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Page 1: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

DAFTAR PESERTA PER ENTITAS

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0000103534975 SUWARTI PESERTA 21/04/1956 CIMANGGIS1 AKTIF 0 59,50006/10/2014

0001085556238 MOLING B PESERTA 07/05/1939 KEL. SEMPER BARAT I2 AKTIF 0 42,5003172040705390002 16/10/2014

0001085556317 SAHARI PESERTA 18/08/1946 KEL. SEMPER BARAT I3 AKTIF 0 42,5003172045808460001 16/10/2014

0001222700343 ZAIMAR PESERTA 30/10/1948 KEL. KEMANGGISAN4 AKTIF 0 42,5003173077010480003 16/10/2014

0001223868161 TUTY SUPENO PESERTA 29/08/1948 KEL. TUGU UTARA I5 AKTIF 0 59,5003172036908480001 06/10/2014

0001224985059 rusminah PESERTA 08/04/1941 KEL. TUGU UTARA I6 AKTIF 0 42,5003172034804410002 17/10/2014

0001225202826 OTJAH EENG PESERTA 15/06/1971 KEL. KOJA7 AKTIF 0 42,5003172035506710013 16/10/2014

0001225815219 ANNA HALIWELA PESERTA 30/11/1942 KEL. PAPANGGO II8 AKTIF 0 42,5003172027011420002 06/10/2014

0001228857748 SOPIAH PESERTA 21/03/1956 KEL. JOHAR BARU I9 AKTIF 0 42,5003171086103560003 06/10/2014

0001233258028 ICIH PESERTA 03/04/1944 CIPAYUNG10 AKTIF 0 42,5003201264304440003 16/10/2014

0001256743359 DWI KUSDARYANTI PESERTA 10/12/1957 PONDOK PUCUNG11 AKTIF 0 59,5003674035012570011 06/10/2014

0001324075926 WARMINI PESERTA 09/02/1951 KEL. WARAKAS12 AKTIF 0 42,5003172034902510003 16/10/2014

0001341249355 0001 HAYATI NURDIN PESERTA 20/12/1949 KEL. KEBON BAWANG II13 AKTIF 0 59,5003172026012490010 01/09/2014

0001341249366 0002 ARIFUDDIN PESERTA 24/12/1957 KEL. WARAKAS14 AKTIF 0 59,5003172022412570007 01/09/2014

0001341249377 0002 MANAWIYAH ISTRI 16/12/1965 KEL. WARAKAS15 AKTIF 0 59,5003172025612650003 01/09/2014

0001341249388 0003 DRS. ABDUL HALIM PESERTA 01/06/1945 KEL. CILINCING I16 AKTIF 0 59,5003172040106450003 01/09/2014

0001341249399 0003 HJ. HASIAH ISTRI 12/04/1952 KEL. CILINCING I17 AKTIF 0 59,5003172045204520002 01/09/2014

0001341249401 0004 TOTON SAIFULLAH PESERTA 20/03/1945 KEC. KELAPA GADING18 AKTIF 0 59,5003172062003450001 01/09/2014

0001341249412 0004 UUN HUNAENAH ISTRI 03/11/1961 KEC. KELAPA GADING19 AKTIF 0 59,5003172064311610001 01/09/2014

0001341249423 0005 MARCUS LAYARDA PESERTA 12/06/1940 KEC. KELAPA GADING20 AKTIF 0 59,5003172061206400003 01/09/2014

0001341249434 0005 HELENA BERLIAN ISTRI 06/02/1949 KEC. KELAPA GADING21 AKTIF 0 59,5003172064602490001 01/09/2014

Page 1 of 4512/5/14 2:21 PM

Page 2: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341249445 0006 BUDOYO SOMO HANDOYO PESERTA 28/12/1933 KEL. TUGU UTARA I22 AKTIF 0 59,5003172032812330001 01/09/2014

0001341249456 0007 WAODE BONSI PESERTA 02/12/1943 KEC. KELAPA GADING23 AKTIF 0 59,5003172024212430003 01/09/2014

0001341249467 0008 HJ. ROHAYA PESERTA 02/06/1945 KEL. KEBON BAWANG II24 AKTIF 0 59,5003172024206450002 01/09/2014

0001341249478 0009 NANA SUDJANA BSC PESERTA 27/12/1948 KEC. KELAPA GADING25 AKTIF 0 59,5003172062712480002 01/09/2014

0001341249489 0010 CAROLINE MUTIS PESERTA 17/07/1944 KEC. KELAPA GADING26 AKTIF 0 59,5003172035707440003 01/09/2014

0001341249491 0011 ROSMIATI PESERTA 11/11/1967 Puskesmas Rawa Badak Selatan27 AKTIF 0 59,5003172035111570001 01/09/2014

