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APPLICATION FORM (Motor Vehicle Insurance)
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Required fields are marked with
*
Application Data
Applicant Name:
*
Mr.
Mrs.
Full Name based on STNK:
*
Home Address:
Office Address:
Telephone (Home):
(ex. 021-5205511)
Telephone (Office):
(ex. 021-5205522)
Telephone (Mobile):
*
(ex. 0811234567)
Fax:
(ex. 021-5205522)
E-Mail Address:
*
Vehicle Detail
Maker:
- Select a maker -
Other or Not Listed
AUDI
BAJAJ
BIMANTARA
BMW
CHERY
CHEVROLET
CHRYSLER
DAEWOO
DAIHATSU
FIAT
FORD
HINO
HONDA
HYUNDAI
ISUZU
JAGUAR
JIALING
KANZEN
KAWASAKI
KIA
KYMCO
LAND ROVER
MAZDA
MERCEDEZ BENZ
MITSUBISHI
NISSAN
OPEL
PEUGEOT
PIAGGIO
PROTON
RENAULT
SSANGYONG
SUBARU
SUZUKI
TIMOR
TOSSA
TOYOTA
TVS
VOLKSWAGEN
VOLVO
YAMAHA
Type:
- Choose Type of Car -
Sedan
Jeep
Limousine
Minibus
Truck
Pick Up
Box
Bus
Motor Cycle
Truck Tronton
Ambulance
E.T.C.
Year :
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Vehicle Value:
IDR
Registration No.:
*
If STNK not yet available, please state as TBA
Vehicle (Addtitional Information)
Radio/Tape and Speaker:
Standard
Additional
None
Brand
Type
Price
Air Conditioner:
Standard
Additional
None
Brand
Type
Price
Alarm Installed:
Yes
No
Other Accessories Installed:
No
Yes
Part Name
Brand
Price
Transmission:
Manual
Automatic
Do you have driver?:
No
Yes
If
yes
, please give the details as follow
Driver Name
Mobile/Home Phone
Coverage Packages
Comprehensive I (Diamond)
Comprehensive
Strike Riot & Civil Commotions
Flood
Earthquake
Terrorism & Sabotage
Third Party Liability (limit up to Rp. 20,000,000.-)
Personal Accident (limit up to Rp. 20,000,000.-)
Comprehensive II (Gold)
Comprehensive
Flood
Third Party Liability (limit up to Rp. 10,000,000.-)
Personal Accident (limit up to Rp. 10,000,000.-)
Comprehensive III (Silver)
Comprehensive
Third Party Liability (limit up to Rp. 10,000,000.-)
Personal Accident (limit up to Rp. 10,000,000.-)
Total Loss Only
Total Loss Only
Strike Riot & Civil Commotions
Flood
Earthquake
Terrorism & Sabotage
Third Party Liability (limit up to Rp. 10,000,000.-)
Personal Accident (limit up to Rp. 10,000,000.-)
Click Here
to calculate estimated Premium pricing based on your vehicle value and coverage package.
General Information
Insurance period will start from :
*
Maret 2010
S
S
R
K
J
S
M
9
22
23
24
25
26
27
28
10
1
2
3
4
5
6
7
11
8
9
10
11
12
13
14
12
15
16
17
18
19
20
21
13
22
23
24
25
26
27
28
14
29
30
31
1
2
3
4
Agreements
Here with I/We inform that all information stated in this application form is true
and it will use in my/our insurance policy with PT. Asuransi Samsung Tugu.
This Application Form is not insurance contract agreement
The coverage of insurance will be started if this Application Form is received and agreed by PT. Asuransi Samsung Tugu
I Agree