E-POLICY OF MSIG TRAVEL INSURANCE

In accordance with your instruction, we hereby declare to have affected insurance on your behalf with following particulars:

POLICY NO :
Nomor Polis
1010001411

INSURED NAME :
Pemegang Polis
AGUSTIAR

INSURED ADDRESS :
JAKARTA
Alamat Tertanggung
,-
-
INSURANCE PERIOD :
Jangka Waktu Pertanggungan
from 10.08.2022 00:00:00 to 12.08.2022 23:59:59
refer to local time, using 24-hour time format in case time displayed
PACKAGE NAME :
TWLB World Wide Leisure Middle (B)
Nama Paket

NUMBER OF PEOPLE :
1
Jumlah Tertanggung

NUMBER OF DAYS :
3
Jumlah Hari

BENEFICIARY :
, Legal Heirs to the Insured
Ahli Waris

BENEFICIARY DOB :
Tanggal Lahir Ahli Waris
..

BENEFICIARY RELATIONSHIP :
Hubungan Dengan Tertanggung

TERITORIAL LIMIT :
Batas Wilayah
WORLDWIDE (include Schengen)

PREMIUM :
170,000.00
Premi

Stamp Duty :
10,000.00
Materai

Total : 180,000.00
Total

LIMIT LIABILITY PER PERSON 2,294,800,000

Jumlah Pertanggungan Per orang

THE INSURED PERSON DETAIL

Name : AGUSTIAR
Dob : 15.08.1974
Passport Number : E0026340
Gender : M
Relationship with Insured :

LIST OF COVERAGES in IDR

Daftar Pertanggungan

- Death / Disablement : 500,000,000.00

- Medical Expenses by accident : 500,000,000.00

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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- Medical Expenses BY sickness (Covid- 500,000,000.00
19Coverage IS limited MAX TO IDR 10.000.000 OF
Medex BY Sickness benefit. ANY pre AND post
travel :

- Repatriation of Mortal Remains : 100,000,000.00

- Compasionate Visit : 20,000,000.00

- Emergency Medical Evacuate & Repatiation : 500,000,000.00

- Lost of Baggage : 20,000,000.00

- Lost of Documents & Passport : 5,000,000.00

- Loss of Money & Personal Possesion : 10,000,000.00

- Delay Baggage : 2,400,000.00

- Travel Cancellation : 10,000,000.00

- Travel Curtailment : 10,000,000.00

- Flight Delay : 2,400,000.00

- Emergency Travel Expense : 15,000,000.00

- Personal Liability : 100,000,000.00

MANDATORY CLAUSES
Klausa Wajib

Computer and Software Date Recognition Exclusion Clause

Terrorism and Sabotage Exclusion Endorsement
War and Terrorism Exclusion Endorsement
Institute Radioactive Contamination, Chemical, Biologocal, Bio-chemical and Electromagnetic Weapons Exclusion Clause CL.370 Property
Damage Clarification Clause
Waiver Clause
Sanction Limitation and Exclusion Clause LMA 3100 PREMIUM
PAYMENT
LMA 5401 - PROPERTY CYBER AND DATA EXCLUSION
COMPLIANCE ENDORSEMENT

ADDITIONAL CLAUSES
Klausa Tambahan

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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 Sickness Medical Expenses Endorsement Emergency
Medical Evacuation and Repatriation Repatriation of
Mortal Remains
Compasionate Visit Loss
of Baggage
Lost of Documents & Passport
Loss of Money & Personal Belongings Delay
Baggage
Travel Cancellation
Travel Curtailment Flight
Delay
Emergency Travel Expense
Hijack Inconvenience Personal
Liability
Contents of unattended House
COVID-19 Coverage Compensation Clause
COVID-19 Corona Virus Exclusion

Call Center Number : Claim Call Center Number +62 21 2927 9631
Claim whatsapp number +62 812 9464 4004
Claim toll free number 0800 1 401 403

It is hereby understood and agreed that this E-policy will remain in full force and effect until be cancelled by the Company but under no
circumstances will it remain in force for period in excess of 30 (thirty) days from inception date of these Insurance Period.

Jakarta, 31.07.2022

Materai Terbayar
Rp. 10,000.00,-

Authorized Signature

Your Duty of Disclosure In addition to providing all basic information necessary to enable us to place the risk you must ensure that you are complying with your
legal duty of disclosure of all material matters relating to the risk. In particular, you must satisfy yourself as to the accuracy and completeness of the information you
provide to Insurers.
In this respect, you must provide all information relating to a risk whether favorable or not, which would influence the judgment of a prudent Insurer in determining
whether he will take the risk, and, if so for what premium and on what terms.
If all such information is not disclosed by you, Insurers have the right to avoid the contract from its commencement which may lead to claim not being met.

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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