No.

SPAJ/
(diisi jika status SPAJ masih Proposal)/If the status
Proposal No: of SPAJ is still Proposal.
No. Polis/
Policy No: (diisi jika status Polis inforced)/If the status of Policy
is inforced.

KUESIONER PERTAMBANGAN
MINING QUESTIONNAIRE
UNTUK DIISI OLEH (CALON) TERTANGGUNG/PESERTA YANG PEKERJAANNYA
MENCAKUP PEKERJAAN DI SEKTOR PERTAMBANGAN
TO BE COMPLETED BY (PROPOSED) INSURED/PARTICIPANT WHO WORKS IN THE MINING SECTOR
- Mohon mengisi dengan menggunakan pulpen hitam, huruf cetak dan tulisan tidak keluar dari kotak, jelas dan memberi tanda
pada kotak jawaban yang sesuai.
Please fill in by using capital letters and black ink within the box provided, and tick (“
”) in the appropriate box.
- Mohon tidak menandatangani kuesioner ini dalam keadaan kosong dan pastikan semua pertanyaan telah diisi dengan lengkap dan benar sebelum menandatanganinya.
- Please do not sign the questionnaire if blank and make sure all the questions are filled in completely and correctly before signing.

Nama (Calon) Tertanggung/Peserta:

Name of (Proposed) Insured/Participant:
Jenis Pekerjaan: (Mohon tuliskan kode sesuai daftar di halaman 2)
Type of Job: (Please write down code as per list in page 2)
1. Lokasi/Location
a. Di mana lokasi tempat Anda bekerja?
Where is your job location?
b. Mohon berikan nama dan alamat lengkap perusahaan tempat Anda bekerja:
Please give detailed name and address of the Company that you are working
for:
c. Apakah Anda bekerja di permukaan tanah? Ya/Yes Tidak/No
Are you working on the surface?
d. Apakah Anda bekerja di bawah tanah? Ya/Yes Tidak/No
Are you working underground?
e. Apakah Anda bekerja langsung di lokasi pertambangan? Ya/Yes Tidak/No, Mohon menjawab pertanyaan no.
Are you working directly in the mining location? 1.f./If “No” please answer question 1.f
f. Jika tidak, apakah kadang-kadang Anda juga bertugas ke lokasi Ya/Yes Tidak/No
pertambangan?/ If not, do you also sometimes work in the mining location?

2. Mohon jelaskan tipe sektor pertambangan yang menjadi bidang Anda? Batubara/Coal
Which sector of mining are you involved in?
Potash, rock-salt, gypsum, tin
Clay and stoneworking
3. Di masa yang akan datang, apakah ada kemungkinan bahwa Anda akan Ya/Yes, Di mana?/Where?
ditugaskan ke daerah atau negara lain?/In the future, are there any chances
for you to be assigned to other region or country? Tidak/No

4. Apakah pernah terjadi kecelakaan maupun penyakit yang Anda alami selama Ya/Yes Tidak/No
bekerja di sektor pertambangan?/Have you ever experienced any accidents or
medical conditions during your work in the mining sector?
Jika YA, mohon dituliskan jenis penyakit dan jenis perawatan./If YES, please
state what illness and type of treatment

5. Apakah Anda pernah mendapat pengobatan untuk gangguan pernafasan? Ya/Yes Tidak/No
Have you ever had treatment for any respiratory disorder?
Jika YA, mohon mengisi Kuesioner Gangguan Pernafasan./If YES, please
complete our Questionnaire for Respiratory Disorder.

Tanda tangan (Calon) Pemegang Polis

sesuai Kartu identitas diri yang dilampirkan
Signature of (Proposed) policy holder as per attached ID Card

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 No. SPAJ/
(diisi jika status SPAJ masih Proposal)/If the status
Proposal No: of SPAJ is still Proposal.
No. Polis/
Policy No: (diisi jika status Polis inforced)/If the status of Policy
is inforced.

