Original

No. : 000472/DN/17/01/22 PREMIUM NOTE

Tgl. : 24 Januari 2022
Date
RefNo : 1710012200001

No. Polis : 11710012200001

Policy No.
Nama & Alamat Tertanggung : YAYASAN POLITEKNIK NEGERI MANADO QQ JURUSAN PARIWISATA (D17PN00022)
Name & Address of Insured BUHA, MAPANGET, KOTA MANADO, PROVINSI SULAWESI UTARA

Jangka Waktu : 23/01/2022 - 23/07/2022 Jenis Asuransi : POLIS STANDAR ASURANSI

Period Type of Insurance KECELAKAAN DIRI
INDONESIA
Catatan / Notes Perincian / Details

Please pay the amount shown in this Premium Note immediately to finalize the Premi : IDR 4,620,000.00
transaction. Payment should be made with a crossed cheque in the name PT. Premium
ASURANSI TRI PAKARTA or transferred to our current account with one of the 4,620,000.00
Premi Netto : IDR
following bank :
Net Premium
Biaya Polis : IDR 50,000.00
Policy Cost

Biaya Materai : IDR 10,000.00

- BNI Cabang Manado Acc. No. 0066420600 Duty Cost
+/- : IDR (0.00)

*Mohon diinput Nomor Polis 11710012200001 pada kolom Berita/Keterangan/No. Referensi Jumlah : IDR 4,680,000.00
pada saat melakukan Transfer. Total

PT. ASURANSI TRI PAKARTA

Tanda Tangan yang Berwenang

Please indicate the Policy No or Note No in the message column on the transfer slip, should payment be
made using bank transfer.

PN0000000I
Nota Premi ini bukan merupakan tanda bukti pembayaran. {B0168554-4DF2-46C7-A17F-393BD5ED0CB8}.rpt /
This Premium Note is not a receipt. TMY
PT. ASURANSI TRI PAKARTA
MANADO
JL. SAM RATULANGI NO. 43
Ph.0431-877005 Fax.0431-8880216
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IKHTISAR PERTANGGUNGAN
POLICY SCHEDULE

POLIS STANDAR ASURANSI KECELAKAAN DIRI INDONESIA

No Polis : 11710012200001 NEW

Policy Number
Nama Tertanggung : YAYASAN POLITEKNIK NEGERI MANADO QQ JURUSAN PARIWISATA
Insured Name
Alamat Tertanggung : BUHA, MAPANGET, KOTA MANADO, PROVINSI SULAWESI UTARA
Address of the Insured 95252
Jangka Waktu Pertanggungan : Mulai dari tanggal 23 Januari 2022 sampai dengan 23 Juli 2022 , kedua
Period of Insured tanggal tersebut pada pukul 12.00 siang waktu setempat dimana harta benda
yang dipertanggungkan berada
Commencing from January 23, 2022 To July 23, 2022 both days at 12 o'clock
noon, local time at the location of the insured property.
Nama : TERLAMPIR
Nama
Jenis Kelamin : PRIA/WANITA
Jenis Kelamin
Tempat Lahir : TERLAMPIR
Tempat Lahir
Tanggal Lahir : 1/23/2022
Tanggal Lahir
Alamat : POLITEKNIK NEGERI MANADO
Alamat
Jabatan : MAHASISWA/MAHASISWI
Jabatan
Keterangan : TERLAMPIR
Keterangan
Ahli Waris : ORANG TUA MAHASISWA
Ahli Waris
Hubungan Ahli Waris : Others (Lain-lain)
Hubungan Ahli Waris
Kelas : II
Kelas
Kategori : Any One Person
Kategori
Nama Kelompok : MAHASISWA PKL JURUSAN PARIWISATA
Nama Kelompok
Lokasi Pertanggungan : MANADO, SULAWESI UTARA
Lokasi Pertanggungan
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Halaman ini adalah bagian dari Polis No.11710012200001

This page is a forming part of Policy No

Jaminan : Jaminan Utama

Coverage - Kecelakaan Diri (A+B+C)

