Inquiry Form


Please fill in the inquiry form, our consultant will be in touch shortly.
Client Profile
Name *
Phone *
Mobile
Email *
Insured Profile
Name *
Address *
Phone
Mobile
Email
Risk Location
Address *
City *
Post Code *
Building
IDR
Details
Building structures *
Number of Floor
Contents
IDR
Details
Stock
IDR
Details
Machinery
IDR
Details
Building Occupation *
Periode Of Cover (dd-mm-yyyy) * Set date To  Set date
Coverage
Please describe others building occupation around the wall of location which will be insured :
Additional Options
Include Earthquake, Volcanic Eruption, and Tsunami (EQVET)
Claim Experience
Is there any claim issue in the risk location? Please describe it if any * :
Policy Document
Do you required hardcopy? An additional charge for policy cost shall be added on accordingly
Security Verification
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Please fill in the number above in the verification code : * 



Disclaimer
The information contained in this application form is true, and the insured object is in the Indonesian territory. PT Howden Insurance Brokers Indonesia is not liable to any lawful obligations arising from any false information in this application form whatsoever.