Dengan ini saya menyatakan bahwa saya telah memberikan jawaban dan keterangan dalam Kuesioner Pertambangan ini dengan sejelas-jelasnya dan sebenar-
benarnya. Saya tidak menyembunyikan informasi apa pun yang dapat memengaruhi penerimaan Surat Pengajuan Asuransi Jiwa (SPAJ) dan/atau Surat
Pengajuan Asuransi Jiwa Tambahan (SPAJT) saya. Saya menyetujui Kuesioner ini akan menjadi bagian yang tidak terpisahkan dari SPAJ dan/atau SPAJT saya
pada PT Prudential Life Assurance dan bahwa penyembunyian informasi apa pun dapat mengakibatkan tidak disetujuinya pengajuan SPAJ dan/atau SPAJT
saya atau batalnya pertanggungan sesuai dengan syarat dan ketentuan Polis.

I declare that the answers I have given in this Mining Questionnaire, to the best of my knowledge, are true and that I have not withheld any information that may
influence the assessment or acceptance of my Life Insurance Policy Application Form (SPAJ)and/or Additional Policy Application Form (SPAJT). I agree that this
Questionnaire will constitute part of my SPAJ and/or SPAJT with PT Prudential Life Assurance and that failure to disclose any fact known to me may cause my
SPAJ and/or SPAJT is not approved or invalidate the insurance as stipulated in the terms and conditions in the Policy.

Dinyatakan di: Tanggal: - - (tgl/bln/thn)

Signed at On (dd/mm/yy)

Tanda tangan (Calon) Pemegang Polis sesuai kartu Tanda tangan (Calon) Tertanggung/Peserta sesuai Tanda Tangan Tenaga Pemasaran/Signature of
identitas diri yang dilampirkan/ Signature of kartu identitas diri yang dilampirkan/Signature of Sales Representative
(Proposed) Policy Holder as per attached ID Card (Proposed) Insured/participant as per attached ID Card

Kode Tenaga Pemasaran/Code of Sales Representative

Catatan: Segala risiko yang timbul akibat ditandatanganinya kuesioner ini dalam keadaan kosong menjadi tanggung jawab (Calon) Pemegang Polis.
Note: All risks that arise by signing this questionnaire in blank will be the (Proposed) Policy Holder’s responsibility.

KODE DAFTAR PEKERJAAN/CODE FOR TYPE OF JOB

1 Automatic Train Attendant 29 Geologist (underground) 57 Power stower

2 Banksman, cageman (surface) 30 Geophysicist (surface) 58 Powered supports maintenance
3 Banksman assistant 31 Geophysicist (underground) 59 Ripper
4 Belt Patrol Man 32 Inspector (surface) 60 Rollerman
5 Brakesman 33 Inspector (underground) 61 Roof bolter
Bunker Control Man with automatic 34 Lampman 62 Rope changer/rope runner
6
equipment
Bunker Control Man with manual or semi 35 Linesman measurer 63 Ropeman
7
automatic equipment
8 Burster 36 Loader (surface) 64 Salvage man/wasteman
37 Loader (underground)/spragger/trammer 65 Shaftsman
9 Check Weighman (mine car)
10 Chemist 38 Locomotive driver 66 Shotfirer
11 Clipper/shackler 39 Locomotive guard 67 Shunter
12 Coal Cutter Mover/Gummer/Tracker 40 Manager (surface) 68 Sinker
13 Coal cutterman 41 Manager (underground) 69 Steel straightener
14 Coal dry cleaning plant operator 42 Undermanager (surface) 70 Supplies transporter
15 Coal trimmer 43 Undermanager (underground) 71 Supports checker
16 Coal washery operator/attendant 44 Manhole maker 72 Timberer/timberman
17 Collier/coal miner 45 Measurer (surface) 73 Tippler operator
18 Conveyor mover 46 Measurer (underground) 74 Transport control operator (surface)
19 Conveyor/slusher operator 47 Mineralogist (surface) 75 Transport control operator (underground)
Cutting loading machine 48 Mineralogist (underground) 76 Wagon traverser operator
20
operator/assistant
21 Driller/borer/hard ground man 49 Mining officer (surface) 77 Water infusion man
22 Electrician/hauler electrician 50 Mining officer (underground) 78 Winding engineman
23 Engineer (surface) 51 Mining surveyor (surface) 79 Bulldozer driver (surface)
24 Engineer (underground) 52 Mining surveyor (underground) 80 Dragline driver (surface)
25 Face console operator 53 Multishot exploder cleaner/tester 81 Dumper driver (surface)
26 Fireman 54 Onsetter, Cageman (underground) 82 Excavator driver (surface)
27 Foreman 55 Packer 83 Scraper driver (surface)
28 Geologist (surface) 56 Power loader man

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