Thursday, 17 July 2025

SURAT PERMINTAAN PERTANGGUNGAN ASURANSI (SPPA) KENDARAAN BERMOTOR – KORPORASI

SURAT PERMINTAAN PERTANGGUNGAN ASURANSI (SPPA)

KENDARAAN BERMOTOR – KORPORASI

DATA CALON TERTANGGUNG :

Status tertanggung : o Baru o Lama

Nama Calon Tertanggung : _________________________________________________________________________________

QQ : ___________________________________________________________________________________________________ Alamat Calon Tertanggung: _________________________________________________________________________________

________________________________________________________________________________________________________

Kota : ______________________________ Kode pos : _____________________________________

NPWP : _______________________________ No Telephone : _____________________________________

No Handphone : _______________________________ Alamat Email : _____________________________________

Bentuk usaha : o PT o FA/CV o Yayasan o Bank

: o Perwakilan Negara Asing o lembaga pemerintah o lembaga keuangan o Partai poltik

: o Koperasi o Lembaga interbasional o Lainnya __________________________

Tujuan Menutup Asuransi : o Perlindungan terhadap Aset Perusahaan o Lainnya _______________________

DATA OBYEK PERTANGGUNGAN :

Merk dan tipe kendaraan : _______________________________________________________________________

Jenis kendaraan : o Sedan/jeep/MVP o Truck/pick up/box o Sepeda motor o Bus

Nomor kerangka : _____________________________________ No Polisi : ________________________

Nomor Mesin : _____________________________________ Tahun Pembuatan : ________________

Penggunaan : o Pribadi o Bisnis o Lainnya Isi Silinder : ________________

KONDISI PERTANGGUNGAN :

Jangka Waktu Pertanggungan : ___ / ___ / ________ Sampai dengan ___ / ___ / ________

Risiko Pertangungan : o Comprehensive o Total loss only

TJH Pihak Ketiga (Rp) : o 5 juta o 10 Juta o 25 Juta o 50 Juta o Lainnya _________________

Kecelakaan diri Pengemudi (Rp) : o 5 juta o 10 Juta o 25 Juta o 50 Juta o Lainnya _________________

Kecelakaan Diri Penumpang (Rp) : o 5 juta o 10 Juta o 25 Juta o 50 Juta o Lainnya _________________

Perluasan jaminan : o Huruhara dan kerusuhan (SRCC)

: o Teroris dan sabotase (TS)

: o Angin Topan, Badai, Hujan Es, Banjir & Tanah Longsor (Windstorm,

Flood & Landslide)

: o Gempa Bumi, Tsunami & Letusan Gunung Berapi (Earthquake, Tsunami &

Volcanic Eruption

UANG PERTANGGUNGAN :

Uang Pertanggungan (Rp) : __________________________

Perlengkapan tambahan (Rp) : __________________________

Total Pertanggungan (Rp) : ___________________________

Perlengkapan tambahan terdiri Dari :

PERNYATAAN SEBAGAI PEMOHON :

Saya/kami menyatakan bahwa data dan keterangan tersebut diatas, termasuk dokumen-dokumen yang saya/kami serahkan adalah benar dan dapat dipertanggung jawabkan kebenaran dan keabsahannya. Apabila dikemudian hari, terbukti data dan keterangan tersebut tidak benar (misrepresentation) dan/atau dokumen yang kami serahkan tidak benar atau palsu atau dipalsukan baik untuk sebagian atau seluruhnya, maka segala akibat hukum dari ketidak benaran tersebut, sepenuhnya menjadi tanggung jawab saya/kami. Tanda tangan Pemohon sesuai KTP/SIM/PASPORT

Saya/kami telah membaca, memahami dan menyetujui ketentuan-ketentuan di dalam formulir ini. Pertanggungan asuransi tidak akan berlaku sampai permohonan ini disetujui dan premi diterima penuh.

________________, ___ / ___ / ______

_____________________________________

Tanda tangan Pemohon sesuai KTP/SIM/PASPORT

Catatan : Calon Tertanggung wajib melampirkan foto copy NPWP dan STNK dari kendaraan yang akan diasuransikan

AIRCRAFT INSURANCE PROPOSAL FORM

SPPA

AIRCRAFT INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them.

A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract

A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract.

