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IKHTISAR PERTANGGUNGAN
POLICY SCHEDULE

POLIS STANDAR ASURANSI KEBAKARAN INDONESIA

NEW
No Polis : 11601012200174
Policy Number
Nama Tertanggung : Mr YUWANANDA PERWIRA HUTAMA QQ Bp IRAWAN
Insured Name
Alamat Tertanggung : JL PRINGGONDANI NO.30 RT07/RW.03 KENEP MANGUNJIWAN, DEMAK
Address of the Insured JAWA TENGAH 59515
Jangka Waktu Pertanggungan : Mulai dari tanggal 31 Maret 2022 sampai dengan 31 Maret 2023 , kedua
Period of Insured tanggal tersebut pada pukul 12.00 siang waktu setempat dimana harta benda
yang dipertanggungkan berada
Commencing from March 31, 2022 To March 31, 2023 both days at 12 o'clock
noon, local time at the location of the insured property.
Kelas Konstruksi : Class I
Construction Class
Kode Okupasi : Dwelling houses not classified as shop houses (ruko) not exceeding 3
Occupation storeys (2976 )
Kategori Risiko : Low Exposure
Risk Category
Lokasi Risiko : JL PRINGGONDANI NO 30 RT 07 RW III KP KENEP MANGUNJIWAN,
Risk Location KECAMATAN DEMAK , KABUPATEN DEMAK , JAWA TENGAH 59515
Penerangan : Listrik
Lighting
Jaminan : Jaminan Utama
Coverage - Fire, Lightning, Explosion, Aircraft Impact and Smoke (FLEXAS as PSAKI
Standard)
Harga Pertanggungan : - ATAS BANGUNAN RUMAH TINGGAL : IDR 300,000,000.00
Sum Insured SHM NO 348 , LUAS BANGUNAN 63 M2
Total Harga Pertanggungan : IDR 300,000,000.00
Klausula : - COMMUNICABLE DISEASE ENDORSEMENT LMA5393
Clauses FOR USE ON PROPERTY INSURANCE

Resiko Sendiri : - Fire, Lightning, Explosion, Aircraft Impact and Smoke (FLEXAS) : Nil
Deductible
Suku Premi : Fire, Lightning, Explosion, Aircraft Impact : 0.29400 ‰
Rate of Premium and Smoke (FLEXAS as PSAKI Standard)

14/09/2022 - 11:07:14AM PST-0001 {3F034C92-4 / YPH / YPH Page 1 of 2

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Halaman ini adalah bagian dari Polis No.11601012200174

This page is a forming part of Policy No

Perhitungan Premi : IDR 300,000,000.00 x 0.29400000‰ : IDR 88,200.00

Premium Calculation
Policy Cost : IDR 50,000.00

Stamp Duty : IDR 10,000.00

Total Premi : IDR 148,200.00

Keterangan : - Clean loss record for past 3 years

Remarks - Not silent risk
Dengan Kesaksian Yang Bertanda Tangan di bawah ini yang diberi wewenang sepatutnya oleh Penanggung dan atas nama Penanggung telah membubuhkan tanda tangannya.
In witness whereof the Undersigned being duty authorized by the Insurers and on behalf of the Insurers has (have) hereunto set his (their) hand(s).

PALEMBANG, 05 April 2022

PT. ASURANSI TRI PAKARTA

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