RI372-01 Company: 2 Branch: 10 Currency:IDR Office: Agent: e-mail: Policy# Prudential Life Assurance Head Office Indonesian Rupiah

Claims Approved AS AT 19/02/2014 Run Date: 19/02/2014 Time: 22:37:23 Page: 1067

PX1 - EAST STAR - JAKARTA 00610411/INDRA PRAYITNO, S.E INDRAPRAYITNO21@GMAIL.COM Life Assured Risk Com. Date 25/10/2013 Coverage Period/month 3 Amount 1,701,400.00 Curr Code IDR Type of Claim Hospital&Surgical Caused by R51

18967903 HARMIATI, HJ

Note: Pengiriman surat pemberitahuan serta pembayaran manfaat klaim akan diproses dan diberitahukan melalui RAISe.