Professional Documents
Culture Documents
Formulir Pendaftaran BPJS PDF
Formulir Pendaftaran BPJS PDF
Formulir Pendaftaran BPJS PDF
"
!$.
Lf&
:\^ZaYV^
:CEAH@YE 85:G5E
=F=5B D9F9EG5
D9?9E>5
6H?5B D9B9E=A5 HD5< 85B 6H?5B D9?9E>5
6585B
D9BK9@9B;;5E5
>5A=B5B FCF=5@ ?9F9<5G5B
6D>F?R_RUN`N[
GN[TTNYIR^VSVXN_V
2
DR`aTN_ 9[`^e 2
C=YF=
C@9< 75@CB D9F9EG5
DRXR^WN
6aXN[ DR[R^VZN H]NU
6aXN[ DRXR^WN
H DRXR^WNAN[QV^V
&&&&&&&&&&&&&&&&&&&
Hgggggggggggggg
=89BG=G5F D9F9EG5
IR^VSVXN_V
B\Z\^
*
?N^`a ?RYaN^TN
)444444
=f44
)444444
)444444
)444444
)444444
+ BNZN @R[TXN]
,
>R[V_ ?RYNZV[
F`N`a_ DR^[VXNUN[
2
2
) 4 @NXV%=NXV3
* 4 DR^RZ]aN[
) 4 ?NcV[3 * 4 6RYaZ ?NcV[3 + 4 >N[QN3, 4 8aQN3
%3"
8R_N'?RYa^NUN[
?RPNZN`N[
?NOa]N`R['?\`N
B\Z\^
GRY]\[
- ?RcN^TN[RTN^NN[
)(
))
B\Z\^
)*
)+
DN__]\^`
),
B\& BDJD
)-
5YNZN` 9ZNVY
).
)/
@%%%@&&M@%%%@&&%%&>@%&&&&@%%&>@%&&&&@%%%
?\QR :N_XR_ f
M&&&@Mf
%% =89BG=G5F FH5A=g=FG9E=
B=? ! ?=G5F # ?=G5D
*
BNZN
'
21 "21 %@%%=
f%%% %%%%%%%%
>R[V_ ?RYNZV[
= = @@=@%&&&&@=
%%%$=@%&&&&@%% %%&&&@%%
>aZYNUYa^N[eN[T QVONeN^
* B\Z\^
/
2%#?RYN_=&*& ?RYN_%%#+&?RYN_===
DN__]\^`
, BNZN DR^a_NUNN[5_a^N[_V
)(
====89BG=G5F 5B5?
5[NX DR^`NZN 2
B=? ! ?=G5F ! ?=G5D
*
BNZN
'
>R[V_ ?RYNZV[
) >aZYNUYa^N[eN[T QVONeN^
* B\Z\^ DN__]\^`
/
, BNZN DR^a_NUNN[5_a^N[_V
)(
<NY*'*
&:;9<87; !
5[NX ?RQaN 2
) B=? #?=G5F #?=G5D
* BNZN
+ GRZ]N` QN[ GN[TTNY@NUV^
, >R[V_ ?RYNZV[
- >aZYNU Ya^N[ eN[T QVONeN^
. B\Z\^
DN__]\^`
!!! !$"#!!! !$!! !!!!! !!!! !$ !!! !$"#!!! !$!! !!!!! $!! !!!
&!!&'&!!&'&!!&' !!!! !' !!!! !' !!!! !' !!!! !!!
?\QR :N_XR_ f
?\QR :N_XR_
@H
5[NX ?R`VTN2
) B=? # ?=G5F # ?=G5D
* BNZN
+ GRZ]N` QN[ GN[TTNY@NUV^
, >R[V_ ?RYNZV[
- >aZYNU Ya^N[ eN[T QVONeN^
. B\Z\^
DN__]\^`
=_VYNU
QR[TN[ Ua^aS XN]V`NYQN[ ZaQNU QVONPN
KN[T OR^`N[QN`N[TN[ QVONcNUV[VOR^`N[TTa[TWNcNO _RPN^NUaXaZ `R^UNQN]XROR[N^N[ QN`NeN[T `R^PN[`aZ&
&
*() &&
:\`\
DR_R^`N
HXa^N[ + d , PZ
:\`\
=_`R^V'FaNZV
HXa^N[ + d , PZ
:\`\
5[NX XR)
HXa^N[ + d , PZ
:\`\
5[NXXR *
HXa^N[ + d , PZ
:\`\
5[NX XR+
HXa^N[ + d , PZ
&
&&&
"
0%34.*4+
0%2%13" 0%+%1*"
#"$".
0%.')2)".
#4+".
$".
0%.%1)-"
0%.6%,%.''"1"
*"-).".
5%1)&)+"2)
40"(
$".
2/2)",
#4+".
0%+%1*"
+%2%("3".
