BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 1

LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 519187 DENISA ARORA AGENCY : 519000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6950851 01 ATHAYADARA AZZAHIRA SIREGAR 519187-04-005186 NINA SARTIKA PANE
316-6854004 01 ADI SETIAWAN 519187-04-012054 AJENG HARDIANTI
316-7006166 01 SUCI LESTARI LUBIS 519187-04-014146 RAHMADANI HASIBUAN
316-6849814 01 ARVI ZULHAM 519187-04-014947 SILVIA MAWARTIKA ANYAR

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 2
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 519194 MUHAMMAD NURHAMID AGENCY : 519000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6888333 01 EDI SANTOSO 519194-04-004873 IRWAN EFFENDI
316-6901136 01 BAYU RUKMA 519194-04-004873 IRWAN EFFENDI
817-5389181 01 M. MORA SYARIF PAPILI 519194-04-005098 WAHYUDI
316-6949697 01 IMANIA LARASATI 519194-04-011311 YENNI MAHDARIANI SIREGAR
316-6921597 01 KEVIN PRANATA 519194-04-014809 YULI SUPRAPTY

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 3
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 519196 HIDAYATI AGENCY : 519000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6854673 01 FAJAR WISNU BROTO 519196-04-013822 EMIL SETIAWAN

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 4
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 522115 MAHARANI KARTIKA KENCANA AGENCY : 522000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-7005580 01 ROHANAH 522115-04-010744 FITRI YULITA VALENTINA
316-6940472 01 RUSLAN 522115-04-011090 NUR LAILA RAHMI
316-6940639 01 PAJUATIN,[Link] 522115-04-011090 NUR LAILA RAHMI

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 5
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 522180 QORI LUSI PRATIWI AGENCY : 522000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6853899 01 HABIBAH 522180-04-012205 DESI MAULIDA
316-6854475 01 AMINAH 522180-04-012205 DESI MAULIDA
316-6940720 01 TAUFIQUR RAHMAN, [Link] 522180-04-012205 DESI MAULIDA
316-6949481 01 TINAMPI RAHAYU 522180-04-012205 DESI MAULIDA
316-7005606 01 MOHAMMAD TAUFAN S SOS 522180-04-012928 DESTI PUTRI ANGGARINI

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 6
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 522197 ANDONI PRIDATAMA AGENCY : 522000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6900393 01 ELLIN VIKAWATI 522197-04-009296 CYNTHIA NALURIA HADI
316-6940696 01 RONI AGUS PRATIKNO ST 522197-04-009845 NURUL AINIYAH

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 7
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 522198 ZAIMATUL MAHBUBAH AGENCY : 522000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6901169 01 SUPRIYADI 522198-04-011943 AGUSTIN PRICILIA DWIYANTI
316-6939581 01 MUHAMDAH 522198-04-011943 AGUSTIN PRICILIA DWIYANTI
316-6854376 01 JOVAN AURICK AXEL SUGIYANTO 522198-04-012204 AZIMATUL CHUSNIAH
316-6940159 01 YAYUK YULIATININGSIH 522198-04-012204 AZIMATUL CHUSNIAH

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 8
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 526159 DINI ASMALIA TALAOHU AGENCY : 526000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6940464 01 RASITO TASRIP SANTOSO 526159-04-011547 TEGUH WIBOWO
316-6940712 01 ECEP KUSNADI, DRS 526159-04-011547 TEGUH WIBOWO
316-7006216 01 ENUR 526159-04-011547 TEGUH WIBOWO
316-6950174 01 LENI HERYANI 526159-04-014462 MUHAMAD SULAIMAN
316-6921589 01 ILHAM MAULANA 526159-04-015312 PUTRI HARDHIYANTI

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 9
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 526161 ZARA UBANI AGENCY : 526000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6854913 01 RATIH NUGRAHANINGTYAS A.I 526161-04-015314 SUCI ALDILA

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 10
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 526173 MAMAN SUDIARTO AGENCY : 526000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6950158 01 AHMAD FATHONI 526173-04-014315 RISNA MAULINA

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 11
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 526182 AISYAH RIESKARANI AGENCY : 526000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6899884 01 ROHMIATI, SE., AK 526182-04-011101 SHEILA ARIAPUTRI
316-6939565 01 MILA AYU HARIYANTI 526182-04-013324 PUTRI NIRINA NURUL IMAM

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 12
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 526207 ARIO DWI WICAKSONO AGENCY : 526000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
315-1582602 01 JONI RACHMAN 526207-04-005125 ANGGILITA PUTRI RIANA
315-1582651 01 VINCENTIUS WIJAYA 526207-04-005125 ANGGILITA PUTRI RIANA
316-8267973 01 DIDIT HARIYADI 526207-04-005125 ANGGILITA PUTRI RIANA
316-8268005 01 FITRI JULAEHA 526207-04-005125 ANGGILITA PUTRI RIANA
815-6952031 01 JONI RACHMAN 526207-04-005125 ANGGILITA PUTRI RIANA
815-6952098 01 VINCENTIUS WIJAYA 526207-04-005125 ANGGILITA PUTRI RIANA
816-9774448 01 KEVIN HENRY TANNER 526207-04-005125 ANGGILITA PUTRI RIANA
315-1582636 01 STEVANIE 526207-04-012182 WAHYU RETNO ANDRIYANI

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 13
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 526208 MAMAN SUDIARTO AGENCY : 526000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6889018 01 MUHAMMAD HALIF WIJDAN 526208-04-006471 TIARA VIDYA KEMALA
316-6901144 01 RABIATUN ADAWIYAH 526208-04-015307 AYU ISNENI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 14
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 527147 RIEKA OCTORA AGENCY : 527000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6940043 01 SUMARMI 527147-04-014811 DECKY FERNANDO PRATAMA
316-6951248 01 SUWARJO 527147-04-014811 DECKY FERNANDO PRATAMA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 15
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 527164 MIRZA AGENCY : 527000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6949911 01 ARIANSYAH 527164-04-013313 LA ROSA
316-6898696 01 AULIA VIBRA XENA 527164-04-013315 NYAYU MUTMAINAH

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 16
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 527168 HERMANSYAH AGENCY : 527000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6922173 01 DELSETRA 527168-04-010284 RIZIA IRSA
316-6840136 01 WENI SARTIWI 527168-04-013316 REGINA CARNEVIA
316-6949796 01 AHMAD NUZUR 527168-04-013695 SRI ESA ADINEGORO
316-6921621 01 MUNAWATI 527168-04-014149 YODIE IRWANTO

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 17
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 528178 BUSTANUL ARIFIN AGENCY : 528000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6853295 01 SRI SALURANINGSIH 528178-04-012192 MULYO SATOTO
316-6854798 01 ISTIFAIYAH 528178-04-012486 LINA ANDRIANA
316-6922751 01 MUHAMMAD SOBIKIN 528178-04-014465 DIAN BINTANG PAMUNGKAS
316-6840995 01 SUPRAPMAN 528178-04-014565 YUDHA BHAKTI TAUFIQURRAHMAN

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 18
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 528200 RESVINA DEWI AGENCY : 528000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6908792 01 AGUS WARSITO 528200-04-014464 APRILIA APITA NINGRUM

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 19
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 528201 TRI WIDIYANTO, SE AGENCY : 528000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6940589 01 ARDIANSYAH 528201-04-012627 RASHID FAILAN SATYANOMADIPRAJA
316-7006083 01 ROHAYATI, [Link] 528201-04-014822 NENI MARLIANA
316-7006190 01 YAYAS ROSMAYAWATI 528201-04-014822 NENI MARLIANA

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 20
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 528202 ASM VACANT BANDUNG AHMAD YANI AGENCY : 528000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6921886 01 SHOFA AWALIYATI FAUZI, HJ 528202-04-013958 YUSRON MUDOFAR
316-6949820 01 SUPRIYANTI 528202-04-014831 KIKI RIZKI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 21
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 528204 SYARIFUDIN YUNUS AGENCY : 528000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6921928 01 ROHMAH WIDIASIH 528204-04-009868 DEDDY KOSWARA

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 22
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 531191 ADE IRVAN ARDIYAN AGENCY : 531000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6950687 01 ERVINA SUSIANTI 531191-04-014832 MEGA SELVIANI
316-7005887 01 MOHAMMAD HARYONO 531191-04-014832 MEGA SELVIANI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 23
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 531193 RANGGA WIDYANA AGENCY : 531000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6940738 01 HADNAWATI, S.P.I 531193-04-010270 YUNI DARLYANTI, [Link]
316-7005341 01 JUNAIDI TRISAPUTRA 531193-04-010270 YUNI DARLYANTI, [Link]

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 24
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 532188 RONY ARISWANTO AGENCY : 532000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
316-6922025 01 ANSARIADI MSC PH SKM 532188-04-011834 GHITA ARIYANI ABDUL MUNIR

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 25
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617281 FARADIKA NOVIANA AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1070294 01 MARSIUS HABEAHAN 617281-04-008581 TRIA DONA STEPALYTHA
817-5285082 01 DAUD SANI 617281-04-013897 JUNI WANTI SIMAMORA
817-5318826 01 ERVINA AMARTYA SANI 617281-04-013897 JUNI WANTI SIMAMORA
517-1448888 01 NY. PARWATI 617281-04-014395 ANITA NOVANIA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 26
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617386 HARIS SARIPUDIN AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5343295 01 ENDAH KUNTHI HASTJARJANI 617386-04-009778 ARTHUR RICKARDO
517-2024605 01 MUNNANDA BAZIAD 617386-04-014056 SEBTRYA BEABY AMITA
517-2025305 01 MUCHAMAD BARKAH 617386-04-014056 SEBTRYA BEABY AMITA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 27
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617397 TUTIK ROCHATI AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1371569 01 FARIDA ARYANI 617397-04-003028 NUR HASANAH
517-1058422 01 WINDA 617397-04-005226 NURNI ZAMZAMI
517-2022492 01 FRISKA ULIA BR PANJAITAN 617397-04-013246 ANITA WIRASTIE
517-1139875 01 SUBOWOTRI CAHYO 617397-04-013756 ANINDHITA ADIRASHANTI
517-1612152 01 ARTHA PRADIPTA ASMAN 617397-04-013756 ANINDHITA ADIRASHANTI
516-9949830 01 SUPRIHATIN 617397-04-015091 IDA ISMAWATI

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 28
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617435 BULCHIA AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2011065 01 RUSMINI 617435-04-013251 MARYANTI EVA ULI PASARIBU
517-2015488 01 ALIFA AMALIA HASNA 617435-04-013251 MARYANTI EVA ULI PASARIBU
817-5353252 01 MONIKE YENI SARAGIH 617435-04-014292 RIRI IRANTI
517-1370397 01 ARTA PERMATA BUNDA 617435-04-014890 DELIZA MAGDALIA FARUWU
517-1021990 01 ZIKRULLAH 617435-04-015087 ERIC RIO HARIANTO
817-5316499 01 ANNISA VIRDIANASARI 617435-04-015087 ERIC RIO HARIANTO

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 29
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617436 ELVIANIS AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1438277 01 SUHENTI 617436-04-014749 ROBBY INDRA WIJAYA

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 30
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617510 MOH. SUKMANARA AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1322240 01 AJENG EKA NURROHMAH K. PUTRI 617510-04-011150 OSVALDO HARIS MANIK
817-5172652 01 LISA WERITA ASTONO 617510-04-011150 OSVALDO HARIS MANIK
817-5260739 01 KHAIRINA NABILAH 617510-04-011150 OSVALDO HARIS MANIK
817-5389496 01 JULIA FARAH DIBA 617510-04-011150 OSVALDO HARIS MANIK
516-9870291 01 SAHRULLAH 617510-04-011361 IRVAN PUTRA SILABAN
817-5463093 01 ALARIC MASKA ALMAHRI 617510-04-012574 KURNIATI
516-9880134 01 ARY MULYADI 617510-04-013503 LINDA ANIE ULINTA
517-2020645 01 NONI ELOKLADESELI 617510-04-013896 ISYE FITRIYULIASTUTI

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 31
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617523 DICKY AFRIZA PUTRA AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1246217 01 DENI HERDIS NUGRAHA 617523-04-002725 YULIANTO PRASETYO
517-2012766 01 WIWI MUSWIROH 617523-04-002725 YULIANTO PRASETYO
517-2026857 01 AZIS MAKMUN 617523-04-002725 YULIANTO PRASETYO
517-2035213 01 INDAH SUSIANTARI 617523-04-002725 YULIANTO PRASETYO
817-5463390 01 SUTRISNO NUGROHO 617523-04-009045 RININTA ANGGRIYANI
517-1057275 01 NUR AFNI INDAH SARI 617523-04-013504 LISA ZULFINA AULIA
517-1112757 01 NUR AFNI INDAH SARI 617523-04-013504 LISA ZULFINA AULIA
517-2034034 01 PATRIA AIRLANGGA 617523-04-014894 MAISARATUZ ZIKRO

