CLA-0201/ 15/10/2018

ALLIANZ LIFE INDONESIA

MEMBER REIMBURSEMENT CLAIM REPORT
AltReg - SubAcc : 2018100999500108-001 Claim Type : Inpatient
Reference No. : Provider Name : RS HERMINA BEKASI
Claim # : 2018100999500146 Date Received : 09/10/2018
Claimant ID/ Name : 000055456889-00/ NENENG ASNIAH Date of Service : 02-Oct-2018 - 06-Oct-2018
Subscriber ID/ Name : 000055456889-00/ NENENG ASNIAH Check # : 100-18101102
Policy # - Option : OB38-NRP/I/NN/FC/00280320 Date Paid 11-Oct-2018
Policy Holder : INDIV-IDR-16 MAY Beneficiary : NENENG ASNIAH
Account # : B C A -0070278961

Benefit Description Qty Billed Payable Benefit Non Payable Benefit Reason Code
SURG MINOR (PER DIS) 1.00 7,500,000.00 7,500,000.00 0.00
DAILY CASH SICK (PER DAY) 5.00 7,500,000.00 7,500,000.00 0.00
TOTAL 15,000,000.00 15,000,000.00 0.00

Reason Code Name Notes

For further information please contact our customer service officer

Allianz Tower Jl. HR. Rasuna Said Kawasan Kuningan Persada Super Blok 2, Jakarta Selatan 12980
Telephone : Allianz Care 1500136 & Allianz Care Sharia 1500139, Facsimile: +6221 2926 8080
Email : Contactus@Allianz.Co.Id, SMS: 08121 333 66 99, Web Site: www.allianz.co.id

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