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PROPOSAL / ILUSTRASI PROGRAM KESEHATAN TAHUNAN
Pemesanan Proposal /Ilustrasi untuk nilai proteksi Untuk kesehatan tanpa nilai Investasi
Nama Lengkap
*
Tanggal Lahir Anda
*
DD
/
MM
/
YYYY
Jenis Kelamin
*
Silakan Pilih
Laki-Laki
Wanita
Alamat
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
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Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
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Country / Region
Email
*
Proposal akan kami kirim Via Email
Phone
*
No yang mudah kami hubungi
Apakah Anda Perokok
*
Silakan Pilih
YA
TIDAK
Kewarga Negaraan Anda
*
Silakan Pilih
WNI
WNA
Perkerjaan Tetap Anda
*
Apakah Anda Memilki Polis Allianz
Ya
Tidak
jika Ya,No Polis
Apakah Anda memiliki polis Allianz khususnya Program TAPRO (untuk mendapatkan diskon 10%)
Silakan Pilih
Please select
Non Syariah
Syariah
Pillihan Rawat Inap
Please select
Rawat Gigi
Rawat Persalinan
Note:
Rawat persalinan jika Anda Wanita
Paket Plan Kamar
*
Plan A Santunan 100.000/hari
Plan B Santunan 150.000/hari
Plan C Santunan 200.000/hari
Plan D Santunan 350.000/hari
Plan E Santunan 500.000/hari
Plan F Santunan 600.000/hari
Plan G Santunan 750.000/hari
Plan H Santunan 1.000.000/hari
Paket Santunan Harian
*
Plan A Santunan 100.000/hari
Plan B Santunan 150.000/hari
Plan C Santunan 200.000/hari
Plan D Santunan 350.000/hari
Plan E Santunan 500.000/hari
Plan F Santunan 600.000/hari
Plan G Santunan 750.000/hari
Plan H Santunan 1.000.000/hari
Nominal Santunan harian yang ingin anda dapatkan (sesuai dengan lama hari rawat inap di rumah sakit)
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