0001341249502 0012 DRS. UDI AMENAN PESERTA 19/10/1955 KEC. KELAPA GADING28 AKTIF 0 59,5003172021910550004 01/09/2014

0001341249513 0012 NURHAYATI ANTA ISTRI 25/05/1954 KEC. KELAPA GADING29 AKTIF 0 59,5003172026505540008 01/09/2014

0001341249524 0013 H.AMBO PESERTA 28/12/1949 KEL. KOJA30 AKTIF 0 59,5003172032812490003 01/09/2014

0001341249535 0013 HJ.BUNGA SUNGGUH SUAMI 28/12/1959 KEL. KOJA31 AKTIF 0 59,5003172036812590005 01/09/2014

0001341249546 0014 F.R EKATININGSIH PESERTA 28/12/1951 KEC. KOJA32 AKTIF 0 59,5003172046812510004 01/09/2014

0001341249557 0015 HJ. YAYAH SUPRIYAH PESERTA 06/12/1941 KEL. PAPANGGO I33 AKTIF 0 59,5003172024612410006 01/09/2014

0001341249568 0016 ENTJEP SUHENDI PESERTA 07/08/1948 KEL. PAPANGGO I34 AKTIF 0 59,5003172020708480003 01/09/2014

0001341249579 0016 LILIS SUMIYATI ISTRI 27/12/1949 KEL. PAPANGGO I35 AKTIF 0 59,5000951036712490064 01/09/2014

0001341249581 0017 JEANET ROOS WANTANIA PESERTA 18/04/1938 KEC. KOJA36 AKTIF 0 59,5003172025804380001 01/09/2014

0001341249592 0018 ERISMA HERMIN TAMBUNAN PESERTA 12/10/1954 Puskesmas Semper Timur37 AKTIF 0 59,5003172045210540004 01/09/2014

0001341249603 0019 YETTY LAURENTINA ROBOT PESERTA 13/07/1947 KEL. KEBON BAWANG II38 AKTIF 0 59,5003172025307470001 01/09/2014

0001341249614 0020 NY YULIANA KAUROUWRUNTU PESERTA 26/11/1937 KEL. KEBON BAWANG II39 AKTIF 0 59,5003172026611371001 01/09/2014

0001341249625 0021 AZIS MALIOBORO PESERTA 14/08/1948 Puskesmas Rawa Badak Selatan40 AKTIF 0 59,5003172031408480003 01/09/2014

0001341249636 0022 HJ.BUNGSU SUTIYAH PESERTA 09/10/1945 KEL. RAWA BADAK II41 AKTIF 0 59,5003172034910450003 01/09/2014

0001341249647 0023 ENDANG PURWADINATA PESERTA 16/06/1952 KEL. RAWA BADAK II42 AKTIF 0 59,5003172031606520004 01/09/2014

0001341249658 0023 WIWIEK SUMIASTUTI ISTRI 27/08/1959 KEL. RAWA BADAK II43 AKTIF 0 59,5003172036708590002 01/09/2014

0001341249669 0024 ERENST MARTHING PESERTA 10/01/1939 KEL. KEBON BAWANG I44 AKTIF 0 59,5003172021001390004 01/09/2014

0001341249671 0024 SENTIANA P MARTHING ISTRI 05/12/1958 KEL. KEBON BAWANG I45 AKTIF 0 59,5003172024512580006 01/09/2014

Page 2 of 4512/5/14 2:21 PM

Page 3: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341249682 0025 MATHILDA KANTOOR PESERTA 15/05/1945 KEC. KOJA46 AKTIF 0 59,5003172025505450003 01/09/2014

0001341249693 0026 ROSALIA TAIDI PALANDUNG PESERTA 05/05/1937 KEL. KEBON BAWANG I47 AKTIF 0 59,5003172024502370001 01/09/2014

