REKAP TRANSAKSI ASURANSI ADMEDIKA PHEWMO PER

MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 1/5/2019 AIDAN MUHSHI NARASENA 19070638-2 PT PHE WMO 8000100609301644
2 1/5/2019 ANINDYA NARASENA 19070638 PT PHE WMO 8000100690301677

TOTAL
ANSI ADMEDIKA PHEWMO PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

1.0005/B/01/2019 PRWT GIGI 1105.0 Rp 725,000.00
1.0006/B/01/2019 B.OBAT & PRWT GIGI 1105.0 Rp 785,000.00

Rp 1,510,000.00
 TOTAL ASURANSI
Rp 725,000.00
Rp 785,000.00

Rp 1,510,000.00
 REKAP TRANSAKSI ASURANSI ALLIANZ PERI
MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 1/11/2019 HILMA FITHRI NAQIYA APKAS-01985 APLIKASI KARY 8000210114084948
2 1/12/2019 GINANJAR CAHYA KOMARA APKAS-01984 APLIKASI KARY 8000210114084955
3 1/12/2019 FITIYA YUMNI MUTHMAINNAH APKAS-01986 APLIKASI KARY 8000210114084922

TOTAL
ASURANSI ALLIANZ PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

1.0018/B/01/2019 R.PENCEGAHAN 1105.0 Rp 625,000.00
1.0020/B/01/2019 R.PENCEGAHAN 1105.0 Rp 625,000.00
1.0019/B/01/2019 R.DASAR 1102 Rp 2,205,000.00

Rp 3,455,000.00
 TOTAL ASURANSI
Rp 625,000.00
Rp 625,000.00
Rp 2,205,000.00

Rp 3,455,000.00
 REKAP TRANSAKSI ASURANSI ASTRA LIFE PERI
MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/6/2019 TUBAGUS EKA IMAL MAULANA 00156-00 PT. TETRA PAK INDONESIA
2 1/6/2019 RATU AISYAH AZZAHRA 00156-02 PT. TETRA PAK INDONESIA
3 1/6/2019 OKTAVIYANTI 00156-01 PT. TETRA PAK INDONESIA

TOTAL
NSAKSI ASURANSI ASTRA LIFE PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000151014409750 1.0008/B/01/2019 R.DASAR 1105.0 Rp475,000.00
8000151014409740 1.0010/B/01/2019 R.DASAR 1102 Rp755,000.00
8000151014409730 1.0014/B/01/2019 R.DASAR 1105.0 Rp1,225,000.00

Rp2,455,000.00
TOTAL ASURANSI
Rp475,000.00
Rp755,000.00
Rp1,225,000.00

Rp2,455,000.00
 REKAP TRANSAKSI ASURANSI AXA MANDIRI PER
MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/12/2019 ANDY ARVID 00406-00 AXA SERVICES INDONESIA
2 1/12/2019 EMILY MALVINA KIARA 00406-02 AXA SERVICES INDONESIA

TOTAL
SAKSI ASURANSI AXA MANDIRI PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000198200897754 1.0022/B/01/2019 R.DASAR 1105.0 Rp 625,000.00
8000198200897747 1.0024/B/01/2019 R.DASAR 1105.0 Rp 225,000.00

Rp 850,000.00
 TOTAL ASURANSI
Rp 625,000.00
Rp 225,000.00

Rp 850,000.00
 REKAP TRANSAKSI ASURANSI BNI LIFE PER
MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 1/6/2019 NALAJUNA ALEGASHA P037609-3 BANK BNI (Persero) Tbk 8000103001785406

TOTAL
ASURANSI BNI LIFE PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

1.0012/B/01/2019 R.DASAR 1102 Rp 1,770,000.00 Rp 177,000.00 Rp 1,593,000.00

Rp 1,770,000.00 Rp 177,000.00 Rp 1,593,000.00

 REKAP TRANSAKSI ASURANSI GENERALI PERIOD
MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 1/6/2019 AHMAD SAMIY BASYAEB 000490-3 PT. DHL EXEL SUPPLY 8000103100959399
2 1/6/2019 SHOFIA SYAHAR BANU 000490-4 PT. DHL EXEL SUPPLY 8000103102985491

TOTAL
RANSI GENERALI PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

5.0009/B/01/2019 R.DASAR 1102 Rp 935,000.00 Rp 935,000.00
5.0007/B/01/2019 R.DASAR 1102 Rp 890,000.00 Rp 325,000.00 Rp 565,000.00

Rp 1,825,000.00 Rp 325,000.00 Rp 1,500,000.00

 REKAP TRANSAKSI ASURANSI LIPPO PERI
MEDIKIDS DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/2/2019 YONYTA RAMADHANI FINESSA NH0988-2 PT AGINCOURT RESOURCES
2 1/12/2019 CASSIEL RAHMADHANIA CN007018-2 PT BANK CIMB NIAGA TBK
3 1/13/2019 YONYTA RAMADHANI FINESSA NH0988-2 PT AGINCOURT RESOURCES