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 32
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617560 CHEVY YOLANDO JULIAN AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1322182 01 IVANA 617560-04-007987 PARTIWI SURYA
817-5171845 01 MUHAMMAD KHOIRUL AZAM 617560-04-013764 NURUL LINAWATI
517-2035049 01 NENI NOVIANTI 617560-04-014899 YOSEP TRIO BARANTICA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 33
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617561 HERYANTI AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1450587 01 AAN SETYAWAN 617561-04-007259 KUSDI
516-9948899 01 PUTU KAMBIUM PRASABA 617561-04-009498 MUHAMMAD TAUFIK
517-1246308 01 AULIA IMRAN MAGHRIBI, SE,.AK 617561-04-009498 MUHAMMAD TAUFIK
517-1321580 01 ARIF RAHMAN HAKIM 617561-04-009498 MUHAMMAD TAUFIK
816-4403928 01 IMAM SUBEKTI 617561-04-012075 PUJI HAYATI
517-1245672 01 EDI SAPUTRA 617561-04-013116 DEDY SYAH PUTRA SEMBIRING
517-2020231 01 WAHYU PURNOMO 617561-04-013116 DEDY SYAH PUTRA SEMBIRING
517-2021882 01 WAHYU PURNOMO 617561-04-013116 DEDY SYAH PUTRA SEMBIRING
517-2023318 01 SITI SARAH 617561-04-013116 DEDY SYAH PUTRA SEMBIRING
517-2022294 01 ENDANG NILAM JUWITA 617561-04-014513 RIDHO ARRAHMAN
515-6379926 01 SADILI SARIPUDIN B. HAKIMI 617561-04-015082 CHRISTINA TAMPUBOLON
815-5225462 01 WAHYU PURNOMO 617561-04-015484 GANDHI SURYA PUTRA

NO. OF LIFE POLICIES = 10

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 34
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617635 M. ALYANO AFGHANI AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1602559 01 SRI ROSITA PUTRI 617635-04-013505 MURNI WANTI S
517-1142283 01 MUHAMMAD HARISUDDIN KUSWADI 617635-04-013766 RAHMAWATI SURYA
817-5353492 01 ANISA SHAFIRA 617635-04-014274 ULFA MASYITOH
517-1139792 01 AHADIYAH NOVIYANTI 617635-04-014511 MAGDALENA GULTOM

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 35
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617642 EVA ROSMELIA AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5276651 01 MARIA K MAHAPUTRI LEWERISSA 617642-04-007132 M. SLAMET KHUMEDI
816-4097563 01 VIONA ELVARIANI PUTRI JACKSON 617642-04-007492 ABDUL FATAH

NO. OF LIFE POLICIES = 0

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 36
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617643 CHANDRA KASMAWIJAYA AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2023656 01 YUNITA YATI 617643-04-014632 SRI SURYANI PUTRI PERTIWI
517-1437246 01 SUMARSIH SYAM 617643-04-015078 ARIF KUSUMAJATI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 37
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 617668 SUWONDO AGENCY : 617000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9947818 01 AHMAD CHAERUDIN 617668-04-013381 RENDI REKSO SAPUTRO
817-5122111 01 AZZAHRA RANIAH ALHARITS 617668-04-013381 RENDI REKSO SAPUTRO
517-1136392 01 DANA MARDIYAH 617668-04-014624 DANIAR SUNDARI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 38
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624302 AYU SETYO KRESNAYATI AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2036583 01 CUT MEUTIA SARI 624302-04-009339 FITRA DEWINTA BR PURBA
816-4170170 01 MARLIN FITRIKA 624302-04-009339 FITRA DEWINTA BR PURBA
517-2034570 01 SURIADI 624302-04-011730 AZWAR ANAS
817-5122426 01 ELDRICH GAVIN CHANDRA 624302-04-012014 SHEYLA SENARI BARUS
817-5449431 01 SRI DEWI MUSI LINGGO 624302-04-012014 SHEYLA SENARI BARUS
517-1320111 01 SOSIAWAN PUTRA SURBAKTI 624302-04-014259 SANTA DEWI SITANGGANG
517-1438350 01 SURYA DARMA TARIGAN 624302-04-014259 SANTA DEWI SITANGGANG
517-2020421 01 LIDIA I HARIANJA 624302-04-014711 RAHMAT TULLAH

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 39
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624342 FITRIA ENDARWATI AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2024779 01 RINA KADANG 624342-04-006980 RACHEL PERMATA SARI
517-2028168 01 APRILIA SANTA YULIKA 624342-04-006980 RACHEL PERMATA SARI
517-2012451 01 SUSILAWATUH HASANAH 624342-04-009968 DEWI ASTUTI
517-2023508 01 LAILA TULUSNI 624342-04-011665 INDRI LESTARI SINUHAJI
517-2024126 01 NELLI HOTMAIDA HUTAURUK 624342-04-011665 INDRI LESTARI SINUHAJI
517-2021908 01 WILLIAM WIJAYA 624342-04-013971 MAHLIL
517-2025719 01 DEFI TAMI MANDA SARI 624342-04-014334 LATIFAH RAHMADHANI
517-1135519 01 ANTHONETA WENIGOMANG 624342-04-015006 SISKA JUWITA REHULINA S

NO. OF LIFE POLICIES = 8

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 40
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624358 NINA KARINA AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5316523 01 HALISYAH HASYIM LUBIS 624358-04-003672 SUSILAWATI
816-4097431 01 AHMAD THAREQ RAZEQ TANI 624358-04-004779 MERY PANGARIBUAN
517-1674491 01 RAHMAT 624358-04-011349 MARTIN SIMANJUNTAK
517-2015934 01 SUMARNI 624358-04-011453 DINADIO SIRINGORINGO
817-5464562 01 SEVENTEEN YOULE SITEPU 624358-04-012249 SONIA BR TARIGAN
517-2011172 01 ROY GOKMA SILALAHI 624358-04-014162 ARFIKA ARIANTY
817-5276099 01 DICKI PUTRA 624358-04-014702 ALEX IBRANI PANJAITAN

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 41
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624360 PRAGUSTINA ANDRIANI LBS AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2021064 01 NANIK NURYANI 624360-04-003054 IRMA MELANI
516-9880126 01 OKTA LESTARI 624360-04-012936 JAMAL ABDULLAH
517-1438491 01 ANDI SAPUTRA 624360-04-012936 JAMAL ABDULLAH
517-2019399 01 BELLA MEZHOLA DALTA AYRI 624360-04-013473 LIAN PURNAMA SARI
517-2032848 01 LENNA ASLIATY 624360-04-013473 LIAN PURNAMA SARI
817-5171548 01 GILBERT PATROVA TAMPUBOLON 624360-04-013473 LIAN PURNAMA SARI
817-5463945 01 FEBY FADHILAH HAPSARI 624360-04-013473 LIAN PURNAMA SARI
817-5463986 01 JESSICA WIDIANA KOSTAN 624360-04-013473 LIAN PURNAMA SARI
517-2028085 01 AGUNG WAHYUDI 624360-04-013713 EFNI AISYAH

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 42
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624526 PERIMITA SITEPU AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2015371 01 YUNITA AMBARWATI 624526-04-004607 ELFRIDA SIMANJUNTAK
517-2020397 01 MASITA 624526-04-004607 ELFRIDA SIMANJUNTAK
517-2020728 01 MARISA JULIANDA 624526-04-004607 ELFRIDA SIMANJUNTAK
517-2036179 01 ARDIANSYAH 624526-04-005435 MUHAMMAD RIZA AULIA
516-9949491 01 NURMAH 624526-04-006981 RUTH SUYATA SINAGA
817-5316192 01 LATEEFAH S. AZ ZAHRA NASWANTO 624526-04-006981 RUTH SUYATA SINAGA
517-2020413 01 FRISKA YUNIRIA 624526-04-008641 YULIZA KURNIAWATI
816-4244827 01 M. FAUZI 624526-04-012238 LONA TOBING
517-2016734 01 NINA LIANA 624526-04-012939 NUR ARDHIYATUL DEWI
517-2036617 01 AMINUDDIN MANSYUR 624526-04-012939 NUR ARDHIYATUL DEWI
517-2034141 01 WINNA MANIK 624526-04-013852 SITI BAROROH BARID
517-2035767 01 ELTA SAVERA 624526-04-013852 SITI BAROROH BARID

NO. OF LIFE POLICIES = 10

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 43
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624539 GILANG AL AZHAR AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2032780 01 MUTIA AMELIA 624539-04-014995 DEWI SINTA
817-5320327 01 NURHAMIDAH NASUTION 624539-04-014995 DEWI SINTA

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 44
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624629 IMELDA ANGELIA HUTAGAOL AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2024282 01 DANIEL 624629-04-002367 HEPPY SIREGAR
517-2036211 01 PATUAN TARULI SIANIPAR 624629-04-003670 DEBORA VELISSA YOSSEVIN
517-2015173 01 ROBBI SAHRI 624629-04-011135 AYU ROSMERI HUTABARAT
517-2022070 01 SRI KURNIATI 624629-04-011135 AYU ROSMERI HUTABARAT
517-1612137 01 RUDI SYAHPUTRA 624629-04-012246 RIDUWAN SIDDIK
817-5432486 01 SALOMO HASIBUAN 624629-04-014199 FITRIANI DASMATIUR SITUMEANG

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 45
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624630 MUHAMMAD NUR LUBIS AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9949582 01 SUPRIONO 624630-04-006433 DWI INDRI YANUARI
817-5316093 01 YANTO 624630-04-008973 RIA FAHREZA DALIMUNTHE
517-2010844 01 JARLAN PASARIBU 624630-04-008974 AGUSTINA
817-5343923 01 MIDUN AFANDI NASUTION 624630-04-009205 HAZRINA LAILI MASNI LUBIS
517-1602435 01 NOVI YANDRI 624630-04-011136 LOLISA EFA MATOVANI
517-2024753 01 ANDRI HALIM 624630-04-011136 LOLISA EFA MATOVANI
517-1112500 01 MERI DAMANIK 624630-04-011576 GUI ISKANDAR NASUTION
517-1560930 01 SANGKOT 624630-04-011576 GUI ISKANDAR NASUTION
517-1561003 01 SUROTO 624630-04-011577 M. REZA ABDILLAH
517-2023805 01 TRIAWAN 624630-04-011577 M. REZA ABDILLAH
517-2018904 01 MAMAD BUDIMAN LUMBAN GAOL 624630-04-013849 NURUL AZMI

NO. OF LIFE POLICIES = 9

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 46
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624640 DEDI KAROJA AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2015041 01 IDA ROYANI 624640-04-005684 HERLINA
517-2016064 01 ISNAINI PUTRI 624640-04-005684 HERLINA
517-1382509 01 HAYATUN NUFUS 624640-04-007686 RAHMAH
517-2022377 01 MUHAMMAD AZZAM AL FATIH 624640-04-008296 NURHAYATI
817-5463929 01 FADLI 624640-04-008296 NURHAYATI
817-5463960 01 BOIHAQI 624640-04-008296 NURHAYATI
517-1181133 01 HARTINI 624640-04-013331 MUHAMMAD AKBAR GINTING
517-1246266 01 KEMAL AULIA FADILA 624640-04-013966 AMANDA FEBRIANA
816-4222781 01 VIRA FRISKA 624640-04-015005 SATRIA PRATAMA

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 47
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624652 FITRI HAYANI AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2025503 01 IRFAN OKTAFIANDI HARAHAP 624652-04-009917 KARTIKA SILVIA PURBA
517-2025750 01 SRIULINA BR. TAMBAN 624652-04-009917 KARTIKA SILVIA PURBA
517-2028341 01 BUDI FERDIANSYAH 624652-04-014477 AGNESIA ALLENSKY
517-2012238 01 DEWITA 624652-04-014713 RITA MELDA SUSANTI
517-2022856 01 ARIYANDA PUTRA 624652-04-014713 RITA MELDA SUSANTI
517-1069346 01 SANISIH 624652-04-014994 DEBI CHYNTIA DENI
517-1320731 01 SRI RAHAYU MURNIATY 624652-04-015189 MUHAMMAD RIFQI HAKIM

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 48
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624653 VINNY YALIZA AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2015421 01 SWANDI SIMORANGKIR 624653-04-000358 YANTI TUMANGGOR
517-2024530 01 HELVA INTANA PURBA 624653-04-000358 YANTI TUMANGGOR
817-5121592 01 NURMAILIS 624653-04-010102 SUCI MEILANI
517-1748691 01 [Link] WARSITO 624653-04-010786 NURUL WIDYA
517-1062382 01 ASEP GUNAWAN 624653-04-014336 OKTOVERI
817-5389215 01 ABDUL HAMID 624653-04-015001 NUR FITRIANI

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 49
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 624654 FITRI INDAH SARI AGENCY : 624000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5354052 01 JOSHUA NATHANAEL R TARIGAN 624654-04-006363 NENSY JULIANI SILITONGA
817-5316168 01 AYU ASFIHANI 624654-04-011457 FERRA SYAH FITRI NASUTION
517-2020462 01 HARRI KURNIAWAN 624654-04-011628 SERPIANA DUMA LISDAWATI
817-5343832 01 HAURA RIZFA SYABILA 624654-04-013590 NURLELI
817-5463853 01 TIARMAULI SIMARMATA 624654-04-014577 KIKI RIZKY ARDIANTI LUBIS

