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20250408_KLIN_Tanggapan atas Permintaan Penjelasan Bursa_31873401_lamp3.pdf

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Page 1 OCR 0.885 
Mitra Proteksindo

Periode

Tanggal — : 19 April 2024 NOTA TAGIHAN

Nomor : 0124/DEBIT NOTE/MB/IV/2024 -

Polis No : 105000803042400013 No. End :
Nama & Alamat Tertanggung : PT. KLINKO KARYA IMAJI TBK

: Jl. Raya Driyorejo KM 25, Desa Semambung
Driyorejo - Gresik

Jenis Asuransi : MACHINERY BREAKDOWN

Catatan Perincian
Pembayaran dapat ditransfer ke rekening : Biaya Premi IDR 5,612,285.00
/Admin 4 Materai IDR 70,000.00
Nama: PT. Mitra Proteksindo Bersama Jumlah IDR 5,682,285.00
IACC No. : PT. BANK MANDIRI KCP SBY DARMO PARK
141-05-4888899-9 RUPIAH
DUE DATE: 13 MEI 2024

Mohon untuk mencantumkan nomor polis untuk pembayaran
melalui transfer

Up, PT- MITRA PROTEKSINDO BERSAMA

UITRA PROT
Dodie Rakhmad Hidayat
Direktur

KSINDO

PT. MITRA PROTEKSINDO BERSAMA
Ciputra World Office Tower Lt. 15 No. 1520
Jalan Mayjend Sungkono No. 89, Surabaya
Page 2 OCR 0.839 
jasa raharja putera

insurance

www jrp.co.id

IKHTISAR PERTANGGUNGAN

ASURANSI MACHINERY BREAKDOWN

NOMOR POLIS
NAMA TERTANGGUNG
ALAMAT TERTANGGUNG

JANGKA WAKTU
PERTANGGUNGAN

LOKASI RISIKO
KODE OKUPANSI

NILAI PERTANGGUNGAN

RISIKO SENDIRI
KLAUSULA
SUBJECT TO

PERHITUNGAN PREMI
- Machinery Breakdown

105000803042400013. (PERPANJANGAN)
PT KLINKO KARYA IMAJI TBK:

Jl, Raya Driyorejo KM 25, Desa Semambung, Driyorejo, Gresik
- 61177

- DETAIL OBJEK PERTANGGUNGAN -

Mulai dari tanggal 27 April 2024 sampai dengan tanggal 27 April 2025
kedua tanggal tersebut pada pukul 12.00 siang waktu setempat dimana
Harta Benda yang dipertanggungkan berada.

Jl. Raya Driyorejo KM 25, Desa Semambung, Driyorejo, Gresik 61177
Pabrik Peralatan RT / Sewing Work

- Machinery Breakdown IDR 3,741,523,392

- RISIKO SENDIRI DAN KLAUSULA -
- Machinery Breakdown : 1096 of claim, minimum IDR 10,000,000.00
Terlampir

- LR nil pada 3 tahun terakhir
- Exclude silent risk
- Exolude pasar risk

- PREMI -

Machinery Breakdown (0.15000 0)

IDR 3,741,523,392.00 x 01546 IDR 5,612,285.09
27 Mpril 2024 - 27 April 2025

ahatapakng sa rehagapatern je

TOTAL PREMI IDR 5,612,285.09

Biaya Polis IDR 50,000.00

Biaya Materai IDR 10,000.00

Materai Kwitansi IDR 10,000.00

Dak OOO.00

TOTAL IDR 5,682,285.09

mam

CATATAN: — Dengan Kesaksian Yang Bertanda Tangan di bawah ini yang diberi wewenang sepatutnya oleh

Penanggung dan atas nama Penanggung telah membubuhkan tanda tangannya.

Psnsitoo,

Surabaya, 25 April 2024
PT ASURANSI JASARAHARJA PUTERA

aharja putera
ce

mM

3 TSALXO81479475

AA Ngr Henry Darmawan

Branch Manager F

Page 1013

PT JASARAHARJA PUTERA No.00-1265110

Jakarta Selatan 12560
D OFFICE : Jl. TB. Simatupang Kavl, Cilandak Timur, S
MEA Dana (0217788-44444 | Fax: (021)788-41234 | Email: pusat@jrp.coid

FRM-0O1/TEK

A9 1RPInsurance @
Page 3 OCR 0.823 
TG jasa raharja putera

insurance

www,jrp.co.id

Halaman ini adalah bagian dari Polis No, 105000803042400013

Klausula 1. Appraisement Clause (1096 of TSI)
2. Automatic Reinstatement of Sum Insured (Additional Premium)
3. Average Relief Clause (8546)
" 4. Cancellation Clause (30 Days)