TOTAL
P TRANSAKSI ASURANSI LIPPO PERIODE 1-15 JANUARI 2019
MEDIKIDS DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000172304763280 1.0002/B/01/2019 PRWTN GIGI 1102 Rp1,085,000.00
8000172304857105 1.0026/B/01/2019 R.DASAR 1102 Rp 2,250,000.00 Rp 450,000.00
8000172304763287 1.0028/B/01/2019 PRWTN GIGI 1102 Rp 1,870,000.00

Rp 5,205,000.00
 TOTAL ASURANSI
Rp1,085,000.00
Rp 1,800,000.00
Rp 1,870,000.00

Rp 4,755,000.00
 NO ASURANSI TOTAL YG DIBYR ASURANSI
1 PHEWMO Rp 1,510,000.00
2 ALLIANZ Rp 3,455,000.00
3 ASTRA LIFE Rp 2,455,000.00
4 AXA MANDIRI Rp 850,000.00
5 BNI LIFE Rp 1,593,000.00
6 GENERALI Rp 1,500,000.00
7 LIPPO Rp 4,755,000.00

TOTAL Rp 16,118,000.00
Rp 16,118,000.00
Rp -
 REKAP TRANSAKSI ASURANSI EQUITY PERIO
MEDIKIDS WAKAF DE

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/19/2019 FELICIA EZRA ABIGAIL 2017007620-2 CARDNO EMERGING MARKETS

TOTAL
AP TRANSAKSI ASURANSI EQUITY PERIODE 16-31 JANUARI 2019
MEDIKIDS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000181504093494 1.0032/B/01/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00

AL Rp 325,000.00
 TOTAL ASURANSI
Rp 325,000.00

Rp 325,000.00
 REKAP TRANSAKSI ASURANSI BNI LIFE PE
MEDIKIDS WAKAF D

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/19/2019 ABDULLAH GHOFFAR IB WKP-KES00174B WIJAYA KARYA (PERSERO)
2 1/20/2019 ZAKY ALVARONIZAM SUBP037914-3 BANK BNI (Persero) Tbk

TOTAL
KAP TRANSAKSI ASURANSI BNI LIFE PERIODE 16-31 JANUARI 2019
MEDIKIDS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000103006525500 1.0040/B/01/2019 PRWTN GIGI 1105.0 Rp 325,000.00
8000103001888036 1.0043/B/01/2019 R.DASAR 1102 Rp 1,180,000.00

AL Rp 1,505,000.00
 EKSES TOTAL ASURANSI
Rp 325,000.00
Rp 118,000.00 Rp 1,062,000.00

Rp 118,000.00 Rp 1,387,000.00
 REKAP TRANSAKSI ASURANSI LIPPO PE
MEDIKIDS WAKAF

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/19/2019 STEVE LEMUEL TIMOTHY CN026852-2 PT BANK CIMB NIAGA TBK
2 1/19/2019 MALIIKA OLESYA EFELO CN030841-2 PT BANK CIMB NIAGA TBK
3 1/19/2019 CASSIEL RAHMADHANIA CN007018-2 PT BANK CIMB NIAGA TBK

TOTAL
KAP TRANSAKSI ASURANSI LIPPO PERIODE 16-31 JANUARI 2019
MEDIKIDS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000172303962054 1.0030/B/01/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00
8000172303822209 1.0034/B/01/2019 R.PENCEGAHAN 1102 Rp 1,360,000.00
8000172304857105 1.0038/B/01/2019 R.DASAR 1102 Rp 650,000.00

L Rp 2,335,000.00
 EKSES TOTAL ASURANSI
Rp 325,000.00
Rp 1,360,000.00
Rp 130,000.00 Rp 520,000.00

Rp 130,000.00 Rp 2,205,000.00
 REKAP TRANSAKSI ASURANSI ADMEDIKA PRUDENTIA
MEDIKIDS WAKAF DEPO

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/19/2019 ANAS TABITA HUTASOIT 1003942 FINANCIAL SERVICE CONSU

TOTAL
NSAKSI ASURANSI ADMEDIKA PRUDENTIAL PERIODE 16-31 JANUARI 2019
MEDIKIDS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000100611933921 1.0036/B/01/2019 PRWTN GIGI 1105.0 Rp 725,000.00

