Baru

PT.
REASURANSI INTERNASIONAL INDONESIA

CLAIM & TECHNICAL ADMINISTRATION REINSURANCE DIVISION
LIST OF CHANGE & PREMIUM ADJUSTMENT

NO : 01105/II/2012/01
ACCOUNTING ENTR : 2nd
: 1
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
COMMENC. CHANGES OF CH.
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
ORIG. COMM. REFUND.COMM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
0000020430
RATNO SUBAGIO
AE00020430
19.06.2008
23.05.2012
01
UBCA2
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
0000028890
UUS MIFTAHUL JALAL
AE00028890
27.04.2012
16.05.2012
01
UBCA2
200,000,000.00
200,000,000.00 2012
550,000.00
504,167.00
55,000.00
50,417.00
0.00
453,750.00
0000031410
. KARSONO
AE00031410
27.01.2012
28.05.2012
01
UBCA2
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0000041110
RUCIE NOVIHARI
AE00041110
29.11.2010
09.05.2012
01
UBCA2
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
0000041120
RUCIE NOVIHARI
AE00041120
29.11.2010
09.05.2012
01
UBCA2
200,000,000.00
100,000,000.00 2011
275,000.00
160,417.00
0.00
0.00
0.00
160,417.00
0000042940
AE00042940
R.D DIANA KENCANA SA
29.11.2010
25.05.2012
01
UBCA2
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
0000042950
AE00042950
R.D DIANA KENCANA SA
29.11.2010
25.05.2012
01
UBCA2
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
0000057440
ALI RAMDANI
AE00057440
27.04.2012
28.05.2012
01
UBCA2
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0000058790
RATNO SUBAGIO
AE00058790
28.12.2010
23.05.2012
01
UBCA2
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
10
0000058800
RATNO SUBAGIO
AE00058800
28.12.2010
23.05.2012
01
UBCA2
150,000,000.00
100,000,000.00 2011
142,000.00
82,833.00
0.00
0.00
0.00
82,833.00
11
0000058830
DENDY KOMARAJAYA
AE00058830
29.11.2010
28.05.2012
01
UBCA2
250,000,000.00
250,000,000.00 2011
180,000.00
90,000.00
0.00
0.00
0.00
90,000.00
12
0000064840
YANTI RISMAYANTI
AE00064840
27.04.2012
28.05.2012
01
UBCA2
250,000,000.00
150,000,000.00 2012
147,000.00
134,750.00
14,700.00
13,475.00
0.00
121,275.00
13
0000064890
HERLIANA SOLIHIN
AE00064890
27.04.2012
28.05.2012
01
UBCA2
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
14
0000020520
AP00020520
B HAPMI ONGKOWIJAYA
10.07.2008
10.05.2012
01
UBCA1
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
15
0000025200
AP00025200
DR DESSY KUSUMAYATI
27.01.2009
10.05.2012
01
UBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
16
0000030630
ALI RAMDANI
AP00030630
27.04.2012
28.05.2012
01
UBCA1
100,000,000.00
50,000,000.00 2012
35,000.00
32,083.00
3,500.00
3,208.00
0.00
28,875.00
17
0000034150
UMI FADHILAH
AP00034150
27.02.2012
22.05.2012
01
UBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
18
0000034330
AP00034330
TIMBUL SAUT SAKKAP S
28.03.2011
28.05.2012
01
UBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
19
0000034970
RUCIE NOVIHARI
AP00034970
29.11.2010
09.05.2012
01
UBCA1
200,000,000.00
200,000,000.00 2011
550,000.00
320,833.00
0.00
0.00
0.00
320,833.00
20
0000036070
WING HANGGODO
AP00036070
02.03.2011
14.05.2012
01
UBCA1
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
21
0000041950
HERYANTO SUTANTO
AP00041950
28.03.2011
01.05.2012
01
UBCA1
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
PT. REASURANSI INTERNASIONAL INDONESIA


NO : 01105/II/2012/01
: 2
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
22
0000078660
DEWI ISABELA
AP00078660
21.10.2009
09.05.2012
01
UBCA1
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
23
0000080980
ADI DHARMA
AP00080980
29.06.2010
09.05.2012
01
UBCA1
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
24
0000097690
AP00097690
R.D. DIANA KENCANA S
29.11.2010
25.05.2012
01
UBCA1
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
25
0000101130
AP00101130
MUHAMAD BAGJA DIRGAN
28.07.2010
28.05.2012
01
UBCA1
350,000,000.00
250,000,000.00 2011
175,000.00
29,167.00
0.00
0.00
0.00
29,167.00
26
0000102070
UUS MIFTAHUL JALAL
AP00102070
27.03.2012
14.05.2012
01
UBCA1
100,000,000.00
100,000,000.00 2012
275,000.00
229,167.00
27,500.00
22,917.00
0.00
206,250.00
27
0000102280
ZAENAL ABIDIN
AP00102280
27.03.2012
07.05.2012
01
UBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
28
0000102340
HERLIANA SOLIHIN
AP00102340
27.04.2012
28.05.2012
01
UBCA1
100,000,000.00
50,000,000.00 2012
39,500.00
36,208.00
3,950.00
3,621.00
0.00
32,587.00
29
0000102350
HESTI SAPTARINI
AP00102350
27.04.2012
23.05.2012
01
UBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
30
0000102390
RIZA ARIANA
AP00102390
27.04.2012
28.05.2012
01
UBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
31
0000102420
SARI NURANI
AP00102420
27.04.2012
28.05.2012
01
UBCA1
150,000,000.00
150,000,000.00 2012
105,000.00
96,250.00
10,500.00
9,625.00
0.00
86,625.00
32
0000103870
AP00103870
DUDUNG BENI HERMAWAN
27.03.2012
08.05.2012
01
UBCA1
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
33
000000183Z
NI WAYAN PADMI .
BD0000183Z
28.09.2009
02.05.2012
01
LBD01
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
34
0000003760
BD00003760
MUHAMMAD YUSUF INDRA
28.01.2010
28.05.2012
01
UBDN2
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
35
0000005650
ISWANTI
BD00005650
20.04.2009
28.05.2012
01
UBDN2
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
36
000000634Z
YASIR .
BD0000634Z
22.06.2010
04.05.2012
01
LBD01
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
37
0000010270
NOOR WAHYUNI
BD00010270
25.03.2009
25.05.2012
01
UBDN2
36,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
38
000001102Z
CHRISTINA .
BD0001102Z
25.07.2011
01.05.2012
01
LBD01
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
39
000001130V
BD0001130V
KASDU PENDIK DEWANTARA .
27.10.2011
10.05.2012
01
LBD01
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
40
000001140V
BD0001140V
RONALD FREDERICH SITOHANG .
27.10.2011
01.05.2012
01
LBD01
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
41
0000048040
SONY HARPRIYONO
BD00048040
01.07.2011
23.05.2012
01
UBDN2
36,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
42
0000048120
NANA JUHANA
BD00048120
26.09.2011
26.05.2012
01
UBDN2
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 3
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
43
0030000007
BP30000007
ROBBY KUSUMAHARTA
26.05.2008
26.05.2012
01
CBP01
185,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
44
000000312Y.02
CD0000312Y
KENYO AYU KARTIKA .
29.12.2009
01.05.2012
01
DN305
15,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
45
0000013810
CM00013810
RAFI ALMASA MUHAMMAD
19.10.2006
04.05.2012
01
UNMPS
5,970,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
46
0000058880
CM00058880
IDA AYU KOMANG DWIST
27.09.2006
27.05.2012
01
UNMPS
6,330,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
47
0000083680
CM00083680
GUNAWAN WASKITO AJI
17.10.2006
24.05.2012
01
UNMPS
5,160,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
48
0000087500
IMAM PRAKOSO
CM00087500
27.11.2006
25.05.2012
01
UNMPS
7,590,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
49
0000096100
TRISTA WIJAYANTI
CM00096100
27.11.2006
22.05.2012
01
UNMPS
9,930,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
50
0000117860
CM00117860
RINANDA ASTRIANI BTB
03.01.2007
03.05.2012
01
UNMPS
5,160,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
51
0000118400
CM00118400
DONNY YANUAR RIZALDI
13.12.2006
21.05.2012
01
UNMPS
5,160,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
52
0000127950
ANNY ISFANDIYARIE
CM00127950
04.01.2007
08.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
53
0000133040
ARIEF LUSENA,ST.
CM00133040
26.01.2007
26.05.2012
01
UNMPS
9,930,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
54
0000155250
MAR'I FIRDAUS
CM00155250
05.02.2008
05.05.2012
01
UNMPS
15,090,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
55
0000161860
YULIANTI RAHAYU
CM00161860
28.05.2007
01.05.2012
01
UNMPS
6,330,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
UNMPS
6,330,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
UNMPS
5,970,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
UNMPS
5,970,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
56
0000161870
CM00161870
TAMARA FRANSISKA .N.
28.05.2007
01.05.2012
57
0000167170
ASEP AHMADI .ST
CM00167170
26.02.2007
29.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
58
0000169530
YULIANA BUDIANTI
CM00169530
14.01.2008
02.05.2012
01
UNMPS
14,370,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
59
0000200380
CM00200380
WULANDARI SUSI LESMA
17.04.2007
17.05.2012
01
UNMPS
5,160,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
60
0000211350
TEDY WAHYUDI
CM00211350
28.06.2007
16.05.2012
01
UNMPS
8,010,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
61
0000217680
CM00217680
GERALD HADISOEMARTO
11.04.2008
11.05.2012
01
UNMPS
9,930,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 4
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
62
0000225310
CM00225310
SALSABILA NAFISAH. H
25.07.2007
25.05.2012
01
UNMPS
5,970,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
63
0000226160
CM00226160
RITA LAKSMITASARI RA
21.05.2007
08.05.2012
01
UNMPS
23,100,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
64
0000234760
ELUS TRISNAWATI
CM00234760
04.09.2007
07.05.2012
01
UNMPS
5,160,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
65
0000241820
CM00241820
JHON FERRY PARDEDE
12.03.2008
12.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
66
0000262970
SHARI ROSSIDA
CM00262970
12.11.2007
29.05.2012
01
UNMPS
8,010,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
67
0000262980
RAFEYFA ASHYLLA
CM00262980
12.11.2007
29.05.2012
01
UNMPS
9,330,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
68
0000264600
IDA BAGUS SUPUTRA
CM00264600
29.10.2007
03.05.2012
01
UNMPS
8,010,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
69
0000265320
LINDA
CM00265320
04.04.2008
10.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
70
0000265720
DATIKA WIDIANI
CM00265720
17.09.2007
02.05.2012
01
UNMPS
8,010,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
71
0000268460
EKA LISTIANI
CM00268460
28.08.2007
21.05.2012
01
UNMPS
5,160,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
72
0000270980
CM00270980
FARREL MUHAMMAD ATHI
25.09.2007
25.05.2012
01
UNMPS
9,330,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
73
0000275110
CM00275110
WIWIK DWI PRAMUDYANI
10.08.2007
28.05.2012
01
UNMPS
17,610,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
74
0000275120
CM00275120
RIO BAGUS WAHYUDIANO
10.08.2007
28.05.2012
01
UNMPS
9,330,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
75
0000277600
HERU SANYOTO
CM00277600
27.03.2008
27.05.2012
01
UNMPS
31,860,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
76
0000281060
SINDY PURBASARI
CM00281060
27.11.2007
27.05.2012
01
UNMPS
8,010,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
77
0000287680
LINDA SIHOMBING
CM00287680
19.03.2008
19.05.2012
01
UNMPS
18,930,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
78
0000289210
ITA SOFIANA
CM00289210
21.02.2008
14.05.2012
01
UNMPS
17,610,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
79
0000289220
CM00289220
FANDI FATURRAHMAN
21.02.2008
14.05.2012
01
UNMPS
9,330,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
80
0000291530
CM00291530
LIVIANA CANNY DEWINT
23.11.2007
03.05.2012
01
UNMPS
17,760,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
81
0000291540
CM00291540
KENNY OCTAVIANTO J
23.11.2007
03.05.2012
01
UNMPS
17,760,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
82
0000298510
CM00298510
MAHENDRA WIBISONO
23.11.2007
07.05.2012
01
UNMPS
12,030,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 5
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
83
0000305920
CM00305920
DIAN INDAH SYAHBANI
27.03.2008
07.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
84
0000305930
CM00305930
FRANKY FONDA ABDI GU
24.04.2008
07.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
85
0000308410
SUSI PARLINA
CM00308410
12.02.2008
12.05.2012
01
UNMPS
9,930,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
86
0000327900
CHRISTIAN
CM00327900
25.04.2008
14.05.2012
01
UNMPS
15,090,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
87
0000348110
MASRIFAH S.SOS
CM00348110
12.12.2007
12.05.2012
01
UNMPS
9,930,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
88
0000350790
CM00350790
CHRISTA LINTANG TYAS
11.01.2008
02.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
89
0000365250
CM00365250
APRILIA PRASETYAWATI
26.12.2007
22.05.2012
01
UNMPS
9,930,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
90
0000365260
AGUNG LUKITO
CM00365260
26.12.2007
22.05.2012
01
UNMPS
9,930,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
91
0000365390
IDA AYU MIRAH SH
CM00365390
11.01.2008
02.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
92
0000377140
MUHAMMAD MUALIM
CM00377140
19.12.2007
22.05.2012
01
UNMPS
8,010,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
93
0000379930
I.B. MADE PASTIKA
CM00379930
23.04.2008
14.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
94
0000390310
CM00390310
NURHAYATI NOVIKA PAN
27.03.2008
23.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
95
0000397410
CM00397410
MUTIA TJOKROKOESOEMO
13.03.2008
13.05.2012
01
UNMPS
14,370,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
96
0000398480
AMSINAH
CM00398480
27.03.2008
29.05.2012
01
UNMPS
14,370,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
97
0000399130
CM00399130
NI GUSTI AYU NYOMAN
25.04.2008
25.05.2012
01
UNMPS
15,090,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
98
0000428010
CM00428010
IKA DUTIA KRISNAMUSI
18.04.2008
02.05.2012
01
UNMPS
8,010,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
99
0000508580
CM00508580
ALBERT SAHAT HALOMOA
21.10.2008
09.05.2012
01
UNMPS
27,780,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
100
000000200Z
PRISCA ADIWIJAYA
DL0000200Z
14.10.2011
14.05.2012
01
HDRHL
40,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
101
000000206Z
DL0000206Z
YENNI SANTI FLORIDA
20.10.2011
21.05.2012
01
HDRHL
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
102
000000107Z
HL0000107Z
CHANDRA HARTISAN SS
22.12.2011
01.05.2012
01
HUMHL
30,000,000.00
30,000,000.00 2011
35,400.00
23,600.00
3,540.00
2,360.00
0.00
21,240.00
103
0000468413
IMKIN0000468413
SUSSY MACHTALINDA
25.01.2006
25.05.2012
01
PMTSHT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 6
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
104
105
106
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
0000484500
IMKIN0000484500
KANIA BAGUS HUTAMA
0000484501
RUSMAN
0000484503
ADI BAGUS HUTAMA
IMKIN0000484501
IMKIN0000484503
DATE OF
DATE OF NATURE
23.02.2006
23.02.2006
23.02.2006
23.03.2012
23.03.2012
23.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
300,000,000.00
250,000,000.00 2012
50,000.00
45,833.00
0.00
0.00
0.00
45,833.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
107
0000484843
IMKIN0000484843
DONY ELLY KURNIAWAN
24.02.2006
24.03.2012
01
PMTSHT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
108
0000488942
HENI PUJIATI
01.03.2006
01.02.2012
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0000488942
109
0000489214.01
IMKIN0000489214
NOVA SRI B NASUTION
24.02.2006
24.02.2012
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
110
0000489556
MAULANA ARIEF
01.03.2006
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
111
112
113
0000489900
TONI
0000491907
PIPIT ARDHYA RINI
0000492506
CUT MAHYUTI
IMKIN0000489556
IMKIN0000489900
IMKIN0000491907
IMKIN0000492506
01.03.2006
06.03.2006
09.03.2006
01.02.2012
06.02.2012
09.02.2012


NO : 01105/II/2012/01
: 7
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
114
115
116
117
118
119
120
Quarter 2012
PAGE
CERT. NO.
0000493570
EVA LIDIAWATI
0000493677
MUHAMAD SYARFIAN
0000493680
AGUSTIN SATRIA
0000493728
HISNAWATI
0000493854
ARDI NURDIN
0000496154
MUNTHE RATNA
0000496462
WADY MURSIDHA
POLICY NO.
IMKIN0000493570
IMKIN0000493677
IMKIN0000493680
IMKIN0000493728
IMKIN0000493854
IMKIN0000496154
IMKIN0000496462
DATE OF
DATE OF NATURE
10.03.2006
10.03.2006
10.03.2006
10.03.2006
13.03.2006
18.03.2006
21.03.2006
10.02.2012
10.02.2012
10.04.2012
10.02.2012
13.02.2012
18.02.2012
21.02.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
GEBBK
3,000,000.00
3,000,000.00 2011
750.00
63.00
0.00
0.00
0.00
63.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBK
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 8
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
121
122
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
0000499522.01
IMKIN0000499522
GUNAWAN RADIWISOTO
0000504467
ALWIN NOVENDAR
IMKIN0000504467
DATE OF
DATE OF NATURE
04.04.2006
25.04.2006
04.02.2012
25.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
GEBBKB
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHT
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
123
0000506881
IMKIN0000506881
DADDY PRAWIRAKUSUMAH
01.05.2006
01.05.2012
01
PMTSHT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
124
0000508255.01
SUPRIATINI
04.05.2006
04.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
125
0000510038
PERDANA HALIM
IMKIN0000508255
IMKIN0000510038
10.05.2006
10.05.2012
126
0000510177
H DOLLAR DURASID
IMKIN0000510177
09.05.2006
09.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
127
0000510479
IMKIN0000510479
DEWAKI KRAMADIBRATA
10.05.2006
10.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
128
0000510552
JOKO HARYONO
IMKIN0000510552
11.05.2006
11.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
129
0000510552.01
MARDIANA HUSIN
IMKIN0000510552
11.05.2006
11.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
130
0000510658
AGUS SUSETYO
IMKIN0000510658
11.05.2006
11.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
131
0000510696
ROSMINI ALIGAPAR
IMKIN0000510696
11.05.2006
11.05.2012
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
132
0000511153
EDY SUSILO
IMKIN0000511153
09.05.2006
09.02.2012
01
GECRPL
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
133
0000511195
IMKIN0000511195
DANI FRANSYO LAHAY
11.05.2006
11.02.2012
134
0000512044
MAS SOEWITO PRIYO
IMKIN0000512044
15.05.2006
15.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
135
0000512119
ADE PURNAMA
IMKIN0000512119
16.05.2006
16.05.2012
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 9
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
136
0000512119.01
ENIH SUNIATI
IMKIN0000512119
16.05.2006
16.05.2012
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
137
0000512166
FARID SETIAWAN
IMKIN0000512166
16.05.2006
16.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
138
0000512184
JOHNY LENGKONG
IMKIN0000512184
16.05.2006
16.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
139
0000512184.01
NENGSUARSIH
IMKIN0000512184
16.05.2006
16.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
140
0000515177
PUDJI ASTUTI
IMKIN0000515177
17.05.2006
17.05.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
141
0000515253
ADE YANA
IMKIN0000515253
17.05.2006
17.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
142
0000515349
NANIEK YUNAENI
IMKIN0000515349
17.05.2006
17.05.2012
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
143
0000515551
IMKIN0000515551
IBNU HAJAR DAMANIK M
18.05.2006
18.03.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
500,000,000.00
206,500,000.00 2011
51,625.00
12,906.00
0.00
0.00
0.00
12,906.00
144
0000518347
JULIATI JUDO SURYA
IMKIN0000518347
01.06.2006
01.03.2012
145
0000521119.01
IMKIN0000521119
MUHAMMAD ASKARI UTOM
14.06.2006
14.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
146
0000521302.01
SRI SUMARYATI
IMKIN0000521302
14.06.2006
14.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
147
0000521926
ALI WARDANA
IMKIN0000521926
16.06.2006
16.02.2012
01
GECRPL
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
148
0000521987.01
IKA DINA LISAPUTRI
IMKIN0000521987
16.06.2006
16.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
149
0000522347
SARIYONO
IMKIN0000522347
19.06.2006
19.02.2012
01
GECRPL
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
150
0000522347.01
WINA WINARTI
IMKIN0000522347
19.06.2006
19.02.2012
01
GECRPL
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
151
0000523475.01
AHMAD TAUFAN
IMKIN0000523475
20.06.2006
20.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
152
0000523500.01
MUKIYAT
IMKIN0000523500
20.06.2006
20.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
153
0000523597.01
EVA VERONICA
IMKIN0000523597
20.06.2006
20.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
154
0000523754.01
IMKIN0000523754
QUEENA DJAJAPRAWIRA
20.06.2006
20.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 10
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
155
0000523873.01
MARIAMIN IBRAHIM
IMKIN0000523873
21.06.2006
21.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
156
0000524031.01
SUKAMTO YACOBUS
IMKIN0000524031
21.06.2006
21.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
157
0000525783.01
R NINO SUTRISNO
IMKIN0000525783
16.06.2006
16.04.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
158
0000534895.01
EUIS A MARIANA
IMKIN0000534895
22.06.2006
22.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
159
0000536242.01
SRI SUHARTINAH
IMKIN0000536242
01.07.2006
01.05.2012
01
GEBBKB
3,000,000.00
2011
0.00
0.00
0.00
0.00
0.00
160
0000537182.01
NUSRAMFERI
IMKIN0000537182
05.07.2006
05.02.2012
01
GEBBKB
7,500,000.00
2011
0.00
0.00
0.00
0.00
0.00
161
0000548798.01
AMIR HASAN
IMKIN0000548798
02.08.2006
02.05.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
162
0000551438
MUHAMMAD ARSYAD
IMKIN0000551438
08.08.2006
08.03.2012
01
PMTSHT
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
163
0000551438.01
IMKIN0000551438
KRESTIYATIE HARIYANT
08.08.2006
08.03.2012
01
PMTSHT
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
164
0000551842.01
MARIA B I ERNAWATI
IMKIN0000551842
10.08.2006
10.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
165
0000552087.01
DEWI YANI
IMKIN0000552087
10.08.2006
10.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
166
0000552782.01
LILY S HALIM
IMKIN0000552782
11.08.2006
11.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
167
0000554389
EKO PRISTIAWAN
IMKIN0000554389
03.08.2006
03.03.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
168
0000554791
GT BRATA
IMKIN0000554791
04.08.2006
04.03.2012
01
DANLFP
34,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
169
0000561632
ERNA J PONTOH
IMKIN0000561632
24.08.2006
24.03.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
170
0000561826
IMKIN0000561826
LEKSI NOORA HENDRA
24.08.2006
24.04.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
171
0000561826.01
MASRUROH
IMKIN0000561826
24.08.2006
24.04.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
172
0000563076
AHMAD HUZAIFAH
IMKIN0000563076
26.08.2006
26.02.2012
01
GECRPL
50,000,000.00
50,000,000.00 2011
59,000.00
29,500.00
0.00
0.00
0.00
29,500.00
173
0000563182.01
IRSAN CANDRA
IMKIN0000563182
26.08.2006
26.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
174
0000563243.01
ALOYSIA YUDHAWATI
IMKIN0000563243
26.08.2006
26.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
175
0000569924
SYABRIANSYAH
IMKIN0000569924
01.09.2006
01.02.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 11
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
176
0000569961
RR LEO RUNTUWENE
IMKIN0000569961
25.08.2006
25.03.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
177
0000572890.01
YANS ZAILANI
IMKIN0000572890
14.09.2006
14.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
178
0000577635.01
IRWAN AKNIS
IMKIN0000577635
20.09.2006
20.02.2012
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
179
0000580379
JEMMY W SUAWA SH
IMKIN0000580379
21.09.2006
21.03.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
180
0000580379.01
MAYA MAMAHIT
IMKIN0000580379
21.09.2006
21.03.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
181
0000580839
YULIZAR DEWA AJI
IMKIN0000580839
22.09.2006
22.03.2012
01
DANLFP
85,000,000.00
85,000,000.00 2011
77,350.00
38,675.00
0.00
0.00
0.00
38,675.00
182
0000581881
TANING YANDONO
IMKIN0000581881
01.09.2006
01.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
183
0000581881.01
MUI IE HALIM
IMKIN0000581881
01.09.2006
01.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
184
0000600599
W.LUSYE TULUNG
IMKIN0000600599
02.11.2006
02.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
185
0000600644
NUR ASNAINI
IMKIN0000600644
02.11.2006
02.05.2012
01
DANLFP
34,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
186
0000600644.01
RAHMAT SALAM
IMKIN0000600644
02.11.2006
02.05.2012
01
DANLFP
34,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
187
0000600912
INDRA HARTAWAN A
IMKIN0000600912
08.11.2006
08.05.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
188
0000615740
SANTO SUHARTO
IMKIN0000615740
07.12.2006
07.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
189
0000618430.01
IMAN SANTOSA
IMKIN0000618430
12.12.2006
12.02.2012
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
190
0000639230
IMKIN0000639230
DANI WARDHANA FIRMAN
24.01.2007
24.02.2012
01
GECRPL
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
191
0000658012.01
ANDI NOVIADI
01.03.2007
01.02.2012
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0000658012
192
0000658408
MISLAN
IMKIN0000658408
02.03.2007
02.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
193
0000658748
SYLVIA FRANSISCA T
IMKIN0000658748
05.03.2007
05.05.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
194
0000658824
IMKIN0000658824
NURHIDAYATI NALAM HUDI
22.02.2007
22.02.2012
01
CIGLCF
500,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
195
0000664166.01
MELLY NANGOI
02.03.2007
02.02.2012
01
GEBBKB
7,500,000.00
7,500,000.00 2011
64,275.00
5,356.00
0.00
0.00
0.00
5,356.00
IMKIN0000664166


NO : 01105/II/2012/01
: 12
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
196
197
198
199
200
201
202
203
Quarter 2012
PAGE
CERT. NO.
0000668609.01
SITI SUNDARI S
0000676047
IR TRI PURWANTO
0000676047.01
SURI EKA APRIANI
0000683817.01
THOMAS TANUDJAJA
POLICY NO.
IMKIN0000668609
IMKIN0000676047
IMKIN0000676047
IMKIN0000683817
0000689020.01
IMKIN0000689020
BUDI LUKITOYO FAKKA
0000691419
CARTINI
0000708169.01
Y ADI SUSENO
0000712691
MAHYUDIN
IMKIN0000691419
IMKIN0000708169
IMKIN0000712691
DATE OF
DATE OF NATURE
20.03.2007
21.03.2007
21.03.2007
11.04.2007
18.04.2007
21.04.2007
19.05.2007
24.05.2007
20.02.2012
21.02.2012
21.02.2012
11.02.2012
18.02.2012
21.03.2012
19.02.2012
24.02.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
AMNTLF
120,000,000.00
120,000,000.00 2011
591,600.00
49,300.00
0.00
0.00
0.00
49,300.00
01
AMNTLF
120,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
204
0000714648
FARIDA
IMKIN0000714648
01.05.2007
01.05.2012
01
AMNTLF
120,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
205
0000714818
SIGIT SISWANTO
IMKIN0000714818
05.05.2007
05.05.2012
01
AMNTLF
120,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
206
0000714963
TULONG R VICTOR
IMKIN0000714963
28.05.2007
28.05.2012
01
GECRPL
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
207
0000738859
ERNINAH
IMKIN0000738859
12.06.2007
12.05.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
208
0000738859.01
YULIAS SAPARUDDIN
IMKIN0000738859
12.06.2007
12.05.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
209
0000738917
MUHAMAD ALFATIH
IMKIN0000738917
13.06.2007
13.04.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
210
0000745490
DADANG SUPRIATNA
IMKIN0000745490
01.07.2007
01.05.2012
01
PMTBPS
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMTBPS
500,000,000.00
206,500,000.00 2011
51,625.00
8,604.00
0.00
0.00
0.00
8,604.00
211
0000750565.01
IMKIN0000750565
IR. M. ARIF PAPUTUNG
09.07.2007
09.02.2012
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
212
000775043
INDRA FAJAR A
IMKIN0000775043
10.08.2007
10.02.2012
01
GECRPL
75,000,000.00
38,000,000.00 2011
26,600.00
13,300.00
0.00
0.00
0.00
13,300.00
213
0000797909
ANDY SANTOSO
IMKIN0000797909
18.09.2007
18.03.2012
01
PMTBPS
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
500,000,000.00
306,500,000.00 2011
76,625.00
38,313.00
0.00
0.00
0.00
38,313.00
214
0000818902
H. RAJA ALI SABRI DA
IMKIN0000818902
02.10.2007
02.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
215
0000818902.01
IMKIN0000818902
SITI HANNIM HASIBUAN
02.10.2007
02.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
216
0000832316
FAHD MIRZA GAZALI
IMKIN0000832316
19.10.2007
19.02.2012
01
GECRPL
75,000,000.00
75,000,000.00 2011
52,500.00
35,000.00
5,250.00
3,500.00
0.00
31,500.00
217
0000836714
ANIK ANDAYANI
IMKIN0000836714
25.10.2007
25.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
218
0000836714.01
RUDOLF KUSINDRIA
IMKIN0000836714
25.10.2007
25.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
219
0000838503
SUMARNI MUSTAFA
IMKIN0000838503
01.11.2007
01.03.2012
01
PMTBPS
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
300,000,000.00
5,000,000.00 2011
1,250.00
833.00
0.00
0.00
0.00
833.00
220
0000839810
GABRIEL SUARUBUN
IMKIN0000839810
01.11.2007
01.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
221
0000839917
FERDIYAN
IMKIN0000839917
01.11.2007
01.02.2012
01
GECRPL
75,000,000.00
75,000,000.00 2011
129,000.00
96,750.00
0.00
0.00
0.00
96,750.00
222
0000839936
IMKIN0000839936
CHAIRUL SALEH SE MSI
01.11.2007
01.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
223
0000863591
BENYAMIN WIDJAJA
IMKIN0000863591
15.11.2007
15.05.2012
01
CIGLPN
100,000,000.00
100,000,000.00 2011
108,000.00
54,000.00
0.00
0.00
0.00
54,000.00
224
0000863723
YULIANTY
IMKIN0000863723
17.11.2007
17.02.2012
01
CIGLPN
300,000,000.00
300,000,000.00 2011
210,000.00
157,500.00
0.00
0.00
0.00
157,500.00
225
0000863751
SUNARNO
IMKIN0000863751
17.11.2007
17.04.2012
01
CIGLPN
500,000,000.00
285,000,000.00 2011
404,700.00
236,075.00
0.00
0.00
0.00
236,075.00
226
0000863828
TJONG FIFI
IMKIN0000863828
19.11.2007
19.02.2012
01
CIGLPN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
227
0000864710
YOGI IRAWAN
IMKIN0000864710
20.11.2007
20.05.2012
01
CIGLPN
200,000,000.00
5,000,000.00 2011
4,250.00
2,125.00
0.00
0.00
0.00
2,125.00
228
0000872172
DEDI SUTISNA
IMKIN0000872172
23.11.2007
23.03.2012
01
PMTBPS
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
300,000,000.00
5,000,000.00 2011
1,250.00
833.00
0.00
0.00
0.00
833.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
229
0000876029
DRS PENDI
IMKIN0000876029
03.12.2007
03.02.2012
01
GECRPL
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
230
0000893927.01
PAHING PRIJANTO
IMKIN0000893927
02.01.2008
02.02.2012
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
231
0000895373
SAMSIR
IMKIN0000895373
03.01.2008
03.03.2012
01
PMTBPS
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
500,000,000.00
6,500,000.00 2012
1,625.00
1,354.00
0.00
0.00
0.00
1,354.00
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
232
0000895373.01
SAMSIR
IMKIN0000895373
03.01.2008
03.03.2012
01
PMTBPS
233
0000921297
EDY
IMKIN0000921297
01.02.2008
01.05.2012
01
CIGLPN
500,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
234
0000928800
HASANUDDIN
IMKIN0000928800
05.02.2008
05.02.2012
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
235
0000954285
ZULHAMIDI
IMKIN0000954285
03.03.2008
03.05.2012
01
LIFCRP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
236
0000965172
TREESYA ROZA
IMKIN0000965172
04.03.2008
04.05.2012
01
LIFCRP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
237
0001008229
NUZULUL MAULUDAH
IMKIN0001008229
15.05.2008
15.03.2012
01
LIFCRP
500,000,000.00
200,000,000.00 2011
144,000.00
24,000.00
0.00
0.00
0.00
24,000.00
01
LIFCRP
500,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
238
0001008294
USMAN
IMKIN0001008294
15.05.2008
15.05.2012
01
LIFCRP
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
239
0001008484
SITTA GAMILIYA
IMKIN0001008484
19.05.2008
19.05.2012
01
LIFCRP
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
240
0001022895
SUKADA I PUTU
IMKIN0001022895
01.06.2008
01.05.2012
01
LIFCRP
100,000,000.00
100,000,000.00 2011
243,000.00
20,250.00
0.00
0.00
0.00
20,250.00
241
0001023447
H MHD BARKAH
IMKIN0001023447
03.06.2008
03.03.2012
01
LIFCRP
500,000,000.00
200,000,000.00 2011
144,000.00
36,000.00
0.00
0.00
0.00
36,000.00
242
0001024479
NAMPAN
IMKIN0001024479
11.06.2008
11.05.2012
01
LIFCRP
200,000,000.00
100,000,000.00 2011
98,000.00
8,167.00
0.00
0.00
0.00
8,167.00
243
0001025218
IMKIN0001025218
TEGUH JAYA PRASODJO
17.06.2008
17.05.2012
01
LIFCRP
200,000,000.00
150,000,000.00 2011
213,000.00
17,750.00
0.00
0.00
0.00
17,750.00
244
0001028547
SRIHANDAYANI
IMKIN0001028547
13.06.2008
13.03.2012
01
LIFCRP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
245
0001037686
TAMAN RIANTO
IMKIN0001037686
04.07.2008
04.03.2012
01
PMTBPL
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
1,000,000,000.00
785,000,000.00 2011
196,250.00
65,417.00
0.00
0.00
0.00
65,417.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
206,500,000.00 2011
51,625.00
17,208.00
0.00
0.00
0.00
17,208.00
246
0001038347
IMKIN0001038347
PRASETYA JOKO PRANOT
04.07.2008
04.03.2012


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
247
0001042429.01
HERISEN SINLUK
IMKIN0001042429
25.07.2008
25.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
106,100.00
35,367.00
0.00
0.00
0.00
35,367.00
248
0001042504.01
MUJIYANA
IMKIN0001042504
25.07.2008
25.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
21,600.00
3,600.00
0.00
0.00
0.00
3,600.00
249
0001042504.03
DWI ASTUTI
IMKIN0001042504
25.07.2008
25.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
12,900.00
2,150.00
0.00
0.00
0.00
2,150.00
250
0001044891
IMKIN0001044891
DODI KUSMAYADI HASAN
19.07.2008
19.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
251
0001044969
FENIA KOESNANHADI
IMKIN0001044969
27.06.2008
27.03.2012
01
LIFCRP
300,000,000.00
200,000,000.00 2011
140,000.00
35,000.00
0.00
0.00
0.00
35,000.00
252
0001045051
YULIA AMIN
IMKIN0001045051
01.07.2008
01.03.2012
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
253
0001045322
IMKIN0001045322
SUSANTO DWI PRASETYO
02.07.2008
02.03.2012
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
254
0001045419
HENY SUPROBOWATI
IMKIN0001045419
02.07.2008
02.03.2012
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
255
0001045570
EDWIN JAYANDARU
IMKIN0001045570
04.07.2008
04.03.2012
01
LIFCRP
300,000,000.00
300,000,000.00 2011
324,000.00
108,000.00
0.00
0.00
0.00
108,000.00
256
0001045649
IMKIN0001045649
SLAMET SULISTYOBUDI.
05.07.2008
05.05.2012
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
257
0001046023
IMKIN0001046023
DADANG DARMAWAN SAPU
11.07.2008
11.05.2012
01
LIFCRP
500,000,000.00
200,000,000.00 2011
284,000.00
47,333.00
0.00
0.00
0.00
47,333.00
258
0001049569
IMKIN0001049569
PARULIAN MARPAUNG
24.07.2008
24.05.2012
01
LIFCRP
300,000,000.00
300,000,000.00 2011
354,000.00
59,000.00
0.00
0.00
0.00
59,000.00
259
0001050608.01
SILVANA K
IMKIN0001050608
21.07.2008
21.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
130,800.00
21,800.00
0.00
0.00
0.00
21,800.00
260
0001050751.01
YOSEPH KUMALA
IMKIN0001050751
22.07.2008
22.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
44,000.00
14,667.00
0.00
0.00
0.00
14,667.00
261
0001050889.01
OEY PIT ENG
IMKIN0001050889
23.07.2008
23.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
117,900.00
39,300.00
0.00
0.00
0.00
39,300.00
262
0001051004.01
NY. YULI SETIADY
IMKIN0001051004
24.07.2008
24.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
69,000.00
11,500.00
0.00
0.00
0.00
11,500.00
263
0001051004.03
HANDI SETIADI
IMKIN0001051004
24.07.2008
24.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
117,900.00
19,650.00
0.00
0.00
0.00
19,650.00
264
0001064939
PRATIKTO
IMKIN0001064939
20.08.2008
20.03.2012
01
LIFCRP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
265
0001069279
TRI NUGROHO
IMKIN0001069279
22.08.2008
22.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
281,500,000.00 2011
70,375.00
17,594.00
0.00
0.00
0.00
17,594.00
01
PMTBPL
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
266
0001069280
ERWIN HUSEIN
IMKIN0001069280
22.08.2008
22.05.2012


NO : 01105/II/2012/01
: 16
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
01
PMTBPL
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1,000,000,000.00
785,000,000.00 2011
196,250.00
49,063.00
0.00
0.00
0.00
49,063.00
267
0001072140
IMKIN0001072140
DYAH AYUNI RESPITORA
26.08.2008
26.03.2012
01
LIFCRP
500,000,000.00
200,000,000.00 2011
140,000.00
58,333.00
0.00
0.00
0.00
58,333.00
268
0001072152
IDA ELFANI
IMKIN0001072152
25.08.2008
25.03.2012
01
LIFCRP
200,000,000.00
200,000,000.00 2011
236,000.00
98,333.00
0.00
0.00
0.00
98,333.00
269
0001072330
IMKIN0001072330
DENNY ARIEF SETIAWAN
01.08.2008
01.02.2012
01
CIGLPN
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
270
0001072351
IMKIN0001072351
CAHYANINGSIH SRI MUL
01.08.2008
01.02.2012
01
CIGLPN
200,000,000.00
100,000,000.00 2011
440,000.00
220,000.00
0.00
0.00
0.00
220,000.00
271
0001074700.01
ARIS SOESANTO
IMKIN0001074700
10.09.2008
10.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
117,900.00
39,300.00
0.00
0.00
0.00
39,300.00
272
0001074991
JASMIN SETIADI
IMKIN0001074991
01.09.2008
01.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
273
0001078637.01
ERLY SINATRA
IMKIN0001078637
10.09.2008
10.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
7,900.00
3,950.00
0.00
0.00
0.00
3,950.00
274
0001078637.03
LIEMANTO
IMKIN0001078637
10.09.2008
10.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
14,200.00
7,100.00
0.00
0.00
0.00
7,100.00
275
0001078637.05
MATTHEW
IMKIN0001078637
10.09.2008
10.03.2012
01
UOBEXP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
276
0001084345.01
TAN MUI LOAN
IMKIN0001084345
25.09.2008
25.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
117,900.00
58,950.00
0.00
0.00
0.00
58,950.00
277
0001084345.03
TJIE PUTRA ARIEF W
IMKIN0001084345
25.09.2008
25.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
95,500.00
47,750.00
0.00
0.00
0.00
47,750.00
278
0001084505.01
BARMAWAN SANUSI
IMKIN0001084505
25.09.2008
25.03.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
279
0001084701.01
BUDI LUKITOYO FAKK
IMKIN0001084701
25.09.2008
25.03.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
280
0001086179
IMKIN0001086179
BENNY TEGUH SANTOSO
10.09.2008
10.03.2012
01
DANLFP
57,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
281
0001097141.01
EDI J KARYOTO
IMKIN0001097141
27.10.2008
27.03.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
282
0001097216.01
BAGUS UTORO
IMKIN0001097216
27.10.2008
27.03.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
283
0001098160
JEFANYA
IMKIN0001098160
10.10.2008
10.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
284
0001111199.01
INDRA GUNAWAN
IMKIN0001111199
21.11.2008
21.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
21,600.00
14,400.00
0.00
0.00
0.00
14,400.00
285
0001113276
DESI NURAIDAH
IMKIN0001113276
03.11.2008
03.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
105,000,000.00 2011
26,250.00
17,500.00
0.00
0.00
0.00
17,500.00


