PENDAFTARAN KLAIM
.....................Daftarkan segera klaim anda dengan mengisi form dibawah ini. Kami akan secepatnya memproses klaim anda.
................................................................ Nama *........................:.........
................................................................ Telepon.......................:...... ..
................................................................ Nomor Polis................:.. ......
................................................................ Email.......................... :.........
................................................................ Kronologi Kejadian.... .:............. ................................................................................................................
................................................................................................................. ................................................................................................................ Masukan kode captha diatas disini: ................................................................................................................ ...................................................................................................................................... Ulangi kode captha? klik disni
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.....................Kantor Pusat
....................Jln. Pintu Besar Selatan No. 78
...................Kec. Taman Sari, Kel. Pinangsia Jakarta Barat 11110
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