formulir aplikasi hospital care plus - aig.co.id · pdf filebeneficial owner perorangan /...

Formulir Aplikasi Hospital Care Plus

1/6Formulir Aplikasi Hospital Care Plus (April 2015)

Tanggal Lahir / Date of Birth D D / M M / Y Y Y Y

Informasi Pemegang Polis / Policy Holder Information*

Hasil UsahaBusiness Income

Lain-LainOthers: .................

Sumber DanaSources of Fund

WirausahaEntrepreneurship

GajiSalary

Tabungan / DepositoSaving / Deposit

≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million Penghasilan Kotorper Bulan (Rp)Monthly Gross Income (IDR)

> 25-50 Juta / million > 10-25 Juta / million

Informasi rekening ini akan digunakan untuk pembayaran manfaat atau transaksi pembayaran lainnya dari PT AIG Insurance Indonesia ("AIG Indonesia") apabila ada.

Nama Bank termasuk Cabang / Bank Name incl Branch ...................................................................................................................................................................

Nama Pemilik Rekening / Account Name ....................................................................................................................................................................................................

Nomor Rekening / Account Number ...............................................................................................................................................................................................................

This account information will be used by PT AIG Insurance Indonesia ("AIG Indonesia") for benefit or others payment transaction, if any.

Pejabat/Pegawai Pemerintah, BUMN, Polisi, TentaraOfficial or Employee of Government or State-owned Entity, Police, Military

PekerjaanOccupation

Karyawan SwastaPrivate Employee

Nama Perusahaan / Company Name ....................................................................................................................................................................................................

Lain-lainOthers: ................

WirausahaEntrepreneur

Pengurus Partai Politik atau Anggota LegislatifPolitical Party Officials or Legislators

Alamat Saat ini / Current Address (Jika berbeda dengan Kartu Identitas)(If different with Identity Card)

No. Telepon RumahHome Phone No.

No. PonselMobile No.

Email ..............................................................................................................................................................................................................................................................

Jabatan / Title ............................................................................................................................................................................................................................................

PensiunRetirement

Profesional (Pengacara, Dokter, dll)Professional (Lawyer, Doctor, etc): ...............................

Kota / City ..................................................................... Provinsi / Province ...........................................................................

Kecamatan / District ...................................................................................................................................................................

Kelurahan / Sub District ..............................................................................................................................................................

.................................................................................................................................................................. RT/RW ....... / .......

Kode Pos / Postal Code ............................................... Negara / Country ...........................................................................

PT AIG Insurance IndonesiaIndonesia Stock Exchange Building Tower 2, Floor 3AJl. Jend. Sudirman Kav. 52-53 Jakarta 12190, IndonesiaAIG @Your Service 0800 124 8888 (toll free) [email protected] www.aig.co.id


Nama Pertama / First Name Nama Tengah / Middle Name Nama Akhir / Last Name

....................................................................................... ................................................................................. ....................................................................................

WNI / Indonesian WNA / Foreigner ..............................................................................................................................Kewarganegaraan / Citizenship

Jenis Kelamin / Gender Laki-Laki / Male Perempuan / Female

Alamat Sesuai Kartu Identitas .......................................................................................................................................................................................................Address refer to Identity Card




.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................

.......................................................................................................................................................................................................

Tempat Lahir / Place of Birth ..............................................................................

Based on PMK No.30/PMK.010/2010 regarding Know Your Customer Principle, please complete below form and give check mark (v) in the box provided.

*Sesuai dengan Kartu Identitas / refer to Identity Card

Wajib diisi dengan lengkap sesuai ketentuan PMK No.30/PMK.010/2010 tentang Prinsip Mengenal Nasabah dan beri tanda cek (v) pada kotak yang tersedia.

........................................................................................................................................................................................................

Kode Negara / Country Code Kode Area / Area Code No. Telepon / Phone No.

Kode Negara / Country Code No. Telepon / Phone No.

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Tujuan AsuransiInsurance Purpose

Perlindungan terhadap Harta Kekayaan / Aset PerusahaanPersonal / Company Asset Protection

Lain-lain: ...............................................................................................Others

Apakah Anda memiliki polis asuransi lain di AIG Indonesia atau di perusahaan lain?Do you have other insurance policy owned in AIG Indonesia or other company?