NO : 01105/II/2012/01
: 17
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
286
287
288
CERT. NO.
0001113276.01
HERI PATMONO
0001115576
D BAMBANG
Quarter 2012
PAGE
POLICY NO.
IMKIN0001113276
IMKIN0001115576
0001115576.01
IMKIN0001115576
D BAMBANG KUSWIDIANT
DATE OF
DATE OF NATURE
03.11.2008
06.11.2008
06.11.2008
03.03.2012
06.03.2012
06.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
105,000,000.00 2011
26,250.00
17,500.00
0.00
0.00
0.00
17,500.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
206,500,000.00 2011
51,625.00
34,417.00
0.00
0.00
0.00
34,417.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
206,500,000.00 2011
51,625.00
34,417.00
0.00
0.00
0.00
34,417.00
289
0001116917
WARSONO
IMKIN0001116917
01.11.2008
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
290
0001125690
ENDANG SURYANI
IMKIN0001125690
19.11.2008
19.05.2012
01
DANLFP
85,000,000.00
85,000,000.00 2011
262,650.00
131,325.00
0.00
0.00
0.00
131,325.00
291
0001125690.01
JAMALUDDIN SE AK
IMKIN0001125690
19.11.2008
19.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
292
0001126293
ANDY
IMKIN0001126293
17.11.2008
17.05.2012
01
LIFCRP
300,000,000.00
100,000,000.00 2011
79,000.00
39,500.00
0.00
0.00
0.00
39,500.00
293
0001133333.01
IMKIN0001133333
HOTMAN DAPOT SINAGA
26.11.2008
26.03.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
127,500.00
85,000.00
0.00
0.00
0.00
85,000.00
294
0001137847
IKA PERMATASARI
IMKIN0001137847
01.12.2008
01.05.2012
01
LIFCRP
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
295
0001138103.01
ERWANTO
IMKIN0001138103
01.12.2008
01.05.2012
01
MANDEX
500,000,000.00
500,000,000.00 2011
780,000.00
455,000.00
0.00
0.00
0.00
455,000.00
296
0001140842
IMKIN0001140842
ADI SUCIPTO (F509368
04.12.2008
04.03.2012
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
297
0001141793.01
AGUS SANTOSA
05.12.2008
05.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
206,500,000.00 2011
51,625.00
38,719.00
0.00
0.00
0.00
38,719.00
IMKIN0001141793
298
0001142487
IMKIN0001142487
I GST AYU OKA RASMIN
05.12.2008
05.05.2012
01
BNIJBT
100,000,000.00
100,000,000.00 2011
349,000.00
203,583.00
0.00
0.00
0.00
203,583.00
299
0001143955
ADI WITOYO
IMKIN0001143955
10.12.2008
10.03.2012
01
LIFCRP
500,000,000.00
500,000,000.00 2011
540,000.00
405,000.00
0.00
0.00
0.00
405,000.00
300
0001145931
IMKIN0001145931
RAHMAT OKTYANSYAH
12.12.2008
12.03.2012
01
LIFCRP
300,000,000.00
300,000,000.00 2011
216,000.00
162,000.00
0.00
0.00
0.00
162,000.00
301
0001151754
NENI FONAWATI
IMKIN0001151754
17.12.2008
17.03.2012
01
BNIJBX
150,000,000.00
150,000,000.00 2011
108,000.00
81,000.00
0.00
0.00
0.00
81,000.00
302
0001156231
ACHMAD SYAUGI
IMKIN0001156231
04.12.2008
04.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
303
0001156485
SUTJIPTO.
IMKIN0001156485
12.12.2008
12.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 18
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
304
0001157610
SUPARDI
IMKIN0001157610
22.12.2008
22.02.2012
01
CIGLPN
200,000,000.00
200,000,000.00 2011
784,000.00
653,333.00
0.00
0.00
0.00
653,333.00
305
0001158457
IMKIN0001158457
RAYA REDINA NAIBAHO
19.12.2008
19.05.2012
01
LIFCRP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
306
0001161391
HARY SUHARJONO
IMKIN0001161391
23.12.2008
23.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
307
0001161391.01
RINI EKA LUCIANA
IMKIN0001161391
23.12.2008
23.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
308
0001163200.01
SANTI INDRIYARINI
IMKIN0001163200
01.01.2009
01.05.2012
01
MANDEX
500,000,000.00
500,000,000.00 2012
590,000.00
393,333.00
0.00
0.00
0.00
393,333.00
309
0001166461
TITIN RATNAWATI SE
IMKIN0001166461
07.01.2009
07.05.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,083.00
0.00
0.00
0.00
1,083.00
310
0001167205
IMKIN0001167205
HERI TANTA SAPUTRA
08.01.2009
08.04.2012
01
CIGLPN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
311
0001167227
MUHAMMAD SYARIEF
IMKIN0001167227
05.01.2009
05.02.2012
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
312
0001170454.01
DANIEL ALEXANDER
IMKIN0001170454
08.01.2009
08.05.2012
01
MANDEX
500,000,000.00
500,000,000.00 2012
645,000.00
430,000.00
0.00
0.00
0.00
430,000.00
313
0001172435.01
IMKIN0001172435
ASFAR BUSTAMIN LAMON
07.01.2009
07.05.2012
01
MANDEX
500,000,000.00
500,000,000.00 2012
860,000.00
573,333.00
0.00
0.00
0.00
573,333.00
314
0001173612.01
HENDRIK GUNAWAN
IMKIN0001173612
09.01.2009
09.05.2012
01
MANDEX
500,000,000.00
500,000,000.00 2012
1,745,000.00
1,163,333.00
0.00
0.00
0.00
1,163,333.00
315
0001173634.01
ISMAIL ARIFIN
IMKIN0001173634
10.01.2009
10.05.2012
01
MANDEX
500,000,000.00
500,000,000.00 2012
1,215,000.00
810,000.00
0.00
0.00
0.00
810,000.00
316
0001179836
TOUFAN WIDHI H.
IMKIN0001179836
13.01.2009
13.05.2012
01
CIGLPN
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
317
0001183721
IMKIN0001183721
RONNY SUADI SUDIBYO
21.01.2009
21.02.2012
01
CIGLPN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
318
0001184743
YOHANES WAHONO
IMKIN0001184743
17.01.2009
17.03.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
319
0001186568
DEWI WENINGSIH
IMKIN0001186568
19.01.2009
19.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
320
0001190643
ARDI SETIADI
IMKIN0001190643
22.01.2009
22.05.2012
01
CIGLPN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
321
0001192599
HERMAN PAU
IMKIN0001192599
15.01.2009
15.05.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
322
0001197308
LILIS MAWATI
IMKIN0001197308
02.02.2009
02.03.2012
01
LIFCRP
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 19
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
323
0001197822.01
NATA SUHENDI
IMKIN0001197822
01.02.2009
01.04.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
324
0001209275
HEADY ERLYANTY
IMKIN0001209275
01.02.2009
01.05.2012
01
PMSSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
325
0001210113.01
ALFA KARDINAL T
IMKIN0001210113
16.02.2009
16.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
326
0001223265
IMKIN0001223265
BUDIARTO SETIOPUTRO
20.02.2009
20.03.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
327
0001224272
IMKIN0001224272
ANGGA YUDIS BIMANTOR
01.03.2009
01.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,354.00
0.00
0.00
0.00
1,354.00
328
329
0001224341
FREDI TRI YUNIANTO
IMKIN0001224341
0001228504
IMKIN0001228504
DIDIEK SATRIO PURBAW
01.03.2009
04.03.2009
01.03.2012
04.05.2012
330
0001233171
IMKIN0001233171
MEDIO NOVALDI CHANTR
12.03.2009
12.03.2012
01
LIFCRP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
331
0001233625
LENNY SULISTYORINI
IMKIN0001233625
12.03.2009
12.03.2012
01
LIFCRP
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
332
0001234915.01
UNTUNG SUBAGYO
IMKIN0001234915
12.03.2009
12.03.2012
01
MANDEX
500,000,000.00
500,000,000.00 2012
2,200,000.00
2,200,000.00
0.00
0.00
0.00
2,200,000.00
333
0001240080
IDA AYU S. KARTIKA
IMKIN0001240080
10.03.2009
10.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
500,000,000.00
300,000,000.00 2011
237,000.00
19,750.00
0.00
0.00
0.00
19,750.00
01
CIGLPN
500,000,000.00
300,000,000.00 2012
255,000.00
255,000.00
0.00
0.00
0.00
255,000.00
01
CIGLPN
300,000,000.00
200,000,000.00 2011
284,000.00
23,667.00
0.00
0.00
0.00
23,667.00
01
CIGLPN
300,000,000.00
300,000,000.00 2012
468,000.00
468,000.00
0.00
0.00
0.00
468,000.00
334
335
336
0001240178
RIZQI SURYANI
0001240211
SLAMET SUHARIADI
0001240261
AMIRUL MUKMININ
IMKIN0001240178
IMKIN0001240211
IMKIN0001240261
06.03.2009
12.03.2009
14.03.2009
06.02.2012
12.02.2012
14.02.2012
337
0001244787
IMKIN0001244787
ANGGORO BUDI SETYAWA
20.03.2009
20.03.2012
01
LIFCRP
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
338
0001248643
MICU
21.03.2009
21.05.2012
01
DANLFP
57,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001248643


NO : 01105/II/2012/01
: 20
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
339
CERT. NO.
0001249731
SUZI NOOR WIJAYA
Quarter 2012
PAGE
POLICY NO.
IMKIN0001249731
DATE OF
DATE OF NATURE
25.03.2009
25.02.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
CIGLPN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
340
0001253314
SITI NURHANDINI
IMKIN0001253314
24.03.2009
24.05.2012
01
BNIJBT
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
341
0001254476.01
HENDY SUTRISNO
IMKIN0001254476
01.04.2009
01.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
342
0001257708.01
ISHAR MADI
IMKIN0001257708
03.04.2009
03.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2012
857,000.00
785,583.00
0.00
0.00
0.00
785,583.00
343
0001258914
ONG TJWAN NIO
IMKIN0001258914
06.04.2009
06.04.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
344
0001258914.01
SRI PURWANTO
IMKIN0001258914
06.04.2009
06.04.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
345
0001264804.01
IMKIN0001264804
ANDI SAPUTRA BASTARI
01.04.2009
01.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
346
0001264843.01
TOTO KUSRIANTO
IMKIN0001264843
06.04.2009
06.04.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
347
0001267416.01
ISBAGI HARYADI
IMKIN0001267416
07.04.2009
07.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMSSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMSSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMSSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMSSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
348
349
350
0001267821
NURUL HASANAH
0001271958
ASNI PRICORIN
0001271976
I KETUT MARTIN
IMKIN0001267821
IMKIN0001271958
IMKIN0001271976
14.04.2009
15.04.2009
15.04.2009
14.03.2012
15.03.2012
15.03.2012
351
0001272618.01
IMKIN0001272618
MOCHAMAD IQBAL ZUALM
16.04.2009
16.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
352
0001272959
SUGENDAR
IMKIN0001272959
04.04.2009
04.05.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
353
0001283889
IDA NURHAYATI
IMKIN0001283889
21.04.2009
21.03.2012
01
PMSSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMSSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
200,000,000.00
100,000,000.00 2011
275,000.00
22,917.00
0.00
0.00
0.00
22,917.00
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
354
0001285266.01
IMKIN0001285266
DENNY FERDINAND ALBE
21.04.2009
21.03.2012


NO : 01105/II/2012/01
: 21
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
355
356
357
358
359
360
361
362
363
364
Quarter 2012
PAGE
CERT. NO.
0001285466
SRIHAYATI
0001285556
ARIES WIJAYA
0001285829.01
HARIS SOMPANA
0001286093
MUHAMAD HERY
0001286228
EKA SAPTA ADINARA
0001286228.01
NURYAMAH
0001286298
TUGIMIN
0001287183
ERNAWATI
0001287390
HADI SUMARYONO ST
POLICY NO.
IMKIN0001285466
IMKIN0001285556
IMKIN0001285829
IMKIN0001286093
IMKIN0001286228
IMKIN0001286228
IMKIN0001286298
IMKIN0001287183
IMKIN0001287390
0001287731
IMKIN0001287731
HJ ANDI MEGAWATI M,S
DATE OF
DATE OF NATURE
27.04.2009
25.04.2009
08.04.2009
01.05.2009
01.05.2009
01.05.2009
01.05.2009
01.05.2009
04.05.2009
01.05.2009
27.03.2012
25.02.2012
20.03.2012
01.05.2012
01.03.2012
01.03.2012
01.03.2012
01.05.2012
04.05.2012
01.05.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMSSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMSSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGHLP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGHLP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
UOBEXP
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,625.00
0.00
0.00
0.00
1,625.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
206,500,000.00 2011
51,625.00
8,604.00
0.00
0.00
0.00
8,604.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,625.00
0.00
0.00
0.00
1,625.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
206,500,000.00 2011
51,625.00
8,604.00
0.00
0.00
0.00
8,604.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,625.00
0.00
0.00
0.00
1,625.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
9,650.00
1,608.00
0.00
0.00
0.00
1,608.00
01
PMTBPL
300,000,000.00
300,000,000.00 2011
75,000.00
12,500.00
0.00
0.00
0.00
12,500.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,625.00
0.00
0.00
0.00
1,625.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
500,000,000.00
6,500,000.00 2012
1,625.00
1,625.00
0.00
0.00
0.00
1,625.00
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 22
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
365
0001288266.01
MELLA MEYLANDINI
IMKIN0001288266
01.05.2009
01.05.2012
01
MANDEX
366
0001288334
WENNY ROSITA
IMKIN0001288334
01.05.2009
01.05.2012
01
367
0001288867
WAWAN HERMAWAN
IMKIN0001288867
01.05.2009
01.03.2012
368
369
0001290545
HARIS PERDANA
IMKIN0001290545
0001290545.01
IMKIN0001290545
RUSMIATI WERNER SH
06.05.2009
06.05.2009
06.03.2012
06.03.2012
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
LIFCRP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
5,000,000.00 2011
1,250.00
208.00
0.00
0.00
0.00
208.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
5,000,000.00 2011
1,250.00
208.00
0.00
0.00
0.00
208.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
370
0001296597.01
IMKIN0001296597
MOCHAMMAD TRIBEKTI M
05.05.2009
05.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
371
0001296938.01
FIRDAUS HAZAIRIN
12.05.2009
12.04.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
552,000.00
46,000.00
0.00
0.00
0.00
46,000.00
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001296938
372
0001299897
YULIANI NINGSIH
IMKIN0001299897
14.05.2009
14.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
373
0001303309.01
IMKIN0001303309
NERRISA NADIA SHANVI
15.05.2009
15.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
70,000.00
11,667.00
0.00
0.00
0.00
11,667.00
01
MANDEX
200,000,000.00
100,000,000.00 2012
70,000.00
70,000.00
0.00
0.00
0.00
70,000.00
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
374
0001303393.01
IMKIN0001303393
BUDI SUSETYO MUHARTO
15.05.2009
15.03.2012
375
0001307160
MULYOTO,BSC
IMKIN0001307160
20.05.2009
20.05.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
376
0001307275
DADANG SUHARNA
IMKIN0001307275
20.05.2009
20.05.2012
01
DANLFP
57,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
377
0001311409
I PUTU LINGGIH ARTA
IMKIN0001311409
26.05.2009
26.05.2012
01
BNIJBT
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
378
0001311701
IMKIN0001311701
PRISCILLA ELIZABETH
26.05.2009
26.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 23
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
379
Quarter 2012
PAGE
CERT. NO.
0001312568.01
ELIN WIDARTI
POLICY NO.
IMKIN0001312568
DATE OF
DATE OF NATURE
20.05.2009
20.04.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMTBPL
300,000,000.00
5,000,000.00 2011
1,250.00
208.00
0.00
0.00
0.00
208.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
380
0001312947
SUTRISNO TANDI
IMKIN0001312947
25.05.2009
25.05.2012
01
DANLFP
85,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
381
0001312969
DESY KRISTINA
IMKIN0001312969
26.05.2009
26.05.2012
01
DANLFP
57,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
382
0001312969.01
FAUZI NOVIAN
IMKIN0001312969
26.05.2009
26.05.2012
01
DANLFP
57,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
383
0001313917
HARIS MENDOPA
IMKIN0001313917
01.06.2009
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
5,000,000.00 2011
1,250.00
313.00
0.00
0.00
0.00
313.00
384
0001316234
BUNYAMIN
IMKIN0001316234
01.06.2009
01.03.2012
01
LIFCRP
100,000,000.00
100,000,000.00 2011
440,000.00
110,000.00
0.00
0.00
0.00
110,000.00
385
0001316247
ERNA AGUSTINA
IMKIN0001316247
01.06.2009
01.05.2012
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
386
0001316289
LILIK PRASTOWO
IMKIN0001316289
01.06.2009
01.03.2012
01
LIFCRP
200,000,000.00
100,000,000.00 2011
91,000.00
22,750.00
0.00
0.00
0.00
22,750.00
387
0001316298
EKO PRIYOHARSONO
IMKIN0001316298
01.06.2009
01.05.2012
01
LIFCRP
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
388
0001320634.01
TRISNI LOEKITAWATI
IMKIN0001320634
02.06.2009
02.05.2012
01
MANCLP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
389
0001321119
ERNA YULIANTI
IMKIN0001321119
03.06.2009
03.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
5,000,000.00 2011
1,250.00
313.00
0.00
0.00
0.00
313.00
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
390
0001324047
IMKIN0001324047
MUHAMMAD SOFYAN GINT
05.06.2009
05.03.2012
01
LIFCRP
391
0001324410
IMKIN0001324410
DIDIEK SATRIO PURBAW
05.06.2009
05.05.2012
01
PMCSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
392
0001326561
MUHAMMAD FARID
IMKIN0001326561
01.06.2009
01.03.2012
01
LIFCRP
50,000,000.00
50,000,000.00 2011
108,000.00
27,000.00
0.00
0.00
0.00
27,000.00
393
0001332722
HANA NORAWATI
IMKIN0001332722
10.06.2009
10.05.2012
01
MANTLP
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
394
0001335537
IMKIN0001335537
OEIJ CAROLIVI WIRYAD
16.06.2009
16.05.2012
01
LIFCRP
200,000,000.00
100,000,000.00 2011
79,000.00
6,583.00
0.00
0.00
0.00
6,583.00


NO : 01105/II/2012/01
: 24
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
395
0001335965
TAMAN RIANTO
IMKIN0001335965
17.06.2009
17.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
396
0001341096
A SIGIT PURNOMO
IMKIN0001341096
17.06.2009
17.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
397
0001346228.01
JUMADIL JOHAR
IMKIN0001346228
24.06.2009
10.05.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
398
0001347130
FREDY
IMKIN0001347130
19.06.2009
19.03.2012
01
DANHCP
10,000,000.00
10,000,000.00 2011
7,200.00
1,800.00
0.00
0.00
0.00
1,800.00
399
0001349335
IMKIN0001349335
STAFANUS ANDRI WINAR
01.07.2009
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
300,000,000.00
5,000,000.00 2011
1,250.00
417.00
0.00
0.00
0.00
417.00
01
PMTBPL
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
1,000,000,000.00
710,000,000.00 2011
177,500.00
29,583.00
0.00
0.00
0.00
29,583.00
400
0001349903
WILLIAM F.JOHANNES
IMKIN0001349903
01.07.2009
01.05.2012
401
0001349964.01
M NOVALINA TRIATI
IMKIN0001349964
01.07.2009
01.03.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
36,000.00
12,000.00
0.00
0.00
0.00
12,000.00
402
0001350920
KARTIKA WATI
IMKIN0001350920
01.07.2009
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
7,100.00
2,367.00
0.00
0.00
0.00
2,367.00
01
PMTBPL
300,000,000.00
300,000,000.00 2011
75,000.00
25,000.00
0.00
0.00
0.00
25,000.00
403
0001351778
RIDA ROSALINA
IMKIN0001351778
02.07.2009
02.02.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
344,000.00
143,333.00
0.00
0.00
0.00
143,333.00
404
0001354056
ONIS SIUS RESI
IMKIN0001354056
04.07.2009
04.05.2012
01
DANLFP
34,000,000.00
34,000,000.00 2011
36,720.00
6,120.00
0.00
0.00
0.00
6,120.00
405
0001354058
NATANAEL ANDREAS
IMKIN0001354058
04.07.2009
04.03.2012
01
DANLFP
85,000,000.00
85,000,000.00 2011
120,700.00
40,233.00
0.00
0.00
0.00
40,233.00
406
0001354770
YEYEN RISMAYANTI
IMKIN0001354770
06.07.2009
06.03.2012
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
407
0001354996.01
IMKIN0001354996
DETTY S H R LIMPELEH
01.07.2009
01.05.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
216,000.00
36,000.00
0.00
0.00
0.00
36,000.00
408
0001355533
ABDUL HAMID SE
IMKIN0001355533
03.07.2009
03.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
409
0001355548
TERDY MENGKO
IMKIN0001355548
03.07.2009
03.02.2012
01
CIGLPN
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
410
0001355699
DWI CAHYONO
IMKIN0001355699
06.07.2009
06.02.2012
01
CIGLPN
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
411
0001357279
AHMAD SETIAWAN
IMKIN0001357279
07.07.2009
07.03.2012
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
412
0001357359
IMKIN0001357359
CHRYSANTHUS CANDRA P
09.07.2009
09.05.2012
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
413
0001357868
ANAS MASKUR
09.07.2009
09.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001357868


NO : 01105/II/2012/01
: 25
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
414
0001357888.01
LISMEILI
IMKIN0001357888
21.07.2009
21.03.2012
01
UOBEXP
415
0001358772
GUPRANSYAH
IMKIN0001358772
09.07.2009
09.05.2012
01
416
0001358781
CAHYO WIDODO
IMKIN0001358781
10.07.2009
10.03.2012
417
0001358998
MAHFUDIN
IMKIN0001358998
10.07.2009
10.03.2012
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
10,000,000.00
10,000,000.00 2011
49,300.00
16,433.00
0.00
0.00
0.00
16,433.00
LIFCRP
500,000,000.00
500,000,000.00 2011
350,000.00
58,333.00
0.00
0.00
0.00
58,333.00
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
750,000,000.00
457,500,000.00 2011
114,375.00
38,125.00
0.00
0.00
0.00
38,125.00
418
0001359086
MASNIWATI MSY
IMKIN0001359086
11.07.2009
11.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
419
0001359086.01
SYAMSUAR
IMKIN0001359086
11.07.2009
11.05.2012
01
DANLFP
85,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
420
0001365553
ABU HANIFAH SP
IMKIN0001365553
14.07.2009
14.05.2012
01
BNIJBX
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
421
0001365917
KIKI SADIKIN
IMKIN0001365917
15.07.2009
15.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
422
0001370570.01
DODI ASEP MASKAR
IMKIN0001370570
14.07.2009
14.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
423
0001376807.01
ENDAH YULI ASTUTI
IMKIN0001376807
21.07.2009
21.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
424
0001378652
IMKIN0001378652
CAKTI KRISJONO WITAR
28.07.2009
28.05.2012
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
425
0001379185
IMKIN0001379185
MOCHAMMAD CHOLILIH
17.07.2009
17.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
426
0001380510
JONI HERMANTO
IMKIN0001380510
01.08.2009
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
427
0001380681
IMKIN0001380681
ARIEF WAHYUDI NUGRAH
01.08.2009
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
428
0001383667
SULIANA
IMKIN0001383667
04.08.2009
04.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
429
0001385524
HERTADI POERNOMO
IMKIN0001385524
01.08.2009
01.03.2012
01
LIFCRP
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
430
0001385725
MEY ENDRAYANI SH
IMKIN0001385725
04.08.2009
04.03.2012
01
LIFCRP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
431
0001386706
EDI
IMKIN0001386706
01.08.2009
01.03.2012
01
HSBTLC
50,000,000.00
50,000,000.00 2011
345,000.00
143,750.00
0.00
0.00
0.00
143,750.00
432
0001386843
WIDJAJANTO K
IMKIN0001386843
04.08.2009
04.05.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
433
0001386950
IMKIN0001386950
NIKEN EKA PRIARNANI
05.08.2009
05.04.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 26
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
434
0001389665
ALBERT YOSIETO
IMKIN0001389665
08.08.2009
08.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
435
0001389938
IMKIN0001389938
ASAD MULYA POHAN, IR
03.08.2009
03.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
436
0001391099.01
DJAROT WINARNO
IMKIN0001391099
10.08.2009
10.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
880,000.00
366,667.00
0.00
0.00
0.00
366,667.00
437
0001392131
JASMINTO
IMKIN0001392131
11.08.2009
11.05.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
438
0001392132
ISMAWARNI SP
IMKIN0001392132
11.08.2009
11.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
439
0001397010
J.SRI PURWANTO
IMKIN0001397010
08.08.2009
08.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
440
0001398349.01
KUNTO WIDIARTO
IMKIN0001398349
13.08.2009
13.05.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
121,500.00
30,375.00
0.00
0.00
0.00
30,375.00
441
0001398606
DINATA
IMKIN0001398606
18.08.2009
18.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
442
0001401928
MASSITOH
IMKIN0001401928
12.08.2009
12.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
443
0001401932
IMKIN0001401932
YUSAK ANTON WIJAYA
12.08.2009
12.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
444
0001401959
BAMBANG BUDIYONO
IMKIN0001401959
12.08.2009
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
445
0001403460
HERIE SUSANTO
IMKIN0001403460
19.08.2009
19.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
446
0001403548
HARDI
IMKIN0001403548
20.08.2009
20.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
447
0001404588
WAHYU ASTUTI
IMKIN0001404588
21.08.2009
21.05.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
448
0001405650
IMKIN0001405650
MONIQUE (MONICA) SUT
27.08.2009
27.05.2012
01
NIAPMK
6,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
449
0001408179
PAUL ARIF BUDIMAN
IMKIN0001408179
24.08.2009
24.03.2012
01
CIGHLP
10,000,000.00
10,000,000.00 2011
12,900.00
5,375.00
0.00
0.00
0.00
5,375.00
450
0001409260
IMKIN0001409260
JOHNNY M PANGGABEAN
25.08.2009
25.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
451
0001409737.01
IMKIN0001409737
BALGIS MUHAMMAD,SP
25.08.2009
25.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
72,000.00
18,000.00
0.00
0.00
0.00
18,000.00
452
0001410014
IMKIN0001410014
DR. GANDA E.M. TAMPU
25.08.2009
25.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
453
0001410876
SETIYONO
IMKIN0001410876
01.09.2009
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
454
0001412118
SUJANTO BE
IMKIN0001412118
01.09.2009
01.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 27
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
455
0001413749
SARAH LAYLA
IMKIN0001413749
01.09.2009
01.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
456
0001413973
ELY MULYANI
IMKIN0001413973
01.09.2009
01.05.2012
01
CIGLPN
200,000,000.00
200,000,000.00 2011
216,000.00
72,000.00
0.00
0.00
0.00
72,000.00
457
0001415300
IMKIN0001415300
MARTEN ENDRA MUKARTO
03.09.2009
03.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
63,750.00
31,875.00
0.00
0.00
0.00
31,875.00
458
0001415300.01
IMKIN0001415300
RAGIL SETYORINI S.PD
03.09.2009
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
459
0001420962.01
CHIDMAT INDERA
IMKIN0001420962
04.09.2009
21.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
39,200.00
9,800.00
0.00
0.00
0.00
9,800.00
460
0001420962.03
IMKIN0001420962
INDERAWATI MUTIARA
04.09.2009
21.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
21,600.00
5,400.00
0.00
0.00
0.00
5,400.00
461
0001421326
RYNI VANDITTA
IMKIN0001421326
11.09.2009
11.03.2012
01
NIAPMD
300,000,000.00
100,000,000.00 2011
70,000.00
35,000.00
0.00
0.00
0.00
35,000.00
462
0001421622.01
FAISAL MARIF
IMKIN0001421622
02.09.2009
02.05.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
275,000.00
91,667.00
0.00
0.00
0.00
91,667.00
463
0001422226
WILLIAM F.JOHANNES
IMKIN0001422226
10.09.2009
10.05.2012
01
PMCSHP
50,000,000.00
50,000,000.00 2011
276,000.00
92,000.00
0.00
0.00
0.00
92,000.00
464
0001422269
FERI LUKMANSARI
IMKIN0001422269
10.09.2009
10.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
465
0001422546
IDAWATI .AMD
IMKIN0001422546
09.09.2009
09.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
466
0001425791.01
DEWA AYU ASRINI
IMKIN0001425791
10.09.2009
10.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
182,000.00
91,000.00
0.00
0.00
0.00
91,000.00
467
0001426593
IMKIN0001426593
INDRA ARI YUDHANTO
14.09.2009
14.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
468
0001428580
AGUNG NUGROHO
IMKIN0001428580
16.09.2009
16.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
425,000.00
247,917.00
0.00
0.00
0.00
247,917.00
469
0001430095
AHMADI
IMKIN0001430095
15.09.2009
15.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
470
0001431519
MARIANDA
IMKIN0001431519
08.09.2009
08.03.2012
01
PMCSHP
50,000,000.00
50,000,000.00 2011
42,500.00
21,250.00
0.00
0.00
0.00
21,250.00
471
0001433033
HENY HATISAH
IMKIN0001433033
25.09.2009
25.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
472
0001433106.01
A BISRUN
IMKIN0001433106
17.09.2009
17.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
473
0001433906
CALVIENO PANGAU
IMKIN0001433906
25.09.2009
25.03.2012
01
LIFCRP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
474
0001434334
HENNI NOORITA
IMKIN0001434334
01.10.2009
01.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
475
0001434334.02
KUSHARDIYANTO
IMKIN0001434334
01.10.2009
01.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
476
0001434993
RIZAL SUPRIADI, SE
IMKIN0001434993
01.10.2009
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
477
0001436186.01
AGUS SURURI
IMKIN0001436186
01.10.2009
01.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
532,000.00
354,667.00
53,200.00
35,467.00
0.00
319,200.00
478
0001437217
ADITYA DARMAWAN
IMKIN0001437217
12.10.2009
12.03.2012
01
NIAPMD
100,000,000.00
100,000,000.00 2011
70,000.00
40,833.00
7,000.00
4,083.00
0.00
36,750.00
479
0001437238
DAHLIA FN
IMKIN0001437238
01.10.2009
01.04.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
480
0001437318
SANDRA
IMKIN0001437318
01.10.2009
01.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
481
0001437425
IMKIN0001437425
NI KADEK ARYAWATI. S
05.10.2009
05.02.2012
01
CIGLPN
300,000,000.00
300,000,000.00 2011
216,000.00
144,000.00
21,600.00
14,400.00
0.00
129,600.00
482
0001439533
IR ARIANTO SUFAAT
IMKIN0001439533
01.10.2009
01.03.2012
01
PMTBPL
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
483
0001439611
RUDI PRAJOGO SH
IMKIN0001439611
01.10.2009
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
484
0001441500.01
AGUNG NUGROHO
IMKIN0001441500
06.10.2009
06.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
384,000.00
256,000.00
38,400.00
25,600.00
0.00
230,400.00
485
0001441763
IMKIN0001441763
IMMACULATA TRI WAHJU
07.10.2009
07.05.2012
01
MANTLF
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
486
0001442671
R YULIESTIE
IMKIN0001442671
08.10.2009
08.04.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
487
0001443504
HANIF RALIBI
IMKIN0001443504
23.10.2009
23.05.2012
01
NIAPMD
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
488
0001443667
FERRY TOBING
IMKIN0001443667
10.10.2009
10.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
489
0001443706
KUSMIATI
IMKIN0001443706
10.10.2009
10.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
490
0001443706.02
SURYANTO
IMKIN0001443706
10.10.2009
10.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
491
0001444023.01
THIO TJOEN HONG
IMKIN0001444023
21.10.2009
21.05.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
492
0001445634
TJENAH AKEMAH
IMKIN0001445634
12.10.2009
12.03.2012
01
MANTLF
75,000,000.00
25,000,000.00 2011
54,000.00
31,500.00
5,400.00
3,150.00
0.00
28,350.00
493
0001448013
ERNI WIDAYATI
IMKIN0001448013
14.10.2009
14.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
494
0001448021
IMKIN0001448021
AA GEDE SEMARA PUTRA
14.10.2009
14.02.2012
01
CIGLPN
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
495
0001448159
IMKIN0001448159
MORUK HALE MAXIMUS D
15.10.2009
15.04.2012
01
BNIJBT
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
496
0001449061
STEPHANNIE LOUIS
14.10.2009
14.04.2012
01
CIGLPN
500,000,000.00
400,000,000.00 2011
280,000.00
140,000.00
28,000.00
14,000.00
0.00
126,000.00
IMKIN0001449061


NO : 01105/II/2012/01
: 29
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
497
0001449169
ANNA FAUZAN
IMKIN0001449169
13.10.2009
13.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
498
0001449227.01
IMKIN0001449227
PAULUS ADI WIJAYA YO
15.10.2009
15.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
499
0001449461
IMKIN0001449461
DARMSTATER MARTINUS
09.10.2009
09.03.2012
01
PMTBPL
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
500
0001450290
IMKIN0001450290
IR. IGN HIMAWAN SULI
15.10.2009
15.04.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
258,000.00
129,000.00
25,800.00
12,900.00
0.00
116,100.00
501
0001452436.01
WEWE
IMKIN0001452436
20.10.2009
20.05.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
258,000.00
107,500.00
25,800.00
10,750.00
0.00
96,750.00
502
0001453579
IMKIN0001453579
ARTHA ULY NAINGGOLAN
21.10.2009
21.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
503
0001453654
IMKIN0001453654
AGUSTINA SETYOWATI
21.10.2009
21.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
504
0001453654.02
KUSRYANTO SH MH
IMKIN0001453654
21.10.2009
21.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
505
0001453708
I KETUT MARTIN
IMKIN0001453708
21.10.2009
21.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
506
0001456390
YATNO
IMKIN0001456390
23.10.2009
23.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
507
0001456923
IMKIN0001456923
HUDSON DIESNATALIS
19.10.2009
19.05.2012
01
CIGLPN
100,000,000.00
100,000,000.00 2011
172,000.00
71,667.00
17,200.00
7,167.00
0.00
64,500.00
508
0001457703
SELVI CHRISTINE TJU
IMKIN0001457703
23.10.2009
23.03.2012
01
HSBTLC
50,000,000.00
20,000,000.00 2011
28,400.00
16,567.00
2,840.00
1,657.00
0.00
14,910.00
509
0001458187
TJHIA FUI PHIN
IMKIN0001458187
26.10.2009
26.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
510
0001458360
WIDI WAHYUDI
IMKIN0001458360
09.11.2009
09.05.2012
01
NIAPMK
2,000,000.00
2,000,000.00 2011
1,580.00
790.00
0.00
0.00
0.00
790.00
511
0001458592.01
ROMLAH LAELA
IMKIN0001458592
26.10.2009
03.03.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
512
0001459537
ADI ABDILAH
IMKIN0001459537
26.10.2009
26.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
513
0001460715
IMKIN0001460715
MUHAMMAD ROSYAD WIDO
23.10.2009
23.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
514
0001461075
IMKIN0001461075
MUSTIKAWATI SANJAYA
09.11.2009
14.05.2012
01
NIAPMK
2,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
515
0001461688.01
EDI ENIKA KAHAR
IMKIN0001461688
20.10.2009
20.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
516
0001462059.01
IMKIN0001462059
CHANDRA HARTISAN SS
27.10.2009
27.05.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
580,000.00
241,667.00
58,000.00
24,167.00
0.00
217,500.00
517
0001462096
WIWIN RAHAYU
01.11.2009
01.03.2012
01
BNIJBT
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001462096


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
518
0001462916
WARRIYODI SH
IMKIN0001462916
01.11.2009
01.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
519
0001463133
FRISKA FEBRINA
IMKIN0001463133
01.11.2009
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
520
0001464000
ELLY SYLVIANA
IMKIN0001464000
01.11.2009
01.03.2012
01
LIFCRP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
521
0001466603
IMKIN0001466603
ELNATH ALPHA YONATAN
01.11.2009
09.05.2012
01
CIGLPN
300,000,000.00
300,000,000.00 2011
210,000.00
105,000.00
0.00
0.00
0.00
105,000.00
522
0001467952
IMKIN0001467952
BUDI MOKO PRABOWO
03.11.2009
03.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
523
0001469612
YENNY GUNAWAN
IMKIN0001469612
09.11.2009
09.05.2012
01
HSBTLC
30,000,000.00
30,000,000.00 2011
42,600.00
21,300.00
0.00
0.00
0.00
21,300.00
524
0001469613
IZMAL B SIREGAR
IMKIN0001469613
09.11.2009
09.05.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
525
0001470844.01
MIMIN SUPRIYADI
IMKIN0001470844
06.11.2009
06.03.2012
01
MANDEX
100,000,000.00
50,000,000.00 2011
137,500.00
91,667.00
0.00
0.00
0.00
91,667.00
526
0001470881.01
SUPRIYONO
IMKIN0001470881
09.11.2009
09.05.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
258,000.00
129,000.00
0.00
0.00
0.00
129,000.00
527
0001470882.01
LAU DAVID WIJAYA
IMKIN0001470882
09.11.2009
09.05.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
118,000.00
59,000.00
0.00
0.00
0.00
59,000.00
528
0001471805
IVAN P
IMKIN0001471805
10.11.2009
10.05.2012
01
HSBTLC
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
529
0001471805.02
OKTAFIANI
IMKIN0001471805
10.11.2009
10.05.2012
01
HSBTLC
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
530
0001472058.01
ATING BUDIARTI
IMKIN0001472058
09.11.2009
09.05.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
96,500.00
48,250.00
0.00
0.00
0.00
48,250.00
531
0001472495.01
FARIDA LEILASARI
IMKIN0001472495
10.11.2009
10.02.2012
01
CIGSRN
400,000,000.00
200,000,000.00 2011
1,390,000.00
1,042,500.00
0.00
0.00
0.00
1,042,500.00
532
0001472709.01
JAUWLY
IMKIN0001472709
18.11.2009
18.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
30,900.00
15,450.00
0.00
0.00
0.00
15,450.00
533
0001473771
INDRA SUSANTI SH
IMKIN0001473771
11.11.2009
11.05.2012
01
BNIJBX
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
534
0001474830
IMKIN0001474830
DOLLY NOVIE RUMUAT
13.11.2009
13.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
535
0001475374
IMKIN0001475374
BASYIR AKHMAD ISKAND
02.11.2009
02.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
536
0001477132
R EVI SAVITRI P
IMKIN0001477132
16.11.2009
16.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
537
0001478295.01
IMKIN0001478295
MOCHAMMAD TRIBEKTI M
11.11.2009
11.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
538
0001478593
AKHMAD SYAMSI
18.11.2009
18.04.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
432,000.00
252,000.00
0.00
0.00
0.00
252,000.00
IMKIN0001478593


NO : 01105/II/2012/01
: 31
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
539
0001478610
PARSIYO
IMKIN0001478610
23.11.2009
23.03.2012
01
NIAPMD
100,000,000.00
100,000,000.00 2011
85,000.00
56,667.00
0.00
0.00
0.00
56,667.00
540
0001479239.01
AGUS GUNAWAN
IMKIN0001479239
13.11.2009
25.03.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
21,600.00
14,400.00
0.00
0.00
0.00
14,400.00
541
0001479966
ELVIA F
IMKIN0001479966
19.11.2009
19.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
542
0001480105.01
MUHAMMAD SYARIEF
IMKIN0001480105
20.11.2009
20.02.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
543
0001480607
JUNAEDI
IMKIN0001480607
21.11.2009
21.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
544
0001480651.01
BONG MUSRIONO
IMKIN0001480651
19.11.2009
19.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
243,000.00
162,000.00
0.00
0.00
0.00
162,000.00
545
0001481375
YENNY HARSONO
IMKIN0001481375
20.11.2009
20.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
546
0001481419
GABRIEL SUKOCO
IMKIN0001481419
20.11.2009
20.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
547
0001482947.01
RUDI EE PAKPAHAN
IMKIN0001482947
23.11.2009
23.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
14,040.00
9,360.00
0.00
0.00
0.00
9,360.00
548
0001485172
ARKELAUS SANGIAN
IMKIN0001485172
24.12.2009
24.05.2012
01
NIAPMD
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
549
0001485183
LANJAR RETNO SARI
IMKIN0001485183
24.12.2009
24.03.2012
01
NIAPMD
100,000,000.00
100,000,000.00 2011
118,000.00
88,500.00
0.00
0.00
0.00
88,500.00
550
0001485612.01
IMKIN0001485612
TUTY SYARIFAH SYAHPU
24.11.2009
24.05.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
156,000.00
78,000.00
0.00
0.00
0.00
78,000.00
551
0001486015
ABU SISWANTO
IMKIN0001486015
25.11.2009
25.02.2012
01
CIGLPN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
552
0001487334
CITY MIRACLE
IMKIN0001487334
01.12.2009
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
553
0001489426
LIE KHIANG
IMKIN0001489426
01.12.2009
01.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
554
0001490407
SUKWANI SABRAN
IMKIN0001490407
01.12.2009
01.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
555
0001491048
PAUL ARIF BUDIMAN
IMKIN0001491048
01.12.2009
01.03.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
645,000.00
483,750.00
0.00
0.00
0.00
483,750.00
556
0001491289
LINA MAJUSIP
IMKIN0001491289
29.12.2009
29.05.2012
01
NIAPMK
2,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
557
0001492292
DWIWINDIANA
IMKIN0001492292
04.12.2009
04.03.2012
01
BNIJBT
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
558
0001492974
IMKIN0001492974
ZAINUDIN JOHANSYAH
04.12.2009
04.04.2012
01
MANTLF
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
559
0001493083
IMKIN0001493083
KENNETH ROBERT SUTHR
03.12.2009
03.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 32
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
560
0001493083.02
IMKIN0001493083
SANDRA ASRININGRUM
03.12.2009
03.03.2012
01
HSBTLC
30,000,000.00
30,000,000.00 2011
27,300.00
20,475.00
0.00
0.00
0.00
20,475.00
561
0001493158
DAISY PAULINA R
IMKIN0001493158
05.12.2009
05.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
562
0001493177
H MARHENTO
IMKIN0001493177
07.12.2009
07.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
563
0001493177.02
LISTIANINGSIH P
IMKIN0001493177
07.12.2009
07.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
564
0001494700.01
SITI NURCAHYANI
IMKIN0001494700
09.12.2009
15.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
7,000.00
4,083.00
0.00
0.00
0.00
4,083.00
565
0001497581.01
IMKIN0001497581
CHRISTIAN LUTHER PAP
11.12.2009
11.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
566
0001497612.01
IMKIN0001497612
GELAR PANGERSA MUNGG
14.12.2009
14.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
140,000.00
105,000.00
0.00
0.00
0.00
105,000.00
567
0001498217
NURWIYANTO
IMKIN0001498217
15.12.2009
15.05.2012
01
BNIJBT
100,000,000.00
100,000,000.00 2011
392,000.00
228,667.00
0.00
0.00
0.00
228,667.00
568
0001498808
PENI HERMAWATI
IMKIN0001498808
15.12.2009
15.03.2012
01
HSBTLC
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
569
0001498915.01
SUKIRMAN
IMKIN0001498915
08.12.2009
08.04.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
140,000.00
93,333.00
0.00
0.00
0.00
93,333.00
570
0001499307
IMAS CUCU ROHAENI
IMKIN0001499307
15.12.2009
15.03.2012
01
BNIJBX
150,000,000.00
150,000,000.00 2011
523,500.00
392,625.00
0.00
0.00
0.00
392,625.00
571
0001499335
APRINUS
IMKIN0001499335
24.12.2009
07.05.2012
01
NIAPMD
300,000,000.00
300,000,000.00 2011
426,000.00
284,000.00
0.00
0.00
0.00
284,000.00
572
0001500388.01
SUPRIA
IMKIN0001500388
16.12.2009
16.03.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
96,500.00
72,375.00
0.00
0.00
0.00
72,375.00
573
0001500417.01
NAJIB NENDRA
IMKIN0001500417
10.12.2009
01.05.2012
01
UOBEXP
10,000,000.00
10,000,000.00 2011
61,800.00
36,050.00
0.00
0.00
0.00
36,050.00
574
0001500438.01
SALLY OCTAVIA
IMKIN0001500438
12.12.2009
28.05.2012
01
UOBEXP
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
575
0001501714
IMKIN0001501714
WAHYU DWINARKO LEKSO
03.12.2009
03.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
576
0001502590
IMKIN0001502590
OMEGA PERMATA SARI
11.12.2009
11.03.2012
01
HSBTLC
50,000,000.00
50,000,000.00 2011
71,000.00
53,250.00
0.00
0.00
0.00
53,250.00
577
0001503093.01
BUDIYONO
IMKIN0001503093
17.12.2009
17.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
578
0001505481.01
ANDRES CHANDRA
IMKIN0001505481
16.12.2009
16.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
70,000.00
52,500.00
0.00
0.00
0.00
52,500.00
579
0001505524.01
TONI
IMKIN0001505524
21.12.2009
21.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
493,000.00
369,750.00
0.00
0.00
0.00
369,750.00
580
0001507387
IMKIN0001507387
NOVAYANTI BIRINGKANA
16.12.2009
16.03.2012
01
PMCSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
581
0001508656.01
YUDHI WAHYUDI
IMKIN0001508656
01.01.2010
01.04.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
582
0001509336
DIAR PRATIWI
IMKIN0001509336
01.01.2010
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
583
0001509336.02
IMKIN0001509336
MOCH. ZEIN AL ASHAR
01.01.2010
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
584
0001509664
DESI NURAIDAH
IMKIN0001509664
01.01.2010
01.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
585
0001509664.01
HERI PATMONO
IMKIN0001509664
01.01.2010
01.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
586
0001511484
SUPARMAN
IMKIN0001511484
01.01.2010
01.04.2012
01
BNIJBT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
587
0001511508
JULISTIYOWATI
IMKIN0001511508
01.01.2010
01.05.2012
01
BNIJBT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
588
0001511949.01
ZAINUL IKHWAN
IMKIN0001511949
04.01.2010
04.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
589
0001512004
ELISABETTH RIANG H
IMKIN0001512004
02.01.2010
02.05.2012
01
HSBTLC
330,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
590
0001512477
H MANSUR,DRS
IMKIN0001512477
05.01.2010
05.05.2012
01
BNIJBT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
591
0001513351.01
WAWAN ERAWAN
IMKIN0001513351
04.01.2010
04.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
592
0001516209
KARTIKA WATI
IMKIN0001516209
11.01.2010
11.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
593
0001516312
WAHJU KURDIJANTI
IMKIN0001516312
11.01.2010
11.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
594
0001516781
HERI SISWOYO
IMKIN0001516781
07.01.2010
07.05.2012
01
DANHCP
10,600,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
595
0001519836
LO FARRAH KARTIKA
IMKIN0001519836
13.01.2010
13.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
596
0001520282.01
IMKIN0001520282
WIWIK CHITRA PRATIWI
06.01.2010
06.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
597
0001520338.01
IMKIN0001520338
I GEDE PARTANAYASA
11.01.2010
11.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
598
0001521074
IMKIN0001521074
MARTIANA NIKMATURROH
13.01.2010
13.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
599
0001521769
SRI RAHMADANI
IMKIN0001521769
14.01.2010
14.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
600
0001522870
IMKIN0001522870
RR ANNISA BUDIUTOMO
11.02.2010
11.03.2012
01
NIAPMK
2,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
601
0001523020
MUZAKKIR H HASAN
14.01.2010
14.05.2012
01
DANHCP
10,600,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001523020


