PT Mandiri AXA General Insurance

Customer Care Center

AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

ARI SUSANTO Tanggal 06 March 2023

BLOK MELATI RT.001 RW.003 REJO Date
KEMIRI PURWOREJO JAWA TENGAH Nomor Ref erensi ECMTRAVI1- 994 080
Reference Number
Asuransi Perjalanan AXA
New Business

IKHTISAR POLIS/ POLICY SCHEDULE

R inc ia n P o l i s / Po l ic y De t a i ls

Nomor Polis ECMTRAVI1- 994 080

Po l ic y Num be r

Nama Pemegang Polis ARI SUSANTO

Po l ic yho lde r Na m e

Alamat Pemegang Polis BLOK MELATI RT. 001 RW. 003 REJOKEMIRI PURWOREJO JAWA TENGAH
Po l ic yho lde r ' s Addre s s

Tujuan Unit ed Kingdom

D e s tina tio n

Jenis Perjalanan Perjalanan Tunggal/S ingle Trip

Trip Type

Paket Manf aat Gold

Be ne fi t Pa cka ge

Periode Asuransi 23 May 2023 to 28 May 2023 (both date inclusive)

Pe r io d o f Ins ura nce

Jumlah Tert anggung Dewasa 1 Orang/ Pe rs o n

Am o unt o f Adult Ins ure d

Jumlah Tert anggung Anak 0 Orang/ P e rs o n

Am o unt o f C hild Ins ure d

P e rhit unga n P re mi / P re mium Calc ulat io n

Premi Kotor IDR 351,000.00
Gross Premium

Biaya Materai IDR 10,000.00

Stampduty

Premi Akhir IDR 361,000.00

Fina l P re m ium

PT Mandiri AXA General Insurance 1 of 7

 PT Mandiri AXA General Insurance
Customer Care Center
AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

Da t a P e rt a nggunga n / Co ve rage Dat a

Nama Tanggal Lahir Passport

No.
Na m e D a te o f B i rth Pa s s po rt
1 ARI SUSANTO 02 February 1988 C849 7883

Deskripsi Manf aat / D e s c r iptio n o f Be ne fi t Uang Pert anggungan /

S um Ins ure d ( ID R )

Kecelakaan Diri / Personal accident 1.300.000.000

Penutupan Penerbangan Ganda / Double In-Flight Coverage 2.600.000.000
Biaya Pengobatan, Gigi dan Lainnya / Medical, Dental and Other Expenses 650.000.000
Biaya Pengobatan Gigi & Lainnya (jika tetap berpergian walaupun disarankan untuk t idak 130.000.000
berpergian oleh pemerintah) / Medical, Dental And Other Expenses (if continue to travel against the government
advise)

Biaya Pengobatan Di Indonesia / Medical expenses in Indonesia 16.250.000

Biaya Pengobatan Di Indonesia (jika tetap berpergian walaupun disarankan untuk t idak berpergian 3.250.000
oleh pemerintah) / Medical Expenses In Indonesia (If Continue To Travel Against The Government Advise)
Pemulangan Jenazah / Repatriation of mortal remain 13.000.000.000
Pemulangan Jenazah (jika tetap berpergian walaupun disarankan untuk t idak berpergian oleh 650.000.000
pemerintah) / Repatriation of mortal remain (if continue to travel against the government advise)
Manfaat Perawatan Anak & Kunjungan Duka / Childcare & compassionate benefit 39.000.000
Manfaat Perawatan Anak & Kunjungan Duka (jika tetap berpergian walaupun disarankan untuk 7.800.000
t idak berpergian oleh pemerintah) / Childcare & Compassionate Benefit (if continue to travel against the
government advise)

Evakuasi Medis Darurat Dan Repatriasi / Emergency medical evacuation & repatriation 13.000.000.000
Evakuasi Medis Darurat Dan Repatriasi (jika tetap berpergian walaupun disarankan untuk t idak 650.000.000
berpergian oleh pemerintah) / Emergency Medical Evacuation & Repatriation (if continue to travel against the
government advise)

Tanggung Jawab Hukum Pribadi / Personal liabilty 1.755.000.000

Keterlambatan Perjalanan (Per 6 Jam) / Travel delay (Per 6 Hours) 650.000 per 6 jam s/d
4 .550.000 / 650.000 per 6 hours up
to 4.550.000

