SURAT PERNYATAAN

Saya yang bertanda tangan dibawah ini ;

Nama Pemegang Polis : .......................................................................................................................................................................................................................................

Nama Tertanggung : .......................................................................................................................................................................................................................................
Nopol : .......................................................................................................................................................................................................................................
No.KTP / SIM : .......................................................................................................................................................................................................................................
No.Telp / Handphone : .......................................................................................................................................................................................................................................
Alamat : .......................................................................................................................................................................................................................................
: ......................................................................................................................................................................................................................................
Nama Ahli Waris : .......................................................................................................................................................................................................................................

Menyatakan dengan
sebenarnya bahwa telah membayar premi asuransi
s/d ................................................................................, tetapi kuitansi tersebut sampai saat ini
.......................................................................................

belum saya temukan untuk keperluan proses Klaim Habis Kontrak/Penebusan/DKB/Nilai

Tunai*

Apabila dikemudian hari kuitansi tersebut saya temukan akan saya kembalikan kepada PT.
AJS Bumiputera dan segala sesuatu yang berkenan dengan kuitansi tersebut bukan
tanggung jawab PT. AJS Bumiputera.

Demikian pernyataan ini saya buat untuk dipergunakan sebagaimana mestinya.

Banjarmasin,...........................................................................................

Materai
6.000

( ............................................................................................)
 SURAT PERNYATAAN

Saya yang bertanda tangan dibawah ini ;

Nama Pemegang Polis : .......................................................................................................................................................................................................................................

Nama Tertanggung : .......................................................................................................................................................................................................................................
Nopol : .......................................................................................................................................................................................................................................
No.KTP / SIM : .......................................................................................................................................................................................................................................
No.Telp / Handphone : .......................................................................................................................................................................................................................................
Alamat : .......................................................................................................................................................................................................................................
: ......................................................................................................................................................................................................................................
Nama Ahli Waris : .......................................................................................................................................................................................................................................

Menyatakan dengan
sebenarnya bahwa telah membayar premi asuransi
s/d ................................................................................, tetapi kuitansi tersebut sampai saat ini
.......................................................................................

belum saya temukan untuk keperluan proses Klaim Habis Kontrak/Penebusan/DKB/Nilai

Tunai*

Apabila dikemudian hari kuitansi tersebut saya temukan akan saya kembalikan kepada PT.
AJS Bumiputera dan segala sesuatu yang berkenan dengan kuitansi tersebut bukan
tanggung jawab PT. AJS Bumiputera.

Demikian pernyataan ini saya buat untuk dipergunakan sebagaimana mestinya.

Banjarmasin,...........................................................................................

Materai
6.000

( ............................................................................................)