Administered by

MC-1184803-60001-626776-V1
24 December 2021 • P 1 / 2

Ms Nidaul Haq Arosyadah Arosyadah Bupa Global

Taman Cikande Blok C12/12 Rt 006 Rw 002 Victory House
Desa Cikande Kec. Jayanti Kab. Trafalgar Place
Tangerang Brighton
Indonesia East Sussex
BN1 4FY
United Kingdom

274480399

Dear Ms Arosyadah

This is your Insurance Certificate that provides a high level summary of your cover. Full
details of the benefits, limitations and exclusions of this health plan can be found in the table
of benefits in your Membership Guide.

The persons listed below is/are a customer of a Raffles Health Insurance Pte Ltd health plan
that provides cover for all eligible treatment, including hospital accommodation and active
treatment, up to an overall annual maximum of USD 10,200,000.00 (sub-limits exist for some
specific benefits), Worldwide Excluding USA.

Kindest regards

Raffles Health Insurance Pte Ltd

Certificate Number MC-1184803-60001-626776-V1 issued on 24/12/2021

Name Date of birth Cover start Cover end Area of cover

Ms Nidaul Haq Arosyadah Arosyadah 10/07/1996 03/01/2022 30/06/2022 Worldwide Excluding USA

Mr Andi Setiawan Setiawan 25/12/1991 03/01/2022 30/06/2022 Worldwide Excluding USA

Corporate Office:
Insured by 585 North Bridge Road #11-00 Raffles
Hospital Singapore 188770

Correspondence Address (Int’l Health Plans):

39 Robinson Road #07-02 Robinson Point
Singapore 068911
Raffles Health Insurance Pte Ltd (“RHI”) (Company Registration Number: 200413569G) is the insurer Tel: +65 6340 1660
and Bupa Global, the trading name of Bupa Insurance Services Limited, is the administrator of Web: www.raffleshealthinsurance.com
RHI international health insurance plans in Singapore. GST Registration No. 200413569G
SGP-PAPR-PORT-1703v1.1
 Administered by

MC-1184803-60001-626776-V1
24 December 2021 • P 2/2

Contract Information

All plans insured by Raffles Health Insurance Pte Ltd

Details for Ms Nidaul Haq Arosyadah Arosyadah (BI-6000-0298-6564)

Date of birth 10/07/1996, resident of Indonesia

Plan Annual maximum (USD)

Sg Company Gold 10,200,000.00

Underwriting terms

Medical history disregarded

Details for Mr Andi Setiawan Setiawan (BI-6000-0298-6565)

Date of birth 25/12/1991, resident of Indonesia

Plan Annual maximum (USD)

Sg Company Gold 10,200,000.00

Underwriting terms

Medical history disregarded

Please note: This table provides a high-level summary only. Full details of the benefits,
limitations and exclusions of this health plan can be found in your Membership Guide.

Corporate Office:
Insured by 585 North Bridge Road #11-00 Raffles
Hospital Singapore 188770

Correspondence Address (Int’l Health Plans):

39 Robinson Road #07-02 Robinson Point
Singapore 068911
Raffles Health Insurance Pte Ltd (“RHI”) (Company Registration Number: 200413569G) is the insurer Tel: +65 6340 1660
and Bupa Global, the trading name of Bupa Insurance Services Limited, is the administrator of Web: www.raffleshealthinsurance.com
RHI international health insurance plans in Singapore. GST Registration No. 200413569G
SGP-PAPR-PORT-1703v1.1