Penundaan Perjalanan / Travel alteration 26.000.000

Kehilangan Uang Muka Atau Pembatalan / Lost of deposit or cancellation 39.000.000
Pengurangan Perjalanan / Trip curtailment 39.000.000
Penerbangan Tidak Sinambung (Per 4 Jam) / Flight misconnection (Per 4 Hours) 650.000 per 4 jam s/d
3.900.000 / 650.000 per 4 hours up
to 3.900.000

Pembajakan (Per 24 Jam) / Hijacking (Per 24 Hours) 650.000 per 24 jam s/d
13.000.000 / 650.000 per 24 hours
up to 13.000.000

Perlindungan Isi Rumah / House hold cover 26.000.000

PT Mandiri AXA General Insurance 2 of 7

 PT Mandiri AXA General Insurance
Customer Care Center
AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

Biaya Resiko Sendiri Kerusakan Dari Kendaraan Yang Tertanggung Sewa / Own Risk For Damage Of Tidak tersedia / Not Available
Rental Vehicle

Telepon Darurat / Emergency Call 1.300.000

Bagasi Dan Barang Milik Pribadi/ Baggage
& Personal Effects Sampai dengan 26.000.000 / up
to 26.000.000
limit setiap barang/set
3.900.000 / limit anyone item/set
IDR 3.900.000
Maksimum 6.500.000 untuk
Laptop / Maximum 6.500.000 for
Laptop

Dokumen Perjalanan / Travel Documents 9.750.000

Kehilangan Uang / Loss Of Money 3.250.000
Keterlambatan Bagasi Minimal 6 Jam / Baggage Delay Minimal 6 Hours 4 .550.000
Perlindungan Kartu Kredit / Credit Card Protection 3.900.000
Santunan Tunai Rumah Sakit / Hospital Cash Allowance 650.000 per hari s/d 6.500.000 /
650.000 per day up to 6.500.000

Santunan Tunai Rumah Sakit (jika tetap berpergian walaupun disarankan untuk t idak berpergian 130.000 per hari s/d 1.300.000 /
oleh pemerintah) / Hospital cash allowance (if continue to travel against the government advise) 130.000 per day up to 1.300.000

a. Kerusakan/ Kehilangan Peralatan Golf / Damage / Loss Of Golfing Equipment Tidak Tersedia / Not Available
b. Hole In One
Asuransi Resiko Terorisme / Terrorism Ya / Yes
Santunan Kehilangan Pendapatan Akibat Kecelakaan / Loss Of Income Due To Accident 1.300.000 per minggu s/d
13.000.000 / 1.300.000 per week up
to 13.000.000

PT Mandiri AXA General Insurance 3 of 7

 PT Mandiri AXA General Insurance
Customer Care Center
AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