Harga Pertanggungan : - Kecelakaan Diri : IDR 3,885,000,000.00

Sum Insured
Total Harga Pertanggungan : IDR 3,885,000,000.00
Klausula : - DISPUTE CLAUSE
Clauses - KLAUSUL PEMBUNUHAN DAN PENGANIAYAAN
- KLAUSUL SANTUNAN GANDA
- SANCTION LIMITATION AND EXCLUSION CLAUSE LMA 3100
- WAIVER CLAUSE
- WARRANTY PAYMENT CLAUSE
Resiko Sendiri : - Kematian : NILL
Deductible - Cacat Tetap Keseluruhan & Sebagian : NILL
- Biaya - biaya Perawatan / Pengobatan : NILL
Suku Premi : Kecelakaan Diri (A+B+C) : IDR 44,000.00
Rate of Premium

Perhitungan Premi : IDR 44,000.00 x 105 Orang IDR 4,620,000.00

Premium Calculation
Policy Cost : IDR 50,000.00

Stamp Duty : IDR 10,000.00

Total Premi : IDR 4,680,000.00

Dengan Kesaksian Yang Bertanda Tangan di bawah ini yang diberi wewenang sepatutnya oleh Penanggung dan atas nama Penanggung telah membubuhkan tanda tangannya.
In witness whereof the Undersigned being duty authorized by the Insurers and on behalf of the Insurers has (have) hereunto set his (their) hand(s).

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Halaman ini adalah bagian dari Polis No.11710012200001

This page is a forming part of Policy No

MANADO, 24 Januari 2022

PT. ASURANSI TRI PAKARTA

PT. ASURANSI TRI PAKARTA

MANADO
JL. SAM RATULANGI NO. 43
Ph.0431-877005 Fax.0431-8880216

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Detail Sum Insured :

No. Deskripsi Jml Harga/unit Harga Pertanggungan

1 ABIGAIL GLORIA SAMBOW 1 37,000,000.00 IDR 37,000,000.00

2 ANDRE IMMANUEL LADI 1 37,000,000.00 IDR 37,000,000.00
3 ANGELITA FAINNADYA PITOI 1 37,000,000.00 IDR 37,000,000.00
4 ANGGUN LIENKI FEBIOLA TUMEWU 1 37,000,000.00 IDR 37,000,000.00
5 ANJELI KRISTINA SUMAJOW 1 37,000,000.00 IDR 37,000,000.00
6 APRIYANA YOLANDA WOLA 1 37,000,000.00 IDR 37,000,000.00
7 ARTYA GELFARI NUSAH 1 37,000,000.00 IDR 37,000,000.00
8 BRITZA KENSI PONTO 1 37,000,000.00 IDR 37,000,000.00
9 CECILIA GLORIA SAWELO 1 37,000,000.00 IDR 37,000,000.00
10 CHARLI NEHEMIA SIGAR 1 37,000,000.00 IDR 37,000,000.00
11 CHRISANTA DISTENI AGU 1 37,000,000.00 IDR 37,000,000.00
12 CHRISTIANI MILANI NATALI PALIT 1 37,000,000.00 IDR 37,000,000.00
13 CHRISTIANO GERRY MARIO RURING 1 37,000,000.00 IDR 37,000,000.00
14 CHRISTYANI ANGGIE TAMBOTO 1 37,000,000.00 IDR 37,000,000.00
15 CHRISTIANO DAVID TANGKABIRINGAN 1 37,000,000.00 IDR 37,000,000.00
16 DEVA TANOD 1 37,000,000.00 IDR 37,000,000.00
17 DJAMALUDDIN WONTOLU 1 37,000,000.00 IDR 37,000,000.00
18 EDEL KLERENSIA MARINGKA 1 37,000,000.00 IDR 37,000,000.00
19 FREECKLEE TATUMPE 1 37,000,000.00 IDR 37,000,000.00
20 JESEL ERLANGGA BAHTERA ANGSAN 1 37,000,000.00 IDR 37,000,000.00
21 VITALIA LONDO 1 37,000,000.00 IDR 37,000,000.00
22 AGSTRI WINDY PRICCILIA TIARA SUMIOK 1 37,000,000.00 IDR 37,000,000.00
23 ALEXANDER IGNACIO MENDONCA 1 37,000,000.00 IDR 37,000,000.00
24 ALFIN CHRITS ELIESER ASSA 1 37,000,000.00 IDR 37,000,000.00
25 ANDREYNA GLORIA KEREN SUWUH 1 37,000,000.00 IDR 37,000,000.00
26 ANGELI MADONA LINTONG 1 37,000,000.00 IDR 37,000,000.00
27 CHRISTIAN RIVAI KOMANSILAN 1 37,000,000.00 IDR 37,000,000.00
28 CHRISTOFFER DANIEL NATOS 1 37,000,000.00 IDR 37,000,000.00
29 DEA FITRI TULANDI 1 37,000,000.00 IDR 37,000,000.00
30 GEERTRUIDA ELIZABETH LALAMENTIK 1 37,000,000.00 IDR 37,000,000.00
31 ENJELIKA NSUMUI 1 37,000,000.00 IDR 37,000,000.00
32 ESTHER IRENE LONTAAN 1 37,000,000.00 IDR 37,000,000.00
33 EUNIKE MOKORIMBAN 1 37,000,000.00 IDR 37,000,000.00
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34 FARADILA RENATHA KALENGKONGAN 1 37,000,000.00 IDR 37,000,000.00

