811000335_CFSPAS20000001_01112022071446

E-CERTIFICATE OF MSIG TRAVEL INSURANCE

In accordance with your instruction, we hereby declare to have affected insurance on your behalf with
following particulars:

POLICY NO 811000335
Nomor Polis Meyretha Elly Marsaulina
Jl pemancingan No 40 RT 5 RW 5
INSURED NAME : From 2022-12-15 To 2023-01-06
Pemegang Polis refer to local time, using 24-hour time format in case time displayed
Worldwide Family B
INSURED ADDRESS : 3
Alamat Tertanggung 23
Schengen
INSURANCE PERIOD :
Jangka Waktu Pertanggungan 840,000.00
0
PACKAGE NAME :
Nama Paket 10,000.00
_______________
NUMBER OF PEOPLE :
Jumlah Tertanggung 850,000.00
3,633,000,000.00
NUMBER OF DAYS :
Jumlah Hari

TERITORIAL LIMIT :
Batas Wilayah

NOTE :
Catatan

PREMIUM :
Premi

Policy Cost :
Biaya Polis

Stamp Duty :
Materai

Total :
Total

LIMIT LIABILITY PER PERSON
Jumlah Pertanggungan Per orang

THE INSURED PERSON DETAIL

Name : Meyretha Elly Marsaulina

Dob : 28.05.1984

Passport Number : C9932785

Gender : Female

Relationship with Insured : Insured

Address : Jl pemancingan No 40 RT 5 RW 5 Jakarta Barat 11630

Beneficiary

Heirs

______________________________________________________________

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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Name : Ronny roy

Dob : 08.11.1980

Passport Number : 3172040811800010

Gender : Male

Relationship with Insured : Husband

Address : JL pemancingan no 40 rt 05 rw 005 kec.srengseng Jakarta
Barat 0

Beneficiary

Heirs

______________________________________________________________

Name : Rasendriya beatrix marshanda

Dob : 28.05.2012

Passport Number : 0

Gender : Female

Relationship with Insured : Children

Address : jl pemancingan no 40 rt 05 rw 005 kec.srengseng Jakarta
Barat 0

Beneficiary

Heirs

______________________________________________________________

LIST OF COVERAGES in IDR
Daftar Pertanggungan

- Death / Disablement 750,000,000.00
- Medex by Accident 750,000,000.00
- Medex by Sickness (including covid 19 coverage) 750,000,000.00

- Repatriation of Mortal Remains 100,000,000.00
- Compasionate Visit 50,000,000.00
- Child Guard 50,000,000.00
- Emergency Medical Evacuate & Repatriation
- Lost of Baggage 750,000,000.00
- Lost of Documents & Passport (500,000 / item) 20,000,000.00 (1,000,000 / item)
- Loss of Money & Personal Possesion 5,000,000.00
20,000,000.00 (Sub limit loss of money
- Delay Baggage 5,000,000)
- Travel Cancellation 4,000,000.00 (500,000 / 6 hours)
- Travel Curtailment 25,000,000.00
- Flight Delay 25,000,000.00
- Emergency Travel Expense 4,000,000.00 (500,000 / 3 hours)
30,000,000.00

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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- Hijack 50,000,000.00
- Personal Liability 200,000,000.00
- Contents of unattended House
50,000,000.00
MANDATORY CLAUSES
Klausa Wajib

Computer and Software Date Recognition Exclusion Clause
Terrorism and Sabotage Exclusion Endorsement
War and Terrorism Exclusion Endorsement
Institute Radioactive Contamination, Chemical, Bio
Property Damage Clarification Clause
Waiver Clause
Sanction Limitation and Exclusion Clause LMA 3100
Compliance Endorsement
Premium Payment Warranty 60 days
LMA 5401 Property Cyber and Data Exclusion

ADDITIONAL CLAUSES
Klausa Tambahan

Sickness Medical Expenses Endorsement
Emergency Medical Evacuation and Repatriation
Repatriation of Mortal Remains
Compasionate Visit
Child Guard
Loss of Baggage
Lost of Documents & Passport
Loss of Money & Personal Belongings
Delay Baggage
Travel Cancellation
Travel Curtailment
Flight Delay
Emergency Travel Expense
Hijack Inconvenience
Personal Liability
Contents of unattended House
Travel Cancellation and Travel Curtailment due to Communicable Disease Exclusion

Call Center Number : Claim Call Center Number +62 21 1500 674
Claim whatsapp number +62 812 9464 4004
Claim toll free number 0800 1 401 403

It is hereby understood and agreed that this E-policy will remain in full force and effect until be cancelled by the Company but
under no circumstances will it remain in force for period in excess of 30 (thirty) days from inception date of these Insurance
Period.

Materai Terbayar
Rp. 10,000.00,-

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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Jakarta, 01-11-2022

Authorized Signature
Your Duty of Disclosure In addition to providing all basic information necessary to enable us to place the risk you must ensure
that you are complying with your legal duty of disclosure of all material matters relating to the risk. In particular, you must satisfy
yourself as to the accuracy and completeness of the information you provide to Insurers.
In this respect, you must provide all information relating to a risk whether favorable or not, which would influence the judgment
of a prudent Insurer in determining whether he will take the risk, and, if so for what premium and on what terms.
If all such information is not disclosed by you, Insurers have the right to avoid the contract from its commencement which may
lead to claim not being met.

PT. Asuransi MSIG Indonesia is registered with and supervised by Otoritas Jasa Keuangan
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