TAL Rp 725,000.00
 TOTAL ASURANSI
Rp 725,000.00

Rp 725,000.00
 REKAP TRANSAKSI ASURANSI R
MEDIKDIS

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 1/20/2019 DAPUNTA RASYDAN ABROR 000063-3 PT. LOTTE MART INDONESI

TOTAL
REKAP TRANSAKSI ASURANSI RELIANCE PERIODE 16-31 JANUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA

8000172512316548 1.0044/B/01/2019 PRWTN GIGI DASAR & PENCEGAHAN 1102

TOTAL
 TOTAL INVOICE EKSES TOTAL ASURANSI
Rp 675,000.00 Rp 67,500.00 Rp 607,500.00

Rp 675,000.00 Rp 67,500.00 Rp 607,500.00

 NO ASURANSI TOTAL YG DIBYR ASURANSI
1 RELAINCE 607,500
2 PRUDENTIAL 725,000
3 LIPPO 2,205,000
4 BNI LIFE 1,387,000
5 EQUITY 325,000

TOTAL 5,249,500
 REKAP TRANSAKSI ASURANSI PERTAMINA HULU ENERGI
MEDIKDIS WAKAF

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/10/2019 ARKANANTA DYLAN NARESWARA 19050166-3 PT PERTAMINA HULU ENERG
2 2/10/2019 ANNISA KAISA RIZQI 19050166-2 PT PERTAMINA HULU ENERG

TOTAL
I PERTAMINA HULU ENERGI (PHE) GROUP PERIODE 1-15 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000100612042011 6.0197/B/02/2019 PRWT GIGI 1102 Rp 1,975,000.00
8000100604045410 6.0196/B/02/2019 PRWT GIGI 1102 Rp 2,400,000.00

Rp 4,375,000.00
 TOTAL ASURANSI
Rp 1,975,000.00
Rp 2,400,000.00

Rp 4,375,000.00
 REKAP TRANSAKSI ASURANSI BNI LIF
MEDIKDIS WAK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/2/2019 M. FARHAN ATHAILLAH PUTRA WKP-KES00112C WIJAYA KARYA (PERSERO)
2 2/2/2019 FITHRIYANI MAHDIYAH SALMA. WKP-KES00112B WIJAYA KARYA (PERSERO)
3 2/2/2019 PRIHASTUTI FAJAR HANDAYANI WKP-KES00112 WIJAYA KARYA (PERSERO)
4 2/9/2019 AQILAH NAJMA DARMAWANTO P047374-3 BANK BNI (Persero) Tbk

TOTAL
SAKSI ASURANSI BNI LIFE PERIODE 1-15 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000103004730680 6.0156/B/02/2019 PRWT GIGI 1105.0 Rp 1,100,000.00
8000103004730672 6.0161/B/02/2019 PRWT GIGI 1105.0 Rp 725,000.00
8000103004730698 6.0160/B/02/2019 PRWT GIGI 1102 Rp 1,425,000.00
8000103003182222 6.0178/B/02/2019 R.DASAR 1104.1 Rp 525,000.00 Rp 52,500.00

Rp 3,775,000.00 Rp 52,500.00
 TOTAL ASURANSI
Rp 1,100,000.00
Rp 725,000.00
Rp 1,425,000.00
Rp 472,500.00

Rp 3,722,500.00
 REKAP TRANSAKSI ASURANSI FWD
MEDIKDIS WAK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/10/2019 OLAV AQUILINO ANGGORO 00747-02 PT RUANG RAYA INDONESIA
2 2/10/2019 WISNU ANGGORO 00747-00 PT RUANG RAYA INDONESIA
3 2/10/2019 OLIVER AMADEO ANGGORO 00747-03 PT RUANG RAYA INDONESIA
4 2/10/2019 OMARDANA SATRIA SUKANDAR 00519-02 PT SOMPO INSURANCE INDO

TOTAL
REKAP TRANSAKSI ASURANSI FWD PERIODE 1-15 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000100617725586 6.0201/B/02/2019 PRWTN GIGI 1102 Rp 1,925,000.00
8000100617725610 6.0199/B/02/2019 PRWTN GIGI 1102 Rp 525,000.00
8000100617725594 6.0203/B/02/2019 PRWTN GIGI 1102 Rp 1,425,000.00
8000100611876559 6.0205/B/02/2019 R.DASAR & R.PENCEGAHAN 1102 Rp 1,800,000.00

TOTAL Rp 5,675,000.00
EKSES TOTAL ASURANSI
Rp 1,925,000.00
Rp 525,000.00
Rp 1,425,000.00
Rp 1,800,000.00

Rp 5,675,000.00
 REKAP TRANSAKSI ASURANSI LIPPO PERIO
MEDIKDIS WAKAF DEP

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/2/2019 CASSIEL RAHMADHANIA CN007018-2 PT BANK CIMB NIAGA TBK
2 2/2/2019 MALIIKA OLESYA EFELO CN030841-2 PT BANK CIMB NIAGA TBK