1. Polis asuransi perjalanan ini mencakup manfaat Medis dan Repatriasi termasuk dalam hal terjadi klaim terkait infeksi pandemi
(termasuk Covid-19), manfaat tersebut tercantum dalam Ikht isar Polis.
This travel insurance policy is covering Medical and Repatriation benefits including in the case of the occurrence of claims related to pandemic infection
(including Covid-19), the benefits be stated in the Policy Schedule.
2. Harap diperhatikan bahwa perjalanan Anda ke negara, area atau acara tertentu yang diadakan di negara atau wilayah tertentu
ketika otoritas pengatur/pemerintah di negara asal / negara tujuan tempat Anda bepergian melarang perjalanan (negara /
daerah dalam st at us "MERAH"), dalam hal ini, kami hanya akan membayar klaim hingga Uang Pert anggungan yang secara khusus
disebutkan dalam Ikht isar Polis Anda
Please note that your trip to a particular country, area or event is held in a particular country or region when the regulatory/governmental authorities in
the country of origin/destination country you are traveling to prohibit travel (the country/region is in " RED " status), in this case , we will only pay claims up
to the Sum Insured specifically stated in your Policy Schedule
* Pengaturan perjalanan dari pemerintah dapat mengacu dari informasi atau berita yang diterbitkan oleh website/aplikasi
resmi yang dikeluarkan oleh Pemerintah atau melalui kedutaan negara tujuan atau juga melalui pemberitaan resmi dari
media.
Travel arrangements from the government can refer to information or news published by the official website/application issued by the Government
or through the embassy of the destination country or also through official news from the media.
3. Harap diperhatikan bahwa sesuai dengan kondisi Polis, Tertanggung wajib mendapatkan vaksinasi yang disarankan oleh
Pemerintah / WHO sebelum melakukan perjalanan
Please note that according to the conditions of the Policy, the Insured is required to get vaccinations recommended by the Government / WHO before
traveling
* Ketentuan vaksin setiap wilayah dapat mengacu dari informasi atau berita yang diterbitkan oleh website/aplikasi resmi
yang dikeluarkan oleh WHO atau melalui kedutaan negara tujuan dan/atau juga melalui pemberitaan resmi dari media.
Vaccine provisions for each region can refer to information or news published by the official website/application issued by WHO or through the
embassy of the destination country and/or also through official news from the media.
4. . Simpanlah Ikht isar Polis ini sebagai catatan perlindungan Asuransi Perjalanan AXA Anda. Ikht isar Polis ini merupakan bagian yang
t idak terpisahkan dari Polis Asuransi Perjalanan AXA.
Keep this Policy Schedule as a protection notes of your AXA Travel Insurance. This Policy Schedule is an integral part of the AXA Travel Insurance
5. Ringkasan Manfaat di atas merupakan limit maksimum. Syarat & Ketentuan yang berlaku terdapat pada Polis Asuransi Perjalanan
AXA.
Summary of Benefits above is the maximum limit. The terms & conditions that apply are contained in the AXA Travel Insurance Policy.
6. Jumlah manfaat yang tercantum pada tabel di atas merupakan tabel manfaat untuk Tertanggung Individu, manfaat per
Keluarga adalah sebesar dua kali manfaat Tertanggung Individu.
The amount of benefits lis ted in the table above is a table of benefits for the Individual Insured, the benefit per Family is twice the benefit of the Individual
Insured Berlaku untuk bagian berikut ini:
Applies to the fo llowing sections:
- Kecelakaan Diri
Personal Accident
- Penutupan Penerbangan Ganda
Double In-Flight Coverage
- Biaya Pengobatan, Gigi dan Lainnya
Medical, Dental and Other Expenses
- Pemulangan Jenazah
Repatriation of Mortal Remain
- Manfaat Perawatan Anak dan Kunjungan Duka
Childcare & Compassionate Benefit
- Evakuasi Medis Darurat dan Repatriasi
Emergency Medical Evacuation & Repatriation
- Kehilangan Uang Muka atau Pembatalan
Loss of Deposit or Cancellation
- Kehilangan Pendapatan Akibat Kecelakaan

PT Mandiri AXA General Insurance 4 of 7

 PT Mandiri AXA General Insurance
Customer Care Center
AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

