Statement of Accounts

14 November 2018

Re: Policy number: Policy start date: Policy renewal date:

P000475993 01/01/2018 01/01/2019

Claim number: C13876953

Invoice 1
Insured member: Suherman Suherman
Invoice date: 28 September 2018
Provider: Shanghai East International Medical Center

Invoice currency Contract currency Payment currency Adjustment reason

Invoice Amount
CNY 3,534.80 USD 508.35 USD 508.35
Reimbursable amount (payment currency amount is highlighted in bold below)
CNY 3,534.80 USD 508.35 USD 508.35

Please notify us immediately if the patient(s) mentioned did not attend the medical provider(s) listed.

Should you have any questions or require any assistance, please do not hesitate to email us at:
client.services@allianzworldwidecare.com. Alternatively, our Helpline is available 24 hours a day, 7 days a
week on: + 353 1 630 1301.

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AWP Health & Life SA, acting through
its Irish Branch, is a limited company
governed by the French Insurance
Code. Registered in France:
No. 401 154 679 RCS Bobigny.
Irish Branch registered in the Irish
Companies Registration Office,
registered No.: 907619, address:
15 Joyce Way, Park West Business
Campus, Nangor Road, Dublin 12,
Ireland.
Allianz Care and Allianz Partners are
registered business names of AWP
Health & Life SA.
Board of Directors- Members:
Dan Assouline (Brazilian),
Fabio De Ferrari (Italian),
Rémi Grenier (French),
Dr. Ulf Lange (German),
Dr. Claudius Leibfritz (German),
Lidia Luka-Lognoné (Polish),
Sylvie Ouziel (French).