Formulir Aplikasi Hospital Income & Surgical Benefit · Formulir Aplikasi Hospital Income & Surgical Benefit Formulir Aplikasi Hospital Income & Surgical Benefit (April 2015) 1/6

Formulir Aplikasi Hospital Income & Surgical Benefit

1/6Formulir Aplikasi Hospital Income & Surgical Benefit (April 2015)

Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y

Informasi Pemegang Polis / Policy Holder Information*

Hasil UsahaBusiness Income

Lain-LainOthers: .................

Sumber DanaSources of Fund

WirausahaEntrepreneurship

GajiSalary

Tabungan / DepositoSaving / Deposit

≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million Penghasilan Kotorper Bulan (Rp)Monthly Gross Income (IDR)

> 25-50 Juta / million > 10-25 Juta / million

Informasi rekening ini akan digunakan untuk pembayaran manfaat atau transaksi pembayaran lainnya dari PT AIG Insurance Indonesia ("AIG Indonesia") apabila ada.

Nama Bank termasuk Cabang / Bank Name incl Branch ...................................................................................................................................................................

Nama Pemilik Rekening / Account Name ....................................................................................................................................................................................................

Nomor Rekening / Account Number ...............................................................................................................................................................................................................

This account information will be used by PT AIG Insurance Indonesia ("AIG Indonesia") for benefit or others payment transaction, if any.

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): ...............................

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

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

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

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

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


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




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


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

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

Tempat Lahir / Place of Birth ..............................................................................

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.

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

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

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

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Tujuan AsuransiInsurance Purpose

Perlindungan terhadap Harta Kekayaan / Aset PerusahaanPersonal / Company Asset Protection

Lain-lain: ...............................................................................................Others

Apakah Anda memiliki polis asuransi lain di AIG Indonesia atau di perusahaan lain?Do you have other insurance policy owned in AIG Indonesia or other company?

Informasi Tambahan / Additional Info

Apakah Anda atau anggota keluarga Anda Pejabat/Pegawai Pemerintah, BUMN, Kepolisian, Militer, Pengurus Partai Politik atau Anggota Legislatif?Do you or your family member is an Official/Employee of Government Institution, State-owned Entity, Police, Military, Political Party Officials or Legislators?

Ya / Yes Tidak / No

No. Nomor Polis / Policy Number Jenis Asuransi / Type of Insurance Perusahaan Asuransi / Insurance Company

TidakNo

Ya, Mohon isi tabel di bawah iniYes, Please complete below table


PekerjaanOccupation


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





(Jika berbeda dengan kartu identitas)(If different with Identity Card)



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

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

PensiunRetirement





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

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




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




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


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

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


Hubungan dengan Pemegang Polis / Relationship with Policy Holder .......................................................................................................................................

Informasi Tertanggung / Insured Information*

(Diisi jika Nama Tertanggung berbeda dengan Pemegang Polis / To be completed if the Insured name is different with Policy Holder Name)

Alamat Saat ini / Current Address ........................................................................................................................................................................................................



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Beneficial Owner Perorangan / Individual Beneficial Owner*

Apakah nama Beneficial Owner sama dengansalah satu di atas?Is Beneficial Owner name same with one of the above? Pemegang Polis

Policy Holder

Ya / Yes TertanggungInsured

Tidak, Mohon diisi Informasi di bawahNo, Please complete below information

Beneficial Owner adalah setiap orang atau badan hukum yang memiliki dana, mengendalikan transaksi Nasabah, yang memberikan kuasa atas terjadinya suatu transaksi dan/atau yang melakukan pengendalianmelalui badan hukum atau perjanjian.Beneficial Owner is any person or legal entity who has the funds, controls the Customer's transaction, provides power of attorney to a transaction and/or does control through legal entity or agreement.

Hasil UsahaBusiness Income

Lain-LainOthers: .................