TOTAL
REKAP TRANSAKSI ASURANSI LIPPO PERIODE 1-15 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000172304857100 6.0154/B/02/2019 R.DASAR 1104.1 Rp 940,000.00 Rp 188,000.00
8000172303822209 6.0143/B/02/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00

OTAL Rp 1,265,000.00 Rp 188,000.00

 TOTAL ASURANSI
Rp 752,000.00
Rp 325,000.00

Rp 1,077,000.00
 REKAP TRANSAKSI ASURANSI RELIANCE PE
MEDIKDIS WAKAF D

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/2/2019 DAPUNTA RASYDAN ABROR 000063-3 PT. LOTTE MART INDONESI

TOTAL
REKAP TRANSAKSI ASURANSI RELIANCE PERIODE 1-15 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000172512316548 6.0149/B/02/2019 RAWAT GIGI DASAR 1102 Rp 875,000.00

TOTAL Rp 875,000.00
 EKSES TOTAL ASURANSI
Rp 182,500.00 Rp 692,500.00

Rp 182,500.00 Rp 692,500.00
 REKAP TRANSAKSI ASURANSI SINARMAS PERIO
MEDIKDIS WAKAF DEPO

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/9/2019 DINA ANDRIANDINI 080001215919_9003 PT BANK BUKOPIN, TBK

TOTAL
P TRANSAKSI ASURANSI SINARMAS PERIODE 1-15 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000151118563372 6.0185/B/02/2019 PRWTN GIGI 1104.1 Rp 5,725,000.00

TAL Rp 5,725,000.00
 TOTAL ASURANSI
Rp 5,725,000.00

Rp 5,725,000.00
 NO ASURANSI TOTAL YG DIBYR ASURANSI
1 SINARMAS Rp 5,725,000.00
2 RELIANCE Rp 692,500.00
3 LIPPO Rp 1,077,000.00
4 FWD Rp 5,675,000.00
5 BNI LIFE Rp 3,722,500.00
6 PHE_HO Rp 4,375,000.00

TOTAL Rp 21,267,000.00
 REKAP TRANSAKSI ASURANSI PHEWMO PERIODE 16-28
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 2/22/2019 NAJMI BAHIYA NARASENA 19070638-3 PT PHE WMO 8000100609301651

TOTAL
 ANSI PHEWMO PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

6.0285/B/02/2019 PRWT GIGI 1102 Rp 1,600,000.00 Rp 1,600,000.00

Rp 1,600,000.00 Rp 1,600,000.00
 REKAP TRANSAKSI ASURANSI ALLIANZ PER
MEDIKDIS WAKAF D

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/17/2019 GINANJAR CAHYA KOMARA APKAS-01984 APLIKASI KARYA ANAK BAN
2 2/23/2019 I MADE WIRADHIKA PRADNYANA BAYIA-01067 BAYER INDONESIA (GROUP)
3 2/23/2019 NI PUTU WISTARANI PRADNYANI BAYIA-01066 BAYER INDONESIA (GROUP)
4 2/23/2019 SHAQUILLA DIVYANISA SYAMSUAR MIDTR-00324 DOMPET ANAK BANGSA, PT

TOTAL
RANSAKSI ASURANSI ALLIANZ PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000210114084955 6.0247/B/02/2019 R.DASAR 1102 Rp 1,025,000.00
8000210110630686 6.0315/B/02/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00
8000210110630694 6.0313/B/02/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00
8000210113979262 6.0328/B/02/2019 R.PENCEGAHAN 1105.0 Rp 400,000.00

Rp 2,075,000.00
 TOTAL ASURANSI
Rp 1,025,000.00
Rp 325,000.00
Rp 325,000.00
Rp 400,000.00

Rp 2,075,000.00
 REKAP TRANSAKSI ASURANSI ANGKASA PURA
MEDIKDIS WAKAF D

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/17/2019 TEGAR ZAFRAN MUKMIN ARROSYID 20002105-3 KC BANDARA HALIM PERDAN
2 2/17/2019 AISHA ABRAR FAHIMA KHAIRUNNISA 20002105-4 KC BANDARA HALIM PERDAN

TOTAL
I ASURANSI ANGKASA PURA II PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000100615814267 6.0250/B/02/2019 PRWTN GIGI 1102 Rp 1,450,000.00
8000100618643689 6.0251/B/02/2019 PRWTN GIGI 1102 Rp 750,000.00

Rp 2,200,000.00
 TOTAL ASURANSI
Rp 1,450,000.00
Rp 750,000.00

Rp 2,200,000.00
 REKAP TRANSAKSI ASURANSI ASTRA LIFE PER
MEDIKDIS WAKA

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

4 2/23/2019 AGUNG SAMBODO 00002-00 PT. EMA INTI MITRA
5 2/23/2019 RAZZAN ATH THAARIQ 00002-02 PT. EMA INTI MITRA
6 2/23/2019 RAZIQ ALTHAF ARSHAQ SAMBODO 00002-03 PT. EMA INTI MITRA

