PT.

ASURANSI ADIRA DINAMIKA

LIST OF PAYMENT REQUEST by Ref No. (For The Period Of 2/19/2013 - 2/19/2013)
Currency : IDR

No .

Request No. Doc. / Account : IDR

Date Reference No.

Profile Remarks (Voucher)

Remarks

Voucher Type Description

Cash Bank Account

Bank Name CCY Original Rate

Bank Account Amount

CCY

Currency Refno Branch Doc No 1

: 2OTH KHP - TRANSFER : Head Office : BK99-013 (Bank BCA HO (Oprs) - (4553009891)) 19/02/2013 M02IB00001-PT. INDOSURANCE BROKER UTAMA PS/IBU/12/19829 KOMISI 21 POLIS CITIBANK-PUSAT , PUSAT-PUSAT 0106988005-PT INDOSURANCE BROKER UTAMA PT SINAR MEDIA KOMUNIKA and/or all subsidiary, and/or affiliated and/or 990112002277 - Property All Risk IDR 3,200.000 associated companies and/or corporations as now exist and/or may hereafter be constituted and/or acquired including their interest as may appear in partnership and/or joint ventures for their respective rights and interest and in addition, financial institutions which hold and or may hold vested interest in the property insured, for their respective rights and interest. PT-04-P - Pembayaran Komisi (cr) BK99-013 IDR 15,328,409.00

003504/PQ/99/02/13

004008/CNH/99/11/12

1.00

3,200.000

004013/CNH/99/11/12

PS/IBU/12/19829

PT SINAR MEDIA KOMUNIKA and/or all subsidiary, and/or affiliated and/or 990112002371 - EQVET Conjunction associated companies and/or corporations as now exist and/or may hereafter be constituted and/or acquired including their interest as may appear in partnership and/or joint ventures for their respective rights and interest and in addition, financial institutions which hold and or may hold vested interest in the property insured, for their respective rights and interest.

IDR

19,200.000

1.00

19,200.000

003635/CNH/99/11/12

PS/IBU/12/20243

PT IDEAL MEDIA SOLUTION QQ PT. SINAR MEDIA KOMUNIKA and/or all 990112003949 - Property All Risk subsidiary, and/or affiliated and/or associated companies and/or corporations as now exist and/or may hereafter be constituted and/or or acquired including their interest as may appear in partnership and/or joint ventures for their respective rights and interest and in addition, financial institutions which hold and/or may hold vested interest in the property insured, for their respective rights and interest.

IDR

5,818.160

1.00

5,818.160

003664/CNH/99/11/12

PS/IBU/12/20243

PT IDEAL MEDIA SOLUTION QQ PT. SINAR MEDIA KOMUNIKA and/or all 990112003954 - EQVET Conjunction subsidiary, and/or affiliated and/or associated companies and/or corporations as now exist and/or may hereafter be constituted and/or or acquired including their interest as may appear in partnership and/or joint ventures for their respective rights and interest and in addition, financial institutions which hold and/or may hold vested interest in the property insured, for their respective rights and interest.

IDR

14,545.440

1.00

14,545.440

corporations as now exist and/or may hereafter be constituted and/or or acquired including their interest as may appear in partnership and/or joint ventures for their respective rights and interest and in addition, financial institutions which hold and/or may hold vested interest in the property insured, for their respective rights and interest.