NO : 01105/II/2012/01
: 34
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
602
0001523033
WILLIAM
IMKIN0001523033
14.01.2010
14.03.2012
01
DANHCP
42,250,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
603
0001524571
A RIVAI RUSJDIN
IMKIN0001524571
23.02.2010
23.05.2012
01
RBSTLE
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
604
0001524571.01
A RIVAI RUSJDIN
IMKIN0001524571
23.02.2010
23.05.2012
01
RBSTLE
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
605
0001524940
SETIYANTO YUWONO
IMKIN0001524940
18.01.2010
18.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
606
0001524976
BONNY SANGGAH SH
IMKIN0001524976
19.01.2010
19.04.2012
01
BNIJBT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
607
0001524998
YOHANES RAJAWALI
IMKIN0001524998
19.01.2010
19.05.2012
01
BNIJBT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
608
0001525038
SUSANTI
IMKIN0001525038
05.03.2010
05.02.2012
01
CIGHCH
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGHCH
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
609
0001525353
PATHURAHMAN,ST
IMKIN0001525353
19.01.2010
19.05.2012
01
BNIJBT
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
610
0001529341.01
FATIMAH HATTA
IMKIN0001529341
22.01.2010
22.03.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
611
0001529723
IMKIN0001529723
HARTADI HENDRATMOKO
18.01.2010
18.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
612
0001530199
BUDIANTO
IMKIN0001530199
20.01.2010
20.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
613
0001531312.01
MADA
IMKIN0001531312
22.01.2010
22.03.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
614
0001531354.01
RENANDI
IMKIN0001531354
25.01.2010
25.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
615
0001531861
YANI NOVIANA
IMKIN0001531861
17.03.2010
17.05.2012
01
NIAPMK
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
616
0001533472.01
SUPRIYANDI
IMKIN0001533472
23.01.2010
23.02.2012
01
CIGSRN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
617
0001535074
ARIE KURNIAWAN
IMKIN0001535074
01.02.2010
01.03.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
618
0001536743.01
IMKIN0001536743
GUSMAN RYNHOT PANJAI
01.02.2010
01.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
619
0001537027.01
IMKIN0001537027
MARY PUDJIASTUTI SUS
02.02.2010
02.03.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
620
0001537038.01
IMKIN0001537038
HARNI HAMDAN TAMLI
02.02.2010
02.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
621
0001537389
SUMARSIYAM
01.02.2010
01.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001537389


NO : 01105/II/2012/01
: 35
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
622
0001537745
ELFI AFIFAH
IMKIN0001537745
03.02.2010
03.03.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
623
0001540062
SRI EKA YULIANI
IMKIN0001540062
05.02.2010
05.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
624
0001541864
IMKIN0001541864
ENDAH TRISETYAWATI
11.02.2010
11.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
625
0001543222
RAJEEV KUMAR R
IMKIN0001543222
09.02.2010
09.05.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
626
0001543222.02
VIDYA S
IMKIN0001543222
09.02.2010
09.05.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
627
0001543713
ABDUL RAHIM SP
IMKIN0001543713
05.02.2010
05.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
628
0001543925
SUNOKO
IMKIN0001543925
03.02.2010
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
629
0001544924.01
DRS SUYANTO SE
IMKIN0001544924
12.02.2010
12.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
630
0001545963
M JAYADI
IMKIN0001545963
12.02.2010
12.03.2012
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
631
0001546107
ODO FADLOELI
IMKIN0001546107
23.02.2010
23.03.2012
01
NIAPMK
2,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
632
0001547737
IMKIN0001547737
JIMMY MANGAMPUL SIMA
04.02.2010
04.05.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
633
0001548194
NOVINDRA M
IMKIN0001548194
12.02.2010
12.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
634
0001548231
IMKIN0001548231
MEI CHRISTINA ROTUA
16.02.2010
16.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
635
0001548346
IMKIN0001548346
IDA BAGUS PUTU ADNYA
17.02.2010
17.03.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
636
0001548844.01
PRATMIN
IMKIN0001548844
17.02.2010
17.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
637
0001549886
RAYMOND WIDJAJA
IMKIN0001549886
16.02.2010
16.03.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
638
0001549888
AZHAR SE AK
IMKIN0001549888
16.02.2010
16.05.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
639
0001549888.02
RINI IRAWATI
IMKIN0001549888
16.02.2010
16.05.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
640
0001550512
SUPRIYANTO
IMKIN0001550512
18.02.2010
18.03.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
641
0001551844
MARULI S R SINAGA
IMKIN0001551844
19.02.2010
19.03.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
642
0001551851
BUDI RAHMANTO
IMKIN0001551851
17.02.2010
17.03.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 36
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
643
0001551926
IMKIN0001551926
HUNGKONO CHANDRA
19.02.2010
19.05.2012
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
644
0001553590.01
IMKIN0001553590
YANTI CHRISNAVIANTI
19.02.2010
19.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
645
0001553738.01
PRI ARTCAHYO
IMKIN0001553738
20.02.2010
20.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
646
0001555652
FIRA MARDIANI
IMKIN0001555652
01.03.2010
01.05.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
647
0001556445
KAMILUS N. U.
IMKIN0001556445
01.03.2010
01.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
648
0001556917
IMKIN0001556917
WIDJANARKO ANDANG
01.03.2010
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
649
0001557140
IDA NURHAYATI
IMKIN0001557140
01.03.2010
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
650
0001557410
IMKIN0001557410
THEDORE EDWARD CHRIS
01.03.2010
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
651
0001557410.01
IMKIN0001557410
YOHANES CHRISTIANTO
01.03.2010
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
652
0001558855.01
ARI TITIS SETIAWAN
IMKIN0001558855
02.03.2010
02.03.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
653
0001558880.01
ANDY TANO TJANDRA
IMKIN0001558880
03.03.2010
03.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
654
0001559708
ARI NUGRAHA P
IMKIN0001559708
02.03.2010
02.03.2012
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
655
0001559711
RANGGA C NUGRAHA
IMKIN0001559711
02.03.2010
02.03.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
656
0001560284
IMKIN0001560284
ERIC YUNIAR WIBOWO
03.03.2010
03.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
350,000.00
29,167.00
0.00
0.00
0.00
29,167.00
01
CIGLPN
500,000,000.00
200,000,000.00 2012
140,000.00
140,000.00
0.00
0.00
0.00
140,000.00
657
0001561954
IMKIN0001561954
ROLAND RIAN ULIANTO
17.03.2010
17.03.2012
01
NIAPMD
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
658
0001561957
BUDI IRIANTI
IMKIN0001561957
05.03.2010
05.05.2012
01
BNIJBT
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
659
0001562677.01
TISNA MANSUR
IMKIN0001562677
01.03.2010
01.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
660
0001562760
DEWI BUDHI EKASARI
IMKIN0001562760
08.03.2010
08.05.2012
01
BNIJBT
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
661
0001562776
IMKIN0001562776
YANUARITA EVAFANI MU
17.03.2010
17.05.2012
01
NIAPMD
500,000,000.00
200,000,000.00 2012
140,000.00
116,667.00
0.00
0.00
0.00
116,667.00
662
0001563434
YESSICA
08.03.2010
08.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001563434


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
663
0001563511
IMKIN0001563511
I GUSTI AGUNG PUTRA
09.03.2010
09.05.2012
01
BNIJBT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
664
0001567792
PULUNG KUSHARIADI
IMKIN0001567792
12.03.2010
12.03.2012
01
MANTLF
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
665
0001567823
IMKIN0001567823
JOVITA IRENE TURANG
15.03.2010
15.03.2012
01
MANTLF
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
666
0001567850.01
AA AHYAUDDIN DENI
IMKIN0001567850
11.03.2010
11.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
667
0001568076.01
MUTYA YUNI LESTARI
IMKIN0001568076
15.03.2010
15.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
668
0001568087.01
AGUNG BAROKAH
IMKIN0001568087
17.03.2010
17.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2012
91,000.00
91,000.00
0.00
0.00
0.00
91,000.00
669
0001568649
WILDAN DESNANDAR
IMKIN0001568649
17.03.2010
17.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
670
0001569780
KRISTIANA MUDJIATI
IMKIN0001569780
17.03.2010
17.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
671
0001571025.01
FARID NUR HAMZAH
IMKIN0001571025
18.03.2010
18.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2012
70,000.00
58,333.00
0.00
0.00
0.00
58,333.00
672
0001571031.01
IMKIN0001571031
UMI ENDAH SUSILOWATI
18.03.2010
18.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2012
142,000.00
142,000.00
0.00
0.00
0.00
142,000.00
673
0001571071.01
IMKIN0001571071
SARI RATNA FRANSISCA
19.03.2010
19.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
674
0001572108
HERRY LANO
IMKIN0001572108
30.03.2010
30.03.2012
01
NIAPMK
2,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
675
0001572617.01
IMKIN0001572617
ROCHIMANUL LAKSANA
22.03.2010
22.03.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
676
0001576655.01
ELLY PURNAWATI
IMKIN0001576655
26.03.2010
26.04.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
677
0001576709.01
PAUL H H PARDEDE
IMKIN0001576709
23.03.2010
23.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
678
0001577301
ARIS MARTONO
IMKIN0001577301
24.03.2010
24.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
679
0001577301.01
IMKIN0001577301
CELIA PRAMONO PUTRI
24.03.2010
24.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
680
0001578190
ANI RATMALA
IMKIN0001578190
01.04.2010
01.05.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
681
0001578764
IMKIN0001578764
HARTADI HENDRATMOKO
02.04.2010
02.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
682
683
Quarter 2012
PAGE
CERT. NO.
0001579175
JENI SYAHRINA
0001579348
INTEN WIDIASTARI I G
POLICY NO.
IMKIN0001579175
IMKIN0001579348
DATE OF
DATE OF NATURE
01.04.2010
19.04.2010
01.03.2012
19.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAPMD
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAPMD
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
684
0001579375
IMKIN0001579375
RIDAR FIRDAUS GINTIN
01.04.2010
01.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
685
0001579929
YOSAFAT RUMOMBE
01.04.2010
01.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
686
687
0001580646
IYOD RIDWAN
0001580646.01
IYOD RIDWAN
IMKIN0001579929
IMKIN0001580646
IMKIN0001580646
19.04.2010
19.04.2010
19.03.2012
19.03.2012
688
0001580721
GUNAWAN PONTOH
IMKIN0001580721
02.03.2010
02.05.2012
01
BNIJBT
689
0001581871
MAYA MAULIZAR AMD
IMKIN0001581871
07.04.2010
07.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAPMK
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAPMK
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
690
691
692
0001581871.02
WIDIASMANTO
0001583075
ZAINUL ARIFIN
0001584397
ROSI
IMKIN0001581871
IMKIN0001583075
IMKIN0001584397
07.04.2010
19.04.2010
07.04.2010
07.03.2012
19.03.2012
07.03.2012
693
0001584539.01
IMKIN0001584539
ARIANA INDAWATI TIRT
07.04.2010
07.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2012
690,000.00
632,500.00
0.00
0.00
0.00
632,500.00
694
0001584935
CHERRIYATI
10.04.2010
10.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
200,000,000.00
200,000,000.00 2011
1,104,000.00
92,000.00
0.00
0.00
0.00
92,000.00
01
MANDEX
200,000,000.00
200,000,000.00 2012
1,236,000.00
1,236,000.00
0.00
0.00
0.00
1,236,000.00
695
0001586699.01
SUDIRMAN BASRI
IMKIN0001584935
IMKIN0001586699
12.04.2010
12.03.2012


NO : 01105/II/2012/01
: 39
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
696
CERT. NO.
0001588519.01
RIA ARINDA
Quarter 2012
PAGE
POLICY NO.
IMKIN0001588519
DATE OF
DATE OF NATURE
12.04.2010
12.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
697
0001588529.01
ERRY GARYATNO
IMKIN0001588529
06.04.2010
31.03.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
698
0001588545.01
IMKIN0001588545
JABMAR SIBURIAN MM D
12.04.2010
12.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2012
690,000.00
632,500.00
0.00
0.00
0.00
632,500.00
699
0001589179
SAHIRUN
14.04.2010
14.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001589179
700
0001589703
JOICE PONTOH
IMKIN0001589703
19.04.2010
19.05.2012
01
BNIJBX
701
0001589974
DANNY ADRIANTO
IMKIN0001589974
07.04.2010
07.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
702
0001593397.01
HERMIN KONDO
IMKIN0001593397
13.04.2010
13.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
703
0001593489
IMKIN0001593489
AGUSTINA INDRAWATI A
10.04.2010
10.05.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
704
0001596504
LENA WATY
IMKIN0001596504
07.04.2010
07.05.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
705
0001596665
SONNY MUNANDAR
IMKIN0001596665
28.04.2010
23.04.2012
01
NIAPMD
500,000,000.00
200,000,000.00 2012
258,000.00
258,000.00
0.00
0.00
0.00
258,000.00
706
0001596860
IRA SUSILO
IMKIN0001596860
16.04.2010
16.05.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
707
0001596960
SRI WREDININGSIH
IMKIN0001596960
17.04.2010
17.05.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
708
0001597460
RANTI MATURINA
IMKIN0001597460
11.06.2010
11.03.2012
01
NIAPMD
300,000,000.00
8,010,000.00 2011
5,607.00
1,402.00
0.00
0.00
0.00
1,402.00
709
0001597772
BANGKIT PURNOMO
IMKIN0001597772
01.04.2010
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
710
0001597785
MUSROI
IMKIN0001597785
01.04.2010
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
711
0001598043
YUSRIDA
IMKIN0001598043
19.04.2010
19.03.2012
712
0001598444.01
IMKIN0001598444
ICHSAN ALHADI YUSUFA
20.04.2010
20.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
713
0001598598.01
FENNIYATI
22.04.2010
22.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001598598


NO : 01105/II/2012/01
: 40
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
714
Quarter 2012
PAGE
CERT. NO.
0001599200
SUMARSIYAM
POLICY NO.
IMKIN0001599200
DATE OF
DATE OF NATURE
27.04.2010
27.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
715
0001600803
WARRIYODI SH
IMKIN0001600803
01.05.2010
01.02.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
716
0001600825
ABDUL ROUP
IMKIN0001600825
01.05.2010
01.03.2012
01
PMCSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
717
718
719
720
0001601891
IMKIN0001601891
DONNY TRI ARFIANTO
0001601899
IR E TEMMY GAWA
IMKIN0001601899
0001601899.02
IMKIN0001601899
MARIA YOSEFINA NENG
0001602991
NI KADEK WARDANI
IMKIN0001602991
01.05.2010
01.05.2010
01.05.2010
01.05.2010
01.03.2012
01.03.2012
01.03.2012
01.03.2012
721
0001604526.01
ENDANG SRI HASTUTI
IMKIN0001604526
05.05.2010
05.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
722
0001604567.01
OKTIA EKA HARDIANA
IMKIN0001604567
05.05.2010
05.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
723
0001605454
FERA
IMKIN0001605454
05.05.2010
05.04.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
724
725
0001606330
I NYOMAN SURADANA
0001606590
AGUS SULAEMAN
IMKIN0001606330
IMKIN0001606590
07.05.2010
08.05.2010
07.03.2012
08.03.2012
726
0001606739
ADANG KUSNANDAR
IMKIN0001606739
06.05.2010
06.05.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
727
0001606945.01
AGUNG PUJIANTORO
IMKIN0001606945
01.05.2010
01.03.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
580,000.00
96,667.00
0.00
0.00
0.00
96,667.00
01
CIGSRN
400,000,000.00
400,000,000.00 2012
640,000.00
640,000.00
0.00
0.00
0.00
640,000.00
01
MANDEX
200,000,000.00
100,000,000.00 2011
108,000.00
9,000.00
0.00
0.00
0.00
9,000.00
728
0001609093.01
IMKIN0001609093
MUHAMMAD SYAFRIL SAL
05.05.2010
05.04.2012


NO : 01105/II/2012/01
: 41
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
729
0001609126.01
IWAN SUHERLAN
IMKIN0001609126
05.05.2010
05.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
730
0001609256.01
ATIK BADIAH
IMKIN0001609256
11.05.2010
11.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
731
0001609274.01
WAN MUHAMAD ZAKI
IMKIN0001609274
07.05.2010
07.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
732
0001609400.01
IMKIN0001609400
MUHARILAS SUHARTININ
06.05.2010
06.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
386,000.00
64,333.00
0.00
0.00
0.00
64,333.00
01
MANDEX
200,000,000.00
200,000,000.00 2012
432,000.00
432,000.00
0.00
0.00
0.00
432,000.00
733
0001609502.01
WAHID HIDAYAT
IMKIN0001609502
07.05.2010
07.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
734
0001610017
LEVY ASM
IMKIN0001610017
12.05.2010
12.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
735
0001611000.01
AMRAINI
IMKIN0001611000
14.05.2010
14.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
736
0001611729
MS KURNIAWAN
IMKIN0001611729
14.05.2010
14.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
96,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
737
738
739
740
741
742
0001611965
BUDI SARONO
0001612096
EKO IRAWAN
0001612172
TRI WAHYU
0001612172.01
TRI WAHYU
IMKIN0001611965
IMKIN0001612096
IMKIN0001612172
IMKIN0001612172
0001613517
IMKIN0001613517
ARSANTO NORENDRO
0001613628
TITIN ZUWARNI
IMKIN0001613628
15.05.2010
17.05.2010
25.05.2010
25.05.2010
03.05.2010
12.05.2010
15.03.2012
17.03.2012
25.03.2012
25.03.2012
03.03.2012
12.03.2012


NO : 01105/II/2012/01
: 42
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
743
0001613953
IMKIN0001613953
M.ARCHAM UBAIDILLAH
19.05.2010
19.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
744
0001614097
SULMAN
18.05.2010
18.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001614097
745
0001614162.01
TEDDY ARSONO
IMKIN0001614162
14.05.2010
14.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
746
0001614343.01
EDDY RIANTO
IMKIN0001614343
12.05.2010
12.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
747
0001614672
ATO SUGIARTO
IMKIN0001614672
12.05.2010
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPS
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
748
749
750
751
0001614861
ARDIANUS NENANG
0001615400
ALDITYA KRISANDY
IMKIN0001614861
IMKIN0001615400
0001615654
IMKIN0001615654
DIAN MARDIAN SANTOSO
0001615654.02
SITI MUSYARIFAH
IMKIN0001615654
18.05.2010
20.05.2010
19.05.2010
19.05.2010
18.03.2012
20.03.2012
19.03.2012
19.03.2012
752
0001615751
IMKIN0001615751
CHRISTIAN THOMAS E S
18.05.2010
18.05.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
753
0001615751.02
IMKIN0001615751
RICCA MARTHA RENI GE
18.05.2010
18.05.2012
01
PMTBPL
6,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
754
0001616751.01
IMKIN0001616751
UNTUNG ENDRO CAHYONO
21.05.2010
21.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
755
0001617581
DEWI OCTAVIYANTI
24.05.2010
24.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001617581
756
0001619266.01
EDY PURNAWAN
IMKIN0001619266
26.05.2010
26.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
757
0001619285.01
IMKIN0001619285
RICKY WAHYU CANDRA
25.05.2010
25.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
758
0001620079
JONI HERMANTO
IMKIN0001620079
01.06.2010
01.03.2012


NO : 01105/II/2012/01
: 43
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
759
0001620773
TITA ROSITA
IMKIN0001620773
01.06.2010
01.05.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
760
0001621485
WILLY SURYA
IMKIN0001621485
01.06.2010
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
761
0001622018.01
HIDAYAT SONDA
IMKIN0001622018
01.06.2010
01.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
762
0001622065
CHOLIMAH
IMKIN0001622065
01.06.2010
01.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
763
0001622086.01
FITRIAH
IMKIN0001622086
01.06.2010
01.05.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
236,000.00
19,667.00
0.00
0.00
0.00
19,667.00
764
0001625306.01
FITRI ANDAYANI
IMKIN0001625306
07.06.2010
07.03.2012
01
HSBCPP
100,000,000.00
100,000,000.00 2011
70,000.00
17,500.00
0.00
0.00
0.00
17,500.00
765
0001625644.01
IMKIN0001625644
HINNANTA WIBOWO WONG
02.06.2010
02.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
766
0001625675.01
HADRANSYAH
IMKIN0001625675
07.06.2010
07.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
440,000.00
36,667.00
0.00
0.00
0.00
36,667.00
767
0001625720.01
IMKIN0001625720
JANGKUNG MULYONO
01.06.2010
01.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
118,000.00
29,500.00
0.00
0.00
0.00
29,500.00
768
0001625733.01
IMKIN0001625733
RULLY AKBARI PANGGAB
01.06.2010
01.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
769
0001625833.01
MUHAMAD RIDWAN
IMKIN0001625833
04.06.2010
04.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
770
0001626197
NURHIDAYAT
IMKIN0001626197
09.06.2010
09.05.2012
01
BNIJBX
200,000,000.00
100,000,000.00 2011
70,000.00
5,833.00
0.00
0.00
0.00
5,833.00
771
0001626914
RUSLI
IMKIN0001626914
05.06.2010
05.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
772
0001626940
ENDANG SRI HASTUTI
IMKIN0001626940
05.06.2010
05.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
773
0001627374.01
ABDUL HAMID SE
IMKIN0001627374
07.06.2010
07.02.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
774
0001628337.01
FIRMAN SAGAF
IMKIN0001628337
09.06.2010
09.05.2012
01
HSBCPP
200,000,000.00
100,000,000.00 2011
309,000.00
25,750.00
0.00
0.00
0.00
25,750.00
775
0001630984
IMKIN0001630984
NOOR LANJAR BUDIONO
14.06.2010
14.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
776
0001632002
HERI PUJIANTO
IMKIN0001632002
09.06.2010
09.03.2012
01
MANCLP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
777
0001632103.01
RONI BUDI ERWANTO
IMKIN0001632103
10.06.2010
10.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
778
0001632671
FAISAL BAHRI
IMKIN0001632671
12.06.2010
12.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
779
0001633038
IMKIN0001633038
SUSSY MACHTALINDA
16.06.2010
16.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
780
0001633204
FACHRURRAZI,DRS
IMKIN0001633204
16.06.2010
16.05.2012
01
BNIJBT
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
781
0001633990
IMKIN0001633990
DIAN PRAMANA PUTRA
14.06.2010
14.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
782
0001634597
ADITYA RIDYA IR
IMKIN0001634597
19.06.2010
19.05.2012
01
BNIJBT
50,000,000.00
50,000,000.00 2011
345,000.00
28,750.00
0.00
0.00
0.00
28,750.00
783
0001634779.01
IMKIN0001634779
ERIC YUNIAR WIBOWO
11.06.2010
11.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
316,000.00
105,333.00
0.00
0.00
0.00
105,333.00
784
0001634901.01
IMKIN0001634901
RADEN DICKE HIKMAT
17.06.2010
17.02.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
785
0001635447
YUSRIZAL
IMKIN0001635447
21.06.2010
21.03.2012
01
BNIJBT
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
786
0001635997
IMKIN0001635997
SUGIYANTO KARSOKARYO
18.06.2010
18.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
787
0001636111
TSHIN JONG CIE
IMKIN0001636111
21.06.2010
21.05.2012
01
MANTLF
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
788
0001636178.01
HASCARYADI DRS
IMKIN0001636178
15.06.2010
15.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
789
0001636237.01
IMKIN0001636237
IMMACULATA TRI WAHJU
19.06.2010
19.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
790
0001636301.01
AJ STEVANO
IMKIN0001636301
18.06.2010
18.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
791
0001636600
IRMA HAMDI
IMKIN0001636600
18.06.2010
18.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
792
0001637202.01
IMKIN0001637202
SISKA NOULA ANGELINA
22.06.2010
22.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
793
0001637227
MARYO S
IMKIN0001637227
23.06.2010
23.05.2012
01
BNIJBT
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
794
0001638554
NURAINI AMALIA
IMKIN0001638554
17.06.2010
17.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
795
0001638725
MUHAMMAD RUM.SH
IMKIN0001638725
18.06.2010
18.05.2012
01
CIGLPN
500,000,000.00
400,000,000.00 2011
280,000.00
23,333.00
0.00
0.00
0.00
23,333.00
796
0001641484.01
KURDIANTO
IMKIN0001641484
22.06.2010
22.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
797
0001641639.01
HENNY WAHYUNI
IMKIN0001641639
24.06.2010
25.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
798
0001642561
IMKIN0001642561
DADDY PRAWIRAKUSUMAH
01.07.2010
01.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
799
0001642698
IR ARIANTO SUFAAT
IMKIN0001642698
01.07.2010
01.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
800
0001643210
KONG LAP WAI
IMKIN0001643210
01.07.2010
01.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
801
0001643255.01
HAMZAH HUSAIN
IMKIN0001643255
01.07.2010
01.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
275,000.00
91,667.00
0.00
0.00
0.00
91,667.00
802
0001643344.01
DEWI KARTIKA SARI
IMKIN0001643344
01.07.2010
01.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
803
0001643927
IMKIN0001643927
TRIAS SANJAYA PUTRA
01.07.2010
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
804
0001644338
IMKIN0001644338
HEROLD DOLVIE ROBBY
01.07.2010
01.03.2012
01
MISLPN
300,000,000.00
300,000,000.00 2011
255,000.00
85,000.00
0.00
0.00
0.00
85,000.00
805
0001646372
ANDRI NOFRIAN
IMKIN0001646372
05.07.2010
05.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
806
0001647574
AAN AINAH
IMKIN0001647574
23.07.2010
23.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
807
0001647574.01
AAN AINAH
IMKIN0001647574
23.07.2010
23.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
808
0001647793
CHRISTIANUS D
IMKIN0001647793
08.07.2010
08.03.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
809
0001648026.01
NOVALIA INDRIASARI
IMKIN0001648026
13.07.2010
13.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
810
0001649744.01
IMKIN0001649744
MOHAMMAD ABDILAH NUR
09.07.2010
09.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
811
0001649798.01
TRISNI LOEKITAWATI
IMKIN0001649798
09.07.2010
09.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
812
0001650234
IMKIN0001650234
AHMAD HANDRI YUSUF
02.07.2010
02.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
813
0001651163
SAK PHIN
IMKIN0001651163
05.07.2010
05.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
814
0001651178.01
IMKIN0001651178
CECEP AANG HERMAWAN
02.07.2010
02.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
815
0001653023
SYAMSURI MUSTOFA
IMKIN0001653023
06.07.2010
06.03.2012
01
PMCSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
816
0001653588
IMKIN0001653588
ENDAH BUDI KUSUMANIN
14.07.2010
14.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
817
0001653752
LUKAS LEKRANSY
IMKIN0001653752
13.07.2010
13.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
818
0001653756
GATOT RIADI
IMKIN0001653756
13.07.2010
13.03.2012
01
DANHCP
50,000,000.00
50,000,000.00 2011
42,500.00
14,167.00
0.00
0.00
0.00
14,167.00
819
0001655606.01
DR KU JANNI
IMKIN0001655606
15.07.2010
15.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
820
0001657824.01
IMKIN0001657824
A WASISTO SETIYONO
19.07.2010
19.02.2012
01
CIGSRN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
821
0001658482.01
IMKIN0001658482
YANTI EVA ULINA BORU
16.07.2010
16.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 46
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
822
0001662799
RUDI SETIAWAN
IMKIN0001662799
21.07.2010
21.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
823
0001663317
WAHYU IRAWAN
IMKIN0001663317
22.07.2010
22.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
824
0001663367
ZAINUDIN
IMKIN0001663367
22.07.2010
22.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
825
0001663401
IMKIN0001663401
KURNIAWAN SASMITHA
22.07.2010
22.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
826
0001663401.02
IMKIN0001663401
NI MADE MIRA DWIPAYA
22.07.2010
22.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
827
0001663468
IMKIN0001663468
RINDI HERLAN SYABAND
23.07.2010
23.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
828
0001664750.01
ETTY MIHARTI
IMKIN0001664750
22.07.2010
22.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
392,000.00
130,667.00
0.00
0.00
0.00
130,667.00
829
0001665215
ROSIKHUL ABROR
IMKIN0001665215
21.07.2010
21.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
830
0001665336
DARMONO
IMKIN0001665336
27.07.2010
27.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
831
0001666833.01
IMKIN0001666833
MARINGAN BANCIN STNT
27.07.2010
27.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
832
0001666878.01
IMKIN0001666878
MOHAMAD DAHLAN SUMAN
28.07.2010
28.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
833
0001666919.01
SUMARSINI
IMKIN0001666919
27.07.2010
27.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
690,000.00
230,000.00
0.00
0.00
0.00
230,000.00
834
0001667027
INAFI TAN
IMKIN0001667027
01.08.2010
01.03.2012
01
PMTBPS
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
835
0001667247
TEGUH BASUKI,BEC
IMKIN0001667247
03.08.2010
03.05.2012
01
BNIJBX
200,000,000.00
100,000,000.00 2011
108,000.00
27,000.00
0.00
0.00
0.00
27,000.00
836
0001667362
LEO AGUSTA
IMKIN0001667362
01.08.2010
01.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
837
0001668959
SYLVIA MUSFRIANTI
IMKIN0001668959
01.08.2010
01.03.2012
01
HSBTLC
50,000,000.00
50,000,000.00 2011
108,000.00
45,000.00
0.00
0.00
0.00
45,000.00
838
0001669038.01
IRAWATI
IMKIN0001669038
02.08.2010
02.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
839
0001669911
FERRY TOBING
IMKIN0001669911
05.08.2010
05.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
840
0001672967
SRI AGUSTINA
IMKIN0001672967
09.08.2010
09.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
841
0001673660
IMKIN0001673660
CAROLUS I NYOMAN MAR
09.08.2010
09.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
842
0001673984
DARMANTO
01.08.2010
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001673984


NO : 01105/II/2012/01
: 47
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
843
0001674600
ZAINUL ARIFIN
IMKIN0001674600
09.08.2010
09.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
350,000.00
175,000.00
0.00
0.00
0.00
175,000.00
844
0001675362
IRWAN P
IMKIN0001675362
11.08.2010
11.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
517,500.00
215,625.00
0.00
0.00
0.00
215,625.00
845
0001675969.01
IMKIN0001675969
POPIE WISYE MATHEOS
03.08.2010
03.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
846
0001676197
IMKIN0001676197
BAMBANG SULISTIONO
09.08.2010
09.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
847
0001678690
SUARTO
IMKIN0001678690
16.08.2010
16.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
848
0001679131
SITI DWI LAZUARDI
IMKIN0001679131
06.08.2010
06.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
849
0001679262
LUKMAN ARIFIN
IMKIN0001679262
03.08.2010
03.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
850
0001679436.01
PUJI ARIANTO
IMKIN0001679436
18.08.2010
18.02.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2011
178,000.00
89,000.00
0.00
0.00
0.00
89,000.00
851
0001680085
HADI SUWEKO
IMKIN0001680085
18.08.2010
18.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
852
0001682868
ELIZABETH MUNA
IMKIN0001682868
19.08.2010
19.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
853
0001682945
CINDY FLORA D
IMKIN0001682945
21.08.2010
21.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
854
0001682950
IMKIN0001682950
RUDY KELANA WIDJAJA
23.08.2010
23.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
855
0001684566
NANANG DWIRINTO
IMKIN0001684566
24.08.2010
24.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
856
0001684582
MONICA LIMANTARA
IMKIN0001684582
25.08.2010
25.05.2012
01
HSBTLC
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
857
0001684610.01
SETYO RINI UTAMI
IMKIN0001684610
25.08.2010
25.05.2012
01
HSBCPP
300,000,000.00
300,000,000.00 2011
354,000.00
88,500.00
0.00
0.00
0.00
88,500.00
858
0001685383
SUGIYANTO
IMKIN0001685383
23.08.2010
23.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
859
0001685767
RINO SUDJARWO
IMKIN0001685767
18.08.2010
18.04.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
860
0001685808
IMKIN0001685808
KADEK WIWIN HENDRA W
18.08.2010
18.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
861
0001686484
IMKIN0001686484
BUDHIE KRISWANTORO
13.08.2010
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
862
0001686484.01
IMKIN0001686484
ERNAWATI ANGGA LEDA
13.08.2010
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
863
0001686488
NUNUNG
13.08.2010
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001686488


NO : 01105/II/2012/01
: 48
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
864
0001687310.01
BUDHI SETIAWAN
IMKIN0001687310
20.08.2010
20.04.2012
01
CIGCFY
200,000,000.00
100,000,000.00 2011
145,000.00
48,333.00
0.00
0.00
0.00
48,333.00
865
0001687350
HARIRSYAH
IMKIN0001687350
23.08.2010
23.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
866
0001687470.01
MUNSIF
IMKIN0001687470
24.08.2010
24.02.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
110,000.00
55,000.00
0.00
0.00
0.00
55,000.00
867
0001688299
SUGENG PRIYANTO
IMKIN0001688299
01.09.2010
01.03.2012
01
BNIJBX
150,000,000.00
50,000,000.00 2011
384,500.00
192,250.00
0.00
0.00
0.00
192,250.00
868
0001689112
IMKIN0001689112
ERIS SETIAWAN BIN UM
01.09.2010
01.03.2012
01
PMTSHI
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
869
0001689950
ANDRI NOFRIAN
IMKIN0001689950
02.09.2010
02.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
870
0001689950.01
DEVVYCENDRAWATI
IMKIN0001689950
02.09.2010
02.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
871
0001691761
LINDA
IMKIN0001691761
01.09.2010
01.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
872
0001692505
EKA RIJANTO
IMKIN0001692505
01.09.2010
01.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
873
0001693063.01
DIAH IDARIYATI
IMKIN0001693063
03.09.2010
03.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
874
0001693483.01
EVI WAHYU LESTARI
IMKIN0001693483
08.09.2010
08.03.2012
01
CIGFYY
200,000,000.00
200,000,000.00 2011
162,000.00
81,000.00
0.00
0.00
0.00
81,000.00
875
0001693678.01
ASEP MAHPUDIN
IMKIN0001693678
07.09.2010
07.04.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
876
0001693702.01
ABDUL RAHIM
IMKIN0001693702
08.09.2010
08.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
79,000.00
26,333.00
0.00
0.00
0.00
26,333.00
877
0001693788.01
IMKIN0001693788
YOKE ROSALINDA PATIA
02.09.2010
02.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
72,000.00
24,000.00
0.00
0.00
0.00
24,000.00
878
0001694319
HERI DWIASTUTI
IMKIN0001694319
01.09.2010
13.05.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
879
0001694319.01
HERI DWIASTUTI
IMKIN0001694319
01.09.2010
13.05.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
880
0001694758
ROSANA PATTY
IMKIN0001694758
16.09.2010
16.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
881
0001694946
ISMURYATI MARIA M
IMKIN0001694946
07.09.2010
07.05.2012
01
BNIJBX
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
882
0001694970
RONI ADE PUTRA
IMKIN0001694970
08.09.2010
08.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
883
0001695778
DIAN TRISNA
IMKIN0001695778
14.09.2010
14.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
884
0001696962
NOVINDRA M
IMKIN0001696962
17.09.2010
17.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 49
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
885
0001697267
RUDI TONI LUBIS
IMKIN0001697267
20.09.2010
20.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
886
0001697946.01
YANNI
IMKIN0001697946
18.09.2010
18.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
887
0001698737
MADE RENANTA
IMKIN0001698737
21.09.2010
02.05.2012
01
BNIJBX
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
888
0001699426.01
IMKIN0001699426
FAROUQ JAMALUDDIN AR
20.09.2010
20.04.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
70,000.00
29,167.00
0.00
0.00
0.00
29,167.00
889
0001700697
IMKIN0001700697
DANAU RAYMOND SUSANT
02.09.2010
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
890
0001700703
ALI HASAN
IMKIN0001700703
02.09.2010
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
891
0001700759
SUDARTO
IMKIN0001700759
08.09.2010
08.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
892
0001700850
IMKIN0001700850
EKA SULIS ANJARWATI
20.09.2010
20.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
893
0001700859
IMKIN0001700859
MEDIANTI PURNAMASARI
20.09.2010
20.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
894
0001701041.01
IMKIN0001701041
FRANSISCUS XAVERIUS
21.09.2010
21.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
895
0001702026.01
TATANG ROCHMANA
IMKIN0001702026
01.09.2010
01.03.2012
01
MANGMK
100,000,000.00
100,000,000.00 2011
79,000.00
39,500.00
0.00
0.00
0.00
39,500.00
896
0001703358
YENNY
IMKIN0001703358
24.09.2010
24.03.2012
01
MISLPN
500,000,000.00
500,000,000.00 2011
350,000.00
175,000.00
0.00
0.00
0.00
175,000.00
897
0001703585
HAMSIR TALENGKA
IMKIN0001703585
24.09.2010
17.02.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
898
0001703662.01
HARDI MULYADI
IMKIN0001703662
22.09.2010
22.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
493,000.00
246,500.00
0.00
0.00
0.00
246,500.00
899
0001704174
REZA FAHROMI
IMKIN0001704174
24.09.2010
24.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
900
0001705253
AGUS ADI CANDRA
IMKIN0001705253
04.10.2010
04.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
901
0001705293.01
MARIANA
IMKIN0001705293
01.10.2010
01.03.2012
01
CIGCFY
200,000,000.00
100,000,000.00 2011
176,000.00
102,667.00
17,600.00
10,267.00
0.00
92,400.00
902
0001705442
YANNY
IMKIN0001705442
01.10.2010
01.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
903
0001707279
CIPTO GHO
IMKIN0001707279
04.10.2010
04.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
904
0001707279.02
SULIANA
IMKIN0001707279
04.10.2010
04.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
905
0001708062
SARYONO
IMKIN0001708062
06.10.2010
06.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 50
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
906
0001708417.01
ANI RATMALA
IMKIN0001708417
04.10.2010
04.05.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
96,500.00
40,208.00
9,650.00
4,021.00
0.00
36,187.00
907
0001709833
IMKIN0001709833
PUTRIANI MUTIARA HIK
11.10.2010
11.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
908
0001709833.02
TEGUH TRI PRIYADI
IMKIN0001709833
11.10.2010
11.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
909
0001710371
MAYA ANDRIYANI
IMKIN0001710371
01.10.2010
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
910
0001711890.01
ADE GUNAWAN
IMKIN0001711890
05.10.2010
05.03.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
45,500.00
26,542.00
4,550.00
2,654.00
0.00
23,888.00
911
0001711899.01
IMKIN0001711899
RIFALDI PAULUS SITAN
05.10.2010
05.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
129,000.00
75,250.00
12,900.00
7,525.00
0.00
67,725.00
912
0001711900.01
AMRIADI
IMKIN0001711900
05.10.2010
05.04.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
913
0001711904.01
YUNITA SIRURU
IMKIN0001711904
05.10.2010
05.04.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
72,000.00
36,000.00
7,200.00
3,600.00
0.00
32,400.00
914
0001711941.01
TOMY EFFENDY
IMKIN0001711941
09.10.2010
09.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
344,000.00
200,667.00
34,400.00
20,067.00
0.00
180,600.00
915
0001711999.01
IMKIN0001711999
ANDRE OLVIJANTO PALO
11.10.2010
11.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
916
0001712057.01
RUSWANTO
IMKIN0001712057
05.10.2010
05.04.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
917
0001712058.01
SUYANTO
IMKIN0001712058
05.10.2010
05.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
70,000.00
29,167.00
7,000.00
2,917.00
0.00
26,250.00
918
0001712184.01
HASANUDDIN DEANG
IMKIN0001712184
08.10.2010
08.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
216,000.00
126,000.00
21,600.00
12,600.00
0.00
113,400.00
919
0001713021.01
JONI FAISOL
IMKIN0001713021
14.10.2010
14.02.2012
01
CIGSRN
300,000,000.00
300,000,000.00 2011
237,000.00
158,000.00
23,700.00
15,800.00
0.00
142,200.00
920
0001714318
RR TITIEK INDAHH
IMKIN0001714318
09.10.2010
09.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
921
0001715482.01
IMKIN0001715482
GANDA MORAHOT PAULIN
19.10.2010
19.02.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
79,000.00
52,667.00
7,900.00
5,267.00
0.00
47,400.00
922
0001715489.01
IMKIN0001715489
YUDHI FARDHINI TRIZA
19.10.2010
19.02.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
923
0001716318
IMKIN0001716318
INDRA ALFAIRUZZABADI
15.10.2010
15.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
924
0001716368.01
IMKIN0001716368
EMANUEL IRAWADI ARYO
13.10.2010
13.04.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
925
0001716373.01
IMKIN0001716373
PRIANDONO DINANTYA
14.10.2010
14.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
926
0001716377.01
FERDINAND SILALAHI
14.10.2010
14.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001716377