Informasi Tambahan / Additional Info

Apakah Anda atau anggota keluarga Anda Pejabat/Pegawai Pemerintah, BUMN, Kepolisian, Militer, Pengurus Partai Politik atau Anggota Legislatif?Do you or your family member is an Official/Employee of Government Institution, State-owned Entity, Police, Military, Political Party Officials or Legislators?

Ya / Yes Tidak / No

No. Nomor Polis / Policy Number Jenis Asuransi / Type of Insurance Perusahaan Asuransi / Insurance Company

TidakNo

Ya, Mohon isi tabel di bawah iniYes, Please complete below table


PekerjaanOccupation


Nama Perusahaan / Company Name .....................................................................................................................................................................................................





(Jika berbeda dengan kartu identitas)(If different with Identity Card)



Email .............................................................................................................................................................................................................................................................

Jabatan / Title ............................................................................................................................................................................................................................................

PensiunRetirement





....................................................................................... ................................................................................. ...................................................................................

.................................................................................................................................................................. RT/RW ....... / .......




Alamat Sesuai Kartu Identitas ........................................................................................................................................................................................................Address refer to Identity Card




.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................

........................................................................................................................................................................................................


Hubungan dengan Pemegang Polis / Relationship with Policy Holder .......................................................................................................................................

Informasi Tertanggung / Insured Information*

(Diisi jika Nama Tertanggung berbeda dengan Pemegang Polis / To be completed if the Insured name is different with Policy Holder Name)

Alamat Saat ini / Current Address ........................................................................................................................................................................................................



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Beneficial Owner Perorangan / Individual Beneficial Owner*

Apakah nama Beneficial Owner sama dengansalah satu di atas?Is Beneficial Owner name same with one of the above? Pemegang Polis

Policy Holder

Ya / Yes TertanggungInsured

Tidak, Mohon diisi Informasi di bawahNo, Please complete below information

Beneficial Owner adalah setiap orang atau badan hukum yang memiliki dana, mengendalikan transaksi Nasabah, yang memberikan kuasa atas terjadinya suatu transaksi dan/atau yang melakukan pengendalianmelalui badan hukum atau perjanjian.Beneficial Owner is any person or legal entity who has the funds, controls the Customer's transaction, provides power of attorney to a transaction and/or does control through legal entity or agreement.

Hasil UsahaBusiness Income

Lain-LainOthers: .................

Sumber DanaSources of Fund

WirausahaEntrepreneurship

GajiSalary

Tabungan / DepositoSaving / Deposit

≤ 10 Juta / million > 50-100 Juta / million > 100 Juta / million > 25-50 Juta / million > 10-25 Juta / million


PekerjaanOccupation


Nama Perusahaan / Company Name .....................................................................................................................................................................................................




Alamat Saat ini / Current Address ........................................................................................................................................................................................................


(Jika berbeda dengan Kartu Identitas)(If different with Identity Card)



Email .............................................................................................................................................................................................................................................................

Jabatan / Title ............................................................................................................................................................................................................................................

PensiunRetirement


Kota / City ..................................................................... Provinsi / Province ............................................................................



....................................................................................... ................................................................................. ....................................................................................

.................................................................................................................................................................. RT/RW ....... / .......

Kode Pos / Postal Code ............................................... Negara / Country ............................................................................



Alamat Sesuai Kartu Identitas ........................................................................................................................................................................................................Address refer to Identity Card




.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................

........................................................................................................................................................................................................


Hubungan dengan Pemegang Polis / Relationship with Policy Holder ........................................................................................................................................

Penghasilan Kotorper Bulan (Rp)Monthly Gross Income (IDR)



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Keterangan Kesehatan / Health InformationYaYes

TidakNo

YaYes

TidakNo

YaYes

TidakNo

1. Apakah Tertanggung/Pemohon pernah mengajukan permohonan asuransi kesehatan/kecelakaan diri/jiwa yang ditolak/ditunda/ ditarik atau polis asuransi kecelakaan/kesehatan yang dimodifikasi/dikenakan rating/dibatalkan/ditolak perpanjangan. Have you or any of your family member ever applied for medical, personal accident, or life insurance which has been declined, postponed, or withdrawn, or modified, rated, canceled, or renewal refused.

