SCHEDULE

COMBINEED LIABILITY POLICY

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We, PT. Bosowa Asuransi hereby agree, In consideration of the payment to us or on behelft of the Assured of the
premium as arranged, to insure against loss damage liability or expense to the extent and in the manner hereinafter
provide
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Type of Cover : Combineed Liability Insurance

Name of Insured : PT. BARASENTOSA LESTARI

Insured Address : Jl. Pintu Air Raya No. 31-B RT. 013 RW. 002 Kel. Pasar Baru Kec. Sawah Besar,
Jakarta Pusat
Periode of Insurance : TBA
Description of Project : Pekerjaan Jasa Pertambangan
Location Of Work : Sumatera Sealatan, Indonesia
Contract With : PT. LOBUNTA KENCANA RAYA
Contract Nr : 122/BSL-LKR/LM/VI/2017
Contract Value : TBA
Limit of Liability : Section I Comprehensive General Liability
Maximum Aggregate Combined single Limit of Indemnity not Exceeding USD.
500,000.00 any one occurrence for the whole periode of Insurance.

Section II Contractor Liability Insurance

Limit of Liability USD. 50.000, any one occurence in respect of bodily injury and in
aggregate for the whole period of insurance.

Section III Automobile Third Party Liability

Limit of Liability USD. 250,000.00 / Vehicle Combined Single Limit any one
occurrence for the whole period of insurance

Section IV Workmen’s Compensation Inusrance

Covering Lump sum compensation for any employee of the insured who sustained
bodily injury by accident arising out of in the course of his employment with the
insured in the business, occurring within territorial limit and during period of insurance
Including occupational disease
Benefit : Local DIC Pertamina Benefit (Excess of BPJS Ketenagakerjaan)
Expatriates Full Pertamina Benefit
It is essential that all relevant Indonesian employees are registered under BPJS
Ketenagakerjaan as any claim payment will into account BPJS Ketenagakerjaan
payment made.
No of Employee : To be advised (TBA)
Name of Local Employee : To be advised (TBA)
Total Payroll : IDR. 1,000,000,000.00

Deductible : - Section I : Comprehensive General Liability and Suddent and Accidental Pollution
10% of Claim Min. USD 2,500.00 a.o.o ( any one Occurrence) for third party Property
Damage Only

- Section II : Automobile Third Party Liability

10% of Claim Min. USD 2,500.00 a.o.o ( any one Occurrence) for third party Property
Damage Only

- Section III : Contractor Liability

NIL

- Section IV : Wokrmen’s Compensation :

In Excess of BPJS Ketenagakerjaan

Detail Vehicle : TBA

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Extension Clauses
Rate
Premium Calculation
In order to avold any possibility of miscomprehension, you are requested to read this Policy and it’s conditions.
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: - 30 days advance written notice to company in the event of cencellation, expiration or
intend charges in the terms and condition.
- Automobile Liability Extention Clause
- Cancellation Clause (30 Day’s)
- Claim Made Basis of Indemnity
- Communicable Disease Endorsment LMA 5396
- Contractual Liability Clause (excluding sole Negligence)
- Cross Liability of Imdemnity Clause
- Completed operation (if providing construction work)
- Electronic Date Recognition Clause “A”
- Exclude Act of God
- Exclude asbestos
- Exclude Blow Out Risk
- Exclude Continuous or Gradual Pollution and Contamination
- Exclude Direct Drilling Activites
- Exclude Drilling Activities Unless Supporting
- Exclude Fines and Penalties
- Exclude offshore activities
- Exclude Professional Indemnity
- Exclude War & Terrorism
- Exclude property under care, custody & control of the insured
- Extra Contractual Obligation Exclusion Clause
- Extra Contractual Obligation exclusion endorsement
- Fire Explosion Liability Clause
- Include Fire and Explosion
- Include Sudden & Accidental Pollution Clause (72 Hours)
- Indemnity to Principal
- Indonesian Jurisdiction and Territory Clause
- Industries, Seepage, Pollution and Contamination Exclusion Clause (NMA 1685)
- Legal costs & Expenses inclusively
- Licenced Vehicle for AL
- Loading and Unloading Clause
- Loss Nitification Clause (30 days)
- NMA 219 Cyber Risk Exclussion Clause
- NMA 2919 War and Terrorism Exclussion Clause
- Physical Damage Clarification Clause
- Product Liability (if Supplying Product Such as Chemical, Food, ect)
- Overseas Visitor Clause (Excl. USA & Canada)
- Principal as Additional Name of Insured
- Seepage and pollution clause NMA 1685
- Waiver of Subrogation Clause
- Warraty Premium Payment Clause (30 days)
: 0.25%
: USD 800,000.00 x 0,25% x 3 year USD 6,000.00
IDR. 84,000,000.00
IDR. 1,000,000.00 x 0,25% x 3 year IDR 7,500,000.00
Policy Cost IDR 50,000.00
Stamp Duty IDR. 20,000.00
Total Premium IDR 91,570,000.00
Palembang, 6 Desember 2022
PT. Bosowa Asuransi
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