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    21

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    Michael Hanny

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    © All Rights Reserved
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    BUKTI PEMBELIAN (RECEIPT) ested Nome: #1635400772905740490 Tange 05 sun 2019, 09:4 (Rabu) DATA PEMESAN DETAIL PEMBAYARAN Nama Ely Martha Barmo P.O, NUMBER ATTS41657 DETAIL TRANSAKSI_—:Lunas, Email ‘lybarmo@yanoo.com PEMBELIANMELALUI Transfer No. Kontak 6281341418058 DATA PENUMPANG MRS Elly Martha Barto (DEWASA) DETAIL PEMBELIAN No. Jenis Barang Desatpst Ji, Harga satuan Rp Total Rp 1 Tiket Pesawat Lion Air (Dewasa) MOH - PL |7 Jun 2019 1 2.021.500 2.021.500 2 Add-ons: Prepaid Baggage ° ° 3 Asuranst ‘CHUBB - Asurans| Peralanan (Penerbangan) - Plan 1 40.500 40.500 Penerbangan Domest TOTAL 2.062.000 BIAYA ADMINISTRASI 3 JUNILAH PEMBAYARAN 2.061.657 Jka Anda membutuhkan informasi leh lon, llakan hubung kami ‘No. Henphone:+42-204-150- \ Email: es@travolcka.com traveloka Passenger Details No. Passengers) Route Ticket Number 1 Ny. ELLY MARTHA BARMO_ Morowali - Makassar 9902191237575 Makassar - Palu Airline Conditions of Carriage ‘Anda wajib membaca dan mengerti syarat dan ketentuan yang ditentukan oleh maskapai berikut. QO WINGS aie ings Air: H:p://traveloka.com/x/coc/iw-id_ID Beatie Ade satiric: pinraveloia.com/s/coctid-d 10 Cancellation Log in ke akun Traveloka Anda melalui www.traveloka,com/login ‘Masuk ke halaman Pemesanan Saya Tekan tombol Refund pada penerbangan yang ingin di-refund |. Baca prosedur dan Syarat Refund lalu isi formulir Refund Online Permintaan Refund akan diproses oleh Traveloka dan memakan waktu 30-90 hari kerja Info prosedur refund dapat Anda baca lebih lengkap di www.traveloka,com/faq/refund Semua proses refund harus dilakukan melalui Traveloka. Proses refund yang dilakukan di luar Traveloka tidak akan diproses. Loni rp os a8 cour Tanggal +: 08 MAY 2019 Nomor : 0a1/VI/CRO/2019 Bersama ini memberitahukan bahwa ; ‘Tanggal Penerbangan : 08 MAY 2019 Nomor Penerbangan +: IW 1333 // JT 852 Rute : MOH ~ UPG - PLW STD /STA : 12:40~13:10 Keterangan/Alasan : Operasional // Pax misconnect From IW 1333 to ID 6230 { tel 07 juni 19) move next day JT 852. Benar bahwa pada penerbangan tersebut terdapat penumpang, dengan ; Nama : BARMO/ELLY MARTHA MRS Kode Booking : CBYKAC Nomor Tiket +: 9902188535852 Demikian surat keterangan penerbangan ini kami buat dengan sebenar~ benarnya, agar dipergunakan dengan sebagaimana mestinya. Hormat kami , ——Birebuls Pa ont ——____ 18 MYDIR Ie, ELLY MARTA BARRO _sesenseeerusenestnseresseccerenstenseses No Fekening : 151-00-046a763-9 PERN ZEBRA INH BLOK £/8 ALU SELATAN Produk dan Jasa Bank Mandiri mandi tabangan rp dan vatas ‘mandi tsbungan rencaa ruplah dan vals ‘mandir tabungan bens rupiah can alos mandi tebungen ha ‘andi tabsngan karyawan 8 pelajor smanditebugan te Tebunganke ‘mandi gkorupih dan valas mandir depot ropiah San vai mandi debit rmandireme smanditinternet ‘mandi cali, seroran hat ‘transfer ruplah dan valas inkasorupiah dan vals eect debt Standing instrtion AF 0856087 HOP Palu Hasarucinn 15102 Tal Oetak 28/07/2017, 1519236 mandiri Tanda safeidepost box rng BETES. embayaran ga kanyawan penioayvan jak pemiayaranaghan stk telepon, tt ‘ek pejalaran ruplah Travelers cheque valuta aing ued invest. rede med kerja Loedi dengan jominan tai Jet perth rama ued pension hens edit mit guns isminan bank ‘refers! bank Iayanan elspor