : ~ BNI SYARIAH FATMAWATI Ace. No, 0081839499 Instatimont fst 26/03/2019 1DR, sed 25/0572019 10K | Please nde te Foley no or Note one message coun onthe tans ip, shoul payment be ‘made using bank vanstor | Note Kortribusinbukan merigakantnda buts pembayaca, ‘Ths Contibuton Note snot» rece. 134,402,846.25 2nd 26/04/2019 OR 34341,846.25 ath 25/06/2019 IDR 197,367,386.12 ‘Not Contibution Biaya Polis: IDR 5,000.00, Policy Cost Blaya Materal ; IDR 6,000.00 Duty Cost “re oR (0.12) | Jumian IR | 137,428,385,00 Total | 34,941 806.25 34,301,846.25 | PT. ASURANS! TRI PAKARTA preci (sear semana 2600128482597 wo PT ASURANSITRI AKA ATOR GABANG SYARIA, JL FALATENAN INO, 1-18 Kan cePOLIS ASURANSI SYARIAH KEBAKARAN INDONESIA ios oy be “Tarn Memberikan y ae PT ASURANS! TRI PAKARTA ee ee a . . el -TRIPA No Polis Policy Number Nama Tertangaung Insured Name Alamat Tertangqung ‘Address of the Insured Jangka Waktu Pertangoungan Period of insured Kelas Konstruks Construction Class Kode Okupasi Occupation Lokasi Risiko Risk Location Jaminan Coverage Harga Pertangaungan ‘Sum Insured IKHTISAR PERTANGGUNGAN POLICY SCHEDULE INDUSTRIAL ALL RISK SHARIA 41001581900001 RENEWAL PTJASA MEDIVEST UL. NANAS NO.43 BANDUNG BANDUNG - 40114 JAWA BARAT Muli dari tanggal 23 Februari 2019 sampai dengan 23 Februari 2020 , kedua ‘tanggal tersebut pada pukul 12.00 siang waktu setempat dimana harta benda yang dipertanggungkan berada Commencing from February 23, 2019 To February 23, 2020 both days at 12 O'clock noon, local tine at the location of the insured property, Class | Other Chemical and Physical Treatments, Washing, Desaliniating esis) JL. INTERCHANGE DAWUAN DESA DAWUAN TENGAH KEG CIKAMPEK KAB. KARAWANG JAWA BARAT 41958 Jaminan Utama others + Industrial All Risk (Exclude Business Interruption and Earthquake, Volcanic Eruption & Tsunami, Typhoon, Storm, Floed & Water Damage/4 3A) - Fire, Lightning, Explosion, Aircraft Impact ané Smoke (FLEXAS) - Riots, Sikes & Malicious Damage plus Cull Commotion (RSMOCC) SECTION | - Material / Property Damage Covering unforseen physical los dasinction of of damage to Property of the insured or for which heihis legally leble as spectied Inthe schedule BANGUNAN IDR 5,985,940,000.00 ‘SARANA PELENGKAP IDR 381,640,000.00 = PERALATAN PABRIK IDR 329,090,000.00 = PERALATAN KANTOR 1DR __232,870,000.00 - MESIN DAN PERALATAN, IDR 78,095,030,000.00 ‘Total Harga Pertanggungan JOR 86,004,570,000.00ts nes teen ‘sete taming par Pay Ne Klausule Clauses ee ~ ALL OTHER CONTENTS CLAUSE ( PAR ) (|DR 50,000,000.