001198/CNH/99/11/12

PS/IBU/12/20214

MR. BING SISWANTO QQ MS. DIRA and/or all subsidiary companies for their respective rights and interest PT. BUKIT MAKMUR MANDIRI UTAMA and/or all subsidiary, affiliated and associated companies and/or corporations as now exist or may hereafter be constituted or acquired including their interest as may appear in parthnership or joint ventures for their respective rights and interest and in addition, financial institutions which hold or may hold vested interest in the property insured, for their respective rights and interest

002328/CNH/99/11/12

PS/IBU/12/20308

990212001936 - HONDA NC110A1C AT B3092BJT - MH1JF8118BK325098 JF81E1323191 990312000720 - 000019 - Cash in Transit

IDR

6,982.000

1.00

6,982.000

IDR

178,560.000

1.00

178,560.000

002496/CNH/99/05/12

No: PS/IBU/11/17608

SAHABAT UKM SAMPOERNA MICROFINANCE and/or all subsidiary companies and all parties for whom the Insured undertakes to Insure for their respective rights and interest SAHABAT UKM SAMPOERNA MICROFINANCE and/or all subsidiary companies and all parties for whom the Insured undertakes to Insure for their respective rights and interest SAHABAT UKM SAMPOERNA MICROFINANCE PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests

991011000027 - 000022 - Personal Accident Individual

IDR

1,779.840

1.00

1,779.840

002681/CNH/99/05/12

No: PS/IBU/11/17608

991011000027 - 000024 - Personal Accident Individual

IDR

18,165.600

1.00

18,165.600

. . .

002766/CNH/99/07/12 001582/CNH/99/10/12

9910011200071 IND/MCC/0050377 04902009/000999 IND/MCC/0050378 04902009/000898 04902009-0050386

991012000029 - 000017 - Personal Accident Individual 990311000353 - 000100 - Marine Cargo

IDR IDR

206,348.160 29,568.240

1.00 1.00

206,348.160 29,568.240

001590/CNH/99/10/12

990311000353 - 000101 - Marine Cargo

IDR

37,827.000

1.00

37,827.000

001854/CNH/99/11/12

990312000025 - 000002 - Marine Cargo

IDR

2,064,048.480

1.00

2,064,048.480

001860/CNH/99/11/12

04902009-0050394

990312000025 - 000004 - Marine Cargo

IDR

930,598.200

1.00

930,598.200

001877/CNH/99/11/12

04902009-0050363

990312000025 - 000010 - Marine Cargo

IDR

815,306.040

1.00

815,306.040

001881/CNH/99/11/12

04902009-0050361

990312000025 - 000012 - Marine Cargo

IDR

2,131,436.160

1.00

2,131,436.160

001973/CNH/99/11/12

04902009-001588/0050891

990312000025 - 000042 - Marine Cargo

IDR

1,465,601.040

1.00

1,465,601.040

001991/CNH/99/11/12

04902009-001406/0050641

990312000025 - 000076 - Marine Cargo

IDR

1,904,559.480

1.00

1,904,559.480

001993/CNH/99/11/12

04902009-001444/0050629

990312000025 - 000079 - Marine Cargo

IDR

27,305.640

1.00

27,305.640

001995/CNH/99/11/12

04902009-001396/0050627

990312000025 - 000080 - Marine Cargo

IDR

1,824,405.120

1.00

1,824,405.120

001997/CNH/99/11/12

04902009-001392/0050622

PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests PT. SALIM IVOMAS PRATAMA and/or all subsidiary companies and/or associated companies for their respective rights and interests Selisih Pembayaran Administrasi Bank

990312000025 - 000085 - Marine Cargo

IDR

2,108,664.360

1.00

2,108,664.360

001999/CNH/99/11/12

04902009-001401/0050613

990312000025 - 000093 - Marine Cargo

IDR

1,539,490.320

1.00

1,539,490.320

. . .

89207000 89201000

Selisih Pembayaran Administrasi Bank Total DocNo Total Branch Total Refno : BK99-013 : Head Office : 2OTH KHP

IDR IDR

-0.280 -5,000.000 IDR IDR IDR

1.00 1.00

-0.280 -5,000.000

15,328,409.000 15,328,409.000 15,328,409.000 Approved By :

Prepared By :

Checked By :

20/02/2013 -16:22:09 (LR-01-002-E-AAD) - 1

Page 3 of 3

CCY

Nominal Voucher No.

003562/PV/99/02/13

Page 3 of 3