PT.

ASURANSI JIWA INHEALTH INDONESIA

LAMPIRAN FORMULIR PENGAJUAN KLAIM

NAMA PPK : KLINIK KIMIA FARMA CILEUNGSI

BULAN PELAYANAN : Februari 2023

TINGKAT PELAYANAN : RJTP

NO FPK : 1004K075032300001

No No SJP Noka Inhealth Nama Peserta PISA Biaya

1 1004K0750223X000001 1001554960149 IRAWAN P 60.000

2 1004K0750223X000005 1051633280417 KHANSA AULIA FAUZAH 2 30.000

3 1004K0750223X000006 1061537929604 GIANDRA ANANDA RUMY 3 60.000

4 1004K0750223X000011 1011545474152 JULIEN M. LOLONG I 60.000

5 1004K0750223X000012 1041435334629 STEFANUS ALVARO GAVRIEL SITOHANG 1 60.000

6 1004K0750223X000013 1011545483466 INDRIATI HASTUTI I 30.000

7 1004K0750223X000021 1011572321128 HUSNIA NURHAFIDZAH I 30.000

8 1004K0750223X000026 1001474962874 MAMAN SUDIRMAN P 30.000

9 1004K0750223X000029 1001425034057 TAUFIK RIFANI P 60.000

10 1004K0750223X000032 1011664537266 VITA SURYANI I 60.000

11 1004K0750223X000035 1011545474152 JULIEN M. LOLONG I 30.000

12 1004K0750223X000036 1001545474151 ALEX PANGALILA P 30.000

13 1004K0750223X000037 1001672500116 INDRA SETIAWAN P 30.000

14 1004K0750223X000042 1001435334625 PAULUS ADI SURYA SITOHANG P 60.000

15 1004K0750223X000048 1041537929602 ROSSI CHALIEF RAMADHANISH 1 120.000

16 1004K0750223X000049 1001534749863 YULIA SARI P 60.000

17 1004K0750223X000050 1011534749864 PIKRI YADI S 60.000

Total 870.000

Lampiran FPK; page 1 of 1; printed 09-Jun-2023 11:24:26