FORMULIR KLAIM ASURANSI PROPERTY ALL RISK

Isilah formulir claim ini dengan lengkap dan benar untuk mempercepat proses penyelesain klaim. Jika ada kotak
pilihan ( ) Harap beri tanda (√). Jika kotak jawaban tidak mencukupi harap di lanjutkan di lembar terpisah.
Pengajuan formulir ini bukanlah pengakuan akan adanya ganti rugi

I. TERTANGGUNG
1. Nama Tertanggung :..................................................................................................................
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2. Alamat Tertanggung :..................................................................................................................
3. No. Telepon /Fax :..................................................................................................................

II. DATA PERTANGGUNGAN

1. Polis No. :..................................................................................................................
2. Periode Polis :..................................................................................................................
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III. DATA OBJEK KLAIM
1. Lokasi Pertanggungan :..................................................................................................................
2. Jumlah Barang yang :..................................................................................................................
dipertanggungkan ..................................................................................................................

IV. URAIAN KECELAKAAN / TERJADINYA KERUGIAN

1. Tempat dan Tanggal Kejadian : ..........................................................................................................
2. Berupa apakah kerugian yang diderita (Sebutkan secara jelas dan terperinci)?
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3. Sebutkan berapa besar kerugian yang ditaksir (Sebutkan secara jelas dan terperinci)?
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4. Usaha - usaha apa yang telah dilakukan setelah terjadinya kecelakaan/kerugian tersebut ?
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ASURANSI PURNA ARTANUGRAHA

Wisma Bumiputera Lt. 16, Jl. Jenderal Sudirman Kav.75, Jakarta, 12910
Telp. (+6221) 5255070 (Hunting), Fax. (+6221) 5220486/87
Homepage : www.asuransiaspan.com | e-mail : aspan@asuransiaspan.com
 5. Apakah kejadian tersebut dilaporkan/diketahui oleh Kepolisian/petugas yang berwenang ?
(Jika ya, mohon dilampirkan surat pelaporan tersebut)
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V. TERANGKAN DENGAN SINGKAT DAN JELAS KRONOLOGIS TERJADINYA KERUGIAN DAN LENGKAPI
DENGAN SKETSA:
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Denah/Gambar/Sketsa Tempat Kejadian

VI. APAKAH PERTANGGUNGAN INI BERJALAN DENGAN ASURANSI LAIN? (JIKA YA, SEBUTKAN
SECARA RINCI)
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VII. JELASKAN APAKAH ADA TUNTUTAN DARI PIHAK KETIGA : Ya Tidak

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Jika ya, berapa perkiraan kerugian pihak ketiga : ........................................................................
Catatan – Mohon lampirkan surat tuntutan dari pihak ketiga

ASURANSI PURNA ARTANUGRAHA

Wisma Bumiputera Lt. 16, Jl. Jenderal Sudirman Kav.75, Jakarta, 12910
Telp. (+6221) 5255070 (Hunting), Fax. (+6221) 5220486/87
Homepage : www.asuransiaspan.com | e-mail : aspan@asuransiaspan.com
VIII. HAL-HAL LAIN YANG PERLU DIJELASKAN SEHUBUNGAN DENGAN KERUGIAN INI
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Laporan ini dibuat dengan sebenarnya oleh:

Nama :
Perusahaan :
Jabatan :

Dengan ini saya/kami menyatakan bahwa pernyataan di atas adalah benar dan bahwa barang yang
hilang atau rusak tersebut benar-benar milik saya/kami.

(TANDA TANGAN & CAP PERUSAHAAN)

ASURANSI PURNA ARTANUGRAHA

Wisma Bumiputera Lt. 16, Jl. Jenderal Sudirman Kav.75, Jakarta, 12910
Telp. (+6221) 5255070 (Hunting), Fax. (+6221) 5220486/87
Homepage : www.asuransiaspan.com | e-mail : aspan@asuransiaspan.com