0001341249704 0027 L HOWAN KOMANSILAN PESERTA 20/03/1942 KEL. KEBON BAWANG I48 AKTIF 0 59,5003172026003420001 01/09/2014

0001341249715 0028 ARYANTI MANDALA PESERTA 04/04/1956 KEL. KEBON BAWANG I49 AKTIF 0 59,5003172024404560003 01/09/2014

0001341249726 0029 NAHOR BARAKATI PESERTA 31/05/1925 KEL. PAPANGGO I50 AKTIF 0 59,5003172023105250001 01/09/2014

0001341249737 0030 NY.MARTHA MAANANALAINATA

PESERTA 05/03/1943 KEL. TANJUNG PRIOK51 AKTIF 0 59,5003172024503430001 01/09/2014

0001341249748 0031 ROSTIATI YASSIN PESERTA 17/05/1960 KEL. KOJA52 AKTIF 0 59,5003172035705600003 01/09/2014

0001341249759 0032 MACHFIROH PESERTA 17/12/1951 KEL. KEBON BAWANG II53 AKTIF 0 59,5003172025712510005 01/09/2014

0001341249761 0033 ROCHATI BT DJUNAEDI PESERTA 13/03/1934 KEL. KOJA54 AKTIF 0 59,5003172035303340002 01/09/2014

0001341249772 0034 H.SAGUNI MARAHUNI PESERTA 23/09/1940 KEL. KEBON BAWANG I55 AKTIF 0 59,5003172022309400001 01/09/2014

0001341249783 0034 HJ.ROHANI ISTRI 15/11/1943 KEL. KEBON BAWANG I56 AKTIF 0 59,5003172025511430001 01/09/2014

0001341249794 0035 CAROLIEN KOUANAK PESERTA 22/11/1935 KEL. KEBON BAWANG I57 AKTIF 0 59,5003172026211350002 01/09/2014

0001341249805 0036 ILYAS IBRAHIM SH PESERTA 21/02/1956 KEL. TANJUNG PRIOK58 AKTIF 0 59,5003172062102560004 01/09/2014

0001341249816 0036 DRA.RATNA NINGRUM ISTRI 30/09/1967 KEL. TANJUNG PRIOK59 AKTIF 0 59,5003172067008670002 01/09/2014

0001341249827 0037 LERLIS BAGINDA PESERTA 05/01/1930 KEL. TUGU UTARA I60 AKTIF 0 59,5003172030501300003 01/09/2014

0001341249838 0037 OLGA SABINE PUSUNG ISTRI 07/06/1939 KEL. TUGU UTARA I61 AKTIF 0 59,5003172034706390001 01/09/2014

0001341249849 0038 MUNAH PESERTA 04/01/1955 KEL. TANJUNG PRIOK62 AKTIF 0 59,5003172034401550001 01/09/2014

0001341249851 0039 SINTJE R INDALAO PESERTA 07/09/1947 KEL. KEBON BAWANG I63 AKTIF 0 59,5003172024709470002 01/09/2014

0001341249873 0039 TOMMIX MAHAGANTI PESERTA 09/03/1958 KEL. KEBON BAWANG I64 AKTIF 0 59,5003172020903580003 01/09/2014

0001341249862 0040 ANTONETTA L DAUD PESERTA 07/02/1938 KEL. KEBON BAWANG I65 AKTIF 0 59,5003172024702380001 01/09/2014

0001341249884 0042 NINING RATNANINGSIHSURACHMAN

PESERTA 02/02/1948 KEL. TUGU UTARA I66 AKTIF 0 59,5003172034202480003 01/09/2014

0001341249895 0043 H.I.H.W TUASELA PESERTA 11/11/1941 KEL. TUGU UTARA I67 AKTIF 0 59,5003172035111410001 01/09/2014

0001341249906 0044 WARSINI PESERTA 18/07/1952 KEL. TANJUNG PRIOK68 AKTIF 0 59,5003172035807520002 01/09/2014

Page 3 of 4512/5/14 2:21 PM

Page 4: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341249917 0045 LUISE TICOALU PESERTA 08/10/1939 KEL. TANJUNG PRIOK69 AKTIF 0 59,5003172064810390001 01/09/2014