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 50
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648212 FEBRY HARTANTO AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1370538 01 ADE IMAS SHOBIHAH 648212-04-011236 ANGGIAT HUTAGALUNG
517-2008772 01 SRI ASTUTI 648212-04-011236 ANGGIAT HUTAGALUNG
517-2028184 01 SITI ROSMIATI 648212-04-011236 ANGGIAT HUTAGALUNG
817-5164139 01 SYAKIRA ILA RAFFANA 648212-04-011236 ANGGIAT HUTAGALUNG
517-2012618 01 ROHYATI 648212-04-012653 NOVLYANA TITAN DAMANIK
517-2035684 01 NENENG ANDRIYANI 648212-04-014253 RITA HIDAYATI
817-5318909 01 MUHAMAD FAKHRUDDIN 648212-04-014253 RITA HIDAYATI
517-1601551 01 NURWADI 648212-04-014860 RIZKA ULFA LUTFIANA

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 51
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648348 RISMA NOVIETA AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5344038 01 IDRUS 648348-04-001349 SILVIANI
817-5121691 01 RUDYANTO NYOMAN 648348-04-005761 ITA ANITA
817-5449530 01 MAHADHIKA WASKITO THORIFA 648348-04-008304 NURTI KINTAMI
817-5315962 01 YENI ALVIANA 648348-04-009876 KHAIRUNA
517-2011107 01 HERMAINI 648348-04-013350 DEBBI SILVIA
817-5343055 01 YUDI SANTOSO 648348-04-013350 DEBBI SILVIA
517-2021049 01 MURIYADI 648348-04-015198 ALAN FIRMANSYAH

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 5
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 52
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648423 AGUNG KHARISMA AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5285025 01 VORIMA NOVANTA SIREGAR 648423-04-014019 YOGIE PARAMA ISKANDAR
817-5432536 01 AMELIA FITRIA 648423-04-014596 FITRIANI SULISTIANINGSIH
517-1438046 01 IQLIMA 648423-04-014722 RIRI SYAFITRI
816-4009147 01 MAHINDA AGGAJOTI 648423-04-014725 MEGA FUJI LARASWATI

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 53
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648446 TOMMY SUSANTO AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1615130 01 A. ATIKURRAHMAN 648446-04-008560 MARDALENA
517-1369233 01 DEBI WAHYUNI 648446-04-009469 MIMIN MINTARSIH
517-2021833 01 DIAN ARDIANSYAH 648446-04-009469 MIMIN MINTARSIH
517-2020280 01 NINING NOVITA 648446-04-010853 SARAH NURFAUZIAH
517-1601924 01 WATINAH 648446-04-014865 WISNU DWI PRASETYO

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 54
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648491 SJOFRAN HARUN AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2024258 01 SANGIDUN 648491-04-008797 PANJI CITRA AJI
517-2033903 01 ALISYA ANGGI ANI PUTRI 648491-04-008797 PANJI CITRA AJI
817-5260473 01 AHMAD ANWAR HAMID 648491-04-011332 HENDRO PURPAMANA
817-5315533 01 MUHAMAD RIDHWAN 648491-04-011332 HENDRO PURPAMANA
817-5316697 01 EDI 648491-04-013216 FITRIATIN
817-5318842 01 DARMAN SOBARI 648491-04-013366 YOSI PUTRI NINGSIH
817-5449720 01 DEDY ASFARI 648491-04-013366 YOSI PUTRI NINGSIH
517-1022303 01 RUSLIANA SINAGA 648491-04-013499 TEGA LESMANA
517-2010786 01 MIARTI 648491-04-013499 TEGA LESMANA
517-2035858 01 NOURMA ROSYIDA 648491-04-013499 TEGA LESMANA

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 5
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 55
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648557 DWI MUHAMMAD JUNAEDI AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
816-8196395 01 INTAN SUCI AMINAH 648557-04-010325 CINDY ANGGUN SANTOSO
817-5284754 01 IVANA SANDRA LUCIANA 648557-04-013222 NENY INDRIANY SIANTURI

NO. OF LIFE POLICIES = 0

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 56
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648585 DEDE SUNANTI AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5122186 01 HERMINDI 648585-04-011445 RIA SASMITA
517-1243966 01 BENNY KSATRIA 648585-04-011863 YULIANA KUSUMA DEWI
517-1244741 01 PUTRI NAZMA AQILA 648585-04-011863 YULIANA KUSUMA DEWI
517-1322018 01 ONG MEY LIE 648585-04-014012 SUCI KOMALA DEWI
517-2025313 01 LEONITA 648585-04-015345 INDY

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 57
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648602 IMAM SULTHANI AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-6466523 01 NOFIN DWI SANTOSO 648602-04-009824 GALIH NOVIANTO
517-1380370 01 BRIAN SUTANTO 648602-04-010330 SITI ADNAN KOTARUMALOS
517-2021981 01 RISKI DWI FEBRIANI 648602-04-010330 SITI ADNAN KOTARUMALOS
817-5121931 01 ABDUL AZIZ SYAHBANSAH .G 648602-04-010330 SITI ADNAN KOTARUMALOS
517-1319766 01 NAJWA AYU CALLISTA 648602-04-010331 ISMAIL SOLEH
517-2024555 01 FAISAL AJI PRAYOGA 648602-04-010331 ISMAIL SOLEH
817-5354680 01 JOSEPH KENZIE EMMANUEL PURNOMO 648602-04-011120 LIYANA
816-9615385 01 RHEYMUSA GANIWALA MUMPUNI 648602-04-015339 ARJUNA HERDIANSYAH

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 58
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648604 VEMLY SURIANY AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5122004 01 EKO SUDIANTO PRAYITNO 648604-04-013212 ASMO DARTO
517-1017337 01 NENENG MARYATI 648604-04-014358 ERWIN JOHANES PANGGABEAN

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 59
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648624 ANGGA SEPTRIA NUGRAHA AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5389512 01 HIKMATUS SABRINA 648624-04-002829 DESY SAGITA
517-2021627 01 JULIYATI 648624-04-005563 FIDITA MULIA WATI
517-2023649 01 WINDY DWI CAHYONO 648624-04-006085 HAYATIN NUFUS
517-2036625 01 SABENI BIN SARIP 648624-04-006085 HAYATIN NUFUS
517-2015207 01 RETNO ASIH 648624-04-008793 ELISA PURBA
517-2022575 01 WARTINI 648624-04-008793 ELISA PURBA
517-2035643 01 MUNIR 648624-04-008793 ELISA PURBA
517-1381402 01 MARIA MAGDALENA S 648624-04-011711 ABDUL HARIS IRWANSYAH
517-2026527 01 DEVY ANGGREANNY 648624-04-012552 WAHYU LUMBAN GAOL
517-1242521 01 RINI MEIDINA 648624-04-015044 YULIA FRANSISKA NASTITI

NO. OF LIFE POLICIES = 9

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 60
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648633 JEPI SUBAHRI AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9947701 01 RIZKA DANO 648633-04-015040 TIRZA FERDIAN SYAHPUTRA
517-1622904 01 ANNURILLAH LISMAYANTI 648633-04-015040 TIRZA FERDIAN SYAHPUTRA
817-5316358 01 HOTMAULI S.H SIDABUTAR 648633-04-015212 VITARA HAYU TRIARDITA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 61
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648634 ANASTASIA MELTA LILIANI AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2009010 01 DIAN PURNAMASARI ALDILLA 648634-04-006384 NONI NURRISNA ARISTRIA
817-5343345 01 PANJI GEMILANG SURYACANDRA 648634-04-006384 NONI NURRISNA ARISTRIA
517-1611782 01 EKY PRASETIA 648634-04-013987 ABED NEGO TAMBUNAN
817-5259277 01 SYIFA ANSHORIANTI 648634-04-013987 ABED NEGO TAMBUNAN

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 62
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648659 MOHD. FASHALI RADIYALLAH AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2023854 01 AMRAN 648659-04-014604 TIARA RIZKYLIA
817-5432320 01 RETNO ANGGRAINI SUSILOWATI 648659-04-015338 ANDREAS DIRK SOMPOTAN

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 63
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 648670 WILDA YANTI AGENCY : 648000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2015678 01 RANI 648670-04-010152 IWAN SUPANDI
517-2025271 01 STEPHANUS HENDRA RICHO P 648670-04-010152 IWAN SUPANDI
817-5344442 01 MUKAJI 648670-04-010152 IWAN SUPANDI
516-3169674 01 MEGA FAIRUS 648670-04-014852 ARNOLD EDUARD TONGGO SIBARANI
517-1002917 01 DUDI RIYANTO 648670-04-014863 VANANI INDRA REIKHSHA
517-1243610 01 ASEP SUGIYANA 648670-04-014863 VANANI INDRA REIKHSHA

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 64
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649257 DIAH PUJI WULANDARI AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1017543 01 ANDHY WAHYU SAPUTRO 649257-04-008095 RATNA SUMINAR
517-1612053 01 IBNU EKO HAPSORO 649257-04-008095 RATNA SUMINAR
517-1140568 01 ERLIXXA RATHULA ASLAMANNET 649257-04-008712 ANI SUSILOWATI, SH
817-5330524 01 AF HERLINA DEWI MAHARANI 649257-04-008712 ANI SUSILOWATI, SH
517-1138992 01 SRI WAHYUNI 649257-04-009808 SRI JOKO SARJITO
517-1394595 01 YATIN TRI SURYANNI 649257-04-009808 SRI JOKO SARJITO
816-4404090 01 SURYO YUNIANDRI 649257-04-010919 DIYAH LESTARI HANDAYANI
517-1612699 01 SURNI HANDAYANI 649257-04-012390 ARIEF EKA YUNI SAPUTRA
817-5121238 01 SINAU RANTAI BILLAH 649257-04-013274 NUZUL APRILLIA DWI SARI
817-5463275 01 ARIS PURNAMA 649257-04-013274 NUZUL APRILLIA DWI SARI
816-4353495 01 EDI SUPARTI 649257-04-014070 PRIA RAHARJA
817-5164170 01 CAHYO TRI HARYANTO 649257-04-014073 ROSIANA EKA PUTRI

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 65
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649355 ARIEF BUDIMAN AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2015322 01 DYAH PUTRI UTAMI 649355-04-004481 SEPNIKA ENGGAR WATI
817-5121717 01 NI KETUT DEVITA SETYA KALIYANI 649355-04-004481 SEPNIKA ENGGAR WATI
517-2028416 01 FARAH ADIBAH ZAHRA 649355-04-010564 NUR ROMDANI HIDAYATI
817-5275026 01 MUJI HASTUTI, IR 649355-04-011998 ERNA DWI KRISTANTI
517-2032939 01 DENI HERMAWAN 649355-04-012863 AGUSTIN HIDAYAH NUR AINI
517-2021692 01 DANANG HERI SANTOSO 649355-04-014410 SILVIA NETY CAHYANINGSIH
517-2032814 01 ADI NOVIA ERIYANTI 649355-04-014524 ADAM JUNIANTO
817-5315954 01 ARI SUHARNO 649355-04-014524 ADAM JUNIANTO
517-2036435 01 NIKMATUL JANNAH 649355-04-014911 ANINDITYA DIAN SULISTYOWATI

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 66
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649419 DWI KARTIKA AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5432304 01 TITIK PURWATI SE 649419-04-001864 I KADE DIANA ARISTIAWAN
817-5343584 01 FITKHI WINDU NORTAQIM 649419-04-005085 TESAR TAKUTUNGGA
817-5389017 01 RUSDIANTO 649419-04-005085 TESAR TAKUTUNGGA
517-1245474 01 UTADI 649419-04-009512 ROHMAD WIDIANTORO
517-2026519 01 ANDRI RAHAYU 649419-04-011995 ERRIDHO PINADI LATIF

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 67
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649563 ASWIN BAHAR AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1140782 01 EKA YULI PURWANTA 649563-04-000662 DIAH PUSPITASARI
816-4131271 01 RIZKY OGAN SAPUTRA 649563-04-007268 LARRY MARTIN H. RADJAGUKGUK
517-2019811 01 TH HARYANI EKO ERAWATI 649563-04-008366 MUTIARA MAELA ALFATH
817-5047862 01 ROSA TRI KRISTERA W SPD 649563-04-011046 OKI RIANDA PUTRA
517-2025768 01 RISNANDI ATMOKO RUDE EDYANA 649563-04-012817 AYU UTAMININGSIH
517-2026808 01 DEWI FEBRIANA SARI 649563-04-012817 AYU UTAMININGSIH
517-1246605 01 MOHAMMAD FIKRI ALAN 649563-04-013007 MARSHA YUSTICIANA
517-2027632 01 USTI KHAIRIAHWATY 649563-04-013007 MARSHA YUSTICIANA
517-2024704 01 ENY NURCAHYATI 649563-04-014757 JESICHA SUKMA MUTIARA EGAMO
517-1449019 01 ARIYANTO 649563-04-015111 ADI BUDI SAPUTRA

NO. OF LIFE POLICIES = 8

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 68
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649603 EKO PRASETYO AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2026410 01 NUR HAYATI 649603-04-004558 DEWI LESTARI WIDYASTUTI
817-5390098 01 KUKUH TRI PANUNTUN 649603-04-004558 DEWI LESTARI WIDYASTUTI
517-2015157 01 CAHYONO 649603-04-010573 SELAMAT ERYANSAH
517-2026196 01 ROMADON 649603-04-012866 WIDYA PERMATASARI
817-5171480 01 YENI SETIAWATI 649603-04-013392 YUNINDA HANDAYANI
517-2027343 01 DIONISIUS LAGA VOLIANTOPUTRA 649603-04-013784 NOVIA DIANA SARI
517-2023763 01 ABDUL KHARIS, H 649603-04-013909 ADDINA TRI JUNDANI
517-1171324 01 DWI HENY RATNAWATI 649603-04-013910 FERA ISMIYATUNISSA
517-1138828 01 NUR BAETI 649603-04-014215 LARAS AYU PUSPITASARI
517-1370223 01 NUR CHAYAROH 649603-04-014215 LARAS AYU PUSPITASARI
517-2015769 01 YAEROTUN 649603-04-014215 LARAS AYU PUSPITASARI
817-5285041 01 KAYLA SALSABILLA 649603-04-014215 LARAS AYU PUSPITASARI
517-1047722 01 SUSILOWATI 649603-04-014759 UTARI ANGGOROWATI