TOTAL
KAP TRANSAKSI ASURANSI ASTRA LIFE PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000151015022399 6.0304/B/02/2019 R.DASAR 1102 Rp 225,000.00
8000151015022373 6.0309/B/02/2019 R.DASAR 1102 Rp 1,825,000.00 Rp 670,000.00
8000151015022365 6.0306/B/02/2019 R.DASAR 1101.1 Rp 425,000.00

AL Rp 2,475,000.00 Rp 670,000.00
 TOTAL ASURANSI
Rp 225,000.00
Rp 1,155,000.00
Rp 425,000.00

Rp 1,805,000.00
 REKAP TRANSAKSI ASURANSI AVRIST PERIODE 16
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 2/17/2019 NABIL AKRAM 001961-3 JASA TEKNOLOGI INFORMAS 8000103504299079

TOTAL
ASURANSI AVRIST PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

6.0254/B/02/2019 R.DASAR 1102 Rp 940,000.00 Rp 188,000.00

Rp 940,000.00 Rp 188,000.00
 TOTAL ASURANSI
Rp 752,000.00

Rp 752,000.00
 REKAP TRANSAKSI ASURANSI B
MEDIKDIS

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/16/2019 AQUINNA RAFANDA WIJAYA BNIS-0073886B PT. BANK BNI SYARIAH
2 2/17/2019 SETYA BHAKTI ARUMBUDI PRN-KES00552A PERUMNAS
3 2/23/2019 NADINE PRN-KES00552C PERUMNAS
4 2/23/2019 RAFANDRA AUDISYA FAHRY PRN-KES00552B PERUMNAS
5 2/23/2019 ROSAYU AULIA DE REZA PRN-KES00552 PERUMNAS

TOTAL
REKAP TRANSAKSI ASURANSI BNI LIFE PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000103004174319 6.0240/B/02/2019 R.DASAR 1102 Rp 2,100,000.00
8000103003406464 6.0245/B/02/2019 R.PENCEGAHAN 1105.0 Rp 725,000.00
8000103003406449 6.0289/B/02/2019 R.PENCEGAHAN 1105.0 Rp 700,000.00
8000103003406456 6.0287/B/02/2019 R.PENCEGAHAN 1105.0 Rp 1,000,000.00
8000103003406472 6.0293/B/02/2019 R.DASAR & R.PENCEGAHAN 1102 Rp 1,525,000.00

OTAL Rp 6,050,000.00
 EKSES TOTAL ASURANSI
Rp 1,100,000.00 Rp 1,000,000.00
Rp 725,000.00
Rp 700,000.00
Rp 1,000,000.00
Rp 1,525,000.00

Rp 1,100,000.00 Rp 4,950,000.00
 REKAP TRANSAKSI ASURANSI BNI SYARIAH PERIODE 16-28
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 2/24/2019 RAYYAN ABHISATYA ITSA-KES00005C PT ITSEC ASIA 8000100617370730

TOTAL
ANSI BNI SYARIAH PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

6.0332/B/02/2019 R.DASAR 1102 Rp 1,375,000.00 Rp 1,375,000.00

Rp 1,375,000.00 Rp 1,375,000.00
 REKAP TRANSAKSI ASURANSI FWD PE
MEDIKDIS WAKA

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 2/16/2019 ZUNAIRA HAFIDZA ALMAHYRA 00005-02 PT ISENTIA JAKARTA 8000100609625281
2 2/23/2019 TRI WINDU ANASTI 00865-00 PT XL AXIATA TBK 8000100612363607
3 2/23/2019 TIARA SALSABILA ANASTIAWAN 00865-02 PT XL AXIATA TBK 8000100612363581
4 2/23/2019 TALITA UFAIRA ANASTIAWAN 00865-03 PT XL AXIATA TBK 8000100612363599
5 2/23/2019 BAYU ARDIYANTO YUWONO 00787-00 PT BANK UOB INDONES8000100612167370
6 2/24/2019 NADEEN SIPAHUTAR 01510-02 PT XL AXIATA TBK 8000100612378837
7 2/24/2019 GUSTAF HARIYONO 01510-00 PT XL AXIATA TBK 8000100612378852
8 2/24/2019 PITRI RESERPINA 01510-01 PT XL AXIATA TBK 8000100612378845
9 2/26/2019 PITRI RESERPINA 01510-01 PT XL AXIATA TBK 8000100612378845
49 2/26/2019 SONY WICAKSONO 00293-00 PT HUTCHISON 3 INDON8000100618376439
63 2/28/2019 KALISHA JANETA WICAKSONO 00293-02 PT HUTCHISON 3 INDON8000100618376421