Day Month Year Day Month Year

Commencement Date of Insurance: Expiry Date of Insurance:

(Which cannot be before the acceptance of the Proposal by the Insurers)

1. PROPOSER

a) Proposer’s Name Company:

Individual:

b) Proposer’s Interest in the Aircraft:

c) Postal Address:

e) Telephone: (Home) (Business) (Cell)

f) E-mail:

g) Occupation: h) Age:

i) Have you or any member of your family residing with you, or directors where the Proposer is a limited company, ever been convicted of any offence other than driving offences?

If ‘YES’ to the above question please give details here YES NO

2. AIRCRAFT DETAILS

a) Manufacturer

b) Model

c) Year

d) Amount of Airframe Time

e) Engines

f) Engine Hours

g) Number of Crew Seats

h) Number of Passenger Seats

i) Average Passenger Load

j) Registration No.

k) Country of Registration

l) Hull and Machinery Value

m) Date of Last Annual

n) Where is the Aircraft kept

o) Where is the Aircraft maintained (location)

p) Name of Maintenance Company

3.

PILOTS

Pilot 1

a) Name

b) Age

c) Hours & Rating

1. Total flying hours

2. Total Turbine Engine Hours

3. Hours make and model

4. Total multi engine hours

d) Type of license held

Pilot 2

e) Name

f) Age

g) Hours & Rating

1. Total flying hours

2. Total Turbine Engine Hours

3. Hours make and model

4. Total multi engine hours

h) Type of license held

Pilot 3

i) Name

j) Age

k) Hours & Rating

1. Total flying hours

2. Total Turbine Engine Hours

3. Hours make and model

4. Total multi engine hours

l) Type of license held

m) Do Pilots attend Manufacturer approved Flight/Simulator training and if so, how often do the pilots attend?

n) Please state the minimum licenses/experience requirement levels for any unnamed pilots.

4. INSURANCE (please tick as appropriate)

Existing Insurance Arrangement YES NO New Craft YES NO

a) Present Insurer

b) Period of Insurance

c) Current Premium

d) Excess

5. LIABILITY INSURANCE

a) Public Liability (Bodily injury & Property damage) – Limit per occurrence: IDR

b) Passenger Liability - Limit per person: IDR

c) Passenger Liability - Limit per occurrence: IDR

d) Crew Personal Accident – Limit per occurrence: IDR

6. USE OF AIRCRAFT (please tick as appropriate)

a) Private Pleasure YES NO

How many trips per month? How many hours per month?

b) Business YES NO

How many trips per month? How many hours per month?

c) Commercial Charter YES NO How many trips per month?

How many hours per month?

d) Rental YES NO

e) Other uses not listed YES NO

How many trips per month?

How many hours per month? How many trips per month?

How many hours per month?

f) If the answer to Question 6 e) is YES please enter details of the Other uses below:

Definitions of Uses:

Private Pleasure is defined as use for private and pleasure purposes but NOT use for any business or profession nor

for hire or reward.

Business is defined as use for the purpose of the Insured’s business or profession but NOT use for hire or reward.

Commercial is defined as use for the carriage by the Insured of passengers, baggage accompanying passengers and

cargo for hire or reward.

Rental is defined as rental, lease, charter or hire by the Insured to any person, company or organization for Private Pleasure and Business uses only, where the operation or the Aircraft is not under the control of the Insured. Rental for any other purposes is NOT insured under this Policy unless specifically declared to Insurers.

7. GEOGRAPHICAL OPERATING AREA OF THE AIRCRAFT

a) Please state Geographical Operating Area of the Aircraft:

b) Does the Aircraft fly to the United States of America? YES NO

c) c) If the answer is YES to Question 7b) above is it for maintenance purposes only? YES NO

d) If the answer is NO to Question 7c) what is the approximate percentage in overall hours the Aircraft is flying in the airspace of the United States of America?

8. PREVIOUS LOSSES OR CLAIMS

a) Have you ever had any accidents or losses whether covered by insurance or not? YES NO

If you have answered ‘YES’ to the above question please give details here

9. DECLARATION

I/we declare that the above statements made by me/us or written in answer to the questions on this form on my/our behalf by someone else are to the best of my/our knowledge and belief true and complete, and no material fact has been misrepresented, misstated or withheld. I/we agree that this proposal shall form the basis of the contract between me/us and the Insurers and will be deemed as incorporated in the Policy to be issued.