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Application Form Unmanned Aerial Vehicles

PT. Waskita Karya is seeking unmanned aerial vehicle (UAV) insurance from PT. Asuransi MSIG Indonesia. The application provides details on the insured company, the UAV pilots and their qualifications, the specific UAV model to be insured, and planned operations. If approved, the policy would provide third party liability and physical damage coverage for a DJI M300 used for surveying and mapping activities in visual line of sight conditions within Jakarta. The applicant declares the information provided is accurate and signing the application does not bind PT. Asuransi MSIG Indonesia to provide coverage until approved in writing.

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Abu Bakar Waskita
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55 views3 pages

Application Form Unmanned Aerial Vehicles

PT. Waskita Karya is seeking unmanned aerial vehicle (UAV) insurance from PT. Asuransi MSIG Indonesia. The application provides details on the insured company, the UAV pilots and their qualifications, the specific UAV model to be insured, and planned operations. If approved, the policy would provide third party liability and physical damage coverage for a DJI M300 used for surveying and mapping activities in visual line of sight conditions within Jakarta. The applicant declares the information provided is accurate and signing the application does not bind PT. Asuransi MSIG Indonesia to provide coverage until approved in writing.

Uploaded by

Abu Bakar Waskita
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PT.

ASURANSI MSIG INDONESIA

UNMANNED AERIAL VEHICLES


INSURANCE PROPOSAL FORM

Insured Details
Insured / Company Name : PT. Waskita Karya (Persero) Tbk.
Registered Owner :
(if different from above)

Occupation : Gedung Waskita Heritage


Address Line 1 : Jl MT Haryono No. 10 RT 11 RW 11
Address Line 2 : Cawang, Kecamatan Jatinegara, Kota Jakarta Timur
Postal Code : 13340 Telephone: 082136502310
Email : [email protected]

Third Party Liability Coverage


Single Limit Bodily Injury and Property Damage Liability
Limit of Liability desired : IDR / USD
Medical Expense Coverage : IDR / USD

Physical Damage Coverage


Unmanned Air Vehicle (If multiple UAV or Fleet, please provide information on separate sheet)
Type: Fixed Wing / Rotary Wing UAV based at (Airport / Location): Waskita Rajawali Tower
Registration Annual
Hull Value
Year of Make & / Estimated
(IDR or MTOW (kg) Range (km)
Build Model Serial Utilization
Number USD) (Hours)
2019 DJI M300 120 2.7 15 Km
PT. ASURANSI MSIG INDONESIA
Application / Usage: Survey and Mapping

Lien Holder (if applicable):


Lien Amount
US$

Pilots
Pilot 1 Pilot 2
Name Galih Yudha Wahyu Saputra Andi Firdaus

Date of Birth 01 July 1994 02 October 1995

License Remote Pilot Certificate DKPPU Remote Pilot Certificate DKPPU


Ministry of Transportation Ministry of Transportation
Total time on UAV 120 Hours 120 Hours

UAV time past 12 months 120 Hours 120 Hours

UAV time on Model 120 Hours 120 Hours

Accidents/Violations 0 Accidents/Violations 0 Accidents/Violations

Operations

Governing Operating Body: Private (Civil) / Government / Commercial / Military / Other


(please describe)

Operating Environment: Urban / Semi-Urban / Rural / Industrial / Coastal / Maritime / Other


(please describe)

Flight Conditions: Visual Line of Sight (VLOS) / Beyond Visual Line of Sight (BVLOS) /
Pattern / Instrument Flight Rules (IFR) Conditions / Night / Other (please describe)

Geographical Area of Operations:

Has any insurer cancelled / refused to renew your insurance policy in the past 5
years? YES / NO
Reason:

Name of Present Insurer :Galih Yudha Wahyu Saputra


Policy Expiry Date :
PT. ASURANSI MSIG INDONESIA
Loss History

Date of Loss
Loss Cause Amount Improvement

Declaration:
I declare that the statements and declarations given are true and that no information has been withheld
that might influence acceptance of this proposed insurance; and I agree that the statements and
declarations given above and signed by me shall be the basis of my contract between myself and PT.
Asuransi MSIG Indonesia. This application does not commit PT. Asuransi MSIG Indonesia to any
liability nor make the applicant liable for any premium unless PT. Asuransi MSIG Indonesia agrees in
writing that coverage has been bound.

Signature of Applicant: Galih Yudha Wahyu Saputra

Date : 15 – May – 2023

Phone Numbe r : +62 821 3650 2310

Email : [email protected]

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