Formulir Permohonan Asuransi Angkutan

FORMULIR PERMOHONAN ASURANSI ANGKUTAN

TYPE ASURANSI                        :  IMPORT / EXPORT / LAND TRANSIT – INTER ISLAND (Coret yang tidak perlu)

                                                  

NAMA DEBITUR                         :

ALAMAT                                    :          

JENIS BARANG (baru/bekas*)     :

(mohon dijabarkan)

NILAI BARANG                          :

GROSS WEIGHT                         :                                                                       B/L or AWB No :

L/C (Bila Ada)                            :                                                              

INVOICE NO                              :                                                                       TANGGAL :

ETD                                          :                                                                       ETA :

RUTE PENGANGKUTAN              :                                                                       KE :

                                               

TRANSHIPMENT (bila ada)          :                                                           CONNECTING VESSEL :

NAMA KAPAL / PESAWAT           :

KONDISI                                   : All Risks as per ICC A

LAMPIRAN                                 : 1. Copy Bill of Lading / Airway Bill

(Mohon dilampirkan)                    2. Copy Invoice / Packing List

Jakarta……………………….., 20                                                                

Pemohon,

           

Nama + tandatangan + Stempel perusahaan

* Coret yang tidak perlu