35 FERENSIA RESITA TAGAH 1 37,000,000.00 IDR 37,000,000.00
36 FITRIA FAUZIA PEREMAN 1 37,000,000.00 IDR 37,000,000.00
37 GISCA VERINA WAROUW 1 37,000,000.00 IDR 37,000,000.00
38 GIZELA ANGELY LIONI PITOY 1 37,000,000.00 IDR 37,000,000.00
39 GLORY SHARON DIAN JANIELLIN GONI 1 37,000,000.00 IDR 37,000,000.00
40 GRASYELA ESTERIINA SOMPIE 1 37,000,000.00 IDR 37,000,000.00
41 HANNA TRIFENA KOWEL 1 37,000,000.00 IDR 37,000,000.00
42 INDAH DEBORA MOKOGINTA 1 37,000,000.00 IDR 37,000,000.00
43 INTAN ANGELINA RIYADI 1 37,000,000.00 IDR 37,000,000.00
44 JOHANES PIETERSON OKTA LEWAN 1 37,000,000.00 IDR 37,000,000.00
45 JOSUA MANTJARI 1 37,000,000.00 IDR 37,000,000.00
46 KRISYE GAGOLA 1 37,000,000.00 IDR 37,000,000.00
47 MARSELINO DANIEL DENNY WEWENGKANG 1 37,000,000.00 IDR 37,000,000.00
48 MICHAEL OWEN LUMENTA 1 37,000,000.00 IDR 37,000,000.00
49 NOFRI VIERI MOYO 1 37,000,000.00 IDR 37,000,000.00
50 NOFRILY IMANUEL JHONATAN TOAR SENDUK 1 37,000,000.00 IDR 37,000,000.00
51 SEVANIA AFRILIA TONGKOTOW 1 37,000,000.00 IDR 37,000,000.00
52 EFRAT MANTIRI RUMONDOR 1 37,000,000.00 IDR 37,000,000.00
53 GERALD JOURDAN LALANGU 1 37,000,000.00 IDR 37,000,000.00
54 HIROYA NATANAEL WARUIS 1 37,000,000.00 IDR 37,000,000.00
55 JUAN DENNIS FELIX TALOKO 1 37,000,000.00 IDR 37,000,000.00
56 WHITNEY SELESTE 1 37,000,000.00 IDR 37,000,000.00
57 VALENCIA K.S. SUMAMPOUW 1 37,000,000.00 IDR 37,000,000.00
58 JULIA LANGOY 1 37,000,000.00 IDR 37,000,000.00
59 KEISYA MARODE 1 37,000,000.00 IDR 37,000,000.00
60 KIRSTEN SAMUEL HENDER 1 37,000,000.00 IDR 37,000,000.00
61 MADELINE PRISKILA VALENTSIA LANGI 1 37,000,000.00 IDR 37,000,000.00
62 MARSELA MELISA SENDUK 1 37,000,000.00 IDR 37,000,000.00
63 MARSELLA A. RUMAYAR 1 37,000,000.00 IDR 37,000,000.00
64 NADILA SAMBENTIRO 1 37,000,000.00 IDR 37,000,000.00
65 NATALIA WOTULO 1 37,000,000.00 IDR 37,000,000.00
66 OLWINCE TINDAGE 1 37,000,000.00 IDR 37,000,000.00
67 PUTRI INDRI DARONDOS 1 37,000,000.00 IDR 37,000,000.00
68 QUWENLY MARGARETHA PAILA 1 37,000,000.00 IDR 37,000,000.00
69 RAFAEL S.H. ALOW 1 37,000,000.00 IDR 37,000,000.00
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70 RAMLI REIGEN NEHEMIA PONTOH 1 37,000,000.00 IDR 37,000,000.00