Sumber DanaSources of Fund

WirausahaEntrepreneurship

GajiSalary

Tabungan / DepositoSaving / Deposit

≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million > 25-50 Juta / million > 10-25 Juta / million


PekerjaanOccupation


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




Alamat Saat ini / Current Address ........................................................................................................................................................................................................


(Jika berbeda dengan Kartu Identitas)(If different with Identity Card)



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

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

PensiunRetirement


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



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

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

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



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




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


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

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


Hubungan dengan Pemegang Polis / Relationship with Policy Holder ........................................................................................................................................

Penghasilan Kotorper Bulan (Rp)Monthly Gross Income (IDR)



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YaYes

TidakNo

YaYes

TidakNo

Apakah Anda memiliki rumah tinggal pribadi?Do you have your own house?

Ya / Yes Tidak / No

Apakah Anda memiliki kendaraan pribadi?Do you have your own car?

Ya / Yes Tidak / No

Apakah Anda sering berpergian ke luar kota atau luar negeri?Do You usually travel domestically/overseas?

Ya / Yes Tidak / No

YaYes

TidakNo

Apakah Anda atau anggota keluarga terdaftar memiliki kerusakan/cidera fisik?Do you or any of your family member listed have any impairment in physical condition?

Apakah Anda atau anggota keluarga terdaftar sedang menerima atau mempunyai kondisi kesehatan yang perlu perhatian atau perawatan pembedahan atau sedang dalam masa pengobatan?Do you or your family member listed now receiving or contemplating any medical attention or surgical treatment or taking any medicine?

Apakah Anda atau anggota keluarga terdaftar pernah mengalami tindakan pembedahan atau perawatan atau pengobatan rumah sakit, sanatorium atau lembaga kesehatan lainnya dalam waktu 5 tahun terakhir?Have you or your family member listed had a surgical operation or been confined or treated any hospital, sanatorium, or other institution in the last 5 years?

AnakChildren

PasanganSpouse

TertanggungInsured

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

Keterangan Kesehatan / Health Information

Ahli Waris / Name of Beneficiary: ..............................................................................................................................................................................................................

Hubungan / Relationship: ...........................................................................................................................................................................................................................

No. Telepon Ahli Waris yang dapat dihubungi / Beneficiary Contact No.: ...........................................................................................................................

Pernahkah Anda atau anggota keluarga terdaftar mengalami tindakan atau dinyatakan mempunyai masalah dengan Jantung, Hipertensi, Diabetes, Kanker, Tumor, Luka Bernanah, TBC, Asma, Epilepsi, Pembengkakan Paru-Paru, Radang Selaput Dada, Radang Usus Besar, Rematik, Hati, Sipilis, atau Penyakit Otak lainnya, Sistem Saraf Pusat, organ yang berkaitan dengan Kandung Kemih, masalah pencernaan, Pankreas dan lainnya?Have you or your family member listed ever been treated for or told having Heart Trouble, Hypertension, Diabetes, Cancer, Tumor, Ulcer, Tuberculosis, Asthma, Epilepsy, Emphysema, Pleurisy, Colitis, Rheumatic, Lever, Syphilis or any other disease of Brain, Central Nervous System, Genitor Urihary Organs, Gastro Intestinal Tract, Liver, Pancreas, etc?


Usia (tahun) / Age (Year)

60

700.000

50-59

600.000

40-4918-39

500.000 400.000

280

350.000

240

300.000

200

250.000

160

200.000

Pilihan Plan (premi tahunan)Plan Option (Annual Premium)

