Original

No. : 014019/DN/01/09/21 PREMIUM NOTE

Tgl. : September 13, 2021
Date
RefNo : RENEWAL 108021901403

No. Polis : 10102012108368

Policy No.
Nama & Alamat Tertanggung : ALEXANDER
Name & Address of Insured TAMAN GRISENDA BLOK H 2 NO.28 RT.07/03 KAPUK MUARA PENJARINGAN JAKARTA
UTARA
Nama & Alamat Penagih : ALEXANDER
Name & Address Collector TAMAN GRISENDA BLOK H 2 NO.28 RT.07/03 KAPUK MUARA PENJARINGAN JAKARTA
UTARA
No Polisi Kendaraan. : B-1594-UJI
Vehicle License No.
Jangka Waktu : September 23, 2021 - September 23, 2022 Jenis Asuransi : PSAKBI
Period Type of Insurance

Catatan / Notes Perincian / Details

Please pay the amount shown in this Premium Note immediately to finalize the Premi : IDR 6,936,800.00
transaction. Payment should be made with a crossed cheque in the name PT Premium
ASURANSI HARTA AMAN PRATAMA, TBK. or transferred to our current account
with one of the following bank : Premi Netto : IDR 6,936,800.00
Net Premium
- BANK CENTRAL ASIA Virtual Account No. 0887910102012108368 Biaya Polis : IDR 35.000,00
Biaya Materai : IDR 20.000,00
Note : Rekening virtual account dapat digunakan 2 hari kerja setelah tanggal 13/09/2021
Jumlah : IDR 6,991,800.00
Total

Please indicate the Policy No or Note No in the message column on the transfer slip, should payment be PT ASURANSI HARTA AMAN PRATAMA, TBK.
made using bank transfer.

Nota Premi ini bukan merupakan tanda bukti pembayaran. PN0000000I / M08WI0002 / HOFIFI
This Premium Note is not a receipt.