0001341249928 0046 AMIN MUHAMAD PESERTA 10/06/1942 KEL. TANJUNG PRIOK70 AKTIF 0 59,5003172021006420008 01/09/2014

0001341249939 0046 AMINAH A ISTRI 31/12/1949 KEL. TANJUNG PRIOK71 AKTIF 0 59,5003172027112490006 01/09/2014

0001341249941 0047 PAULIEN OROH PESERTA 15/10/1943 KEC. KELAPA GADING72 AKTIF 0 59,5003172025510430005 01/09/2014

0001341249952 0048 HL.TITI LESTARI PESERTA 04/02/1954 KEL. TANJUNG PRIOK73 AKTIF 0 59,5003172024402540004 01/09/2014

0001341249963 0049 MINGGU BIN SAPPA PESERTA 05/10/1935 KEL. WARAKAS74 AKTIF 0 59,5003172020510350002 01/09/2014

0001341249974 0049 SUTARSIH ISTRI 11/01/1940 KEL. WARAKAS75 AKTIF 0 59,5003172025101400001 01/09/2014

0001341249985 0050 HAMDIAH PESERTA 21/12/1947 KEL. KEBON BAWANG I76 AKTIF 0 59,5003172026112470006 01/09/2014

0001341249996 0051 IBRAHIM PADUPPA PESERTA 17/03/1941 KEL. KEBON BAWANG I77 AKTIF 0 59,5003172021703410002 01/09/2014

0001341250007 0051 INTANG ISTRI 25/12/1953 KEL. KEBON BAWANG I78 AKTIF 0 59,5003172026512530016 01/09/2014

0001341250018 0052 LAODE MARFUDDIN PESERTA 14/04/1947 KEL. TUGU UTARA I79 AKTIF 0 59,5003172031404470003 01/09/2014

0001341250029 0052 NUR AIDA ISTRI 10/03/1958 KEL. TUGU UTARA I80 AKTIF 0 59,5003172035003580002 01/09/2014

0001341250031 0053 MARHUBIN HARUN PESERTA 15/05/1937 KEL. KEBON BAWANG II81 AKTIF 0 59,5003172021505370003 01/09/2014

0001341250042 0054 J.N. JACOBUS PESERTA 17/02/1927 KEL. WARAKAS82 AKTIF 0 59,5000951031702270021 01/09/2014

0001341250053 0054 RUSBIYANI ISTRI 04/01/1950 KEL. WARAKAS83 AKTIF 0 59,5003172024401500002 01/09/2014

0001341250064 0055 ADDAS PESERTA 11/09/1938 KEL. TANJUNG PRIOK84 AKTIF 0 59,5003172031109380001 01/09/2014

0001341250075 0055 HAERIAH ISTRI 16/01/1944 KEL. TANJUNG PRIOK85 AKTIF 0 59,5003172035601440002 01/09/2014

0001341250086 0056 SJAHBUDIN PESERTA 01/05/1939 KEL. TUGU UTARA I86 AKTIF 0 59,5003172030105390002 01/09/2014

0001341250097 0056 WARYUNAH ISTRI 31/12/1947 KEL. TUGU UTARA I87 AKTIF 0 59,5003172037112470030 01/09/2014

0001341250108 0057 JOHANES HATU RIWU PESERTA 22/11/1939 KEL. TANJUNG PRIOK88 AKTIF 0 59,5003172042211390001 01/09/2014

0001341250119 0057 SOFIA ISTRI 17/02/1942 KEL. TANJUNG PRIOK89 AKTIF 0 59,5003172045702420001 01/09/2014

0001341250121 0058 MOH ALI AKIL PESERTA 01/12/1938 KEL. KEBON BAWANG II90 AKTIF 0 59,5003172020112380006 01/09/2014

0001341250132 0059 H.ISMAIL PESERTA 12/11/1941 KEL. TUGU UTARA I91 AKTIF 0 59,5003172031211410002 01/09/2014

0001341250143 0059 ROSMAETY ISTRI 12/05/1952 KEL. TUGU UTARA I92 AKTIF 0 59,5000951045205524007 01/09/2014

Page 4 of 4512/5/14 2:21 PM

Page 5: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341250154 0060 RESMIATI PESERTA 17/01/1951 KEC. TANJUNG PRIOK93 AKTIF 0 59,5003172035701510001 01/09/2014

0001341250165 0061 SINTJE LALIMBAT UDAMPOH PESERTA 02/12/1941 KEC. KELAPA GADING94 AKTIF 0 59,5003172024212410001 01/09/2014

0001341250176 0062 DJAMALUDDIN ODE GUNDU PESERTA 03/07/1938 KEL. TANJUNG PRIOK95 AKTIF 0 59,5003172020307380001 01/09/2014

