Formulir Permohonan simas mobil
Data Tertanggung
Objek Pertanggungan
Kondisi Pertanggungan
Pembayaran
Nama MO :
*
Nama Depan
*
Nama Tengah
Nama Akhir
No KTP
*
Kewarganegaraan
*
Tempat / Tanggal Lahir
*
Status Perkawinan
Jenis Kelamin
*
Jumlah Tanggungan
Belum Menikah
Menikah
Janda
Duda
Pria
Wanita
Alamat Rumah
*
Kota
*
Kecamatan
Kelurahan
Kode Pos
Telepon Rumah
*
Handphone
*
Fax
Email
*
Pekerjaan
*
Jabatan
Nama Perusahaan
--Pilih Pekerjaan--
ACCOUNTING MANAGER
ADJUSTER
ADMIN
ADVISOR
AHLI BEDAH
AKUNTAN
ANAK
ANGGOTA LSM
ARSITEK
ARTIS
ASISTEN
ASISTEN PRESDIR
ASISTEN ADJUSTER
ASISTEN AGRONOMI
ASISTEN DIVISI
ASISTEN KEBUN
ASISTEN KEPALA
ASISTEN MANAGER MARKETING
ASISTEN MANAGER PABRIK
ASISTEN PABRIK
ASISTEN TEKNIK
ASSISTANT ENGINEER
AUDITOR INTERNAL
AUDITOR PUBLIK
BOILER SPV.
BURUH BANGUNAN
BURUH PABRIK
CAMP MANAGER
CAST COATING MANAGER
CAUSTIC SODA OPERATION
CHEMICAL ENGINEER
CHIEF ACCOUNTING
CHIEF ENGINEER
CHIEF PULP MAKING DIV
CIVIL ENGINEER
COMPUTER SYSTEM SPECIALIST
CONSULTANT
CONTROLLER
DEALER
DEPUTY GENERAL MANAGER
DEPUTY SECTION CHIEF
DEVELOPMENT MANAGER
DIREKTUR
DIREKTUR UTAMA
DOKTER
DOKTER ANAK
DOKTER GIGI
DOKTER HEWAN
DOKTER JIWA
DOKTER KANDUNGAN
DOKTER UMUM
EKSPEDISI
ELECTRICAL ENGINEER
ENGINEER
ESTATE MANAGER
EXECUTIVE
FINANCE & ACC MANAGER
FOREST MANAGER
FOREST SILVICULTURIST
FORESTRY
FORESTRY ENGINEER
FORESTRY MANAGER
FORESTRY SUPPORT
FORESTRY SUPPORT AUDIT
GENERAL MANAGER
GIS SPECIALIST
GURU
HARVESTING & HE SUPPORT
HARVESTING CONTROLLER
HEAD OFFICE
HEAVY EQUIPMENT ENGINEER
IBU RUMAH TANGGA
IBU RUMAH TANGGA
IN SERVICE TRAINING MANAGER
INSINYUR
INSINYUR BAGIAN DESAIN
INSINYUR BAGIAN INSTALASI
INSINYUR BAGIAN LISTRIK
INSINYUR PELAKSANA DI LAPANGAN
INSINYUR PRODUKSI
INSINYUR PROYEK
INSTALLATION
INSTRUMENT MANAGER
INVENTORY COORDINATOR
JURU TULIS
KARYAWAN BANK
KARYAWAN TOKO
KASIR
KENEK
KEPALA PERWAKILAN
KEPALA POLIKLINIK
KEPALA TATA USAHA
KOLEKTOR
KOMISARIS
KURIR
MAHASISWA
MAINTENANCE ENGINEER
MANAGEMENT
MANAGEMENT ADVISOR
MANAGER
MANAGER PELAKSANA
MANAJER KILANG MINYAK
MANDOR PABRIK
MARKETING
MARKETING MANAGER
MATERIAL ENGINEER
MECHANICAL ENGINEER
MECHANISED LOGG. SPECIALIST
MEKANIK
MESSENGER
MONTIR
OFFICE STAFF
OPERATING ENGINEER
PEDAGANG
PEGAWAI BUMN
PEGAWAI NEGERI
PELAJAR / MAHASISWA
PEMASANG TURBIN
PEMBOR TURBIN
PEMOTONG RAMBUT
PENASEHAT
PENGACARA
PENGACARA
PENGAWAS PELAKSANA
PENGELAS TURBIN
PENSIUNAN
PETANI
PRESDIR
PROCESS ENGINEER
PRODUCTION CONVERTING
PRODUCTION ENGINEER
PRODUCTION MANAGER
PRODUCTION SUPERVISOR
PROJECTOR COORDINATOR
PURCHASING MANAGER
QC MANAGER
QUALITY CONTROL
RESEARCH SCIENTIST
ROAD MAINTENNANCE
SALES
SALES MANAGER
SALES SHOWROOM
SALESMAN
SANTRI
SATPAM
SECURITY / OFFICE BOY
SEKRETARIS
SENIOR ASSISTANT TO MD
SENIOR MECHANICAL ENGINEER
SERVICE
SHIFT IN CHARGE
SITE MANAGER
STAF UMUM & PENGAWASAN
STAFF
STAFF (PEMADAM KEBAKARAN)
STAFF (SECURITY)
STAFF ACCOUNTING
STAFF BUDGET
STAFF KEUANGAN
STAFF UMUM & PEMBELIAN
SUPERVISOR
SUPERVISOR PELAKSANA
SUPERVISOR SALES ADMINISTRASI
SUPIR
SUPIR ANGKUTAN UMUM
SUPIR PRIBADI
TECHNICAL
TECHNICAL ADVISOR
TECHNICAL CONS.