'#
B5A5
(#
)#
@9B;?5D
2
@5<=E
2
2
FG5GHFD9EB=?5<5B
5@5A5G G9AD5G G=B;;5@
2
2
2
*#
+#
&# B5A5
G9AD5G C5B G5B;;5@
>9B=F?9@5A=B
)#
B DJD
>HA@5< =HE5B K5B; C=65K5E
?9@5FD9E5J5G5B
*#
+#
,#
-#
%$#
'#
(#
@5<=E
=_V
QR[TN[ N[TXN _R_aNVQR[TN[ _`N`a_ ]R^[VXNUN[
=_V_R_aNVQR[TN[ NYNZN` `RZ]N` `V[TTNY_NN` N`Na `RZ]N` `V[TTNYeN[T
`R^PN`N`]NQN ?GD
=_V
_R_aNVQR[TN[ [\Z\^
X\[`NX eN[T ZaQNU QVUaOa[TV
=_V
QR[TN[ N[TXN _R_aNV_`N`a_ XRcN^TN[RTN^NN[QN[ `aYV_N_NYXRON[T_NN[
=_V
_R_aNVQR[TN[ Va^N[WNZV[N[ XR_RUN`N[eN[T QVONeN^XN[
=_V
QR[TN[ N[TXN _R_aNVXRYN_
]R^NcN`N[ eN[T QV]VYVU
=_V
QR[TN[ [\Z\^
]N__]\^` eN[T QVZVYVXV
=_V
QR[TN[ B\Z\^ D\YV_5_a^N[_V YNV[WVXN
ZRZVYVXV
=_V
QR[TN[ [NZN ]R^a_NUNN[ ]R[N[TTa[T
^R_VX\
BCACE D5FFDCEG
BCACE DCYYF5FHE5BF=
=_V
QR[TN[ [\Z\^
cNWVO
]NWNX
eN[T QVZVYVXV
=_V
_R_aNVQR[TN[ NYN
ZN` _a^N` RYRX`^\[VXeN[T QVZVYVXV
=_VB\Z\^
=QR[`V`N_eN[T `R^`R^N ]NQN ?GD'?N^`a ?RYaN^TN$
QN[ ONTVJN^TN
BRTN^N5_V[T ZR[TV_V [\Z\^
^RTV_`R^eN[T `R^PN`N` ]NQN ?N^`a =WV[
GV[TTNY
FRZR[`N^N ' ?N^`a =WV[
GR`N]
BNZN _R_aNVQR[TN[ [NZN eN[T `R^PN[`aZ QNYNZF? DR[TN[TXN`N[ ' F?
DR[_Va[ ' ?N^`a GN[QNDR[QaQaX RYRX`^\[VX
JVYNeNU?NO' ?\`N `RZ]N` _R^`N`N[TTNY$OaYN[QN[ `NUa[ XRYNUV^N[
]R_R^`N
[\Z\^
]N__]\^` eN[T QVZVYVXV
B\Z\^ D\YV_5_a^N[_V YNV[WVXN
ZRZVYVXV
[NZN ]R^a_NUNN[ ]R[N[TTa[T
^R_VX\
BNZN Da_XR_ZN_' C\X`R^ XRYaN^TN
eN[T ZR[WNQV]VYVUN[
BNZN C\X`R^ ;VTVeN[T ZR[WNQV]VYVUN[
=_V
QR[TN[ [NZN ]R^a_NUNN[ ]R[N[TTa[T
^R_VX\
=_V
QR[TN[ BNZN Da_XR_ZN_' C\X`R^ XRYaN^TN
eN[T ZR[WNQV]VYVUN[
=_V
QR[TN[ BNZN C\X`R^ ;VTVeN[T ZR[WNQV]VYVUN[
2
2
5B5? ?98H5
%# B=?' ?=G5F' ?=G5D
?98H5
&#
B5A5 5B5?
#"
(#
>9B=F?9@5A=B
$"
B DJD
>HA@5< =HE5B K5B; 8=65K5E
?9@5FD9E5J5G5B
=_V
QR[TN[ [\Z\^
cNWVO
]NWNXeN[T QVZVYVXV
=_V
_R_aNVQR[TN[ Va^N[WNZV[N[XR_RUN`N[eN[T QVONeN^XN[
=_V
QR[TN[ N[TXN _R_aNVXRYN_
]R^NcN`N[ eN[T QV]VYVU
*#
BCACE D5FFDCEG
+#
BCACE DCYYF5FHE5BF=
,#
B5A5
%" &B5A5
%$# B5A5
@5<=E
D9EHF5<55B 5FHE5BF=
=_V
QR[TN[ [\Z\^
=_V
QR[TN[ B\Z\^
D\YV_5_a^N[_V YNV[WVXN
ZRZVYVXV
=_V
QR[TN[ [NZN ]R^a_NUNN[ ]R[N[TTa[T
^R_VX\
=_V
QR[TN[ BNZN Da_XR_ZN_' 8\X`R^ XRYaN^TN
eN[T ZR[WNQV]VYVUN[
=_V
QR[TN[ BNZN 8\X`R^ ;VTVeN[T ZR[WNQV
]VYVUN[
$
5B5? ?9G=;5
%# B=?' ?=G5F' ?=G5D
$ &#
@5<=E
#"
(#
>9B=F?9@5A=B
B DJD
=_V
QR[TN[ [\Z\^
$"
*#
BCACE D5FFDCEG
BCACE DCYYF5FHE5BF=
+#
8=65K5E
cNWVO
]NWNX
eN[T QVZVYVXV
=_V
_R_aNVQR[TN[ Va^N[WNZV[N[XR_RUN`N[eN[T QVONeN^XN[
=_V
QR[TN[ N[TXN _R_aNVXRYN_
]R^NcN`N[ eN[T QV]VYVU
2
=_V
QR[TN[ [\Z\^
=_V
QR[TN[ B\Z\^
,#
B5A5
D9EHF5<55B 5FHE5BF=
=_V
QR[TN[ [NZN ]R^a_NUNN[ ]R[N[TTa[T
%"
B5A5
=_V
QR[TN[ BNZN Da_XR_ZN_' 8\X`R^ XRYaN^TN
eN[T ZR[WNQV
]VYVUN[
%$# B5A5
^R_VX\
=_V
QR[TN[ BNZN 8\X`R^ ;VTVeN[T ZR[WNQV]VYVUN[