Loss Of Income due to Accident

7. Seluruh manfaat di atas tetap berlaku apabila kerugian yang t imbul disebabkan oleh t indakan terorisme.
All of the above benefits will still be valid if the losses are caused by acts of terrorism.
8. Periode Perjalanan :
Travel Period
a. Lamanya setiap perjalanan berdasarkan "Perjalanan Tunggal" t idak akan melebihi 180 hari kalender sejak tanggal
dimulainya Perjalanan.
The period of each "Single Travel" shall not exceed 180 (one hundred eighty) calender days s ince the starting date of Travel.
b. Lamanya setiap perjalanan berdasarkan "Program Setahun" t idak akan melebihi 90 hari kalender dari tanggal dimulainya
Perjalanan.
The period of each "Annual Program" travel shall not exceed 90 (ninety) calender days s ince the starting date of Travel
9. Usia yang dapat dipertanggungkan :
Covered Age
- Usia minimum untuk dijamin berdasarkan Polis ini adalah 1 tahun pada saat tanggal keberangkatan dan/atau usia maksimum
untuk dijamin berdasarkan Polis ini adalah 85 tahun sebelum tanggal keberangkatan kecuali secara khusus telah kami setujui.
Minimum age for insurance coverage based on this Policy is 1 year old on the date of departure, whereas the maximum age is 85 years old before the
date of departure, unless specifically agreed otherwise.
- Untuk Tertanggung yang telah berusia lebih dari 65 tahun sampai dengan 75 tahun maka manfaat-manfaat asuransi ini
(Biaya Pengobatan, Gigi dan Lainnya dan Evakuasi Medis Darurat dan Repatriasi) diberikan sebesar 35% dari batas maksimum
yang tercantum dalam ikht isar polis
Insured Persons of more than 65 until 75 years of age are only entitled 35% of these insurance benefits (Medical, Dental and Other Expenses and
Emergency Medical Evacuation & Repatriation) out of the maximum threshold stated in the Policy Schedule
- Untuk Tertanggung yang telah berusia lebih dari 75 tahun sampai dengan 85 tahun maka manfaat-manfaat asuransi ini
(Biaya Pengobatan, Gigi dan Lainnya dan Evakuasi Medis Darurat dan Repatriasi) diberikan sebesar 15% dari batas maksimum
yang tercantum dalam ikht isar polis
Insured Persons of more than 75 until 85 years of age are only entitled 15% of these insurance benefits (Medical, Dental and Other Expenses and
Emergency Medical Evacuation & Repatriation) out of the maximum threshold stated in the Policy Schedule
10. Manfaat yang tercantum dalam tabel merupakan manfaat selama periode polis.
Benefits lis ted in the table represent benefits during the policy period.
11. Bea meterai telah dibayarkan secara komputerisasi sesuai dengan persetujuan sistem Dirjen Pajak No. SI-000002/SK/WPJ.04
/KP.01/2019 tanggal 02/06/2019.
Stamp duty has been settled with computerized as per approval of Dirjen Pajak system number No. SI- 000002/SK/WPJ.04 /KP.01/2019 dated 06/02/2019.
12. Polis ini dibuat secara otomatis oleh sistem elektronik milik PT Mandiri AXA General Insurance, tanpa mencantumkan stempel
dan tanda tangan basah t idak mengurangi keabsahan polis ini.
This policy is automatic generated by an electronic system owned by PT Mandiri AXA General Insurance, without the inclusion of stamp and wet s ignature
not diminish the validity of this policy.

PT Mandiri AXA General Insurance 5 of 7

 PT Mandiri AXA General Insurance
Customer Care Center
AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

Tertanggung dapat mengajukan pengaduan langsung ke customer service walk in di kantor cabang terdekat, atau melalui telepon
ke Customer Care Center MAGI di no telepon 1500 733 dan email ke customer.general@axa-mandiri.co.id.
The Insured can submit a complaint directly to the walk-in customer service at the nearest office, or by telephone to the MAGI Customer Care Center at 1500
733 and email to customer.general@axa-mandiri.co.id.

Jika terjadi keadaan darurat selama perjalanan, hubungi kami di AXA Travel Assistance 24 jam di nomor (+60) 376 283 985 atau
Customer Care Center 1500 733 dan bisa dihubungi pada pukul 08:00 - 17:00 di hari Senin sampai Jumat.
If an emergency occurs during the trip, please contact us at AXA Travel Assistance 24 hours at (+60) 376 283 985 or Customer Care at 1500733 and can be
contacted at 08.00 - 17:00 Monday to Friday.

Jika saya terbukti memberikan data, pernyataan, informasi dan jawaban yang t idak benar atau t idak lengkap secara sengaja
maupun t idak sengaja, saya sadar, memahami dan menyetujui bahwa PT Mandiri AXA General Insurance memiliki hak untuk
membatalkan Polis ini. Tanpa berkewajiban untuk membayar manfaat apapun atau mengembalikan premi yang telah saya
bayarkan.
If I am proven to have provided incorrect or incomplete data, statements, information and answers intentionally or unintentionally, I am aware, understand
and agree that PT Mandiri AXA General Insurance has the right to cancel this Policy. Without being obliged to pay any benefits or return the premiums I have
paid.

Terima kasih atas kepercayaan Anda kepada AXA Mandiri dalam memilih perlindungan perjalanan Anda.
Thank you for your trust in AXA Mandiri in choosing your travel protection.