71 RASEL AMANGA 1 37,000,000.00 IDR 37,000,000.00
72 ROLANDO MEGUEL RONDONUWU 1 37,000,000.00 IDR 37,000,000.00
73 SAPUTRA PULUHULAWA 1 37,000,000.00 IDR 37,000,000.00
74 TEGAR RAMADHANA RIYADI SYAHPUTRA 1 37,000,000.00 IDR 37,000,000.00
75 GRESSIA MARGARETA LIMAHU 1 37,000,000.00 IDR 37,000,000.00
76 LODEWIJK JEZZY TICOALU 1 37,000,000.00 IDR 37,000,000.00
77 MARCHELIA M. WUA 1 37,000,000.00 IDR 37,000,000.00
78 MARIA ELISABETH AMU 1 37,000,000.00 IDR 37,000,000.00
79 MARTASYA IMMANUELA PUTRIYANI KERMITE 1 37,000,000.00 IDR 37,000,000.00
80 NOEL GABRIEL NOMMENSEN FLOHR 1 37,000,000.00 IDR 37,000,000.00
81 ORLANDO TUMUDAI 1 37,000,000.00 IDR 37,000,000.00
82 JESSIKA CARENT CRISTEN KAIDUN 1 37,000,000.00 IDR 37,000,000.00
83 SEFANIA CHRISTY RIMBING 1 37,000,000.00 IDR 37,000,000.00
84 SELVI MARSHELA MEWO 1 37,000,000.00 IDR 37,000,000.00
85 SIDNEY R RUMINTJAB 1 37,000,000.00 IDR 37,000,000.00
86 SONIA ESTER PAPARANG 1 37,000,000.00 IDR 37,000,000.00
87 SRI MULYANI HINELO 1 37,000,000.00 IDR 37,000,000.00
88 STEFANNY KALANGIT 1 37,000,000.00 IDR 37,000,000.00
89 SYERIKA TAKALAMINGAN 1 37,000,000.00 IDR 37,000,000.00
90 TIRSA ANASTASYA LUMENTUT 1 37,000,000.00 IDR 37,000,000.00
91 VEBRY VERONIKA FELICIA SOLUNG 1 37,000,000.00 IDR 37,000,000.00
92 VERNANDO CHRISTOVER BALAATI 1 37,000,000.00 IDR 37,000,000.00
93 YAHYA ANSIGA 1 37,000,000.00 IDR 37,000,000.00
94 YASON SAPAER 1 37,000,000.00 IDR 37,000,000.00
95 YOSUA LUMINTANG 1 37,000,000.00 IDR 37,000,000.00
96 DANIEL JHOSUA RUMENGAN 1 37,000,000.00 IDR 37,000,000.00
97 MICHELLE MIKHA KANDIOH 1 37,000,000.00 IDR 37,000,000.00
98 SAVIO AUGUSTO DECALVO LAHU 1 37,000,000.00 IDR 37,000,000.00
99 SIESILIA BEATRIX ANGELA LIJU 1 37,000,000.00 IDR 37,000,000.00
100 TESALONIKA ELIZABETH KINDANGEN 1 37,000,000.00 IDR 37,000,000.00
101 THANIA MAGHDALENA SOMBA 1 37,000,000.00 IDR 37,000,000.00
102 TREY OWEN LEGION TUWAIDAN 1 37,000,000.00 IDR 37,000,000.00
103 VIRGIAWAN JAVIER SAVIOLA SOLEMAN 1 37,000,000.00 IDR 37,000,000.00
104 YUDISTIRA SHEVCHENKO POLII 1 37,000,000.00 IDR 37,000,000.00
105 JONATHAN RONDONUWU 1 37,000,000.00 IDR 37,000,000.00
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TOTAL IDR 3,885,000,000.00

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