NO. OF LIFE POLICIES = 10

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 69
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649660 CHUSNA OKTAVIA NINGTYAS AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5122384 01 FARANDENASH A. FADEY KATILI 649660-04-001236 AMALIA NUR AFNI
817-5343188 01 INDAH DWI TANTI 649660-04-003626 DIAN KUSUMANINGSIH
517-1245938 01 IKSAURA ANJELITA 649660-04-005245 IIN MEKAR KUSUMA DEWI
517-2025651 01 NURUS SYADID 649660-04-005245 IIN MEKAR KUSUMA DEWI
816-4009337 01 PURWANTO 649660-04-011902 ULFATUL RAHMADIA PUTRI
817-5330573 01 FENNY MEIVITA 649660-04-013133 AAN DARWATI
817-5431793 01 AHMAD FARIDI 649660-04-013133 AAN DARWATI
817-5463176 01 POERNOMO HANTORO 649660-04-014758 RIZKI CHOIRU NISA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 70
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649661 WIJI RAHAYU AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2024241 01 DAYU SUKMA 649661-04-003205 DANU PADMA SARI
517-2016742 01 JENNY WIDYASTUTY RAHARDJO 649661-04-005395 MILLA FITRIA LISNARENI
516-9950168 01 DEDY PRASETYO 649661-04-005860 DYAH NUR FITRIAH
517-2021270 01 YULI ENDANG NURSANTI 649661-04-008065 PUTUT ARDI PITOYO
517-2033291 01 NUR HIDAYATI 649661-04-008065 PUTUT ARDI PITOYO
517-2023177 01 MEKAR SEKAR SARI 649661-04-008094 KRISNA GERRY PERMANA PUTRA
517-2028002 01 NAILA ALIKA PUTRI 649661-04-009678 ANNISA RAHAYUNI
817-5047763 01 MARIA THERESIA SRI HARTATI,DRA 649661-04-011479 DINAR INDRIANY
817-5389629 01 DOMINIK FEDDE YOGASWARA 649661-04-011479 DINAR INDRIANY
517-1288938 01 AKBAR FEBRIANSYAH MAULANA 649661-04-013144 YENI RAHMAWATI
817-5462897 01 I PARISUNU HASTUTI ADVENTIEKA 649661-04-013144 YENI RAHMAWATI
816-4166921 01 R. ERWIN P. PAMUNGKAS SAPTONO 649661-04-013663 ALI HUSIN NASUTION
517-1089344 01 NURUL LUSIANI 649661-04-014760 VERANIKA YULIANA
817-5260432 01 BRAMASTA SURYA PRADHANA 649661-04-014912 BENEDICTA DYANA ARDIATRI P
816-4261722 01 IKA NAROLITA 649661-04-015386 IRA ANGGUN LESTARI

NO. OF LIFE POLICIES = 9

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 71
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649662 CAHYANA KRISNA PUTRA AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2021015 01 MUHAMMAD SUJATI 649662-04-003702 MEYDA RINA HANDAYANI
517-1112542 01 ANINDITA KEISHA AFRIANI 649662-04-014763 LODIA CAHYANI
517-2021817 01 FERY ANDI ANDANI 649662-04-015276 NURSETO BRYAN PRAYOGO
517-2033044 01 AHMAD WAHID RIFAI 649662-04-015276 NURSETO BRYAN PRAYOGO

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 72
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649672 RATI KUMALA PUTRI AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5431314 01 HEDIANA YUDHA PRAWIRA 649672-04-011180 NOVIA WIDIASTININGRUM

NO. OF LIFE POLICIES = 0

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 73
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 649673 SETYA PUSPITAWATI AGENCY : 649000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2011982 01 SUGENG ADRI SANTOSA 649673-04-007610 RIA WIDIANINGSIH
517-1602195 01 SUKANTI 649673-04-008266 ZAENAL ARIFIN
517-2032954 01 YOSI SUCHIPTO 649673-04-008266 ZAENAL ARIFIN
517-2022005 01 YANUAR PAMBUDI 649673-04-009480 ADITYA SUGANDA
517-2012444 01 PURNOTO 649673-04-014074 USWATUN NASIKHAH
816-4041082 01 TRI HARTANTO, ST 649673-04-014647 NAILI FEBRIANTI
517-2024902 01 AGUS PURWANTO 649673-04-015274 LITA YUAN PROBONINGRUM

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 74
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650125 OKTAVIA TITIK EROWATI AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1106296 01 DJONI 650125-04-006118 ROSITA VEBRIESTI RATRI
517-2027095 01 ARDI AINUR RACHMAT 650125-04-011109 MEGA AYU WULANDARI
817-5276586 01 AIRINDRA NAILA FAIHA 650125-04-011109 MEGA AYU WULANDARI
817-5315814 01 ARJUNA ZHAFRAN ALGHIFARI 650125-04-011109 MEGA AYU WULANDARI
517-2021874 01 MARTHA TRI ASAVIRA 650125-04-014419 ELSA MONICA
517-2025388 01 LIA YULIARTI PUSPITA 650125-04-014528 PRIMATYASTA KIFFANI RACHMADYA
517-2033754 01 HERMEN TRIYOSO 650125-04-014528 PRIMATYASTA KIFFANI RACHMADYA

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 75
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650200 WAHYU SRI WARDANI AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5275836 01 FRANSISCA WIJAYA 650200-04-008105 BELINDA RIZKI MAHARANI
517-1371601 01 JUWANTO 650200-04-009413 NURUL INAYAH
816-4227608 01 NINIK SURYANI 650200-04-009413 NURUL INAYAH
517-1313652 01 SUMARNO 650200-04-011686 DWI JALU PRASETYO
517-2025396 01 HERMAN HUBERTUS JEBATU, S. PD 650200-04-013794 SAKINAH FILLAH
517-2033796 01 DIAN IRMA SANTI 650200-04-013794 SAKINAH FILLAH

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 76
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650201 DEVI MASITA AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2024324 01 IMAM BUCHORI 650201-04-000313 YULLY TRI HARTINI
517-2024431 01 SITI AMINAH 650201-04-009289 SETIA NILGA MARETA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 77
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650401 REGGY MERDEKA AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5344053 01 HARTINIK 650401-04-006822 VITA OKTAVIANA
516-9880258 01 LILIES MARIANI 650401-04-008838 KHOIRUN NIKMAH
517-1372641 01 BINTI MAHMUDAH 650401-04-008838 KHOIRUN NIKMAH
517-2020371 01 RAHAJU ASTUTI, DRA 650401-04-008852 NIKEN WULANDARI
517-2012253 01 ELIS SHOLIKAH KUSUMAWATI 650401-04-009162 DIAN NOVITA SARI
517-2015009 01 ZAKIYATUL HABIBAH 650401-04-009162 DIAN NOVITA SARI
517-2023029 01 IBNU SHOLIKIN 650401-04-009162 DIAN NOVITA SARI
517-2023565 01 SIHANA 650401-04-009162 DIAN NOVITA SARI
517-1172561 01 ISALUNA SANDI 650401-04-010028 ANIES WIDYASARI
517-1560906 01 ALIFI HARIYADI 650401-04-010028 ANIES WIDYASARI
517-2026550 01 ALIFI HARIYADI 650401-04-010028 ANIES WIDYASARI
517-2019118 01 IBNU AGUS WIDODO 650401-04-010139 ANINDYA GUPITA KIRANA
817-5122095 01 PUSPITASARI 650401-04-013157 SOFIA INDRIANA
517-2025792 01 ANDIK WIDODO 650401-04-013671 DEWI LESTARI WULAN

NO. OF LIFE POLICIES = 12

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 78
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650402 YUDHI ROCHMADI AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5120867 01 WINDIARTI DWI TRESNANI 650402-04-002734 TIYAS PURIYANDARI
517-1186496 01 KHARIS MISBAHUDIN 650402-04-004070 SISCA NUR VISTA DEWI
816-4166038 01 RIZKI DAMIA SUGIONO 650402-04-004070 SISCA NUR VISTA DEWI
517-1141061 01 SAMSUDIN 650402-04-007667 FARIZKA FITRINALDI
517-1244964 01 BUDI SANJAYA 650402-04-007667 FARIZKA FITRINALDI
517-2022542 01 AHMAD AKBAR 650402-04-010765 ELNA OKTAVIRA
517-1057085 01 BUDI PRISTIWANTO 650402-04-012424 IKA AGUSTINA
517-1139263 01 KHUSNUL LATIFAH 650402-04-012424 IKA AGUSTINA
517-1848020 01 JOHAN RIO PRAMANA 650402-04-012424 IKA AGUSTINA
817-5388951 01 LAZIO AL DAVANO 650402-04-012424 IKA AGUSTINA
817-5389900 01 SUDARMAN 650402-04-012424 IKA AGUSTINA
517-1042343 01 HANIFA HABIB RIDOLILLAH 650402-04-012743 SRI AYU PERDANA
517-1603268 01 DAMAI BAGAS KURNIASANDY 650402-04-012743 SRI AYU PERDANA
517-2014846 01 NURUL YAQIN 650402-04-013151 MAMIK WINARSIH
816-4192703 01 RUSIYONO 650402-04-013408 RENNY DYA NAFITRI
517-1018368 01 UMI MASRUROH 650402-04-014076 AJENG OKTASA WARDANY
517-1393183 01 MARSUNI 650402-04-014076 AJENG OKTASA WARDANY
817-5344178 01 ZAENUL FATTAH 650402-04-014087 SHANDIPUTRA BUDHI PERDANA
517-2008905 01 HUSNUL KHOTIMAH 650402-04-014652 ANINDHITA TWINIARTY S
517-1111502 01 AGUS CAHYONO 650402-04-014654 ELA PUSPITASARI

NO. OF LIFE POLICIES = 14

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 79
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650410 INTAN ROSARY TUSSY AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2034950 01 AZARIA NATASHA 650410-04-012410 DEWI NURLITA SARASWATI

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 80
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650416 WAHYU CHANDRA AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2026188 01 R. MAS AHMAD ZAKARIA 650416-04-000861 GIRI MAY ANJANI
517-2027178 01 SYLVIA RATNASARI 650416-04-001929 NUR ROCHMAH NOVIANTI
817-5259988 01 MOH NAUWAL FADLAN 650416-04-004485 HERNY
816-4207113 01 FITRIA 650416-04-011434 DUTA RAHYUDANTONO
816-4316914 01 MUHAMMAD ZIDANE 650416-04-011434 DUTA RAHYUDANTONO
817-5353674 01 ANA ROKHMATUS SA'DIYAH 650416-04-011434 DUTA RAHYUDANTONO
517-2020215 01 RIZKI RUSDIANSYAH 650416-04-012401 ARIEF FEBRIYANTO
517-2021361 01 ANNISA KUSUMA RAHMANI 650416-04-013791 NAHDIA RACHMAYANTI

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 81
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650520 ELISABETH SANDRA FERNANDEZ AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1068850 01 SAKHA AHMAD RAFA PUTRA 650520-04-008367 NAOMI DRESTI HAPSARI
517-1386120 01 CHAESARA DIKITA KEMASARI 650520-04-008367 NAOMI DRESTI HAPSARI
516-9879342 01 FAHRURROZI FIRMANSYAH 650520-04-014658 FURQON HAKIM QODRI
517-1057176 01 NI'MATUL FAUZIYAH 650520-04-015118 ANGGRIANA DESY DWI HARSANTI

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 82
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650567 MENGKI ANDRIANTO AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2021973 01 ALDILA HEIDY KUSUMA 650567-04-009522 AL MUTAKIM
817-5344533 01 ATALARISSA MUTIARA SANY 650567-04-011113 FIRMA KUSUMA INDRAYANI
516-9880118 01 ARIF RIZAL 650567-04-015128 SISKA RAHMAYANI
517-1450678 01 RIZKY ERIANDANI 650567-04-015128 SISKA RAHMAYANI

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 83
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650648 NANANG SUPRIYANTO AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2021452 01 SUGENG MUFLIH.H 650648-04-014086 SETIA BUDI

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 84
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650649 SITI AZZA AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1393555 01 WHISNU SAKTI BUANA 650649-04-011698 RATNA KARTIKASARI
517-1055220 01 SRI LESTARI RAHAYU NING TYAS 650649-04-013154 RIRIN FATMAWATI
816-4339163 01 NAYSILLA DEWI DARMAYANTI 650649-04-014767 DYTA AMELYA SUPRIYADI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 85
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 650667 DONI MILON DANU AGENCY : 650000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2021148 01 ELISYA PUTRI JELITA SOLEHA 650667-04-004961 MASRUR JUNAIDI
517-2034398 01 HERLINA SETYO NINGSIH 650667-04-014421 JOUHAR TAUFIQURROHMAN
517-2020991 01 AUGUST ENDANG SHOLEHAWATI 650667-04-014653 AYNUR ROCHMAH
517-2027970 01 BUDI PITOJO 650667-04-014653 AYNUR ROCHMAH