Jakarta, 06 March 2023

PT Mandiri AXA General Insurance

I Dewa Putu Sidan Bayu

Head of Operations Processing and Service

PT Mandiri AXA General Insurance 6 of 7

 PT Mandiri AXA General Insurance
Customer Care Center
AXA Tower lt. GF
Jl. Prof. Dr. Satrio Kav.18, Kuningan City
Jakarta 12940, Indonesia
Tel : 1500733 (Senin-Jumat, 08.00-17.00 WIB)
Email : customer.general@axa-mandiri.co.id
Website : www.axa-mandiri.co.id

PREMIUM NOTE
Date: 06/03/2023
No.: INV-IT-8411761

No. Referensi : ECMTRAVI1-994080

Reference No.
Nama & Alamat Tertanggung : ARI SUSANTO
Name & Address of Insured BLOK MELATI RT.001 RW.003 REJO
KEMIRI PURWOREJO JAWA TENGAH
,
Jangka Waktu : 23/05/2023 - 28/05/2023
Period
Jenis Asuransi : Asuransi Perjalanan AXA
Type of Insurance

Cat at an / No te s Perincian / D e ta i ls

Pembayaran dilakukan melalui t ransaksi bank t ransfer ke Premi : IDR 351,000.00

Rekening No. a.n PT MANDIRI AXA GENERAL INSURANCE, dengan Premium
mencantumkan Nomor Referensi Polis yang dibayarkan dan Biaya : IDR 10,000.00
Nama Tertanggung dengan format : No. Referensi Polis Materai
ECMTRAVI1-994080 a.n ARI SUSANTO Duty Cost

Jumlah : IDR 361,000 . 00

Payment should be done thru bank t ransfer to Account No. PT
To ta l
MANDIRI AXA GENERAL INSURANCE, with stating the Policy
Reference Number and Insured Name with format : No. Referensi
Polis ECMTRAVI1-994080 a.n ARI SUSANTO

PT Mandiri AXA General Insurance

Tuliskan no. referensi polis atau no. nota dikolom pesan pada slip
t ransfer.

Please input the Policy Reference No or Note No in the message column on I Dewa Put u Sidan Bayu
the transfer s lip. Head of Operat ions Processing and Service
Dokumen ini BUKAN BUKTI PEMBAYARAN
This Document is not a proof of payment

PT Mandiri AXA General Insurance 7 of 7

 Booking Confirmation
Please present either an electronic or paper copy of your booking confirmation upon check-in.
agoda agoda agoda agoda agoda agoda agoda agoda agoda agoda agoda

Booking ID : 963026105 Number of Rooms : 1

Booking Reference No : 3806645236 Number of Extra Beds : 0
Client : ARI SUSANTO Number of Adults : 2
Member ID : 365534154
Number of Children : 0
Country of Residence : Indonesia
Room Type : Standard Room with 1 double bed
Property : ibis budget London Heathrow Central
Promotion :
Address : 700 Bath Road, Cranford, Hounslow,
Heathrow, London, United Kingdom, For Full Promotion details and conditions see confirmation email
TW5 9TW
700 Bath Road Hertz House Cranford, Heathrow,
London, United Kingdom, TW5 9TW

Cancellation Policy: 0D20P_20P

Benefits Included: -

Arrival : May 23, 2023 Departure : May 28, 2023

Payment Details :
Please note: Payment for this booking has not been collected by Agoda. Payment for this booking must be
collected by the property.

Note to property: Reservation was made under Booking.com booking ID 3806645236

Remarks :
Included : Taxes and fees IDR 1588285
All special requests are subject to availability upon arrival

Call our Customer Service Center 24/7 :

Customer Support : +44 20 3027 7900, +62 21 2561 7999, +1 866 656 8207
(Long distance charge may apply)

Notes
IMPORTANT: At check-in, you must present a valid photo ID with your address confirming the same name as the lead guest on the booking. For
bookings paid with a credit card, you may also need to present the card used to make the payment. Failure to do so may result in the hotel
requesting additional payment or your reservation not being honored.
All rooms are guaranteed on the day of arrival. In the case of a no-show, your room(s) will be released and you will be subject to the terms and
conditions of the Cancellation/No-Show Policy specified at the time you made the booking as well as noted in the Confirmation Email.
The total price for this booking does not include mini-bar items, telephone usage, laundry service, etc. The property will bill you directly.
In cases where Breakfast is included with the room rate, please note that certain properties may charge extra for children travelling with their
parents. If applicable, the property will bill you directly. Upon arrival, if you have any questions, please verify with the property.
 Generated On Sat, 29 Apr 2023 05:57 GMT

