PT Asuransi QBE Pool Indonesia PT Asuransi QBE Pool Sudirman Indonesia MidPlaza 2, 23rd Floor, Jalan Jenderal Kav. 10-11, Jakarta 10220, Indonesia
MidPlaza 23rd Jenderal Sudirman Phone: +622,(21) 572Floor, 3737Jalan Fax: +62 (21) 571 0547/48 Kav. 10-11, Jakarta 10220, Indonesia Phone: +62 (21)Email: 572 3737 Fax: +62 (21) 571 0547/48 www.qbe.co.id
[email protected] www.qbe.co.id Email:
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QBE Combined Claim Form
QBE Combined Claim Form
Formulir Klaim Gabungan QBE
Contents
Daftar Isi
A.
THE INSURED
A.
TERTANGGUNG
B.
DETAILS OF LOSS DAMAGE OR OCCURRENCE
B.
KETERANGAN KEHILANGAN KERUSAKAN ATAU KEJADIAN
C.
RESPONSIBILITY / WITNESSES
C.
TANGGUNG JAWAB / SAKSI-SAKSI
D.
BURGLARY LOSS
D.
KEBONGKARAN / PENCURIAN
E.
FIRE LOSS
E.
KEBAKARAN
F.
WINDSTORM & FLOOD
F.
ANGIN TOPAN & BANJIR
G.
INSURANCE HISTORY
G.
SEJARAH ASURANSI
H.
DESCRIPTION OF PROPERTY LOST OR DAMAGED
H.
JENIS BARANG YANG HILANG ATAU RUSAK
I.
DECLARATION
I.
PERNYATAAN
J.
JURISDICTION
J.
YURISDIKSI
Important
Penting
•
This form is issued without admission of liability, and it must be completed and returned to the company immediately, whether or not a claim is made
•
Formulir ini diberikan tanpa adanya tanggung jawab polis, dan harus diisi lengkap dan dikembalikan kepada perusahaan segera, baik ada klaim ataupun tidak
•
Attach all quotations obtained for replacement of or repair to the damaged or missing property
•
Lampirkan semua estimasi biaya penggantian atau perbaikan barang yang rusak atau hilang
•
Attach valuations and receipt for purchases whenever possible
•
Lampirkan kuitansi pembelian atau bukti penilaian
•
Advise Police immediately in the event of loss by Burglary, Housebreaking, Theft, Suspected Malicious Damage, Travelers Baggage
•
Laporkan segera ke Polisi untuk kehilangan barang yang di sebabkan Pembongkaran, Pencurian, atau tindak kejahatan lainnya
•
Attach any letter of demand or other correspondence that you may receive from any third party
•
Lampirkan surat tuntutan atau korespondensi lainnya yang mungkin anda terima dari pihak ketiga
•
Do not make any admission of liability for loss or damage caused by you to third party
•
Jangan membuat pernyataan bertanggung jawab atas kehilangan atau kerusakan kepada pihak ketiga
Policy No (No. Polis):
Claim No (No. Klaim):
PT. ASURANSI QBE INDONESIA, Part of QBE Asia Pacific Operations
And a of member of the QBEQBE Insurance GroupGroup Limited – incorporated in A.C.T., Australia A member the worldwide Insurance rd
MidPlaza 2, 23 floor, Jalan Jendral Sudirman Kav. 10-11, Jakarta 10220, Indonesia Phone: +62 (21) 572 3737 Fax: +62 (21) 571 0547/48
[email protected] www.qbe.co.id
QBE Combined Claim Form A. THE INSURED TERTANGGUNG Mohon diisi lengkap:
Please fill out details of Insured: (a) Name:…………………………………………………………………..………
(a) Nama:
(b) Address:…………………………………………………..……………………
(b) Alamat:
……………………………………………………………………..…………… Telephone number:…………………………………………………..……….
(c) No. Telepon:
(d) Policy number:………………………………………………………….……..
(d) No. Polis:
(c)
(e) Has the premium been paid? (f)
YES θ
(e) Apakah premi sudah dibayar?
NO θ
(f) Nama pihak lain yang memiliki
Name of other interested parties (Hire Purchase, Lease, etc), if any: …………………………………………………………………….……..……..
(g) Are there other insurance in force which would cover this in whole or in part.
YES θ
NO θ
if
answer is Yes, please advise the name of the Insurer and the policy details:…………………………………………………………….……………
(Bank, Leasing, dll) jika ada: (g) Apakah ada Asuransi lainnya yang menjamin kerugian ini? Bila YA, mohon sebutkan persh. Asuransi dan nomor polisnya
B. DETAILS OF LOSS DAMAGE OR OCCURRENCE KETERANGAN KEHILANGAN KERUSAKAN ATAU KEJADIAN 1.
(a) Date of loss, damage or occurrence ………./………./…………….… (b) Time of damage or occurrence? ………………………..…….am/pm
2.
What time was the loss, damage or occurrence reported to you (if applicable)? ……………………………………………………..…….am/pm
3.