NO : 01105/II/2012/01
: 51
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
927
0001716405.01
IMKIN0001716405
NOVITA LAMRIA SIMATU
18.10.2010
18.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
928
0001716436.01
IMKIN0001716436
DADANG SUDARSONO
12.10.2010
12.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
108,000.00
45,000.00
10,800.00
4,500.00
0.00
40,500.00
929
0001716696
IMKIN0001716696
DEDI FAHMI FIRMANSYA
15.10.2010
15.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
930
0001717544
IMKIN0001717544
YENTI ONGGO SAPUTRA
13.10.2010
13.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
931
0001717552
ABD AZIZ
IMKIN0001717552
13.10.2010
13.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
932
0001718691.01
ADI SUSANTO
IMKIN0001718691
19.10.2010
19.03.2012
01
HSBCPP
100,000,000.00
100,000,000.00 2011
349,000.00
203,583.00
34,900.00
20,358.00
0.00
183,225.00
933
0001718861
DWI SULISTIANI
IMKIN0001718861
19.10.2010
19.02.2012
01
CIGHPL
400,000,000.00
100,000,000.00 2011
70,000.00
46,667.00
7,000.00
4,667.00
0.00
42,000.00
934
0001719178.01
ERNI WIDAYATI
IMKIN0001719178
26.10.2010
26.05.2012
01
CIGSRN
50,000,000.00
50,000,000.00 2011
220,500.00
91,875.00
22,050.00
9,188.00
0.00
82,687.00
935
0001720691
WILLY
IMKIN0001720691
25.10.2010
25.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
350,000.00
233,333.00
35,000.00
23,333.00
0.00
210,000.00
936
0001720972.01
LUCYANA MARIS
IMKIN0001720972
26.10.2010
26.03.2012
01
HSBCPP
200,000,000.00
100,000,000.00 2011
129,000.00
75,250.00
12,900.00
7,525.00
0.00
67,725.00
937
0001720973.01
ZERI PURWOKO
IMKIN0001720973
27.10.2010
27.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
938
0001721148
SUGIANTO
IMKIN0001721148
20.10.2010
20.05.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
939
0001721149
FANDI FASARILLA
IMKIN0001721149
20.10.2010
20.05.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
940
0001721214
SLAMET WAHYUDI
IMKIN0001721214
21.10.2010
21.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
941
0001722133.01
ANDRI BUDIMAN
IMKIN0001722133
25.10.2010
25.05.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
36,000.00
15,000.00
3,600.00
1,500.00
0.00
13,500.00
942
0001722446.01
SRI ENDAH W
IMKIN0001722446
06.10.2010
06.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
943
0001722653.01
ROKHAYATI
IMKIN0001722653
07.10.2010
07.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
944
0001722665
IMKIN0001722665
CH MAYA KARTIKASARI
01.10.2010
03.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
945
0001722665.01
IMKIN0001722665
CH MAYA KARTIKASARI
01.10.2010
03.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
946
0001722714
MUHAMMAD RIFAI
IMKIN0001722714
26.10.2010
26.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
947
0001722845.01
SUAIB RISDA
IMKIN0001722845
19.10.2010
19.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 52
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
948
0001722896.01
DEDDY OKTAVIANTO
IMKIN0001722896
26.10.2010
26.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
949
0001722942.01
AMRAN H B
IMKIN0001722942
27.10.2010
27.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
85,000.00
35,417.00
8,500.00
3,542.00
0.00
31,875.00
950
0001723101.01
YUYUN YUNIARTI
IMKIN0001723101
25.10.2010
25.05.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
951
0001723117.01
IMKIN0001723117
HENDRAWAN JATI PRASE
26.10.2010
26.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
79,000.00
32,917.00
7,900.00
3,292.00
0.00
29,625.00
952
0001724894.01
REZA ROSSADY
IMKIN0001724894
01.11.2010
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
0.00
0.00
0.00
3,033.00
953
0001725020.01
IMKIN0001725020
H MUHAMMAD TAJUDDIN
02.11.2010
02.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
12,545.00
7,318.00
0.00
0.00
0.00
7,318.00
954
0001725020.03
RINI TOWIDJODJO
IMKIN0001725020
02.11.2010
02.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
10,140.00
5,915.00
0.00
0.00
0.00
5,915.00
955
0001725495
JULIANTI
IMKIN0001725495
01.11.2010
01.03.2012
01
DANHCP
50,000,000.00
50,000,000.00 2011
35,000.00
23,333.00
0.00
0.00
0.00
23,333.00
956
0001725622.01
IMKIN0001725622
SYAMSURIA MOKODOMPIT
01.11.2010
01.03.2012
01
MANDEX
100,000,000.00
100,000,000.00 2011
690,000.00
460,000.00
0.00
0.00
0.00
460,000.00
957
0001725632.01
SYAHRIL GUNANDAR
IMKIN0001725632
01.11.2010
01.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
70,000.00
46,667.00
0.00
0.00
0.00
46,667.00
958
0001725653.01
GAJALI RAHMA
IMKIN0001725653
01.11.2010
01.05.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
98,000.00
49,000.00
0.00
0.00
0.00
49,000.00
959
0001726512.01
LELY
IMKIN0001726512
03.11.2010
03.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
0.00
0.00
0.00
3,033.00
960
0001726512.03
RICKY STEVEN
IMKIN0001726512
03.11.2010
03.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
0.00
0.00
0.00
3,033.00
961
0001726800.01
BAGUS PERMADI
IMKIN0001726800
02.11.2010
02.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
962
0001726932.01
SOFIAN SUPRIOTO
IMKIN0001726932
02.11.2010
02.02.2012
01
CIGSRN
300,000,000.00
300,000,000.00 2011
237,000.00
177,750.00
0.00
0.00
0.00
177,750.00
963
0001727060
NANCY
IMKIN0001727060
01.11.2010
01.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
964
0001727079
RUDY RUSADY
IMKIN0001727079
01.11.2010
01.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
965
0001729251
RENNY
IMKIN0001729251
02.11.2010
02.05.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
966
0001729426.01
LINA
IMKIN0001729426
10.11.2010
10.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
967
0001729430.01
FITRIA WIDANINGSIH
IMKIN0001729430
11.11.2010
11.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
968
0001729531.01
AGUS SURYANA
IMKIN0001729531
05.11.2010
05.05.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
39,500.00
19,750.00
0.00
0.00
0.00
19,750.00


NO : 01105/II/2012/01
: 53
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
969
0001729547.01
ADI PRAUTOMO
IMKIN0001729547
03.11.2010
03.05.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
236,000.00
118,000.00
0.00
0.00
0.00
118,000.00
970
0001729635.01
IMKIN0001729635
INTAN IDRIANSARI IDR
11.11.2010
11.03.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
971
0001729677.01
ELZY DRIANDRY
IMKIN0001729677
03.11.2010
03.05.2012
01
MANGMK
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
972
0001729852.01
IMKIN0001729852
IMAN RANDAL TARIGAN
09.11.2010
09.03.2012
01
MANDEX
200,000,000.00
100,000,000.00 2011
142,000.00
94,667.00
0.00
0.00
0.00
94,667.00
973
0001730108.01
NOLIS NURSANTI
IMKIN0001730108
01.11.2010
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
15,795.00
10,530.00
0.00
0.00
0.00
10,530.00
974
0001731014
IRMA SARI
IMKIN0001731014
11.11.2010
11.05.2012
01
CIGLPN
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
975
0001731286
DEDE SULAEMAN
IMKIN0001731286
15.11.2010
15.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
976
0001731381.01
HERRY KURNIAWAN
IMKIN0001731381
13.11.2010
13.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
2,275.00
0.00
0.00
0.00
2,275.00
977
0001732210.01
SIGIT SISWOYO
IMKIN0001732210
15.11.2010
15.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,950.00
2,633.00
0.00
0.00
0.00
2,633.00
978
0001732417.01
LEVY ASM
IMKIN0001732417
15.11.2010
15.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
979
0001732552
IMKIN0001732552
REINHAD WESLY HASIHO
16.11.2010
04.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
980
0001732552.01
IMKIN0001732552
REINHAD WESLY HASIHO
16.11.2010
04.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
981
0001734110.01
IMKIN0001734110
VIKTOR MORI SEBAYANG
10.11.2010
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
14,040.00
9,360.00
0.00
0.00
0.00
9,360.00
982
0001734115
EFFENDI APRIYANTO
IMKIN0001734115
10.11.2010
10.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
983
0001734434
RAFDINAL
IMKIN0001734434
18.11.2010
18.05.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
784,000.00
392,000.00
0.00
0.00
0.00
392,000.00
984
0001734457
ABRIMAN
IMKIN0001734457
18.11.2010
18.04.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
236,000.00
137,667.00
0.00
0.00
0.00
137,667.00
985
0001734813
ENDAH PUSPITA RINI
IMKIN0001734813
18.11.2010
18.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
68,250.00
45,500.00
0.00
0.00
0.00
45,500.00
986
0001735578.01
VERA MARSELLY
IMKIN0001735578
10.11.2010
10.02.2012
01
CIGSRN
100,000,000.00
100,000,000.00 2011
122,000.00
91,500.00
0.00
0.00
0.00
91,500.00
987
0001736844.01
HENDARWIN
IMKIN0001736844
13.11.2010
13.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
216,000.00
144,000.00
0.00
0.00
0.00
144,000.00
988
0001736895.01
DEWI SUKAESIH
IMKIN0001736895
13.11.2010
13.05.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
79,000.00
39,500.00
0.00
0.00
0.00
39,500.00
989
0001736967.01
YUSUF RIZAL
IMKIN0001736967
11.11.2010
11.04.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 54
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
990
0001736988.01
BATU SUGIARTO
IMKIN0001736988
12.11.2010
12.04.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
991
0001737375.01
DEIVY NANGIN
IMKIN0001737375
19.11.2010
19.05.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
258,000.00
129,000.00
0.00
0.00
0.00
129,000.00
992
0001737699
GO MARTIN WIOGO
IMKIN0001737699
10.11.2010
10.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
993
0001737713
TJIU KOEI YIONG
IMKIN0001737713
15.11.2010
15.03.2012
01
DANHCP
25,000,000.00
25,000,000.00 2011
21,250.00
14,167.00
0.00
0.00
0.00
14,167.00
994
0001738679.01
SUPRIANTO
IMKIN0001738679
19.11.2010
19.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
7,800.00
5,200.00
0.00
0.00
0.00
5,200.00
995
0001738709.01
KARMAN SOESANTO
IMKIN0001738709
20.11.2010
20.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
8,385.00
5,590.00
0.00
0.00
0.00
5,590.00
996
0001739084
PANDU FEBRIARSO
IMKIN0001739084
22.11.2010
26.05.2012
01
NISINP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
997
0001739084.01
PANDU FEBRIARSO
IMKIN0001739084
22.11.2010
26.05.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
998
0001739886.01
SUMARYANA
IMKIN0001739886
25.11.2010
25.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
0.00
0.00
0.00
3,033.00
999
0001740758
ARIAWAN SUTOMO
IMKIN0001740758
19.11.2010
19.03.2012
01
CIGLPO
500,000,000.00
500,000,000.00 2011
350,000.00
233,333.00
0.00
0.00
0.00
233,333.00
1000
0001740930
HENDRY GOZALI
IMKIN0001740930
19.11.2010
19.05.2012
01
MISLPN
500,000,000.00
500,000,000.00 2011
1,745,000.00
872,500.00
0.00
0.00
0.00
872,500.00
1001
0001741233.01
MARSELLI N
IMKIN0001741233
25.11.2010
25.03.2012
01
MANDEX
50,000,000.00
50,000,000.00 2011
276,000.00
184,000.00
0.00
0.00
0.00
184,000.00
1002
0001741256.01
IMKIN0001741256
BUDI ARIYANTO SUTRIS
23.11.2010
23.03.2012
01
MANDEX
200,000,000.00
200,000,000.00 2011
486,000.00
324,000.00
0.00
0.00
0.00
324,000.00
1003
0001741864.01
MINA WIDYAWATI
IMKIN0001741864
01.12.2010
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
9,230.00
5,384.00
0.00
0.00
0.00
5,384.00
1004
0001741864.03
IMKIN0001741864
TEGUH SADSETYOBUDI
01.12.2010
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
9,230.00
5,384.00
0.00
0.00
0.00
5,384.00
1005
0001741883
BUGIANTO
IMKIN0001741883
01.12.2010
01.03.2012
01
PMSSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1006
0001741981.01
CHAMDUN MAHMUDI
IMKIN0001741981
01.12.2010
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
10,140.00
7,605.00
0.00
0.00
0.00
7,605.00
1007
0001742485.01
EDA JUBAIDA
IMKIN0001742485
02.12.2010
02.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
0.00
0.00
0.00
2,625.00
1008
0001742485.03
SYAMSURI MUSTOFA
IMKIN0001742485
02.12.2010
02.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
4,900.00
3,675.00
0.00
0.00
0.00
3,675.00
1009
0001742971
ADI PRAWITA
IMKIN0001742971
01.12.2010
01.04.2012
01
BCASHP
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1010
0001744800
SUSIAWITA
IMKIN0001744800
01.12.2010
01.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 55
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1011
0001744982.01
IMKIN0001744982
ENNY RUSMINAWATY RAC
01.12.2010
01.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1012
0001746850
MAHMUD
IMKIN0001746850
06.12.2010
06.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1013
0001747003
SUPRIADY PAKAYA
IMKIN0001747003
08.12.2010
08.03.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
105,000.00
0.00
0.00
0.00
105,000.00
1014
0001748688.01
THE PAU CHING
IMKIN0001748688
09.12.2010
09.03.2012
01
HSBCPP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1015
0001750903.01
DIAN NOVIA WARDANI
IMKIN0001750903
04.12.2010
04.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,042.00
0.00
0.00
0.00
2,042.00
1016
0001751104
RAMLAH
IMKIN0001751104
10.12.2010
10.04.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1017
0001752315
MUHAMMAD ABDUH
IMKIN0001752315
15.12.2010
15.05.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1018
0001752431
SUGENG
IMKIN0001752431
18.12.2010
18.05.2012
01
HSBTLC
70,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1019
0001752458.01
DEWI MAIMUNAH
IMKIN0001752458
14.12.2010
14.03.2012
01
HSBCPP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1020
0001752542.01
BAMBANG PURNAMA
IMKIN0001752542
01.12.2010
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
8,600.00
6,450.00
0.00
0.00
0.00
6,450.00
1021
0001752601.01
M IQBAL SYAFEI
IMKIN0001752601
06.12.2010
06.05.2012
01
PMTBPL
6,500,000.00
5,000,000.00 2011
3,500.00
2,042.00
0.00
0.00
0.00
2,042.00
1022
0001752866
SORYADI
IMKIN0001752866
10.12.2010
10.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1023
0001752881.01
ANDI PUTRA
IMKIN0001752881
10.12.2010
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
0.00
0.00
0.00
3,413.00
1024
0001752915.01
DEDE SUPRIADI
IMKIN0001752915
11.12.2010
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
12,545.00
9,409.00
0.00
0.00
0.00
9,409.00
1025
0001753064
RULLY
IMKIN0001753064
13.12.2010
13.03.2012
01
PMTSHI
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1026
0001753090.01
IMKIN0001753090
ROSA ETY KARTIKAWATI
14.12.2010
14.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
0.00
0.00
0.00
2,625.00
1027
0001753462
PITER
IMKIN0001753462
17.12.2010
17.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1028
0001754762
RATNA SUZANNA
IMKIN0001754762
21.12.2010
21.04.2012
01
BNIJBX
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1029
0001755238
SHELVY IRAWAN
IMKIN0001755238
09.12.2010
09.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1030
0001755282
IMKIN0001755282
ANTHON JONTAH RAYO
17.12.2010
17.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1031
0001755332
DRS MAD SOLEH
20.12.2010
20.03.2012
01
HSBTLC
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001755332


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 56
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
1032
0001755456
ANANG SOPIAN
IMKIN0001755456
27.12.2010
27.03.2012
01
NISINP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1033
0001755456.01
ANANG SOPIAN
IMKIN0001755456
27.12.2010
27.03.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1034
0001755641
SETYO NUGROHO
IMKIN0001755641
27.12.2010
27.05.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1035
0001755641.01
SETYO NUGROHO
IMKIN0001755641
27.12.2010
27.05.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1036
0001756124
MARTINAR
IMKIN0001756124
14.12.2010
14.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1037
0001758525.01
NURSANTI DORIANA
IMKIN0001758525
27.12.2010
27.02.2012
01
CIGSRN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1038
0001758585.01
IMKIN0001758585
MUHAMMAD FARID BAAY
21.12.2010
21.05.2012
01
MANDEX
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1039
0001758591.01
IMKIN0001758591
MICHAEL CHRISTIAN LI
22.12.2010
22.03.2012
01
MANDEX
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1040
0001758828
DODIK GUNAWAN ST
IMKIN0001758828
01.01.2011
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1041
0001759266
ENDANG TARYANA
IMKIN0001759266
01.01.2011
01.03.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1042
0001760226
EVA NAPITUPULU
IMKIN0001760226
13.01.2011
13.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1043
0001760226.01
EVA NAPITUPULU
IMKIN0001760226
13.01.2011
13.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1044
0001760300
TRI ASMININGDIAH
IMKIN0001760300
01.01.2011
01.03.2012
01
DAFLPN
500,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1045
0001760708
WIDODO
IMKIN0001760708
04.01.2011
04.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1046
0001760735
HENKI GOOSA M,SE
IMKIN0001760735
03.01.2011
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1047
0001761583.01
RUDY KARTONO
IMKIN0001761583
06.01.2011
06.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
9,230.00
7,692.00
0.00
0.00
0.00
7,692.00
1048
0001761598.01
ASPI ALETRI
IMKIN0001761598
06.01.2011
06.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
0.00
0.00
0.00
3,792.00
1049
0001763086
AGUNG C WIBOWO
IMKIN0001763086
04.01.2011
04.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1050
0001763282
RHOMA DHANNIATI
IMKIN0001763282
06.01.2011
06.05.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1051
0001763352
IMKIN0001763352
UNANA TISNA JUMENA
06.01.2011
06.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1052
0001763359
IMKIN0001763359
NANCY ANGELA HENDRIK
06.01.2011
06.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 57
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1053
0001763365
IMKIN0001763365
NI NYOMAN SRI APRIAW
06.01.2011
06.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1054
0001763636.01
METHA TENGGARA
IMKIN0001763636
10.01.2011
10.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1055
0001763792.01
ELFA WATI
IMKIN0001763792
10.01.2011
10.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1056
0001763845.01
YOVI CHANDRA
IMKIN0001763845
10.01.2011
10.03.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1057
0001764946
RONALD SITORUS
IMKIN0001764946
11.01.2011
11.03.2012
01
DANHCP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1058
0001764975.01
NG MIAW PHIN
IMKIN0001764975
11.01.2011
11.03.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1059
0001764997.01
IMKIN0001764997
DRS. AGUS PUTUT WIBI
11.01.2011
11.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1060
0001765079
RUSKIMAN
IMKIN0001765079
07.01.2011
07.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1061
0001765661
FAISAL BAHRI
IMKIN0001765661
13.01.2011
13.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1062
0001766029
NURFIQ DIANTO
IMKIN0001766029
07.01.2011
07.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1063
0001766032
KARTIKA SARI
IMKIN0001766032
07.01.2011
07.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1064
0001766085
IMKIN0001766085
ENDRA BUDI HERMANTO
07.01.2011
07.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1065
0001766233.01
PAUL ARIF BUDIMAN
IMKIN0001766233
11.01.2011
11.03.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2012
580,000.00
483,333.00
0.00
0.00
0.00
483,333.00
1066
0001766858.01
WURI HANDAYANI
IMKIN0001766858
15.01.2011
15.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
3,683.00
0.00
0.00
0.00
3,683.00
1067
0001766858.03
YUNI SETIAWAN
IMKIN0001766858
15.01.2011
15.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
7,020.00
4,680.00
0.00
0.00
0.00
4,680.00
1068
0001767020.01
VIVI RYANTIE
IMKIN0001767020
15.01.2011
15.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1069
0001767177
MIRYANTI
IMKIN0001767177
14.01.2011
14.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1070
0001767415.01
BENNI WINTANA
IMKIN0001767415
17.01.2011
17.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1071
0001767415.03
IMKIN0001767415
CHERISTIN MEGAWATI
17.01.2011
17.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1072
0001767575.01
MARHABAN
IMKIN0001767575
17.01.2011
17.02.2012
01
CIGSRN
300,000,000.00
100,000,000.00 2012
96,000.00
88,000.00
0.00
0.00
0.00
88,000.00
1073
0001767781.01
SARALINLIA RAMLI
IMKIN0001767781
11.01.2011
11.03.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 58
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1074
0001767790.01
IMKIN0001767790
AGUSTINUS GH TAMBUNA
13.01.2011
13.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1075
0001768582.01
DENI ANDRIANTO
IMKIN0001768582
11.01.2011
11.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1076
0001768609.01
DENI SUKANDI
IMKIN0001768609
11.01.2011
11.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1077
0001769716
ZULKARNAIN
IMKIN0001769716
18.01.2011
18.03.2012
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1078
0001769771.01
MUJI LESTARI
IMKIN0001769771
19.01.2011
19.03.2012
01
HSBCPP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1079
0001769943
RIA KARTIKA SARI
IMKIN0001769943
18.01.2011
18.02.2012
01
CIGLPN
500,000,000.00
300,000,000.00 2012
294,000.00
269,500.00
0.00
0.00
0.00
269,500.00
1080
0001770440
HENDRI KURNIAWAN
IMKIN0001770440
20.01.2011
20.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1081
0001770728
UNTUNG
IMKIN0001770728
20.01.2011
20.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1082
0001770883.01
FATRIA ASIA AVANTI
IMKIN0001770883
12.01.2011
12.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1083
0001771031
MUHAMMAD YASIN
IMKIN0001771031
13.01.2011
13.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1084
0001771126
WIDI NURWORO
IMKIN0001771126
15.01.2011
15.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1085
0001771212.01
AZIZ MUSLIM
IMKIN0001771212
18.01.2011
18.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
0.00
0.00
0.00
3,792.00
1086
0001771226
SANJAYA
IMKIN0001771226
18.01.2011
18.05.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1087
0001771248
ARIS BUDIYANTO
IMKIN0001771248
18.01.2011
18.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1088
0001771269.01
IMKIN0001771269
YOVITA SARI KARTIKA
19.01.2011
19.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1089
0001771668
FESTIYANI
IMKIN0001771668
25.01.2011
25.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1090
0001771668.01
FESTIYANI
IMKIN0001771668
25.01.2011
25.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1091
0001771978.01
SUSY SUNARSIH
IMKIN0001771978
18.01.2011
18.05.2012
01
MANCGP
35,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1092
0001772017.01
NI MADE DWI INDAH P
IMKIN0001772017
18.01.2011
18.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1093
0001772039.01
DIDIK NUGROHO
IMKIN0001772039
19.01.2011
19.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1094
0001772127
GIARSIH
IMKIN0001772127
21.01.2011
21.03.2012
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 59
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1095
0001772178
MARINGAN BANCIN
IMKIN0001772178
24.01.2011
24.03.2012
01
HSBTLC
70,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1096
0001772229
DWI MERLINA
IMKIN0001772229
26.01.2011
26.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1097
0001772229.01
DWI MERLINA
IMKIN0001772229
26.01.2011
26.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1098
0001772368.01
IGHARRY SUWARTO
IMKIN0001772368
22.01.2011
22.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
55,705.00
46,421.00
0.00
0.00
0.00
46,421.00
1099
0001772526
IMKIN0001772526
HERMAN L. HARTAWAN,
26.01.2011
26.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1100
0001772921.01
IMKIN0001772921
GALIH FAJAR ATMANEGA
24.01.2011
24.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
0.00
0.00
0.00
3,792.00
1101
0001773788
YUDI HARNADI
IMKIN0001773788
26.01.2011
26.03.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1102
0001774027
TYAS MUNASWATI R.
IMKIN0001774027
25.01.2011
25.02.2012
01
CIGLPN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1103
0001774028
DINA DAMAYANTI
IMKIN0001774028
26.01.2011
26.05.2012
01
CIGLPN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1104
0001774525.01
SRI ENDANG ELVIANI
IMKIN0001774525
01.02.2011
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1105
0001774548.01
FANDI FASARILLA
IMKIN0001774548
01.02.2011
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,413.00
0.00
0.00
0.00
3,413.00
1106
0001774934.01
IMKIN0001774934
YUDIT MELINDA TAHER
01.02.2011
01.03.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1107
0001774935.01
TINA AGUSTINA
IMKIN0001774935
01.02.2011
01.03.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1108
0001775459.01
LUKMANUL HAKIM
IMKIN0001775459
02.02.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00
1109
0001775481.01
IMKIN0001775481
MARDIANA R. LINTANG
02.02.2011
02.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1110
0001776082.01
I WAYAN SUDANA
IMKIN0001776082
05.02.2011
05.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1111
0001777547.01
EKO SOEMARTONO
IMKIN0001777547
01.02.2011
01.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1112
0001777664.01
ELIN PARLINA
IMKIN0001777664
05.02.2011
05.05.2012
01
MANGMK
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1113
0001779271
RONI ARFANTO
IMKIN0001779271
12.02.2011
12.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1114
0001779272
IMKIN0001779272
VERONIKA DIANA YULIA
12.02.2011
12.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1115
0001779272.01
IMKIN0001779272
VINCENTIUS TOMY SIDH
12.02.2011
12.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 60
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
1116
0001779405
GUNADI
IMKIN0001779405
10.02.2011
10.05.2012
01
BNIJBX
1117
0001779753
PURWANTI
IMKIN0001779753
10.02.2011
10.03.2012
01
1118
0001780746.01
HERIYANTO
IMKIN0001780746
09.02.2011
09.05.2012
1119
0001781487.01
IMKIN0001781487
MARIA STEFANI SEBAST
17.02.2011
1120
0001781646
TEDDY WIRIYADI
IMKIN0001781646
1121
0001781677.01
TONY SUSANTO
1122
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
17.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
18.02.2011
18.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001781677
17.02.2011
17.02.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0001781686.01
HELENA
IMKIN0001781686
14.02.2011
14.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1123
0001781720
TONY SUSILO
IMKIN0001781720
01.02.2011
01.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1124
0001781769.01
IMKIN0001781769
LILIK FARID BUDIAWAN
01.02.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,707.00
0.00
0.00
0.00
4,707.00
1125
0001781784.01
MISILAH
IMKIN0001781784
01.02.2011
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1126
0001781810.01
MINIYATI
IMKIN0001781810
01.02.2011
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1127
0001781835
ROSADI
IMKIN0001781835
02.02.2011
02.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1128
0001781996.01
ALBERT YOSIETO
IMKIN0001781996
17.02.2011
17.03.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1129
0001782151
SUHERMAN
IMKIN0001782151
14.02.2011
14.03.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1130
0001782448
AFRIZAL
IMKIN0001782448
18.02.2011
18.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1131
0001783263
IMKIN0001783263
ANTHONY SENO SUBROTO
21.02.2011
21.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1132
0001784072.01
HENGKI RIYANTO
IMKIN0001784072
04.02.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00
1133
0001784109.01
HANIF EKA PUTRA
IMKIN0001784109
04.02.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00
1134
0001784136.01
TEGUH RIYANTO
IMKIN0001784136
04.02.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00
1135
0001784150.01
AAN NUR ANGGONO
IMKIN0001784150
04.02.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00
1136
0001784182.01
IMKIN0001784182
ISA FAHRIZAL BUSTOMI
04.02.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00


NO : 01105/II/2012/01
: 61
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1137
0001784503.01
IMKIN0001784503
PUTU POPPY AIMY WIDY
08.02.2011
08.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,413.00
0.00
0.00
0.00
3,413.00
1138
0001784610.01
IMKIN0001784610
M YOKA DESTHURAKA
10.02.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
0.00
0.00
0.00
4,171.00
1139
0001784976
ADE SUHARYANATA
IMKIN0001784976
22.02.2011
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1140
0001785072
INDRA A E SETIAWAN
IMKIN0001785072
22.02.2011
22.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1141
0001785202.01
DEDY A SUSANTO
IMKIN0001785202
22.02.2011
22.03.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1142
0001785223.01
IMKIN0001785223
SYIFA MUFIEDATUSSALA
22.02.2011
22.03.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1143
0001785805
INDRAWADI
IMKIN0001785805
16.02.2011
16.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1144
0001785805.01
YUNI RIALISA
IMKIN0001785805
16.02.2011
16.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1145
0001786386.01
ELLY KENDRAWATI
IMKIN0001786386
21.02.2011
21.05.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1146
0001786431.01
IMKIN0001786431
BAHRID BUSENG DRS H
22.02.2011
22.01.2012
01
CIGSRN
50,000,000.00
50,000,000.00 2011
154,500.00
12,875.00
15,450.00
1,288.00
0.00
11,587.00
01
CIGSRN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1147
0001787462.01
RIZI LUQMAN HAKIM
IMKIN0001787462
01.03.2011
01.03.2012
01
PMTBPL
1148
0001788332.01
SITI ULFAH
IMKIN0001788332
01.03.2011
01.03.2012
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1149
0001788338.01
JULIATI
IMKIN0001788338
01.03.2011
01.03.2012
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1150
0001788350.01
RUSMIYATI
IMKIN0001788350
01.03.2011
01.05.2012
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1151
0001788357.01
SOLIHA
IMKIN0001788357
01.03.2011
01.03.2012
01
MANGMK
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1152
0001788393
IMKIN0001788393
IR FENCY TEMMY GAWA
01.03.2011
01.03.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1153
0001788404.01
JASMINTO
IMKIN0001788404
01.03.2011
01.05.2012
01
HSBCPP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1154
0001788441.01
AZHAR LUBIS
IMKIN0001788441
01.03.2011
01.05.2012
01
HSBCPP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1155
0001788699
IMKIN0001788699
CATARINA TRIMURTI MU
01.03.2011
01.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1156
0001788699.01
IMKIN0001788699
YOSEPH MULYO SANTOSO
01.03.2011
01.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1157
0001789051.01
IMKIN0001789051
R ADITYA NOTOSUPRAPT
03.03.2011
03.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1158
0001789073.01
IMKIN0001789073
ANGGA DESTRIA YUDIST
03.03.2011
03.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1159
0001789214
WINARNI
IMKIN0001789214
03.03.2011
03.03.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1160
0001789261
ALDY RIVANSYAH
IMKIN0001789261
07.03.2011
07.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1161
0001789626.01
YULI
IMKIN0001789626
04.03.2011
04.05.2012
01
MANGMK
200,000,000.00
56,600,000.00 2012
48,110.00
40,092.00
0.00
0.00
0.00
40,092.00
1162
0001789857
ROY H
IMKIN0001789857
03.03.2011
03.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1163
0001790011
IMKIN0001790011
CHARLES M MAMAHIT
03.03.2011
03.02.2012
01
CIGLPN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1164
0001790376
IMKIN0001790376
R ADITYA NOTOSUPRAPT
01.03.2011
01.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1165
0001791385
WATI SUKMAWATI
IMKIN0001791385
11.03.2011
11.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1166
0001791385.01
WATI SUKMAWATI
IMKIN0001791385
11.03.2011
11.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1167
0001791413
LIANAWATI SANTOSO
IMKIN0001791413
08.03.2011
08.03.2012
01
HSBTLC
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1168
0001792960
IMKIN0001792960
NI MADE RIKA HARMINI
03.03.2011
03.02.2012
01
CIGLPN
300,000,000.00
300,000,000.00 2011
210,000.00
17,500.00
21,000.00
1,750.00
0.00
15,750.00
01
CIGLPN
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1169
0001793067.01
SLAMET SANTOSO
IMKIN0001793067
09.03.2011
09.05.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1170
0001793187.01
YENNY GOZAL
IMKIN0001793187
03.03.2011
03.05.2012
01
MANGMK
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1171
0001793208.01
VIVI NURI
IMKIN0001793208
09.03.2011
09.05.2012
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1172
0001793820.01
IMKIN0001793820
JULIAN MICHO RAWUNG
11.03.2011
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1173
0001793846.01
IMKIN0001793846
FRENGKY MAMAHID ANGK
01.03.2011
01.02.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2011
1,390,000.00
115,833.00
139,000.00
11,583.00
0.00
104,250.00
01
CIGSRN
200,000,000.00
200,000,000.00 2012
1,552,000.00
1,552,000.00
0.00
0.00
0.00
1,552,000.00
1174
0001794744.01
TRILINDA MARDIANA
IMKIN0001794744
10.03.2011
10.05.2012
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1175
0001794795.01
LOMALIA SARI. B.PT
IMKIN0001794795
11.03.2011
11.05.2012
01
MANDEX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1176
0001795371
IMKIN0001795371
RUDI HARYANTO PAULUS
14.03.2011
14.03.2012
01
DANHCP
40,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1177
0001795425
TAUFIK RAHMAN
IMKIN0001795425
14.03.2011
14.03.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1178
0001795428
SYAHRONI
IMKIN0001795428
14.03.2011
14.03.2012
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1179
0001797039.01
IMKIN0001797039
IRWAN RADIAN SAPUTRA
21.03.2011
21.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1180
0001797232.01
IMKIN0001797232
BERNADETTE MURNIATI
21.03.2011
21.05.2012
01
HSBCPP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1181
0001797242.01
RIDWAN
IMKIN0001797242
21.03.2011
21.05.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1182
0001797584
IMKIN0001797584
SIOE JOENG BOESONO
01.03.2011
01.03.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1183
0001797646.01
LEO PRANATA
IMKIN0001797646
02.03.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1184
0001797646.03
MULIA HAYDINA
IMKIN0001797646
02.03.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1185
0001797783.01
TANTOWI ABDILLAH
IMKIN0001797783
03.03.2011
03.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
32,045.00
32,045.00
0.00
0.00
0.00
32,045.00
1186
0001797819.01
MARIO SYAUFI
IMKIN0001797819
03.03.2011
03.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
0.00
0.00
0.00
3,792.00
1187
0001797867.01
AGUNG SETYA BUDI
IMKIN0001797867
03.03.2011
03.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
0.00
0.00
0.00
3,792.00
1188
0001797932.01
DENI SUGITO
IMKIN0001797932
03.03.2011
03.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1189
0001798299.01
ISTINAH
IMKIN0001798299
10.03.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
7,020.00
7,020.00
0.00
0.00
0.00
7,020.00
1190
0001798321.01
IMKIN0001798321
ELIZABETH AUDITH RAT
10.03.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
11,180.00
11,180.00
0.00
0.00
0.00
11,180.00
1191
0001798350.01
AHMAD YUSUF
IMKIN0001798350
10.03.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
4,680.00
0.00
0.00
0.00
4,680.00
1192
0001798350.03
DINA SARI INTANIA
IMKIN0001798350
10.03.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1193
0001798381.01
YUSRI AFRIANTO
IMKIN0001798381
10.03.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1194
0001798409.01
DOEDY SOELISTYO
IMKIN0001798409
11.03.2011
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
11,180.00
11,180.00
0.00
0.00
0.00
11,180.00
1195
0001798457.01
RUDIONO
IMKIN0001798457
11.03.2011
11.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
20,085.00
16,738.00
0.00
0.00
0.00
16,738.00
1196
0001798671.01
IMKIN0001798671
JERRY JAMES SITANIAP
14.03.2011
14.05.2012
01
CIGYSR
400,000,000.00
300,000,000.00 2012
399,000.00
332,500.00
0.00
0.00
0.00
332,500.00


NO : 01105/II/2012/01
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PAGE
: 64
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
1197
0001798881.01
TRI TURI YANTO
IMKIN0001798881
01.03.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,915.00
5,915.00
0.00
0.00
0.00
5,915.00
1198
0001800360.01
YENNY HOO
IMKIN0001800360
23.03.2011
23.05.2012
01
CIGSRN
400,000,000.00
330,000,000.00 2012
1,455,300.00
1,212,750.00
0.00
0.00
0.00
1,212,750.00
1199
0001800363
IMKIN0001800363
MARYCEL ROSA NOYA
24.03.2011
24.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1200
0001800950.01
LULUK HARDONO
IMKIN0001800950
23.03.2011
23.05.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
10,140.00
8,450.00
0.00
0.00
0.00
8,450.00
1201
0001801174
FREDY KUNCORO
IMKIN0001801174
09.03.2011
09.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1202
0001801280
RENI RUMENGAN`SH
IMKIN0001801280
21.03.2011
21.03.2012
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1203
0001801381.01
RAKHMAD DEWO
IMKIN0001801381
02.03.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1204
0001801552.01
SULAIMAN YUSUF
IMKIN0001801552
02.03.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
14,040.00
14,040.00
0.00
0.00
0.00
14,040.00
1205
0001801929.01
IMKIN0001801929
DRH HAMONG SUHARSONO
23.03.2011
23.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
20,085.00
20,085.00
0.00
0.00
0.00
20,085.00
1206
0001802425.01
HENDRIK
IMKIN0001802425
21.03.2011
21.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
20,085.00
20,085.00
0.00
0.00
0.00
20,085.00
1207
0001804098.01
BUGIANTO
IMKIN0001804098
01.04.2011
01.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
28,600.00
28,600.00
0.00
0.00
0.00
28,600.00
1208
0001804209
MUHAMAD AFFANDI
IMKIN0001804209
01.04.2011
01.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
96,750.00
8,063.00
9,675.00
806.00
0.00
7,257.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1209
0001804669
I GEDE SUARSA
IMKIN0001804669
01.04.2011
01.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1210
0001805586
IMKIN0001805586
RANI KUSUMA NINGRUM
01.04.2011
01.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1211
0001806171.01
IMKIN0001806171
RIRISMAWATI NAINGGOL
04.04.2011
05.05.2012
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1212
0001806178.01
SRI HANDAYANI
01.04.2011
01.03.2012
01
MANGMK
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANGMK
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANGMK
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANGMK
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
HSBTLC
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1213
1214
0001806228.01
TAUFIK WALHIDAYAH
0001806532
IWAN
IMKIN0001806178
IMKIN0001806228
IMKIN0001806532
04.04.2011
01.04.2011
04.03.2012
01.03.2012


NO : 01105/II/2012/01
: 65
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1215
0001806637
AGUSTINA
IMKIN0001806637
01.04.2011
01.05.2012
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1216
0001806646
SULIYANSYAH
IMKIN0001806646
01.04.2011
01.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1217
0001806769
TRI NUGROHO
IMKIN0001806769
06.04.2011
06.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1218
0001807079
ARI BUDI LESTARI
IMKIN0001807079
08.04.2011
08.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
292.00
350.00
29.00
0.00
263.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1219
1220
1221
1222
1223
0001807079.01
ARI BUDI LESTARI
0001807332.01
MAULANA AGUSTIN
0001807359.01
ABDULAH
0001807787.01
AMIR
0001807787.03
YURNIS
IMKIN0001807079
IMKIN0001807332
IMKIN0001807359
IMKIN0001807787
IMKIN0001807787
08.04.2011
01.04.2011
01.04.2011
05.04.2011
05.04.2011
08.03.2012
01.03.2012
01.03.2012
05.03.2012
05.03.2012
1224
0001808726.01
ERNI WIDAYATI
IMKIN0001808726
11.04.2011
11.05.2012
01
HSBCPP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1225
0001808731.01
LUKMAN HAKIM
IMKIN0001808731
08.04.2011
08.05.2012
01
MANGMK
200,000,000.00
200,000,000.00 2012
784,000.00
718,667.00
0.00
0.00
0.00
718,667.00
1226
0001808751.01
NENI KURNIANINGSIH
IMKIN0001808751
08.04.2011
08.05.2012
01
MANDEX
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1227
0001808762.01
IMKIN0001808762
MATEUS FRANSIUS HARI
11.04.2011
11.04.2012
01
MANGMK
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1228
0001808778
SRI WIDAYANTI
12.04.2011
12.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1229
0001809019
HERI SUSANTO
IMKIN0001808778
IMKIN0001809019
11.04.2011
11.03.2012


NO : 01105/II/2012/01
: 66
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1230
0001809810
RABIAH
IMKIN0001809810
07.04.2011
07.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1231
0001810776.01
IMKIN0001810776
MAULANA PAMUNGKAS
13.04.2011
13.03.2012
01
CIGYSR
300,000,000.00
300,000,000.00 2011
237,000.00
19,750.00
23,700.00
1,975.00
0.00
17,775.00
01
CIGYSR
300,000,000.00
100,000,000.00 2012
79,000.00
79,000.00
0.00
0.00
0.00
79,000.00
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1232
1233
0001811505
IMKIN0001811505
YUS HARUDIAN PUTRA
0001811507
ILHAM BUKA
IMKIN0001811507
19.04.2011
19.04.2011
19.03.2012
19.03.2012
1234
0001811510
IDA AYU ARIE MAYUNI
IMKIN0001811510
19.04.2011
19.05.2012
01
BNIJBX
1235
0001811655
HUSNI YUSUF
IMKIN0001811655
18.04.2011
18.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1236
0001811735.01
RIDWAN PERMANA
IMKIN0001811735
18.04.2011
18.05.2012
01
MANUTD
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1237
0001811761.01
SANTI SEPTIANI
IMKIN0001811761
12.04.2011
12.03.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
70,000.00
5,833.00
7,000.00
583.00
0.00
5,250.00
01
MANGMK
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1238
0001811773.01
LOKITA
IMKIN0001811773
14.04.2011
14.05.2012
01
MANGMK
1239
0001812081.01
IMKIN0001812081
MILKA SARI NASUTION
07.04.2011
07.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1240
0001812088.01
ILHAM SANJAYA
07.04.2011
07.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
292.00
350.00
29.00
0.00
263.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001812088
1241
0001812125.01
YULI TRIONO
IMKIN0001812125
08.04.2011
08.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1242
0001812321.01
KHOIRUN
IMKIN0001812321
13.04.2011
13.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
292.00
350.00
29.00
0.00
263.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1243
0001812366.01
IMKIN0001812366
IRVAN SENO SEPTIANA
14.04.2011
14.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1244
0001812417.01
DJAP SJOEN NGO
IMKIN0001812417
15.04.2011
15.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
40,170.00
36,823.00
0.00
0.00
0.00
36,823.00
1245
0001813557
KENIET CHAHYORINI
IMKIN0001813557
20.04.2011
20.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 67
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
1246
1247
1248
1249
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
0001813800
IMKIN0001813800
DWI RETNO SULISTIYAN
0001813917.01
IMKIN0001813917
SUMURUNG MANURUNG
0001814199
IMKIN0001814199
EKO PRAYITNO NAEN SA
0001814730
SALASIAH
IMKIN0001814730
DATE OF
DATE OF NATURE
19.04.2011
18.04.2011
21.04.2011
21.04.2011
19.03.2012
18.02.2012
21.03.2012
21.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGSRN
400,000,000.00
400,000,000.00 2011
532,000.00
88,667.00
53,200.00
8,867.00
0.00
79,800.00
01
CIGSRN
400,000,000.00
300,000,000.00 2012
435,000.00
435,000.00
0.00
0.00
0.00
435,000.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1250
0001815153
NICO LEONG
IMKIN0001815153
25.04.2011
25.05.2012
01
BNIJBX
1251
0001815278.01
YUDI ARIJANTO
IMKIN0001815278
19.04.2011
19.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1252
0001815303.01
IMKIN0001815303
FRECIYANA BOEDIJONO
19.04.2011
19.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1253
0001815324.01
RENDY ISMANSYAH
20.04.2011
20.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
292.00
350.00
29.00
0.00
263.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANUTV
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MANUTV
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1254
IMKIN0001815324
0001815485.01
IMKIN0001815485
DEWA AYU MADE LILY D
03.05.2011
03.06.2011
1255
0001815622.01
YANCHE
IMKIN0001815622
20.04.2011
20.05.2012
01
HSBCPP
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1256
0001815649.01
MOCH FIRMANSYAH
IMKIN0001815649
25.04.2011
25.05.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1257
0001815866
MARTINA MUCHLIAT
IMKIN0001815866
26.04.2011
26.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1258
0001816054
HARTUTIK
IMKIN0001816054
26.04.2011
26.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
590,000.00
98,333.00
59,000.00
9,833.00
0.00
88,500.00
01
CIGLPN
500,000,000.00
100,000,000.00 2012
129,000.00
129,000.00
0.00
0.00
0.00
129,000.00
1259
0001816473.01
SOEDARWANTO
IMKIN0001816473
26.04.2011
26.05.2012
01
MANCGP
70,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1260
0001816652.01
KARDINAT SAPAN
IMKIN0001816652
28.04.2011
28.03.2012
01
MISSRN
200,000,000.00
200,000,000.00 2011
158,000.00
13,167.00
15,800.00
1,317.00
0.00
11,850.00
01
MISSRN
200,000,000.00
200,000,000.00 2012
162,000.00
162,000.00
0.00
0.00
0.00
162,000.00
01
CIGSRN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1261
0001816659.01
IMKIN0001816659
EMNY JUNE C SIMATUPA
27.04.2011
27.02.2012


NO : 01105/II/2012/01
: 68
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
1262
Quarter 2012
PAGE
CERT. NO.
0001817021
IFAN FARIANDA
POLICY NO.
IMKIN0001817021
DATE OF
DATE OF NATURE
01.05.2011
01.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
75,000,000.00 2011
52,500.00
8,750.00
5,250.00
875.00
0.00
7,875.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1263
0001817021.01
MUTY NUBIKASARI
IMKIN0001817021
01.05.2011
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1264
0001817124
IMKIN0001817124
DWI PRASETYO NUGROHO
01.05.2011
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
4,680.00
0.00
0.00
0.00
4,680.00
1265
1266
0001817124.01
IMKIN0001817124
PRIMA NIENDYA SUKMA
0001817162.01
RIYONOSIDI
IMKIN0001817162
01.05.2011
02.05.2011
01.03.2012
02.03.2012
1267
0001817172.01
ALPHARD MUAMMAR
IMKIN0001817172
12.05.2011
12.05.2012
01
MANUTD
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1268
0001817308.01
SUHARTONO
IMKIN0001817308
02.05.2011
02.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1269
0001817530
JUSTIAN SALIM
IMKIN0001817530
02.05.2011
02.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1270
0001817540
ADY MULYADY
IMKIN0001817540
03.05.2011
03.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1271
0001817987
WANDALIH TJHIN
IMKIN0001817987
04.05.2011
04.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1272
0001818040
IMKIN0001818040
ALOYSIUS KRISTIAWAN
01.05.2011
01.03.2012
1273
0001818526.01
DEDY SUPRIATNA
IMKIN0001818526
01.05.2011
01.05.2012
01
MANDEX
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1274
0001818548
EKA NURNINGSIH
IMKIN0001818548
01.05.2011
01.05.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1275
0001818606
WIWIN WINARNI
IMKIN0001818606
11.05.2011
11.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1276
0001818606.01
WIWIN WINARNI
IMKIN0001818606
11.05.2011
11.03.2012


