No.

SPAJ/Polis:
SPAJ/Policy No.

KUESIONER PELAUT
MERCHANT MARINE QUESTIONNAIRE

UNTUK DIISI OLEH (CALON) TERTANGGUNG/PESERTA

TO BE COMPLETED BY (PROPOSED) INSURED/PARTICIPANT

Nama (Calon) Tertanggung/Peserta: :

Life To Be Assured Name

Jenis pekerjaan : ( Mohon tuliskan kode sesuai daftar di bawah ini)

Type of Job (Please write down code as per below list)

KODE DAFTAR PEKERJAAN / OCCUPATION LIST CODE

1 Attendant - hydrofoil or Attendant - jetfoil 21 Lighterman
2 Bargeman 22 Lighthouse keeper
3 Baggage master 23 Light keeper - docks and harbours
4 Boatswain 24 Navigator
5 Captain (includes Chief Officer, Deck Officer, 25 Passenger Officer - hovercraft
Master, Mate dan Skipper)
6 Captain - hovercraft or Commander 26 Pilot
7 Car lasher 27 Pilot - hydrofoil or Pilot - jetfoil
Catering staff (includes Catering officer, Chef Cook,
8 28 Survey Sounder
Galley Hand)
9 Dredger driver 29 Tugboatman
10 Dredgerman 30 Tugman
11 Dredgermaster 31 Watchman - inland waterways
12 Dredging superintendent 32 Pilot superintendent
Engineer (includes Chief Engineer, Electrical
13 Engineer, Engineer officer, Refrigeration’s Engineer, 33 Purser
Ship’s Engineer)
14 Engineer - hovercraft (includes First Officer) 34 Quartmaster
Engine-room Worker (includes Donkeyman, Engine-
15 room rating, Engine-room storekeeper, Fireman, 35 Radio Officer
Greaser, Leading Hand, Mechanic, Oiler, Pumpman,
Stoker, Winchman)
16 Entertainments Officer 36 Seaman (includes Deck Hand-boy and
rating, Cable Hand
17 Ferryman 37 Steerer
18 Foreman lighterman 38 Steward (includes Chief and Second steward
Lainnya, jelaskan:/Others, please specify:
19 Junk boat worker or Sampan worker
39 ………………………………………..........
………………………………………..........
20 Leadsman ………………………………………..........
………………………………………..........

Tanda tangan (Calon) Pemegang Polis sesuai Tanda tangan (Calon) Tertanggung/Peserta
kartu identitas diri yang dilampirkan sesuai kartu identitas diri yang dilampirkan
Signature of (Proposed) Policy Holder as per attached ID Card Signature of (Proposed) Insured/Participant as per attached ID Card

Mohon lembar Kuesioner ini tidak ditandatangani dalam keadaan kosong dan pastikan semua informasi yang diminta
telah diisi dengan benar sebelum ditandatangani./Please do not sign the form in blank and make sure all the required information have been
filled appropriately prior to signing.

PT Prudential Life Assurance

Prudential Tower – Jl. Jend. Sudirman Kav. 79, Jakarta 12910, Indonesia
Tel: (62 21) 2995 8888 Fax: (62 21) 2995 8800
Prudential Customer Line: 500085
E-mail: customer.idn@prudential.co.id Website: www.prudential.co.id
Q.C.6/Merchant Marine Quest/Underwriting Dept/150611
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 No. SPAJ/Polis:
SPAJ/Policy No.

1. Apakah Anda melakukan pekerjaan di laut (atau di masa mendatang akan melakukan pekerjaan di laut )?/Does your
occupation involve going to sea (or is it likely to be so in the future?)
□ Ya/Yes □ Tidak/No
Jika YA, mohon melengkapi kuesioner ini dengan lengkap./If YES, please complete the rest of this questionnaire.

2. Anda melakukan pekerjaan pada jenis kapal yang mana?/Which of the following types of vessel do you work on?
□ Ocean liner
□ Barge, dredger, lighter, lightship, tug or weathership
□ Cable and pipe-laying vessel, factory ship, oil rig barge or supply ship
□ Passenger vessel/ferry
□ Cargo vessel
□ Lainnya, mohon jelaskan:/Other, please explain:………………………………………

3. Berapa persen dari pekerjaan Anda menyangkut pekerjaan manual atau fisik?/What percentage of your duties are of
a manual or physical nature?

