PT.

ASURANSI MSIG INDONESIA

UNMANNED AERIAL VEHICLES

INSURANCE PROPOSAL FORM

Insured Details
Insured / Company Name KJSB Indra Pramudita
: _________________________________________________
Registered Owner Indra pramudita
: _________________________________________________
(if different from above)

Occupation : _________________________________________________
Address Line 1 Serut RT 01, Palbapang, Bantul,
: _________________________________________________
Address Line 2 D.I Yogyakarta
: _________________________________________________
Postal Code
55713 085163575737
: ________________ Telephone: ________________
kjsbindrapramudita@gmail.com
Email : ___________________________________________

Third Party Liability Coverage

Single Limit Bodily Injury and Property Damage Liability
Limit of Liability desired : IDR / USD ____________________
Medical Expense Coverage : IDR / USD ____________________

Physical Damage Coverage

Unmanned Air Vehicle (If multiple UAV or Fleet, please provide information on separate
sheet)
Type: Fixed Wing / Rotary Wing UAV based at (Airport / Location): ______________________
Registration Annual
Hull Value
Year of Make & / Estimated
(IDR or MTOW (kg) Range (km)
Build Model Serial Utilization
USD)
Number (Hours)
2022 vtol TG-NV2-020 80.000.000 7kg 5
2022 vtol TG-NV2-019 80.000.000 7kg 5
PT. ASURANSI MSIG INDONESIA
Application / Usage: (i.e. Photography, Agricultural, Exploration, Transportation etc.)
___MAPPING_____________________________________________________________

Lien Holder (if applicable): _________________________________________________

Lien Amount
US$_______________________________________________________________

Pilots

Pilot 1 Pilot 2
Name BUNTAR ARI ZUFRI A
Date of Birth 12-06-1995 11-03-1994
License APDI 3489-2023 APDI 3493-2023
Total time on UAV 50 HOURS 50 HOURS

UAV time past 12 months

UAV time on Model VTOL, MULTICOPTER VTOL, MULTICOPTER
NO NO
Accidents/Violations

Operations

Governing Operating Body: Private (Civil) / Government

_________________________________________________________________________

Operating Environment: Urban / Semi-Urban / Rural / Industrial / Coastal / Maritime

_________________________________________________________________________

Flight Conditions: Visual Line of Sight (VLOS) / Beyond Visual Line of Sight (BVLOS)
/______
Geographical Area of Operations: FIELD,
URBAN___________________________________________________________________
______
Has any insurer cancelled / refused to renew your insurance policy in the past 5
years? YES / NO
Reason: NO___________________________________________________________________

Name of Present Insurer : ________________________________________________

Policy Expiry Date : _____________________________________________________
PT. ASURANSI MSIG INDONESIA
Loss History

Date of Loss
Loss Cause Amount Improvement
- - - -

Declaration:
I declare that the statements and declarations given are true and that no information has
been withheld that might influence acceptance of this proposed insurance; and I agree that
the statements and declarations given above and signed by me shall be the basis of my
contract between myself and PT. Asuransi MSIG Indonesia. This application does not
commit PT. Asuransi MSIG Indonesia to any liability nor make the applicant liable for any
premium unless PT. Asuransi MSIG Indonesia agrees in writing that coverage has been
bound.

Signature of Applicant : _________________________

INDRA PRAMUDITA, S.T
Pemimpin

Date : 10 FEBRUARI 2023

Phone Numbe r : 081314839231

Email : kjsbindrapramudita@gmail.com