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 86
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657455 ANIS SRI RAHAYU AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-3212557 01 IKHSAN SANJAYA SAPUTRA 657455-04-010260 REGGIE ANDIKA
517-2015785 01 ADILA JANNATI PUTRI 657455-04-014191 ERNA SETYANI
817-5448920 01 STEVEN TEE 657455-04-014392 YENNI CHRISTINA
817-5431330 01 SULIS DWILASWORO 657455-04-015052 DEDE MUSADAD
515-6306655 01 FERNANDO SIMANUNGKALIT 657455-04-015056 DIAH WINI DITA A N
515-6306663 01 SYAIFUDIN NURJAMAN 657455-04-015056 DIAH WINI DITA A N
517-1181513 01 JOKO WIYANTO 657455-04-015056 DIAH WINI DITA A N
517-1612640 01 RINI INDRIYATI 657455-04-015056 DIAH WINI DITA A N
517-1437402 01 USMAN 657455-04-015066 NADIA NURISLAMIAH
816-9681353 01 DESTI NATASYA ASHAFANI 657455-04-015221 ATIKA FAIQOH

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 87
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657458 HARSIYANTI KURNIASIH AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2011099 01 HERRY PRIYONO, SE,MBA,IR 657458-04-004283 YUNITA ANGGUN MUSTIKA PUTRI
517-2011768 01 AISYAH AYUDIA INARA 657458-04-005904 SITI MASPUPAH
517-2025495 01 AZKA PUTRA RAFFA GILYANTO 657458-04-005904 SITI MASPUPAH
516-9950077 01 AULIA FACHRIZA INDARYANTO 657458-04-011912 KRISTIANTO SUDRAJAT
517-2012279 01 SITI SUPRIYATI 657458-04-013433 SANTI BAYU SUCI
517-2024068 01 YATI NURHAYATI 657458-04-013433 SANTI BAYU SUCI
517-2020553 01 RINI MAYASARI 657458-04-015366 SONIA INDAH MAWARNI

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 88
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657461 MARIANA MAGDALENA AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9949012 01 ANDRE MATHEW 657461-04-006911 SARI WIDYASTUTI, SE
517-2035452 01 SUYANTI 657461-04-008828 DYAN WAHYU RETNONINGRUM
517-2009069 01 BERLIAN PASARIBU 657461-04-011383 ELEN SENTIA SARAGIH
517-3045443 01 RACHELLIA INDAH CAHYANTI 657461-04-011383 ELEN SENTIA SARAGIH
817-5329542 01 MARIA WIDIANTI 657461-04-012116 CENDY LARAS MEGAWATI S
817-5353500 01 HAERUL YAMIN 657461-04-012504 FADILLAH
517-1558892 01 OKTO KHAISAR 657461-04-014391 TSANA KARIMAH

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 89
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657465 RINI FEBRINA AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
816-2032992 01 ARJUNA IHSAN WIBOWO 657465-04-001097 TUTI ADAWIYAH
516-9879656 01 REZA ASHARY 657465-04-003392 NOVITA ANGGRAENI
517-1236622 01 WIDI ALIFIANTO 657465-04-007089 ERAWATI
517-1532442 01 MUHAMMAD ALDO 657465-04-007089 ERAWATI
816-1977262 01 ADEEVA AFSHEEN QUEENSY P 657465-04-007799 MELDA SIAHAAN
516-2125461 01 CLARITA LIGAYA ISKANDAR 657465-04-011615 NURLIANA YUSMIRANI HATY
516-3529729 01 NOVI FITMAWATI 657465-04-012676 EVALINA H. HUTAURUK
516-8770781 01 SUTIONO, [Link] 657465-04-012676 EVALINA H. HUTAURUK
816-2026093 01 MOCHAMMAD ARIF RAMADHAN 657465-04-012676 EVALINA H. HUTAURUK
817-5343675 01 ANI NIGERIAWATI 657465-04-012676 EVALINA H. HUTAURUK
816-9706358 01 MARTINUS KASWORO 657465-04-013739 ARDIAN SUHADI
817-5330490 01 ADAM RIJALDI ABDILAH 657465-04-014502 ANNA NOVITA LUMBAN GAOL
817-5122087 01 HENDRIKO BERMAN 657465-04-014507 SOFIA JULIANA
516-3242349 01 AFANDY 657465-04-015478 SYAFTAFRIMA PERBAWARISKI

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 7
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 90
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657558 YOPPY MAIRIZON RS AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9950739 01 ENDRI HASTUTI 657558-04-011201 FRENGKY SINGGALINGGING
517-2025677 01 ANDI LUQMAN HAKIM FRIYADI ISHA 657558-04-012816 ARRIA JANOVIE
517-1382376 01 WAHYU HERDIYANTO 657558-04-014208 INDRA RAJA NASUTION

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 91
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657590 GILANG PRIMA AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
816-8128810 01 ALISHA PURI LIYANA 657590-04-003386 SRI WULANDARI
517-1393076 01 MUHAMMAD ARI SETIAWAN 657590-04-011644 LIA AMALIAH
817-5329807 01 RICHARDO SAMOSIR 657590-04-012006 RAHMAT
517-1823536 01 AQUEENZA SHABRINA ANINDIRA 657590-04-013743 ELLA ANINDYA PRATIWI
517-2022815 01 FIKA FATMILA 657590-04-014873 EPRILIA WINARDI
515-8509413 01 GIFFAR 657590-04-015057 ERVINA RAMADHAN

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 92
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657598 IRMA KEMALA DEWI AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2031048 01 DIAH WULANDARI SKOM 657598-04-005052 YANTI
516-9948030 01 UJANG SARFUDIN 657598-04-010851 RATIH NINDHYAKIRANA
517-1686925 01 ARIEF WIJAYA 657598-04-012007 RIZKI SULISTYOWATI
517-2015140 01 LEONY TRISNA 657598-04-012113 MELI MAILANI
517-2035692 01 DESYIANTI 657598-04-012113 MELI MAILANI
517-1069734 01 ENGELBERT L.T SUMENGE 657598-04-015209 SANU FRINTANIA
517-1057028 01 MAKBUL 657598-04-015235 RIA MARSELLA

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 93
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657599 WEDYA LESTARI SE AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1057754 01 HARDI BESTURA P. 657599-04-011367 WILLY WIRANATA. N
517-2009002 01 RORO SEKARSARRY MAHENDRAWATI 657599-04-012316 DEPIPIH RIDAUL FAUZIAH
517-1372054 01 VANI MEGARANI 657599-04-014388 RAHMA YUMITA
816-4219126 01 MUHAMMAD SOFYAN YOFLEK 657599-04-014616 PUTRI REZEKI AMELIA
517-1069288 01 AYU WULANDARI 657599-04-014866 ADZKIA AULIA RAHMI
817-5463713 01 ROKI CANDRA 657599-04-015080 ASTRI IVO
517-1246381 01 RENATHA FEBRIANTI 657599-04-015236 RIZKY DEVI PERMATASARI

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 94
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657601 SYAFRUDIN EFENDI AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2022922 01 PURNO TRI PRABOWO 657601-04-007113 R RIAN ARIANTO YUDONO
517-2009424 01 UTARI TRIYANTI 657601-04-008426 M. RIGI ASTONO
517-2022757 01 SAOJI 657601-04-008426 M. RIGI ASTONO
517-1140402 01 AWALUDDIN 657601-04-008689 FIFI ANGGRAINI
517-2025354 01 ADHITYA PERDANA 657601-04-008709 SITI NURLAELA NAPIAH
517-1021560 01 SUCIPTO 657601-04-011264 SINTAULI BR SIDABALOK
517-1171282 01 DADAN 657601-04-011264 SINTAULI BR SIDABALOK
517-1370728 01 YESI ANGGRAENI 657601-04-011264 SINTAULI BR SIDABALOK
517-1436800 01 GUNANTO 657601-04-011264 SINTAULI BR SIDABALOK
517-2036450 01 WAWAN SETIAWAN 657601-04-011277 GELORARIA RONAULI TAMBUNAN
517-2014952 01 IIS SATINAH 657601-04-011770 MUKHAMAD KAMAL RIZAL
517-2025172 01 ROBBY SAEFULLAH 657601-04-011770 MUKHAMAD KAMAL RIZAL
517-2016544 01 MURJIATI 657601-04-011999 DANIEL PANDAPOTAN MARBUN
517-2026055 01 SURNAWATI 657601-04-011999 DANIEL PANDAPOTAN MARBUN
517-2019837 01 JAED WIBOWO 657601-04-013745 FARADINA QUROTTA AYUN
517-2020314 01 MOCKAMAD ARIS ANDOKO 657601-04-013745 FARADINA QUROTTA AYUN
517-2022328 01 ARIANTO 657601-04-013745 FARADINA QUROTTA AYUN
517-2026931 01 RAFI MAULANA 657601-04-013745 FARADINA QUROTTA AYUN
517-2024027 01 WIDYAWATI MARBUN 657601-04-015065 MAULINA NAZIAH
517-1090334 01 WINDIYA HAPITASARI 657601-04-015219 AGATHARIA NOVITA SIANTURI
517-1235558 01 ANJAS MAWI 657601-04-015219 AGATHARIA NOVITA SIANTURI
516-9893764 01 YULIANI 657601-04-015220 ANDAN WARIH PUSPA SETIA
517-1193070 01 SITI FATIMAH 657601-04-015220 ANDAN WARIH PUSPA SETIA

NO. OF LIFE POLICIES = 23

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________
DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 95
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657645 NESYA MESIANA OROH AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1057614 01 MARTUTI DWI HANDAYANI 657645-04-010731 ENDANG WIARTI
516-2122468 01 EKO SETIARSO 657645-04-010941 DWINTA LESTARI
516-6463884 01 MARIA N. TAMBUNAN, IR, MM 657645-04-010943 SEIRA HASYA FALAHAN
517-1171332 01 RONI MARKONI SE 657645-04-010943 SEIRA HASYA FALAHAN
517-1090425 01 ABDI GHAFFAR 657645-04-013106 AZIDDIN
517-1312936 01 MORENA TANTILIA 657645-04-013243 WINDA SARI TAMPUBOLON
517-1372542 01 ATALIA FANGIDAE 657645-04-013243 WINDA SARI TAMPUBOLON

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 96
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 657656 TRISAYUDDIY PRAYITNO AGENCY : 657000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5319691 01 ISTAFA BHIZAK KAYAGA 657656-04-012123 CHAREN EMELDA DAHLIA
817-5329625 01 UTOMO DEWANTO 657656-04-012123 CHAREN EMELDA DAHLIA
516-9842753 01 SARI DAMAYANTI SITOMPUL 657656-04-014279 WATINI ANGGUN PRATIWI
517-2015074 01 KOMY ANDRAYANI 657656-04-014279 WATINI ANGGUN PRATIWI
517-2015447 01 RAYYAN ALFIANDRA LUKMAN 657656-04-014279 WATINI ANGGUN PRATIWI
517-1290132 01 JUNAEDI 657656-04-015077 YESSI PRATIWI
517-1747214 01 CANDRA ANGGIT DEWANTARA 657656-04-015077 YESSI PRATIWI

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 97
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658469 MARLINA M. SUMAJOW AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1369217 01 FARADILA DAENG BARANG 658469-04-008376 CHAIRUNNISA
517-1561045 01 SARTIKA SAHID 658469-04-008376 CHAIRUNNISA
517-2036716 01 NOVITA UTHY 658469-04-008376 CHAIRUNNISA
817-5162992 01 ANITA KRIPTIANI 658469-04-008376 CHAIRUNNISA
817-5164626 01 ABDUL AFIF UMASUGI 658469-04-008376 CHAIRUNNISA
817-5464109 01 TASLIM TENGKU IDRIS, SH 658469-04-008376 CHAIRUNNISA
517-2027061 01 HAMIDAH 658469-04-010909 JULIO GEORGE KAWILARANG
517-2023326 01 AMINAH MAKU 658469-04-012746 EKA MURIANI LIMBANADI
816-4301353 01 MIKE LYDIA LINTONG 658469-04-012746 EKA MURIANI LIMBANADI
517-2015413 01 DARIYATMO GINTING 658469-04-013045 ROMARIO ORLANDO KATUUK
517-1070278 01 SURYANINGSIH PO'OE 658469-04-013612 DESYA CHIJAYANTI
517-1141996 01 NATALIA JANNY LELET 658469-04-014243 REGINA MICHICO PANGALILA
517-2022641 01 LISTIHANI LAMANI 658469-04-014441 MARLEN MEILANI RUMENGAN
517-2022765 01 MARINE FLORA MALINGKAS 658469-04-015405 JENIFER NAJOAN
517-2028028 01 MEIDWIN SAMUEL LAHU 658469-04-015405 JENIFER NAJOAN

NO. OF LIFE POLICIES = 11

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 98
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658470 MEILANI AMELIA SEMBUNG AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2011685 01 ATIKA NATALIA GINTING 658470-04-009722 LUSI SIWU
517-2016155 01 DELIANA PAKAYA 658470-04-013686 LESLY DEBORA RUNTURAMBI
517-2036146 01 ALZALIKA GITA SYABANIA SUBAGYO 658470-04-013686 LESLY DEBORA RUNTURAMBI

