EMPLOYEE APPLICATION FORM

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Name

PRIVATE & CONFIDENTIAL

A. EMPLOYMENT DETAILS
Date (dd/mm/yyyy) 7 March 2019
Position for Medical Provider Relation Job nature

Source of Recruitment filled by HR

B. PERSONAL PARTICULAR
Employee

Name as appeared on ID/PP Andreas Wijaya Gender Male

Name on Birth Certificate Andreas Wijaya
Place of Birth Jakarta Country Indonesia

Date of Birth (dd-mm-yyyy) July 16, 1988 Age 31 years old

ID Number 3172011607880004

NPWP Number 169328747047000

Religion Catholic Nationality WNI

Address on ID Perumahan Villa Kapuk Mas 2
Jl. Vikamas Barat 5 Blok F7 No. 6
Kapuk Muara, Penjaringan, Jakarta Utara
City Jakarta
Post Code 14460

Domicille Address Perumahan Villa Kapuk Mas 2

Jl. Vikamas Barat 5 Blok F7 No. 6
Kapuk Muara, Penjaringan, Jakarta Utara
City Jakarta14460
Post Code 14460

Contact numbers
Mobile phone Residential Telephone No.
08999250773 081384393911 0215415157

Personal e-mail address dreas.wijaya@gmail.com Emergency Contact No.

Emergency Contact Person Andy Saputra 0811881423

Relationship Father

To be filled after Confirm to Join Generali (Agreement Signing)

Name on BCA Account

Number of account Branch

Andreas Wijaya

September 5, 2019
Immediate Family Details

Spouse's name Margaret Lestari Gender Female

Date of Birth (mm-dd-yyyy) Mar 1 1988 Place of Birth Jakarta

Profession Employee Employer

Children Name Date of Birth Gender

Audrey Emery Wijaya Dec 19 2017 Female

Father Andy Saputra Occupation Retired

Date of Birth (mm-dd-yyyy) Jul 13 1955 Domicile Jakarta

Mother Han Swan Giok Occupation Housewife

Date of Birth (mm-dd-yyyy) Jun 16 1958 Domicile Jakarta

Siblings' detail
Name Mrs. Krisnawati Wijaya Occupation Housewife

Age 38 Domicile Bekasi

Name Mrs. Linasari Occupation Housewife

Age 35 Domicile Singapore

Name Mr. Ivan Wijaya Occupation Student

Age 19 Domicile Jakarta

Name Occupation

Age Domicile

Name Occupation
Age Domicile

Name Occupation

Age Domicile

0
C. FORMAL EDUCATION

Periode
Name Degree Major GPA
Start End
Senior High School Tarakanita 2 Jul 1 2004 Jun 1 2006 Science
Academy -
University Tarumanagara Jul 1 2006 Apr 15 2013
Post Garduate -

D. INFORMAL EDUCATION / COURSE / SEMINAR

Periode
Name of Institution & Location Subject / Topic Awards
Start End
Indonesian Heart Association Jakarta Apr 7 2015 Apr 8 2015 ECG
LOMA Jakarta May 1 2015 May 1 2015 Insurance Fundamental

Indonesian Heart Association Jakarta Oct 14 2016 Oct 16 2016 ACLS

IKABI Jakarta Aug 28 2015 Aug 30 2015 ATLS
PERINASIA Jakarta Jul 21 2018 Jul 22 2018 Neonatal Resuscitation

Computer Programming Language & Operating System

Windows, Microsoft Word, Microsoft Excel, Microsoft Power Points, Photoshop

Most windows software nowadays

International Language Proficiency

Written Spoken Listening

English Excellent Good Good

E. MEMBERSHIP OF PROFESIONAL, SOCIAL, OR POLITICAL ACTIVITIES

Name of Organisation Periode Activities Position

F. HOBBY AND INTEREST

Activities
Magic
Reading

#REF!
G. EMPLOYMENT HISTORY
Start with the present employment, including temporary work and vocational training

Present Employment

Employer Pantai Indah Kapuk Hospital Position Title

Nature Business Hospital Job Description
Address Jl. Pantai Indah Utara 3 Give medical services to every patient i
Pantai Indah Kapuk, Jakarta Utara room, ward, and High Care Unit

Phone 0215885100
Employment Dates From Sep 1 2015 To Jan 31 2019
Supervisor Name Dr. Purwanto May we contact Yes

Reason leaving If No, please explain

1. I want to find a job which do not have 24 hours shift.
2. I passed the test for the Civil Employee for Sanglah
General Hospital in Denpasar, but I give up due to
family reason.

