No.

: 000726/DN/JB/05/21 PREMIUM NOTE

Tgl. : 17-Mei-2021
Date JB02252102605
RefNo :

No. Polis : 1JB02252102490

Policy No.
Nama & Alamat Tertanggung : HAMDATUN RAKHMANIA (MHOPS00003)
Name & Address of Insured JL. ADIYAKSA NO. 92A RT. 005/002 KEL. KACANG PEDANG KEC. GERUNGGANG,
KOTA PANGKAL PINANG
No. Polisi : TBA
License Number
Jangka Waktu : 06/05/2021 - 06/05/2022 Jenis Asuransi : PSAKBI(Polis Std.
Period Type of Insurance As.Kendaraan Bermotor
Indonesia)
Effective Date : 06/05/2021

Catatan / Notes Perincian / Details

Please pay the amount shown in this Premium Note immediately to finalize the Premi : IDR 4,912,000.00
transaction. Payment should be made with a crossed cheque in the name Premium
PT.KSK Insurance Indonesia or transferred to our current account with one of
the following bank :
Premi Netto : IDR 4,912,000.00
For currency IDR (Indonesian Rupiah) : Net Premium
Bank BCA Kantor Cabang Pembantu Cyber II Biaya Polis : IDR 25,000.00
Gedung Cyber II, Lantai Dasar Policy Cost
Jl. H.R. Rasuna Said Blok X-5 Kav. 13 – Jakarta
Acc No : 6070326505 Biaya Materai : IDR 10,000.00
Duty Cost
For currency USD (United States Dollar) : Jumlah : IDR 4,947,000.00
Bank Danamon Cabang Comm Desk Jakarta Total
Ciputra World – DBS Bank Tower 24 Floor
Jl. Prof. Dr. Satrio Kav 3 – 5 Jakarta
Acc No : 72590326
SWIFT CODE : BDINIDJA

Please indicate the Policy No or Note No in the message column on the transfer slip, should payment be PT.KSK Insurance Indonesia
made using bank transfer.

Nota Premi ini bukan merupakan tanda bukti pembayaran. PN0000000I.rpt / Nydia
This Premium Note is not a receipt.