RINCIAN TAGIHAN PREMI ASURANSI

NO. INVOICE : 0950/III/ISL/INV-PJK/2020

PEMEGANG POLIS : PT BPR AMBULU DHANAARTHA
NO. POLIS INDUK : 200111000044
CABANG : BPR AMBULU DHANAARTHA CABANG RAMBIPUJI Page : 1

NO NO.PESERTA NAMA PESERTA TGL.LAHIR MASA TGL. MULAI TGL. AKHIR UP PREMI FEE PREMI BY PREMI NETTO
. ASURANSI BASE TAMBAHAN SERTIFIKAT

1 027064 ANIK MISRIATI 13 Mar 1980 6 03/03/2020 03/09/2020 2,700,000 5,000 0 0 0 5,000

2 027065 MAKIE 01 Jul 1977 6 03/03/2020 03/09/2020 6,000,000 13,860 0 0 0 13,860

3 027066 SUPRIADI 15 Jan 1985 12 03/03/2020 03/03/2021 4,000,000 6,920 0 0 0 6,920

4 027067 MISBARI 01 Jul 1964 6 03/03/2020 03/09/2020 2,000,000 13,240 0 0 0 13,240

5 027068 MOCH IMRON 14 Jul 1990 12 03/03/2020 03/03/2021 2,700,000 5,000 0 0 0 5,000

6 027069 SUTIYANINGSIH 06 Sep 1968 12 03/03/2020 03/03/2021 4,000,000 24,960 0 0 0 24,960

7 027070 IMROATUN NAFIAH 09 Aug 1995 6 03/03/2020 03/09/2020 4,000,000 5,000 0 0 0 5,000

8 027071 WARDATUS SHOLEHAH 02 Oct 1983 6 04/03/2020 04/09/2020 3,500,000 5,000 0 0 0 5,000

9 027072 RIBUT KARIAMAN 14 Oct 1993 6 04/03/2020 04/09/2020 6,500,000 5,395 0 0 0 5,395

10 027073 ACHMAD SURUJI 16 Jan 1973 12 04/03/2020 04/03/2021 4,500,000 20,295 0 0 0 20,295

11 027074 AGUS HARYONO 29 Sep 1986 12 04/03/2020 04/03/2021 2,000,000 5,000 0 0 0 5,000

12 027075 AMIN 01 Dec 1972 12 04/03/2020 04/03/2021 4,800,000 21,648 0 0 0 21,648

13 027137 BENI PRAKOSO 06 May 1997 6 12/03/2020 12/09/2020 4,500,000 5,000 0 0 0 5,000

14 027138 KARIM 21 Feb 1966 6 13/03/2020 13/09/2020 4,100,000 22,714 0 0 0 22,714

15 027139 ROHANI 30 Jul 1968 6 13/03/2020 13/09/2020 2,500,000 11,950 0 0 0 11,950

16 027140 M TOHIR 06 Aug 1965 6 13/03/2020 13/09/2020 2,000,000 12,140 0 0 0 12,140

17 027141 RIRIN 06 Aug 1988 12 13/03/2020 13/03/2021 3,000,000 5,000 0 0 0 5,000

18 027142 GUNAWAN RAHARJO 02 Aug 1982 6 13/03/2020 13/09/2020 6,000,000 9,060 0 0 0 9,060

19 027143 FARIDA 19 Apr 1980 6 14/03/2020 14/09/2020 2,000,000 5,000 0 0 0 5,000

20 027144 SURYADI 27 Sep 1981 6 16/03/2020 16/09/2020 8,000,000 12,080 0 0 0 12,080

21 027145 SULISTIYOWATI 11 Sep 1985 12 16/03/2020 16/03/2021 2,000,000 5,000 0 0 0 5,000

22 027146 MUHAMAD MASKUR 01 Mar 1983 12 16/03/2020 16/03/2021 2,000,000 5,000 0 0 0 5,000

23 027147 KAHAR SUJATWOKO 03 Feb 1980 12 16/03/2020 16/03/2021 6,000,000 15,120 0 0 0 15,120

24 027148 SAFII 02 Mar 1958 12 16/03/2020 16/03/2021 3,000,000 48,750 0 0 0 48,750

25 027076 BAMBANG SURYONO 29 Mar 1983 6 04/03/2020 04/09/2020 3,500,000 5,000 0 0 0 5,000

26 027077 SUPIYATI 10 Jul 1976 12 04/03/2020 04/03/2021 3,000,000 10,590 0 0 0 10,590

27 027078 RATIMIN 16 Jul 1968 6 04/03/2020 04/09/2020 1,500,000 7,170 0 0 0 7,170

