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