IKHTISAR PERTANGGUNGAN
POLIS STANDAR ASURANSI KENDARAAN BERMOTOR
No. Polis
Nama Tertanggung
Alamat Tertanggung
Jangka Waktu Pertanggung
Objek Pertanggungan
Jenis Kendaraan
Merek Kendaraan
Model/Tipe Kendaraan
Tahun Pembuatan
No. Polisi
No. Rangka
No. Mesin
Penggunaan
Jumlah Tempat Duduk
Warna Kendaraan
Catatan Kerusakan Kendaraan
Perlengkapan Tambahan
Total Harga Pertanggungan
Pertanggungan Tambahan
Jenis Pertanggungan
: Q2021MV0000212 (Baru)
: CHRISTIAN PRANADJAJA. S
: JL. GD.ELOK UTR I FE-2/9 RT 014 RW 011 KELAPA GADING TIMUR KELAPA
GADING JAKARTA UTARA
: Mulai 09 April 2021 hingga 09 April 2022
(Pertanggungan ini dimulai dan berakhir pukul 12.00 siang waktu setempat di
mana obyek pertanggungan berada)
: Non Truck
: SUZUKI
: XL7 BETA AT
: 2021
: B TBA
: MHYANC22SMJ101850
: K15BT1252533
: Pribadi
: 1
: MET.MAGMA GRAY 2
: -
: -
: Kendaraan dan Perlengkapan Tambahan IDR 231,000,000.00
: Huru-hara dan Kerusuhan IDR 231,000,000.00
: Terorisme dan Sabotase IDR 231,000,000.00
: Angin Topan, Banjir, Badai, Angin Ribut, dan Tanah Longsor IDR 231,000,000.00
: Gempa Bumi, Tsunami, dan Letusan Gunung Berapi IDR 231,000,000.00
: Tanggung Jawab Hukum terhadap Pihak Ketiga IDR 10,000,000.00
: Kecelakaan Diri untuk Pengemudi IDR 10,000,000.00
: Kecelakaan Diri untuk Penumpang IDR 10,000,000.00
: Fasilitas Bengkel Authorized IDR 231,000,000.00
: Comprehensive (2.080%)
: Huru-hara dan Kerusuhan (0.050%)
: Terorisme dan Sabotase (0.050%)
: Angin Topan, Banjir, Badai, Angin Ribut, dan Tanah Longsor (0.100%)
: Gempa Bumi, Tsunami, dan Letusan Gunung Berapi (0.100%)
: Tanggung Jawab Hukum terhadap Pihak Ketiga (1.000%)
: Kecelakaan Diri untuk Pengemudi (0.500%)
: Kecelakaan Diri untuk Penumpang (0.100%)
: Fasilitas Bengkel Authorized (0.050%)
 IKHTISAR PERTANGGUNGAN
POLIS STANDAR ASURANSI KENDARAAN BERMOTOR

RISIKO SENDIRI
- Kerusakan Sebagian : IDR 300,000.00 untuk setiap kejadian
- Kerusakan Total Baik Pencurian Atau Kecelakaan : IDR 300,000.00 untuk setiap kejadian
- Kerusuhan dan Huru Hara : 10% dari nilai klaim yang disetujui, minimal IDR 500,000.00 untuk setiap kejadian
- Terorisme dan Sabotase : 10% dari nilai klaim yang disetujui, minimal IDR 500,000.00 untuk setiap kejadian
- Banjir, Angin Topan, Badai : 10% dari nilai klaim yang disetujui, minimal IDR 500,000.00 untuk setiap kejadian
- Gempa Bumi, Letusan Gunung Berapi dan Tsunami : 10% dari nilai klaim yang disetujui, minimal IDR 500,000.00
untuk setiap kejadian
- Tanggung Jawab Hukum Pihak ke 3 : NIL
- Asuransi Kecelakaan Diri / Medex : NIL

KLAUSUL WAJIB
- Buku Wording Standar PSAKBI 2017
- Ambulance Fee Clause
- Automatic Addition and Deletion Clause
- Average Relief Clause (85%)
- Constructive Total Loss Clause (75% of Loss as Total Loss)
- Loss Notification Clause (7 Days)
- Prorata Return Premium Clause
- Sanctions Limitation and Exclusion Clause
- Towing Fee Clause (0.5% of Sum Insured, Maximum. Rp 1,000,000)
- Transit Extension Clause (Inter Island)
- Warranty Premium Clause (30 Days)
- Klausula Pengesampingan (Pasal 1266 dan 1267 KUHPER)
- Klausul Sister Cars KL. KBM.MAG-11

KLAUSUL TAMBAHAN
- Klausul Angin Topan, Badai, Hujan Es, Banjir dan/atau Tanah Longsor KL. KBM - 12
- Klausul Gempa Bumi, Tsunami dan/atau Letusan Gunung Berapi KL. KBM - 11
- Klausul Huru - hara, Terorisme dan Sabotase
- Klausul Kecelakaan Diri KL. KBM - 05/16
- Klausul Authorized Workshop

