Statement of Accounts

07 December 2023

Re: Policy number: Policy start date: Policy renewal date:

P003880613 01/01/2023 01/01/2024

Claim number: C26492735

Invoice 1
Insured member: Tjossy Mitaart Sipasulta
Invoice date: 25 November 2023
Provider: Optik Melawai

Invoice currency Contract currency Payment currency Adjustment reason

Invoice Amount
IDR 14,745,000.00 CHF 839.29 IDR 14,745,000.00
Deductions
●
IDR 3,325,526.40 CHF 189.29 IDR 3,325,526.40 Excluded under terms
and conditions: Kindly
note that your optical
ceiling was not enough
to cover your expenses.
As soon as your contract
is extended, submit a
copy of this form for
adjustment.
Reimbursable amount (payment currency amount is highlighted in bold below)
IDR 11,419,473.60 CHF 650.00 IDR 11,419,473.60

If you have any questions or need any help, please email us at: IOM.Helpline@Allianz.com. Or you can call
our Helpline 24 hours a day, 7 days a week on: +353 1 629 7199.

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AWP Health & Life Services Limited (Allianz Care) is the administrator of your policy. AWP Health & Life Services Limited is registered in Ireland. Registered Office: 15 Joyce Way,
Park West Business Campus, Nangor Road, Dublin 12. Allianz Care and Allianz Partners are registered business names of AWP Health & Life Services Limited.