4. Pernahkah Anda mengalami kecelakaan atau sakit sehubungan dengan pekerjaan Anda?/Have you had any
accidents or illnesses associated with your duties?
□ Ya/Yes □ Tidak/No
Jika YA, jelaskan kapan dan jenis kecelakaan/sakitnya./If YES, please explain when and type of accidents/ailments.

Tanda tangan (Calon) Pemegang Polis sesuai Tanda tangan (Calon) Tertanggung/Peserta
kartu identitas diri yang dilampirkan sesuai kartu identitas diri yang dilampirkan
Signature of (Proposed) Policy Holder as per attached ID Card Signature of (Proposed) Insured/Participant as per attached ID Card

Mohon lembar Kuesioner ini tidak ditandatangani dalam keadaan kosong dan pastikan semua informasi yang diminta
telah diisi dengan benar sebelum ditandatangani./Please do not sign the form in blank and make sure all the required information have been
filled appropriately prior to signing.

PT Prudential Life Assurance

Prudential Tower – Jl. Jend. Sudirman Kav. 79, Jakarta 12910, Indonesia
Tel: (62 21) 2995 8888 Fax: (62 21) 2995 8800
Prudential Customer Line: 500085
E-mail: customer.idn@prudential.co.id Website: www.prudential.co.id
Q.C.6/Merchant Marine Quest/Underwriting Dept/150611
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 No. SPAJ/Polis:
SPAJ/Policy No.

Dengan ini saya telah memberikan jawaban dan keterangan dalam Kuesioner Pelaut ini dengan sejelas-jelasnya dan
sebenar-benarnya. Saya tidak menyembunyikan informasi apa pun yang dapat memengaruhi penerimaan Surat
Pengajuan Asuransi Jiwa (SPAJ) saya. Saya menyetujui Kuesioner ini akan menjadi bagian dari SPAJ saya pada PT
Prudential Life Assurance dan bahwa penyembunyian informasi material apa pun dapat mengakibatkan batalnya
kontrak asuransi jiwa sebagaimana diatur dalam SPAJ dimaksud.

I declare that the answers I have given in this Merchant Marine Questionnaire, to the best of my knowledge, are true
and that I have not withheld any material information that may influence the assessment or acceptance of my Life
Insurance Policy Application Form. I agree that this Questionnaire will constitute part of my Application Form with
PT Prudential Life Assurance and that failure to disclose any material fact known to me may invalidate the contract as
stipulated in the respective Application Form.

di ……………………….tanggal ……………. bulan ……………..……. 20 ………

Signed at on month of

…..………………………………………….......... …..…………………………………………..
Nama & Tanda Tangan Disaksikan oleh: Nama & Tanda Tangan Tenaga Pemasaran
(Calon) Tertanggung/Peserta Witnessed by Name & Signature of Sales Representative
Name & Signature of (Proposed) Insured/Participant (Sales Representative’s No: )

PERHATIAN: Mohon tanda tangan sesuai kartu identitas diri yang dilampirkan
ATTENTION: Please note that the signature must be the same with the one shown in the ID card

Tanda tangan (Calon) Pemegang Polis sesuai Tanda tangan (Calon) Tertanggung/Peserta
kartu identitas diri yang dilampirkan sesuai kartu identitas diri yang dilampirkan
Signature of (Proposed) Policy Holder as per attached ID Card Signature of (Proposed) Insured/Participant as per attached ID Card

Mohon lembar Kuesioner ini tidak ditandatangani dalam keadaan kosong dan pastikan semua informasi yang diminta
telah diisi dengan benar sebelum ditandatangani./Please do not sign the form in blank and make sure all the required information have been
filled appropriately prior to signing.

PT Prudential Life Assurance

Prudential Tower – Jl. Jend. Sudirman Kav. 79, Jakarta 12910, Indonesia
Tel: (62 21) 2995 8888 Fax: (62 21) 2995 8800
Prudential Customer Line: 500085
E-mail: customer.idn@prudential.co.id Website: www.prudential.co.id
Q.C.6/Merchant Marine Quest/Underwriting Dept/150611
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