AnakChildren

PasanganSpouse

TertanggungInsured

2. Apakah Tertanggung menderita/menerima perawatan untuk hal-hal dibawah ini? Are you suffering or having treatment for the items listed below?

a. Keluhan pada dada/pernapasan (Asma, Bronkitis, TBC), masalah pernapasan termasuk pendarahan pada saluran pernapasan, masalah pada jantung atau sakit dada (misalnya: Demam Rematik, Hipertensi). Complaint on chest, or respiration (eg. Asthma, Bronchitis, Tuberculosis) or other problem on respiration including bleeding in respiratory system? Problem on hearth or painful chest (eg. Rheumatic Fever, Hypertension).

b. Nyeri Dada (Angina), Murmur, Serangan Jantung, Kelainan Darah, Kelainan Pembuluh Darah. Painful Chest (Angina), Murmur, Heart Attack or deviation on blood or blood vessel.

c. Keluhan organ pencernaan atau hati (termasuk Hepatitis atau pembawa Hepatitis), Ginjal, Kandung Empedu, Diabetes, Kelenjar Gondok. Complaint on digestion organ or liver (inc. Hepatitis or Hepatitis carrier), Kidney, Gall bladder, Diabetes, Aneurysm.

d. Kelainan Mental/Otak, masalah pada Sistem Saraf termasuk Epilepsi, Kelumpuhan, Pusing-Pusing, Sakit Kepala Berkepanjangan, Kehilangan Keseimbangan. Mental, Mind Disorder, or problem on Neural System including Epilepsy, Paralysis, long term headache or lose balance.

e. Kanker, Tumor, Kista, pembengkakan atau pertumbuhan yang lainnya. Cancer, Tumor, Leprosy, Swelling, or any other development.

f. Nyeri/masalah punggung, tulang belakang, otot, persendian, asam urat, ketidakmampuan fisik, kondisi yang mempengaruhi penglihatan, kecepatan/pendengaran. Painful or problems on the back, back bone, muscle or spinal column, gout of physical disablement, condition that affect vision, velocity or sense of hearing.

3. Apakah Anda pernah memakai narkotika, atau kebiasaan menggunakan obat-obatan, atau dirawat, atau konsultasi yang berhubungan dengan pemakaian obat-obatan atau alkohol? Have you ever used any narcotic or ever had a habit of using drugs, or had any treatment or consultation related with alcohol or drug consumption?

4. Apakah Anda pernah menerima atau berharap akan mendapatkan konsultasi kesehatan atau pemeriksaan mengenai AIDS, infeksi HIV, atau penyakit yang ditularkan lewat seks, atau gejala keletihan, Diare berkepanjangan, atau kelainan kulit? Have you ever had or wish to have consultation, health advice, or examination related to AIDS, HIV infections or any disease infected through any sexually transmitted disease, or have a symptom or exhaustion, Acute Diarrhea or abnormal Skin Deviation?

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Bila ada jawaban “Ya” atas pertanyaan di atas mohon berikan penjelasan lebih lanjut di lembaran terpisah, termasuk detil kondisi, tanggal dan perawatannya.If your answer ‘Yes’, to any of above questions, please explain on separate paper, including detail of condition, date & its treatment.

Tanggal dan alasan kunjungan terakhir / Date and reason of the most recent visit: .................................................................................................................

Nama Dokter Keluarga / Family doctor’s name: .................................................................................................................................................................................

Alamat / Address: .........................................................................................................................................................................................................................................