0001341250187 0062 WAODE MUSNAINI DJAYA ISTRI 22/12/1942 KEL. TANJUNG PRIOK96 AKTIF 0 59,5003172026212420001 01/09/2014

0001341250198 0063 FEMMY PARTH PESERTA 30/09/1947 KEL. TANJUNG PRIOK97 AKTIF 0 59,5003172027009470003 01/09/2014

0001341250209 0064 NURSIMA PESERTA 15/11/1945 KEL. KEBON BAWANG I98 AKTIF 0 59,5003172025511450007 01/09/2014

0001341250211 0065 RAMZAH BT H SYAIFUDIN PESERTA 08/12/1939 KEL. SEMPER BARAT I99 AKTIF 0 59,5003172044812390001 01/09/2014

0001341250222 0066 R.SUDJARYANTO PESERTA 24/12/1949 KEL. KLP GADING TIMUR II100 AKTIF 0 59,5003172062412490003 01/09/2014

0001341250233 0066 ANNA TATIK SUGIARTI ISTRI 13/07/1954 KEL. KLP GADING TIMUR II101 AKTIF 0 59,5003172065307540002 01/09/2014

0001341250244 0067 PETRUS MANAHAMPY PESERTA 13/03/1936 KEL. WARAKAS102 AKTIF 0 59,5003172021303360001 01/09/2014

0001341250255 0068 ARDJA WIDJAYA PESERTA 01/03/1945 KEC. TANAH ABANG103 AKTIF 0 59,5003171070103450000 01/09/2014

0001341250266 0068 NURTINAWATI ISTRI 07/06/1951 KEC. TANAH ABANG104 AKTIF 0 59,5003171074706510002 01/09/2014

0001341250277 0069 MARSYAHYUDI PAIMIN PESERTA 22/09/1948 KEC. KEMAYORAN105 AKTIF 0 59,5003171032209480000 01/09/2014

0001341250288 0070 ABDUL DJABBAR MAKKAH PESERTA 25/04/1945 KEL. SERDANG106 AKTIF 0 59,5003171032504450005 01/09/2014

0001341250299 0070 H. SUBAEDAH ISTRI 26/12/1955 KEL. SERDANG107 AKTIF 0 59,5003171036612550009 01/09/2014

0001341250301 0071 NY.MARTHA SAKKA PESERTA 14/10/1936 KEC. JOHAR BARU108 AKTIF 0 59,5003171085410360002 01/09/2014

0001341250312 0072 NY.MIP. SUPITH PESERTA 26/11/1931 KEC. SENEN109 AKTIF 0 59,5003171046611310001 01/09/2014

0001341250323 0073 SOEPARSO PESERTA 28/03/1939 KEC. CEMPAKA PUTIH110 AKTIF 0 59,5003171052803390001 01/09/2014

0001341250334 0074 SUDJOKO PESERTA 23/11/1932 KEC. GAMBIR111 AKTIF 0 59,5003171012311320001 01/09/2014

0001341250345 0074 KAIRINA ISTRI 17/01/1944 KEC. GAMBIR112 AKTIF 0 59,5003171015701440001 01/09/2014

0001341250356 0075 YUSMAINI PESERTA 10/10/1951 KEL. PETOJO UTARA113 AKTIF 0 59,5003171015010510001 01/09/2014

0001341250367 0076 EDY SUPOYO SUGENG PESERTA 30/06/1953 KEL. PETOJO UTARA114 AKTIF 0 59,5003171010903093303 01/09/2014

0001341250378 0076 MARNI MARPAUNG ISTRI 17/01/1960 KEL. PETOJO UTARA115 AKTIF 0 59,5003171010903093303 01/09/2014

0001341250389 0077 MARLEDA MARPAUNG PESERTA 18/08/1939 KEL. PETOJO UTARA116 AKTIF 0 59,5003171015808390001 01/09/2014

Page 5 of 4512/5/14 2:21 PM

Page 6: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341250391 0078 ENING DINARTI PESERTA 07/04/1938 KEL. SERDANG117 AKTIF 0 59,5003171034704380003 01/09/2014

0001341250402 0079 KOESDARTO PESERTA 13/10/1945 KEC. CEMPAKA PUTIH118 AKTIF 0 59,5003171051310450002 01/09/2014

0001341250413 0079 SRI SAYEKTINING SUMARNI ISTRI 24/12/1953 KEC. CEMPAKA PUTIH119 AKTIF 0 59,5003171056412530002 01/09/2014

