INQUIRY HOME
QUESTIONAIRE FORM / FORM PENGISIAN
 
CLIENT PROFILE / DATA KLIEN
  Name / Nama*
  Phone / Telpon*
  Mobile / HP*
  Email / Email*
INSURED PROFILE / DATA TERTANGGUNG
  Name / Nama*
  Address / Alamat*
  Phone / Telpon*
  Mobile / HP*
  Email / Email*
RISK LOCATION / LOKASI PERTANGGUNGAN
  Address / Alamat*
  City / Kota*
  Post Code / Kode Pos*
  Building / Bangunan IDR        :
  DETAILS :
  Building Structure / Struktur Bangunan
  Number of Floor / Jumlah Lantai
  Content / Isi IDR        :
  DETAILS :
  Stocks / Stok IDR        :
  DETAILS :
  Machinery / Mesin IDR        :
  DETAILS :
  Building Occupation / Penggunaan Bangunan
  Period of Cover / Periode pertanggungan (dd mm yy) From To
  Coverage / Cover Asuransi
  Please discribe any other information / mohon diinformasikan jika ada tambahan informasi
 
  Additional Option / Opsi Tambahan
  Including Earthquake, Volcanic Eruption and Tsunami
CLAIM EXPERIENCE / PENGALAMAN KLAIM
  Is there any claim issue in the location / apakah ada masalah klaim sebelumnya di lokasi pertanggungan ?
 
POLICY DOCUMENT / DOKUMEN POLIS
  Do you required Hardcopy/apakah memerlukan polis hardcopy? Additional charge will applied/biaya tambahan akan dikenakan
SECURITY VERIVICATION / VERIFIKASI KEAMANAN
   
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