Keterangan Kesehatan / Health InformationYaYes

TidakNo

YaYes

TidakNo

YaYes

TidakNo

AnakChildren

PasanganSpouse

TertanggungInsured

5. Adakah orang tua, kakak/adik, yang meninggal atau menderita Penyakit Jantung, Stroke, Hipertensi, Diabetes, Ginjal, Kelainan Mental, Hepatitis (atau pembawa Hepatitis), Kanker, atau penyakit keturunan lain? Jika “Ya” jelaskan umur, hubungan dan penyebab kematian, atau kondisinya. Did any of your deceased parents, brother/sister have a Stroke, Hypertension, Diabetes, Kidney Illness, Mental Disorder, Hepatitis (or Hepatitis carrier), Cancer or other inherited disease? If ‘Yes’, please explain the age, relationship, and cause of decease, or the conditions

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6. Apakah penglihatan Anda dalam bentuk apapun mengalami kelainan atau kelainan pada fisik? Has your vision for any reason, deviated or physically deviated?

7. Apakah Anda akan atau sedang atau telah mengunjungi rumah sakit, klinik, atau dokter 5 tahun terakhir untuk X-Ray, Ultrasonogram, tes darah, CT Scan, Biopsy, ECG Urin, MRI atau pemeriksaan lain selain kepentingan pekerjaan? Have you been in or visited hospital, clinic, or doctor in the past 5 years for diagnoses such as X-Ray, Ultrasonogram, blood test, CT Scan, Biopsy, ECG Urine, MRI or other diagnosis beside for job reason?

Apakah Anda memilikirumah tinggal pribadi?Do you have your own house?

Apakah Anda memiliki kendaraanpribadi?Do you have your own car?

Apakah Anda sering berpergianke luar kota atau luar negeri?Do you usually travel domestically/overseas?

Ya / Yes Tidak / No

Ya / Yes Tidak / No

Ya / Yes Tidak / No

Plan 1 Plan 2 Plan 3 Plan 4 Plan 5

Jenis Plan / Plan Option

Tertanggung sajaInsured

Rp/US$

Rp 20.000

Tertanggung & PasanganInsured and Spouse

Rp/US$

AnakChildren

Rp/US$

Jumlah Premi TahunanTotal Annual Premium

Rp/US$

Biaya Polis & MateraiStamp Duty and Policy Cost

Premi Tahunan / Annual Premium

US$ 3

Ahli Waris / Name of Beneficiary: ..............................................................................................................................................................................................................

Hubungan / Relationship: ...........................................................................................................................................................................................................................

No. Telepon Ahli Waris yang dapat dihubungi / Beneficiary Contact No.: ...........................................................................................................................



Kartu Kredit / Credit Card

Nama Pemegang Kartu: ..................................................................Name of Card Holder

No. Visa/Master/BCA Card:

Masa BerlakuExpiry Date

Tanda tangan Pemegang Kartu Signature of Card Holder

Pernyataan atas Cara Pembayaran Premi / Statement of Premium Payment Method

............................................................

No. Rekening Bank:Bank Account Number

Nama Pemilik / Account Name ............................................................

kirim bukti transfer ke kantor pusat AIG Indonesia atau kirim melalui:please send the transfer receipt to AIG Indonesia:fax. : 021 5291 4801/4802e-mail : [email protected]

Bank No. Rek (US$)

Citibank 010 265 001 8 010 265 051 4

BCA 458 300 985 2 458 370 089 0

HSBC 001 016 963 068 001 016 963 115

No. Rek (Rp)

D D / M M / Y Y Y Y

Saya dengan ini menyatakan bahwa pada saat aplikasi Saya disetujui, Saya sepakat untuk melunasi premi secara penuh dengan cara sebagai berikut:I hereby that at the time the application is approved, I agree to fully pay the premium in below method

Transfer dari Nama Bank:Transfer from Bank

*Lampirkan Salinan KTP/SIM/Paspor/KIMS/KITAS/KITAP (Attach Copy of Identity/SIM/Passport/KIMS/KITAS/KITAP)

Setuju / Agree Tidak setuju / Disagree

DENGAN MENCENTANG KOLOM SETUJU / BY CHECKING AGREE COLUMN: 1). Saya/Kami setuju bahwa setiap informasi yang diperoleh atau disimpan oleh AIG Indonesia, baik yang terdapat dalam aplikasi ini atau yang diperoleh dengan cara lain, dapat dipergunakan dan diungkapkan oleh AIG Indonesia kepada individu/perusahaan/pihak ketiga (di dalam atau di luar Indonesia) untuk melakukan segala aktivitas yang berhubungan dengan polis Saya/Kami dan/atau AIG Indonesia. Saya/Kami mengerti bahwa ketidaksetujuan Saya/Kami atas kebijakan tersebut dapat mengakibatkan ditolaknya pengajuan formulir aplikasi ini. I/We agree that every information been obtain or kept by AIG Indonesia, both that contained in this application or being obtain by other means, can be used and disclosed by AIG Indonesia to individuals/entities/any third parties (within or outside Indonesia) to do any activities which related to My/Our Policy and/or AIG Indonesia. I/We understand that our disagreement on this policy may have impact on the rejection of this application form.

