Samsung Tugu Indonesia
 

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APPLICATION FORM (Motor Vehicle Insurance)
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Required fields are marked with *
Application Data
  5. (ex. 021-5205511)
  6. (ex. 021-5205522)
  7. (ex. 0811234567)
  8. (ex. 021-5205522)
  9.  

Vehicle Detail
  2. Year :
  3. IDR

  4. If STNK not yet available, please state as TBA
Vehicle (Addtitional Information)
Product Packages
  1. Exclusive
    Comprehensive
    Act of God, Civil Commotion, Terrorism & Sabotage
    Natural Perils (Flood, Earthquake)
    Third Party Liability with a limit of IDR 10,000,000 any one accident
    Personal Accident (driver) with a limit of IDR 25,000,000 any one accident
    Personal Accident (passenger max. 4 person) with a limit of IDR 25,000,000 any one accident
    Personal Accident Owner with a limit of IDR 50,000,000 any one accident
    Personal Accident Owner's spouse with a limit of IDR 50,000,000 any one accident
    Medical Expenses with a limit of IDR 25,000,000 any one accident
    Other Benefits
    - Authorized Workshop
    - STNK Renewal Services (Service Fee Only)
    - Emision Test Service (1x per Year)
    - Replacement Car (valid from 3 days, max. 5 days)
    Classic Comprehensive
    Comprehensive
    Strike, Riot, Civil Commotion, Terrorism, Sabotage (SRCCTS)
    Natural Perils (Flood, Eathquake)
    Third Party Liability with a limit of IDR 5,000,000 any one accident
    Personal Accident (driver) with a limit of IDR 5,000,000 any one accident
    Medical Expenses (driver) with a limit of IDR 500,000 any one accident
    Classic Total Loss Only
    Total Loss Only
    Strike, Riot, Civil Commotion, Terrorism, Sabotage (SRCCTS)
    Natural Perils (Flood, Eathquake)
    Third Party Liability with a limit of IDR 5,000,000 any one accident
    Personal Accident (driver) with a limit of IDR 5,000,000 any one accident
    Medical Expenses (driver) with a limit of IDR 500,000 any one accident

    Click Here to calculate estimated Premium pricing based on your vehicle value and coverage package.
General Information
  1. Insurance period will start from : *
    Open the calendar popup.
     
Agreements
  1. 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