impor {ual bel barkotes |asese sur berharga den aan CHUBB Certificate of Insurance Chubb Travel Insurance PT Chubb General Insurance Indonesia (hereafter called the “Company") hereby insures the Insured Person(s) named in this Certificate of Insurance, subject to the terms, conditions and exclusions contained in the Chubb Travel Insurance Insurance Master Policy No. 5200101760 (hereafter called the “Policy”). Policy Details Certificate Number ‘TTMDAA732912 ‘Total Premium Payable Rp 40,500.00 Period of Insurance 07 Jun 2019 to 07 Jun 2019 Plan Type OneWay (Domestic) Destination MOH - PLW To Elly Martha Barmo (05 Jun 1989 Customer Service Hotline: +62 1500 257 (24 hours, 7 days per week) E:traveLid@chubb.com Beneficiary / Abli Wari: Beneficiary will be subject to the provisions of laws of the Republic of Indonesia IN WITNESS WHEREOF the Company has caused this Certificate of Insurance to + be executed and the coverage shall be effective throughout the Period of Insurance as stated inthis Certificate of Insurance, provided that this Certificate of Insurance shall nat be binding on the Company unless this Certificate of Insurance i signed by an authorised representative of the Company. se Authorized signature Date of Issue: 05 Jun 2019 {asks rn ean nt or at mir ernie Na cove ean al isons, Gab reece ‘Som ta ab eed SM eps dem ‘Chats Gren farmer lnomsn ged lei yarns as Rng. CHUBB Formulir Klaim Asuransi Perjalanan - Traveloka Travel Insurance Claim Form - Traveloka Jenls Produk / Product Type: Mhrenerbangan / Flight Ckereta api/ train CApenginapan/ Hotel. = C0 Bagasi / Luggage ‘Monon agar mengisiseluruh isan pada halaman ini menggunakan hur kapital. Kindly fillin all he felds on this page using the uppercase etter. ‘A. Data Tertanggung / Insured Information i ore THIN DAA ar izal TTT) cy Number 2. Nama Tetanggung, fre MAT RIT IATA, ALR TMT ‘Name of insured ‘Tempat dan Tanggal Lahir [HoTtTo We 14 Place and Date of Birth 4. Jes Kean Chavis S 5. NomorKaretdenias cxrnpapen [FE Dead Nm 6. Nomor Pokok aj Pajak pwr) ATS): TATA) Tax Registration Number 7. Alamat / Address 8. Koca/Kabupaten Sonatas 9. Kode Pos / Pastal Code shal 10. Nomor Telepoa ‘Rumah / Home Phone Moker ELL Oooo Seluler/ Mobile (Dishes) - ah (slolsiB 11, Alamat Email Email Address 12. Hubungan dengan Tertanggung, Relationship with he Insured 13, Pembayaran Klaim Claim Setiement a. Bank /Bank b.Cabang/ Branch ©. Nomor Rekening ‘Account Number 4. PemilkRekening Beneficiary Name 1B. Data Klaim / Claim Information 1. Jens Klaim B iim type 2 Tas idan a. aera Dateofloss Page 1 of 2 Lots Kalan cr Tecton fla 4. Apalah nda mengauhan Wai i perasabaon auras an? [vas Fafa no Do you also submit this claim to another insurance company? Jka ya, mohon disebutkan nama perusahaan asuransitersebut yes, please state the insurance company name 6. Kronolng Refadian/Chronolgy of ass Pada Wan Sumat Ag Dew ApIg ‘mengalomi Penwndaan penorl Apuom Powiocl ola Atawert 2b vaclava Glen acmaai Reaeseeen Seg Brevongm Moroweli- Meleacsar clenqon Demis Pesawat Wings Air th). 