2) Saya/Kami menyatakan bahwa semua pernyataan yang diberikan dalam aplikasi ini adalah benar dan Saya/Kami tidak menyembunyikan, salah menyatakan atau salah menuliskan semua fakta yang ada. I/We hereby confirm that the statements contained in this form are correct and I/We have not concealed, misrepresented or misstated any material facts.

3). Saya/Kami telah membaca, memahami dan menyetujui syarat dan ketentuan produk asuransi yang telah dijelaskan baik secara lisan atau melalui Ringkasan Produk. Perlindungan asuransi akan dimulai dengan memperhatikan persetujuan dari AIG Indonesia terhadap aplikasi Saya/Kami dan pembayaran premi atas perlindungan asuransi telah diterima oleh AIG Indonesia. I/We had read, understood, and agreed the terms and conditions of insurance product that been explained by both verbally or using Product Summary. Insurance coverage will be commenced subject to conformity from AIG Indonesia to My/Our application and premium payment of such insurance coverage been received by AIG Indonesia.

Pernyataan Nasabah / Customer Disclaimer

Broker / Agent

Nama / Name: ..............................................................

Kode / Code:

Tanggal / Date: ................ / .................. / .....................D D M M 2 0 Y Y

Formulir aplikasi dan dokumen pendukung harap dikirim ke kantor pusat atau kantor cabang AIG Indonesia terdekat.Please send the application form and supporting documents to AIG Indonesia head office or branches.

PERHATIAN! Jangan menandatangani formulir aplikasi ini dalam keadaan kosong / belum diisi.WARNING! Do not sign this application form if it is still blank / not yet filled out.

Pemohon / Applicant

Tanggal / Date: ................ / .................. / .....................D D M M 2 0 Y Y

This application form is part of main application form with Policy Holder name

Formulir Aplikasi Untuk Tertanggung TambahanApplication Form For Additional InsuredFormulir aplikasi ini adalah bagian tidak terpisahkan dari formulir aplikasi utama atas nama Pemegang Polis ....................................................................................................................................

*Sesuai dengan Kartu Identitas / refer to Identity Card



Informasi Tertanggung Tambahan / Additional Insured Information*

1/2Formulir Aplikasi Untuk Tertanggung Tambahan (April 2015)





Email .............................................................................................................................................................................................................................................................

No. Kartu Identitas / Identity Card No. ........................................................................................................................................................................................................

Kode Negara / Country Code Kode Area / Area Code No Telepon / Phone No.



....................................................................................... ................................................................................. ....................................................................................






.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................

........................................................................................................................................................................................................Diisi jika berbeda dengan tertanggungutama di aplikasi utamaTo be completed if different with maininsured in master application

Alamat / Address

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Tanggal Lahir / Date of Birth D D / M M / Y Y Y YTempat Lahir / Place of Birth ..............................................................................





Email .............................................................................................................................................................................................................................................................





....................................................................................... ................................................................................. ....................................................................................






.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................


Alamat / Address

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2/2Formulir Aplikasi Untuk Tertanggung Tambahan (April 2015)





Email .............................................................................................................................................................................................................................................................





....................................................................................... ................................................................................. ....................................................................................






.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................


Alamat / Address

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Email .............................................................................................................................................................................................................................................................





....................................................................................... ................................................................................. ....................................................................................






.................................................................................................................................................................. RT/RW ....... / .......


........................................................................................................................................................................................................


Alamat / Address

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formulir aplikasi hospital care plus - aig.co.id · pdf filebeneficial owner perorangan /...

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