PT Asuransi Allianz Life Indonesia

CLA-0201/ 15/05/2023

MEMBER REIMBURSEMENT CLAIM REPORT

AltReg - SubAcc : 2023013099500100-001 Claim Type : Fixed Daily cash
Reference No. : Provider Name : RS ROYAL PROGRESS
Claim # : 2023032399500225 Date Received : 23/03/2023
Claimant ID/ Name : 000072939819 / BENI BRAHMANTIO Date of Service : 16-Jan-2023 - 20-Jan-2023
Subscriber ID/ Name : 000072939819 / BENI BRAHMANTIO Check # : 100-230512051
Policy # - Option : O694-NRP/I/NN/HSP/0016310 Date Paid 12-May-2023
Policy Holder : INDHSAC-IDR-20 OCT Beneficiary : BENI BRAHMANTIO
Account # : BRI -023001134647505

Benefit Description Qty Billed Payable Benefit Non Payable Benefit Reason Code
DAILY CASH SICK (PER DAY) 5.00 3,250,000.00 3,250,000.00 0.00
TOTAL 3,250,000.00 3,250,000.00 0.00

Reason Code Name Notes

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