Plan 1

Plan 2

Plan 3US$

US$

Santunan Harian Rawat Inap Rumah Sakit / Hospital Income

Tertanggung SajaInsured

1.400.000

560

700.000

1.200.000

480

600.000

1.000.000

400

500.000

800.000

320

400.000

Plan 1

Plan 2US$

Plan 3US$

US$

Tertanggung danPasanganInsured and Spouse

1.750.000

280

875.000

1.500.000

240

750.000

1.250.000

200

625.000

1.000.000

160

500.000

Plan 1

Plan 2Rp

US$

US$

Plan 3

US$

Tertanggung danKeluargaInsured and Family

140

210.000

84

120

180.000

72

100

150.000

60

80

120.000

48

280

420.000

168

240

360.000

144

200

300.000

120

160

240.000

96

350

525.000

210

300

450.000

180

250

375.000

150

200

300.000

120

Rp

Rp

Rp

Rp

US$

Rp

Rp

Rp

Rp

Kelas Jenis Pertanggungan / Class Type of Coverage

RpRp US$

1 2Pilihan Plan (premi tahunan)Plan Option (Annual Premium)

Tertanggung SajaInsured

Kecelakaan Diri / Personal Accident

US$


Plan 1

Plan 2

Plan 3


Plan 1

Plan 2

Plan 3

Plan 1

Plan 2

Plan 3

540

280

145

428

220

115

300

155

80

1.350.000

700.000

362.500

1.070.000

550.000

287.500

750.000

387.500

200.000

440

225

115

350

178

90

245

125

65

1.100.000

562.500

287.500

875.000

445.000

225.000

612.500

312.500

162.500



Kartu Kredit / Credit Card

Nama Pemegang Kartu: ..................................................................Name of Card Holder

No. Visa/Master/BCA Card:

Masa BerlakuExpiry Date

Tanda tangan Pemegang Kartu Signature of Card Holder

Pernyataan atas Cara Pembayaran Premi / Statement of Premium Payment Method

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

No. Rekening Bank:Bank Account Number

Nama Pemilik / Account Name ............................................................

kirim bukti transfer ke kantor pusat AIG Indonesia atau kirim melalui:please send the transfer receipt to AIG Indonesia:fax. : 021 5291 4801/4802e-mail : [email protected]

Bank No. Rek (US$)

Citibank 010 265 001 8 010 265 051 4

BCA 458 300 985 2 458 370 089 0

HSBC 001 016 963 068 001 016 963 115

No. Rek (Rp)

D D / M M / Y Y Y Y

Saya dengan ini menyatakan bahwa pada saat aplikasi Saya disetujui, Saya sepakat untuk melunasi premi secara penuh dengan cara sebagai berikut:I hereby that at the time the application is approved, I agree to fully pay the premium in below method

Transfer dari Nama Bank:Transfer from Bank

*Lampirkan Salinan KTP/SIM/Paspor/KIMS/KITAS/KITAP (Attach Copy of Identity/SIM/Passport/KIMS/KITAS/KITAP)

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

This application form is part of main application form with Policy Holder name

Formulir Aplikasi Untuk Tertanggung TambahanApplication Form For Additional InsuredFormulir aplikasi ini adalah bagian tidak terpisahkan dari formulir aplikasi utama atas nama Pemegang Polis ....................................................................................................................................

*Sesuai dengan Kartu Identitas / refer to Identity Card



Informasi Tertanggung Tambahan / Additional Insured Information*

1/2Formulir Aplikasi Untuk Tertanggung Tambahan (April 2015)





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

No. Kartu Identitas / Identity Card No. ........................................................................................................................................................................................................

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



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






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


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

........................................................................................................................................................................................................Diisi jika berbeda dengan tertanggungutama di aplikasi utamaTo be completed if different with maininsured in master application

Alamat / Address

++

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





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





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






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


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


Alamat / Address

++


2/2Formulir Aplikasi Untuk Tertanggung Tambahan (April 2015)





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





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






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


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


Alamat / Address

++






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





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






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


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


Alamat / Address

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Formulir Aplikasi Hospital Income & Surgical Benefit · Formulir Aplikasi Hospital Income & Surgical Benefit Formulir Aplikasi Hospital Income & Surgical Benefit (April 2015) 1/6

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