Dear Mr Ari Susanto, E-TICKET RECEIPT

Thank you for choosing Qatar Airways. Booking Reference W4AN8C
We look forward to welcoming you onboard.
Ticket Number 157-2105193672

Flight / Operated By Departs / Arrives Class Fare Basis Travel Not Valid Special Services

QR959 JKT (CGK), Soekarno Hatta International ECONOMY (O) OJIDP3RX Before - 23-May-23
Qatar Airways Tue, 23 May 2023 09:05 Baggage After - 30-Jun-23
Allowance
Confirmed
DOH (DOH), Hamad International Airport 25 Kg
Tue, 23 May 2023 13:20

QR005 DOH (DOH), Hamad International Airport ECONOMY (O) OJIDP3RX Before - 23-May-23
Qatar Airways Tue, 23 May 2023 16:40 Baggage After - 30-Jun-23
Allowance
Confirmed
LON (LHR), Heathrow Airport 25 Kg
Tue, 23 May 2023 22:00

QR016 LON (LHR), Heathrow Airport ECONOMY (O) OJIDP3RW Before - 23-May-23
Qatar Airways Sun, 28 May 2023 21:55 Baggage After - 23-Sep-23
Allowance
Confirmed
DOH (DOH), Hamad International Airport 25 Kg
Mon, 29 May 2023 06:40

QR954 DOH (DOH), Hamad International Airport ECONOMY (O) OJIDP3RW Before - 23-May-23
Qatar Airways Mon, 29 May 2023 08:30 Baggage After - 23-Sep-23
Allowance
Confirmed
JKT (CGK), Soekarno Hatta International 25 Kg
Mon, 29 May 2023 21:30

Receipt Contact Details

Ticket Fare IDR 3236000.00 Date of Purchase 29-Apr-23

Taxes and Carrier IDR 5428400.00 YQ , IDR 649200.00 YR , IDR 266400.00 D5 , IDR Office Visit www.qatarairways.com/contactus
imposedFees 486200.00 Passenger Facility Charge PFC (G4AF) , IDR 14800.00 PZ , IDR
486200.00 QA , IDR 81200.00 R9 , IDR 1674800.00 GB , IDR 1027200.00
UB

Total IDR 13350400.00

Payment CREDITCARD 461700xxxxxx4787

This ticket was purchased on qatarairways.com. If you did not pay for this ticket directly through qatarairways.com or received this ticket from a travel agent, please contact the
nearest Qatar Airways office immediately.

• PAX /C1-4 NON END/CHNG PENALTIES AS PER RULE

Note:Qatar Airways may request additional payment verification for itineraries paid for with credit cards..

Purchase conditions:

• Check-in and Boarding

Arrive at least three hours before your flight. There may be delays at the airport due to extra check-in procedures. Ensure you have plenty of time to check-in safely and make
your way to your gate.
• For more information on baggage rules and restrictions on Qatar Airways flights, please click here.
• Baggage allowance may differ for flights operated by another carrier. Please click here for more details.
• Should you wish to change your booking, and the originally purchased fare or booking class is not available for your new flights, difference of fare will be collected on top of
the change fee if the rule permits changes.
• If you have a stopover in Doha, please click here for more information.
• An additional administrative/service fee for rebooking/cancellation may apply.
• When a ticket is booked with a combination of fares, the most restrictive cancellation rule will apply.
• Fares are not guaranteed until full payment is received and tickets are issued.
• Where applicable, local airport taxes will be collected at time of check-in.
• Additional card transaction fees may apply and is dependent on the card issuer.
• You should carry a copy of this booking confirmation while you travel as it may be required for immigration purposes.
• Remember to check your immigration and health requirements before you travel and ensure you carry the required travel documents.
• If you are holding a non-Qatar Airways ticket for a connection afterwards, you will need to hold immigration approval to land at the final city in your itinerary that
is ticketed by Qatar Airways.
• In the event of any taxes, fees or charges, which you have paid to us at the time of the ticket issuance are abolished or reduced such that they no longer apply to you, or a
lesser amount is due, or you have not used the relevant portion of the ticket, you will be entitled to claim a refund of those.
• Please be advised that in the event you do not show up for any flight without advising us in advance with minimum three hours prior to flight departure, your return or onward
Notice