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 99
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658473 NUR HIKMAH AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9948568 01 LHUTER PALIMBUNGA 658473-04-010387 MARYAM YUSUF BARMANSYAH
817-5275885 01 ST HARTATI 658473-04-010387 MARYAM YUSUF BARMANSYAH

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 100
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658488 HARIS TEGUH S AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1602120 01 MARTHINA P. W. PESULIMA S 658488-04-003135 RACHEL KASTANYA
817-5316291 01 DARMIATI 658488-04-003135 RACHEL KASTANYA
817-5342974 01 MELVI JANTI LEIWAKABESSY 658488-04-003135 RACHEL KASTANYA
817-5122012 01 WA RAM NAYA 658488-04-004701 SITI FANY ANGRAENI
817-5463838 01 JAMIL SAMSUDIN 658488-04-004701 SITI FANY ANGRAENI
517-2024001 01 JENNY SOPLANIT 658488-04-009723 NADYA MASUKU
517-2035254 01 ALEXANDER RONI TAHALELE 658488-04-009723 NADYA MASUKU

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 101
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658535 DWI PRASETYO AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1602575 01 NUR FARIDA PAGASTIATY 658535-04-014159 ANJAR PERMATASARI B
517-1322158 01 ABSYAR SYAFIQ ABUBAKAR 658535-04-014223 MASUARA
517-2015595 01 LA MALUDI 658535-04-014223 MASUARA

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 102
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658536 MUHAMMAD ADNAN AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5121881 01 NI MADE HARTATI 658536-04-008831 ATIS SURYA WIGUNA
517-1602013 01 MOH RIZAL 658536-04-011019 JOECHIANA ROSIDI
817-5342834 01 AHMAD FAHMI RAFISQI 658536-04-014445 SADDAM
817-5463697 01 MUH FATIH RIZQILLAH 658536-04-014445 SADDAM

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 103
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658554 ABD. RAHIM U AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1060857 01 HERMAN TJIANG 658554-04-003638 JULIANTO
517-2033317 01 SYARIEF RAHMAT TASMAN, SH 658554-04-011472 SUCI RAHMADANI
816-4351895 01 KEVIN ADITHYA 658554-04-013416 A EVA SUSANTI S
817-5432692 01 BURHANUDDIN 658554-04-014442 NURUL QADRI SAMAD
817-5450694 01 FRANSISKA CORNELIA 658554-04-014442 NURUL QADRI SAMAD

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 104
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658588 AKMARIZAL AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5285132 01 INDRA ENRIS 658588-04-002556 ASRIANI
817-5449365 01 RIZKA VARHANA ANIS 658588-04-002556 ASRIANI
517-2019670 01 HASTINY 658588-04-008126 DEVY YULITHA Z. A
817-5164014 01 AZ ZAHRAH PUTRI FATIMAH 658588-04-011884 CHAIRIL ABDILLAH
817-5122244 01 NIRWASITA ZAHWA RAMADHANI 658588-04-011885 DEWI RATIH MM
817-5344467 01 TOHIRUN, SE 658588-04-011885 DEWI RATIH MM
517-1058109 01 A. MUH. RIVAL BAKSAL 658588-04-012881 IRMAYANTI
517-1139560 01 ADE GUSTI WARMAN 658588-04-012881 IRMAYANTI
817-5047219 01 HERLINA [Link] 658588-04-012881 IRMAYANTI
817-5449423 01 AHMAD 658588-04-014229 MUTMAINNAH
817-5162745 01 AVILIANI KHAERUNNISA 658588-04-015141 RATNAWATI
817-5318925 01 AGENG WICAKSANA BHAKTI 658588-04-015141 RATNAWATI
817-5122061 01 EKA RIYANTO TANGGO, ST 658588-04-015143 SARI MUTMAINNAH
817-5464588 01 REINALD MARULI SILALAHI 658588-04-015143 SARI MUTMAINNAH

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 11
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 105
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 658664 IWAN NUGROHO AGENCY : 658000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2011891 01 MAHMUDDIN 658664-04-011880 SANDI NAYOAN

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 106
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 662529 ANA MARIE RESUBUN AGENCY : 662000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-6728922 01 LINDA 662529-04-005873 ANACE ABIA RUMBIAK
516-2127970 01 NURITA ROSDIANA SILITONGA 662529-04-013422 ANGGEL REBEKA BESOUW
516-8344009 01 ESAU ASSO 662529-04-013422 ANGGEL REBEKA BESOUW
816-9281527 01 MICHAEL A. I. NAJOAN 662529-04-013422 ANGGEL REBEKA BESOUW
517-2023284 01 YUNINGSIH 662529-04-013813 JOHAN DITYA NARENDRA
517-2023557 01 YUNINGSIH 662529-04-013813 JOHAN DITYA NARENDRA
817-5389488 01 ADIBA SAQILLA HIDAYAT 662529-04-013813 JOHAN DITYA NARENDRA
816-4162367 01 CLARITA ANGGEL JOBER MERAUDJE 662529-04-014165 ASEP JUANDA

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 107
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 662530 IRFAN ZAINAL AGENCY : 662000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1245284 01 AMANDA ARBERTINA RAHAYAAN 662530-04-011009 MARIA ELVINA CWALA
817-5354102 01 SOMUNTUL P. SIMATUPANG 662530-04-011009 MARIA ELVINA CWALA
817-5463317 01 RUSLINA LEMPUNG 662530-04-011009 MARIA ELVINA CWALA
817-5463796 01 RIFFAT JAZMIN FR. THOSULLY 662530-04-013936 MONICA RATUNUMAN
517-2027525 01 SARLOTA SMAS 662530-04-015296 ARYANI ANDI LAMBERE
817-5284879 01 ANDO EKO M WIDODO 662530-04-015411 YUBELINA PULALO

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 108
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 662593 MIRWAN SAPUTRA MANSYUR AGENCY : 662000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1305047 01 YERMIAS FURAY 662593-04-010801 SINTA DEWI SALURABA
517-2022211 01 SUHAEFI SAMPER 662593-04-010801 SINTA DEWI SALURABA
517-2026071 01 FIDELIO ANDERSON PERANGINANGIN 662593-04-010801 SINTA DEWI SALURABA
517-2028739 01 JOHAN FREDERIK KOIBUR 662593-04-010801 SINTA DEWI SALURABA
815-5037917 01 ALFIAN RATMO 662593-04-014124 AGNES CLARA V. M. TAPUN
517-1139610 01 HASAN RUMASUKUN 662593-04-014126 RINI MUGIYANTINI
517-1139636 01 HASAN RUMASUKUN 662593-04-014126 RINI MUGIYANTINI
517-2021403 01 RIKMON MANDAK 662593-04-014789 MESRA LINA PURBA

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 109
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665570 ADHITYA PRAKASA AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5122277 01 MAMAT RIZAL 665570-04-002403 NOVI HERAWATI
817-5463937 01 M. FIRLIE HIDAYAT 665570-04-002403 NOVI HERAWATI
517-2021767 01 RISMALENI 665570-04-009735 ENDA OKTA WULANDARI
517-2034968 01 HARIYANI 665570-04-010148 LESTINAH SITOMPUL
517-2014788 01 SAPRIADI 665570-04-012030 H RAHMAT GULTOM
817-5389165 01 BUDI HIDAYAT 665570-04-012030 H RAHMAT GULTOM
817-5342826 01 REZZA GERRI 665570-04-012279 RINI JULIYATI
817-5344632 01 AL JEFRI LUKI MARADONA 665570-04-012279 RINI JULIYATI
817-5163792 01 IBNATY RANIAH MUYASSARAH 665570-04-012282 TENNIE ARWANI

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 110
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665574 NIKEN YOHANA SARI AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2027384 01 MUHAMMAD ABID AL FATIH 665574-04-005039 MARINA
517-1056897 01 ABRAHAM NICHOLAS SIMANGUNSONG 665574-04-010724 KIKI RIZKY YULIANTI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 111
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665575 RIDHO RAFALDO AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2024795 01 GUSTIN NOVIA SARI 665575-04-011502 FRESSCA DINA SUSHANTI
517-2020710 01 MURNI ASIH 665575-04-012791 MULKAN HENDIANSYAH
517-2024761 01 SUYOTO 665575-04-013719 EKO SAPUTRA
517-2012436 01 ANDRIANTO HERMAN LOPIES 665575-04-014590 RISKIKA MAYA
817-5343659 01 DWIANA PUTRI 665575-04-014590 RISKIKA MAYA

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 112
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665576 SILVA HULIDAYANTI AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2012709 01 EKA YULYANTI 665576-04-009945 DHITA CITRA FRAGISTA
817-5449555 01 ANNISA FITRI 665576-04-009945 DHITA CITRA FRAGISTA
517-2018896 01 GITA PRASTIKA 665576-04-010031 RUSMIATI. [Link]
517-2030909 01 GANIS NURYANI 665576-04-010031 RUSMIATI. [Link]
517-2016452 01 AHMAD SOFYAN 665576-04-012518 BALQIS FAYRUWZ FATIN
517-2024845 01 HENDRIK 665576-04-012518 BALQIS FAYRUWZ FATIN
517-2027418 01 ANDI ARYADI 665576-04-012518 BALQIS FAYRUWZ FATIN
517-2033846 01 AGUNG PUJA NUGROHO 665576-04-012518 BALQIS FAYRUWZ FATIN
517-2035544 01 YAYAN SATRIA 665576-04-012522 MUHAMMAD YUSUF
817-5164337 01 MUSLIM 665576-04-012634 ADE PUTRA INDAWAN
517-2035429 01 HARYADI 665576-04-012944 ARIEF RACHAMAN HAKIM
817-5464182 01 RIDWAN GULTOM 665576-04-012944 ARIEF RACHAMAN HAKIM
517-1181679 01 KHAIRUNNISA TANJUNG AMD KEP 665576-04-013209 TIARA ANGGRAINI
817-5330375 01 MUHAMMAD NAJAR 665576-04-013209 TIARA ANGGRAINI
817-5449480 01 RAHMAT HIDAYAT 665576-04-013209 TIARA ANGGRAINI
517-2022609 01 RAPINAH 665576-04-013856 INTAN KEMUNING SARI
817-5122152 01 AHMAD REYNANDA RIZQI 665576-04-015452 MERY SUSANTI DIAN PRASTIWI

NO. OF LIFE POLICIES = 11

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 113
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665577 TITIEN NOVIANTI AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5464083 01 AGUS SUHARNO 665577-04-011213 SANDITYA FEBRIANI
517-1438269 01 ERISFA 665577-04-011394 MIRZA HANS ANDIKA
817-5121907 01 DESY PURWANTI 665577-04-011630 NENTI OUCIS SARA
817-5344152 01 NURHALIMAH 665577-04-012027 IDA PUSPITA SARI
817-5390130 01 HARTINI 665577-04-012027 IDA PUSPITA SARI
517-1381832 01 FIKRY KHALIFAH MUHAMAD ZAKY 665577-04-012635 DEVI ARY SANTI
817-5344426 01 EVA SUSANTI 665577-04-012635 DEVI ARY SANTI
817-5464265 01 ALBERT WIDIYUTA GATAPRASOMYA 665577-04-012639 NURUL HIKMAH
817-5122293 01 M SURATMAN 665577-04-014716 RICKY SULISTYO
517-2020082 01 SAFRUDIN GINTING 665577-04-014851 YULI PURNAMA SARI

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 7
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 114
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665578 WAHYU NOVRIANTO AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5172454 01 METRIA HADI 665578-04-005909 SRI RAHAYU
517-2027483 01 AGUNG MULYONO 665578-04-012943 AGI VEOLETA
517-2033101 01 NURHASANAH 665578-04-014493 SA DYAH ZAHROTUL RIYADH
517-2018987 01 JONI HERIWIBOWO 665578-04-014844 AYU YULIANA

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 115
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665579 YULIA NAVRATILOVA AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5122046 01 INDRA KURNIAWAN 665579-04-010443 NURUL ALDELANI
517-2022427 01 JUANA 665579-04-012952 SIZTY PUTRI TAMA
517-2021155 01 YUSUF APRIYANTO 665579-04-014350 YESI GUSLENI

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 116
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665596 INDAH PRANICA AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5432338 01 MAHENDRA SINATRA ANTAN DJAYA P 665596-04-013087 LILIANI
817-5163032 01 CAHYO PRASOJO 665596-04-014588 NINDY YULINDA
517-2019225 01 VIVI SELVIA ALZA 665596-04-015195 RISKA YULIANI

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 117
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665597 FIKRI AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2019761 01 STEFANY VENNYSHA 665597-04-004250 MIKE GUSPITA
817-5329880 01 ALDINOL PUTRA 665597-04-006496 RIENDIANA AMIR
517-1449969 01 DAVINIA DEA QUEENSHA 665597-04-015015 YUNI SARI SITEPU
817-5172298 01 SILFANA YENITA 665597-04-015015 YUNI SARI SITEPU

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 118
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665623 NINDI AGUSTIRA AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5121444 01 M. ICHSAN ARIFIN 665623-04-006180 KARDO VEMRA RISKI
817-5389702 01 ALDRIDGE EL RAFIF KAFADI 665623-04-006180 KARDO VEMRA RISKI
517-2020249 01 SIMON ALFANIS SIDABUTAR 665623-04-012026 EMELIA