Place and/or premises where it occurred:……………………..…………... …………………………………………………………………..………………
4.
Please state full particulars how loss, damage or accident occurred: …………………………………………………………………………………… ……………………………………………………………………………………
1. (a) Tanggal kejadian? (b) Jam berapa? 2. Kapan kerusakan atau kejadian dilaporkan pada anda? 3. Alamat tempat kejadian: 4. Mohon jelaskan bagaimana terjadinya kehilangan, kerusakan atau kejadian:
…………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… 5.
Please describe nature of damage or injury: ……………………………………………………………………………………
5. Mohon jelaskan jenis kerusakan atau kecelakaan:
…………………………………………………………………………………… …………………………………………………………………………………… C. RESPONSIBILITY / WITNESSES TANGGUNG JAWAB / SAKSI-SAKSI 1.
Was another person, in your opinion, responsible for loss or damage or cause of the occurrence?
YES θ
NO θ
If reply is YES, please give full details: (a) Name:……………………………………………….…………………… PT. ASURANSI QBE INDONESIA, Part of QBE Asia Pacific Operations And a member of the QBE Insurance Group Limited – incorporated in A.C.T., Australia MidPlaza 2, 23rd floor, Jalan Jendral Sudirman Kav. 10-11, Jakarta 10220, Indonesia Phone: +62 (21) 572 3737 Fax: +62 (21) 571 0547/48
[email protected] www.qbe.co.id
1. Menurut Anda, adakah orang lain yang bertanggung jawab untuk kerugian atau kerusakan? Jika YA, mohon sebutkan: (a) Nama:
QBE Combined Claim Form (b) Address:……………………………………………………………………
(b) Alamat:
……………………………………………………………………………... (c)
Telephone number:…………………………………..………………….
(c)
(d) Reason:……………………………………………………………………
No. Telepon:
(d) Alasannya:
………….…………………………………………………..……………… …………….…………………………………………………………….… ………….…………………………………………………………….…… ……….……………………………………………………………………. 2.
Was there a witness to this event?
YES θ
NO θ
2. Apakah ada saksi-saksi? Jika YA, mohon sebutkan:
If reply is YES, please give full details: (a) Name:………………………………………………………………………
(a) Nama:
(b) Address:……………………………………………………………………
(b) Alamat:
……………………………………………………………….…………….. (c)
(c)
Telephone number:……………………………………………………….
No. Telepon:
D. BURGLARY LOSS KEBONGKARAN / PENCURIAN 1.
If claiming under Multi Risk, Burglary, Housebreaking, Theft. Malicious Damage, Baggage, advise the following: (a) Full details of methods used by offender ………………………………………………………………...…………… ………………………………………………………………...……………
1. Jika klaim Pembongkaran, pencurian, kehilangan barang atau tindak kejahatan lainnya, mohon jelaskan: (a) Jelaskan bagaimana peristiwa terjadi
………………………………………………………………...…………… ………………………………………………………………...…………… …………………………………………………………………………...… (b) What time were the Police notified?…………………...……….am/pm (c)
Which police station was it reported?…………………………………..
(d) What was the police officer’s name you reported it to?
(b) Kapan dilaporkan Polisi? (c)
Alamat Kantor Polisi (d) Nama Petugas
…………………………………………………………..…………………. 2.
2. Jika tidak dilaporkan ke Polisi,
Please state the reason if not reported to Police: ……………………………………………………………………………………
mohon jelaskan alasannya:
…………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………
(a) Sudahkan kerugian di umumkan? Jika YA, mohon jelaskan dan lampirkan bukti iklan If answered YES, give particulars and attach copy of advertisement
(a) Has the loss been advertised?
YES θ
NO θ
to this form……………………………………………………………..…. ……………………………………………………………………………... (b) When was the property last seen by you? ……………………………. (c)
(b) Kapan terakhir kalinya barang tersebut terlihat oleh anda?
(c) Pada saat terjadinya kerugian, sudah berapa lama bangunan tidak di ……………………………………………………………………………... huni?
At the time of loss how long had premises been unoccupied?
PT. ASURANSI QBE INDONESIA, Part of QBE Asia Pacific Operations And a member of the QBE Insurance Group Limited – incorporated in A.C.T., Australia MidPlaza 2, 23rd floor, Jalan Jendral Sudirman Kav. 10-11, Jakarta 10220, Indonesia Phone: +62 (21) 572 3737 Fax: +62 (21) 571 0547/48
[email protected] www.qbe.co.id
QBE Combined Claim Form E. FIRE LOSS KEBAKARAN 1.
Are you the sole owner of the damage property? YES θ NO θ
1. Apakah Anda pemilik tunggal barang yang rusak tersebut? Jika
If NO, give details of interested parties. ………………………………………………..………………………………..…
TIDAK, mohon sebutkan pihak
……………..………………………………………….………………………….
lainnya.
…………………………………………………………………………………… …………………………………………………………………………………… 2.