TECHNICAL ENGINEER
TECHNICAL MANAGER
TECHNICAL STAFF
TECHNICAL SUPPORT MANAGER
TOUR GUIDE/PEMANDU WISATA
TRAINER
TRAINING COORDINATOR
TRANSPORTATION MANAGER
TURIS
WIRASWASTA
WIRASWASTA
WORKSHOP SUPERVISOR
--Pilih Jabatan--
--NONE--
ASISTEN MANAGER
ASISTEN SUPERVISOR
BRANCH MANAGER
DEPUTY BRANCH MANAGER
DIREKTUR
FINANCIAL CONSULTANT
GENERAL MANAGER
HR GA MANAGER
KOMISARIS
MANAGER
MARKETING CONSULTANT
MARKETING OFFICER
NEW RECRUITMENT
PEMILIK
PRESIDEN DIREKTUR
PROFESSIONAL AGENT
REGIONAL MANAGER
SENIOR FINANCIAL CONSULTANT
STAFF
SUPERVISOR
Alamat Kantor
Telepon Kantor
Extension
Alamat Korespondensi
Bidang Usaha
--Pilih Bidang Pekerjaan--
ACCOUNTING / AUDIT / TAXATION
ADMINISTRATION / CLERICAL SUPPORT / SECRETARIAL
ADVERTISING
AEROSPACE / AVIATION
AGRICULTURE / FORESTRY / FISHING
AIRLINE
ARCHITECTURAL SERVICES
ATHLETICS / FITNESS / SPORTS and RECREATION
AUTOMOTIVE
BANKING
BENGKEL
BROKER (PEMERINTAH)
BROKER (SWASTA)
BUILDING / CONSTRUCTION
BUMN/BUMD
BUSINESS ANALYSIS / DATA ANALYSIS
BUSINESS CONSULTANCY
BUSINESS DEVELOPMENT
CALL CENTRE
CHEMICAL
CIVIL SERVICES
COMPANY SECRETARY
COUNSELING
CREDIT COLLECTION
CUSTOMER SERVICE
DAGANG
DESIGN
DEVELOPER
DISTRIBUTOR ALAT BERAT
DOCUMENTARY CREDIT / BILLS PROCESSING
EDITORIAL / JOURNALISM
EDUCATION
ELECTRONIC
EMPLOYMENT FACILITY SERVICE
ENERGY / NATURAL RESOURCES / OIL and GAS
ENGINEERING
ENTERTAINMENT - ARTISTS / SINGERS / MUSICIANS
ENVIRONMENTAL SCIENCE / WASTE MANAGEMENT
EXPORT
FINANCE / LEASING
FOOD and BEVERAGE
FORESTRY
GEMS and JEWELRY
GENERAL INSURANCE
GENERAL MANAGEMENT
GOVERNMENT
HEALTH / BEAUTY CARE
HOLDING COMPANY
HOSPITALITY / HOTEL SERVICES
HOTEL
HUMAN RESOURCES / RECRUITMENT
IMPORT
INDUSTRI
INFORMATION TECHNOLOGY (I.T.)