NO. OF LIFE POLICIES = 1

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 119
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 665631 YONA PURIANDARI AGENCY : 665000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2011016 01 NOVALIA 665631-04-008412 DERI SILVIANI
517-2011453 01 M ARLAN 665631-04-008412 DERI SILVIANI
817-5284846 01 SITI SOFIAH 665631-04-008412 DERI SILVIANI
817-5122459 01 LUCREZIA AZZAHRA SIMANGUNSONG 665631-04-011807 DEBBY PERMATA HATI
817-5464174 01 RISKY TODING 665631-04-013343 NANI APRINA
817-5389108 01 IIS SRIJATIMULYA 665631-04-014343 RISKA WULAN SARI
517-2027467 01 ADE RISQI PRATAMA 665631-04-015196 RIFKI ARI SADEWO
517-2035494 01 SAFIN ALLARIQ ATHALLAH 665631-04-015196 RIFKI ARI SADEWO

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 120
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 666580 EPAN SETIAWAN AGENCY : 666000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2025693 01 VITRIAH BULU LAGA,[Link] 666580-04-007636 AMANDA ROSDIANI LEONARD
517-1245326 01 YOHANES YOHAN SUSILO 666580-04-012887 MARIANUS YOHANES BALI TOA
816-4353396 01 ICHA DIONI LOIT 666580-04-015295 WIDYA YULIANTI TASLIM

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 121
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 666581 LEONARDO RONALD PATTY AGENCY : 666000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1611600 01 DARMAWAN 666581-04-005794 AGUS SUPRIANTO
816-4077771 01 PUTRA SATIA 666581-04-005794 AGUS SUPRIANTO
817-5316549 01 NI KOMANG SITIARI 666581-04-005794 AGUS SUPRIANTO
517-2026444 01 MUH. YUSUF 666581-04-007639 ESY YANTI LUPIANA
516-9949459 01 MOH. KHOLIQ 666581-04-008800 NIMAS KARTIKA SARI
517-2035338 01 I MADE SUANDI KUSUMA ANTARA ST 666581-04-008800 NIMAS KARTIKA SARI
517-2033341 01 YUHANNAH, S. PD. 666581-04-010371 SOLATIAH
517-2011545 01 MUHAMMAD HUSNI 666581-04-011299 ZULVA AWALIA SARI
816-4405055 01 MUHAMMAD THORIQ FATHURROSYAD 666581-04-011649 KHRISNA CAPELLA UTAMA
517-2020223 01 SURYANI 666581-04-013616 DIAN SAVITRI
817-5449449 01 RYAN ANWAR 666581-04-013616 DIAN SAVITRI
817-5121683 01 AISYA MADINA PUTRI 666581-04-013933 FITRI ASRIANI

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 5
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 122
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 666582 R. BINTANG PERMANA PUTRA AGENCY : 666000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2035528 01 NYOMAN DIAN HAUSELINA 666582-04-000647 PUTU SUARTAWAN
517-2021643 01 RATNA WIDIA KURNIAWATI 666582-04-007275 GEDE PANDE ADNYANA
517-1319196 01 I MADE DARMA UTAMA 666582-04-013304 RINA JULIANA
517-2025917 01 I MADE BUDIANA, SE 666582-04-013680 DWI DESIANA EFFENDI
517-2033499 01 HENI MARDIATI 666582-04-013680 DWI DESIANA EFFENDI
817-5344608 01 GUSTI AGUNG JOLI ARYAWATI 666582-04-013680 DWI DESIANA EFFENDI
517-2025669 01 NI KOMANG ANINDYA MAHESWARI 666582-04-013681 NI PUTU AYU NANA ERLYNDA
517-1562522 01 ADISA 666582-04-014543 GUNAWAN
517-2033259 01 ARY KURNIAWATI 666582-04-014543 GUNAWAN

NO. OF LIFE POLICIES = 8

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 123
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 666583 TRIA SASAE AGENCY : 666000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1135055 01 I KADEK PUTRA WIBAWA 666583-04-009547 I PUTU SUDARMA ADI PUTRA
517-1604217 01 ANAK AGUNG GEDE WIRSANA PUTRA 666583-04-009547 I PUTU SUDARMA ADI PUTRA
517-1186595 01 NI WAYAN KARIANTI 666583-04-011294 IDA BAGUS MADE WEDA ARSA
517-1245722 01 SUKRI HAMDI 666583-04-012454 NI KETUT DELLA INDAH PRATIWI
517-1172330 01 LUH KADEK AYU YUNITA SARI 666583-04-013301 NI KETUT KARTINI ASIH
817-5286452 01 I KADEK DWI MAHENDRA WINATA 666583-04-013301 NI KETUT KARTINI ASIH
817-5319931 01 KOMANG ABHINAYA MAHACARA 666583-04-013301 NI KETUT KARTINI ASIH
816-4350764 01 FRANCECCO SULTAN JAYA 666583-04-013302 NI NYOMAN SANTI DEWI
517-1171803 01 LUH GEDE DEFIK MEIGANTINI 666583-04-014931 SANTI OKTAVIA
517-1017287 01 NI KOMANG PARMIASIH 666583-04-015406 KADEK SRI SUARNI
517-1141004 01 MADE BAGUS SYAILENDRA S. 666583-04-015406 KADEK SRI SUARNI

NO. OF LIFE POLICIES = 8

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 124
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 666584 WISYE WIDYA ELIANSA AGENCY : 666000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1194219 01 PUTU MIRAH AMELIA PUTRI 666584-04-009551 AYU PUSPITA DEWI LESTARI
817-5276495 01 NI MADE PARMI, [Link] 666584-04-010709 IDA BAGUS MISWADANTA PRADAKSA
517-2008913 01 PURWANTO 666584-04-011514 RENNY KURNIANINGSIH
517-2016320 01 A. A. ISTRI OKKI INDIRA PUTRI 666584-04-011514 RENNY KURNIANINGSIH
517-2016395 01 NURHASANAH 666584-04-011514 RENNY KURNIANINGSIH

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 125
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668606 ADINDA NUURLEIZA AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1602088 01 DWI RAHMATANTI 668606-04-006304 TRISYANDI
817-5164600 01 MOCHAMMAD TRESNA RAMADHAN 668606-04-006304 TRISYANDI
517-2024688 01 MILLAH ZUHROTUL HAYATI 668606-04-008088 KIAGUS SYUKUR RISSAFULLAH ZULV
517-2027681 01 MUDJO SEMEDI 668606-04-008088 KIAGUS SYUKUR RISSAFULLAH ZULV
517-2026535 01 MISDI PRAYITNO 668606-04-010560 SUPRIATNA
517-2021536 01 KRISNA WARDHANA 668606-04-013265 NOKI RONA SURYA
817-5432163 01 ZHUBHAN ADZANI RAMADHAN CHERMA 668606-04-013265 NOKI RONA SURYA
517-2022286 01 MAWAR WATY SIMANJUNTAK 668606-04-014211 JIA FEBRIYAN

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 126
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668608 CITRA WULAN YULIANTY AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5463762 01 MAHARANI ZAIHAN FAIRUZ 668608-04-008942 ONING KOMALA DEWI
817-5171704 01 ETTY TACHSIJANI 668608-04-010817 ADINI BUDIARTI
517-2011727 01 YUNI HAYATI 668608-04-011293 JONI HAPINAL TANJUNG
817-5344400 01 ATEP RIAN GUNAWAN 668608-04-011293 JONI HAPINAL TANJUNG
517-2023714 01 CHRISMAN 668608-04-012056 HANDI ROBANA

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 3
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 127
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668609 DANIEL AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2020611 01 SRI KURNIA 668609-04-010813 IWAN RIDWAN
817-5464455 01 MUTIARA MARWAH 668609-04-010813 IWAN RIDWAN
517-1140873 01 TUTI KELANAWATI AMK 668609-04-010827 RIAD FADILAH
517-2015439 01 SRI MUNIGAR SARAH 668609-04-010827 RIAD FADILAH
817-5048613 01 CANDRA DIRGANTARA 668609-04-010827 RIAD FADILAH
817-5162794 01 SALMA FATIHAH HUMAIRA NUGRAHA 668609-04-010827 RIAD FADILAH
817-5431827 01 ASRIYANI SALSABILA 668609-04-010827 RIAD FADILAH
817-5432460 01 MIRA ANDILLA 668609-04-010827 RIAD FADILAH
817-5449183 01 TROPHY GEO DISANSYAH 668609-04-010827 RIAD FADILAH
517-2036062 01 ALI SUBRATA 668609-04-014523 YULIA APRILIANI
517-2027392 01 IKHSAN NURHOLIK 668609-04-014635 ANGGA DINI AKBAR
517-1525644 01 RAWITO 668609-04-014643 SILVIA FAUZIAH

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 128
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668612 WINDU KENCANA AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5121436 01 [Link] NURJANAH 668612-04-002181 LINAH FIRLIANAH
517-1004335 01 RINITA 668612-04-002246 CICAH SITI KAMISAH
517-1018178 01 MUHAMMAD TOHA 668612-04-002246 CICAH SITI KAMISAH
517-1656001 01 NANO ROMANSYAH 668612-04-002246 CICAH SITI KAMISAH
816-4338975 01 SOLEHUDIN 668612-04-002246 CICAH SITI KAMISAH
817-5276180 01 ELLI SUHERLIAWATI 668612-04-008536 RINI NURAENI
517-2025420 01 SONA 668612-04-009854 ARIS ISKANDAR
816-7834335 01 ANTO 668612-04-011058 DEWI SRI PRIMA SARI
817-5285033 01 AGUS SUPRIYANTO 668612-04-014065 GONI KADAR ALAM
517-1602484 01 PUADI 668612-04-014520 LAILA KASTURI
817-5389710 01 EDI SUPRIYADI 668612-04-014520 LAILA KASTURI

NO. OF LIFE POLICIES = 5

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 129
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668613 YULIA PATMAWATI AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5316721 01 JUANDA LESMANA 668613-04-008526 NURFAIDA ROHMAWATI
817-5390304 01 KEISYA PUTRI ANINDIYA 668613-04-008526 NURFAIDA ROHMAWATI
517-1021552 01 MAYANG HARYOKO 668613-04-010058 DENI MULYANA, SE
517-1062606 01 SITI KHODIJAH 668613-04-010058 DENI MULYANA, SE
517-1320939 01 SUNARYA 668613-04-010058 DENI MULYANA, SE
816-4338777 01 MUHAMAD ROBI 668613-04-010058 DENI MULYANA, SE
817-5163180 01 BADRIAH 668613-04-010058 DENI MULYANA, SE
517-1306334 01 USNIAWATI 668613-04-012583 ANDRIANA HERLAMBANG
816-4106166 01 EWOD.H 668613-04-012583 ANDRIANA HERLAMBANG
817-5463705 01 LAELA SARI 668613-04-012583 ANDRIANA HERLAMBANG
817-5286635 01 MOCH. ALLURA NUROCHMAN 668613-04-013907 NOVI SAFRINENGSIH
817-5431876 01 DANISHA FAHMA SANIA 668613-04-013907 NOVI SAFRINENGSIH
517-2032947 01 RIDWAN 668613-04-014202 GUNTUR PRIO GUNTORO
517-1005456 01 ANGGI DWIARNO NOER IMANI 668613-04-014518 IKA RACHMA WIDYAWATI
517-2026212 01 ANISA DWI SAPUTRI 668613-04-014518 IKA RACHMA WIDYAWATI
517-2030859 01 GUNTUR MAULANA 668613-04-014518 IKA RACHMA WIDYAWATI
517-1437311 01 KEVIN AZKA REYNAND ABQARI 668613-04-014906 MIYA ZAM ZAM LUTFI
517-1623381 01 RATNASARI 668613-04-014906 MIYA ZAM ZAM LUTFI
517-1382715 01 IWAN SUBHAN HOLIK 668613-04-015110 MUHAMMAD IRVANOVRISTA
816-4145255 01 SARONIH 668613-04-015110 MUHAMMAD IRVANOVRISTA
816-4402789 01 RAFAEYZA DANENDRA PRAYOGA 668613-04-015110 MUHAMMAD IRVANOVRISTA
817-5260721 01 DIANA NABILAH 668613-04-015110 MUHAMMAD IRVANOVRISTA
817-5171308 01 KARTONO 668613-04-015264 DIDIT ADI PERMANA

NO. OF LIFE POLICIES = 11

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 12
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________
DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 130
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668632 ITA PUSPITASARI AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1611931 01 EDI MARTHIN GUNDHARSAH 668632-04-007023 RISNA DATIAH
517-2008921 01 AHMAD SYARIPUDIN 668632-04-008250 AMALIA ARISKA
517-2011784 01 MERIA DAELI 668632-04-009787 IKHRAM EZVAVA
517-1371312 01 RUDOLF VALENTINO 668632-04-010470 HIKMA YULIARTI
517-2015033 01 DIYANA SOPYAN 668632-04-010470 HIKMA YULIARTI
517-2025529 01 RD. INDRA NURHADI RUSLI, SIP 668632-04-010834 SEPTI MAULANI IDOLA