What was the total value of the property insured by the policy at the time
2. Berapa Harga Pertanggungan asuransinya?
of loss? (i)
Building: Rp………………………..
(i) Bangunan:
(ii)
Contents: Rp…………………….….
(ii) Isi:
F. WINDSTORM & FLOOD ANGIN TOPAN & BANJIR If claiming for windstorm, hurricane, cyclone, typhoon, water damage or flood please advise the following: (a) Through what type of opening did wind, rain or water enter the premises?…………………………………………………..……………………
Jika anda klaim kerusakan karena angin topan, badai, air atau banjir: (a) Bagaimana angin, hujan atau air masuk ke dalam bangunan?
...……………….……………………………….……………………...………… …. ……………………..……………………..…………………………………. (b) Did windstorm, hurricane, cyclone, typhoon cause opening to premises. YES θ NO θ
If answered YES, please describe cause :
……………………………………………………………………………………
(b) Apakah angin topan atau badai merusakkan bangunan? Jika YA, mohon jelaskan
…………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… G. INSURANCE HISTORY SEJARAH ASURANSI 1.
Have you ever previously sustained loss, damage or caused damage or injury to third parties?
YES θ NO θ
If answered YES, give details of such losses and amounts involved …………………………………..…………………………………..…………… ……………………..………………………………..…………………………… …..…………………………………..…………………………………………… 2.
Was an Insurance Company Involved?
YES θ NO θ
If answered YES, please state below name of company and year of claim:…………………………………..…………………………………..…. ………..…………………………………..……….…………………………… PT. ASURANSI QBE INDONESIA, Part of QBE Asia Pacific Operations And a member of the QBE Insurance Group Limited – incorporated in A.C.T., Australia MidPlaza 2, 23rd floor, Jalan Jendral Sudirman Kav. 10-11, Jakarta 10220, Indonesia Phone: +62 (21) 572 3737 Fax: +62 (21) 571 0547/48
[email protected] www.qbe.co.id
1. Apakah anda pernah mengalami kerugian, kerusakan, atau menyebabkan kerugian atau kecelakaan pada pihak ketiga? Jika YA, mohon jelaskan berikut jumlah kerugiannya 2. Apakah ada persh. Asuransi lainnya yang terlibat? Jika YA, mohon sebutkan nama persh. asuransi dan tahun terjadinya klaim
QBE Combined Claim Form H. DESCRIPTION OF PROPERTY LOST OR DAMAGED JENIS BARANG YANG HILANG ATAU RUSAK IF INSUFFICIENT SPACE PLEASE ATTACH SEPARATE LIST Jika tidak cukup,mohon dibuat dalam lembar terpisah Description of property lost or damaged Jenis barang yang hilang atau rusak
From whom purchased Dibeli dari
Deduction for Date depreciation and purchase Original purchase wear and tear Tanggal price Pengurangan Amount claimed pembelian Harga pembelian depresiasi / aus Jumlah klaim
Total I. DECLARATION PERNYATAAN I/We the Insured do Solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the Policy and in no manner deliberately caused the said loss or damage or sought unjustly to benefit thereby any fraud or willful misrepresentation and that information shown on this form is true that I/We have not concealed any information relating to this claim. Saya/Kami Tertanggung, dengan jujur dan sungguh-sungguh menyatakan bahwa Saya/Kami telah melengkapi kondisi dan persyaratan (jika ada) dalam polis dan tidak ada tindakan yang sengaja dilakukan yang menyebabkan kehilangan atau kerugian tersebut atau mengharapkan keuntungan atas kebohongan atau kesalahan yang disengaja dan bahwa seluruh informasi yang tertera dalam formulir ini adalah benar dan bahwa Saya/Kami tidak menyembunyikan informasi sehubungan dengan klaim ini.
Signature:…..…………..……. Company seal:…………..….……Name:………………….…………..Date:……….……… Tanda tangan Cap Perusahaan Nama Tanggal J. JURISDICTION YURISDIKSI The content and use of this form and any agreement entered into pursuant to this form or any dealing in relation to or arising from this form are governed by the laws of Indonesia and in relation to those matter, the parties submit to the jurisdiction of the courts of that country. Isi dan penggunaan dari formulir ini dan seluruh perjanjian yang disepakati sehubungan dengan formulir ini atau seluruh transaksi sehubungan dengan atau timbul dari formulir ini adalah berdasarkan hokum Indonesia dan oleh karenanya, semua pihak sepakat untuk mengajukan permasalahan berdasarkan yurisdiksi dan pengadilan di negara Indonesia. PT. ASURANSI QBE INDONESIA, Part of QBE Asia Pacific Operations And a member of the QBE Insurance Group Limited – incorporated in A.C.T., Australia MidPlaza 2, 23rd floor, Jalan Jendral Sudirman Kav. 10-11, Jakarta 10220, Indonesia Phone: +62 (21) 572 3737 Fax: +62 (21) 571 0547/48
[email protected] www.qbe.co.id