- in aggregate) ALTERATIONS CLAUSE (1AR ) APPRAISEMENT CLAUSE (6% of sum insured) ARCHITECTS, SURVEYORS AND CONSULTING ENGINEERS EXPENSES. CLAUSE (10% OF TS! ANYONE LOCATION) AUTOMATIC REINSTATEMENT OF SUM INSURED CLAUSE (SUBJECT TO ADDITIONAL PREMIUM) AVERAGE RELIEF CLAUSE (85%) AWNINGS BLINDS SIGNS OR OTHER OUTOOOR FITTINGS OF EVERY DESCRIPTION CLAUSE (Max Rp. 10,000,000.00) BANKERS CLAUSE PT BANK SYARIAH MANDIR BRAND AND LABEL CLAUSE BURST PIPES ENDORSEMENT + CAPITAL ADDITIONS (10% of TS!) CIVIL AUTHORITIES CLAUSE CLAIM PREPARATION CLAUSE ‘COMPUTER RECORDS CLAUSE CONTRACT PRICE CLAUSE. COST OF RE-ERECTION CLAUSE (COST OF RE-WRITING RECORDS AND CLAIMS PREPARATION CLAUSE CYBER AGGREGATION CLAUSE - NMA 2015 DEFERRED PREMIUM CLAUSE ~ DEFINITION CLAUSE DESIGNATION CLAUSE(S) DISPUTE CLAUSE (Syariah) EARTHQUAKE EXCLUSION CLAUSE ELECTRONIC DATE RECOGNITION EXCLUSION CLAUSE (A) EMPLOYEES PERSONAL EFFECTS CLAUSE ERRORS AND OMISSION CLAUSE - ESCALATION CLAUSE (15%) EXPEDITING EXPENSES CLAUSE (10% OF LOSS) EXTRA CONTRACTUAL OBLIGATION EXCLUSION CLAUSE FIRE BRIGADES CHARGES (max IDR 100,000,000) FIRE EXTINGUISHING COST CLAUSE (max IDR 100,000,000) GENERAL INTEREST CLAUSE IMPACT BY OWN VEHICLES CLAUSE INDUSTRIES, SEEPAGE, POLLUTION AND CONTAMINATION EXCLUSION CLAUSE ( NMA 1685 ) INFORMATION TECHNOLOGY HAZARD CLARIFICATION CLAUSE (NMA 2912) INTERNAL REMOVAL CLAUSE KLAUSULA WAKALAH BIL LURAH LOSS NOTIFICATION CLAUSE (30 DAYS) LOSS OF DAMAGED GOODS CLAUSETRIPA Morborsan yang ter man staan sito Konsisi Condition eae MINOR ALTERATIONS AND REPAIRS CLAUSE MISDESCRIPTION CLAUSE NON-INVALIDATION CLAUSE ~ NOTICE OF CANCELLATION CLAUSE (30 DAYS EXCEPT FOR. 1A*CC3 DAYS) NUCLEAR ENERGY EXCLUSION CLAUSE 1994 - NMA 1975 (A) ( WORLDWIDE EXCLUDING USA AND CANADA) OCCUPATION AND /OR ILLICIT OBJECT CLAUSE, OUTBUILDINGS CLAUSE PAIR AND SET CLAUSE PAYMENT ON ACCOUNT CLAUSE PROFESIONAL FEES CLAUSE PROPERTY DAMAGE CLARIFICATION CLAUSE PRORATA RETURN OF PREMIUM CLAUSE PUBLIC AUTHORITIES CLAUSE REINSTATEMENT VALUE CLAUSE REMOVAL OF DEBRIS CLAUSE (10% of Sum Insured inal. In TS!) REPLACEMENT VALUE CLAUSE. RIOTS, STRIKES, MALICIOUS DAMAGE AND CIVIL COMMOTIONS ENDORSEMENT (Code : 4.18 / 2007) SANCTION LIMITATION AND EXCLUSION CLAUSE - JW2010/004 SELLING PRICE CLAUSE - SERVICES CLAUSE SMOKE AND VEHICLE IMPACT ENDORSEMENT (CODE : 4.11 - o1/i2/199a) ‘SPRINKLER LEAKAGE CLAUSE (IF APPLICABLE) ‘STRUCTURAL ALTERATION CLAUSE. - TEMPORARY REMOVAL CLAUSE ‘TERRORISM EXCLUSION CLAUSE (NMA 2920) ‘THEFT ENDORSEMENT (FORCIBLE ENTRY) - TOTAL ASBESTOS EXCLUSION TRANSMISSION AND DISTRIBUTION LINES EXCLUSION CLAUSE VEHICLE IMPACT CLAUSE WAIVER CLAUSE WAIVER OF SUBROGATION CLAUSE WAR AND CIVIL WAR EXCLUSION CLAUSE WORKMENS CLAUSE = Warranty sufficient and working FEA devices - Warranted 24 hours security guards - Warranty safety measures in respect of theft risk - Warranty all machineries are well maintained according to SOP - Not Silent Risk - Detail Mesin bukan buatan Chinaa “TRIPA omen yang tera esiko Sendiri Deductible Rate of Premium Perhitungan Premi Premium Caleulstion alls ini metupakan perpaniang + Riots, Stikes and