FORM AIG BUSINESS TRAVELGUARD (ATAG) · Alamat Sesuai Kartu Identitas ... Kota / City ... Minimarket, Jasa pengelola parkir, Rumah makan, SPBU, Pedagang isi ulang pulsa, Penjual barang

Formulir Aplikasi AIG Business (ATAG)

1/3Formulir Aplikasi AIG Business (ATAG) (April 2015)

Informasi Nasabah Korporasi / Corporate Customer Information*

Nama Pertama / First Name Nama Tengah / Middle Name Nama Akhir / Last Name

....................................................................................... ................................................................................. ....................................................................................

WNI / Indonesian WNA / Foreigner ..............................................................................................................................Kewarganegaraan / Citizenship

Jenis Kelamin / Gender Laki-Laki / Male Perempuan / Female

Alamat Sesuai Kartu Identitas ........................................................................................................................................................................................................Address refer to Identity Card ........................................................................................................................................................................................................

Tempat Lahir / Place of Birth .............................................................................. Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y

Informasi Pejabat Berwenang / Authorized Person Information*

Kota / City ..................................................................... Provinsi / Province ............................................................................

Kecamatan / District ...................................................................................................................................................................

Kelurahan / Sub District ..............................................................................................................................................................

................................................................................................................................................................... RT/RW ....... / .......

Kode Pos / Postal Code ............................................... Negara / Country ............................................................................

Apakah bidang usahaAndaIs your Line of Business

Tidak / No

Ya / Yes

Pedagang valuta asing, Jasa pengiriman uang, Off shore company, Dealer mobil, Agen perjalanan, Pedagang perhiasan/batu permata/logam berharga, Perusahaan perdagangan ekspor impor, Minimarket, Jasa pengelola parkir, Rumah makan, SPBU, Pedagang isi ulang pulsa, Penjual barang elektronik, Advokat, Akuntan, Konsultasi keuangan, Dealer barang antik dan seni, Agen properti.Foreign exchange traders, Remittance, Off shore company, Car dealers, Travel agents, Jewelers / gemstone / precious metals, Import-export trading company, Minimarket, Parking management services, Restaurants, Gas stations, Reload traders, Sellers of electronics, Lawyers, Accountants, Financial consulting, Antiques and art dealers, Estate agents.

........................................................................................................................................................................................................Bidang UsahaType of Business

Nama PerusahaanCompany Name

Alamat Perusahaan ........................................................................................................................................................................................................Company Address

Kota / City ..................................................................... Provinsi / Province ...........................................................................

Kecamatan / District ...................................................................................................................................................................

Kelurahan / Sub District ..............................................................................................................................................................

................................................................................................................................................................... RT/RW ....... / .......

SIUPBusiness Licence

Salinan / Copy of

KTP/KITAS/Paspor Direktur Perusahaan/Pejabat BerwenangIdentity/KITAS/Passport from the Director/Authorized Person

Hasil InvestasiInvestment

Lain-lainOthers: ...............................................................

Surat KuasaUntuk perwakilan resmi danbukan direksi perusahaanLetter of Attorneyfor authorized representative andnot director of company

Sumber Dana / Fund Resources

No. Telepon KantorWork Phone No.

Kode Area / Area Code No. Telepon / Phone No.

Terlampir / Attached

NPWPTax Registration Number

Akte Pendirian PerusahaanDeed of Incorporation

Hasil UsahaBusiness Income

Kode Negara / Country Code

+Kode Pos / Postal Code ............................................... Negara / Country ............................................................................

PT AIG Insurance IndonesiaIndonesia Stock Exchange Building Tower 2, Floor 3AJl. Jend. Sudirman Kav. 52-53 Jakarta 12190, IndonesiaAIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id

PT AIG Insurance IndonesiaIndonesia Stock Exchange Building Tower 2, Floor 3AJl. Jend. Sudirman Kav. 52-53 Jakarta 12190, IndonesiaAIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id

Based on PMK No.30/PMK.010/2010 regarding Know Your Customer Principle, please complete below form and give check mark (v) in the box provided.

*Sesuai dengan Kartu Identitas / refer to Identity Card

Wajib diisi dengan lengkap sesuai ketentuan PMK No.30/PMK.010/2010 tentang Prinsip Mengenal Nasabah dan beri tanda cek (v) pada kotak yang tersedia.

........................................................................................................................................................................................................

........................................................................................................................................................................................................

Informasi Underwriting / Underwriting Information

1. Periode Asuransi / Period of Insurance

2. Jumlah Karyawan : Number of Employee

3. Apakah saat ini Anda memiliki produk asuransi perjalanan kelompok? Do you currently have Group Travel Insurance Product

Jika "Ya", tuliskan nama perusahaan asuransi tersebut ............................................................................................... If "Yes", state the name of Insurance company at this time

*Jika lebih dari 5 mohon lampirkan daftar nama di file yang terpisah / if more than 5 please attach the list in separate file **Paspor digunakan untuk Internasional Plan / Passport applied for International Plan

4. Tertanggung : Insured Person

Dasar Pertanggungan / Basis of Coverage

OrangPerson

Nama Tertanggung*Name of Insured

JabatanTitle

Periode AsuransiPeriod of Insurance

Jumlah TertanggungNumber of Insured Person

Informasi Jenis Klaimdan Penyebabnya

Claim Types & Cause Information

Jumlah Klaimyang di BayarNumber of Paid Claim

Rasio KerugianLoss Ratio

YaYes

TidakNo

KaryawanEmployee

............