Deskrip si klausul dap at dilihat p ada halaman lamp iran

 IKHTISAR PERTANGGUNGAN
POLIS STANDAR ASURANSI KENDARAAN BERMOTOR
PERHITUNGAN PREMI
No. Jaminan Pertanggungan Perhitungan Premi Premi
1. Comprehensive IDR 231,000,000.00 x 2.080% IDR 4,804,800.00
2. Huru-hara dan Kerusuhan IDR 231,000,000.00 x 0.050% IDR 115,500.00
3. Terorisme dan Sabotase IDR 231,000,000.00 x 0.050% IDR 115,500.00
4. Angin Topan, Banjir, Badai, Angin Ribut, dan IDR 231,000,000.00 x 0.100% IDR 231,000.00
Tanah Longsor
5. Gempa Bumi, Tsunami, dan Letusan Gunung IDR 231,000,000.00 x 0.100% IDR 231,000.00
Berapi
6. Tanggung Jawab Hukum terhadap Pihak IDR 10,000,000.00 x 1.000% IDR 100,000.00
Ketiga
7. Kecelakaan Diri untuk Pengemudi IDR 10,000,000.00 x 0.500% IDR 50,000.00
8. Kecelakaan Diri untuk Penumpang IDR 10,000,000.00 x 4 x 0.100% IDR 40,000.00
9. Fasilitas Bengkel Authorized IDR 231,000,000.00 x 0.050% IDR 115,500.00
Discount (IDR 1,450,825.00)
Biaya Admin IDR 35,000.00
Total IDR 4,387,475.00

PEMBAYARAN PREMI
Premi asuransi sudah harus dibayarkan dan diterima oleh Qoala paling lambat tanggal 24/05/21. Jika premi asuransi
tidak dibayarkan dalam jangka waktu tersebut menyebabkan batalnya polis secara otomatis dan pembayaran premi
asuransi untuk masa yang sudah berjalan sesuai dengan ketentuan-ketentuan dalam Polis Standar Asuransi
Kendaraan bermotor Indonesia.

Jakarta, 09 April 2021

Tanda Tangan yang Berwenang

PT Asuransi Multi Artha Guna

PERHATIAN: UNTUK MENGHINDARI KEMUNGKINAN TERJADINYA SALAH PENGERTIAN,

MOHON TERTANGGUNG MEMBACA SYARAT POLIS DENGAN SEBAIK-BAIKNYA

Catatan
. Polis as urans i ini tidak menggunakan tanda tangan bas ah karena menggunakan pers etujuan otomatis
. Biaya materai yang tercantum pada polis as urans i s udah dibayar lunas
. Pertanggungan as urans i ini mengacu kepada wording polis , ketentuan klaus ula-klaus ula yang dis ebutkan di dalam ikhtis ar
pertanggungan as urans i
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KLAUSUL

KLAUSUL WAJIB

AMBULANCE FEE CLAUSE

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AUTOMATIC ADDITION AND DELETION CLAUSE

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AVERAGE RELIEF CLAUSE (85%)

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CONSTRUCTIVE TOTAL LOSS CLAUSE (75% OF LOSS AS TOTAL LOSS)

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LOSS NOTIFICATION CLAUSE (7 DAYS)

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PRORATA RETURN PREMIUM CLAUSE

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SANCTIONS LIMITATION AND EXCLUSION CLAUSE

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TOWING FEE CLAUSE (0.5% OF SUM INSURED, MAXIMUM Rp1.000. 000)

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TRANSIT EXTENSION CLAUSE (INTER ISLAND)

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WARRANTY PREMIUM CLAUSE (30 DAYS)

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KLAUSULA PENGESAMPINGAN (PASAL 1266 DAN 1267 KUHPER)

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KLAUSUL SISTER CARS KL. KBM.MAG-11

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Call:!"#$%&"'(%&")&!*!!!!!!!Email:!+,-./010213,4+/5
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KLAUSUL TAMBAHAN
KLAUSUL PERLENGKAPAN NON-STANDARD KL. KBM.MAG-01A
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KLAUSUL GEMPA BUMI, TSUNAMI DAN/ATAU LETUSAN GUNUNG BERAPI KL. KBM - 11
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KLAUSUL HURU - HARA, TERORISME DAN SABOTASE

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KLAUSUL KECELAKAAN DIRI KL. KBM - 05/16

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KLAUSUL AUTHORIZED WORKSHOP

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KLAUSUL KERUSAKAN YANG TELAH TERJADI SEBELUM /PADA SAAT PENUTUPAN

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Call:!"#$%&"'(%&")&!*!!!!!!!Email:!+,-./010213,4+/5