The Insurance Declaration Form is a fundamental document in Indonesian insurance practice, required under Law No. 40 of 2014 on Insurance and related OJK regulations. This form must be completed at the initiation of any insurance policy in Indonesia, serving as the basis for the insurance contract. It captures critical information about the policyholder, the subject matter of insurance, and relevant risk factors, forming the foundation for the insurer's risk assessment and policy terms. The document ensures compliance with regulatory requirements while protecting both the insurer's and policyholder's interests through proper disclosure. The form is designed to meet strict regulatory standards, including consumer protection requirements and anti-money laundering provisions, making it essential for all insurance transactions in Indonesia.
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1. Policyholder Information: Basic details of the policyholder including full name, ID number, address, contact information, and occupation
2. Insurance Product Details: Specific information about the type of insurance product being applied for, including coverage type and amount
3. Risk Declaration: Mandatory declarations about risk factors relevant to the insurance coverage
4. Health and Medical History: For life and health insurance, detailed medical history and current health status declarations
5. Financial Information: Declaration of financial status and source of funds for premium payments (required for AML compliance)
6. Beneficiary Information: Details of named beneficiaries including full names, relationships, and allocation percentages
7. Previous Insurance History: Declaration of existing or previous insurance policies and any claims history
8. Authorization and Consent: Permissions for data processing, medical information access, and policy administration
9. Declarations of Truth: Statement confirming all provided information is true and acknowledgment of consequences for false declarations
10. Signatures: Designated spaces for policyholder, witness, and insurance agent signatures with dates
1. Vehicle Information: For motor vehicle insurance: detailed information about the vehicle including registration, specifications, and usage
2. Property Details: For property insurance: detailed description of property, location, security measures, and value
3. Business Operations: For commercial insurance: details of business activities, employees, and risk management procedures
4. Travel Details: For travel insurance: information about travel dates, destinations, and purpose
5. Additional Riders: Optional coverage additions specific to the policy type
6. Family Member Information: For family health plans: details of family members to be covered under the policy
1. Schedule A - Premium Payment Details: Payment schedule, methods, and terms including frequency and due dates
2. Schedule B - Coverage Summary: Detailed breakdown of coverage amounts, limits, and exclusions
3. Schedule C - Required Documents: List of supporting documents that must be submitted with the declaration form
4. Appendix 1 - Medical Questionnaire: Detailed health-related questions for life and health insurance applications
5. Appendix 2 - Risk Assessment Form: Specific risk evaluation questions based on insurance type
6. Appendix 3 - Beneficiary Designation Form: Detailed form for multiple beneficiary designations and conditions
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