1333 daw Penerdangan Makocar- Pala dengan Jems pesca Bak Aw lA 6230, Jam enerbaran Secuai ket Movpwall -Mclaccar W.50- 13-00 WTA don eae IGA - io wR. Fada hav oo Aevsdbut eoneen Nk Sap au Le Geple Jen 10.00 A dom new) M Feet Sd paver me Aska dele aaD ponder tan beluwnay A A Fie Hrowlolea Mawpon Thadkapa, Ynengeras Pewndaan PererDangan Vaile Secora mm maupun terviss. Saya Mabe Arbérona}cedlean ads Ag UB Juni 2010) nam 08.00 Worpa! Aon Morowals . Male assay don lays Malassar- Vali pada Sam 4.20 wie “Weer _Nomor ; 30219 1233535 Vode Vookany 1 CBY AC €. Pernyataan/Penyerahan Kuasa / Declaration/Authorization ‘Saya/kami menyatakan bahwa selarah informa tersebut tas diberkan deny sebenarbenarnya dan Saya/Karni tidak menahan/ ‘menyembunyikan informasi yang mempengaruhi PT Chubb General Insurance Indonesia dalam pertimbangan klaim, Saya/Kami mengert Klin fn dapat dita atau dikurangl ka nformasi yang diberikan dak benar. 1/e declare that the information given inthe above ae true and complete in every detail and I/We do not withhold any information key to afect PT Chubb General insurance Indonesia's consideration ofthe claim. / We understand thecaim may be refused or reduced i the given informations incorrect. ‘Saya/Kami mengerti dan menyetujui babwa PT Chubb General Insurance indonesia dapat mengumpulkan dan menyimpan data pribad Says/Kami atau informasilinnya untuk kepentingan peneltian, penyelidikan dan perhitungan/penyesuaian Kiaim, termasuk untuk keperiuan survel. Untuk ‘mencapai hal tersebut, Saya/Kami menyetuju dan member laasa kepada PT Chubb General Insurance Indonesia untuk memberikan dan/a ‘mendapatkan data pribadi Saya/Kami dan/atau informasilainnya kepada atau dari pak ketiga balk di dalam mauypun di luar wlayah Republik indonesia, termasuk para penyedia jas, perusahzan asuransi lain, Asoslas Asurans terkaltdan/atau perusahaan fin dalam kelompok usaha PT Chubb General Insurance Indonesia, {We understand and agree that PT Chubl General Insurance Indonesia can collet and record MyyOur personal data or any information forthe purpose (of dlaim research, investigation and caleulation/ adjustment, including survey purpose. To achieve this 'We consent to and authorize PT Chubb General Insurance Indonesia to give and/or obtain Myyour personal data or any information too from any third parties in or outside the Republic of Indonesia, {nluding servic providers, other insurance companies, related Insurance Assocation and/or ether companies within PT Chubb General Insurance Indonesia group of business. re ee ere Chubb. Insured." PT Chubb General Insurance Indonesia Kaneoe Layanan Haim, J. Manga Du Raya, Komplek Grand Boutique Centre Blok No. 24 Jakarta 14430, Indonesia Tel +62) 6230 9S | Hotline 1500257 |Web ww.chubs com Layanan Kiam Onine: www chums {an oye ning angle hina rh poten ‘Steam eso Page 2 of 2 Kroavloe, Keyan Ter EAT PEAVADAAN PENERBAAGAN DARL BAnpara MoPowalr kb PALU TRANST, Dl BaAnDaRa SuvyeA HASAALODA Makassar Rada hor Jpmak AyL oY Sun B09 5 . A mengalomi Penur Amngpon hayuenn Movowwals - Pale Cees ie Pee eon alent Penerbawgan Morowali - Makacgar Aegon Peowar eee ase dow Penerbangan Makassar. Raia Argon paaoart Pahl Air lA baro, Jam Porerbangan seuai ‘ket MoroWal- Makassar Ihso- \o0 wy Aan Makassav - Pala \6-05- Yi wre. Pada Nor umat Aeredort Saya Siddh Chek’ M As Dondara Movowal 3 v Jem 0-00 rps aan Menunggu a von tun ya Sam, i Pada Jom iso wpa Pela ada Penerbangawn “Aan *eAdle ada pembertanan Sebelam na don prhak traveloka maura magkapai mewgenar penundaah — peverba Var Sear “sar wmoulon Aertvlre. Don Saya Mant AVeranakalkan bola han @otu rgl 8 pum Gola, Jom 09.00 ita daw wat; ke Makassar don “low yur lars Makagar- falu pala gan ‘Heo leiqa. Tet Nowor | 9909 IA BPSIS Vode Boling . COL XAC Pau aote) ona a PARMD Reps Kelp: ELL MARTHA BARHO KARTU KELUARGA -« No. 7271031706100008 K.7271.00¢2756 = = = a P

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