TOTAL
NSAKSI ASURANSI FWD PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

6.0238/B/02/2019 PRWT GIGI 1102 Rp 325,000.00
6.0291/B/02/2019 R.PENCEGAHAN 1105.0 Rp 725,000.00
6.0296/B/02/2019 R.DASAR 1102 Rp 790,000.00
6.0298/B/02/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00
6.0302/B/02/2019 PRWT GIGI 1102 Rp 1,125,000.00
6.0326/B/02/2019 R.PENCEGAHAN 1105.0 Rp 400,000.00
6.0322/B/02/2019 R.PENCEGAHAN 1105.0 Rp 725,000.00
6.0324/B/02/2019 R.PENCEGAHAN 1105.0 Rp 1,395,000.00
6.0347/B/02/2019 R.DASAR 1102 Rp 575,000.00
6.0349/B/02/2019 R.DASAR 1102 Rp 875,000.00
6.0354/B/02/2019 R.DASAR 1102 Rp 425,000.00

Rp 7,685,000.00
 TOTAL ASURANSI
Rp 325,000.00
Rp 725,000.00
Rp 790,000.00
Rp 325,000.00
Rp 1,125,000.00
Rp 400,000.00
Rp 725,000.00
Rp 1,395,000.00
Rp 575,000.00
Rp 875,000.00
Rp 425,000.00

Rp 7,685,000.00
 REKAP TRANSAKSI ASURANSI GENER
MEDIKDIS WA

NO TANGGAL NAMA PESERTA NO. PESERTA

1 2/17/2019 UBAYD IBNU RAUF 009961-4

TOTAL
 REKAP TRANSAKSI ASURANSI GENERALI PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

COMPANY NO KARTU NO INVOICE PERAWATAN DIAGNOSA

PT. BANK HSBC INDONESIA 8000103104005470 6.0261/B/02/2019 R.PENCEGAHAN 1105.0

TOTAL
 TOTAL INVOICE EKSES TOTAL ASURANSI
Rp 325,000.00 Rp 325,000.00

Rp 325,000.00 Rp 325,000.00
 REKAP TRANSAKSI ASURANSI LIPPO PERIODE 16-
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 2/21/2019 SITI NUR HAERLENA CN036653-1 PT BANK CIMB NIAGA TBK 8000172305322489
2 2/22/2019 LENNY HALISAPUTRI NH0988-0 PT AGINCOURT RESOURCES 8000172304763295

TOTAL
SURANSI LIPPO PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

6.0277/B/02/2019 R.DASAR 1104.1 Rp 475,000.00 Rp 475,000.00
6.0280/B/02/2019 R.PENCEGAHAN 1105.1 Rp 1,075,000.00 Rp 1,075,000.00

Rp 1,550,000.00 Rp 1,550,000.00
 REKAP TRANSAKSI ASURANSI UMUM
MEDIKDI

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/16/2019 ALTAIR RAFFASYA ALHUSEN OMO000422-2 SAHABAT MOBIL NUSANTARA
2 2/16/2019 RISTIA OKTORA OMO000422-1 SAHABAT MOBIL NUSANTARA
3 2/16/2019 BRAGA ARYASATYA RAMADHANU CURAH000013-2 HUMPUSS TRANSPORTASI CU

TOTAL
SAKSI ASURANSI UMUM MEGA CHS PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000100618461629 1.0048/B/02/2019 PRWT GIGI 1102 Rp 690,000.00
8000100618461637 1.0050/B/02/2019 PRWT GIGI 1102 Rp 1,175,000.00
8000100612973934 6.0230/B/02/2019 R.DASAR 1102.0 Rp 825,000.00

L Rp 2,690,000.00
EKSES TOTAL ASURANSI
Rp 690,000.00
Rp 1,175,000.00
Rp 825,000.00

Rp 2,690,000.00
 REKAP TRANSAKSI ASURANSI RELIANC
MEDIKDIS WAK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/17/2019 AMEENA KEIRRA PUTRI RAHADIAN 000095-3 PT TAISHO PHARMACEUTICA
2 2/17/2019 SHAREEN MALEEHA PUTRI RAHADIAN 000095-4 PT TAISHO PHARMACEUTICA

TOTAL
SAKSI ASURANSI RELIANCE PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000172512620246 6.0264/B/02/2019 PERAWATAN GIGI 1104.0 Rp 1,025,000.00
8000172512620253 6.0265/B/02/2019 PERAWATAN GIGI 1102 Rp 325,000.00

Rp 1,350,000.00
 TOTAL ASURANSI
Rp 1,025,000.00
Rp 325,000.00

Rp 1,350,000.00
 REKAP TRANSAKSI ASURANSI SINARMAS PERIO
MEDIKDIS WAKAF DEPO

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/16/2019 NARISYA WAFA ZAHIDAH 080001263665_360 PUSAT ADMINISTRASI UNIV

