RI372-02 Company: 2 Branch: 10 Currency:IDR Office: Agent: e-mail: Policy# Prudential Life Assurance Head Office Indonesian

Rupiah

Claims Declined AS AT 30/09/2011

Run Date: 30/09/2011 Time: 1:26:43 Page: 49

AT6B - PRU VISION - JAKARTA 00292744/ARY TJIPTAHARDJA ARYTJIPT@GMAIL.COM Life Assured Risk Com. Date 06/07/2011 06/07/2011 Coverage Period/month 1 1 Amount 36,150,000.00 15,431,900.00 Curr Code IDR IDR Type of Claim Hospital&Surgical Hospital&Surgical Caused by J03 A01 Reason to Decline

77120969 BARTIN SUHERTINAH 77120969 BARTIN SUHERTINAH

Note: Surat Pemberitahuan akan dikirimkan tiga hari kerja setelah Klaim tidak disetujui untuk dibayarkan.

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