NO : 01105/II/2012/01
: 69
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
1277
1278
1279
1280
1281
Quarter 2012
PAGE
CERT. NO.
0001818607
MELINDA TRIYANTI
0001818607.01
MELINDA TRIYANTI
0001819413
FATRA ANGGARA
POLICY NO.
IMKIN0001818607
IMKIN0001818607
IMKIN0001819413
0001819695
IMKIN0001819695
RAMADHAN MANSYUR
0001819715
DEDY APRIANTO
IMKIN0001819715
DATE OF
DATE OF NATURE
11.05.2011
11.05.2011
06.05.2011
09.05.2011
06.05.2011
11.03.2012
11.03.2012
06.03.2012
09.03.2012
06.04.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
96,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
23,333.00
14,000.00
2,333.00
0.00
21,000.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
23,333.00
14,000.00
2,333.00
0.00
21,000.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
150,000,000.00
150,000,000.00 2011
105,000.00
8,750.00
10,500.00
875.00
0.00
7,875.00
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1282
0001819726
ADE PRISKA SAMITRA
IMKIN0001819726
06.05.2011
06.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1283
0001820095
RUSTAM
IMKIN0001820095
09.05.2011
09.03.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
550,000.00
91,667.00
55,000.00
9,167.00
0.00
82,500.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
23,333.00
14,000.00
2,333.00
0.00
21,000.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
9,230.00
1,538.00
923.00
154.00
0.00
1,384.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
10,140.00
10,140.00
0.00
0.00
0.00
10,140.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
32,045.00
5,341.00
3,205.00
534.00
0.00
4,807.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
35,880.00
35,880.00
0.00
0.00
0.00
35,880.00
1284
1285
1286
0001820430
NUR HASAN SIDIQ
0001820499.01
DEDEH KURNIA
0001820499.03
IR MIFTAHUDIN
IMKIN0001820430
IMKIN0001820499
IMKIN0001820499
11.05.2011
11.05.2011
11.05.2011
11.03.2012
11.03.2012
11.03.2012
1287
0001820753.01
WAN MAYA SURI
IMKIN0001820753
01.05.2011
01.05.2012
01
CIGYSR
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1288
0001820855.01
IMKIN0001820855
STANNY OKTAVIANI PUT
04.05.2011
04.04.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
79,000.00
6,583.00
7,900.00
658.00
0.00
5,925.00
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1289
1290
0001821145
FAHMI
0001821158
KARYO UTOMO
IMKIN0001821145
IMKIN0001821158
06.05.2011
09.05.2011
06.03.2012
09.03.2012


NO : 01105/II/2012/01
: 70
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1291
0001821190.01
ADI WINARDO
IMKIN0001821190
19.05.2011
19.05.2012
01
MANUTV
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1292
0001821196.01
SOFA HARIS
IMKIN0001821196
19.05.2011
19.05.2012
01
MANUTV
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1293
0001821268
IMKIN0001821268
MUHAMAD ZULKARNAEN
01.05.2011
01.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1294
1295
1296
1297
1298
1299
1300
0001821300
NOVI ARIANTI
0001821336
SYARIFUDDIN
0001821418
WAHYUDI M
0001821483
MUHAMMAD ARIS
0001821504
NURRIA IHSANUDIN
IMKIN0001821300
IMKIN0001821336
IMKIN0001821418
IMKIN0001821483
IMKIN0001821504
0001821730.01
IMKIN0001821730
ARI HENDRA ANGGARA
0001821731.01
ANDRI RUSIYANTO
IMKIN0001821731
01.05.2011
01.05.2011
01.05.2011
01.05.2011
01.05.2011
02.05.2011
02.05.2011
01.03.2012
01.03.2012
01.03.2012
01.03.2012
01.03.2012
02.03.2012
02.03.2012
1301
0001821773.01
ABU SOFYAN
IMKIN0001821773
02.05.2011
02.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
8,385.00
8,385.00
0.00
0.00
0.00
8,385.00
1302
0001821773.03
RADIAH
IMKIN0001821773
02.05.2011
02.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1303
0001822130
IMKIN0001822130
BOBBY FERRY MANALU
12.05.2011
12.03.2012
01
PMCSHP
25,000,000.00
25,000,000.00 2011
21,250.00
3,542.00
2,125.00
354.00
0.00
3,188.00
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
75,000,000.00
75,000,000.00 2011
106,500.00
17,750.00
10,650.00
1,775.00
0.00
15,975.00
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1304
0001822149
SUGIO WIJAYA
IMKIN0001822149
12.05.2011
12.03.2012


NO : 01105/II/2012/01
: 71
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
1305
0001822356.01
NAPSIRIN HADI
Quarter 2012
PAGE
POLICY NO.
IMKIN0001822356
DATE OF
DATE OF NATURE
09.05.2011
09.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1306
0001822649
AZHARI
IMKIN0001822649
10.05.2011
10.05.2012
01
BNIJBX
1307
0001822877.01
IMKIN0001822877
IR PIGOU TORORI DWI
04.05.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
9,230.00
1,538.00
923.00
154.00
0.00
1,384.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
10,140.00
10,140.00
0.00
0.00
0.00
10,140.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
22,685.00
3,781.00
2,269.00
378.00
0.00
3,403.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
25,480.00
25,480.00
0.00
0.00
0.00
25,480.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
01
PMTBPL
5,000,000.00
5,000,000.00 2012
3,500.00
3,500.00
0.00
0.00
0.00
3,500.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
5,915.00
986.00
592.00
99.00
0.00
887.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
6,370.00
0.00
0.00
0.00
6,370.00
01
CIGSRN
100,000,000.00
100,000,000.00 2011
348,000.00
87,000.00
34,800.00
8,700.00
0.00
78,300.00
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
CIGLPN
100,000,000.00
100,000,000.00 2011
275,000.00
68,750.00
27,500.00
6,875.00
0.00
61,875.00
01
CIGLPN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1308
1309
1310
1311
1312
1313
1314
1315
1316
1317
0001822882.01
AGUS SETYAWAN
0001822894.01
H.ABDUL RAZAK
IMKIN0001822882
IMKIN0001822894
0001822912.01
IMKIN0001822912
BAYU STEVIA ANANTA
0001822957.01
ARI KURNIAWAN
IMKIN0001822957
0001822961.01
IMKIN0001822961
AMSSAL JAYA SIANIPAR
0001822970.01
CECEP KUSNANDAR
0001823023.01
ICHLAS FIRMANSYAH
IMKIN0001822970
IMKIN0001823023
0001823059.01
IMKIN0001823059
FANNY TROFIEN RUMOKO
0001823184.01
WIDIO NUGRAHWATI
IMKIN0001823184
0001823214
IMKIN0001823214
BAHRID BUSENG DRS H
04.05.2011
04.05.2011
04.05.2011
05.05.2011
05.05.2011
05.05.2011
06.05.2011
06.05.2011
06.05.2011
05.05.2011
04.03.2012
04.03.2012
04.03.2012
05.03.2012
05.03.2012
05.03.2012
06.03.2012
06.03.2012
06.02.2012
05.02.2012


NO : 01105/II/2012/01
: 72
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
1318
1319
1320
1321
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
0001823746
IMKIN0001823746
MARTHA MONIKA LINGGA
0001824947.01
SANUDI
0001824971.01
SUKARYO B RUSBAD
0001825118.01
AGUS SURAHMAN
IMKIN0001824947
IMKIN0001824971
IMKIN0001825118
DATE OF
DATE OF NATURE
12.05.2011
10.05.2011
10.05.2011
12.05.2011
12.03.2012
10.03.2012
10.03.2012
12.03.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
0.00
0.00
0.00
4,550.00
1322
0001825381.01
ANDRY ABADI UTAMA
IMKIN0001825381
19.05.2011
19.05.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1323
0001825393.01
IMKIN0001825393
KAPAITRIYA SARI NING
18.05.2011
18.05.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
70,000.00
70,000.00
0.00
0.00
0.00
70,000.00
1324
0001825555
IMKIN0001825555
NUSIRWAN DALIMUNTHE
18.05.2011
18.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1325
0001825748.01
AANG JUNAEDI
18.05.2011
18.03.2012
01
MISSRN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
MISSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIDRD
150,000,000.00
150,000,000.00 2011
177,000.00
14,750.00
17,700.00
1,475.00
0.00
13,275.00
01
BNIDRD
150,000,000.00
100,000,000.00 2012
129,000.00
129,000.00
0.00
0.00
0.00
129,000.00
1326
0001826538.01
ABRIMAN
IMKIN0001825748
IMKIN0001826538
20.05.2011
20.04.2012
1327
0001826570.01
TEGUH BASUKI,BEC
IMKIN0001826570
21.05.2011
21.05.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
118,000.00
118,000.00
0.00
0.00
0.00
118,000.00
1328
0001826577
HENDRA SETIONO
IMKIN0001826577
20.05.2011
20.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1329
0001826596
JOHAN MAIS OLEY
IMKIN0001826596
20.05.2011
20.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1330
0001826614
IMKIN0001826614
AZIS PURNOMO PUTRO,S
21.05.2011
21.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1331
0001826629
SUHARTONO
IMKIN0001826629
21.05.2011
21.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1332
0001826941
RIRIN ANDIANI
IMKIN0001826941
23.05.2011
23.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1333
0001826955
HENDRIK L TIWOW
IMKIN0001826955
23.05.2011
23.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1334
0001826979
IMKIN0001826979
I WAYAN AJI SEDANA.A
23.05.2011
23.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 73
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
1335
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
0001827150
IMKIN0001827150
MUHAMMAD MARMAN TUHA
DATE OF
DATE OF NATURE
24.05.2011
24.04.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
PMCSHP
75,000,000.00
75,000,000.00 2011
52,500.00
4,375.00
5,250.00
438.00
0.00
3,937.00
01
PMCSHP
75,000,000.00
75,000,000.00 2012
52,500.00
52,500.00
0.00
0.00
0.00
52,500.00
1336
0001827163
LILI AYENI,SH
IMKIN0001827163
24.05.2011
24.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1337
0001827175
IMKIN0001827175
ARIF FARHAN BUDIYANT
24.05.2011
24.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1338
0001827396
HENDRA OKRIMALFI
23.05.2011
23.03.2012
01
DANHCP
40,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
40,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
DANHCP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
27,600.00
4,600.00
2,760.00
460.00
0.00
4,140.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1339
1340
1341
1342
1343
0001827422
PRANYONO
IMKIN0001827396
IMKIN0001827422
0001827512.01
IMKIN0001827512
IR WALMEN SITINDAON
0001827537
MIRWAN ARSYAD
0001827537.01
SRI SETIYONINGSIH
0001827550.01
ADRIANUS HARYO P
IMKIN0001827537
IMKIN0001827537
IMKIN0001827550
20.05.2011
18.05.2011
20.05.2011
20.05.2011
20.05.2011
20.03.2012
18.03.2012
20.03.2012
20.03.2012
20.03.2012
1344
0001827669
RULLY CAHYANI
IMKIN0001827669
13.05.2011
13.05.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1345
0001827712
RUDI TONI LUBIS
IMKIN0001827712
14.05.2011
14.05.2012
01
PMTSHI
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1346
0001828487
MUH AMIN
IMKIN0001828487
25.05.2011
25.05.2012
01
BNIHLF
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1347
0001828817.01
DJOKO WIJONO
IMKIN0001828817
23.05.2011
23.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,950.00
658.00
395.00
66.00
0.00
592.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
MANUTV
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1348
1349
0001828836.01
BAGUS PRABOWO
0001829089.01
TEVERI BENTI
IMKIN0001828836
IMKIN0001829089
24.05.2011
24.05.2011
24.03.2012
15.05.2012


NO : 01105/II/2012/01
: 74
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1350
0001829142.01
BAMBANG SADONO
IMKIN0001829142
20.05.2011
20.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1351
0001829142.03
SUGIARTI
IMKIN0001829142
20.05.2011
20.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1352
0001829211.01
SUPRATMAN
IMKIN0001829211
24.05.2011
24.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
22,000.00
3,667.00
2,200.00
367.00
0.00
3,300.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1353
0001829810
IMKIN0001829810
NURUL LAILATUS SA`AD
01.06.2011
01.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1354
0001829814
IKE AMELIA
IMKIN0001829814
01.06.2011
01.04.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1355
0001829886
SUTARTI
IMKIN0001829886
01.06.2011
01.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1356
0001829889.01
TOPAN WIBAWA
IMKIN0001829889
01.06.2011
01.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1357
0001829929.01
IMKIN0001829929
AMALIA FEBRY SADHANA
01.06.2011
01.05.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
70,000.00
5,833.00
7,000.00
583.00
0.00
5,250.00
1358
0001829978.01
RONI WIJAYANTO
IMKIN0001829978
01.06.2011
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
875.00
350.00
88.00
0.00
787.00
1359
0001830019
TAN TJIN TIONG
IMKIN0001830019
01.06.2011
01.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
3,090,000.00
1,030,000.00
309,000.00
103,000.00
0.00
927,000.00
1360
0001833204
JEJE
IMKIN0001833204
06.06.2011
06.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1361
0001833301.01
DADANG
IMKIN0001833301
06.06.2011
06.03.2012
01
HSBCPP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1362
0001833310.01
MIRRA HASTUTY
IMKIN0001833310
09.06.2011
09.03.2012
01
HSBCPP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1363
0001833337.01
MURWANTO
IMKIN0001833337
01.06.2011
01.03.2012
01
MANGMK
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1364
0001833376.01
IMKIN0001833376
AGOES EDY SETIAWAN
06.06.2011
06.05.2012
01
MANGMK
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1365
0001833403.01
EKO SUDARMAWAN
IMKIN0001833403
07.06.2011
07.05.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
118,000.00
9,833.00
11,800.00
983.00
0.00
8,850.00
1366
0001833977.01
IMKIN0001833977
BAHARUDIN UMASUGI
01.06.2011
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
1367
0001833977.03
INDAH PRATIWI
IMKIN0001833977
01.06.2011
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
1368
0001834062.01
IYAR WIARSIH
IMKIN0001834062
01.06.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
8,385.00
2,096.00
839.00
210.00
0.00
1,886.00
1369
0001834096.01
AKHMAD NABHANI ST
IMKIN0001834096
01.06.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,138.00
455.00
114.00
0.00
1,024.00


NO : 01105/II/2012/01
: 75
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1370
0001834175.01
IMKIN0001834175
FARID KUMBORO ARIEF
04.06.2011
04.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
1371
0001834294.01
ERIKA SULISTYANI
IMKIN0001834294
07.06.2011
07.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
1372
0001834613.01
LILIS AISAH
IMKIN0001834613
13.06.2011
13.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
379.00
455.00
38.00
0.00
341.00
1373
0001834613.03
SYAHBUDIN
IMKIN0001834613
13.06.2011
13.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
9,230.00
769.00
923.00
77.00
0.00
692.00
1374
0001836416
YUSPIK ALWI LUBIS
IMKIN0001836416
13.06.2011
13.03.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1375
0001836537.01
MUHAMAD HANAPI
IMKIN0001836537
06.06.2011
06.05.2012
01
HSBCPP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1376
0001836583.01
IMKIN0001836583
MADI SINGGIH SASMORO
03.06.2011
03.05.2012
01
MANGMK
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1377
0001836605.01
IMKIN0001836605
MUHAMMAD ALI PURKON
09.06.2011
09.04.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
118,000.00
19,667.00
11,800.00
1,967.00
0.00
17,700.00
1378
0001836619.01
IMKIN0001836619
KHAERUL BUDHY NAGARA
07.06.2011
07.03.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
118,000.00
29,500.00
11,800.00
2,950.00
0.00
26,550.00
1379
0001836664.01
WITASARI
IMKIN0001836664
10.06.2011
10.05.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
172,000.00
14,333.00
17,200.00
1,433.00
0.00
12,900.00
1380
0001836668.01
NENI ARIANI
IMKIN0001836668
08.06.2011
08.03.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
70,000.00
17,500.00
7,000.00
1,750.00
0.00
15,750.00
1381
0001836673.01
NUR CHOLIS MAJID
IMKIN0001836673
10.06.2011
10.05.2012
01
MANGMK
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1382
0001836688.01
IMKIN0001836688
DESIYANI PUJI WAHYUN
09.06.2011
09.03.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
70,000.00
17,500.00
7,000.00
1,750.00
0.00
15,750.00
1383
0001836735.01
IMKIN0001836735
DHIRA ANINDYA NIRMAL
14.06.2011
14.03.2012
01
MANGMK
200,000,000.00
100,000,000.00 2011
70,000.00
17,500.00
7,000.00
1,750.00
0.00
15,750.00
1384
0001836753
IMKIN0001836753
FAJAR KURNIANINGSIH
14.06.2011
14.05.2012
01
DANHCP
40,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1385
0001837157.01
IMKIN0001837157
ENDANG MURTI ANDRINI
16.06.2011
16.04.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
1386
0001837319
IMKIN0001837319
SUDRAJAT ABDUL MUNAW
15.06.2011
15.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1387
0001837983.01
YUSRIZAL, SE
IMKIN0001837983
17.06.2011
17.03.2012
01
BNIDRD
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1388
0001838176
DADANG SAPUTRA
IMKIN0001838176
16.06.2011
16.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1389
0001839569.01
RAHMAD BUDI AJI
IMKIN0001839569
22.06.2011
22.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,138.00
455.00
114.00
0.00
1,024.00
1390
0001840235.01
T HENNY HANDAJANI
IMKIN0001840235
22.06.2011
22.05.2012
01
HSBCPP
50,000,000.00
50,000,000.00 2011
59,000.00
4,917.00
5,900.00
492.00
0.00
4,425.00


NO : 01105/II/2012/01
: 76
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1391
0001840313
LABUDI
IMKIN0001840313
17.06.2011
17.02.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
486,000.00
162,000.00
48,600.00
16,200.00
0.00
145,800.00
1392
0001840434
YUYUN
IMKIN0001840434
22.06.2011
22.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1393
0001840577
PUTRI PRIHATINI
IMKIN0001840577
21.06.2011
21.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1394
0001841042.01
ANIH HADYANTI
IMKIN0001841042
21.06.2011
21.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
13,750.00
3,438.00
1,375.00
344.00
0.00
3,094.00
1395
0001841078
IMKIN0001841078
MUHAMMAD RICKY RIVAI
10.06.2011
10.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1396
0001842005.01
ANDRI KUSNANDAR
IMKIN0001842005
01.07.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,517.00
455.00
152.00
0.00
1,365.00
1397
0001842005.03
IMKIN0001842005
RAHAYU INDAH HANDAYA
01.07.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,517.00
455.00
152.00
0.00
1,365.00
1398
0001842278.01
INDAH AGUS LESTARI
IMKIN0001842278
01.07.2011
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
1,167.00
350.00
117.00
0.00
1,050.00
1399
0001842716.01
IBNU ABBAS
IMKIN0001842716
01.07.2011
01.02.2012
01
CIGSRN
100,000,000.00
100,000,000.00 2011
621,000.00
258,750.00
62,100.00
25,875.00
0.00
232,875.00
1400
0001842954
SUGENG WIRNALI
IMKIN0001842954
02.07.2011
02.05.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1401
0001843018
CASMARI
IMKIN0001843018
06.07.2011
06.03.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1402
0001843018.01
CASMARI
IMKIN0001843018
06.07.2011
06.03.2012
01
NISINP
96,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1403
0001843250.01
LUKMAN ARIFIN
IMKIN0001843250
04.07.2011
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,517.00
455.00
152.00
0.00
1,365.00
1404
0001843344.01
AZHAR BSC
IMKIN0001843344
05.07.2011
05.03.2012
01
BNIDRD
50,000,000.00
50,000,000.00 2011
345,000.00
115,000.00
34,500.00
11,500.00
0.00
103,500.00
1405
0001843381
SANTOSO OEY
IMKIN0001843381
05.07.2011
05.05.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
486,000.00
81,000.00
48,600.00
8,100.00
0.00
72,900.00
1406
0001843382
SANTOSO OEY
IMKIN0001843382
05.07.2011
05.05.2012
01
CIGLPR
500,000,000.00
500,000,000.00 2011
1,215,000.00
202,500.00
121,500.00
20,250.00
0.00
182,250.00
1407
0001843485.01
ASEP SURIANA
IMKIN0001843485
05.07.2011
05.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
1,167.00
350.00
117.00
0.00
1,050.00
1408
0001843683
ARIA SRI FITRIANA
IMKIN0001843683
08.07.2011
08.03.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1409
0001843683.01
ARIA SRI FITRIANA
IMKIN0001843683
08.07.2011
08.03.2012
01
NISINP
96,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1410
0001844006
IMKIN0001844006
FRANS MARSINTA PUTRA
01.07.2011
01.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1411
0001844108
MUHAMAD SALADIN
04.07.2011
04.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001844108


NO : 01105/II/2012/01
: 77
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1412
0001844276
HASANUDDIN
IMKIN0001844276
01.07.2011
01.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1413
0001844545.01
SURI LATIFAH
IMKIN0001844545
06.07.2011
06.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
1414
0001844606
IMKIN0001844606
TJIO WIESIONG-SUWIRY
22.07.2011
22.05.2012
01
IMCGLP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1415
0001844611.01
IMKIN0001844611
MARYCEL ROSA NOYA
07.07.2011
07.05.2012
01
BNIDRD
250,000,000.00
250,000,000.00 2011
175,000.00
29,167.00
17,500.00
2,917.00
0.00
26,250.00
1416
0001844660
AFRIANATA
IMKIN0001844660
05.07.2011
05.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1417
0001844845.01
HANDI WIDIYANTO
IMKIN0001844845
01.07.2011
01.02.2012
01
CIGSRN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1418
0001844856.01
WIWI MULYANA
IMKIN0001844856
05.07.2011
05.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
316,000.00
131,667.00
31,600.00
13,167.00
0.00
118,500.00
1419
0001844878
IMKIN0001844878
R TURADJA AULIA NUG
05.07.2011
05.05.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
140,000.00
23,333.00
14,000.00
2,333.00
0.00
21,000.00
1420
0001845546.01
HERI SUTIANTO
IMKIN0001845546
07.07.2011
07.04.2012
01
HSBCPP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1421
0001845603
IMKIN0001845603
RIZAL STIONO SUTAJAY
05.07.2011
05.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1422
0001846081
NOVELIA ADISITA
IMKIN0001846081
09.07.2011
09.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1423
0001846410.01
PURMADI
IMKIN0001846410
11.07.2011
11.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
588,000.00
98,000.00
58,800.00
9,800.00
0.00
88,200.00
1424
0001846900.01
SARAH LAYLA
IMKIN0001846900
12.07.2011
12.03.2012
01
HSBCPP
300,000,000.00
300,000,000.00 2011
210,000.00
70,000.00
21,000.00
7,000.00
0.00
63,000.00
1425
0001847197
IMAM SUTIKNO
IMKIN0001847197
11.07.2011
11.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1426
0001847226
TERIMABAIK HAREFA
IMKIN0001847226
12.07.2011
12.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1427
0001847239
IMKIN0001847239
ERMINA SARILANTI TAM
12.07.2011
12.03.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1428
0001847287
SOFYAN SYAHRUDY
IMKIN0001847287
11.07.2011
11.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1429
0001847302
RIANDY SETIAWAN
IMKIN0001847302
07.07.2011
07.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1430
0001847342
EDY SUHARTO
IMKIN0001847342
15.07.2011
15.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1431
0001847342.01
EDY SUHARTO
IMKIN0001847342
15.07.2011
15.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1432
0001847469
REZA FAHLEVI
IMKIN0001847469
08.07.2011
08.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 78
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1433
0001848091
NURMA HISA DESI
IMKIN0001848091
14.07.2011
14.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1434
0001848342.01
YONATHAN
IMKIN0001848342
08.07.2011
08.05.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
79,000.00
13,167.00
7,900.00
1,317.00
0.00
11,850.00
1435
0001848391.01
IMKIN0001848391
GINANJAR DHANU UTOMO
11.07.2011
11.05.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
316,000.00
52,667.00
31,600.00
5,267.00
0.00
47,400.00
1436
0001848503
MUHAMAD HUSIN
IMKIN0001848503
05.07.2011
05.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1437
0001848803
LATIFAH
IMKIN0001848803
16.07.2011
16.03.2012
01
HSBTLC
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1438
0001848913.01
IMKIN0001848913
JENDA MALEM TARIGAN
08.07.2011
08.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
22,685.00
7,562.00
2,269.00
756.00
0.00
6,806.00
1439
0001849396
J SOFYAN BRAHIM
IMKIN0001849396
15.07.2011
15.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1440
0001849766
IMKIN0001849766
ELFINA AGUSTIN VENDA
18.07.2011
18.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1441
0001849842
RUDYANTO TJANDRA
IMKIN0001849842
18.07.2011
18.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1442
0001850116.01
ANEKA ASMIN
IMKIN0001850116
19.07.2011
19.04.2012
01
BNIDRD
50,000,000.00
50,000,000.00 2011
246,500.00
61,625.00
24,650.00
6,163.00
0.00
55,462.00
1443
0001850379
SUDIRMAN AMIN
IMKIN0001850379
18.07.2011
18.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1444
0001850606
RUSLI RAJAB
IMKIN0001850606
18.07.2011
18.05.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1445
0001850625
AHMAD RIZKI
IMKIN0001850625
18.07.2011
18.03.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1446
0001851013
HJ. JUMIANI, SE
IMKIN0001851013
20.07.2011
20.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1447
0001851013.01
JUJU ANTORO
IMKIN0001851013
20.07.2011
20.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1448
0001851391
TJIE KHENG
IMKIN0001851391
19.07.2011
19.04.2012
01
CIGLPN
100,000,000.00
100,000,000.00 2011
690,000.00
172,500.00
69,000.00
17,250.00
0.00
155,250.00
1449
0001851398
SUNARKO
IMKIN0001851398
18.07.2011
18.02.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
170,000.00
70,833.00
17,000.00
7,083.00
0.00
63,750.00
1450
0001851415
MUHAMMAD HUSNI
IMKIN0001851415
20.07.2011
20.02.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
196,000.00
81,667.00
19,600.00
8,167.00
0.00
73,500.00
1451
0001851461
GHOZALI HAMZAH
IMKIN0001851461
21.07.2011
21.04.2012
01
BNIHLF
10,000,000.00
10,000,000.00 2011
7,000.00
1,750.00
700.00
175.00
0.00
1,575.00
1452
0001851463
I GEDE SUARSA
IMKIN0001851463
21.07.2011
21.05.2012
01
BNIHLF
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1453
0001851500
IMKIN0001851500
SYAHRIAR BENNI PUTRA
21.07.2011
21.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
96,750.00
32,250.00
9,675.00
3,225.00
0.00
29,025.00


NO : 01105/II/2012/01
: 79
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1454
0001851602.01
SITI MUJILAH
IMKIN0001851602
13.07.2011
13.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
7,800.00
2,600.00
780.00
260.00
0.00
2,340.00
1455
0001851707
PANJI SETIAWAN
IMKIN0001851707
18.07.2011
18.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1456
0001851894.01
ADITYA
IMKIN0001851894
22.07.2011
22.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,517.00
455.00
152.00
0.00
1,365.00
1457
0001852017
HENDRIK SAPUTRA
IMKIN0001852017
20.07.2011
20.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1458
0001852019
YUNITA HERAWATI
IMKIN0001852019
20.07.2011
20.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1459
0001852112
AHMAD KHOLIK
IMKIN0001852112
19.07.2011
19.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1460
0001852405.01
VICTOR VICEROY
IMKIN0001852405
25.07.2011
25.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,517.00
455.00
152.00
0.00
1,365.00
1461
0001853084.01
MULYA WARDANA
IMKIN0001853084
22.07.2011
22.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
1462
0001853085.01
PRISKA
IMKIN0001853085
22.07.2011
22.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
1,167.00
350.00
117.00
0.00
1,050.00
1463
0001853102
IMKIN0001853102
INDRIANI SEPTYNINGSI
22.07.2011
22.03.2012
01
PMTSHI
50,000,000.00
50,000,000.00 2011
35,000.00
11,667.00
3,500.00
1,167.00
0.00
10,500.00
1464
0001853135.01
KHABIBI
IMKIN0001853135
22.07.2011
22.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
1465
0001853148.01
SARDI
IMKIN0001853148
22.07.2011
22.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,517.00
455.00
152.00
0.00
1,365.00
1466
0001853162.01
YUWONO SAPUTRO
IMKIN0001853162
22.07.2011
22.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
583.00
350.00
58.00
0.00
525.00
1467
0001853178
ACHMAD SYAHRIFAL
IMKIN0001853178
23.07.2011
23.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1468
0001853199.01
IMKIN0001853199
YULVITA PELITANINGSI
23.07.2011
23.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
758.00
455.00
76.00
0.00
682.00
1469
0001853200.01
PAIMAN
IMKIN0001853200
23.07.2011
23.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
25,480.00
8,493.00
2,548.00
849.00
0.00
7,644.00
1470
0001853235.01
IMKIN0001853235
NORA OKTASARI RASMA
23.07.2011
23.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
9,650.00
3,217.00
965.00
322.00
0.00
2,895.00
1471
0001853245
IMKIN0001853245
KADEK WIWIN HENDRA W
20.07.2011
20.05.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
52,500.00
8,750.00
5,250.00
875.00
0.00
7,875.00
1472
0001853248
MOHAMAD GUNAWAN
IMKIN0001853248
20.07.2011
20.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1473
0001853443.01
ISRAN NOOR
IMKIN0001853443
26.07.2011
26.03.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
927,000.00
309,000.00
92,700.00
30,900.00
0.00
278,100.00
1474
0001854472.01
HENDRY AGUSMAN
IMKIN0001854472
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
8,385.00
3,494.00
839.00
350.00
0.00
3,144.00


NO : 01105/II/2012/01
: 80
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1475
0001854472.03
IRAWATI
IMKIN0001854472
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
7,020.00
2,925.00
702.00
293.00
0.00
2,632.00
1476
0001854583
WISMOKO TRI ALDRI
IMKIN0001854583
01.08.2011
01.03.2012
01
PMCSHP
50,000,000.00
50,000,000.00 2011
59,000.00
24,583.00
5,900.00
2,458.00
0.00
22,125.00
1477
0001855048
TARYUDIN
IMKIN0001855048
01.08.2011
01.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1478
0001855070
IMKIN0001855070
JOKO TRI HARJANTO`SE
01.08.2011
01.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1479
0001855098
IMKIN0001855098
SYAMSUL BAHRI CHAN
01.08.2011
01.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1480
0001855315.01
CENNING AGUSTIA
IMKIN0001855315
02.08.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,896.00
455.00
190.00
0.00
1,706.00
1481
0001855376
RIKO RISMANTO
IMKIN0001855376
02.08.2011
02.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1482
0001855750.01
PITER
IMKIN0001855750
04.08.2011
04.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
258,000.00
64,500.00
25,800.00
6,450.00
0.00
58,050.00
1483
0001856029
SUWIGNYO
IMKIN0001856029
03.08.2011
03.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1484
0001856274.01
LUSI FEBRIANTI
IMKIN0001856274
01.08.2011
01.12.2011
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,600.00
2,400.00
360.00
240.00
0.00
2,160.00
1485
0001856294.01
LUTFI NURCAHYO
IMKIN0001856294
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,896.00
455.00
190.00
0.00
1,706.00
1486
0001856295.01
MSYUKUR
IMKIN0001856295
01.08.2011
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
1,458.00
350.00
146.00
0.00
1,312.00
1487
0001856341.01
NI KOMANG SRIANTI
IMKIN0001856341
01.08.2011
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
1,458.00
350.00
146.00
0.00
1,312.00
1488
0001856381.01
SUJARNO
IMKIN0001856381
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,896.00
455.00
190.00
0.00
1,706.00
1489
0001856385.01
M. AGUS
IMKIN0001856385
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,896.00
455.00
190.00
0.00
1,706.00
1490
0001856424.01
IMKIN0001856424
KRISTO FURUS WIDI UT
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
1,896.00
455.00
190.00
0.00
1,706.00
1491
0001856428.01
IMKIN0001856428
TATOS RIDWAN A FAUZI
01.08.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
6,370.00
2,654.00
637.00
265.00
0.00
2,389.00
1492
0001856511.01
IMKIN0001856511
ROHMAT IMANUDIN BIN
01.08.2011
01.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
875.00
350.00
88.00
0.00
787.00
1493
0001857069
ADRIANSYAH
IMKIN0001857069
01.08.2011
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1494
0001857090.01
IMKIN0001857090
MAYPRI ASTRI NOVIYAN
01.08.2011
01.03.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
79,000.00
32,917.00
7,900.00
3,292.00
0.00
29,625.00
1495
0001857095.01
IMKIN0001857095
HARLIE BOY OKTAVERI
01.08.2011
01.02.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2011
158,000.00
79,000.00
15,800.00
7,900.00
0.00
71,100.00


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 81
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
1496
0001857338
SOLEIL SAMOSIR
IMKIN0001857338
02.08.2011
02.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1497
0001857487
AGUNG SETYA BUDI
IMKIN0001857487
06.08.2011
06.05.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
52,500.00
13,125.00
5,250.00
1,313.00
0.00
11,812.00
1498
0001857647.01
IR JACKY WATIMURY
IMKIN0001857647
05.08.2011
05.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
4,550.00
1,896.00
455.00
190.00
0.00
1,706.00
1499
0001857955
EDI EKO SISWANTO
IMKIN0001857955
08.08.2011
08.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1500
0001858172
YUS AFFANDI
IMKIN0001858172
08.08.2011
08.03.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
1,380,000.00
575,000.00
138,000.00
57,500.00
0.00
517,500.00
1501
0001858185
YAN FONTABA
IMKIN0001858185
08.08.2011
08.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1502
0001858251.01
HERDIANTO
IMKIN0001858251
09.08.2011
09.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
1,458.00
350.00
146.00
0.00
1,312.00
1503
0001858301.01
LEONARD E BANAM
IMKIN0001858301
10.08.2011
16.04.2012
01
BNIDRR
105,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1504
0001858470.01
LIDYA IMELDA
IMKIN0001858470
10.08.2011
10.05.2012
01
CIGSRN
300,000,000.00
300,000,000.00 2011
366,000.00
91,500.00
36,600.00
9,150.00
0.00
82,350.00
1505
0001858877.01
MUKTAR SYAH
IMKIN0001858877
05.08.2011
05.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
316,000.00
158,000.00
31,600.00
15,800.00
0.00
142,200.00
1506
0001858936.01
M E ALEXANDRA
IMKIN0001858936
11.08.2011
11.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1507
0001859100.01
RAHMA TRISTIYANTI
IMKIN0001859100
11.08.2011
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
12,545.00
5,227.00
1,255.00
523.00
0.00
4,704.00
1508
0001859369
IMKIN0001859369
ABDUL GANI HANDOKO
10.08.2011
10.03.2012
01
DANHCP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1509
0001859512.01
WIWIN RAHAYU
IMKIN0001859512
12.08.2011
12.03.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2011
79,000.00
32,917.00
7,900.00
3,292.00
0.00
29,625.00
1510
0001860713.01
IMKIN0001860713
MEISA ARDHI NUGROHO
16.08.2011
16.05.2012
01
BNIDRD
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1511
0001860914
VERONICA LOMO
IMKIN0001860914
11.08.2011
11.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1512
0001860925.01
FIRA MARDIANI
IMKIN0001860925
13.08.2011
13.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1513
0001860926.01
RUSMI
IMKIN0001860926
12.08.2011
12.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1514
0001861067
WAHYONO
IMKIN0001861067
16.08.2011
16.05.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1515
0001862092.01
IMKIN0001862092
RETNO ENDANG SRIHARJ
20.08.2011
20.03.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
105,000.00
43,750.00
10,500.00
4,375.00
0.00
39,375.00
1516
0001862217
IRAWAN
23.08.2011
23.03.2012
01
NISINP
96,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001862217
SUM ASSURED
NON POOL


NO : 01105/II/2012/01
: 82
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
1517
0001862217.01
IRAWAN
IMKIN0001862217
23.08.2011
23.03.2012
01
NISINP
1518
0001862288.01
IMKIN0001862288
BAMBANG AGUNG SUSILO
09.08.2011
09.05.2012
01
1519
0001862326.01
SAMSIR SS
IMKIN0001862326
10.08.2011
10.03.2012
1520
0001862442
IMKIN0001862442
MIRNA MAISARA DAULAY
18.08.2011
1521
0001863043.01
MAISYE M PONTOAN
IMKIN0001863043
1522
0001863612
KAMARIAH
1523
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
PMTBPL
6,500,000.00
6,500,000.00 2011
8,385.00
2,096.00
839.00
210.00
0.00
1,886.00
01
PMTBPL
6,500,000.00
6,500,000.00 2011
7,670.00
3,196.00
767.00
320.00
0.00
2,876.00
18.05.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
23.08.2011
23.05.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
532,000.00
133,000.00
53,200.00
13,300.00
0.00
119,700.00
IMKIN0001863612
15.08.2011
15.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
0001863612.01
RUSLIANSYAH
IMKIN0001863612
15.08.2011
15.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1524
0001863632
EKA LINDA YANI
IMKIN0001863632
15.08.2011
15.05.2012
01
PMTSHI
50,000,000.00
50,000,000.00 2011
36,000.00
9,000.00
3,600.00
900.00
0.00
8,100.00
1525
0001863637
IMKIN0001863637
YOHANES CHRISTIANTO
16.08.2011
16.03.2012
01
PMTSHI
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1526
0001863797
YOLA KURNIAWAN
IMKIN0001863797
24.08.2011
09.04.2012
01
IMCGLP
500,000,000.00
500,000,000.00 2011
490,000.00
163,333.00
49,000.00
16,333.00
0.00
147,000.00
1527
0001863799
HANDY SUPRIJADI
IMKIN0001863799
24.08.2011
09.05.2012
01
IMCGLP
500,000,000.00
500,000,000.00 2011
645,000.00
161,250.00
64,500.00
16,125.00
0.00
145,125.00
1528
0001864529
IMKIN0001864529
BARDASAWAN SUGIRI
01.09.2011
01.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1529
0001864555
DODY ISKANDAR
IMKIN0001864555
01.09.2011
01.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1530
0001864759
RAMDAN
IMKIN0001864759
01.09.2011
01.03.2012
01
PMTSHI
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1531
0001865045.01
MOCHSYIHABUDIN
IMKIN0001865045
10.09.2011
10.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1532
0001866074
IMKIN0001866074
YOGA PAMUNGKAS HASIBUAN
05.09.2011
05.03.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1533
0001866100
USMIATI
IMKIN0001866100
07.09.2011
07.05.2012
01
DANHCP
10,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1534
0001866117
KARTA
IMKIN0001866117
05.09.2011
05.03.2012
01
HSBTLC
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1535
0001866225
KHO BOK BENG
IMKIN0001866225
21.09.2011
21.03.2012
01
IMCGLP
500,000,000.00
200,000,000.00 2011
182,000.00
91,000.00
18,200.00
9,100.00
0.00
81,900.00
1536
0001867426.01
LESDINER HASIBUAN
IMKIN0001867426
13.09.2011
13.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
258,000.00
86,000.00
25,800.00
8,600.00
0.00
77,400.00
1537
0001868035.01
DR GERALD TOREH
IMKIN0001868035
13.09.2011
13.05.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
316,000.00
105,333.00
31,600.00
10,533.00
0.00
94,800.00


