PUBLIC AND/OR PERSONAL LIABILITY CLAIM FORM

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1 PUBLIC AND/OR PERSONAL LIABILITY CLAIM FORM IMPORTANT NOTICE Please read the Claim Form fully prior to answering the questions. If anyone holds you responsible for their accident/injury, insist their claim must be in writing. Any communication received must be forwarded to PT ACE Jaya Proteksi immediately. Do not admit liability. If there is insufficient space or further comment on any area is considered necessary, please attach additional pages. Please send the completed Claim Form, as soon as possible, to your insurance advisor or broker or to: Claims Manager PT ACE Jaya Proteksi World Trade Centre Building, 13 th Floor, Jl. Jend. Sudirman, Kav , Jakarta Indonesia THE INSURED Name of Insured : Occupation : Phone No. : THIRD PARTY Name : Age : Phone No. : Private Business General Description :

2 PARTICULARS OF ACCIDENT/INCIDENT Date of accident/incident : / / Time : am/pm Date reported by : / / Time : am/pm Exact location of accident/incident: HOW REPORTED In Person By Telephone By Letter Other By whom (Name) : To whom was incident reported? (Name) : Position/Title : if reported in person was he/she by themselves? q Yes q No (if No ) Assisted By whom (Name) : Escorted Describe the incident or accident in as much details as possible (attach additional pages if necessary)

3 Have you admitted responsibility in any way? q Yes q No (if yes give details) CAUSE Was accident due to : 1. BY THE ACTIONS OF ANY INDIVIDUAL q Yes q No if yes, their name, address and relationship to you (i.e claimant, employee, member of you family, subcontractor, etc.) Name Address Relationship Reason why 2. PROPERTY Do you own the property? Yes q No q (if no state name and address of owner) Do you occupy the property? Yes q No q (if no state name of tenants and the type of tenancy) Had any notice been given of any defect or hazard by your agent or tenants Yes q No q if yes state date notified / / By whom were you notified? What details were notified?

4 What type of property caused the accident? (E.g defect in the property or spillage of some substance, etc.)? 3. PLANT OR EQUIPMENT Yes q No q (if yes describe plant or equipment and its uses) 4. MOTOR VEHICLE Yes q No q Type of Vehicle : Registration Number : Drivers Name : Owners Name : 5. ANIMAL Yes q No q Type of Animal How long have you owned the Animal Is the animal normally confined behind fences Has the Animal been involved in any similar incident

5 CONDITIONS Type of Footwear Was Third Party Lighting Flat Shoe q Carrying parcels Yes q No q Excessive Yes q No q High heels q Wearing spectacles Yes q No q Interior Yes q No q Thongs q Using cane/crutches Yes q No q Satisfactory Yes q No q Other q Walking Surfaces Wet q Broken q Dirty q Worn q Uneven q Torn q If child involved, was she/he accompanied by an adult at time of accident Yes q No q TREATMENT Was treatment given at the scene of the accident Yes q No q if yes by whom : How severe was the injury in your opinion : Trivial/Minor/Major/Serious (Please Circle) Was transport provided? Yes q No q Was Ambulance used? Yes q No q WITNESS AND THEIR RELATIONSHIP (i.e employer, members of your family, etc.) Did a Police Officer attend the accident/incident Yes q No q Name Address Relationship if so, name of Police Officer Police Station Did police lay any changes of intimate action may be taken? if so, please supply full details

6 PROPERTY DAMAGE / LOST Description of property damaged / Lost: Nature and extent of damage / Lost Has any demand for this damage / Lost been made against you Yes q No q Please attach any receipts you have paid to third parties, and provide brief details of amount below: DECLARATION The information and answers given above are to the best of our/my knowledge and belief. We/I have not withheld any information likely to affect PT ACE Jaya Proteksi consideration of the claim. I hereby authorise PT ACE Jaya Proteksi or its Authorised Representative to collect and record any personal data of the policyholder and claimant(s), and disclose such personal data to appropriate third parties in or outside the Republic of Indonesia, including its service providers to deliver services or carry out certain business activities on its behalf and to other ACE companies. Furthermore, I hereby consent to PT ACE Jaya Proteksi recording, using and disclosing such personal data in this way. Signature Date 2013 ACE Group. Coverages underwritten by one or more companies of the ACE Group. Not all coverages available in all jurisdictions. ACE, ACE logo, and ACE insured are trademarks of ACE Limited.

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