NO. OF LIFE POLICIES = 6

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 0
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 131
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668639 SUPANDI AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2020041 01 HOLID 668639-04-006541 ALI NURJAMAN
517-1611956 01 MICHELLE THEODORIS MAGDALENA 668639-04-010718 TRIANA UTAMI AZIZAH
817-5121873 01 AZZQUERRA L. AALINARROHMAN 668639-04-010718 TRIANA UTAMI AZIZAH
517-2016221 01 TIETIE WINDAWATI 668639-04-014908 PRIHATIN NUR ASIH

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 132
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668655 ADE CHANDRICO AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1141178 01 LIA DWI LESTARI 668655-04-012584 AJENG KARTIKAWATI
517-2010885 01 DIKIE PRABOWO 668655-04-013260 ANGGI RAHMA PUTRA
517-2012048 01 SHINTA MALINDA 668655-04-013269 REZA AGUNG PAMUNGKAS
817-5316283 01 KEY VIRENDRA SHAFWANA 668655-04-014521 REZA ABURIZAL
517-2024092 01 TOVAN LAKSANA PUTRA 668655-04-014910 REGITA MEISYA

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 133
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 668665 MOHAMAD ZAENUL ARIFIN AGENCY : 668000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-2022120 01 SYAFIAH, SE 668665-04-004551 YENI KUSUMAWATI
817-5343998 01 RIA NURYANI 668665-04-004551 YENI KUSUMAWATI
517-1070468 01 UJANG SUHENDA 668665-04-010183 HERU MULYADI
517-1381287 01 M ARNO SAJIWA PUTRA 668665-04-010183 HERU MULYADI
816-4244702 01 MUHAMMAD ALIF NURFADILAH 668665-04-010183 HERU MULYADI
817-5462764 01 PAHRI PAJAN AKBAR 668665-04-010818 DERISMA AMIA K
517-2011040 01 MOCH SAEPUL HIDAYAT M 668665-04-010830 YUSUP MAULANA
517-2011735 01 RANI KUSUMAWATI 668665-04-010830 YUSUP MAULANA
517-2023789 01 DEDE JAELANI 668665-04-010830 YUSUP MAULANA
517-2033739 01 IJANG MULYADI 668665-04-010830 YUSUP MAULANA
816-8196429 01 SRI LATIPAH 668665-04-013777 YUNIARTI
817-5172082 01 ANISA NURHASANAH 668665-04-013777 YUNIARTI
517-1018046 01 HENDRA PRAJA 668665-04-014177 DEDEN RUSDIANSYAH
517-2026907 01 UJANG SUHENDI 668665-04-014201 FUJI APRIANI
517-2035171 01 MAEMUNAH 668665-04-014209 INGE RAHMAH PUTRIANI
817-5320434 01 ELIS SUMIATI 668665-04-014209 INGE RAHMAH PUTRIANI
516-9895983 01 CECENG SUKANDA 668665-04-015107 DEDE YUSUP
517-1105512 01 DALWI HAIDIR MAULANA 668665-04-015107 DEDE YUSUP
517-1530974 01 RENITA SELAWATI 668665-04-015107 DEDE YUSUP
817-5274748 01 DICKY WILLIAM TAMBUNAN 668665-04-015107 DEDE YUSUP

NO. OF LIFE POLICIES = 13

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 7
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
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LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669616 GARY ARIEF AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5319790 01 SALMA WIDAD 669616-04-009538 MARULI TUA SINAGA
817-5046948 01 JUNAIDI MUHAMMAD ZAKARIA 669616-04-010352 RATNA DEVI
517-2023045 01 JAMILAH 669616-04-013801 MUHAMMAD ANDIKA SAINUDDING
517-2025784 01 LILIS SURYANI 669616-04-013801 MUHAMMAD ANDIKA SAINUDDING
517-2035726 01 MUHAMMAD REYHAN AFFANDI 669616-04-014095 INDRIANI

NO. OF LIFE POLICIES = 3

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 2
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 135
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669617 RINI MARIATI AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
516-9948386 01 PAULUS SETYA LALAU 669617-04-009059 ENNY JUANIARTI
817-5274789 01 YONDI 669617-04-009059 ENNY JUANIARTI
817-5285900 01 EMY RITA SOFIA 669617-04-009059 ENNY JUANIARTI
816-4436316 01 MUHAMMAD ALFATHIR DUKHAN 669617-04-009535 DESKY RANTI ANGGRAENI
817-5286668 01 IWAN TAN 669617-04-009535 DESKY RANTI ANGGRAENI
817-5463531 01 SENDY FITRIYANTI 669617-04-009535 DESKY RANTI ANGGRAENI
817-5285314 01 PUTRI WULANDARI 669617-04-010581 DELLA PUSPITA SARI
817-5449068 01 SUDIANTORO 669617-04-010581 DELLA PUSPITA SARI
517-1182461 01 HERY PURWANTO 669617-04-014668 RIZA SOFIAN

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 7
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 136
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669619 ROSIHAN EKASAPUTRA AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5389942 01 TJHAI SIAT KHIM 669619-04-003225 TONNY USMAN
817-5390015 01 HENDI 669619-04-003225 TONNY USMAN
816-4405188 01 FATHIA ZAKIATUL ILMA 669619-04-009966 SARIFANI, [Link]
816-4405303 01 HAFIZH ZAKI ABDURRASYID 669619-04-009966 SARIFANI, [Link]
817-5315582 01 DINDA LESTARI 669619-04-011023 IRMA ERPINA IK
517-2022724 01 ANDRI KURNIAWAN 669619-04-011172 URAY ASTRI WULANDARI
517-2023862 01 ERMAWATI 669619-04-011172 URAY ASTRI WULANDARI
517-1058158 01 JANE LAURIDSEN 669619-04-012693 SIANNE SEVIRNE WIDIADA
517-2021551 01 KHO HONG SUAN 669619-04-014100 REZHA KURNIAWAN

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 5
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 137
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669620 SI PUTU SURYA DHARMA AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
816-4300850 01 RESTY TAMIA 669620-04-007223 ROBBY HENDRATNA
817-5330284 01 SAHID FAHMI RAMDANI 669620-04-007223 ROBBY HENDRATNA
517-2035312 01 BERKAT TUAH 669620-04-009167 YULIANI FITRIATI
517-2034216 01 KARMILA WATI 669620-04-010586 ELLY VERONIKA
816-4077847 01 MUQORROBIN ANAS 669620-04-011175 SUMINTO ADI PRABOWO
816-4192463 01 HANUN SORAYA 669620-04-011175 SUMINTO ADI PRABOWO
817-5463887 01 ADE MANASA AKOB 669620-04-011175 SUMINTO ADI PRABOWO
517-2036708 01 GLORY FELICIA SITORUS 669620-04-013799 DESY ARMAYANTI
816-4166871 01 ALFIAN RIVAI 669620-04-014429 ALFRID
517-2034406 01 SUNDARI 669620-04-014531 ASNI NOVITA RUMAPEA

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 6
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 138
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669621 ULLY JUNITASARI RAHMAWATI AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1056673 01 EKA KUSUMA YANTI 669621-04-009424 EKA KUSUMA YANTI
517-2022849 01 SAIPULLAH 669621-04-012357 NURSIDAH
817-5122079 01 GENJI PRATAMA AL-BANJARI 669621-04-012357 NURSIDAH

NO. OF LIFE POLICIES = 2

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 1
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 139
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669646 FERYAMA RANTEALLO AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5122442 01 MURTAJA AZIZAH KHALISH 669646-04-003436 MUTHI'AH EKAWATI
817-5121741 01 RAISHA AQILA ARIADI 669646-04-008370 AHMAD SUBKI
517-1140410 01 NURIANI 669646-04-009421 NUR HASNIAR
517-1371585 01 ALJIMUS OSKAR MO'A 669646-04-009421 NUR HASNIAR
517-1394322 01 RAHMANTO 669646-04-009421 NUR HASNIAR
517-1562324 01 JUKSAM 669646-04-009421 NUR HASNIAR
517-2020637 01 HERLANG MAPPATITTI 669646-04-009421 NUR HASNIAR
517-2034943 01 AJENG NASTITI 669646-04-009421 NUR HASNIAR
517-1765034 01 ADHYA ZAYAN HASTIANTO 669646-04-011027 AMANDA YASMIN
517-2011008 01 ZULKIFLI 669646-04-011027 AMANDA YASMIN
517-1057119 01 SULISTYANINGSIH 669646-04-012604 YULY PRAMUDITA
816-4077896 01 LUQMAN HAKIM TATAGPUTRA 669646-04-012604 YULY PRAMUDITA
816-4405154 01 M DODI SAPUTRA 669646-04-012604 YULY PRAMUDITA
817-5171167 01 ABDUL AZIZ MUSLIM 669646-04-012604 YULY PRAMUDITA
817-5285868 01 DIAN SONI 669646-04-012604 YULY PRAMUDITA
817-5449464 01 HERMAN 669646-04-012604 YULY PRAMUDITA
516-9881579 01 MAINI HANDAYANI 669646-04-013546 CAROLLIN
517-1721474 01 IRA SUGIANTI ALFIANA 669646-04-013919 ADIN MIZIAR NURDIN
517-2027665 01 SUSILAWATI 669646-04-013919 ADIN MIZIAR NURDIN
517-1322026 01 DWI FIDIANTI 669646-04-014106 KALOH VIRGINIA GABRIELA YACOBA
517-1619058 01 ASYIFA BILQIS HERNANDA 669646-04-014106 KALOH VIRGINIA GABRIELA YACOBA
516-9948873 01 WAHYU WIDAYAT 669646-04-014666 FAUZAN NOOR RAHMAN
817-5121642 01 ERIK PRATAMA 669646-04-014666 FAUZAN NOOR RAHMAN
817-5343105 01 RESTU FERDIANSYAH 669646-04-014666 FAUZAN NOOR RAHMAN
516-9879102 01 MELADI 669646-04-015402 ROFI SHOLIKHAH
516-9879607 01 NICKO DEMUS 669646-04-015402 ROFI SHOLIKHAH
517-1438392 01 LIMARDO PASARIBU 669646-04-015402 ROFI SHOLIKHAH
517-2018953 01 AAI NIA NIRA WATI 669646-04-015402 ROFI SHOLIKHAH
517-2026014 01 NITALIA 669646-04-015402 ROFI SHOLIKHAH
517-2024597 01 AWANDA AFRILYANTO 669646-04-015537 YANTI ABRAR

NO. OF LIFE POLICIES = 21

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 9
NO. OF HOUSEHOLDER POLIIES = 0
PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 140
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669647 ANDHYKA PRASETYA AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
817-5121923 01 NOORMAWATI 669647-04-006687 WIRA MILIYANTI
817-5389074 01 ARNIYAH 669647-04-006687 WIRA MILIYANTI
517-1372708 01 NURLIA 669647-04-008735 LINA S.
517-2018797 01 JULPA HALIDA 669647-04-008735 LINA S.
817-5432247 01 F. HERY CHRISTANTO 669647-04-010198 ARI HERAWATI
517-1160186 01 AMIRUDIN 669647-04-010481 MUHAMMAD ALIANSYAH
517-1234957 01 ASRAR 669647-04-010481 MUHAMMAD ALIANSYAH
817-5464380 01 RIRIS ERNAWATI 669647-04-010481 MUHAMMAD ALIANSYAH
817-5121949 01 MUHAMMAD AZRIEL ADRAFIE 669647-04-010807 ELYDA YUNIATI SILABAN

NO. OF LIFE POLICIES = 4

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 5
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 141
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

LOCATION : /

UNIT : 669666 RANDI APRIL DILLA PRATAMA AGENCY : 669000

PNO LIFE INSURED AGENT AGENT_NAME REMARKS
517-1246548 01 MUHAMMAD SOLIHIN AGUS SUBYANTO 669666-04-009792 RIA FITRIANI
517-2033275 01 YUDHI SAPUTRA 669666-04-012157 ALFIANTI MANDASSARI
517-1602518 01 NURLINDA 669666-04-012158 TAUFIK FAMUJI ARTIAJI
517-2024340 01 NASRUN 669666-04-012158 TAUFIK FAMUJI ARTIAJI
517-2033168 01 SITI SAMSIAH 669666-04-012350 FENLY MEWENGKANG
517-1450264 01 ROBERTO HENDRIK TUWAIDAN 669666-04-012598 CHRIS TOPHER
817-5121972 01 DIANA OKTIANES 669666-04-014092 EVA NINGSIH DERMASARI
817-5390056 01 SANDREA PRAJA NUGRAHA 669666-04-014092 EVA NINGSIH DERMASARI
817-5432148 01 AFIFAH NUR AZIZAH 669666-04-014431 APRILIA RAMADHANI ANGGI P
817-5047722 01 ABDUL BASIT 669666-04-014436 NIRWANA LAIJE
517-2022260 01 SURIADI 669666-04-014923 HAMBALI RAMLI

NO. OF LIFE POLICIES = 7

NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 4
NO. OF HOUSEHOLDER POLIIES = 0

PLEASE SIGN AND RETURN :

SIGNATURE ______________________

DATE : __________
BANCASSURANCE AXA MANDIRI FINANCIAL SERVICES 2018/02/09 PAGE 142
LF107.2 (UW) NEW POLICIES ISSUED REPORT (BRIEF)

TOTAL : NO. OF MED.P REQ. FOR R/I 0

T O T A L S :
NO. OF LIFE POLICIES = 620
NO. OF DI POLICIES = 0
NO. OF HEALTH POLICIES = 295
NO. OF HOUSEHOLDER POLIIES = 0