NO : 01105/II/2012/01
: 83
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1538
0001868358.01
A BUDI SURYANTO
IMKIN0001868358
15.09.2011
15.05.2012
01
BNIDRR
105,000,000.00
105,000,000.00 2011
193,200.00
64,400.00
19,320.00
6,440.00
0.00
57,960.00
1539
0001868415
IMKIN0001868415
ANTONIUS HERUJIYANTO
15.09.2011
15.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1540
0001868492.01
MUHAMMAD TAMRIN
IMKIN0001868492
01.09.2011
01.02.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2011
388,000.00
226,333.00
38,800.00
22,633.00
0.00
203,700.00
1541
0001868581.01
YADI SURYADI
IMKIN0001868581
06.09.2011
06.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
532,000.00
310,333.00
53,200.00
31,033.00
0.00
279,300.00
1542
0001868582
SABARIMAN
IMKIN0001868582
01.09.2011
01.02.2012
01
CIGLPN
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1543
0001869973.01
ELY SUSIAWATI
IMKIN0001869973
19.09.2011
19.03.2012
01
PMTBPS
5,000,000.00
5,000,000.00 2011
3,500.00
1,750.00
350.00
175.00
0.00
1,575.00
1544
0001869973.03
SIGIT PRAYITNO
IMKIN0001869973
19.09.2011
19.03.2012
01
PMTBPS
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1545
0001870304.01
IR FIRDAUS ANST
IMKIN0001870304
05.09.2011
05.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1546
0001870308.01
IMKIN0001870308
I GUSTI KADEK SUARDANA
06.09.2011
06.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1547
0001871162
ANA SHELA TIARA
IMKIN0001871162
17.09.2011
17.03.2012
01
BCASHP
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1548
0001871162.01
IMKIN0001871162
RAYMOND ABD. RACHMAN
17.09.2011
17.03.2012
01
BCASHP
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1549
0001871597.01
IMKIN0001871597
RISYANDY ADY SAPUTRA
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1550
0001871603.01
CUCUP SUPRIATNA
IMKIN0001871603
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1551
0001871613.01
AGUS PERMADI
IMKIN0001871613
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1552
0001871615.01
DINA SARI
IMKIN0001871615
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1553
0001871615.03
EDWIN SAMPEPANA
IMKIN0001871615
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1554
0001871649.01
RASIMAN
IMKIN0001871649
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1555
0001871670.01
DJONI LUMINTANG
IMKIN0001871670
12.09.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1556
0001872124
IMKIN0001872124
ADITYO HARI NUGROHO
14.09.2011
14.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1557
0001872128
CUCUP SUPRIATNA
IMKIN0001872128
14.09.2011
14.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
59,250.00
29,625.00
5,925.00
2,963.00
0.00
26,662.00
1558
0001872341
IMKIN0001872341
KIRANA ANGGRAHITA PRAMESTI
22.09.2011
22.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 84
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1559
0001872341.01
IMKIN0001872341
RACHMADI SUSILO WIDODO
22.09.2011
22.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1560
0001872341.02
IMKIN0001872341
SHAFIRA DERASTI ALTAFFA
22.09.2011
22.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1561
0001872341.03
WIDIASTUTI
IMKIN0001872341
22.09.2011
22.05.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
88,500.00
29,500.00
8,850.00
2,950.00
0.00
26,550.00
1562
0001872345
IMKIN0001872345
STELA LARISA CHANDRA
22.09.2011
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1563
0001872345.01
WAN WAN CANDRA
IMKIN0001872345
22.09.2011
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1564
0001872345.02
YULIA
IMKIN0001872345
22.09.2011
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1565
0001872361.01
BAMBANG SANTOSO
IMKIN0001872361
22.09.2011
22.04.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1566
0001872447.01
SUKUR A M ARIF
IMKIN0001872447
15.09.2011
15.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
776,000.00
452,667.00
77,600.00
45,267.00
0.00
407,400.00
1567
0001872637.01
IMKIN0001872637
BABUL JANNASRI HAFSA
08.09.2011
08.03.2012
01
MANGPL
200,000,000.00
100,000,000.00 2011
85,000.00
42,500.00
8,500.00
4,250.00
0.00
38,250.00
1568
0001872761
IMKIN0001872761
FEBRIADHY MAULANA SAADIPUTRA
21.09.2011
21.03.2012
01
DANHCP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1569
0001872766.01
IMKIN0001872766
PRAHESTI RETYARSARI
20.09.2011
20.05.2012
01
MANGPL
200,000,000.00
100,000,000.00 2011
91,000.00
30,333.00
9,100.00
3,033.00
0.00
27,300.00
1570
0001873270
SLAMET SUGIARTO
IMKIN0001873270
23.09.2011
23.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1571
0001873298.01
RESTU SITANGGANG
IMKIN0001873298
20.09.2011
20.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1572
0001873298.03
SYARIFAH HUSNA
IMKIN0001873298
20.09.2011
20.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1573
0001873468
IMKIN0001873468
DANTE HARTLEY BARAHAMA
23.09.2011
23.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1574
0001873786
AGUS SUSANTO
IMKIN0001873786
27.09.2011
27.04.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1575
0001873852
TITI
IMKIN0001873852
24.09.2011
24.03.2012
01
HSBTLC
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1576
0001874135.01
FEBRI TRI PUTRINI
IMKIN0001874135
01.10.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
2,654.00
455.00
265.00
0.00
2,389.00
1577
0001874145.01
SUNARTI
IMKIN0001874145
01.10.2011
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
5,915.00
3,450.00
592.00
345.00
0.00
3,105.00
1578
0001874145.03
IMKIN0001874145
SYAHLAN JUKHRI NASUTION ST
01.10.2011
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1579
0001874185.01
IMKIN0001874185
ILHAM FITRIAN MUBAROK
01.10.2011
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 85
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1580
0001874185.03
IMKIN0001874185
TRI LESTARI SUCI SUSILOWATI
01.10.2011
01.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1581
0001874559.01
INDRA A E SETIAWAN
IMKIN0001874559
01.10.2011
01.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
105,000.00
43,750.00
10,500.00
4,375.00
0.00
39,375.00
1582
0001874601
ALBERT ICHSAN
IMKIN0001874601
01.10.2011
01.03.2012
01
BNIDRD
100,000,000.00
100,000,000.00 2011
440,000.00
256,667.00
44,000.00
25,667.00
0.00
231,000.00
1583
0001874620.01
SETIA WIJAYA S.SOS
IMKIN0001874620
01.10.2011
01.05.2012
01
BNIDRD
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1584
0001875434
IMKIN0001875434
OCTAVIANUS MATHYS HUKOM
06.10.2011
06.03.2012
01
NISINP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1585
0001875434.01
IMKIN0001875434
OCTAVIANUS MATHYS HUKOM
06.10.2011
06.03.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1586
0001875534.01
HASYIMS SOS
IMKIN0001875534
04.10.2011
04.05.2012
01
BNIDRD
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1587
0001875671.01
SURYADINATA
IMKIN0001875671
04.10.2011
04.05.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1588
0001876710
BUDY HERIYAWAN
IMKIN0001876710
06.10.2011
16.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1589
0001876710.01
BUDY HERIYAWAN
IMKIN0001876710
06.10.2011
16.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1590
0001876712
IRMA DIYAH
IMKIN0001876712
10.10.2011
10.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1591
0001876712.01
IRMA DIYAH
IMKIN0001876712
10.10.2011
10.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1592
0001876768.01
JAKA PURWANTO
IMKIN0001876768
03.10.2011
03.02.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2011
388,000.00
258,667.00
38,800.00
25,867.00
0.00
232,800.00
1593
0001876779.01
IMKIN0001876779
LISNA NURINDAH SARI
05.10.2011
05.02.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2011
158,000.00
105,333.00
15,800.00
10,533.00
0.00
94,800.00
1594
0001877233
RIZZALUNA
IMKIN0001877233
07.10.2011
07.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1595
0001877527
NI MADE SURYANI
IMKIN0001877527
10.10.2011
10.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1596
0001877571
IMKIN0001877571
ABDUL GHONI EFFENDY
10.10.2011
10.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1597
0001878712
MUSNI
IMKIN0001878712
11.10.2011
11.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1598
0001878712.01
RUSLIM BAMBANG
IMKIN0001878712
11.10.2011
11.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1599
0001878728
SETIYA BUDI
IMKIN0001878728
11.10.2011
11.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1600
0001880195
SUSANTO
IMKIN0001880195
06.10.2011
06.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 86
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1601
0001880628
IMKIN0001880628
HENDRA TRI LAKSONO
14.10.2011
14.04.2012
01
BNIJB3
140,000,000.00
140,000,000.00 2011
140,000.00
70,000.00
14,000.00
7,000.00
0.00
63,000.00
1602
0001881426.01
DAHNIAR NASUTION
IMKIN0001881426
17.10.2011
17.05.2012
01
MANGPL
200,000,000.00
200,000,000.00 2011
140,000.00
58,333.00
14,000.00
5,833.00
0.00
52,500.00
1603
0001881466
IMKIN0001881466
SAMBAS BENNY RUMBAYAN
11.10.2011
11.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1604
0001881785.01
NURWIYANTO
IMKIN0001881785
03.10.2011
03.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
588,000.00
245,000.00
58,800.00
24,500.00
0.00
220,500.00
1605
0001882000.01
AKHMAD SYAMSI
IMKIN0001882000
18.10.2011
18.04.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
324,000.00
162,000.00
32,400.00
16,200.00
0.00
145,800.00
1606
0001882333
IMKIN0001882333
TJOA RUSLI ANGGREK
19.10.2011
19.04.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1607
0001883249
IMKIN0001883249
GANDY JAYA BUDIHARTO
21.10.2011
21.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1608
0001884131.01
EUIS AISYAH
IMKIN0001884131
12.10.2011
12.05.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1609
0001884138.01
JUWANTO
IMKIN0001884138
12.10.2011
12.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1610
0001884446
IMKIN0001884446
SATYASTA MARTUA GIDEON
25.10.2011
25.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1611
0001884741.01
HENNY TRIHERLISADI
IMKIN0001884741
19.10.2011
19.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1612
0001884802.01
RONDYAH
IMKIN0001884802
21.10.2011
21.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1613
0001884802.03
SUJANA
IMKIN0001884802
21.10.2011
21.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1614
0001884826.01
SULASTRI
IMKIN0001884826
22.10.2011
22.03.2012
01
PMTBPL
5,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1615
0001885183.01
H SANUDIN
IMKIN0001885183
24.10.2011
24.03.2012
01
PMTBPL
6,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1616
0001885191
REZA SUKENDI
IMKIN0001885191
24.10.2011
24.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1617
0001885596.01
MUHSIN
IMKIN0001885596
01.11.2011
01.05.2012
01
BNIDRD
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1618
0001885649.01
RIZZALUNA
IMKIN0001885649
01.11.2011
01.03.2012
01
PMTBPS
5,000,000.00
5,000,000.00 2011
3,500.00
2,333.00
350.00
233.00
0.00
2,100.00
1619
0001885728.01
PULUNG KUSHARIADI
IMKIN0001885728
01.11.2011
01.03.2012
01
MANGPL
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1620
0001885740.01
NOFRIZA MAHAYU
IMKIN0001885740
01.11.2011
01.03.2012
01
MANGPL
200,000,000.00
100,000,000.00 2011
70,000.00
46,667.00
7,000.00
4,667.00
0.00
42,000.00
1621
0001885765.01
EDY SETIYONO
IMKIN0001885765
01.11.2011
01.03.2012
01
MANGPX
70,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 87
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1622
0001886170
DEDI WIJAYA
IMKIN0001886170
04.11.2011
04.03.2012
01
NISINP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1623
0001886170.01
DEDI WIJAYA
IMKIN0001886170
04.11.2011
04.03.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1624
0001886190
ANDREAS JOSEPH H
IMKIN0001886190
02.11.2011
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1625
0001886190.01
IMKIN0001886190
HERAWATI SUMINDRA
02.11.2011
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1626
0001886190.02
WILLIAM SURYA H
IMKIN0001886190
02.11.2011
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1627
0001886482.01
IMKIN0001886482
LINDA PERMANASARI,S SOS
03.11.2011
03.05.2012
01
BNIDRR
70,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1628
0001887103.01
WINO SUMARNO
IMKIN0001887103
07.11.2011
07.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
324,000.00
162,000.00
32,400.00
16,200.00
0.00
145,800.00
1629
0001887500.01
MARSUDI
IMKIN0001887500
01.11.2011
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
19,600.00
13,067.00
1,960.00
1,307.00
0.00
11,760.00
1630
0001888257
SUPRIADI
IMKIN0001888257
10.11.2011
10.02.2012
01
CIGLPN
200,000,000.00
30,000,000.00 2011
32,400.00
24,300.00
3,240.00
2,430.00
0.00
21,870.00
1631
0001888329
ARI SETYADI
IMKIN0001888329
15.11.2011
15.03.2012
01
IMCGLP
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1632
0001889184
IMKIN0001889184
TARA AGNESSTASHA M
15.11.2011
15.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1633
0001889187
MUHAMMAD HAMZAH
IMKIN0001889187
15.11.2011
15.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1634
0001889189
M IQBAL SYAFEI
IMKIN0001889189
15.11.2011
15.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1635
0001889249
CATHERINA
IMKIN0001889249
15.11.2011
15.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1636
0001889249.01
HENDRA KRISNANDA
IMKIN0001889249
15.11.2011
15.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1637
0001889513
ZAINAL ABIDIN
IMKIN0001889513
09.11.2011
09.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1638
0001890016.01
AGUS SUSANTO
IMKIN0001890016
16.11.2011
16.04.2012
01
BNIDRR
105,000,000.00
105,000,000.00 2011
136,500.00
79,625.00
13,650.00
7,963.00
0.00
71,662.00
1639
0001890571
IMKIN0001890571
YUSTINA TRUSTININGSIH
21.11.2011
21.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1640
0001890571.01
IMKIN0001890571
YUSTINA TRUSTININGSIH
21.11.2011
21.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1641
0001890573
POEDJI RAHAYU
IMKIN0001890573
21.11.2011
21.03.2012
01
NISINP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1642
0001890573.01
POEDJI RAHAYU
IMKIN0001890573
21.11.2011
21.03.2012
01
NISINP
72,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 88
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1643
0001890650
MOH KHOIRI
IMKIN0001890650
21.11.2011
21.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
231,750.00
154,500.00
23,175.00
15,450.00
0.00
139,050.00
1644
0001892203.01
DENI MULYANA
IMKIN0001892203
15.11.2011
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1645
0001892211.01
ADE SUSENO
IMKIN0001892211
15.11.2011
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1646
0001892264.01
IMKIN0001892264
DIMAS GALUH SWASANA
15.11.2011
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1647
0001892303.01
IMAN FIRMANSYAH
IMKIN0001892303
15.11.2011
15.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
2,275.00
455.00
228.00
0.00
2,047.00
1648
0001892338.01
SARONI
IMKIN0001892338
16.11.2011
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1649
0001892378.01
NURMAYANNA N
IMKIN0001892378
16.11.2011
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1650
0001892457.01
RIDWAN
IMKIN0001892457
17.11.2011
17.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
10,140.00
6,760.00
1,014.00
676.00
0.00
6,084.00
1651
0001892480.01
AHMAD EFFENDI
IMKIN0001892480
17.11.2011
17.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1652
0001892485.01
Muhammad SUHELMI
IMKIN0001892485
17.11.2011
17.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,680.00
2,730.00
468.00
273.00
0.00
2,457.00
1653
0001892492.01
IMKIN0001892492
BONG PAP KONG (ELYAS)
17.11.2011
17.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
32,045.00
21,363.00
3,205.00
2,137.00
0.00
19,226.00
1654
0001892509.01
IMKIN0001892509
ENGGAR WAHYUNINGSIH
18.11.2011
18.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
11,180.00
7,453.00
1,118.00
745.00
0.00
6,708.00
1655
0001892518.01
IMKIN0001892518
KRESNALDY EKA PUTRA
18.11.2011
18.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
2,275.00
455.00
228.00
0.00
2,047.00
1656
0001892522.01
APRIANUS ROFIQ
IMKIN0001892522
18.11.2011
18.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1657
0001892522.03
NIA MARYANI
IMKIN0001892522
18.11.2011
18.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1658
0001892527.01
ERSANTI ATMADJA
IMKIN0001892527
18.11.2011
18.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
2,275.00
455.00
228.00
0.00
2,047.00
1659
0001892546.01
OKE NUGRAHA SE
IMKIN0001892546
21.11.2011
21.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
5,135.00
3,423.00
514.00
343.00
0.00
3,080.00
1660
0001892768.01
IMKIN0001892768
KOESNAENY SETYAWATI
23.11.2011
23.03.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1661
0001893492
AGUST SULAIMAN S.S
IMKIN0001893492
24.11.2011
24.05.2012
01
PMCSHP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1662
0001893687
ERVINA D RORING
IMKIN0001893687
24.11.2011
24.05.2012
01
CIGLPN
300,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1663
0001893693
FAUZI HASAN
IMKIN0001893693
25.11.2011
25.02.2012
01
CIGLPN
500,000,000.00
500,000,000.00 2011
1,545,000.00
1,158,750.00
154,500.00
115,875.00
0.00
1,042,875.00


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 89
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
1664
0001894289.01
AYU PUJI ASTUTI
IMKIN0001894289
01.12.2011
01.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
105,000.00
61,250.00
10,500.00
6,125.00
0.00
55,125.00
1665
0001894321.01
KAMILUS N U
IMKIN0001894321
01.12.2011
01.04.2012
01
BNIDRD
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1666
0001894358.01
ROMMY ANTONIUS
IMKIN0001894358
01.12.2011
01.03.2012
01
MANGPL
200,000,000.00
200,000,000.00 2011
196,000.00
147,000.00
19,600.00
14,700.00
0.00
132,300.00
1667
0001894361.01
SAPTO RIANDOKO
IMKIN0001894361
01.12.2011
01.05.2012
01
MANGPL
100,000,000.00
50,000,000.00 2011
78,000.00
45,500.00
7,800.00
4,550.00
0.00
40,950.00
1668
0001894397.01
IMKIN0001894397
NUNIK SRI NURHAYANI
01.12.2011
01.05.2012
01
BNIDRD
150,000,000.00
150,000,000.00 2011
927,000.00
540,750.00
92,700.00
54,075.00
0.00
486,675.00
1669
0001894596
IRFAN FANANI
IMKIN0001894596
02.12.2011
02.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1670
0001894784
PETER GOZALI
IMKIN0001894784
01.12.2011
01.03.2012
01
BCASHP
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1671
0001895194
IMKIN0001895194
DRS FX SULISTIYONO MM
01.12.2011
01.02.2012
01
CIGLPN
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1672
0001895201.01
IMKIN0001895201
JULIA DEWI NINGSIH KAKOMORE
01.12.2011
01.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
488,000.00
406,667.00
48,800.00
40,667.00
0.00
366,000.00
1673
0001895668.01
SUKADI
IMKIN0001895668
06.12.2011
06.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
9,650.00
7,238.00
965.00
724.00
0.00
6,514.00
1674
0001895668.03
YOPI RAMADHANI
IMKIN0001895668
06.12.2011
06.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
7,100.00
5,325.00
710.00
533.00
0.00
4,792.00
1675
0001895674
AHMAD FAUZI SH
IMKIN0001895674
06.12.2011
06.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1676
0001895723
SILVIA YUNIATI
IMKIN0001895723
06.12.2011
06.05.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
81,667.00
14,000.00
8,167.00
0.00
73,500.00
1677
0001895727
RAYZAND LEAZ
IMKIN0001895727
07.12.2011
07.05.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
81,667.00
14,000.00
8,167.00
0.00
73,500.00
1678
0001895730
IMKIN0001895730
WILHELMUS LAURENS RATELA
07.12.2011
07.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1679
0001895734
MELLOVA
IMKIN0001895734
06.12.2011
06.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1680
0001895754.01
ERNAWATI
IMKIN0001895754
01.12.2011
01.05.2012
01
HSBCPP
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1681
0001895782.01
IMKIN0001895782
YUDHIE EPUSDI YADHEI
01.12.2011
01.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1682
0001896271.01
PRIMATA OKTA DELA
IMKIN0001896271
07.12.2011
07.03.2012
01
PMTBPS
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1683
0001896279
IMKIN0001896279
ANGGIE KEMALA DWI PUTRI
08.12.2011
08.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1684
0001896298
IMKIN0001896298
NI NENGAH SUKERTIASIH
08.12.2011
08.03.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 90
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1685
0001896407.01
DARSONO
IMKIN0001896407
09.12.2011
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1686
0001896540.01
DJOKO SUHARTO
IMKIN0001896540
09.12.2011
09.05.2012
01
BNIDRD
50,000,000.00
50,000,000.00 2011
384,500.00
224,292.00
38,450.00
22,429.00
0.00
201,863.00
1687
0001896599
MUHAMMAD JALIL
IMKIN0001896599
02.12.2011
02.02.2012
01
CIGLPN
500,000,000.00
200,000,000.00 2011
158,000.00
131,667.00
15,800.00
13,167.00
0.00
118,500.00
1688
0001896842
LESDINER HASIBUAN
IMKIN0001896842
12.12.2011
12.05.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
386,000.00
225,167.00
38,600.00
22,517.00
0.00
202,650.00
1689
0001896845
YOSEP NUGROHO
IMKIN0001896845
13.12.2011
13.05.2012
01
BNIJBX
200,000,000.00
200,000,000.00 2011
140,000.00
81,667.00
14,000.00
8,167.00
0.00
73,500.00
1690
0001897084
DINA SARI
IMKIN0001897084
09.12.2011
09.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
52,500.00
39,375.00
5,250.00
3,938.00
0.00
35,437.00
1691
0001897084.01
EDWIN SAMPEPANA
IMKIN0001897084
09.12.2011
09.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2011
52,500.00
39,375.00
5,250.00
3,938.00
0.00
35,437.00
1692
0001897084.02
M RIFALDI
IMKIN0001897084
09.12.2011
09.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1693
0001897084.03
URIEL
IMKIN0001897084
09.12.2011
09.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1694
0001897120
WAHID SUHERMANTO
IMKIN0001897120
14.12.2011
14.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1695
0001897156
IMKIN0001897156
G. AJI SURYA WICAKSONO
12.12.2011
12.05.2012
01
PMCSHP
25,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1696
0001897323.01
TOMY HERWANTO
IMKIN0001897323
02.12.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
17,875.00
13,406.00
1,788.00
1,341.00
0.00
12,065.00
1697
0001897326.01
NANI VINOZA
IMKIN0001897326
02.12.2011
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
40,170.00
30,128.00
4,017.00
3,013.00
0.00
27,115.00
1698
0001897377.01
AWAN RISWANDI
IMKIN0001897377
05.12.2011
05.04.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,950.00
2,633.00
395.00
263.00
0.00
2,370.00
1699
0001897377.03
NENGSRI WAHYUNI
IMKIN0001897377
05.12.2011
05.04.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,333.00
350.00
233.00
0.00
2,100.00
1700
0001897384.01
ENDANG WIYATI
IMKIN0001897384
05.12.2011
05.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
5,525.00
4,144.00
553.00
415.00
0.00
3,729.00
1701
0001897390.01
HERU PRAMONO
IMKIN0001897390
05.12.2011
05.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
8,385.00
4,891.00
839.00
489.00
0.00
4,402.00
1702
0001897418.01
NICHOLAS ARLIEA
IMKIN0001897418
06.12.2011
06.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1703
0001897452.01
DANI
IMKIN0001897452
06.12.2011
06.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
2,654.00
455.00
265.00
0.00
2,389.00
1704
0001897503.01
A MUNIF FANDI
IMKIN0001897503
07.12.2011
07.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1705
0001897506.01
SUBANDI
IMKIN0001897506
07.12.2011
07.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
5,900.00
4,425.00
590.00
443.00
0.00
3,982.00


NO : 01105/II/2012/01
: 91
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1706
0001897554.01
DENI KURNIAWAN
IMKIN0001897554
08.12.2011
08.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1707
0001897576.01
HERI FIRMANSYAH
IMKIN0001897576
08.12.2011
08.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1708
0001897628.01
IMKIN0001897628
KARUNA MURTI WIDJAJA
15.12.2011
15.05.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
441,000.00
257,250.00
44,100.00
25,725.00
0.00
231,525.00
1709
0001898733
HASYIMS SOS
IMKIN0001898733
15.12.2011
15.05.2012
01
BNIJBX
150,000,000.00
150,000,000.00 2011
463,500.00
270,375.00
46,350.00
27,038.00
0.00
243,337.00
1710
0001898771
IMKIN0001898771
CAHYANTI PURNAMASARI
01.12.2011
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1711
0001898788
DIANA PUJI LESTARI
IMKIN0001898788
06.12.2011
06.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1712
0001898868
IMKIN0001898868
YANTI YANUARINI ROSNURHAYATI
17.12.2011
17.04.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1713
0001899655
IMKIN0001899655
TEJO AGUS WINARTO WAHYUDI
20.12.2011
20.03.2012
01
BNIJB3
140,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1714
0001899658
MUKHTAR M USMAN
IMKIN0001899658
20.12.2011
20.05.2012
01
BNIJBX
150,000,000.00
150,000,000.00 2011
364,500.00
212,625.00
36,450.00
21,263.00
0.00
191,362.00
1715
0001899662.01
NURHIDAYAH
IMKIN0001899662
20.12.2011
12.05.2012
01
MANGPL
200,000,000.00
200,000,000.00 2011
158,000.00
92,167.00
15,800.00
9,217.00
0.00
82,950.00
1716
0001900548
LISA SUNDARI
IMKIN0001900548
10.12.2011
10.04.2012
01
BCASHP
20,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1717
0001900823
ASNAWI
IMKIN0001900823
01.12.2011
01.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1718
0001900844
ZAMZAMI
IMKIN0001900844
01.12.2011
01.03.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1719
0001900955.01
RANI KARTIKA SARI
IMKIN0001900955
21.12.2011
21.03.2012
01
HSBCPP
200,000,000.00
100,000,000.00 2011
79,000.00
59,250.00
7,900.00
5,925.00
0.00
53,325.00
1720
0001901002.01
PURKON
IMKIN0001901002
09.12.2011
09.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
12,545.00
7,318.00
1,255.00
732.00
0.00
6,586.00
1721
0001901011.01
DAYENI AMD
IMKIN0001901011
09.12.2011
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
6,370.00
4,778.00
637.00
478.00
0.00
4,300.00
1722
0001901023.01
RINA EFENDI
IMKIN0001901023
09.12.2011
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1723
0001901033.01
HERI HANDAYANI
IMKIN0001901033
10.12.2011
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
5,135.00
3,851.00
514.00
386.00
0.00
3,465.00
1724
0001901064.01
EKO SUPRIJANTO
IMKIN0001901064
12.12.2011
12.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
5,135.00
3,851.00
514.00
386.00
0.00
3,465.00
1725
0001901072.01
SULASTRI
IMKIN0001901072
12.12.2011
12.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,042.00
350.00
204.00
0.00
1,838.00
1726
0001901078.01
IMKIN0001901078
EMMANUEL VIALLRESA SUSILO
13.12.2011
13.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,042.00
350.00
204.00
0.00
1,838.00


NO : 01105/II/2012/01
: 92
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1727
0001901092.01
NURLIYANINGSIH
IMKIN0001901092
13.12.2011
13.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,042.00
350.00
204.00
0.00
1,838.00
1728
0001901106.01
ARLAND A
IMKIN0001901106
13.12.2011
13.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1729
0001901107.01
ERIKA YUTIASARI
IMKIN0001901107
14.12.2011
14.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1730
0001901151.01
I KETUT WANA
IMKIN0001901151
14.12.2011
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,680.00
3,510.00
468.00
351.00
0.00
3,159.00
1731
0001901157.01
HADIANSYAH
IMKIN0001901157
14.12.2011
14.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,625.00
350.00
263.00
0.00
2,362.00
1732
0001901176.01
MUDJIJONO
IMKIN0001901176
15.12.2011
15.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
30,900.00
23,175.00
3,090.00
2,318.00
0.00
20,857.00
1733
0001901187.01
ABDUL AZIS
IMKIN0001901187
15.12.2011
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1734
0001901213.01
NUNUNG MUJIATMI
IMKIN0001901213
15.12.2011
15.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
22,000.00
16,500.00
2,200.00
1,650.00
0.00
14,850.00
1735
0001901224.01
EDI SANTOSO
IMKIN0001901224
16.12.2011
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
25,480.00
19,110.00
2,548.00
1,911.00
0.00
17,199.00
1736
0001901227.01
WINDI SEJATI
IMKIN0001901227
16.12.2011
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2011
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1737
0001901306.01
NUR WIDAYAT
IMKIN0001901306
21.12.2011
21.05.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
3,500.00
2,042.00
350.00
204.00
0.00
1,838.00
1738
0001901319
DANU BRATA
IMKIN0001901319
12.12.2011
12.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1739
0001901324
RIMA
IMKIN0001901324
13.12.2011
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1740
0001901348.01
NANI NARGIATI
IMKIN0001901348
20.12.2011
20.03.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1741
0001901366.01
BROTO WIKANTO
IMKIN0001901366
19.12.2011
19.05.2012
01
CIGSRN
50,000,000.00
50,000,000.00 2011
174,000.00
101,500.00
17,400.00
10,150.00
0.00
91,350.00
1742
0001901369.01
RUDY
IMKIN0001901369
20.12.2011
20.02.2012
01
CIGSRN
200,000,000.00
100,000,000.00 2011
79,000.00
65,833.00
7,900.00
6,583.00
0.00
59,250.00
1743
0001901372.01
PURWANTO
IMKIN0001901372
20.12.2011
20.02.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1744
0001901638.01
IMKIN0001901638
MOCH RIZKI ARIEFIADI
20.12.2011
20.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
7,100.00
5,325.00
710.00
533.00
0.00
4,792.00
1745
0001901638.03
IMKIN0001901638
RD RATNA M NURANTI
20.12.2011
20.03.2012
01
PMTBPL
5,000,000.00
5,000,000.00 2011
7,100.00
5,325.00
710.00
533.00
0.00
4,792.00
1746
0001902204.01
EMI SULASMI
IMKIN0001902204
23.12.2011
23.05.2012
01
BNIDRR
70,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1747
0001902558
CARMO
IMKIN0001902558
23.12.2011
23.05.2012
01
BNIJBX
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 93
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1748
0001902605.01
ITA CAMELIA
IMKIN0001902605
23.12.2011
23.02.2012
01
CIGSRN
100,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1749
0001902608.01
SONNY SALFIDI
IMKIN0001902608
23.12.2011
23.05.2012
01
CIGSRN
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1750
0001902913
ARIEF WAHYUDI
IMKIN0001902913
23.12.2011
23.05.2012
01
BNIJBX
150,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1751
0001902937.01
YENNY SOFIA
IMKIN0001902937
20.12.2011
20.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
532,000.00
443,333.00
53,200.00
44,333.00
0.00
399,000.00
1752
0001902939.01
IMKIN0001902939
FRANSISKUS SURYO WINAHYU
23.12.2011
23.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2011
316,000.00
263,333.00
31,600.00
26,333.00
0.00
237,000.00
1753
0001902942
RINA
IMKIN0001902942
23.12.2011
02.03.2012
01
NISINP
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1754
0001902942.01
RINA
IMKIN0001902942
23.12.2011
02.03.2012
01
NISINP
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1755
0001903097
DEWI SURYANINGSIH
IMKIN0001903097
01.12.2011
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1756
0001903160
YANI SRI MULYANI
IMKIN0001903160
27.12.2011
27.05.2012
01
BNIJB3
105,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
1757
0001903455
SOFYAN
IMKIN0001903455
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1758
0001903509
DIAN INDRIYANTO
IMKIN0001903509
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1759
0001903536
MIMIN AMINAH
IMKIN0001903536
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1760
0001903555
IMKIN0001903555
SUTAN BATARA PUTRA PANE
01.01.2012
01.05.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1761
0001903563
ZULKANI
IMKIN0001903563
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1762
0001903570
MUSTAQIM KARIM
IMKIN0001903570
01.01.2012
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1763
0001903570.01
SITI HARDIANTI PUTRI
IMKIN0001903570
01.01.2012
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1764
0001903589
DEWI SULISTIANA
IMKIN0001903589
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1765
0001903598
IMKIN0001903598
IMAM BHAKTIAR NUGROHO
01.01.2012
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1766
0001903696.01
DEDI SUTISNA
IMKIN0001903696
01.01.2012
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1767
0001903850.01
ILHAM NUSANTARA
IMKIN0001903850
01.01.2012
01.02.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1768
0001903911
IMKIN0001903911
M. RASYA RAMADHANI RR
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 94
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1769
0001903911.01
IMKIN0001903911
M. REHAN RAMATULLAH RR
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1770
0001903911.02
RUSLI
IMKIN0001903911
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1771
0001903941
MOCH ERWIN
IMKIN0001903941
02.01.2012
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1772
0001904051
RUSLI
IMKIN0001904051
01.01.2012
01.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1773
0001904249.01
RUSMANA
IMKIN0001904249
04.01.2012
04.05.2012
01
BNIDRR
70,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1774
0001904268
ASEP SUTISNA
IMKIN0001904268
01.01.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1775
0001904276
AHMAD JAENUDIN
IMKIN0001904276
01.01.2012
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1776
0001904830
M DAHLAN
IMKIN0001904830
05.01.2012
23.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1777
0001904830.01
M DAHLAN
IMKIN0001904830
05.01.2012
23.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1778
0001904867.01
ANDRIYANA
IMKIN0001904867
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1779
0001904869.01
IMKIN0001904869
FAJAR TRIYONO SUWANDI
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
4,604.00
553.00
461.00
0.00
4,143.00
1780
0001904908.01
IMKIN0001904908
MAHENDRA ARDIYANTO
01.01.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1781
0001904913.01
SUNARTI
IMKIN0001904913
01.01.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
40,170.00
26,780.00
4,017.00
2,678.00
0.00
24,102.00
1782
0001904941.01
PESTA PARHUSIP
IMKIN0001904941
01.01.2012
01.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
3,851.00
514.00
386.00
0.00
3,465.00
1783
0001904957.01
IMKIN0001904957
JOKO KUNCORO WIBISONO
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,915.00
4,929.00
592.00
493.00
0.00
4,436.00
1784
0001904960.01
NURDIN
IMKIN0001904960
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1785
0001904979.01
HERCULES SIAHAAN
IMKIN0001904979
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1786
0001904996.01
IMKIN0001904996
MUHAMAD FAHRUROJI
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1787
0001905037.01
HJ. ICOH
IMKIN0001905037
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
35,880.00
29,900.00
3,588.00
2,990.00
0.00
26,910.00
1788
0001905037.03
OTO HAMBALI
IMKIN0001905037
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
35,880.00
29,900.00
3,588.00
2,990.00
0.00
26,910.00
1789
0001905039.01
WENI FIRDANINGSIH
IMKIN0001905039
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00


NO : 01105/II/2012/01
: 95
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1790
0001905044.01
UTINAH
IMKIN0001905044
01.01.2012
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1791
0001905073.01
IMKIN0001905073
GUNAWAN ABDUL GOFUR
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1792
0001905121.01
RAHIM SAID
IMKIN0001905121
01.01.2012
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1793
0001905157.01
TJUN SEN
IMKIN0001905157
01.01.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
3,423.00
514.00
343.00
0.00
3,080.00
1794
0001905181.01
NUR SAMIAJI
IMKIN0001905181
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,915.00
4,929.00
592.00
493.00
0.00
4,436.00
1795
0001905205.01
YOGA RIANDA
IMKIN0001905205
02.01.2012
02.02.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2012
1,092,000.00
1,001,000.00
109,200.00
100,100.00
0.00
900,900.00
1796
0001905226.01
IMKIN0001905226
OKTAVIANA ULI SIMATUPANG
01.01.2012
01.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1797
0001905227.01
MUSIDUL FAHMI
IMKIN0001905227
02.01.2012
02.02.2012
01
CIGSRN
300,000,000.00
100,000,000.00 2012
79,000.00
72,417.00
7,900.00
7,242.00
0.00
65,175.00
1798
0001905228.01
RUSDI
IMKIN0001905228
02.01.2012
02.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1799
0001905239
ABDUL RASYID SPD
IMKIN0001905239
01.01.2012
01.02.2012
01
CIGLPN
300,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1800
0001905242.01
TRIWAHYUNINGRUM
IMKIN0001905242
02.01.2012
02.02.2012
01
CIGSRN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1801
0001905245.01
AGUS PERMANA S
IMKIN0001905245
01.01.2012
01.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1802
0001905260.01
IMKIN0001905260
JOHN DAVIDSON PANDIE
06.01.2012
06.02.2012
01
CIGSRN
300,000,000.00
100,000,000.00 2012
145,000.00
132,917.00
14,500.00
13,292.00
0.00
119,625.00
1803
0001905265.01
NIDIAWATI
IMKIN0001905265
03.01.2012
03.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1804
0001905277.01
IMKIN0001905277
BAMBANG IRWANSYAH
03.01.2012
03.05.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2012
316,000.00
210,667.00
31,600.00
21,067.00
0.00
189,600.00
1805
0001905280.01
EFRAIM ARIESANDY
IMKIN0001905280
04.01.2012
04.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1806
0001905284.01
WIWIN WARNADHY
IMKIN0001905284
04.01.2012
04.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1807
0001905285.01
SUGENG SARYONO
IMKIN0001905285
04.01.2012
04.02.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
237,000.00
217,250.00
23,700.00
21,725.00
0.00
195,525.00
1808
0001905317
YENI NURAINI
IMKIN0001905317
06.01.2012
06.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1809
0001905384.01
IMKIN0001905384
MELANTON SILITONGA
06.01.2012
06.05.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
690,000.00
460,000.00
69,000.00
46,000.00
0.00
414,000.00
1810
0001905402.01
IMKIN0001905402
LUH AYU MATRAM MINI
07.01.2012
07.05.2012
01
BNIDRD
150,000,000.00
50,000,000.00 2012
35,000.00
23,333.00
3,500.00
2,333.00
0.00
21,000.00


NO : 01105/II/2012/01
: 96
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1811
0001905453
YAFET CAWENDY
IMKIN0001905453
09.01.2012
09.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1812
0001905696.01
IMKIN0001905696
BAGUS PERMANA PUTRA
11.01.2012
11.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1813
0001905704.01
ADE ISKANDARSYAH
IMKIN0001905704
11.01.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1814
0001905838
SUDARSONO
IMKIN0001905838
11.01.2012
11.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1815
0001906016.01
YUANY PRASETYA
IMKIN0001906016
06.01.2012
06.01.2012
01
CIGSRN
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1816
0001906021.01
R ALEX J SETIJOBUDI
IMKIN0001906021
09.01.2012
09.02.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1817
0001906028.01
JUMARI SIDIK
IMKIN0001906028
10.01.2012
10.02.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
399,000.00
365,750.00
39,900.00
36,575.00
0.00
329,175.00
1818
0001906030.01
AGUS PRATIKNO
IMKIN0001906030
09.01.2012
09.05.2012
01
CIGSRN
200,000,000.00
200,000,000.00 2012
178,000.00
118,667.00
17,800.00
11,867.00
0.00
106,800.00
1819
0001906031.01
SITTI ARA USMAN
IMKIN0001906031
09.01.2012
09.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1820
0001906049
ROISAH
IMKIN0001906049
04.01.2012
04.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1821
0001906684
SRI MARYANI
IMKIN0001906684
12.01.2012
12.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1822
0001906781.01
INDRA NALDO
IMKIN0001906781
12.01.2012
12.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1823
0001906781.03
RINI RISWANI
IMKIN0001906781
12.01.2012
12.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1824
0001906873.01
IMKIN0001906873
NURDIAH KRISNO WULAN
13.01.2012
13.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
20,085.00
16,738.00
2,009.00
1,674.00
0.00
15,064.00
1825
0001907194
SUKRIANI
IMKIN0001907194
16.01.2012
16.03.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1826
0001907251
SUPANDI
IMKIN0001907251
12.01.2012
12.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1827
0001907590.01
ARMAN ARDIANTO
IMKIN0001907590
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
5,308.00
637.00
531.00
0.00
4,777.00
1828
0001907593.01
NIRWANSYAH
IMKIN0001907593
01.01.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
4,247.00
637.00
425.00
0.00
3,822.00
1829
0001907596.01
ZULKIFLI
IMKIN0001907596
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1830
0001907598.01
SOFHIA APRILLIA
IMKIN0001907598
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1831
0001907608.01
MAULIDDIN
IMKIN0001907608
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
8,385.00
6,988.00
839.00
699.00
0.00
6,289.00


NO : 01105/II/2012/01
: 97
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1832
0001907610.01
HARYANTO
IMKIN0001907610
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
4,604.00
553.00
461.00
0.00
4,143.00
1833
0001907657.01
MINKHATUL MAULA
IMKIN0001907657
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1834
0001907671.01
IMKIN0001907671
PEPEN EFENDI B TARYA
01.01.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,915.00
4,929.00
592.00
493.00
0.00
4,436.00
1835
0001907702.01
IMKIN0001907702
KARNODO B RUSLANI
02.01.2012
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1836
0001907706.01
FUAD PRIANTO
IMKIN0001907706
02.01.2012
02.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1837
0001907751.01
IMKIN0001907751
ASEP HANDRIAN WINATA
02.01.2012
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1838
0001907752.01
DIAN NOVIANTO
IMKIN0001907752
02.01.2012
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,279.00
514.00
428.00
0.00
3,851.00
1839
0001907766.01
I MADE SUMERTA
IMKIN0001907766
02.01.2012
02.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1840
0001907768.01
IMKIN0001907768
MUHAMAD FITRI PERDANA
02.01.2012
02.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1841
0001907804.01
ARISTO EDITA
IMKIN0001907804
03.01.2012
03.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1842
0001907819.01
IWAN SETIAWAN
IMKIN0001907819
03.01.2012
03.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1843
0001907831.01
ANDI SANINDA
IMKIN0001907831
03.01.2012
03.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1844
0001907844.01
IMKIN0001907844
EKA PUTRI HELDAWATI
04.01.2012
04.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1845
0001907889.01
YADI HARYADI
IMKIN0001907889
04.01.2012
04.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
8,385.00
5,590.00
839.00
559.00
0.00
5,031.00
1846
0001907891.01
WALUYO
IMKIN0001907891
04.01.2012
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1847
0001907900.01
SURIYADI GINTING
IMKIN0001907900
04.01.2012
04.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,279.00
514.00
428.00
0.00
3,851.00
1848
0001907926.01
ALIBI APRIATIN
IMKIN0001907926
05.01.2012
05.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1849
0001908071.01
HERIYADI
IMKIN0001908071
07.01.2012
07.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
3,900.00
468.00
390.00
0.00
3,510.00
1850
0001908087.01
ANJAR FEBRIANTO
IMKIN0001908087
07.01.2012
07.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1851
0001908113.01
RIDHO ARIFIN
IMKIN0001908113
09.01.2012
09.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,033.00
455.00
303.00
0.00
2,730.00
1852
0001908114.01
IMKIN0001908114
BAMBANG TRI ATMOKO
09.01.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
8,385.00
6,988.00
839.00
699.00
0.00
6,289.00


NO : 01105/II/2012/01
: 98
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1853
0001908115.01
IMKIN0001908115
DHARMA PUSPA SUTANTO
09.01.2012
09.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1854
0001908178.01
HARIADI
IMKIN0001908178
10.01.2012
10.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1855
0001908178.03
SITI NURHAYATI
IMKIN0001908178
10.01.2012
10.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1856
0001908190.01
HJ HUSNIAH
IMKIN0001908190
10.01.2012
10.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1857
0001908191.01
ELI HARDIANI
IMKIN0001908191
10.01.2012
10.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1858
0001908196.01
I WAYAN DARMANA
IMKIN0001908196
10.01.2012
10.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
20,085.00
15,064.00
2,009.00
1,507.00
0.00
13,557.00
1859
0001909316.01
DODI PRASETYO
IMKIN0001909316
17.01.2012
17.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1860
0001909482.01
HARYANTO
IMKIN0001909482
11.01.2012
11.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1861
0001909492.01
TINTON HARIBOWO
IMKIN0001909492
11.01.2012
11.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1862
0001909570.01
IMKIN0001909570
NUNNY NOOR SADIAH
13.01.2012
13.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1863
0001909571.01
YUSMAR KALDERA
IMKIN0001909571
13.01.2012
13.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1864
0001909575.01
IMKIN0001909575
MOHAMMAD HUSEN SUHARDI
14.01.2012
14.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1865
0001909590.01
IMKIN0001909590
SYAMSYUAR NASUTION
14.01.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
12,545.00
10,454.00
1,255.00
1,046.00
0.00
9,408.00
1866
0001909601
BENI RIYANTO
IMKIN0001909601
11.01.2012
11.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1867
0001909688.01
DWI KUSWINDARYATI
IMKIN0001909688
12.01.2012
12.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1868
0001909714.01
LORENA
IMKIN0001909714
01.01.2012
01.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1869
0001909718.01
IMKIN0001909718
ABDILLAH HAMDI (2N1BT3)
02.01.2012
02.02.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
399,000.00
365,750.00
39,900.00
36,575.00
0.00
329,175.00
1870
0001909720.01
IMKIN0001909720
DRS ADRIANTO M HUM
04.01.2012
04.02.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1871
0001909788
AMBRIN ILAM
IMKIN0001909788
17.01.2012
17.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1872
0001909788.01
IKRAM MULHAQ
IMKIN0001909788
17.01.2012
17.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1873
0001909788.02
SITI MEILIYA
IMKIN0001909788
17.01.2012
17.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 99
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1874
0001909788.03
YANTI ALI
IMKIN0001909788
17.01.2012
17.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1875
0001910120.01
SUMARNI
IMKIN0001910120
12.01.2012
12.02.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1876
0001910138.01
ASEP JULI
IMKIN0001910138
16.01.2012
16.02.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
237,000.00
217,250.00
23,700.00
21,725.00
0.00
195,525.00
1877
0001910159.01
IMKIN0001910159
RAUF ASRI BATUBARA
16.01.2012
16.05.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
306,000.00
204,000.00
30,600.00
20,400.00
0.00
183,600.00
1878
0001910192.01
IMKIN0001910192
ALLEN FERRY HUKOM
18.01.2012
18.01.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1879
0001910193.01
IMKIN0001910193
YONA YOAN SAHETAPY
19.01.2012
19.02.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
306,000.00
280,500.00
30,600.00
28,050.00
0.00
252,450.00
1880
0001910502
IKA SOPHIA
IMKIN0001910502
24.01.2012
24.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1881
0001910502.01
IKA SOPHIA
IMKIN0001910502
24.01.2012
24.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1882
0001910508
INAH
IMKIN0001910508
24.01.2012
24.05.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1883
0001910508.01
INAH
IMKIN0001910508
24.01.2012
24.05.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1884
0001911100.01
ERIK SULAEMAN
IMKIN0001911100
16.01.2012
16.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1885
0001911109.01
APRIYANTO
IMKIN0001911109
16.01.2012
16.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1886
0001911111.01
SUMARNO
IMKIN0001911111
16.01.2012
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
3,900.00
468.00
390.00
0.00
3,510.00
1887
0001911126.01
APRIANY
IMKIN0001911126
16.01.2012
16.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1888
0001911213.01
AGUNG NUGROHO
IMKIN0001911213
20.01.2012
20.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1889
0001911213.03
IMKIN0001911213
ERVITA NURUL CHAMIDAH
20.01.2012
20.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1890
0001911224.01
IMKIN0001911224
SRI ROZIATY BINTI MUMOD ALI
21.01.2012
21.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
10,140.00
7,605.00
1,014.00
761.00
0.00
6,844.00
1891
0001911235.01
SARI PUJIANTI
IMKIN0001911235
21.01.2012
21.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1892
0001911249.01
PUTU FEBY CORYKA
IMKIN0001911249
21.01.2012
21.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
1893
0001911250.01
YANTI HERAWATI
IMKIN0001911250
21.01.2012
21.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
3,900.00
468.00
390.00
0.00
3,510.00
1894
0001911267
HARI PRABOWO
IMKIN0001911267
24.01.2012
24.02.2012
01
CIGLPN
300,000,000.00
100,000,000.00 2012
275,000.00
252,083.00
27,500.00
25,208.00
0.00
226,875.00


