JASARAHARIA PUTERA 2, Quotation Slip — Dated December 1* 2022 COMBINED LIABILITY INSURANCE PT. ARTHAMIGAS ‘TYPE OF INSURANCE SECTION I : COMBINED LIABILITY INSURANCE WORKMEN'S COMPENSATION ACT SECTION II : EMPLOYER'S LIABILITY INSURANCE SECTION IIT : COMPREHENSIVE GENERAL SECTION SECTION IV + AUTOMOBILE LIABILITY THE INSURED : PT PERTAMINA HULU MAHAKAM ( PHE ) , Ltd Principal / Owner and/or PT ARTHAMIGAS as Sub-contractor(s) and Suppliers for their site activities and any participants. in the construction and erection of the Projectall for their respective right and interest ‘ADDRESS, TBA - Jakarta PERIOD OF INSURANCE 36 Months, February 1 , 2023 up to January 31, 2026 PROJECT TITLE : ELECTRICAL PREVENTIVE MAINTENANCE at BALIKPAPAN OFFICE CONTRACT NO . SZ0800095A-DSTRL RISK LOCATION: Balikpapan ~ East Kalimantan ( Office - Onshore ) CONTRACT VALUE: IDR 9,167,903,168.00 INSURANCE COVERAGE ‘SECTION I - WORKMEN'S COMPENSATION ACT INSURED INTEREST —: Covering legal liability of the Insured for damage in respect of personal injury by accident to pay compensation to the employee of the Insured in the course of his employment by the Insured in the Business up to the lump sum cash benefit as provided for in the Laws referred to in the specification. NUMBER OF EMPLOYEEEEEYEE EES. Local Workers BENEFIT : PERTAMINA Benefit In access of BPJS Ketenagakerjaan DEDUCTIBLE : Compensation under BPJS Ketenagakerjaan ‘TOTAL PAYROLL SECTION I - EMPLOYER'S LIABILITY INTEREST + Covering legal liability of the Insured for damages (including claimant ‘costs and expenses) in respect of bodily injury and/or death to anyone person under a contract of service or apprenticeship with the Insured in connection with the Project and happening during period of insurance within the Republic of Indonesia. LIMIT OF LIABILITY USD 150,000.00 anyone occurrence and in aggregate NUMBER OF EMPLOYEES : Estimate : TBA (Local Workers) Chan eSNG SA, 89 Sg i S120, a yk Kantor Pamasaran Cour: (021) 8:50 4, cbr poi Kantor PamaseranSogr.(025') 8551208, togrip ch © webs jpcoi, ema smabpangG.cldo JASARAHARJA PUTERA TERMS CONDITIONS =: Claims Made basis of indemnity Indonesia Jurisdiction + Tocover claims by the Insured's Employees, against the Principal DEDUCTIBLE NIL 3. SECTION III : COMPREHENSIVE GENERAL LIABILITY INTEREST : Covering the Insured’s legal Liability to third parties in respect of accidental bodily injury and/or property damage arising out from thelnsured activities LIMIT OF LIABILITY : USD 150,000.00 anyone occurrence in aggregate DEDUCTIBLE + 10% of claim subject to minimum USD 2,500 for material damage Body Injury NIL EXTENDED COVER Primary Insurance cover, Additional Insured Claim Made Basis Indemnity with cover as per inception date Defective Sanitary Installation clause BMAT Important Notice Clause Indonesia Jurisdiction Clause Warranty Payment Clause 30 days Loss Notification Clause ~ 14 days Notice Cancellation Clause ~ 14 days Waiver Right of Subrogation Against Principal ( s ) Cross Liability Clause Break & Review Clause ADDITIONAL EXCLUSION Professional Liablity Penalty and Fine Personal Injury Watercraft liability Car Park Liability Punitive or Exemplary damages Exclude ionizing, radiation, contamination Terrorism and Sabotage Exclusion Endorsement Cyber Liability Exclusion Clause Pure Financial Loss Loss of use Consequential Loss Act of God /Force Majeure Contractual Liability Exclusion Total asbestos exclusion clause PT JASARAHARIA PUTERA A4ANG JAKARTA SMATUPANG SUA AURAL 1, 8S! hn, rt Sen, OO 1, EL FTO anor Pomasaan Club: (021) 40 S040, cour cole Kantor Pemasaran Bogor (251 695 120, ope 08 ebia pce oman pray cle= & JASARAHARIA PUTERA 4, AUTOMOBILE LIABILITY LIMIT OF LIABILITY USD 450,000.00 anyone occurrence in aggregate DEDUCTIBLE ——_: 10% of Claim, minimum USD 500.00 SECURITY : PT ASURANSI JASA RAHARJA PUTERA = 100% SUBJECKTIVITY — : STNC until binding date. Nil loss record for the past 3 years Nama dan Data diri employee Nama dan Gaji setahun dari karyawan tetap Nomor polisi atau Mesin dari kendaraan/unit 33 MONTHS PREMIUM —: WCA CALCULATION EL co + 0.10 % x TOTAL SALARY USD 150,000 x 0,080% x 36/12 USD 150,000 x 0,080% x 36/12 =TBA uUsD 360.00 Usp 360.00 ATPL: USD 150,000 x 0.080% x 36/12 =USD 360.00 TOTAL PREMIUM EL & CGL (excluding Policy Cost and Stamp Duty ) Jakarta, December 2022 Tongku Ritonga ‘Asmen Bisnis 1 PT JASARAWARIA PUTERA CABANG sKARTA TO SRATUPANG SMA AMARA Sitar! Cnr, ra Ser, O10 31, Fn TOME ‘USD 4.080.00 Kantor Pemazaran Clo (021) 49 040, boro Kantor Pemesaan Bogor: (251) 835 1230, odbc ‘webs poo ema smuupangG.cld