TOTAL
ANSAKSI ASURANSI SINARMAS PERIODE 16-28 FEBRUARI 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000151119007858 6.0234/B/02/2019 PRWT GIGI 1102 Rp 325,000.00

Rp 325,000.00
 TOTAL ASURANSI
Rp 325,000.00

Rp 325,000.00
 NO ASURANSI TOTAL YG DIBYR ASURANSI
1 SINARMAS Rp 325,000.00
2 RELIANCE Rp 1,350,000.00
3 MEGA INSURANCE Rp 2,690,000.00
4 LIPPO Rp 1,550,000.00
5 GENERALI Rp 325,000.00
6 FWD Rp 7,685,000.00
7 BNI SYARIAH Rp 1,375,000.00
8 BNI LIFE Rp 4,950,000.00
9 AVRIST Rp 752,000.00
10 ASTRA LIFE Rp 1,805,000.00
11 ANGKASA PURA 2 Rp 2,200,000.00
12 ALLIANZ Rp 2,075,000.00
13 PHEWMO Rp 1,600,000.00

TOTAL Rp 28,682,000.00
 REKAP TRANSAKSI ASURANSI ALLIANZ P
MEDIKDIS WAKAF D

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 3/8/2019 ASIH NURUL WARDHANI RUMAP-00574 RUMA, PT 8000210114174152
2 3/10/2019 ANDRESTA RAMADHAN SETIAWAN RUMAP-00573 RUMA, PT 8000210114174186
3 3/12/2019 ASIH NURUL WARDHANI RUMAP-00574 RUMA, PT 8000210114174152

TOTAL
KSI ASURANSI ALLIANZ PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

6.0423/B/03/2019 R.DASAR & R.PENCEGAHAN 1105.0 Rp 925,000.00
6.0435/B/03/2019 R.PENCEGAHAN 1105.0 Rp 775,000.00
6.0447/B/03/2019 R.DASAR 1104.1 Rp 1,225,000.00

Rp 2,925,000.00
 TOTAL ASURANSI CABANG
Rp 925,000.00
Rp 775,000.00
Rp 1,225,000.00

Rp 2,925,000.00
 REKAP TRANSAKSI ASURANSI ANGKASA PU
MEDIKDIS WAKAF

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 3/3/2019 AISHA ABRAR FAHIMA KHAIRUNNISA 20002105-4 KC BANDARA HALIM PERDAN
2 3/3/2019 TEGAR ZAFRAN MUKMIN ARROSYID 20002105-3 KC BANDARA HALIM PERDAN

TOTAL
AKSI ASURANSI ANGKASA PURA II PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000100618643689 6.0378/B/03/2019 PRWTN GIGI 1102 Rp 375,000.00
8000100615814267 6.0377/B/03/2019 PRWTN GIGI 1102 Rp 875,000.00

Rp 1,250,000.00
 TOTAL ASURANSI
Rp 375,000.00
Rp 875,000.00

Rp 1,250,000.00
 REKAP TRANSAKSI ASURANSI AVRIST PERIODE 1-1
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 3/10/2019 RAINNA SHANNON SOFIA 0000897-2 MUFG BANK, LTD 8000103502411783

TOTAL
SI ASURANSI AVRIST PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

6.0440/B/03/2019 R.PENCEGAHAN 1105.0 Rp 325,000.00 Rp 325,000.00

Rp 325,000.00 Rp 325,000.00
 REKAP TRANSAKSI ASURANSI AXA MANDIRI
MEDIKDIS WAKAF DE

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 3/3/2019 DHIANY RACHMA ESANINGTYAS 00460-00 AXA FINANCIAL INDONESIA
2 3/3/2019 RADHIKA ALVAREYNDRA SETYANTO 00460-02 AXA FINANCIAL INDONESIA

TOTAL
NSAKSI ASURANSI AXA MANDIRI PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000198200797491 6.0389/B/03/2019 R.DASAR 1102 Rp 1,075,000.00
8000198200797483 6.0391/B/03/2019 R.DASAR 1102 Rp 1,115,000.00

Rp 2,190,000.00
 TOTAL ASURANSI
Rp 1,075,000.00
Rp 1,115,000.00

Rp 2,190,000.00
 REKAP TRANSAKSI ASURANSI BCA LIFE PERIODE 1-
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY NO KARTU

1 3/2/2019 NOFI KUSTIARDI PTI000175-1 PT. PROFESIONAL TELEKOM 8000100613954107

TOTAL
I ASURANSI BCA LIFE PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES TOTAL ASURANSI

6.0366/B/03/2019 R.PENCEGAHAN 1105.0 Rp 625,000.00 Rp 625,000.00

Rp 625,000.00 Rp 625,000.00
 REKAP TRANSAKSI ASURAN
MEDIK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 3/3/2019 RAHADHIONO ADI SETYANTO SABW-0316010045 PT. SASMITA BUMI WIJAYA
2 3/13/2019 ALKHALIFI DZIKRI HADI AVB-KES00020B ADVANTIC BUSINESS, PT