• To make a change to your booking, you can use the 'Manage Booking' option on qatarairways.com or contact the nearest Qatar Airways office. Please refer to
qatarairways.com/contact for details.
• You can check Qatar Airways flights' status at fs.qatarairways.com/fltstatus
• For feedback and complaints please visit qatarairways.com/tell-us
Data Protection Notice: Your personal data will be processed in accordance with the applicable carrier’s privacy policy and, if your booking is made via a reservation system
provider (“GDS”), with its privacy policy. These are available at http://www.iatatravelcenter.com/privacy or from the carrier or GDS directly. You should read this documentation,
which applies to your booking and specifies, for example, how your personal data is collected, stored, used, disclosed and transferred (applicable for interline carriage).
Infant bassinet information:The following conditions will apply to customers travelling on Qatar Airways operated flights who have requested for a bassinet seat for the infant;

• The maximum body weight of an infant should not exceed 11kgs (24lbs);
• The infant must be less than 2 years old, and;
• The infant must fit within the confines of the baby bassinet.
NEXT STEPS

Note: Your travel itinerary is subject to Qatar Airways' full conditions of carriage, available at qatarairways.com/legal or upon request from your nearest Qatar Airways office.
ITINERARY LONDON 23-29 MAY 2023
DAY 1 (23-05-2023)b fd

- Travel from Jakarta Soekarno Hatta International Airport to London

- (QATAR AIRWAYS QR-959)
- TRANSIT DOHA QATAR 1J 45M (QATAR AIRWAYS QR-015)
- ARRIVAL AT LONDON HEATHROW AIRPORT
- Towards Hotel ibis budget London Heathrow Central. 700 Bath Road Hertz House Cranford,
Heathrow,London, United Kingdom, TW5 9TW
- Rest and enjoy the atmosphere around the hotel
DAY 2 (24-05-2023)
- Breakfast and get ready to start the activity
- Tower Bridge
- Buckingham Palace
- Trafalgar Square
- Big Ben / Westminster
- BACK TO HOTEL ibis budget London Heathrow Central. 700 Bath Road Hertz House Cranford,
Heathrow,London, United Kingdom, TW5 9TW
DAY 3 (25-05-2023)
- Breakfast and get ready to start the activityTower Bridge
- Harry Potter Studio
- Imperial War Museum di South East London
- Take a walk while enjoying culinary delights
- BACK TO HOTEL Towards Hotel ibis budget London Heathrow Central. 700 Bath Road Hertz House
Cranford, Heathrow,London, United Kingdom, TW5 9TW
DAY 4 (26-05-2023)
- Breakfast and get ready to start the activity
- Tower Bridge
- Oxford Circus
- Piccadilly Circus
- Chinatown
- BACK TO HOTEL Towards Hotel ibis budget London Heathrow Central. 700 Bath Road Hertz House
Cranford, Heathrow,London, United Kingdom, TW5 9TW
DAY 5 (27-05-2023)
- Breakfast and get ready to start the activityTower Bridge
- Stadium Tour sightseeing visiting some of the stadiums
- Tottenham Hotspurs, Arsenal, Chelsea (Adjust sufficient time to visit)
- BACK TO HOTEL Towards Hotel ibis budget London Heathrow Central. 700 Bath Road Hertz House
Cranford, Heathrow,London, United Kingdom, TW5 9TW
DAY 6 (28-05-2023)
- Breakfast and get ready for the airport for the return trip to Indonesia
- LONDON HEATHROW AIRPORT – SOEKARNO HATTA AIRPORT JAKARTA
- QATAR AIRWAYS QR-016 transid DUBAY QR-954
DAY 7 (29-05-2023)
- Arrive at SOEKARNO HATTA AIRPORT JAKARTA
 ANNUAL LEAVE PERMIT

Jakarta, 17 May 2023

To.
HRD
PT. Prima Sentosa Tekstil
Jakarta

The undersigned below :

Name : Ari Susanto

ID : PST-0791
Position : Head Production

Hereby submit a request for annual leave for 2023 for 7 (Seven) working days, starting from
May 23, 2023 to May 29, 2023 and will return to work on May 30, 2023.

During my leave I will be on vacation to United Kingdom. Thus, I make this application so
that it can be considered properly.

Sincerely yours, Sincerely yours,

Budiman Hartono Ari Susanto

HRD Manager ID PST-0791