Insurance Declaration Form Template for Indonesia

Create a bespoke document in minutes,  or upload and review your own.

4.6 / 5
4.8 / 5

Let's create your Insurance Declaration Form

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

Insurance Declaration Form

"I need an Insurance Declaration Form for a manufacturing company in Jakarta, covering property and machinery insurance starting March 2025, that includes specific sections for industrial risk assessment and multiple facility locations."

Document background
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.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant legal definitions
Relevant Industries

Insurance

Banking & Financial Services

Healthcare

Real Estate

Manufacturing

Transportation

Retail

Construction

Hospitality

Agriculture

Mining

Education

Professional Services

Relevant Teams

Legal

Compliance

Risk Management

Underwriting

Claims Processing

Customer Service

Operations

Product Development

Sales

Administration

Finance

Actuarial

Relevant Roles

Insurance Underwriter

Risk Manager

Compliance Officer

Insurance Agent

Insurance Broker

Claims Manager

Legal Counsel

Financial Controller

Chief Risk Officer

Policy Administrator

Business Development Manager

Customer Service Representative

Operations Manager

Product Manager

Actuarial Analyst

Industries
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

Find the exact document you need

Personal Accident Claim Form

An Indonesian-compliant Personal Accident Claim Form for filing insurance claims related to personal accidents, adhering to OJK regulations.

find out more

Professional Indemnity Proposal Form

An OJK-compliant professional indemnity insurance proposal form for professional service providers in Indonesia, designed to assess risks and coverage requirements.

find out more

Medical Insurance Claim Form

An Indonesian-compliant medical insurance claim form for processing healthcare expense reimbursements, aligned with national insurance and healthcare regulations.

find out more

Insurance Claim Form

An Indonesian-compliant Insurance Claim Form that facilitates the submission and processing of insurance claims under OJK regulations.

find out more

Health Insurance Waiver

An Indonesian legal document allowing individuals to decline supplementary health insurance while maintaining mandatory BPJS coverage.

find out more

Insurance Waiver

An Insurance Waiver document compliant with Indonesian insurance laws and OJK regulations, enabling the formal waiver of insurance rights or benefits.

find out more

Accident Claim Form

An Indonesian-compliant insurance claim form for reporting and processing accident-related claims under Indonesian insurance law and OJK regulations.

find out more

Medical Claim Form

An Indonesian-compliant form for submitting medical expense reimbursement claims to insurance providers or BPJS Kesehatan, facilitating the processing of healthcare expense claims.

find out more

Insurance Reimbursement Form

An Indonesian-compliant insurance reimbursement claim form for requesting compensation for medical expenses, aligned with OJK regulations and local insurance laws.

find out more

Motor Claim Form

An Indonesian-compliant motor vehicle insurance claim form used to initiate and process insurance claims for vehicle-related incidents under Indonesian law.

find out more

Insurance Verification Form

An Indonesian-compliant formal document used to verify and confirm insurance coverage details, meeting OJK regulatory requirements.

find out more

Car Insurance Form

An Indonesian-compliant car insurance form establishing coverage terms and conditions between insurer and policyholder under Indonesian insurance regulations.

find out more

Travel Insurance Form

An Indonesian-compliant travel insurance form outlining coverage terms, conditions, and claims procedures under OJK regulations.

find out more

Expired Medicare Card Renewal Form

An Indonesian administrative form for renewing expired Medicare/BPJS Healthcare cards under Indonesian healthcare regulations.

find out more

Waiver Of Subrogation General Liability

An Indonesian law-compliant agreement where an insurer waives its right to recover paid claims from third parties under general liability insurance.

find out more

General Liability Form

An Indonesian law-governed document that establishes liability terms, limitations, and indemnification obligations between business parties.

find out more

Insurance Certificate Of Liability

An Indonesian Insurance Certificate of Liability document that provides proof of liability insurance coverage, compliant with OJK regulations and Indonesian insurance law.

find out more

Workers Comp Exemption Certificate

An Indonesian legal document certifying a worker's exemption from mandatory national workers' compensation insurance requirements under BPJS Ketenagakerjaan regulations.

find out more

Health Waiver Form

An Indonesian-compliant healthcare waiver document establishing informed consent and liability terms between healthcare providers and patients.

find out more

Workers Compensation Waiver

An Indonesian law-compliant document outlining an employee's waiver of certain workers' compensation rights while preserving mandatory statutory benefits.

find out more

Waiver Of Subrogation Form

An Indonesian law-compliant document where an insurer waives its right to recover paid claims from third parties, structured under Insurance Law No. 40 of 2014.

find out more

Health Insurance Waiver Form

An Indonesian legal document for formally declining health insurance coverage, compliant with national healthcare regulations and BPJS requirements.

find out more

Group Insurance Form

An Indonesian legal document establishing group insurance coverage between an insurer and an organization, outlining coverage terms, premiums, and claims procedures in compliance with Indonesian insurance regulations.

find out more

Insurance Proposal Form

An Indonesian law-compliant document used to collect essential information for insurance policy issuance, meeting OJK regulatory requirements.

find out more

Insurance Declaration Form

An Indonesian-law compliant Insurance Declaration Form capturing essential policyholder information and risk declarations for insurance coverage assessment.

find out more

Insurance Affidavit

A notarized sworn statement used in Indonesian insurance proceedings that provides legally binding declarations regarding insurance-related matters.

find out more

Download our whitepaper on the future of AI in Legal

By providing your email address you are consenting to our Privacy Notice.
Thank you for downloading our whitepaper. This should arrive in your inbox shortly. In the meantime, why not jump straight to a section that interests you here: https://www.genieai.co/our-research
Oops! Something went wrong while submitting the form.

Genie’s Security Promise

Genie is the safest place to draft. Here’s how we prioritise your privacy and security.

Your documents are private:

We do not train on your data; Genie’s AI improves independently

All data stored on Genie is private to your organisation

Your documents are protected:

Your documents are protected by ultra-secure 256-bit encryption

Our bank-grade security infrastructure undergoes regular external audits

We are ISO27001 certified, so your data is secure

Organizational security

You retain IP ownership of your documents

You have full control over your data and who gets to see it

Innovation in privacy:

Genie partnered with the Computational Privacy Department at Imperial College London

Together, we ran a £1 million research project on privacy and anonymity in legal contracts

Want to know more?

Visit our Trust Centre for more details and real-time security updates.