PT ASURANSI PERISAI LISTRIK NASIONAL

Telp : (021) 799 5888, Fax : (021) 791 84342

FORMULIR PERMOHONAN
ASURANSI HOLE IN ONE

Nama Tertanggung : .............................................................................................................................................

Alamat Tertanggung : .............................................................................................................................................

Nama Turnamen : .............................................................................................................................................

Hari / Tanggal Turnamen : .............................................................................................................................................

Shot Gun / Tee Off *) : Jam. .......................... WIB

Lokasi Turnamen : .............................................................................................................................................

Jumlah Peserta : ........................................ orang (Amatir)

Detil Pertanggungan :
Hole Nilai Hadiah
No. Jenis Hadiah
Jarak (Rp)

1.

2.

3.

4.

Total Nilai Hadiah

Jakarta, .....................................
a/n. Panitia Penyelenggara

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