Fidelity Guarantee Insurance

Quotation Slip

No.   (New/Renewal)

TYPE                                              :     FIDELITY GUARANTEE INSURANCE

                                                              

INSURED                                            :     PT. XXXXXXXXXXXX and/or Associated Co. and/or Affiliated Co. and/or f.t.r.r.i

ADDRESS                                     :     TBA

PERIOD                                         :     XXXXXXXX, 2006 to XXXXXXXXX, 2007

                                                               At 12.00 noon local time (both days inclusive)

LIMIT OF INDEMNITY                :     USD. XXXXXXXXX any one person or any one loss and in the aggregate.

                                                               In any one period of Insurance : Unlimited..

INTEREST AND SUM INSURED :

Covering the Insured for acts of any of their employees involving larceny, embezzlement or fraudulent and/or misappropriation of money including all company’s assets such as company’s motor-car and motor-cycle, stocks and inventory etc. belonging to the Insured and entrusted to the employee and which shall be committed during the continuance of this insurance and during the uninterrupted employment of the employee and discovered during the continuance of this insurance and/or within the twelve calendar months after the expiration of the policy or the death, dismissal, resignation or retirement of the employee from the service of the Insured whichever of these events shall first occur.

Total Number of Employee :             XX Person consisting of all office staff cleaning servicing drivers and messengers

(unnamed).

EXTENSION CLAUSE

1.     Beneficiary Clause i.f.o.  :  xxxxxx

2.     Breach of Warranty Clause

3.     Errors and Omission Clause

4.     Indonesian Jurisdiction Clause

5.     Loss Notification Clause (30 days)

6.     New Location Clause (berlaku untuk penutupan outlet atau showroom lebih dari satu)

7.     Nominated Loss Adjusters Clause

8.     Notification Clause

9.     Payment on Account Clause

10. Reinstatement Value Clause

11. Thirty (30) Days Cancellation Notice Clause

FLAT ANNUAL PREMIUM                :               USD. _____.00                                                   

Deductible                            :               USD. 000.00 per any one loss or series of losses arising out of the same event.

SECURITY           :

Jakarta, ____________, 2006

Signed in and on behalf of                                                                                            AGREED AND ACC