To : Juliyani Number : 008.50.201.23.

000755

Jl. Lingkungan Desa Dwi Warga Tunggal Jaya Dates : July 13, 2023
RT.06 RW.04 Kel. Dwi Warga Tunggal Jaya Kec. Branch : Bandar Lampung
Banjar Agung Kab. Tulang Bawang Provonsi
Lampung

DEBIT NOTE

Policy Number : 008.4050.201.2023.000492.00

Your Reference : -
Period : From July 12, 2023 To July 12, 2024
Total Sum Insured / Limit : IDR 5,600,000,000.00
Class of Business : Fire
Description : -

Details : Premium : IDR 7,110,400.00

Administration Cost : IDR 19,000.00
Stamp Duty : IDR 10,000.00
Total : IDR 7,139,400.00

Due By : August 14, 2023

TOTAL : IDR 7,139,400.00

AUTHORIZED SIGNATURE

IMPORTANT
This is not a proof of payment
Method of payment :
1. Virtual Account :
- BCA ( ATM, E-banking, LLG / RTGS, and Cash deposit at Bank BCA counters ).
- DANAMON ( ATM, E-banking, LLG / RTGS, and Cash deposit at Bank DANAMON counters ).
- MANDIRI ( ATM, E-banking, LLG / RTGS, and Cash deposit at Bank MANDIRI counters ).
- BNI ( ATM, E-banking, LLG / RTGS, and Cash deposit at Bank BNI counters ).
- INDOMARET (Kasir, i-Kios, i-Saku, Klik Indomaret).
2. Transfer to PT. Asuransi Wahana Tata account,
at Mandiri B.Lampung (Giro) - BANDARLAMPUNG, account number: 114.0086000.117
3. Cross Cheque payable to PT. Asuransi Wahana Tata
4. Credit Card ( Visa / Master Card / BCA Card )
(please call our Finance Department Staff, at phone number : 0721-482853 )

Your Virtual Account Number / Payment Code :

- BCA : 00029 0085 0201 2300 0755
- DANAMON : 8999 2307 0080 0467
- MANDIRI : 89342 2307 0800 467
- BNI : 9885 9953 0080 0467
- INDOMARET : 2307 0080 0467
In the event that the premium payment time has passed the grace period as provided in the Policy/Debit Note,
then claims that occur before premium payment is made are not guaranteed and PT Asuransi Wahana Tata is
released from all responsibilities.

PT.ASURANSI WAHANA TATA CABANG BANDAR LAMPUNG Page 1 / 1

JL. LAKSAMANA MALAHAYATI NO. 43
TELP. 0721-482853. FAX. 0721-481644