Insurance Certificate

Carles Tarigan
COSL Indo Cat - 1 Medical + Dental
Indonesia

Policy number: P004178494

Group scheme: COSL Indo Cat - 1 Medical + Dental / 68286
Start date: 18 Mar 2023
Renewal date: 01 Mar 2024
Contract currency: USD

Policyholder: Carles Tarigan, 22 Sep 1976

Area of cover: Summit - Worldwide excluding USA
Core Plan: COSL Indo Cat 1 Core Plan
Out-patient Plan: COSL Indo Cat 1 Out-patient Plan
Dental Plan: COSL Indo Cat 1 Dental Plan
Additional cover: COSL Indo Cat 1 Maternity Plan
Additional cover: COSL Indo Cat 1 Repatriation
Additional cover: COSL Indo Cat 1 Wellness Plan
Underwriting terms: Non-underwritten

The applicable conditions are the Company Agreement and the employee terms and conditions. The terms
and conditions are detailed in your Employee Benefit Guide.

Please verify the policy details on this certificate and let us know within 30 days of receipt if any corrections
are necessary.

If you have any questions or need any help, please email us at: client.services@allianzworldwidecare.com. Or
you can call our Helpline 24 hours a day, 7 days a week on: + 353 1 630 1301.

Yours sincerely,

Mark Mackin Eamonn O'Flynn

Manager – Policy Management Head of Operations
Allianz Care Allianz Care

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Board of Directors - Members: Tomas Kunzmann (German), Lidia Luka-Lognoné (Polish), Jean-Marc Pailhol (French). AWP Health & Life SA, acting through its Irish Branch, is a limited
company governed by the French Insurance Code. Registered in France: No. 401 154 679 RCS Bobigny. Irish Branch registered in the Irish Companies Registration Office, registered No.:
907619, address: 15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland. Allianz Care and Allianz Partners are registered business names of AWP Health & Life SA.