INSTANSI KESEHATAN
JASA
JASA PENYIMPANAN FILE
JUNIOR EXECUTIVE
KONTRAKTOR
LABORATORY
LEGAL & COMPLIANCE
LEMBAGA KEUANGAN
LEMBAGA/YAYASAN SOSIAL
LIFE INSURANCE
LIFE SCIENCE
LOGISTICS - DISTRIBUTION / INVENTORY MGT / WAREHOUSING
MANUFACTURING
MARKETING / PUBLIC RELATIONS
MEDIA
MEDIA and COMMUNICATIONS
MEDICAL SERVICES
MERCHANDISING
MESIN - MESIN
MILITARY / DEFENSE
MINING
OFFSHORE
OIL & GAS SERVICE
ORDER PROCESSING and OPERATION / SETTLEMENT
OUTSOURCING
PABRIK MARMER
PACKAGING
PELAYARAN
PEMBORONG
PERDAGANGAN DALAM NEGERI
PETROLEUM / PETROCHEMICAL
PHARMACEUTICAL
PHOTOGRAPHY / VIDEO
PLANTATION
PRINTING / PUBLISHING
PROCUREMENT / PURCHASING / SOURCING
PROPERTY
PULP & PAPPER
QUALITY ASSURANCE, CONTROL & TESTING/ISO
QUALITY ASSURANCE, CONTROL and TESTING / ISO
RESEARCH / SURVEY SERVICES
RESEARCH and DEVELOPMENT (R and D)
RESTORAN
SALES
SALON
SCIENTIST
SECURITY
SHOW ROOM
SHOWROOM
SKILLED WORKER
SOCIAL SERVICES - COMMUNITY / NON-PROFIT ORGANIZATION
STUDENT / FRESH GRADUATE / NO EXPERIENCE
SUPPLIER
TECHNICIAN
TELECOMMUNICATIONS
TOP EXECUTIVES (CEO, CFO, CTO, GM, MD ETC.)
TOURISM / TRAVEL AGENCY
TRADING & DISTRIBUTION
TRANSLATION / INTERPRETATION
TRANSPORTATION / SHIPPING / FREIGHT FORWARDING
TRAVEL
UTILITIES
WOOD INDUSTRY
Penghasilan Per Tahun
Sumber Penghasilan
< Rp.10Jt
> Rp.10Jt-25Jt
> Rp.25Jt s/d 50Jt
> Rp.50Jt - 100Jt
> Rp.100Jt - 300Jt
> Rp.300Jt
Hasil Usaha
Gaji Bulanan
Wirausaha
Lain-lain
Jika Lainnya, Sebutkan
Obyek Pertanggungan
No Polisi
*
No. Rangka
*
No. Mesin
*
Merk
*
Type / Model
*
Warna Mobil
*
Tahun Pembuatan
*
Penggunaan
*
Apakah Parkir Di Garasi
*
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
--Pilih--
PRIBADI / DINAS
KOMERSIL
--Pilih--
Ya
Tidak
Harga Kendaraan (Rp)
*
Check Harga Mobil
Kerusakan Sebelum Asuransi :
Perlengkapan non-standard (tambahan) pada kendaraan harap dirincikan (Optional)
:
Nama Perlengkapan
Merk
Harga
Kondisi Pertanggungan
Harga Pertanggungan
Jenis asuransi
*
-- Pilihan Asuransi --
Gabungan
Kerugian Total
TPL ONLY
Periode Pertanggungan Mulai
*
Perluasan :
Gempa Bumi, Tsunami, dan atau Letusan Gunung Berapi
Angin topan, Badai, Hujan es, Banjir, Tanah longsor
Teroris & Sabotase
HURU HARA DAN KERUSUHAN(SRCC)
Jaminan kecelakaan diri pengemudi
orang
Rp. 0,-
Rp. 10.000.000,-
Rp. 25.000.000,-
Rp. 50.000.000,-
Jaminan kecelakaan diri penumpang
orang
Rp. 0,-
Rp. 10.000.000,-
Rp. 25.000.000,-
Rp. 50.000.000,-
(max 4 orang)
Tarif Premi TJH Pihak Ketiga
Rp. 0,-
Rp. 5.000.000,-
Rp. 10.000.000,-
Rp. 25.000.000,-
Rp. 50.000.000,-
Rp. 100.000.000,-
Harga Casco
Casco Lainnya
Rp. 0,-
Rp. 10.000.000,-
Rp. 25.000.000,-
Rp. 50.000.000,-
Lainnya -
Informasi Pengemudi
Nama Pengemudi
SIM Pengemudi
Premi
Rp.
Metode Pembayaran
Menyatakan bahwa keterangan-keterangan tersebut di atas dibuat dengan sejujur-jujurnya dan sesuai dengan keadaan sebenarnya.
Menyadari bahwa keterangan-keterangan tersebut akan digunakan sebagai dasar, serta merupakan bagian dari Polis yang akan diterbitkan, oleh karenanya ketidakbenarannya akan mengakibatkan batalnya pertanggungan dan ditolaknya setiap klaim oleh Penanggung.
Mengerti bahwa pertanggungan yang diminta ini baru berlaku setelah mendapat pemberitahuan persetujuan dari Penanggung berupa bukti softcopy polis.
Saya sudah membaca, dan setuju semua keterangan di atas
*