28 027079 KHOLIL AFNANI 23 Nov 1975 6 05/03/2020 05/09/2020 4,000,000 9,880 0 0 0 9,880
RINCIAN TAGIHAN PREMI ASURANSI

NO. INVOICE : 0950/III/ISL/INV-PJK/2020

PEMEGANG POLIS : PT BPR AMBULU DHANAARTHA
NO. POLIS INDUK : 200111000044
CABANG : BPR AMBULU DHANAARTHA CABANG RAMBIPUJI Page : 2

NO NO.PESERTA NAMA PESERTA TGL.LAHIR MASA TGL. MULAI TGL. AKHIR UP PREMI FEE PREMI BY PREMI NETTO
. ASURANSI BASE TAMBAHAN SERTIFIKAT

29 027080 MISNANTO 02 Sep 1986 6 05/03/2020 05/09/2020 3,200,000 5,000 0 0 0 5,000

30 027081 SUMARTO 27 Sep 1971 6 05/03/2020 05/09/2020 5,000,000 17,100 0 0 0 17,100

31 027082 HOPET ABD SYUKUR 26 Feb 1979 6 05/03/2020 05/09/2020 4,800,000 9,264 0 0 0 9,264

32 027083 SUPARNO 10 Oct 1970 6 05/03/2020 05/09/2020 2,700,000 9,963 0 0 0 9,963

33 027084 M MUCHLISIN 11 Sep 1975 6 05/03/2020 05/09/2020 5,000,000 12,350 0 0 0 12,350

34 027085 MUJAYANAH 16 Mar 1977 6 05/03/2020 05/09/2020 4,000,000 9,240 0 0 0 9,240

35 027086 M SOLIHIN HIDAYAT 08 Apr 1970 6 05/03/2020 05/09/2020 6,000,000 23,880 0 0 0 23,880

36 027087 MOH AGUS SALIM 06 Jan 1994 6 06/03/2020 06/09/2020 3,000,000 5,000 0 0 0 5,000

37 027149 SUYITNO 11 Aug 1965 6 16/03/2020 16/09/2020 3,000,000 18,210 0 0 0 18,210

38 027150 LUTFI ROHMAN 12 Nov 1984 12 16/03/2020 16/03/2021 2,000,000 5,000 0 0 0 5,000

39 027151 BAWON HARIANTO 05 May 1985 12 16/03/2020 16/03/2021 6,000,000 10,380 0 0 0 10,380

40 027152 KASIYATI 01 Jul 1966 12 16/03/2020 16/03/2021 6,000,000 47,460 0 0 0 47,460

41 027153 WAGIMAN P RIRIS 01 Jul 1963 6 16/03/2020 16/09/2020 3,500,000 25,200 0 0 0 25,200

42 027154 MAHFUD 05 Dec 1970 6 16/03/2020 16/09/2020 3,500,000 12,915 0 0 0 12,915

43 027155 BASKORO PRIYO PRIBADI 14 Apr 1978 6 16/03/2020 16/09/2020 3,200,000 6,688 0 0 0 6,688

44 027156 ABDUR RAHMAN 20 Jul 1974 12 16/03/2020 16/03/2021 5,000,000 20,750 0 0 0 20,750

45 027157 MUHAMMAD ALI RIDHO 11 May 1995 6 16/03/2020 16/09/2020 4,500,000 5,000 0 0 0 5,000

46 027158 DANDIK YUNI WICAKSONO 06 Jun 1969 6 16/03/2020 16/09/2020 3,400,000 14,858 0 0 0 14,858

47 027159 SUBARI 16 May 1966 6 17/03/2020 17/09/2020 3,000,000 16,620 0 0 0 16,620

48 027160 KACONG ARIF 29 Mar 1984 12 17/03/2020 17/03/2021 3,200,000 5,888 0 0 0 5,888

49 027088 MUHAMMAD SINWAN 28 Mar 1983 12 06/03/2020 06/03/2021 3,000,000 5,970 0 0 0 5,970

50 027089 INDAH 03 Jan 1978 6 06/03/2020 06/09/2020 6,000,000 12,540 0 0 0 12,540

51 027090 SUPRIYADI 09 Sep 1969 6 06/03/2020 06/09/2020 1,000,000 5,000 0 0 0 5,000

52 027091 SUNARTO 07 Aug 1972 6 07/03/2020 07/09/2020 4,500,000 15,390 0 0 0 15,390