NO : 01105/II/2012/01
: 100
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
1895
0001911267.01
YENI SURYANI
IMKIN0001911267
24.01.2012
24.02.2012
01
CIGLPN
1896
0001911580.01
ROSIANA
IMKIN0001911580
21.01.2012
21.03.2012
01
1897
0001912385
ABDUL MUFIK IKROMI
IMKIN0001912385
16.01.2012
16.03.2012
1898
0001912392
SILVA LEWAN
IMKIN0001912392
19.01.2012
1899
0001912407
BOBY MONAREH
IMKIN0001912407
1900
0001912484
ADHAGIA ASY SYAMS
1901
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
300,000,000.00
50,000,000.00 2012
54,000.00
49,500.00
5,400.00
4,950.00
0.00
44,550.00
PMTBPS
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
19.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
20.01.2012
20.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001912484
24.01.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0001912484.01
SUTIAH
IMKIN0001912484
24.01.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1902
0001912825.01
DEDI HARIADI
IMKIN0001912825
24.01.2012
24.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1903
0001912826.01
IMKIN0001912826
DHEDY ALAMSYAH LESSY
24.01.2012
24.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1904
0001912835.01
SOLEH RIDWAN
IMKIN0001912835
24.01.2012
24.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1905
0001912839.01
HENDRA WIJAYANTO
IMKIN0001912839
24.01.2012
24.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1906
0001912868.01
EDRIZON EFFENDI SE
IMKIN0001912868
19.01.2012
19.02.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1907
0001912872.01
SUTEJA I WAYAN
IMKIN0001912872
20.01.2012
20.02.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
399,000.00
365,750.00
39,900.00
36,575.00
0.00
329,175.00
1908
0001912890.01
GUSTINA
IMKIN0001912890
26.01.2012
26.02.2012
01
CIGSRN
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1909
0001912975
TINTON HARIBOWO
IMKIN0001912975
26.01.2012
26.05.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1910
0001913105.01
DEPI
IMKIN0001913105
26.01.2012
26.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1911
0001913118.01
IMKIN0001913118
AGUSTINA QQ M CHANDRA WIJAYA
26.01.2012
26.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
1912
0001913123.01
SUROJI
IMKIN0001913123
26.01.2012
26.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,279.00
514.00
428.00
0.00
3,851.00
1913
0001913126.01
IMKIN0001913126
SUKARSIH QQ HANI LUTFIAH PUTRI
26.01.2012
26.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
11,180.00
9,317.00
1,118.00
932.00
0.00
8,385.00
1914
0001913130.01
FITRAWATI
IMKIN0001913130
26.01.2012
26.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
3,900.00
468.00
390.00
0.00
3,510.00
1915
0001913151
CUCUP SUPRIATNA
IMKIN0001913151
05.01.2012
05.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 101
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1916
0001913155
SUSANTY
IMKIN0001913155
05.01.2012
05.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1917
0001913158
KHUMAIROH
IMKIN0001913158
06.01.2012
06.05.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1918
0001913232
EDY MASYKUR
IMKIN0001913232
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2012
162,000.00
148,500.00
16,200.00
14,850.00
0.00
133,650.00
1919
0001913242
RIYONOSIDI
IMKIN0001913242
01.02.2012
01.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1920
0001913248
AGUNG WIBOWO
IMKIN0001913248
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1921
0001913267
PARTONO
IMKIN0001913267
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1922
0001913294
ATI ISAMAWATI
IMKIN0001913294
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1923
0001913299
MUHAMAD YUNUS
IMKIN0001913299
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1924
0001913300
BUDIAMAN
IMKIN0001913300
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1925
0001913313
IMKIN0001913313
INGGIT PRIMA AGUSTIN
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1926
0001913315
WIWIK SRIHARTINI
IMKIN0001913315
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1927
0001913316
IR JACKY WATIMURY
IMKIN0001913316
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1928
0001913321
NUR BADRI ANWAR
IMKIN0001913321
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1929
0001913324
AKHMAD NABHANI ST
IMKIN0001913324
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1930
0001913326
ALI MUTAQIN
IMKIN0001913326
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1931
0001913330
MELAHANI SE
IMKIN0001913330
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1932
0001913330.01
MUSLIM
IMKIN0001913330
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1933
0001913339
ADRI ABRAR
IMKIN0001913339
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1934
0001913341
IMKIN0001913341
NI KADEK MULIANI ARDANA
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1935
0001913348
IMKIN0001913348
ADHI FAJAR DARMAMUKTI
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1936
0001913352
SATIMAN
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001913352


NO : 01105/II/2012/01
: 102
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1937
0001913367
IMKIN0001913367
CITRA PERMATA DEWI
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1938
0001913367.01
DODY HARYAWAN
IMKIN0001913367
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1939
0001913369
TAUFIQURRAHMAN
IMKIN0001913369
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1940
0001913502.01
SIDIK SARYATNO
IMKIN0001913502
01.02.2012
01.03.2012
01
PMTBPS
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1941
0001913522.01
IMKIN0001913522
INDRA PARINDRIANTO
01.02.2012
01.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
9,230.00
8,461.00
923.00
846.00
0.00
7,615.00
1942
0001913662
PURWATI NINGRUM
IMKIN0001913662
03.02.2012
03.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1943
0001913662.01
PURWATI NINGRUM
IMKIN0001913662
03.02.2012
03.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1944
0001914207
MAHIAR
IMKIN0001914207
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1945
0001914267
TOTO PRIYANTO
IMKIN0001914267
02.02.2012
02.02.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1946
0001914268.01
LORAWATI LOWIS
IMKIN0001914268
01.02.2012
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1947
0001914288.01
AHMAD RUKONI
IMKIN0001914288
01.02.2012
01.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
1948
0001914290
GHOVINDARE SUKMA
IMKIN0001914290
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1949
0001914309
ADE ANDRIAN
IMKIN0001914309
02.02.2012
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1950
0001914340
SYAMSUDDIN
IMKIN0001914340
02.02.2012
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1951
0001914345
NI LUH HENDRAYANI
IMKIN0001914345
02.02.2012
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1952
0001914719
I WAYAN SUARDANA
IMKIN0001914719
02.02.2012
02.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1953
0001914737
IMKIN0001914737
YOGI SYARIF HIDAYAT
03.02.2012
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1954
0001914781
LILLAH SEPTI SARI
IMKIN0001914781
03.02.2012
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1955
0001914792
TAPIP GUNTUR
IMKIN0001914792
03.02.2012
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1956
0001914800
EXBAR DEPI SUGARA
IMKIN0001914800
04.02.2012
04.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1957
0001914806
IMKIN0001914806
LAKSITA WENING KUSUMA
04.02.2012
04.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 103
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1958
0001914808
NURMIATI
IMKIN0001914808
04.02.2012
04.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1959
0001914818
DIAN HARVEBY ZEN
IMKIN0001914818
03.02.2012
03.03.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1960
0001914956
HALIMAH SADIYAH
IMKIN0001914956
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1961
0001914956.01
IRVAN MAULANA
IMKIN0001914956
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1962
0001914956.02
KURNIA MULYANI
IMKIN0001914956
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1963
0001914956.03
RAHMAT
IMKIN0001914956
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1964
0001914983
CIEN YE
IMKIN0001914983
04.02.2012
04.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1965
0001915090
IMKIN0001915090
ANDHINA PUTRI HERIYANTI
06.02.2012
06.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1966
0001915095
SURATNO
IMKIN0001915095
06.02.2012
06.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1967
0001915181
SASTRIYANI
IMKIN0001915181
09.02.2012
09.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1968
0001915181.01
SASTRIYANI
IMKIN0001915181
09.02.2012
09.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1969
0001915201.01
SUHERYANTI
IMKIN0001915201
01.02.2012
01.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1970
0001915214.01
NUR ARIFIN
IMKIN0001915214
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
1971
0001915223.01
AGUSTINA VIVIN
IMKIN0001915223
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
1972
0001915231.01
IMKIN0001915231
DENNIS S S PURBA QQ GITA P
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
10,140.00
9,295.00
1,014.00
930.00
0.00
8,365.00
1973
0001915247.01
VIDI HANDOKO
IMKIN0001915247
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
1974
0001915256.01
SANUSI KARTAJAYA
IMKIN0001915256
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
25,480.00
23,357.00
2,548.00
2,336.00
0.00
21,021.00
1975
0001915269.01
IMKIN0001915269
NI KETUT TRESNADEWI
01.02.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
4,144.00
553.00
415.00
0.00
3,729.00
1976
0001915276.01
YONATAN
IMKIN0001915276
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
1977
0001915281.01
IMKIN0001915281
VIVIN NUR INDAH SARI
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
1978
0001915309.01
SUMIYATI
01.02.2012
01.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
25,480.00
23,357.00
2,548.00
2,336.00
0.00
21,021.00
IMKIN0001915309


NO : 01105/II/2012/01
: 104
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1979
0001915521
IMKIN0001915521
FATTURAKHMAN RIZKY I
01.02.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1980
0001915526
HEDI GUNAWAN
IMKIN0001915526
02.02.2012
02.02.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1981
0001915564
IMKIN0001915564
NGAKAN KETUT SINARBUDI
09.02.2012
09.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1982
0001915564.01
IMKIN0001915564
NGAKAN KETUT SINARBUDI
09.02.2012
09.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1983
0001915679
SUHARYADI
IMKIN0001915679
07.02.2012
07.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1984
0001915680
IMKIN0001915680
MEI NOVELINA HUTAURUK
07.02.2012
07.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1985
0001915681
IMKIN0001915681
DEBI DESIANA PRADIPTA
07.02.2012
07.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1986
0001915681.01
RANGGA PRADIPTA
IMKIN0001915681
07.02.2012
07.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1987
0001915682
MAHRUF
IMKIN0001915682
07.02.2012
07.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1988
0001916001.01
AGATHA FELISA
IMKIN0001916001
07.02.2012
07.05.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1989
0001916329
DEWI LANNY POSASI
IMKIN0001916329
08.02.2012
10.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1990
0001916331
AFANDY GUNAWAN
IMKIN0001916331
08.02.2012
08.02.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1991
0001916331.01
SARINAH
IMKIN0001916331
08.02.2012
08.02.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1992
0001916352.01
IMKIN0001916352
NI KETUT YANI PRATIWI MARYANA
08.02.2012
08.05.2012
01
BNIDRR
105,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1993
0001916356.01
RAHMADONI
IMKIN0001916356
08.02.2012
08.03.2012
01
MANGPL
200,000,000.00
200,000,000.00 2012
140,000.00
128,333.00
14,000.00
12,833.00
0.00
115,500.00
1994
0001916359.01
SUGENG SUGIYONO
IMKIN0001916359
08.02.2012
08.05.2012
01
MANGPL
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1995
0001916360.01
MARTONO
IMKIN0001916360
08.02.2012
08.03.2012
01
MANGPL
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1996
0001916519
IMKIN0001916519
SIGIT WAHYU IRAWAN
09.02.2012
09.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1997
0001916524
EUIS ATIKA
IMKIN0001916524
09.02.2012
09.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1998
0001916524.01
SUMARGONO
IMKIN0001916524
09.02.2012
09.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
1999
0001916701.01
BAKRI POMPIDO
IMKIN0001916701
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
11,180.00
10,248.00
1,118.00
1,025.00
0.00
9,223.00


NO : 01105/II/2012/01
: 105
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2000
0001916701.03
HILMAWATI
IMKIN0001916701
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,707.00
514.00
471.00
0.00
4,236.00
2001
0001916704.01
MASROH
IMKIN0001916704
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,915.00
5,422.00
592.00
543.00
0.00
4,879.00
2002
0001916704.03
TEUKU MUTTAQIN
IMKIN0001916704
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
9,230.00
8,461.00
923.00
846.00
0.00
7,615.00
2003
0001916715.01
HASRUL
IMKIN0001916715
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2004
0001916716.01
NOVI ARIANTI
IMKIN0001916716
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2005
0001916716.03
WIRA ROSANDI
IMKIN0001916716
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2006
0001916843
DOVI KORNIAWAN
IMKIN0001916843
15.02.2012
15.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2007
0001916843.01
DOVI KORNIAWAN
IMKIN0001916843
15.02.2012
15.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2008
0001916869.01
ADRI ABRAR
IMKIN0001916869
09.02.2012
09.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2009
0001916983.01
YULIYONO
IMKIN0001916983
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2010
0001916985.01
ETI SETIAWATI
IMKIN0001916985
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
9,230.00
8,461.00
923.00
846.00
0.00
7,615.00
2011
0001916985.03
IMKIN0001916985
MOHAMMAD THARIQ D
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
7,670.00
7,031.00
767.00
703.00
0.00
6,328.00
2012
0001916993.01
IMKIN0001916993
RADITYA EKA PRASETIA
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2013
0001916997.01
SURYA JAYA
IMKIN0001916997
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2014
0001917009.01
IMRON FAISAL
IMKIN0001917009
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
5,065.00
553.00
507.00
0.00
4,558.00
2015
0001917009.03
WINDY HERNITA
IMKIN0001917009
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
4,290.00
468.00
429.00
0.00
3,861.00
2016
0001917019.01
TEDY RUSMANA
IMKIN0001917019
11.02.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2017
0001917021
DASRI PURWANTO
IMKIN0001917021
11.02.2012
11.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2018
0001917093.01
CAESAR PANDU P
IMKIN0001917093
10.02.2012
10.04.2012
01
HSBCPP
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2019
0001917098.01
IRVAN FAUZI
IMKIN0001917098
09.02.2012
09.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2020
0001917119
JOKO PRIYADI
IMKIN0001917119
13.02.2012
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 106
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2021
0001917132.01
ASMAT
IMKIN0001917132
13.02.2012
13.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
17,875.00
16,385.00
1,788.00
1,639.00
0.00
14,746.00
2022
0001917205.01
DIDI SUPRIHADI
IMKIN0001917205
14.02.2012
14.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2023
0001917778.01
HENDRO SUSILO
IMKIN0001917778
14.02.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2024
0001917781.01
IMKIN0001917781
ANDRA MEGA PUTRA LENGKEI
14.02.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2025
0001917781.03
IMKIN0001917781
WIWI SULISTYOWATI LENGKEI
14.02.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2026
0001917790
DWI HARIATI
IMKIN0001917790
14.02.2012
14.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2027
0001917790.01
NUR HARIANTO
IMKIN0001917790
14.02.2012
14.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2028
0001917792.01
M. WAHYU SOEGITO
IMKIN0001917792
14.02.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
7,020.00
6,435.00
702.00
644.00
0.00
5,791.00
2029
0001917792.03
IMKIN0001917792
NANCY ANGELA HENDRIKS
14.02.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2030
0001917811.01
I GEDE OKA WINAYA
IMKIN0001917811
15.02.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
4,290.00
468.00
429.00
0.00
3,861.00
2031
0001917811.03
IMKIN0001917811
NI KETUT PURNAMA WATI
15.02.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,707.00
514.00
471.00
0.00
4,236.00
2032
0001918405.01
MOCHAMMAD USMAN
IMKIN0001918405
14.02.2012
14.03.2012
01
MANGPL
200,000,000.00
200,000,000.00 2012
216,000.00
198,000.00
21,600.00
19,800.00
0.00
178,200.00
2033
0001918412
SYARIFAH MAIRIZA
IMKIN0001918412
14.02.2012
14.03.2012
01
HSBTLC
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2034
0001918602.01
MAMAN BIN H MISIN
IMKIN0001918602
07.02.2012
07.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2035
0001918602.03
NITA
IMKIN0001918602
07.02.2012
07.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2036
0001918617.01
EKO BUDIONO
IMKIN0001918617
07.02.2012
07.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
2037
0001918623.01
ANAS
IMKIN0001918623
07.02.2012
07.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2038
0001918623.03
RASYIDHA
IMKIN0001918623
07.02.2012
07.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2039
0001918627.01
KUNTJORO
IMKIN0001918627
07.02.2012
07.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2040
0001918627.03
IMKIN0001918627
SRI SUSILOWATI DEWI
07.02.2012
07.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2041
0001918717.01
IMKIN0001918717
RHIMO BUDI SANTOSO
09.02.2012
09.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 107
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
2042
0001918719.01
NORCHOLIFAH
IMKIN0001918719
09.02.2012
09.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,413.00
455.00
341.00
0.00
3,072.00
2043
0001918760.01
IMKIN0001918760
RITA ERNAWATI SIANTURI
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2044
0001918772.01
SOPANDI
IMKIN0001918772
10.02.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2045
0001918790.01
HENI MEDAWATI
IMKIN0001918790
10.02.2012
10.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2046
0001918808.01
SUPRINGGO
IMKIN0001918808
10.02.2012
10.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2047
0001918815.01
CHOIRIYAH
IMKIN0001918815
11.02.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2048
0001918824.01
IMKIN0001918824
CHRISTYA FERONIATEE
11.02.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
5,839.00
637.00
584.00
0.00
5,255.00
2049
0001918832.01
BURHANUDIN
IMKIN0001918832
11.02.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2050
0001918834.01
CUCUP B KATMA
IMKIN0001918834
11.02.2012
11.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
3,510.00
468.00
351.00
0.00
3,159.00
2051
0001918845.01
PINAN
IMKIN0001918845
11.02.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
5,065.00
553.00
507.00
0.00
4,558.00
2052
0001918851.01
MASLINA
IMKIN0001918851
11.02.2012
11.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2053
0001919286
MALEMTA SIHOTANG
IMKIN0001919286
17.02.2012
17.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2054
0001919286.01
MALEMTA SIHOTANG
IMKIN0001919286
17.02.2012
17.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2055
0001919288
IMKIN0001919288
SURYAWAN,I KOMANG
17.02.2012
17.05.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2056
0001919288.01
IMKIN0001919288
SURYAWAN,I KOMANG
17.02.2012
17.05.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2057
0001919621.01
ABDUL PASIANGAN
IMKIN0001919621
16.02.2012
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
14,040.00
12,870.00
1,404.00
1,287.00
0.00
11,583.00
2058
0001919621.03
IMKIN0001919621
LIFTA LISU KARAMPOAN
16.02.2012
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2059
0001919633.01
ELLY NOVI ASTUTI
IMKIN0001919633
16.02.2012
16.05.2012
01
HSBCPP
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2060
0001919640
MARIATIE
IMKIN0001919640
16.02.2012
16.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2061
0001919642.01
IMKIN0001919642
GERRIT STEFANUS PATTIWAEL .
16.02.2012
16.05.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2062
0001919754.01
FARIDAH
17.02.2012
17.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
9,230.00
8,461.00
923.00
846.00
0.00
7,615.00
IMKIN0001919754
SUM ASSURED
NON POOL


NO : 01105/II/2012/01
: 108
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2063
0001919828.01
PUJI WALUYO
IMKIN0001919828
18.02.2012
18.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2064
0001919832.01
IMKIN0001919832
GEDE MAHENDRA JAYA
18.02.2012
18.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,915.00
4,929.00
592.00
493.00
0.00
4,436.00
2065
0001919835
KARNILA WATI
IMKIN0001919835
20.02.2012
20.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2066
0001919856
IMKIN0001919856
AHMAD ARIP ERWANSYAH
20.02.2012
20.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2067
0001919877
IMKIN0001919877
AGUSTINUS KURNIAWAN
13.02.2012
13.03.2012
01
PMCSHP
75,000,000.00
75,000,000.00 2012
117,000.00
107,250.00
11,700.00
10,725.00
0.00
96,525.00
2068
0001919877.01
IMKIN0001919877
ANGELINE EKA FENTIE
13.02.2012
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2069
0001919877.02
LINA SAPTAWATI
IMKIN0001919877
13.02.2012
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2070
0001919902
IMKIN0001919902
LIE KIEM LIAM/R. SUMADI, BA
16.02.2012
16.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2071
0001919904
PANCE PERNANDO
IMKIN0001919904
17.02.2012
17.02.2012
01
BCASHP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2072
0001919913
IMKIN0001919913
HJ.ANDI MASJARNI P.M.
17.02.2012
17.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2073
0001919914
IMKIN0001919914
ABDUL KHALIM ROMADHON
17.02.2012
17.03.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2074
0001919970.01
IGA AGUNG UTAMI Y
IMKIN0001919970
17.02.2012
17.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2075
0001919981.01
YUDI MUDJIONO
IMKIN0001919981
18.02.2012
18.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
4,707.00
514.00
471.00
0.00
4,236.00
2076
0001920003
IMKIN0001920003
HANDYAS ARIF SAPUTRA
03.02.2012
03.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2077
0001920017
ERLY DAMAYANTI
IMKIN0001920017
08.02.2012
08.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2078
0001920022
HENNY NOVITASARI
IMKIN0001920022
10.02.2012
10.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2079
0001920039.01
HELIANA NOVIANTI
IMKIN0001920039
18.02.2012
18.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2080
0001920222.01
IMKIN0001920222
REY RIZKY RAMADANI
21.02.2012
21.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,680.00
4,290.00
468.00
429.00
0.00
3,861.00
2081
0001920223.01
DICKY ARNANDA
IMKIN0001920223
21.02.2012
21.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
7,020.00
6,435.00
702.00
644.00
0.00
5,791.00
2082
0001920647
IMKIN0001920647
I KETUT MAHATMA ADITYA S
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2083
0001920647.01
IMKIN0001920647
I KOMANG SENTANU ADI P
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 109
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
2084
0001920647.02
I NENGAH DANU
IMKIN0001920647
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2085
0001920647.03
IMKIN0001920647
NI KADEK KRISNA P DEWI
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2086
0001920647.04
IMKIN0001920647
NI PUTU SARAS P DEWI
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2087
0001920647.05
NI WAYAN SUWATRI
IMKIN0001920647
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2088
0001920649.01
I NENGAH DANU
IMKIN0001920649
22.02.2012
22.03.2012
01
PMTBPS
6,500,000.00
6,500,000.00 2012
10,140.00
9,295.00
1,014.00
930.00
0.00
8,365.00
2089
0001921016.01
TRIE LESTARI
IMKIN0001921016
22.02.2012
22.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2090
0001921031.01
ZAENI
IMKIN0001921031
23.02.2012
23.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
5,839.00
637.00
584.00
0.00
5,255.00
2091
0001921032.01
ZULIYATNO
IMKIN0001921032
23.02.2012
23.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2092
0001921300
AGUS NURAJI
IMKIN0001921300
23.02.2012
23.04.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2093
0001921541
IMKIN0001921541
BAYU WICAKSANA SATRIEYA
23.02.2012
23.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2094
0001921542
ERLENI
IMKIN0001921542
17.02.2012
17.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2095
0001921688
CENDY WIJAYA
IMKIN0001921688
09.02.2012
09.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2096
0001921698
MAHMUD YANI
IMKIN0001921698
08.02.2012
08.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2097
0001921707
SYLVIA YOLANDA
IMKIN0001921707
21.02.2012
21.03.2012
01
HSBTLC
30,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2098
0001921721
A N NURAEN
IMKIN0001921721
23.02.2012
27.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2099
0001921721.01
A N NURAEN
IMKIN0001921721
23.02.2012
27.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2100
0001921758.01
SRI NURJIWATI
IMKIN0001921758
13.02.2012
13.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
10,140.00
9,295.00
1,014.00
930.00
0.00
8,365.00
2101
0001921784.01
SUPRIATINI
IMKIN0001921784
13.02.2012
13.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
5,065.00
553.00
507.00
0.00
4,558.00
2102
0001921794.01
IMKIN0001921794
DWI BUDIAWAN ASMARA
14.02.2012
14.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2103
0001921813.01
IMKIN0001921813
HANHAN SUBHANUDIN
14.02.2012
14.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2104
0001921813.03
MERY SEBASTIANI AD
14.02.2012
14.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001921813
SUM ASSURED
NON POOL


NO : 01105/II/2012/01
: 110
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2105
0001921856.01
HADIJAH
IMKIN0001921856
14.02.2012
14.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2106
0001921862.01
DJUMASNA
IMKIN0001921862
15.02.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
5,065.00
553.00
507.00
0.00
4,558.00
2107
0001921869.01
SURATNO
IMKIN0001921869
15.02.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2108
0001921873.01
IMKIN0001921873
LUKI FAISAL ADITIA SUSANTO
15.02.2012
15.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2109
0001921878.01
IMKIN0001921878
TANU SRIWIDJAJA THIO
15.02.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
5,839.00
637.00
584.00
0.00
5,255.00
2110
0001921892.01
MUJAROAH
IMKIN0001921892
15.02.2012
15.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2111
0001921896.01
IMKIN0001921896
HENDRIK NAPITUPULU
15.02.2012
15.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2112
0001921902.01
DWI SUWARSIH
IMKIN0001921902
15.02.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2113
0001921913.01
IMKIN0001921913
DIAN RETNO MURTI NINGRUM
16.02.2012
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2114
0001921919.01
YULI TRI MARYANI
IMKIN0001921919
16.02.2012
16.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2115
0001921929.01
MUKARROMAH
IMKIN0001921929
16.02.2012
16.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2116
0001921929.03
MULYADI
IMKIN0001921929
16.02.2012
16.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2117
0001921953.01
MUHAMAD SOLIHIN
IMKIN0001921953
20.02.2012
20.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
2118
0001921971.01
RAHMAT MINARTO
IMKIN0001921971
20.02.2012
20.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
2119
0001921983.01
IMKIN0001921983
RL FRANSISKA NATALIA
20.02.2012
20.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2120
0001922015.01
IMKIN0001922015
HANIEL ONESIMUS LARAT
21.02.2012
21.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
5,065.00
553.00
507.00
0.00
4,558.00
2121
0001922021.01
DENI STEPANUS AMD
IMKIN0001922021
21.02.2012
21.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
8,385.00
6,289.00
839.00
629.00
0.00
5,660.00
2122
0001922046.01
SRI REDJEKI
IMKIN0001922046
22.02.2012
22.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
25,480.00
23,357.00
2,548.00
2,336.00
0.00
21,021.00
2123
0001922062
SARI RUHENI ASIH
IMKIN0001922062
13.02.2012
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2124
0001922062.01
IMKIN0001922062
YOSSY ELHAM KHUSJANA B R
13.02.2012
13.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2125
0001922064
ILHAMSYAH
14.02.2012
14.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001922064


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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2126
0001922077
MOKHAMAD SAHLAN
IMKIN0001922077
22.02.2012
22.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2127
0001922078
IMKIN0001922078
EDWARD TAUFIQ RACHMAN A.
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2128
0001922168
ALICE INDRA
IMKIN0001922168
10.02.2012
10.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2129
0001922250
IMKIN0001922250
NAZARULLAH JAMALUDDIN
17.02.2012
17.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2130
0001922436
IMKIN0001922436
DIAN PUTRA PERDANA
22.02.2012
22.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2131
0001922531
IMKIN0001922531
PURNAMA ADHIPUTRA
20.02.2012
20.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2132
0001922575
YULIANTI LIU
IMKIN0001922575
21.02.2012
21.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2133
0001922681
NORFAN A
IMKIN0001922681
16.02.2012
16.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2134
0001922696
ANEKE SONDAKH
IMKIN0001922696
07.02.2012
07.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2135
0001922699
T FUAD BEY
IMKIN0001922699
20.02.2012
20.05.2012
01
BNIJBA
105,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2136
0001922713
RAUDAH FITRIANA
IMKIN0001922713
14.02.2012
14.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2137
0001922720
TARMIZI
IMKIN0001922720
08.02.2012
08.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2138
0001922776
YATI ROSYATI
IMKIN0001922776
22.02.2012
22.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2139
0001922780
YENI FATMAWATI H
IMKIN0001922780
24.02.2012
27.05.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2140
0001922780.01
YENI FATMAWATI H
IMKIN0001922780
24.02.2012
27.05.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2141
0001922946
KHAMIM
IMKIN0001922946
24.02.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2142
0001922953
DENI MUHARAM
IMKIN0001922953
24.02.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2143
0001922953.01
ICA APRILIANA
IMKIN0001922953
24.02.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2144
0001922953.02
KADARISMAN
IMKIN0001922953
24.02.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2145
0001922953.03
MUSRIFAH
IMKIN0001922953
24.02.2012
24.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2146
0001922997.01
AMAT USUF
IMKIN0001922997
25.02.2012
25.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 112
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
NO.
CERT. NO.
2147
0001923014.01
AGNI SAPTARINI
IMKIN0001923014
24.02.2012
24.05.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2148
0001923015.01
RIZALDY PUTRA
IMKIN0001923015
25.02.2012
25.05.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2149
0001923025.01
JUSTIAN SALIM .
IMKIN0001923025
24.02.2012
24.04.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2150
0001923031.01
IMKIN0001923031
YUDO ADRY RUMAYAR
24.02.2012
24.04.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2151
0001923154
IMKIN0001923154
MUBARAK YASIR ANDI M.
23.02.2012
23.03.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2152
0001923173
IMKIN0001923173
ARIMBI MASNUN BASRI
24.02.2012
24.05.2012
01
BNIJBA
140,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2153
0001923606
IMKIN0001923606
NANDANG HERMANSYAH
01.03.2012
01.05.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2154
0001923656.01
MULIYONO
IMKIN0001923656
01.03.2012
01.05.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
70,000.00
58,333.00
7,000.00
5,833.00
0.00
52,500.00
2155
0001923671
HELMI NUR EFENDI
IMKIN0001923671
01.03.2012
01.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2156
0001923682.01
ZESAR KAEMONG
IMKIN0001923682
01.03.2012
01.03.2012
01
BNIDRD
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2157
0001924051
MARYONO
IMKIN0001924051
01.03.2012
01.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2158
0001924055
LIM HIE KIONG
IMKIN0001924055
01.03.2012
01.03.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2159
0001924385
IMKIN0001924385
TEGUH AGUNG SAPUTRO
01.03.2012
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2160
0001924388
IMKIN0001924388
ADITYO HARYONUGROHO
01.03.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2161
0001924517
HENDRA
IMKIN0001924517
01.03.2012
01.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2162
0001924537
ILYAS MAARIF
IMKIN0001924537
01.03.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2163
0001924566
EUIS AISYAH
IMKIN0001924566
02.03.2012
02.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2164
0001924573
YUSUP MAULANA
IMKIN0001924573
02.03.2012
02.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2165
0001925019
IMKIN0001925019
BAMBANG AGUNG SUSILO
06.03.2012
06.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2166
0001925132.01
I GEDE SUARSA
IMKIN0001925132
07.03.2012
07.03.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2167
0001925189
IRVAN MULYANA
IMKIN0001925189
01.03.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2168
0001925193
IG DAVID VIRGIAWAN
IMKIN0001925193
01.03.2012
01.03.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2169
0001925750.01
RITA ZAHARA DRA
IMKIN0001925750
07.03.2012
07.03.2012
01
BNIDRR
105,000,000.00
10,000,000.00 2012
49,800.00
49,800.00
4,980.00
4,980.00
0.00
44,820.00
2170
0001926216.01
NENO
IMKIN0001926216
01.03.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
2171
0001926277.01
ELPRANDO TANJUNG
IMKIN0001926277
01.03.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
2172
0001926369.01
RUMINI
IMKIN0001926369
01.03.2012
01.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2173
0001926375.01
HENDRO SAPUTRO
IMKIN0001926375
02.03.2012
02.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2174
0001926416.01
RIRIN DEWI ARDIANTI
IMKIN0001926416
05.03.2012
05.05.2012
01
CIGSRN
400,000,000.00
400,000,000.00 2012
316,000.00
263,333.00
31,600.00
26,333.00
0.00
237,000.00
2175
0001926563
BUDI DJAUHARI T
IMKIN0001926563
03.03.2012
03.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2176
0001926825
WAHONO
IMKIN0001926825
09.03.2012
09.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2177
0001926843.01
DIPI
IMKIN0001926843
10.03.2012
10.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2178
0001926891.01
NANY
IMKIN0001926891
01.03.2012
01.05.2012
01
HSBCPP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2179
0001927436
IMKIN0001927436
SATRIYO HERU IRAWAN
12.03.2012
12.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2180
0001927436.01
IMKIN0001927436
SATRIYO HERU IRAWAN
12.03.2012
12.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2181
0001927438
SITI AMINAH
IMKIN0001927438
01.03.2012
01.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2182
0001927438.01
SITI AMINAH
IMKIN0001927438
01.03.2012
01.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2183
0001927445
IRWANTO
IMKIN0001927445
12.03.2012
12.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2184
0001927445.01
IRWANTO
IMKIN0001927445
12.03.2012
12.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2185
0001927455
WARTINI
IMKIN0001927455
07.03.2012
07.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2186
0001927455.01
WARTINI
IMKIN0001927455
07.03.2012
07.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2187
0001927457
SUMARNO
IMKIN0001927457
12.03.2012
12.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2188
0001927457.01
SUMARNO
IMKIN0001927457
12.03.2012
12.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 114
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2189
0001927462
WIHARTA
IMKIN0001927462
08.03.2012
08.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2190
0001927462.01
WIHARTA
IMKIN0001927462
08.03.2012
08.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2191
0001928314
ATIK WULANDARI
IMKIN0001928314
09.03.2012
09.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2192
0001928314.01
ATIK WULANDARI
IMKIN0001928314
09.03.2012
09.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2193
0001928332
ANDRI GUNAWAN
IMKIN0001928332
05.03.2012
05.05.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2194
0001928400
SUYATNO
IMKIN0001928400
13.03.2012
13.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2195
0001928400.01
SUYATNO
IMKIN0001928400
13.03.2012
13.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2196
0001928789
MINARNO
IMKIN0001928789
16.03.2012
03.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2197
0001928789.01
MINARNO
IMKIN0001928789
16.03.2012
03.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2198
0001928790
ROHADI ADENAN
IMKIN0001928790
16.03.2012
16.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2199
0001928790.01
ROHADI ADENAN
IMKIN0001928790
16.03.2012
16.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2200
0001928791
MUSLIM
IMKIN0001928791
12.03.2012
12.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2201
0001928791.01
MUSLIM
IMKIN0001928791
12.03.2012
12.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2202
0001928792
WAHYU HANDOKO
IMKIN0001928792
16.03.2012
16.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2203
0001928792.01
WAHYU HANDOKO
IMKIN0001928792
16.03.2012
16.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2204
0001928961
EDDY FIRNANDA
IMKIN0001928961
16.03.2012
16.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2205
0001928961.01
EDDY FIRNANDA
IMKIN0001928961
16.03.2012
16.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2206
0001929075
DYANE SUBEKTI
IMKIN0001929075
20.03.2012
20.03.2012
01
IMCGLP
500,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2207
0001929305.01
SUPRANOWO
IMKIN0001929305
08.03.2012
08.03.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2208
0001929340.01
AGUS BUDIARTO
IMKIN0001929340
08.03.2012
21.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2209
0001929451.01
IMKIN0001929451
ADE INDRAYANI UDJUDEDA
09.03.2012
09.03.2012
01
CIGSRN
400,000,000.00
300,000,000.00 2012
267,000.00
267,000.00
26,700.00
26,700.00
0.00
240,300.00


NO : 01105/II/2012/01
: 115
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2210
0001929452.01
ROSYIDAH RAHMAH
IMKIN0001929452
09.03.2012
01.05.2012
01
CIGSRN
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2211
0001930575
ASEP SHOLIHIN
IMKIN0001930575
20.03.2012
20.03.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2212
0001930575.01
ASEP SHOLIHIN
IMKIN0001930575
20.03.2012
20.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2213
0001930579
ALI IMRON SUSANTO
IMKIN0001930579
16.03.2012
03.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2214
0001930579.01
ALI IMRON SUSANTO
IMKIN0001930579
16.03.2012
03.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2215
0001930584
DINAR JANUARINI
IMKIN0001930584
22.03.2012
22.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2216
0001930584.01
DINAR JANUARINI
IMKIN0001930584
22.03.2012
22.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2217
0001930586
T SUWARTONO
IMKIN0001930586
19.03.2012
19.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2218
0001930586.01
T SUWARTONO
IMKIN0001930586
19.03.2012
19.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2219
0001931652
AMIRUDDIN HIDAYAT
IMKIN0001931652
12.03.2012
12.03.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2220
0001931652.01
AMIRUDDIN HIDAYAT
IMKIN0001931652
12.03.2012
12.03.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2221
0001931805.01
TUSYADI
IMKIN0001931805
14.03.2012
14.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2222
0001931905.01
IMKIN0001931905
LUH GDE EKA WISMITA
15.03.2012
15.03.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2223
0001931995.01
HERAWATI
IMKIN0001931995
15.03.2012
15.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
3,792.00
455.00
379.00
0.00
3,413.00
2224
0001932072
MUKTI BIANTI
IMKIN0001932072
17.03.2012
17.05.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2225
0001932363
SYAMSUL BAHRI
IMKIN0001932363
21.03.2012
21.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2226
0001932383
IMKIN0001932383
GREGORIUS YORA LAKSO SETIYONO
21.03.2012
21.05.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2227
0001932518
AGUS SUPRIANTO
IMKIN0001932518
21.03.2012
26.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2228
0001932518.01
AGUS SUPRIANTO
IMKIN0001932518
21.03.2012
26.04.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2229
0001932714
IMKIN0001932714
BISUK SHINDORO HADIARTO
27.03.2012
27.03.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2230
0001932714.01
IMKIN0001932714
BISUK SHINDORO HADIARTO
27.03.2012
27.03.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 116
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2231
0001932718
IMKIN0001932718
DIDIK PRASETYO HADI
27.03.2012
03.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2232
0001932718.01
IMKIN0001932718
DIDIK PRASETYO HADI
27.03.2012
03.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2233
0001932817
HAMIDAHTUR RAHMI
IMKIN0001932817
26.03.2012
26.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2234
0001932921
IMKIN0001932921
ERWINA IRIANI MAWUNTU
05.03.2012
05.05.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2235
0001932933
ZULYADI
IMKIN0001932933
05.03.2012
05.03.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2236
0001933032
JUNAIDI
IMKIN0001933032
01.04.2012
01.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2237
0001933064
MARTINI
IMKIN0001933064
01.04.2012
01.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2238
0001933111
IMKIN0001933111
ARIEF RAHMAN SYAHPUTRA N SH
01.04.2012
01.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2239
0001933464.01
NENNI NURAENI
IMKIN0001933464
03.04.2012
03.04.2012
01
BNIDRD
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2240
0001933466.01
SISKA AMELIA
IMKIN0001933466
03.04.2012
03.04.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2241
0001934105
LISTRI NURJANAH
IMKIN0001934105
09.04.2012
09.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2242
0001934105.01
LISTRI NURJANAH
IMKIN0001934105
09.04.2012
09.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2243
0001934519
YUSUF ISNAINI
IMKIN0001934519
01.04.2012
02.05.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2244
0001934519.01
YUSUF ISNAINI
IMKIN0001934519
01.04.2012
02.05.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2245
0001934572.01
AGUSRIZAL SE
IMKIN0001934572
04.04.2012
04.04.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
118,000.00
118,000.00
11,800.00
11,800.00
0.00
106,200.00
2246
0001934574.01
ARISWANA
IMKIN0001934574
04.04.2012
04.04.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2247
0001934584.01
IMKIN0001934584
EVI JULINDA SINULINGGA
04.04.2012
04.05.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
70,000.00
64,167.00
7,000.00
6,417.00
0.00
57,750.00
2248
0001934591.01
TJHEN HONG FONG
IMKIN0001934591
04.04.2012
04.04.2012
01
BNIDRD
150,000,000.00
110,000,000.00 2012
77,000.00
77,000.00
7,700.00
7,700.00
0.00
69,300.00
2249
0001934601.01
DJONI HERU WIBOWO
IMKIN0001934601
05.04.2012
05.04.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
275,000.00
275,000.00
27,500.00
27,500.00
0.00
247,500.00
2250
0001934613
IMKIN0001934613
RITA DEAR MARIANI MANURUNG
04.04.2012
03.05.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2251
0001934613.01
IMKIN0001934613
RITA DEAR MARIANI MANURUNG
04.04.2012
03.05.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 117
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2252
0001935643
NOR KOMALA DEWI
IMKIN0001935643
05.04.2012
05.04.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2253
0001935649.01
NURHAYATI
IMKIN0001935649
05.04.2012
05.04.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2254
0001935667
FREDY BALAPADANG
IMKIN0001935667
27.04.2012
27.04.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2255
0001935667.01
FREDY BALAPADANG
IMKIN0001935667
27.04.2012
27.04.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2256
0001935674
NOVI DIANA
IMKIN0001935674
11.04.2012
11.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2257
0001935674.01
NOVI DIANA
IMKIN0001935674
11.04.2012
11.04.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2258
0001936078
IMKIN0001936078
GUNAWAN AGUS PRIYANTO
10.04.2012
10.04.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2259
0001936091
AWAN RISWANDI
IMKIN0001936091
10.04.2012
10.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2260
0001936515
AKHMAD BASUKI
IMKIN0001936515
04.04.2012
04.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2261
0001936599
INDAYANI
IMKIN0001936599
07.04.2012
07.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2262
0001936841
IMKIN0001936841
KASLAN EFENRI SIMANJUNTAK
13.04.2012
13.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2263
0001936841.01
IMKIN0001936841
KASLAN EFENRI SIMANJUNTAK
13.04.2012
13.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2264
0001936849
AMINUDDIN
IMKIN0001936849
13.04.2012
13.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2265
0001936849.01
AMINUDDIN
IMKIN0001936849
13.04.2012
13.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2266
0001936859
M. RIDHO PURNOMO
IMKIN0001936859
13.04.2012
13.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2267
0001936859.01
M. RIDHO PURNOMO
IMKIN0001936859
13.04.2012
13.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2268
0001936860
SALMAN AL FARISI
IMKIN0001936860
13.04.2012
13.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2269
0001936860.01
SALMAN AL FARISI
IMKIN0001936860
13.04.2012
13.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2270
0001936865
SAEPUL HUSNA
IMKIN0001936865
13.04.2012
13.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2271
0001936865.01
SAEPUL HUSNA
IMKIN0001936865
13.04.2012
13.04.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2272
0001936866
SEPTI SETYIO HADI
IMKIN0001936866
13.04.2012
13.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 118
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
2273
0001936866.01
SEPTI SETYIO HADI
IMKIN0001936866
13.04.2012
13.04.2012
01
NISINP
2274
0001937008.01
WITRI YANTI
IMKIN0001937008
04.04.2012
04.05.2012
01
2275
0001937175.01
INDRA SAPUTRA
IMKIN0001937175
07.04.2012
07.04.2012
2276
0001937201.01
NOVIANTI
IMKIN0001937201
07.04.2012
2277
0001937241.01
LESTARI WIDAYATI
IMKIN0001937241
2278
0001937273.01
RIWANTI
2279
0001937275.01
RIKA A GULTOM
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,171.00
455.00
417.00
0.00
3,754.00
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
07.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
7,670.00
7,670.00
767.00
767.00
0.00
6,903.00
01.04.2012
01.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001937273
01.04.2012
01.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,525.00
5,525.00
553.00
553.00
0.00
4,972.00
IMKIN0001937275
01.04.2012
01.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
28,600.00
28,600.00
2,860.00
2,860.00
0.00
25,740.00
2280
0001937277.01
IMKIN0001937277
FUTU WIJAYA PUJI PUTRA
01.04.2012
01.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2281
0001937284.01
HAIDER
IMKIN0001937284
01.04.2012
01.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2282
0001937286.01
YULIANTI HIDAYAT
IMKIN0001937286
01.04.2012
01.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
25,480.00
25,480.00
2,548.00
2,548.00
0.00
22,932.00
2283
0001937308.01
EKA ROSADI
IMKIN0001937308
01.04.2012
01.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2284
0001937490
IMKIN0001937490
CHRESOLITA WIBAWA
09.04.2012
09.04.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2285
0001937679
IMKIN0001937679
PRASETYANI SUCI PURBO PUTRI
11.04.2012
11.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2286
0001937760.01
SUEB
IMKIN0001937760
11.04.2012
11.04.2012
01
BNIDRD
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2287
0001937762.01
MOCHAMAD SYAFI I
IMKIN0001937762
12.04.2012
12.04.2012
01
BNIDRD
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2288
0001937763.01
ABD FATTAH
IMKIN0001937763
12.04.2012
12.04.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
85,000.00
85,000.00
8,500.00
8,500.00
0.00
76,500.00
2289
0001937990
IMKIN0001937990
JUSNIAR RUMADIANTO
10.04.2012
10.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2290
0001938212.01
DIRHAMSYAH RIVAI
IMKIN0001938212
14.04.2012
14.04.2012
01
BNIDRD
150,000,000.00
100,000,000.00 2012
156,000.00
156,000.00
15,600.00
15,600.00
0.00
140,400.00
2291
0001939034
ZULKARNAIN
IMKIN0001939034
18.04.2012
18.04.2012
01
BNIJBX
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2292
0001939497
IMKIN0001939497
LIBERT BUTAR BUTAR
19.04.2012
19.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2293
0001939840
AGUNG RAHADI
13.04.2012
13.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001939840