Malicious Damage (RSMD) : 10 % of Claim minimum IDR 10,000,000.00 for any one accident + Others/Theft/Accidental Damage : IDR 2.600,000.00 for any one accident ~ Fite, Lightning, Explosion, Aircratt Impact and Smoke (FLEXAS) 0.1 % of TSI oF 10 % of Claim (whichever is higher) + Civil Commotion : 10 % of Claim minimum ; IDR 10,000,000.00 for any ‘one accident Riots, Strikes & Malicious Damage plus Givil Commotion (RSMDCC) Fire, Lightning, Explosion, Aircraft Impact ‘and Smoke (FLEXAS) Others IDR 85,004,570,000.00 x 0.00100000%e IDR 85,004,570,000.00 x 0.00100000%. IDR 85,004,570,000,00 x 1.61400000%. Policy Cost ‘Stamp Duty Total Premi isn 11001551800001 ‘This Policy is issued in renewal with Policy number(s) tea. ste weuastn tpi o Parsoag.n ‘ness wo be Unsere bang ay satay Te ince sd onl hs Easoe ba fal ea or IDR 1oR, oR 1oR (0.00100 1.61400 %e 0.00100 te 185,004.57, 85,004.57 137,197,376.98 55,000.00, 6,000.00“~~ TRIPA {inspotes etemng part ay Ne JAKARTA, 23 Februari 2019 PT. ASURANS! TRI PAKARTA BEAWATERA NS Ro. 0000, —— Pr ASURANSITRIPAKARTA AWTOR CABANG SWARUN, JL FALATEKAN NO 1718 AKA edean aso TRIPA so suaote nn sossssna) Detail Sum Insured: No. Deskripsi unt] Hergafunit Harga Pertanggungan 1] BANGUNAN + | 4,137,270,0000 OR 4.187,270,000 60 a 2| LOADING Bay 1] 813,870,000.00 | 1oR 613,870,000.00, 3) MESS KARYAWAN 1] 149,280,000.00 | 1oR 149,230 000.00 4] RUMAH POMPA 1] 9,030,000.00 } 10 9,030,000.00 5] 7PS LIMBAH 83 1] 30,470,000.00 | 10 30,470,000.00 5] GUDANG LIMBAH 83 1 | 123,420,000 00 | 1oR 123.420,000.00 7| GUDANG LIMBAH Ba 1 | 176,760,000.00 | IDR 175,760,000.00 8) BANGUNAN TEMPaT CuCl 1] 82,700,000.00 | 10 82,700,000.00 8] BANGUNAN TRAFO. 4] 54,280,000.00 }10R '54,280,000.00 10] Pos uaca, 1] 24,380,000.00 J 108 224,380,000.00 11] KANTOR 4] 442,710,000.00 | 10R 442,710,000.00 12] BANGUNAN UTILITAS DAN WORKSHOP 1] 90,710,000.00 | 10R 90,710,000.00 13] BANGUNAN TANGK! SOLAR 1] 32,110,000.00 | oR 32,110,000.09, TOTAL IDR 5,865,940,000.00 No. Deskripsi um] Hargafunit Harga Pertanggungan 7] INCENERATOR PLANT. 1 | 30,363,700,000,10R——-30,363,700, 000.00 00 2) GENERATOR SET +] 424,370,000.00 | 10 424,370,000.00 3] SCREW AIR COMPRESSOR 1} 130,920,000 .00 | 1oR 130,920,000.00 4) AiR DRYER 11] 12,660,000.00 | 10 12,650,000,00 5| PRESSURE TANK 1] 7,180,000.00 | 10R 7,190,000.00 6] TANGKI SOLAR 1] 40,700,000.00 | oR 40,700,000.00 7| TANGKIAIR 4] 99,820,000.00 | 10, #9,820,000.00 | FIRE EXTINGULER 4] 36,480,000 00 | 10 36 480,000.00 9] TIMBANGAN DIGITAL, 1 | 12,280,000.00 | 10 12,280,000.00 10] INSTALASI AIR 8ERSIH 1] 208,150,000.00 } 10 208,150,000.00 11] INCENERATOR PLANT (BARU) 1 | 46,488,860,000,|10R ———_45.488,650,000.00 00 12] SCREW AIR COMPRESSOR 4] 287,980,000.00 | 1oR 287,990,000.00 16] JEMBATAN TIMBANG 1,| 982,130,000.00 | 10 1282,130,000,00 TOTAL IDR 78,095,030,000.00