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ADDENDUM PAGE HALAMAN LAMPIRAN

Policy Number. Nomor Polis.
21/33138/02UIG-K023-001 21/33138/02UIG-K023-001

Cedera.
Injury.

Eye’s injury – Blurry vision on the crew’s Cedera mata – Penglihatan kabur pada mata
right eye with Glaucoma. kanan kru dengan Glaukoma

Disability Status/ Compensation Amount Status Disabilitas/Jumlah Kompensasi.

5% of PA limit disability grade 5% dari batas kelas Disabilitas PA (Kontribusi
(contribution on a goodwill basis)
atas dasar niat baik) 5% dari TWD 50,000
5% of TWD 50,000 or USD 1,707.
atau USD 1,707.

Names of Parties related. Nama para Pihak.

Maritime Mutual Insurance Association Maritime Mutual Insurance Association (NZ)
(NZ) (Principal) (Principal)
Tsai, Jyh-Horng 0934-157-753 (Assured) Tsai, Jyh-Horng 0934-157-753 (Assured)

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