Organization Chart

Head of ER

General General
Practitioner Practitioner General
Practitioner

Nurse and medical Nurse and medical Nurse and medical

support staf support staf support staf

Referees

Name Years of Known Organization Phone Relationship

Previous Employment
Employer PT Prudential Life Assurance Position Title
Nature Business Insurance Job Description
Address Prudential Tower Doing risk selection for new business a
Jl. Jend. Sudirman Kav. 79 policy
Jakarta, 12910

Phone 02129958888
Employment Dates From Jun 1 2014 To Jul 31 2015
Supervisor Name Ms. Lisda May we contact Yes

Reason leaving If No, please explain

Previous Employment
Employer Position Title
Nature Business Job Description
Address

Phone
Employment Dates From To
Supervisor Name May we contact Yes

Reason leaving If No, please explain

Previous Employment
Employer Position Title
Nature Business Job Description
Address

Phone
Employment Dates From To
Supervisor Name May we contact Yes

Reason leaving If No, please explain

Previous Employment
Employer Position Title
Nature Business Job Description
Address

Phone
Employment Dates From To
Supervisor Name May we contact Yes

Reason leaving If No, please explain

 General Practitioner

s to every patient in emergency

h Care Unit

ner

and medical
t staf

Relationship

Senior Underwriter

or new business and alteration

H. GENERAL INFORMATION

1. Have you been or are suffering from any physical disability or disease? No
If Yes, please explain

2. Have you been addicted drugs ? No

If Yes, please explain

3. Have you ever applied for any post with Generali Life Insurance ? No
If Yes, please explain

4. Have you previously been employed at this company or its subsidiaries? No

If Yes, please explain

5. Do you have any relatives working with Generali Life Insurance? No

If Yes, please explain

6. Have you ever been dismissed or suspended by any previous company or organisation? No
If Yes, please explain

7. Have you ever declared bankrupt ? No

If Yes, please explain

8. Have you ever been charge or convicted in any Court of Law ? No

If Yes, please explain

9. Are you willing to work over time ? Yes

If Yes, please explain I will work over time if the company need me to do it

10. Are you willing to assigned outside your point hire ? Yes
If Yes, please explain I will do the assignment outside my point hire to help the company grow even bigger

11. Have you signed a promissory note or an acknowledgement of indebtedness for which amount pledge has not already paid ? No
If Yes, please explain

H. IMPORTANT
Personal Information Collection Statement
The Information you provide to us is collected for the purpose of :
a. Facilitating communication between the Generali Indonesia and yourself
b. Processing your personal record with Generali Indonesia
c. May be transferred to Assicurazioni Generali Parent Company and to other Companies of Generali Group for the
employee's training, management development purposes
You have the right to obtain acccess and to request correction of any personal information concerning your family
members. Request for such access can be made to the Human Resource Department.

I. DECLARATION
I authorized the investigation of all information provided by me in this Application for Employment Form except those
pertaining to my current employment. I understand that as part of the recruitment process, PT Asuransi Jiwa Generali
Indonesia will ask me to submit copies or reference letter of my current and previous employers, copies of relevant
certificates, last salary statement, and check my reference. I also understand the misrepresentation or ommision of
facts called herein will be sufficient cause for cancellation of consideration for the employment or dismissal from the
Generali's service if I have been employed.
I hereby declare that the information contained in this form is true and correct. I understand that I am liable to be
dismissed if it discovered that information is not true and corect in any particular point with the standing any
provisions in my contact of service with Generali.

Date Name & Signature

(mm-dd-yyyy)

Mar 7 2019 Andreas Wijaya