( IKHTISAR PERTANGGUNGAN )
TYPE OF INSURANCE : POLIS ASURANSI KECELAKAAN DIRI
( TIPE ASURANSI )
MOP NO : MOP/10/2023/P06/001
( NOMOR MOP )
POLICY NO : P06-10-08-2023-30020763
( NOMOR POLIS )
CONTRACT NO : 23-015786
( NOMOR KONTRAK )
INSURED NAME : SRI DEWI RITA TAMPUBOLON
( NAMA TERTANGGUNG )
ADDRESS : JL. ADE IRMA SURYANI NO.07 A
( ALAMAT )
BIRTH DATE : 11 MARET 1972
( TANGGAL LAHIR )
INSURANCE PERIOD : 21 AGUSTUS 2023 - 21 NOVEMBER 2023
( PERIODE POLIS )
BOTH DATES INCLUSIVE AT 12:00 NOON LOCAL TIME AT THE LOCATION OF THE INSURED ADDRESS
( JAM 12:00 SIANG WAKTU SETEMPAT DIMANA OBYEK PERTANGGUNGAN BERADA )
AUTHORIZE SIGNATURE