53 027092 SUYANTO 28 Jul 1974 6 07/03/2020 07/09/2020 900,000 5,000 0 0 0 5,000

54 027093 SUWARKI ILYAS 10 Jul 1970 6 07/03/2020 07/09/2020 4,400,000 17,512 0 0 0 17,512

55 027094 BUARI 01 Jul 1961 12 09/03/2020 09/03/2021 2,000,000 24,760 0 0 0 24,760

56 027095 EMI ERMAWATI 03 Aug 2000 6 09/03/2020 09/09/2020 6,000,000 5,000 0 0 0 5,000
RINCIAN TAGIHAN PREMI ASURANSI

NO. INVOICE : 0950/III/ISL/INV-PJK/2020

PEMEGANG POLIS : PT BPR AMBULU DHANAARTHA
NO. POLIS INDUK : 200111000044
CABANG : BPR AMBULU DHANAARTHA CABANG RAMBIPUJI Page : 3

NO NO.PESERTA NAMA PESERTA TGL.LAHIR MASA TGL. MULAI TGL. AKHIR UP PREMI FEE PREMI BY PREMI NETTO
. ASURANSI BASE TAMBAHAN SERTIFIKAT

57 027096 AHMAD NUR HALIM 03 May 1971 12 09/03/2020 09/03/2021 4,000,000 21,080 0 0 0 21,080

58 027097 BUNAMIN 12 Oct 1965 6 09/03/2020 09/09/2020 2,350,000 13,019 0 0 0 13,019

59 027098 NANIK SUMIATI 28 Feb 1985 6 09/03/2020 09/09/2020 25,000,000 30,250 0 0 0 30,250

60 027099 TOHAR 30 Sep 1969 6 09/03/2020 09/09/2020 2,700,000 10,746 0 0 0 10,746

61 027100 MOCHAMAD TAUFIQ 01 Jul 1985 12 09/03/2020 09/03/2021 3,000,000 5,190 0 0 0 5,190

62 027101 H MOH YUSUF 10 Dec 1970 6 09/03/2020 09/09/2020 3,500,000 12,915 0 0 0 12,915

63 027102 WAGIMIN 30 Jul 1982 6 09/03/2020 09/09/2020 4,500,000 6,795 0 0 0 6,795

64 027103 ICUK SUGIHARTO 12 Nov 1985 6 09/03/2020 09/09/2020 4,200,000 5,000 0 0 0 5,000

65 027104 ASTUTIK 29 Dec 1988 6 09/03/2020 09/09/2020 3,000,000 5,000 0 0 0 5,000

66 027105 AGUS SUPRIYANTO 28 Feb 1985 6 09/03/2020 09/09/2020 1,500,000 5,000 0 0 0 5,000

67 027106 TIMIN 27 Jul 1976 6 10/03/2020 10/09/2020 1,500,000 5,000 0 0 0 5,000

68 027107 LASIMAN 05 Dec 1962 12 10/03/2020 10/03/2021 2,000,000 20,560 0 0 0 20,560

69 027108 NURSAHID 25 Jun 1985 6 10/03/2020 10/09/2020 4,000,000 5,000 0 0 0 5,000

70 027109 HERMINA 14 Jan 1968 12 10/03/2020 10/03/2021 2,000,000 13,660 0 0 0 13,660

71 027110 YANTO P RODIA 08 Sep 1973 12 10/03/2020 10/03/2021 2,500,000 11,275 0 0 0 11,275

72 027111 SUYONO 12 Nov 1961 6 10/03/2020 10/09/2020 3,000,000 23,460 0 0 0 23,460

73 027112 HAMIDATUZ ZAKIYAH 02 May 1994 6 10/03/2020 10/09/2020 4,200,000 5,000 0 0 0 5,000

74 027113 HARIYADI 10 Jul 1970 6 10/03/2020 10/09/2020 4,200,000 16,716 0 0 0 16,716

75 027114 M IMRON WAHYUDI 27 Jan 1996 12 10/03/2020 10/03/2021 4,000,000 5,000 0 0 0 5,000

76 027115 MARSILA 17 May 1973 6 10/03/2020 10/09/2020 2,000,000 6,320 0 0 0 6,320