NO : 01105/II/2012/01
: 119
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2294
0001939971
AKHMAD SUSANTO
IMKIN0001939971
12.04.2012
12.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2295
0001940059
M IAN NURDIANSYAH
IMKIN0001940059
18.04.2012
18.04.2012
01
HSBTLC
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2296
0001940075
RUPIYANTO
IMKIN0001940075
24.04.2012
24.04.2012
01
NISINP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2297
0001940075.01
RUPIYANTO
IMKIN0001940075
24.04.2012
24.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2298
0001940076
SOPINAH
IMKIN0001940076
24.04.2012
24.04.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2299
0001940076.01
SOPINAH
IMKIN0001940076
24.04.2012
24.04.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2300
0001940082
NURMELIA IHYANDA
IMKIN0001940082
24.04.2012
24.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2301
0001940082.01
NURMELIA IHYANDA
IMKIN0001940082
24.04.2012
24.04.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2302
0001940093
IMAN SANTOSA
IMKIN0001940093
27.04.2012
27.04.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2303
0001940093.01
IMAN SANTOSA
IMKIN0001940093
27.04.2012
27.04.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2304
0001940115.01
KYLIE ICAVIA
IMKIN0001940115
09.04.2012
09.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2305
0001940135.01
IMKIN0001940135
OKTAVIANI FRIDAYANTI SPT
09.04.2012
09.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2306
0001940230.01
IMKIN0001940230
RAMDAN FIRMANSYAH
12.04.2012
12.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2307
0001940245.01
IMKIN0001940245
NANANG GUSMAN FACHRUROZI
13.04.2012
13.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2308
0001940311.01
MAMAT
IMKIN0001940311
14.04.2012
14.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
5,135.00
5,135.00
514.00
514.00
0.00
4,621.00
2309
0001940340.01
IMKIN0001940340
NI LUH PUTU YULIANTINI
14.04.2012
14.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2310
0001940351.01
NI NENGAH SATRIANI
IMKIN0001940351
14.04.2012
14.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2311
0001940362.01
ABDUL ROHMAN
IMKIN0001940362
14.04.2012
14.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2312
0001940371
FELEX BILLI PRADETA
IMKIN0001940371
09.04.2012
09.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2313
0001940374
ARIF RACHMAN
IMKIN0001940374
10.04.2012
10.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2314
0001940377
TJIOE SUNARTI
IMKIN0001940377
10.04.2012
10.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
Quarter 2012
PAGE
: 120
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
NO.
CERT. NO.
2315
0001940383
BAYU SRILANTO
IMKIN0001940383
12.04.2012
12.04.2012
01
PMCSHP
2316
0001940498
YANTY
IMKIN0001940498
16.04.2012
16.04.2012
01
2317
0001940520
DEWI RAHAYU
IMKIN0001940520
18.04.2012
18.04.2012
2318
0001940725
YOGIE PRABOWO
IMKIN0001940725
12.04.2012
2319
0001940792
WARDI
IMKIN0001940792
2320
0001940812.01
NENG IDA
2321
0001940897.01
WULANDARI
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
12.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
11.04.2012
11.04.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001940812
12.04.2012
12.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
IMKIN0001940897
23.04.2012
23.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
6,370.00
637.00
637.00
0.00
5,733.00
2322
0001940945
IMKIN0001940945
HARTO SUBROTO YUWONO
19.04.2012
19.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2323
0001940969
MELAWATI
IMKIN0001940969
20.04.2012
20.04.2012
01
BCASHP
20,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2324
0001940977
MARIANA
IMKIN0001940977
20.04.2012
20.04.2012
01
BCASHP
10,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2325
0001941176.01
UMAN WIBOWO
IMKIN0001941176
16.04.2012
16.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2326
0001941204.01
ROEKIMAN
IMKIN0001941204
16.04.2012
16.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
44,850.00
44,850.00
4,485.00
4,485.00
0.00
40,365.00
2327
0001941211.01
SRIYONO
IMKIN0001941211
16.04.2012
16.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2328
0001941215.01
IMKIN0001941215
ELI PANGESTINING WIDHIASIH SE
16.04.2012
16.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2329
0001941217.01
RAHMAT HIDAYAT
IMKIN0001941217
16.04.2012
10.05.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2330
0001941230.01
IRWAN SETIAWAN
IMKIN0001941230
17.04.2012
17.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2331
0001941257.01
IMKIN0001941257
RIO GUNAWAN PRATAMA
17.04.2012
17.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2332
0001941309.01
GIYATMI
IMKIN0001941309
20.04.2012
20.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2333
0001941316.01
ARTA JAYA
IMKIN0001941316
20.04.2012
20.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2334
0001941329
EUIS ERMAYANI
IMKIN0001941329
16.04.2012
16.04.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2335
0001941338
RADIH KUSWARA
IMKIN0001941338
17.04.2012
17.04.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 121
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2336
0001941339
RENDY EKA SAPUTRA
IMKIN0001941339
17.04.2012
17.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2337
0001941343
SYAMSUL ANAM
IMKIN0001941343
19.04.2012
19.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2338
0001941346
JOKO SURYANTO
IMKIN0001941346
19.04.2012
19.04.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2339
0001941350
ARI YANTY
IMKIN0001941350
20.04.2012
20.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2340
0001941535.01
NENI SRIHAYATIN
IMKIN0001941535
18.04.2012
18.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
6,370.00
6,370.00
637.00
637.00
0.00
5,733.00
2341
0001941629
HERMANSES WP BA
IMKIN0001941629
24.04.2012
24.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2342
0001941677
ERYANTI .
IMKIN0001941677
24.04.2012
24.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2343
0001941721
SITI ANISAH
IMKIN0001941721
26.04.2012
26.04.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2344
0001941721.01
SITI ANISAH
IMKIN0001941721
26.04.2012
26.04.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2345
0001941816
SUPRIYO
IMKIN0001941816
27.04.2012
27.04.2012
01
NISINP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2346
0001941816.01
SUPRIYO
IMKIN0001941816
27.04.2012
27.04.2012
01
NISINP
48,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2347
0001942130
ZAENAL ABIDIN
IMKIN0001942130
26.04.2012
26.04.2012
01
BNIJBX
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2348
0001942401.01
HERYANTO
IMKIN0001942401
23.04.2012
23.04.2012
01
PMTBPL
5,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2349
0001942411.01
KOMANG ANTARA
IMKIN0001942411
23.04.2012
23.04.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2350
0001942523
YANNA
IMKIN0001942523
24.04.2012
24.04.2012
01
PMCSHP
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2351
0001942534
WATUNI
IMKIN0001942534
25.04.2012
25.04.2012
01
PMCSHP
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2352
0001943517.01
KUKUH PRABOWO
IMKIN0001943517
01.05.2012
01.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00
2353
0001947357
SATRIA SATYAWAN
IMKIN0001947357
12.05.2012
12.05.2012
01
PMCSHP
25,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2354
0001951053
SRI HANDAYANI
IMKIN0001951053
16.05.2012
16.05.2012
01
NISINP
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2355
0001951053.01
SRI HANDAYANI
IMKIN0001951053
16.05.2012
16.05.2012
01
NISINP
96,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2356
0001951184.01
HALIM
IMKIN0001951184
23.05.2012
23.05.2012
01
PMTBPL
6,500,000.00
6,500,000.00 2012
4,550.00
4,550.00
455.00
455.00
0.00
4,095.00


NO : 01105/II/2012/01
: 122
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2357
000000179Z
EDI SAPARUDIN.SE. .
LE0000179Z
02.03.2011
29.05.2012
01
LBCA1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2358
000001006Z
LE0001006Z
DEWI TIRTA AYUMAS .
01.07.2011
08.05.2012
01
LBCA1
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2359
000002481V
FRANKY RGOSAL .
LE0002481V
28.12.2011
08.05.2012
01
LBCA1
200,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2360
0000000920
YOSEFA SULAIMAN
MU00000920
24.04.2012
16.05.2012
01
UBMU11
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2361
0000004580
DANIEL ADI SAPUTRO
MU00004580
26.03.2012
02.05.2012
01
UBMU1
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2362
0000005530.01
NERIA OLEANDA
MU00005530
11.04.2012
09.05.2012
01
UBMU11
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2363
0000014230
REZA ADAM FERDIAN
MU00014230
24.04.2012
28.05.2012
01
UBMU11
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2364
0000001900.01
NA00001900
SRI INDAH APRILYANTI
03.07.2008
14.05.2012
01
UBNG2
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2365
0000005610
NA00005610
YULIANTO INDRAPRAJA
18.06.2008
02.05.2012
01
UBNG2
48,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2366
0000010030
NA00010030
OH CORRIE DELAIS HAL
05.06.2008
04.05.2012
01
UBNG2
30,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2367
0000011310
ANGGANANTYO
NA00011310
11.08.2008
21.05.2012
01
UBNG2
36,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2368
0000015710.01
NENENG SUSANTI
NA00015710
25.07.2008
25.05.2012
01
UBNG2
36,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2369
0000051350.01
ANESTYA RISKINA
NA00051350
06.01.2009
21.05.2012
01
UBNG2
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2370
0000076080
HJ TATI KRISTIANTI
NA00076080
19.09.2008
01.05.2012
01
UBNG2
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2371
0000102330
AISYAH
NA00102330
26.11.2008
26.05.2012
01
UBNG2
36,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2372
0000138830
NA00138830
WAHYU KRISTI UNTARI
18.03.2010
23.05.2012
01
UBNG2
36,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2373
0000157210
NA00157210
HENDRY ZAPUTRA TEDJA
28.04.2010
28.05.2012
01
UBNG2
36,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2374
0000000240
. GUNAWAN
NF00000240
25.11.2010
04.05.2012
01
LDRNF
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2375
0000000240.02
ENY HERAWATI
NF00000240
25.11.2010
04.05.2012
01
LDRNF
50,000,000.00
50,000,000.00 2011
802,000.00
467,833.00
0.00
0.00
0.00
467,833.00
2376
000000031Y
ENDANG MELATI .
NF0000031Y
22.11.2011
16.05.2012
01
LDRNF
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2377
0000000750
TAN GIOK MIE
NF00000750
11.01.2011
02.05.2012
01
LDRNF
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 123
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2378
0000001580
TJENTIS MELIAWATI
NF00001580
24.02.2011
11.05.2012
01
LDRNF
75,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2379
0000004060.01
. ROOSVITANINGSIH
NF00004060
22.02.2012
22.05.2012
01
LDRNF
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2380
0000004240.01
NF00004240
. A. D. M. MANURUNG / BR SITUMORANG
27.03.2012
21.05.2012
01
LDRNF
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2381
000000444Z
BASRUDDIN .
NF0000444Z
29.11.2010
07.05.2012
01
LDRNF
50,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2382
000000574Z
NF0000574Z
HENRY TJONDRO HARTON
16.03.2011
15.05.2012
01
LDRNF
100,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2383
000000578Z
JOHN WAHA .
NF0000578Z
16.03.2011
01.05.2012
01
LDRNF
50,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2384
000000706Z
JULIA INAWATI .
NF0000706Z
28.11.2011
04.05.2012
01
LDRNF
75,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2385
0000006740
. SETIAWAN
PA00006740
30.08.2010
14.05.2012
01
UBPM1
108,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2386
0000006700
SP00006700
LINA YULIANTI YULIAN
24.09.2008
24.05.2012
01
USCB1
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2387
0000024460
SURYA YUNINGSIH
SP00024460
17.06.2010
15.05.2012
01
USCB1
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2388
0000024670
SRI KALINAWATI
SP00024670
05.11.2010
05.05.2012
01
USCB1
60,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2389
0000001134
SOPHIA LOREN
TTMIN0000001134
21.03.2006
21.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2390
2391
2392
0000001138
SUSILOWATI
0000003046.01
IR. HARDJANTO
0000003877
COK GDE KAMINATA
TTMIN0000001138
TTMIN0000003046
TTMIN0000003877
19.03.2006
03.04.2006
21.03.2006
19.02.2012
03.02.2012
21.02.2012


NO : 01105/II/2012/01
: 124
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
2393
2394
2395
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
0000003892
TTMIN0000003892
DRS. BAMBANG P. SUMO
0000004383
ARIFIN
0000004858.01
EKO PURWANTO
TTMIN0000004383
TTMIN0000004858
DATE OF
DATE OF NATURE
18.03.2006
26.03.2006
22.05.2006
18.02.2012
26.02.2012
22.02.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
18,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2396
0000006748
NANA SURYANA
TTMIN0000006748
01.08.2007
01.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2397
0000011115.01
TTMIN0000011115
DRS. SUKAMTO YACOBUS
20.04.2006
20.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
7,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2398
2399
2400
2401
0000011854.01
TITIN PATIMAH
0000011862.01
ENGKOS KOSWARA
0000012010.01
SAHIDIN
0000012077.01
SRI KUSMIATI
TTMIN0000011854
TTMIN0000011862
TTMIN0000012010
TTMIN0000012077
09.05.2006
13.05.2006
30.03.2006
11.04.2006
09.02.2012
13.02.2012
29.02.2012
11.02.2012
2402
0000012964.01
TTMIN0000012964
GANI AHMAD RUKMANA
06.08.2006
06.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2403
0000013574.01
ERLIN ESTININGTYAS
10.04.2006
10.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
TTMIN0000013574


NO : 01105/II/2012/01
: 125
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
2404
2405
2406
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
0000013666.01
TTMIN0000013666
HERAWAN HARYANTO
0000013943.01
EMI ARIANI
TTMIN0000013943
0000014106.01
TTMIN0000014106
LILY WIDJAYA HARSONO
DATE OF
DATE OF NATURE
26.04.2006
11.04.2006
12.05.2006
26.02.2012
11.02.2012
12.02.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2407
0000014256.01
DEDI SUJADI
TTMIN0000014256
12.08.2006
12.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
2408
0000014613.01
TJOE SIN MEI
TTMIN0000014613
02.07.2006
02.02.2012
01
GEBBKB
0.00
2011
0.00
0.00
2409
0000014783.01
TTMIN0000014783
FAUZIA ABDURACHMAN
09.05.2006
09.05.2012
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2410
0000014901.01
ANIK UMI NURAINI
TTMIN0000014901
10.04.2006
10.05.2012
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2411
0000017031.01
SUWARNO DURMAN
TTMIN0000017031
02.08.2006
02.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2412
0000017707.01
HELMAWATI
TTMIN0000017707
29.04.2006
29.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2413
0000018327.01
TTMIN0000018327
IGN. DJOKO SADHONO
17.07.2006
17.02.2012
01
GEBBKB
0.00
2011
0.00
0.00
2414
0000018856.01
HERDIANSYAH
TTMIN0000018856
11.08.2006
11.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2415
0000019248.01
MOHAMAD LUTFI
TTMIN0000019248
13.08.2006
13.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2416
0000019692.01
TOTO SUTJIPTO
TTMIN0000019692
16.05.2006
16.05.2012
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2417
0000021125.01
POPON SUTIHATTY
TTMIN0000021125
06.05.2006
06.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2418
0000022025.01
TATANG SUKARNA
TTMIN0000022025
28.05.2006
28.05.2012
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2419
0000022084.01
NENY MULYANI
TTMIN0000022084
11.06.2006
11.05.2012
01
GEBBKB
3,000,000.00
3,000,000.00 2011
18,540.00
1,545.00
0.00
0.00
0.00
1,545.00
2420
0000022554.01
TRIYANA ANDI
TTMIN0000022554
07.08.2006
07.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 126
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2421
0000023736.01
TTMIN0000023736
MARIA BLANDINA SHA H
10.02.2007
10.02.2012
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2422
0000023961.01
TTMIN0000023961
INDRAWATI HANDOKO
19.09.2006
19.05.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2423
0000024814.01
AHMAD MULYADI
09.05.2006
09.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
TTMIN0000024814
2424
0000026673.01
TRESYA MARINA
TTMIN0000026673
23.01.2007
23.02.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2425
0000026680.01
SITI JUMHANAH
TTMIN0000026680
01.02.2007
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2426
0000027453
TTMIN0000027453
DIAN MELINDA KRISTIA
12.08.2007
12.05.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2427
0000027744.01
TTMIN0000027744
FAJAR RINA MARYANTI
01.11.2006
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2428
0000027844.01
EKO YULIARTANTO
TTMIN0000027844
11.07.2006
11.02.2012
01
GEBBKB
3,000,000.00
2011
0.00
0.00
0.00
0.00
0.00
2429
0000027939.01
IRAWAN HARTANTO
TTMIN0000027939
03.08.2006
03.05.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2430
0000028900.01
SRI WAHYUNI S
TTMIN0000028900
03.06.2006
03.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2431
0000029079.01
TTMIN0000029079
CECEP KURNIAWAN RS
20.07.2006
20.02.2012
01
GEBBKB
3,000,000.00
2011
0.00
0.00
0.00
0.00
0.00
2432
0000029235.01
ALI SURYONO
TTMIN0000029235
21.06.2006
21.05.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2433
0000030178.01
SUMNARDI
TTMIN0000030178
19.06.2006
19.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2434
0000030610.01
TRUBUS HARYANTO
TTMIN0000030610
17.05.2006
17.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2435
0000030800.01
TTMIN0000030800
AGUSTINA MARGI RAHAY
12.06.2006
12.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2436
0000030880.01
ANIS FITRIANINGSIH
TTMIN0000030880
03.09.2006
03.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2437
0000031545.01
INASTUTI KARDJUI
TTMIN0000031545
30.07.2006
29.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2438
0000033469.01
LIM FIE LIEN
TTMIN0000033469
02.01.2007
02.05.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2439
0000033844.01
A HAMIDZAM
TTMIN0000033844
15.03.2007
15.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 127
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2440
0000034586.01
AGUSTINA
TTMIN0000034586
27.09.2006
27.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2441
0000034844.01
ASMONO
TTMIN0000034844
14.09.2006
14.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2442
0000035296.01
TTMIN0000035296
MOCH FATCHURAHMAN
01.11.2006
01.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2443
0000035423.01
SUNARDI .DRS
TTMIN0000035423
23.09.2006
23.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2444
0000035432.01
CAKRUM
TTMIN0000035432
11.09.2006
11.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2445
0000036044.01
TTMIN0000036044
SONHAJI SURYO LAKSMO
16.10.2006
16.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2446
0000036156.01
ENDAH SHITA LAKSMI
TTMIN0000036156
25.08.2006
25.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2447
0000037297.01
A RAHMAN
TTMIN0000037297
13.01.2007
13.04.2012
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2448
0000037653.01
WAHYUDI JULIANTO
TTMIN0000037653
10.09.2006
10.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2449
0000037879.01
LUCIA HENDRAWATI
TTMIN0000037879
23.05.2007
23.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2450
0000038012.01
TTMIN0000038012
IVAN HASUDUNGAN PARD
11.09.2006
11.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2451
0000038546.01
TTMIN0000038546
S. TRISNU WIJAYA LUK
01.11.2006
01.04.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2452
0000041735.01
KUSMIATI
TTMIN0000041735
01.11.2006
01.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2453
0000042747.01
JANI SUMARJAN I.A. H
TTMIN0000042747
02.11.2006
02.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2454
0000044223.01
ADI DHARMA
TTMIN0000044223
03.08.2006
03.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2455
0000045979.01
TTMIN0000045979
ANTONIUS SUTOPO SE
09.08.2006
09.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2456
0000047258.01
FX. SUPARJO
TTMIN0000047258
05.10.2006
05.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2457
0000047451.01
MUJIHARTO
TTMIN0000047451
22.08.2006
22.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2458
0000048505.01
MUKHLIS S.SPD
TTMIN0000048505
01.12.2006
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2459
0000048917.01
NINING RUKMINI
TTMIN0000048917
01.12.2006
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 128
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2460
0000049831.01
ILA NURLELA
TTMIN0000049831
04.01.2007
04.02.2012
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2461
0000050544.01
TTMIN0000050544
TJIOE LILY SAMPURNA
06.03.2007
06.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2462
0000050983.01
ELAN BIANTORO
TTMIN0000050983
01.02.2007
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2463
0000051077.01
TINAWATI HALIM
TTMIN0000051077
11.11.2006
11.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2464
0000051231.01
ASTRALITA
TTMIN0000051231
08.11.2006
08.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2465
0000052230.01
TJIE FUNG KUO
TTMIN0000052230
09.03.2007
09.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2466
0000052241.01
TTMIN0000052241
SILVIANAWATI SUHENDR
18.03.2007
18.03.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2467
0000054217.01
SISWOKO UTOMO
TTMIN0000054217
02.12.2006
02.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2468
0000054434.01
ACHMAD ALI
TTMIN0000054434
21.01.2007
21.02.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2469
0000056233.01
TITIS YANUARI
TTMIN0000056233
22.08.2007
22.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2470
0000056630.01
SUPRIYANTI
TTMIN0000056630
05.08.2006
05.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2471
0000057171.01
HENNY SUKMAWATI
TTMIN0000057171
18.12.2006
18.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2472
0000060091.01
SRI HASTUTI
TTMIN0000060091
26.11.2006
26.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2473
0000061062.01
HARVEY
TTMIN0000061062
07.06.2007
07.05.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2474
0000061915.01
M DJAMAL GANI
TTMIN0000061915
14.07.2007
14.02.2012
01
GEBNKB
3,000,000.00
2011
0.00
0.00
0.00
0.00
0.00
2475
0000062058.01
TTMIN0000062058
LAMEN ROYAMI MANULAN
09.05.2007
09.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2476
2477
0000066158.01
FAHD MIRZA GAZALI
0000066749.01
HADI YENI
TTMIN0000066158
TTMIN0000066749
01.05.2007
01.02.2007
01.02.2012
01.02.2012


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PAGE
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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
DATE OF
DATE OF NATURE
PLAN
CODE
2478
0000066767.01
SOEHARIJANTO
TTMIN0000066767
02.02.2007
02.02.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2479
0000067678.01
OOM KOMARIAH
TTMIN0000067678
13.05.2007
13.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
TTMIN0000073216
20.05.2007
20.04.2012
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
PREM. DUE TO
CEDANT
CERT. NO.
0000073216.01
LUKMAN HANAFI
SUM ASSURED
PREM. DUE TO
REINSURERS
NO.
2480
POLICY NO.
NON POOL
2481
0000075676
IR. M. AZMI RIDHO
TTMIN0000075676
01.08.2007
01.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2482
0000077102.01
YANI MULYANI
TTMIN0000077102
16.03.2007
16.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2483
0000078129.01
TTMIN0000078129
JOSEFINE CHRISTI TAN
11.03.2007
11.02.2012
2484
0000078516.01
WAHYU SETIAWAN
TTMIN0000078516
01.06.2007
01.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2485
0000078731.01
SUPARMI
TTMIN0000078731
01.06.2007
01.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2486
0000078774.01
M.JUNAIDI
TTMIN0000078774
04.06.2007
04.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2487
0000078821.01
SITI HERLINA
TTMIN0000078821
08.06.2007
08.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2488
0000078933.01
GUSRITA KENCANA
TTMIN0000078933
01.05.2007
01.02.2012
01
GEBBKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
0.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2489
0000080918.01
DRS. YAYT RUHIMAT
TTMIN0000080918
13.12.2006
13.02.2012
01
GEBNKB
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2490
0000102536.01
LILI SUMANTRI ALIA
TTMIN0000102536
08.04.2007
08.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2491
0000115699.01
HENDRA OCBRON
TTMIN0000115699
12.04.2007
12.05.2012
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2492
0000115831.01
DANOFAN. F
TTMIN0000115831
19.04.2007
19.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2493
0000116590.01
WENTY MARETINA
TTMIN0000116590
12.03.2007
12.02.2012


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TYPE OF REINS.
: TREATY
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LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
2494
2495
2496
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
0000116758.01
TTMIN0000116758
TATANG SUHENDAR MULI
0000117324.01
ANDI SUGIANTO
0000117961.01
HANNY DWI YANTI
TTMIN0000117324
TTMIN0000117961
DATE OF
DATE OF NATURE
04.03.2007
05.05.2007
11.05.2007
04.02.2012
05.02.2012
11.02.2012
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2497
0000118580
AGUNG YULIANTO
TTMIN0000118580
02.09.2007
02.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2498
0000118992.01
TTMIN0000118992
BUDI LUKITOYO FAKKAR
03.08.2007
03.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2499
0000119788.01
JUNAEDI HIDAYAT
TTMIN0000119788
24.08.2007
24.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2500
0000120251.01
CHASY C.ANWAR
TTMIN0000120251
23.06.2007
23.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2501
0000120281.01
JOHN EDWARD
TTMIN0000120281
20.07.2007
20.02.2012
01
GEBBKB
3,000,000.00
2011
0.00
0.00
0.00
0.00
0.00
2502
0000120322.01
SUHERMANTO
TTMIN0000120322
17.07.2007
17.02.2012
01
GEBNKB
3,000,000.00
2011
0.00
0.00
0.00
0.00
0.00
2503
0000123736
SUNARMI
TTMIN0000123736
08.09.2007
08.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2504
0000123766.01
MISDI
TTMIN0000123766
10.09.2007
10.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2505
0000123768
SITI NURIATI
TTMIN0000123768
10.09.2007
10.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2506
0000124239.01
ROSALIA P.W.W
TTMIN0000124239
08.09.2007
08.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2507
0000126531.01
KOESNOE EFENDI
TTMIN0000126531
01.09.2007
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2508
0000127974.01
PARMAN HS
TTMIN0000127974
17.05.2007
17.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2509
0000128177.01
TTMIN0000128177
IR. ENDANG SAEPUDIN
01.09.2007
01.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2510
0000131025.01
DEWI
TTMIN0000131025
04.08.2007
04.05.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2511
000131029.01
PUTU EKA PUTRI R.
TTMIN0000131029
05.08.2007
05.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00


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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
2512
0000131121.01
CITRA FELLINY GONY
TTMIN0000131121
13.08.2007
13.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
2513
0000131432.01
RINI MURDIAWATI
TTMIN0000131432
09.07.2007
09.02.2012
01
GEBNKB
3,000,000.00
2011
0.00
0.00
2514
0000131960
WIWIK
TTMIN0000131960
01.09.2007
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
2515
0000132577.01
NOVI PRATIWI DEWI
TTMIN0000132577
01.07.2007
01.02.2012
01
GEBBKB
3,000,000.00
2011
0.00
0.00
2516
0000133028.01
INDRA FAJAR A
TTMIN0000133028
24.06.2007
24.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
2517
0000134675.01
ANIK ANDAYANI
TTMIN0000134675
01.06.2007
01.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
2518
0000135040.01
DEWI SUSILAWATI
TTMIN0000135040
10.06.2007
10.02.2012
01
GEBNKB
3,000,000.00
0.00 2011
2519
0000135208.01
YUDITH YULIANO
TTMIN0000135208
18.05.2007
18.02.2012
01
GEBNKB
3,000,000.00
01
GEBNKB
01
2520
0000135264.01
TTMIN0000135264
YULIANA PURNAMASARI
20.05.2007
20.02.2012

0.00
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
GEBNKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBNKB
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2521
0000139299.01
SAMAN
TTMIN0000139299
01.07.2007
01.02.2012
01
GEBNKB
3,000,000.00
2011
0.00
0.00
2522
0000139534.01
ENDANG
TTMIN0000139534
11.06.2007
11.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2523
0000007130
TU00007130
DR. SLAMET SOEBAGIO
16.04.2007
16.05.2012
01
UNMPS
15,870,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2524
0000007300
BAHRUDDIN S.KOM
TU00007300
23.04.2007
29.05.2012
01
UNMPS
21,930,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2525
0000011940
TU00011940
NAWA POERWANA THALO
09.05.2007
02.05.2012
01
UNMPS
11,430,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2526
0000011580
UB00011580
ANTOINETTE MINTJE AM
28.08.2008
11.05.2012
01
UUS02
54,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
UUS02
54,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
01
UUS02
45,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
UUS02
45,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2527
0000022970
YENY SOLINATA
UB00022970
13.03.2009
16.05.2012
2528
0000028160
APIPUDIN SAG
UB00028160
05.02.2009
05.05.2012
01
UUS02
27,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2529
0000032190
UB00032190
HENDRA TANU WIDJAJA
13.03.2009
16.05.2012
01
UUS02
90,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
UUS02
90,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


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TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2530
0000039040
. SHERLY
UB00039040
29.03.2010
03.05.2012
01
UUS02
45,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2531
0000053550
FAIZAL AHMAD
UB00053550
12.11.2009
12.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2532
0000064170
DR.ERNY MASYITAH
UB00064170
27.09.2010
08.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2533
0000067310
. WIDARSO
UB00067310
18.08.2010
24.05.2012
01
UUS02
27,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2534
0000070300
AHMAD RIFAI
UB00070300
25.02.2010
25.05.2012
01
UUS02
27,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2535
0000073980
WONG TJI ON
UB00073980
24.08.2010
24.05.2012
01
UUS02
45,000,000.00
45,000,000.00 2011
157,050.00
39,263.00
0.00
0.00
0.00
39,263.00
2536
0000084150
REZKI PUNDARI
UB00084150
17.01.2011
22.05.2012
01
UUS02
22,500,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2537
0000084600
IDA AYU SUASTINI
UB00084600
17.01.2011
08.05.2012
01
UUS02
27,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2538
0000089400
RINCA ERLINGGA
UB00089400
28.12.2010
28.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2539
0000091950
EKA MUNING
UB00091950
11.07.2011
11.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2540
0000093880
UB00093880
EKO SUPRIYANTO TJAND
04.07.2011
04.05.2012
01
UUS02
27,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2541
0000098380
. SUGIYANTO
UB00098380
05.04.2012
02.05.2012
01
UUS02
135,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2542
0000106120
IKA PERMATASARI
UB00106120
01.06.2011
07.05.2012
01
UUS02
72,000,000.00
72,000,000.00 2011
50,400.00
4,200.00
5,040.00
420.00
0.00
3,780.00
2543
0000113820
UB00113820
HENDRIK PURNOMO SH
25.07.2011
25.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2544
0000114420
UB00114420
HARYATI NURUL HIDAYAT
17.11.2011
01.05.2012
01
UUS02
27,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2545
0000114850
AINUR ROFIQ
UB00114850
24.06.2011
24.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2546
0000116910
UB00116910
DADANG AGUS SETYANTO
25.07.2011
25.05.2012
01
UUS02
27,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2547
0000118040
KURNIA TURAHMI
UB00118040
27.01.2012
01.05.2012
01
UUS02
135,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2548
0000123580
. DIENDY
UB00123580
04.10.2011
04.05.2012
01
UUS02
45,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2549
0000125120
PUTRI DWIMIRNANI
UB00125120
02.04.2012
02.05.2012
01
UUS02
27,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2550
0000125150
DODY WAHDIANSYAH
UB00125150
27.04.2012
23.05.2012
01
UUS02
90,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00


NO : 01105/II/2012/01
: 133
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
Quarter 2012
PAGE
CERT. NO.
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
2551
0000125380
TITIN KOMALASARI
UB00125380
16.03.2012
28.05.2012
01
UUS02
90,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2552
0000126600
TRI RETNOWATI
UB00126600
14.11.2011
10.05.2012
01
UUS02
36,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2553
0000135110
UB00135110
MOHAMMAD HAMDAR. S. SOS
05.04.2012
09.05.2012
01
UUS02
135,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2554
0000135260
UB00135260
ABRAHAM SALADIN MONGULA
24.04.2012
11.05.2012
01
UUS02
72,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2555
0000136090
DENNY SAPUTRA
UB00136090
27.04.2012
28.05.2012
01
UUS02
90,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2556
0000138220
DINDIN SAEFUDIN SE
UB00138220
20.04.2012
07.05.2012
01
UUS02
45,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2557
0000138330
UB00138330
WINDI WERDININGRUM
02.04.2012
09.05.2012
01
UUS02
45,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2558
0000138470
GINO HERRYANSYAH
UB00138470
24.04.2012
23.05.2012
01
UUS02
90,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2559
000000659Z
UC0000659Z
RICHARD EDUARD MAHIE
09.12.2009
22.05.2012
01
ROP03
100,000,000.00
100,000,000.00 2011
243,000.00
141,750.00
0.00
0.00
0.00
141,750.00
2560
000001031Z
FASBIR ZAD .
UC0001031Z
18.03.2010
01.05.2012
01
ROP01
200,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2561
0000007300
HEPPI J M SILALAHI S
UD00007300
16.09.2010
16.05.2012
01
UUS03
27,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2562
0000009460
BRYAN BILVEN
UD00009460
08.11.2011
24.05.2012
01
UUS03
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2563
0000010830
ATI SOFIATI
UD00010830
07.10.2011
03.05.2012
01
UUS03
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2564
0000011380
NUR HASNIAWATI
UD00011380
16.08.2011
21.05.2012
01
UUS03
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2565
0000011860
UD00011860
MEUTIA RIZKY AMANDA
05.08.2011
05.05.2012
01
UUS03
90,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2566
0000020440
YUDHI KRISTANTO ST
UD00020440
24.02.2011
24.05.2012
01
UUS04
18,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2567
0000030720
NUR ASIKIN
UD00030720
17.11.2011
24.05.2012
01
UUS03
90,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2568
0000040340
KURNIA TURAHMI
UD00040340
27.01.2012
01.05.2012
01
UUS03
27,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2569
0000047650
. HERNILAWATI
UD00047650
27.04.2012
15.05.2012
01
UUS03
108,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
2570
0000003080
. R.A MELISSA
UH00003080
09.08.2011
21.05.2012
01
UUH01
18,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
09.02.2012
01
GEBBKB
3,000,000.00
0.00 2011
0.00
0.00
0.00
0.00
0.00
0.00
2570


NO : 01105/II/2012/01
: 134
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
2570
DATE OF
DATE OF NATURE
23.03.2012
TOTAL :
PLAN
CODE
SUM ASSURED
SUM REASSURED
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
YEAR
ORIGINALPREM.
60,000,000.00
3,000,000.00 2011
750.00
63.00
0.00
0.00
0.00
63.00
3,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
GEBBK
01
GEBBKB
01
GEBBK
60,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
300,000,000.00
250,000,000.00 2012
50,000.00
45,833.00
0.00
0.00
0.00
45,833.00
01
NIAOP
300,000,000.00
150,000,000.00 2012
30,000.00
27,500.00
0.00
0.00
0.00
27,500.00
01
NIAOP
300,000,000.00
150,000,000.00 2012
30,000.00
27,500.00
0.00
0.00
0.00
27,500.00
01
NIAOP
150,000,000.00
0.00 2012
0.00
0.00
0.00
0.00
0.00
0.00
01
NIAOP
300,000,000.00
250,000,000.00 2012
50,000.00
45,833.00
0.00
0.00
0.00
45,833.00
01
NIAOP
300,000,000.00
150,000,000.00 2012
30,000.00
27,500.00
0.00
0.00
0.00
27,500.00
4 AMNTLF
480,000,000.00
120,000,000.00
591,600.00
49,300.00
0.00
0.00
0.00
49,300.00
16 BCASHP
300,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
51 BNIDRD
6,950,000,000.00
3,710,000,000.00
8,376,500.00
4,269,251.00
793,200.00
386,726.00
0.00
3,882,526.00
8 BNIDRR
735,000,000.00
220,000,000.00
379,500.00
193,825.00
37,950.00
19,383.00
0.00
174,443.00
13 BNIHLF
130,000,000.00
10,000,000.00
7,000.00
1,750.00
700.00
175.00
0.00
1,575.00
3 BNIJB3
385,000,000.00
140,000,000.00
140,000.00
70,000.00
14,000.00
7,000.00
0.00
63,000.00
2 BNIJBA
245,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
21 BNIJBT
1,650,000,000.00
250,000,000.00
1,086,000.00
461,000.00
0.00
0.00
0.00
461,000.00
142 BNIJBX
26,650,000,000.00
3,600,000,000.00
6,875,000.00
3,283,959.00
408,900.00
169,860.00
0.00
3,114,101.00
1 CBP01
185,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2 CIGCFY
400,000,000.00
200,000,000.00
321,000.00
151,000.00
17,600.00
10,267.00
0.00
140,733.00


NO : 01105/II/2012/01
: 135
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
1 CIGFYY
200,000,000.00
200,000,000.00
162,000.00
81,000.00
0.00
0.00
0.00
81,000.00
2 CIGHCH
20,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
3 CIGHLP
30,000,000.00
10,000,000.00
12,900.00
5,375.00
0.00
0.00
0.00
5,375.00
1 CIGHPL
400,000,000.00
100,000,000.00
70,000.00
46,667.00
7,000.00
4,667.00
0.00
42,000.00
1 CIGLCF
500,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
83 CIGLPN
22,500,000,000.00
10,670,000,000.00
16,251,350.00
8,047,666.00
967,340.00
414,021.00
0.00
7,633,645.00
1 CIGLPO
500,000,000.00
500,000,000.00
350,000.00
233,333.00
0.00
0.00
0.00
233,333.00
1 CIGLPR
500,000,000.00
500,000,000.00
1,215,000.00
202,500.00
121,500.00
20,250.00
0.00
182,250.00
98 CIGSRN
22,700,000,000.00
15,580,000,000.00
24,274,300.00
15,564,168.00
1,658,300.00
949,536.00
0.00
14,614,634.00
4 CIGYSR
1,200,000,000.00
700,000,000.00
715,000.00
431,250.00
23,700.00
1,975.00
0.00
429,275.00
1 DAFLPN
500,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
127 DANHCP
2,493,450,000.00
135,000,000.00
105,950.00
53,467.00
0.00
0.00
0.00
53,467.00
41 DANLFP
2,917,000,000.00
289,000,000.00
497,420.00
216,353.00
0.00
0.00
0.00
216,353.00
1 DN305
15,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
4 GEBBK
126,000,000.00
6,000,000.00
1,500.00
126.00
0.00
0.00
0.00
126.00
226 GEBBKB
2,109,000,000.00
10,500,000.00
82,815.00
6,901.00
0.00
0.00
0.00
6,901.00
45 GEBNKB
99,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
38 GECRPL
2,425,000,000.00
238,000,000.00
267,100.00
174,550.00
5,250.00
3,500.00
0.00
171,050.00
90,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
47 HSBCPP
4,950,000,000.00
1,150,000,000.00
1,559,000.00
544,750.00
82,600.00
41,300.00
0.00
503,450.00
100 HSBTLC
4,240,000,000.00
230,000,000.00
622,300.00
300,342.00
2,840.00
1,657.00
0.00
298,685.00
1 HUMHL
30,000,000.00
30,000,000.00
35,400.00
23,600.00
3,540.00
2,360.00
0.00
21,240.00
6 IMCGLP
2,400,000,000.00
1,200,000,000.00
1,317,000.00
415,583.00
131,700.00
41,558.00
0.00
374,025.00
3 LBCA1
500,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
5 LBD01
800,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
11 LDRNF
650,000,000.00
50,000,000.00
802,000.00
467,833.00
0.00
0.00
0.00
467,833.00
2 HDRHL


NO : 01105/II/2012/01
: 136
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
POLICY NO.
DATE OF
DATE OF NATURE
PLAN
CODE
51 LIFCRP
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
11,100,000,000.00
3,900,000,000.00
4,223,000.00
1,343,332.00
0.00
0.00
0.00
1,343,332.00
2 MANCGP
105,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2 MANCLP
150,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
195 MANDEX
24,500,000,000.00
11,100,000,000.00
25,454,500.00
15,460,336.00
153,900.00
76,968.00
0.00
15,383,369.00
35 MANGMK
5,450,000,000.00
1,356,600,000.00
1,866,110.00
975,258.00
87,600.00
13,749.00
0.00
961,509.00
12 MANGPL
1,950,000,000.00
1,350,000,000.00
1,174,000.00
788,833.00
117,400.00
78,883.00
0.00
709,950.00
1 MANGPX
70,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
6 MANTLF
395,000,000.00
25,000,000.00
54,000.00
31,500.00
5,400.00
3,150.00
0.00
28,350.00
1 MANTLP
300,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2 MANUTD
100,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
5 MANUTV
450,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
3 MISLPN
1,300,000,000.00
1,300,000,000.00
2,350,000.00
1,132,500.00
0.00
0.00
0.00
1,132,500.00
4 MISSRN
600,000,000.00
400,000,000.00
320,000.00
175,167.00
15,800.00
1,317.00
0.00
173,850.00
18 NIAOP
3,600,000,000.00
1,200,000,000.00
240,000.00
219,999.00
0.00
0.00
0.00
219,999.00
13 NIAPMD
3,100,000,000.00
1,108,010,000.00
1,172,607.00
881,069.00
7,000.00
4,083.00
0.00
876,986.00
10 NIAPMK
48,000,000.00
2,000,000.00
1,580.00
790.00
0.00
0.00
0.00
790.00
164 NISINP
10,997,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
313 PMCSHP
21,100,000,000.00
1,525,000,000.00
2,374,250.00
1,128,063.00
135,375.00
66,933.00
0.00
1,061,134.00
10 PMSSHP
625,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
646 PMTBPL
19,540,000,000.00
7,447,000,000.00
4,095,310.00
2,477,040.00
204,421.00
139,061.00
0.00
2,338,018.00
35 PMTBPS
3,061,000,000.00
809,500,000.00
251,310.00
120,025.00
5,717.00
4,873.00
0.00
115,154.00
55 PMTSHI
2,675,000,000.00
100,000,000.00
71,000.00
20,667.00
7,100.00
2,067.00
0.00
18,600.00
7 PMTSHT
350,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2 RBSTLE
225,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 ROP01
200,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 ROP03
100,000,000.00
100,000,000.00
243,000.00
141,750.00
0.00
0.00
0.00
141,750.00


NO : 01105/II/2012/01
: 137
TYPE OF REINS.
: TREATY
CURRENCY
: RUPIAH
LINE OF BUSINESS
: INDIVIDUAL
COMPANY
: PT ASURANSI CIGNA
CLASS OF BUSINESS
: NON MEDICAL
POOL CODE
: 022
NO.
CERT. NO.
Quarter 2012
PAGE
DATE OF
DATE OF NATURE
POLICY NO.
GRAND TOTAL
PLAN
CODE
SUM ASSURED
SUM REASSURED
YEAR
ORIGINALPREM.
REFUND PREM.
NON POOL
PREM. DUE TO
REINSURERS
PREM. DUE TO
CEDANT
19 UBCA1
2,600,000,000.00
800,000,000.00
1,179,500.00
743,708.00
45,450.00
39,371.00
0.00
704,338.00
13 UBCA2
2,050,000,000.00
800,000,000.00
1,294,000.00
972,167.00
69,700.00
63,892.00
0.00
908,275.00
5 UBDN2
252,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 UBMU1
100,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
3 UBMU11
300,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
10 UBNG2
398,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 UBPM1
108,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
60 UNMPS
646,470,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
32 UOBEXP
270,000,000.00
210,000,000.00
1,226,600.00
421,100.00
0.00
0.00
0.00
421,100.00
3 USCB1
180,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 UUH01
18,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
36 UUS02
2,056,500,000.00
117,000,000.00
207,450.00
43,463.00
5,040.00
420.00
0.00
43,043.00
8 UUS03
396,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 UUS04
18,000,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
232,488,420,000.00
73,498,610,000.00
113,915,852.00
0.00
59,803,367.00
2570
62,372,316.00
5,136,023.00
2,569,002.00
Jakarta, 01 June 2012
COMPANY
PT REASURANSI INTERNASIONAL INDONESIA
SHARE
100.00%
GROSS PREMIUM
62,372,316.00
COMMISSION
2,569,002.00
NET. PREMIUM
59,803,314.00

CLAIM & TECHNICAL ADM. REINS. DEPARTMENT
REMARKS :
01
Cancellation
09 July 2012
SECTION HEAD

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REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT

ORIG. COMM. REFUND.COMM.

PT. REASURANSI INTERNASIONAL INDONESIA

LIST OF CHANGE & PREMIUM ADJUSTMENT