TOTAL
REKAP TRANSAKSI ASURANSI BNI LIFE PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000103007187714 6.0395/B/03/2019 PERWATAN GIGI 1102 Rp 1,325,000.00
8000103006590975 6.0452/B/03/2019 R.DASAR & R.PENCEGAHAN 1102 Rp 1,175,000.00

AL Rp 2,500,000.00
 EKSES TOTAL ASURANSI
Rp 265,000.00 Rp 1,060,000.00
Rp 1,175,000.00

Rp 265,000.00 Rp 2,235,000.00
 REKAP TRANSAKSI ASURANSI FW
MEDIKDIS WA

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 3/1/2019 ALSYAZANI FAIREL ATHARIZZ CALI 00012-02 PT MSA INDONESIA
2 3/12/2019 ZHAFRAN NARARYA MUHAMMAD 00339-03 PT HUTCHISON 3 INDONESI

TOTAL
REKAP TRANSAKSI ASURANSI FWD PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000100616550720 6.0360/B/03/2019 PRWTN GIGI 1105.0 Rp 325,000.00
8000100618375837 6.0444/B/03/2019 R.DASAR & R.PENCEGAHAN 1102 Rp 675,000.00

OTAL Rp 1,000,000.00
EKSES TOTAL ASURANSI CABANG
Rp 325,000.00
Rp 675,000.00

Rp 1,000,000.00
 REKAP TRANSAKSI ASURANSI LIPPO
MEDIKDIS WAKA

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 3/3/2019 FATHI ARKAN NAIM 180904-5 PT ACTAVIS INDONESIA
2 3/3/2019 FADHIYA ALYQA NAIM 180904-3 PT ACTAVIS INDONESIA
3 3/3/2019 FAKHIRA ASHYLA NAIM 180904-4 PT ACTAVIS INDONESIA

TOTAL
REKAP TRANSAKSI ASURANSI LIPPO PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE

8000172305321747 3.0385/B/03/2019 R.DASAR 1102 Rp 1,240,000.00
8000172305300683 6.0380/B/03/2019 R.DASAR & R.PENCEGAHAN 1102 Rp 1,375,000.00
8000172305300709 6.0382/B/03/2019 R.DASAR 1102 Rp 1,450,000.00

TOTAL Rp 4,065,000.00
EKSES TOTAL ASURANSI
Rp 1,240,000.00
Rp 1,375,000.00
Rp 1,450,000.00

Rp 4,065,000.00
 REKAP TRANSAKSI ASURANSI SINARMAS PERIO
MEDIKDIS WAKAF DEPOK

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 2/3/2019 RIZAVIA M PUTRI 080001208199_1283 PT. BANK BUKOPIN, TBK

TOTAL
P TRANSAKSI ASURANSI SINARMAS PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000151118499643 6.0387/B/03/2019 PRWTN GIGI 1102 Rp 450,000.00

AL Rp 450,000.00
 TOTAL ASURANSI
Rp 450,000.00

Rp 450,000.00
 REKAP TRANSAKSI ASURANSI TAKAFUL KEL
MEDIKDIS WAKA

NO TANGGAL NAMA PESERTA NO. PESERTA COMPANY

1 3/14/2019 GHAIDAN DZAKIANDRA ZUFARO 00009A PT. CITRA KOMUNIKASI LS

TOTAL
NSAKSI ASURANSI TAKAFUL KELUARGA PERIODE 1-15 MARET 2019
MEDIKDIS WAKAF DEPOK

NO KARTU NO INVOICE PERAWATAN DIAGNOSA TOTAL INVOICE EKSES

8000172701486375 6.0456/B/03/2019 R.PENCEGAHAN 1105 Rp 325,000.00 Rp 75,000.00

Rp 325,000.00 Rp 75,000.00
 TOTAL ASURANSI
Rp 250,000.00

Rp 250,000.00
 NO ASURANSI TOTAL YG DIBYR ASURANSI
1 TAKAFUL KELUARGA Rp 250,000.00
2 SINARMAS Rp 450,000.00
3 LIPPO Rp 4,065,000.00
4 FWD Rp 1,000,000.00
5 BNI LIFE Rp 2,235,000.00
6 BCA LIFE Rp 625,000.00
7 AXA MANDIRI Rp 2,190,000.00
8 AVRIST Rp 325,000.00
9 ANGKASA PURA 2 Rp 1,250,000.00
10 ALLIANZ Rp 2,925,000.00

TOTAL Rp 15,315,000.00