# AG Insurance FORMULIR KLAIM ASURANSI KEC) DIRI PERSONAL ACCIDENT CLAIM FORM INFORMASI UMUM GENERAL INFORMATION No.Polis Policy No. The Insured ‘Nama Beserta Panieipant Name ‘Tempat & Tangeal Lahr Peseria Place & Birthday of Participant ‘Alamat Pesera Participant Adress ‘Nama Abli Wars 1) Suamitsti Beneficiaries Spouse ‘Alama! Korespondens Correspondence Address ‘No, Telepon Phone No. 2 Birth Child ‘Comespondence Address Phone No. 3) Orang ua Kandung Origin Parents ‘Comespondence Address Phone No. ‘Waktu Kecelakaan ‘Timeof Accident Place of Accident Cause of Accident ‘Akibat dari Kecelakaan © Kematisn ‘Consequence ofthe Accident Death farohon pilih salah satw) Tempat Kematin :o indi (eae Seer Pl of Det ‘Piao cee Cee Hospital 0 Rumah Tingeal Home © TempatLalunsa ‘ther Place AG Insurance/Claims/PA Form sap Eastcote G SMkhoun B Bandung serie Tele fo Gedung Gant avihePT. ARTHAGRAHA GENERAL INSURANCE Waktu Kem Time of Death Penuchab Kematuan ‘Cause of Death 1 Cacat Tetap Permanent Disablement agian Tubuh vane mana Which Par of Body Biaya Pengobatan ‘Medical Expenses BBapian Tubuh vang mana Which Par of Body PERTANYAAN-PERTANYAAN QUESTIONAIRES », wa atau Polis Asurans Kecelokaan van lain? Jika a 2 ‘Does the participant has another Life Insurance Policy or Personal Accident Policy? Ifyes, please sate? 2, iki Cacat Te iam dinsuransika? Jka ‘buh vang mand? Does the participant had carried Permanent Disablement before Insure? If yes, whieh pat of body’? 53) Apakah peserta memiliki penvakitantung?Jika ada seiak Kapan? ‘Does the participant had a hear disease? If yes since when? DOKUMEN-DOK\ DI DOCUMENTS REQUIREMENT Wika diperlukan Penanesune masih meni hak untuk meninta dotumen-dokwnen tambhan lina di uae formalin (required. the insurer sil have ight o ask any additional documents ouside this form) DOKUMEN-DOKUMEN UMUM (GENERAL DOCUMENTS 1) Fotooopy bukti pembevaran prem asuransi ‘Copy of insurance premium payment evidence 2) Kronologi kecelakaan ‘Chronology ofthe accident 3) otocopy KP / Paspor Pest ‘Copy of Pantcipant ID Card / Passport 4) Fotocops Karts Keluarea Copy of Residential Card 5)» Fotocony asin belek (ike pesera bertndak sebagai pengemud pada soa! kecelakaan (Copy of valid Driving Licensed (ifthe pariipam act as driver during the accident) 6 Kepolisian tempat (tia diperlulan, ergantuig dari jens heat Copy of Local Police Repot i necessary, depend on te ofthe accident) 7) Surat Tuntuian Klaim asi dari Ahi Waris yang sh Original Caim Leter from Lega Beneficiary 8) Surat Kuaa asi dari Abli Waris yang sah ka yong mengojuan Kai bukan ol waris yang sab) Original Authorized Leter from Legal Beneficiary (the elaiman is na a egal benejiciary) 9) Lesalsc Suat Ketranean Peneailan (ka Ai Waris dak sesua etentuan haku van bela ‘egalize Official Cour Letter ifthe Beneficiary snot comply wth legal law)PT. ARTHAGRAHA GENERAL INSURANCE DOKUMEN-DOKUMEN KHUSUS ‘SPECIAL DOCUMENTS. a. ic Saya / Kami menyatakan bahwa semua peryatean danatau keterangan yang ada pada formul KEMATIAN DEATH 1) Fotosopy Akte Kelahiran Peseta Copy of Panicipant’s Birth Cerificate 2) Legalisc Surat Keterangan Kematian dari pemerintahsetempavang berwenang Legalize Death Official Letter from local auorized authority 5) Legalise Sur! Keterangan Kematan dai Doker yang memsriksapserta Legalize Deth Oficial Leer rm Doctor who examine the patipant 4) LegalisieSurat Ke Sekt ita peers mening! dad egalze Death Offical Leer rom Hospital (the partici death in the Hospital) 5) Legalise Surat Keterean Penguburn sari pemernah st abu Legalize Burial Official Letter ftom local autheized authority (ifthe pardcipant is buried) 6) Lezalisr Akte Kematon dari pemeriniah setempal ving berwenang. Legalize Death Certificate from local authorized authority CACATTETAP PERMANENT DISABLEMENT 1) Legals Hasil Diagnoss dari Dokzer dan'stan Rumah Saki yang menangani peserta “Legalize Diagnosis Result from Doctor and/ot Hospital who/which is examine the participant 2) Fotacopy Hasil Laboratorium (ita ada Copy of Laboratorium Result (fan) 3) Dokunen asi perncian biaa-biaya pengobatan dari Dokter dan/atau Rumah Sakit Original document about deals of medical expenses from Doctor andlor Hospital BIAYA PENGOBATAN MEDICAL EXPENSES 1) Legalisir asl Di Dokter dan/atau iu {agli Dingosis Result om Doctor andlor Hospal whofwhch is examin the pericpat 2) Fotocony HasiL Laboraorium (ita aay ‘Copy of Laboratorium Result fry) 3) Dokumen asi perneianbiya-biava pengobetan dri Dokterdantav Rumah Sait (Original document about details of medical expenses from Doctor and/or Hospital, ‘adalah benar.Jika ada pernyataan dan/atau keterangan yang tidak benar pada formulir ini, maka Saya / Kami setuju bahwa PT, ARTHAGRAHA GENERAL INSURANCE tidak wajib untuk membayar dan mempertimbangkan Klaim ini 1/ We hereby declare that all statements andlor information in this form are true. If there is any false, incorrect or ‘misleading statements and/or information, then I / We agreed that PT. ARTHAGRAHA GENERAL INSURANCE is released from any liability to pay this claims). Ditandatangani di signed at ‘Tanggal / date on sess ‘Nama Jelas / Clear Name ‘Tanda tangan yang berwenang / Authorized Sis (diene mika (Complete with company seal fact as company representative)