............

No. KTP atau Paspor** Identity No. or Passport Plan

Pengalaman Klaim / Claim Experience

Jumlah Klaimterhutang

Number of Payable Claim

Tempat dan Tanggal LahirPlace and Date of birth

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Pejabat/Pegawai Pemerintah, BUMN, Polisi, TentaraOfficial or Employee of Government or State-owned Entity, Police, Military

PekerjaanOccupation

Karyawan SwastaPrivate Employee

Nama Perusahaan / Company Name .....................................................................................................................................................................................................

Lain-lainOthers: ................

WirausahaEntrepreneur

Pengurus Partai Politik atau Anggota LegislatifPolitical Party Officials or Legislators

Alamat Saat ini / Current Address (Jika berbeda dengan Kartu Identitas)(If Different with Identity Card)

No. Telepon RumahHome Phone No.

No. PonselMobile No.

Email .............................................................................................................................................................................................................................................................

Jabatan / Title .............................................................................................................................................................................................................................................

PensiunRetirement

Profesional (Pengacara, Dokter, dll)Professional (Lawyer, Doctor, etc): ...............................

Kode Negara / Country Code Kode Area / Area Code No. Telepon / Phone No.

Kode Negara / Country Code No. Telepon / Phone No.

Kota / City ..................................................................... Provinsi / Province ............................................................................

Kecamatan / District ...................................................................................................................................................................

Kelurahan / Sub District ..............................................................................................................................................................

.................................................................................................................................................................. RT/RW ....... / .......

Kode Pos / Postal Code ............................................... Negara / Country ............................................................................

........................................................................................................................................................................................................

++

Tanggal BerlakuEffective Date

D D / M M / Y Y Y Y Tanggal BerakhirExpiry Date

D D / M M / Y Y Y Y

........................................................................................................................................................................................................

Setuju / Agree Tidak setuju / Disagree

DENGAN MENCENTANG KOLOM SETUJU / BY CHECKING AGREE COLUMN: 1). Saya/Kami setuju bahwa setiap informasi yang diperoleh atau disimpan oleh AIG Indonesia, baik yang terdapat dalam aplikasi ini atau yang diperoleh dengan cara lain, dapat dipergunakan dan diungkapkan oleh AIG Indonesia kepada individu/perusahaan/pihak ketiga (di dalam atau di luar Indonesia) untuk melakukan segala aktivitas yang berhubungan dengan polis Saya/Kami dan/atau AIG Indonesia. Saya/Kami mengerti bahwa ketidaksetujuan Saya/Kami atas kebijakan tersebut dapat mengakibatkan ditolaknya pengajuan formulir aplikasi ini. I/We agree that every information been obtain or kept by AIG Indonesia, both that contained in this application or being obtain by other means, can be used and disclosed by AIG Indonesia to individuals/entities/any third parties (within or outside Indonesia) to do any activities which related to My/Our Policy and/or AIG Indonesia. I/We understand that our disagreement on this policy may have impact on the rejection of this application form.

2) Saya/Kami menyatakan bahwa semua pernyataan yang diberikan dalam aplikasi ini adalah benar dan Saya/Kami tidak menyembunyikan, salah menyatakan atau salah menuliskan semua fakta yang ada. I/We hereby confirm that the statements contained in this form are correct and I/We have not concealed, misrepresented or misstated any material facts.

3). Saya/Kami telah membaca, memahami dan menyetujui syarat dan ketentuan produk asuransi yang telah dijelaskan baik secara lisan atau melalui Ringkasan Produk. Perlindungan asuransi akan dimulai dengan memperhatikan persetujuan dari AIG Indonesia terhadap aplikasi Saya/Kami dan pembayaran premi atas perlindungan asuransi telah diterima oleh AIG Indonesia. I/We had read, understood, and agreed the terms and conditions of insurance product that been explained by both verbally or using Product Summary. Insurance coverage will be commenced subject to conformity from AIG Indonesia to My/Our application and premium payment of such insurance coverage been received by AIG Indonesia.

Pernyataan Nasabah / Customer Disclaimer

Broker / Agent

Nama / Name: ..............................................................

Kode / Code:

Tanggal / Date: ................ / .................. / .....................D D M M 2 0 Y Y

Formulir aplikasi dan dokumen pendukung harap dikirim ke kantor pusat atau kantor cabang AIG Indonesia terdekat.Please send the application form and supporting documents to AIG Indonesia head office or branches.

PERHATIAN! Jangan menandatangani formulir aplikasi ini dalam keadaan kosong / belum diisi.WARNING! Do not sign this application form if it is still blank / not yet filled out.

Pemohon / Applicant

Tanggal / Date: ................ / .................. / .....................D D M M 2 0 Y Y

3/3Formulir Aplikasi AIG Business (ATAG) (April 2015)