2

Informasi Nasabah Korporasi / Corporate Customer Information*

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

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

Informasi Pejabat Berwenang / Authorized Person Information*

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

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

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

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

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

Apakah bidang usahaAndaIs your Line of Business

Tidak / No

Ya / Yes

Pedagang valuta asing, Jasa pengiriman uang, Off shore company, Dealer mobil, Agen perjalanan, Pedagang perhiasan/batu permata/logam berharga, Perusahaan perdagangan ekspor impor, Minimarket, Jasa pengelola parkir, Rumah makan, SPBU, Pedagang isi ulang pulsa, Penjual barang elektronik, Advokat, Akuntan, Konsultasi keuangan, Dealer barang antik dan seni, Agen properti.Foreign exchange traders, Remittance, Off shore company, Car dealers, Travel agents, Jewelers / gemstone / precious metals, Import-export trading company, Minimarket, Parking management services, Restaurants, Gas stations, Reload traders, Sellers of electronics, Lawyers, Accountants, Financial consulting, Antiques and art dealers, Estate agents.

........................................................................................................................................................................................................Bidang UsahaType of Business

Nama PerusahaanCompany Name

Alamat Perusahaan ........................................................................................................................................................................................................Company Address

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

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

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

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

SIUPBusiness Licence

Salinan / Copy of

KTP/KITAS/Paspor Direktur Perusahaan/Pejabat BerwenangIdentity/KITAS/Passport from the Director/Authorized Person

Hasil InvestasiInvestment

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

Surat KuasaUntuk perwakilan resmi danbukan direksi perusahaanLetter of Attorneyfor authorized representative andnot director of company

Sumber Dana / Fund Resources

No. Telepon KantorWork Phone No.

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

Terlampir / Attached

NPWPTax Registration Number

Akte Pendirian PerusahaanDeed of Incorporation

Hasil UsahaBusiness Income

Kode Negara / Country Code

+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) contact.indonesia@aig.com www.aig.co.id

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) contact.indonesia@aig.com www.aig.co.id

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.

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

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

1/3Formulir Aplikasi AIG Business Accident Guard (ABAG) (April 2015)

Formulir Aplikasi AIG Business Accident Guard (ABAG)

ADD OnlyPertanggungan Yang dipilih / Selected Benefit

YaYes

TidakNo

4. Apakah memiliki karyawan yang bekerja di luar Indonesia? Is there any employee based outside of Indonesia?

KaryawanEmployee

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

YaYes

TidakNo

5. Apakah karyawan tersebut dipekerjakan oleh kantor di Indonesia? Please advise if the employee is employed by the Indonesia office

Jika Anda mengisi "Ya" untuk jawaban pertanyaan diatas, mohon mengisi tabel dibawah ini:If "Yes" to Q4, kindly provide the following details

ADD + AMR

*Jika lebih dari 5 silahkan lampirkan tabel peserta di dokumen terpisah.*if more than 5 please attach the list in separate file.

Nama Karyawan*Name of Employee

Kelas PekerjaanJob Class

Negara TempatKaryawan Bekerja

Country where Employee is Located

Nilai Pertanggungan/PlanSum Insured/Plan Selected

(For Pre-underwritten Product)

Tempat dan Tanggal LahirPlace and Date of birth

Informasi Underwriting / Underwriting Information

3. Tertanggung : Insured Person

OrangPerson

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

1. Periode Asuransi / Period of Insurance

Tanggal BerlakuEffective Date

2. Jumlah Karyawan : Number of Employee

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): ...............................

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

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

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

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

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

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

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

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

++

D D / M M / Y Y Y Y Tanggal BerakhirExpiry Date

D D / M M / Y Y Y Y

2/3Formulir Aplikasi AIG Business Accident Guard (ABAG) (April 2015)

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

3/3Formulir Aplikasi AIG Business Accident Guard (ABAG) (April 2015)

Sejarah Klaim / Claim ExperiencePrevious Insurer

Jika anda mengisi "Ya" untuk jawaban pertanyaan diatas, mohon mengisi tabel dibawah ini:If "Yes" to Q6, kindly provide the following details

YaYes

6. Apakah ada karyawan yang melakukan pekerjaan yang memiliki resiko tinggi? Is there any employee engaged in a hazardous occupation?

TidakNo

(Contoh pekerjaan beresiko tinggi: Kru Transportasi Udara, Kru Transportasi Laut, Minyak dan Gas, Tunneling, Pertambangan, Penebangan kayu, Nelayan/ Pelaut, Penambangan Terbuka, Angkatan Bersenjata, Polisi, Penjaga bersenjata atau pengawal, Perkebunan, Olahragawan Profesional, Pemeran pengganti/ pemain sirkus, Pembersih jendela dan pekerjaan konstruksi (kecuali untuk rumah tinggal dan bangunan sampai dengan 3 lantai), Penggergajian, Pembalap, Pekerja bawah tanah, Pembangunan bendungan, jembatan, terowongan, Entertainer Professional, Scaffolders, Perusahaan Feri, Tukang Las, Penyelam, Sandblaster, Pekerja Anjungan Lepas Pantai, dsb).(Hazardous occupation eg, Air crew, Sea Crew,Oil and Gas, Tunneling, Mining, Logging, Fisherman, Quarry, Armed Forces, Police, Armed guards or Bodyguards, Plantations, Professional sportman/ woman, Stuntman, window cleaners and construction works that up to 3 stories, sawmil, racing driver, underground work, construction of dams, bridges, tunnels, professional entertainers, scaffolders, ferry companies, Welder, Diver, Sandblaster, Offshore Workers, armed guards, etc)

Periode PerlindunganPeriod of Coverage

Jumlah karyawanyang diasuransikan

Number of Insured

Klaim yang dibayarkanPaid Claims

Jumlah klaim terhutangOutstanding Claims

Rasio KerugianLoss Ratio

Jumlah KaryawanNumber of Employee

Kelas PekerjaanJob Class

Negara TempatKaryawan Bekerja

Country where Employee is Located

Nilai Pertanggungan/PlanSum Insured/Plan

Tempat dan Tanggal LahirPlace and Date of birth

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