Fine Certificate ‫ﺷﻬﺎﺩﺓ ﺍﻟﻤﺨﺎﻟﻔﺔ‬

Fine barcode ©FC2023120501936r¬ ‫ﺑﺎﺭﻛﻮﺩ ﺍﻟﻤﺨﺎﻟﻔﺔ‬

Fine Certificate No. FC2023120501936 ‫ﺭﻗﻢ ﺷﻬﺎﺩﺓ ﺍﻟﻤﺨﺎﻟﻔﺔ‬

EID/UID/TL No: 784198972093797 /‫ ﺍﻟﺮﻗﻢ ﺍﻟﻤﻮﺣﺪ‬/‫ﻫﻮﻳﺔ ﺍﻹﻣﺎﺭﺍﺕ‬
:‫ﺍﻟﺮﺧﺼﺔ ﺍﻟﺘﺠﺎﺭﻳﺔ‬
Fine Generation Date: 05/12/2023 :‫ﺗﺎﺭﻳﺦ ﺇﺻﺪﺍﺭ ﺍﻟﻤﺨﺎﻟﻔﺔ‬
Fine Payment Due Date: 08/12/2023 :‫ﺗﺎﺭﻳﺦ ﺍﺳﺘﺤﻘﺎﻕ ﺍﻟﻤﺨﺎﻟﻔﺔ‬
Policyholder Name: GILANG NOVIANDI ‫ﺍﺳﻢ ﺣﺎﻣﻞ ﺍﻟﻮﺛﻴﻘﺔ‬

Fine statement issued for the forgoing facility as per ‫ﻛﺸﻒ ﺑﻴﺎﻥ ﺍﻟﻐﺮﺍﻣﺎﺕ ﺍﻟﻤﺘﺮﺗﺒﺔ ﻋﻠﻰ ﺍﻟﻤﻨﺸﺄﺓ ﺃﻋﻼﻩ‬
template no (4) attached in the Executive Regulation of
‫( ﺍﻟﻤﻠﺤﻖ ﺑﺎﻟﻼﺋﺤﺔ ﺍﻟﺘﻨﻔﻴﺬﻳﺔ‬4) ‫ﺑﻤﻮﺟﺐ ﺍﻟﺠﺪﻭﻝ ﺭﻗﻢ‬
the Law no (23/2005) on the health insurance system in
the Emirate of Abu Dhabi. ‫ ﺑﺸﺄﻥ ﺍﻟﻀﻤﺎﻥ ﺍﻟﺼﺤﻲ‬2005 ‫ ﻟﺴﻨﺔ‬23 ‫ﻟﻠﻘﺎﻧﻮﻥ ﺭﻗﻢ‬
.‫ﺑﺈﻣﺎﺭﺓ ﺃﺑﻮﻇﺒﻲ‬
Total Fine Monthly Fine Number of Number of Months The Period Employee Name Serial No.
(AED) (AED) Fine from the where the worker is during which ‫ﺍﺳﻢ ﺍﻟﻌﺎﻣﻞ‬ ‫ﺭﻗﻢ ﺗﺴﻠﺴﻠﻲ‬
‫ﺇﺟﻤﺎﻟﻲ‬ ‫ﺍﻟﻐﺮﺍﻣﺔ ﺷﻬﺮﻳﺎ‬ template No not Enrolled under the Employee
‫ﺍﻟﻐﺮﺍﻣﺔ‬ (‫)ﺩﺭﻫﻢ‬ (4) the Health is not Insured
(‫)ﺩﺭﻫﻢ‬ ‫ﺭﻗﻢ ﺍﻟﻤﺨﺎﻟﻔﺔ ﻣﻦ‬ Insurance Policy ‫ﺍﻟﻔﺘﺮﺓ ﻏﻴﺮ ﺍﻟﻤﺆﻣﻦ‬
(4) ‫ﺍﻟﺠﺪﻭﻝ ﺭﻗﻢ‬ ‫ﻋﺪﺩ ﺍﻷﺷﻬﺮ ﺍﻟﺘﻲ ﻓﻴﻬﺎ‬ ‫ﺧﻼﻟﻬﺎ ﻋﻠﻰ‬
‫ﻋﺪﻡ ﺍﺷﺘﺮﺍﻙ ﺑﺎﻟﻀﻤﺎﻥ‬ ‫ﺍﻟﻌﺎﻣﻞ‬
‫ﺍﻟﺼﺤﻲ ﻋﻦ ﺍﻟﻌﺎﻣﻞ‬
05/10/2023 to
300 1 1 29/11/2023 (55 FADILA FARADHI 1
300
days)
Total Fines (AED)
300
:(‫ﺍﻹﺟﻤﺎﻟﻲ ﺍﻟﻜﻠﻲ ﻟﻠﻐﺮﺍﻣﺎﺕ ﺃﻋﻼﻩ )ﺩﺭﻫﻢ‬

Please note that the fine payable by you is calculated
up to the date set out above. Please ensure that the
fine is paid within three calendar days of the date set
out above. Any delay in the payment of the fine will
require a recalculation of the fine payable.
‫ﻧﻔﻴﺪﻛﻢ ﺑﺄﻧﻪ ﺗﻢ ﺍﺣﺘﺴﺎﺏ ﺍﻟﻤﺨﺎﻟﻔﺔ ﺍﻟﻤﺴﺘﺤﻘﺔ ﻋﻠﻴﻜﻢ‬
‫ ﻳﺮﺟﻰ ﺍﻟﺘﺄﻛﺪ ﻣﻦ ﺩﻓﻊ‬.‫ﺣﺘﻰ ﺍﻟﺘﺎﺭﻳﺦ ﺍﻟﻤﺤﺪﺩ ﺃﻋﻼﻩ‬
‫ﺍﻟﻐﺮﺍﻣﺔ ﺧﻼﻝ ﺛﻼﺙ ﺃﻳﺎﻡ ﺗﻘﻮﻳﻤﻴﺔ ﻣﺤﺘﺴﺒﺔ ﻣﻦ‬
‫ ﻭﻧﻨﻮﻩ ﺑﺄﻥ ﺃﻱ ﺗﺄﺧﻴﺮ ﻓﻲ ﺳﺪﺍﺩ‬.‫ﺍﻟﺘﺎﺭﻳﺦ ﺍﻟﻤﺤﺪﺩ ﺃﻋﻼﻩ‬
‫ﺍﻟﻐﺮﺍﻣﺎﺕ ﺳﻴﺆﺩﻱ ﺇﻟﻰ ﺇﻋﺎﺩﺓ ﺍﺣﺘﺴﺎﺏ ﺍﻟﻐﺮﺍﻣﺔ‬
.‫ﺍﻟﻤﺴﺘﺤﻘﺔ‬

MEMBER CONFIDENTIAL │ 10953R01 │ 1 of 1