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Endorsement Slip

This document is an endorsement certificate for an insurance policy held by Johana Pratikno. It notes that endorsement certificate 000008 has been revised to correct the name listed from "Setianawati Kartika Dewi" to "Tan Tjik Boen". The endorsement must be attached to the policy, which is in effect from October 17, 2018 to October 21, 2018.

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Bagoes Prasetyo
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800 views1 page

Endorsement Slip

This document is an endorsement certificate for an insurance policy held by Johana Pratikno. It notes that endorsement certificate 000008 has been revised to correct the name listed from "Setianawati Kartika Dewi" to "Tan Tjik Boen". The endorsement must be attached to the policy, which is in effect from October 17, 2018 to October 21, 2018.

Uploaded by

Bagoes Prasetyo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Original

ENDORSEMENT
ENDORSEMENT No. : 0 Attaching to and forming part of Policy : FPG.11.1031.18.00021
Name of Insured : JOHANA PRATIKNO M01CF00004

Address of Insured : JL.BUNGA SONGGOLANGIT NO.37 RT/RW 003/012 KEL.TULUSREJO


KEC.LOWOKWARU
Period of Insurance : October 17, 2018 - October 21, 2018

Sum Insured : As Attached

Interest Insured : As Attached

It is hereby noted and agreed that the policy mentioned above is revised as follows:
ENDORSEMENT CERTIFICATE 000008

Dalam Polis ini terdapat Endorsement certificate no. 000008 sbb:


* Sebelumnya tertulis : Setianawati Kartika Dewi
* Seharusnys tertulis : Tan Tjik Boen

Malang, October 17, 2018


for and on behalf of
PT. ASURANSI FPG INDONESIA

-This Endorsement must be attached to the Policy-

AHEEEHAPLIHGPEACLDFBODDBOPAHEEEHA
BNFFFNBPFDAGBKAKBOMCAKJCEPBNFFFNB
DNELFNFKNJHKFCIOLAMOHCIODPINGPNFI
KGAJCBFINDFFCKCPNECPOABGDFAENDNEJ
EGOLMIFFFPPNDNBPKCEPBCNHAGBJOHNLJ
KBKKACFCNABKHGAGNEDPNCAHCFAPOHNIJ
MFFFFNEPLADAKGCOECOOKCIAAHFHACNEI
APBBBPAPFOFBFOHONGAPOCBNAEGCAAPOB
HHHHHHHPHHPPHHHPHHPPPHPPHPHPPPPHH

ESNM00000E
{32F49F9D-3C91-40B1-AF90-53763CC7703D}.rpt / giri
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