77 027116 SITI NUR FADILAH 12 Jan 1988 12 10/03/2020 10/03/2021 3,800,000 5,244 0 0 0 5,244

78 027117 UMI KULSUM 10 Oct 1975 6 11/03/2020 11/09/2020 5,000,000 12,350 0 0 0 12,350

79 027118 ARSITO 12 Nov 1966 12 11/03/2020 11/03/2021 3,200,000 22,752 0 0 0 22,752

80 027119 SENEMA HANDAYANI 13 Jul 1979 12 11/03/2020 11/03/2021 5,300,000 14,575 0 0 0 14,575

81 027120 SIGIT DWI PRASETYO 09 Dec 1983 24 11/03/2020 11/03/2022 30,000,000 113,700 0 0 0 113,700

82 027121 ALIMAN 13 Feb 1968 6 11/03/2020 11/09/2020 3,000,000 14,340 0 0 0 14,340

83 027122 M KARTIMAN 15 Jan 1963 6 11/03/2020 11/09/2020 4,000,000 28,800 0 0 0 28,800

84 027123 FARIDATUL ISMAH 06 Aug 1985 12 11/03/2020 11/03/2021 1,500,000 5,000 0 0 0 5,000
RINCIAN TAGIHAN PREMI ASURANSI

NO. INVOICE : 0950/III/ISL/INV-PJK/2020

PEMEGANG POLIS : PT BPR AMBULU DHANAARTHA
NO. POLIS INDUK : 200111000044
CABANG : BPR AMBULU DHANAARTHA CABANG RAMBIPUJI Page : 4

NO NO.PESERTA NAMA PESERTA TGL.LAHIR MASA TGL. MULAI TGL. AKHIR UP PREMI FEE PREMI BY PREMI NETTO
. ASURANSI BASE TAMBAHAN SERTIFIKAT

85 027124 MUHAMMAD IRFAN 08 Aug 1992 12 11/03/2020 11/03/2021 4,000,000 5,000 0 0 0 5,000

86 027125 MISDI 01 Jul 1963 6 11/03/2020 11/09/2020 4,000,000 28,800 0 0 0 28,800

87 027126 MOH JUMARI 30 Dec 1978 6 11/03/2020 11/09/2020 2,000,000 5,000 0 0 0 5,000

88 027127 FATHUL MUIN 03 Apr 1981 6 11/03/2020 11/09/2020 15,000,000 24,300 0 0 0 24,300

89 027128 MUAWANAH 01 Jul 1978 6 12/03/2020 12/09/2020 2,500,000 5,225 0 0 0 5,225

90 027129 MUHAMMAD ROHIM 12 Apr 1985 12 12/03/2020 12/03/2021 1,500,000 5,000 0 0 0 5,000

91 027130 SETIOWATI 28 Mar 1972 12 12/03/2020 12/03/2021 2,500,000 12,225 0 0 0 12,225

92 027131 HAYUL WAFI 01 Dec 1994 6 12/03/2020 12/09/2020 5,000,000 5,000 0 0 0 5,000

93 027132 SITI FATIMAH 11 Nov 1976 6 12/03/2020 12/09/2020 2,400,000 5,544 0 0 0 5,544

94 027133 SARIP 25 Sep 1968 6 12/03/2020 12/09/2020 4,000,000 17,480 0 0 0 17,480

95 027134 MULYONO 04 Mar 1969 6 12/03/2020 12/09/2020 3,200,000 13,984 0 0 0 13,984

96 027135 IMAM GOZALI 17 Jul 1992 6 12/03/2020 12/09/2020 4,800,000 5,000 0 0 0 5,000

97 027161 ABDUL GOFOR 12 Feb 1980 6 17/03/2020 17/09/2020 10,000,000 17,600 0 0 0 17,600

98 027162 ASIS RIYONO 24 Apr 1962 12 17/03/2020 17/03/2021 7,000,000 78,190 0 0 0 78,190

99 027163 ANANG WAHYUDI 05 Apr 1981 6 17/03/2020 17/09/2020 1,400,000 5,000 0 0 0 5,000

100 027164 ANSOR 01 Jul 1956 6 17/03/2020 17/09/2020 4,900,000 72,863 0 0 0 72,863

101 027165 ABDURROHIM 01 Sep 1982 6 17/03/2020 17/09/2020 2,900,000 5,000 0 0 0 5,000

102 027136 KUSNADI 01 Jul 1980 12 12/03/2020 12/03/2021 2,500,000 6,300 0 0 0 6,300

1,453,968 0 0.00 0.00 1,453,968

GRAND TOTAL

Tgl. Cetak : 19 Maret 2020