5. Communicable Disease Exclusion Clause - MA 5394

6. Cost Of Re-Witing Records And Claims Preparation Clause (Limit IDR. 100.000 000)

7. Cyber Risk Exclusion Clause (NMA 2915)

8 Electronic Date Recognition Clause (EDRC)-A

9. Endorsement 001 Cover for Loss or Damage due to Strike, Riot and Civil Gommotion
(SRCC)

10, Endorsement 006 Cover of Extra Charges for Overtime, Night Work, Work on Public
Holidays, Express Freight Clause (Limit 1094 of loss, max IDR 100.00.000)

11. Endorsement 007 Cover of Extra Charges for Airreight (Limit 1094 of loss, max IDR
100.000.000)

12. Endorsement 313 Cover for Internal Fire, Internal Chemical Explosion and Direct Lightning

18.  Endorsement 320 Cover for Lubricating Oil or Retrigerant (IDR. 250.000.000)

14. Error and Omission Clause

15. Expediting Expenses Clause (Limit 1096 of claim)

16. Extra Contractual Obligation Exclusion Clause

17. Fire Brigade Charges Clause (Reasonable Cost)

18. Fire Extinguishing Expenses Clause (Reasonable Cost)

19. IT Clarification Agreement

20. IT Hazard Clarification Clause (NMA 2912)

21. Loss Notification Glause (30 days)

22. Maintenance of machinery should be doing regulary in accordance with the manufacture
recommendation

23. Misdescription Clause

24. Nominated AdJuster Clause - PT. Atlas Adjusting Indonesia - PT. General Adjuster - PT.
Sedgwick Adjuster Indonesia - PT. SDP Crawford

25. Payment On Acoount Clause (2596 of claim)

26. Premium Payment Warranty (PPW) / Warranted Premium Clause (WPC) 30 Days # Grace
period 30 days

27. . Removal of Debris Clause (1096 of loss)

28.  Terrorism Exclusion Endorsement

29. Total Asbestos Exclusion

30. Transmission & Distribution Lines Exclusion Clause

31. War and Civil War Exolusion Clause

Note :

1 Dokumen Ini dibubuhi tanda tangan elektronik melalui mekanisme approval dari sistom
2. Dokumen Ini sah Jika dibubuhi cap perusahaan
3. Keabsahan polis/bond ini dapat divorifikasi secara online melalui website http://www jasaraharja-putera.co.id atau

Pensi. Page 2013

PT JASARAHARJA PUTERA No.00-1265111

HEAD OFFICE : Jl. TB. Simatupang Kavi, Cilandak Tirnur, Jakarta Selatan 12560

- Fax (021)788-41234.| Email: pusat@jrp.co.ic
Phone: (021)788-44444 | Fax: (021) ga

surance

Smaurahea

A8 JRPInsurance MD
Page 4 OCR 0.760 
"| www.jrp.co.id
jasa raharja putera
insurance

Detail Sum Insured :
Machinery Breakdown
No.

Description aty Price/unit Sum Insured
1

Spinning Machine, Type : Dreff 2/86 FT, Year : 2010 1.00|  2,741,523,392.0011R

2,741,523,392.00
2. | Mesin Borghi, Type : BM 15, Year: 2009, SN : 3333 1.00|  1,000,000,000.00|iDR 1,000,000,000.00
TOTAL — IDR 3,741,523,392.00
—— AA.
aus Page 3013
PT JASARAHARIA PUTERA Selatan 12560 No.00-1265112
HEAD OFFICE -Jl. TB. Simatupang Kavl, Cilandak Tirnur, Jakarta Selatan 125

Phone: (021)788-44444 | Fax: (021)788-41234 | Email: pusat@jrp.co.id

FRM-OOI/TEK
rp. insurance

JRPinsurancee DO

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File Open PDF
Source IDX
Size2.11 MB
Published8 Apr 2025
Pages4
Characters5,865
Text sourceOCR
OCR confidence0.827

Names mentioned 12 people and organisations named in the text · linked when the evidence is strong

linked org KLINKO KARYA IMAJI TBK p.1 ×5
linked org BANK MANDIRI p.1
unresolved org PT. Mitra Proteksindo Bersama Jumlah IDR p.1
unresolved org PT. BANK MANDIRI KCP SBY DARMO PARK p.1
unresolved org PT. MITRA PROTEKSINDO BERSAMA Ciputra World Office Tower p.1
unresolved org PT ASURANSI JASARAHARJA PUTERA p.2
unresolved org PT JASARAHARJA PUTERA p.2 ×2
unresolved org PT. Atlas Adjusting Indonesia p.3
unresolved org PT. General Adjuster p.3
unresolved org PT. Sedgwick Adjuster Indonesia p.3
unresolved org PT. SDP Crawford p.3
unresolved org PT JASARAHARIA PUTERA Selatan p.4

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