0001341250424 0080 ADE NADIR PESERTA 15/11/1948 KEL. HARAPAN MULYA120 AKTIF 0 59,5003171031511480001 01/09/2014

0001341250435 0080 MASNI ISTRI 09/08/1965 KEL. HARAPAN MULYA121 AKTIF 0 59,5003171034908650002 01/09/2014

0001341250446 0081 R TUASELA PESERTA 08/08/1941 KEL. PETOJO UTARA122 AKTIF 0 59,5003171014807410001 01/09/2014

0001341250457 0082 H.GAZALI SYARIF PESERTA 18/06/1934 KEL. PETOJO UTARA123 AKTIF 0 59,5003171011806340001 01/09/2014

0001341250468 0083 EFFIE DJAMA PESERTA 15/03/1943 KEL. SERDANG124 AKTIF 0 59,5003171035503430002 01/09/2014

0001341250479 0084 SITI MUJENAH PESERTA 01/01/1938 KEL. UTAN PANJANG125 AKTIF 0 59,5003171034101380005 01/09/2014

0001341250481 0085 FARIDA ZULFIKAR PESERTA 15/10/1945 KEL. PETOJO UTARA126 AKTIF 0 59,5003171015510450004 01/09/2014

0001341250492 0086 NY.ERNAWATI MANOSSOH PESERTA 19/06/1933 KEL. PETOJO UTARA127 AKTIF 0 59,5003171015906330001 01/09/2014

0001341250503 0087 HAJJAH RAHMAH PESERTA 17/11/1946 KEL. SUNGAI BAMBU128 AKTIF 0 59,5003172025700460000 01/09/2014

0001341250514 0088 OLLY JEHOSUA TAMPI PESERTA 04/10/1953 KEL. PEGANGSAAN DUA129 AKTIF 0 59,5003172064410530000 01/09/2014

0001341250525 0089 ROHANA M.LUMI PESERTA 26/04/1938 KEL. KEBON KOSONG I130 AKTIF 0 59,5003171036604380001 01/09/2014

0001341250536 0090 HUSNI AM PESERTA 16/07/1946 KEC. TANAH ABANG131 AKTIF 0 59,5003171071607460003 01/09/2014

0001341250547 0090 HERLINA ABBAS HUSNI ISTRI 25/04/1953 KEC. TANAH ABANG132 AKTIF 0 59,5003171076504530002 01/09/2014

0001341250558 0091 VICTORIA SOEBI PESERTA 16/06/1951 KEL.KWITANG133 AKTIF 0 59,5003171045606510003 01/09/2014

0001341250569 0092 H.TAJUS BUKY PESERTA 01/02/1939 KEL. PETOJO SELATAN134 AKTIF 0 59,5003171010102390002 01/09/2014

0001341250571 0092 HJ.ISNANIAR ISTRI 04/04/1943 KEL. PETOJO SELATAN135 AKTIF 0 59,5003171014404430003 01/09/2014

0001341250582 0093 TH PADENGKE PESERTA 27/09/1929 KEC. SAWAH BESAR136 AKTIF 0 59,5003171022709290002 01/09/2014

0001341250593 0094 SURYANTI BINTI SALEH PESERTA 06/05/1931 KEL. JOHAR BARU I137 AKTIF 0 59,5003171084605310002 01/09/2014

0001341250604 0095 ANNIE S.T RUNTU PESERTA 16/11/1946 KEC. CEMPAKA PUTIH138 AKTIF 0 59,5003171055611460001 01/09/2014

0001341250615 0096 ELSA DAMIN SEBAYANG PESERTA 18/10/1950 KEC. TANAH ABANG139 AKTIF 0 59,5003171075810500005 01/09/2014

0001341250626 0097 SUDARWATI PESERTA 04/06/1954 KEL.KWITANG140 AKTIF 0 59,5003171044406540001 01/09/2014

Page 6 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341250637 0098 MULYANI PESERTA 07/05/1958 KEL. PETAMBURAN141 AKTIF 0 59,5003171074705580008 01/09/2014

0001341250648 0099 CW.MAITIMU PESERTA 02/05/1933 KEL. PETOJO UTARA142 AKTIF 0 59,5003171010205330001 01/09/2014

0001341250659 0099 NY.D.B. MAITIMU ISTRI 06/05/1937 KEL. PETOJO UTARA143 AKTIF 0 59,5003171014605370004 01/09/2014

0001341250661 0101 NY.SOPIA CHRISTINA PESERTA 04/09/1947 KEL. PETOJO UTARA144 AKTIF 0 59,5003171014409470002 01/09/2014

0001341250672 0102 SOEDARTO PESERTA 20/09/1954 KEL. RAWA SARI145 AKTIF 0 59,5003171052009540001 01/09/2014

0001341250683 0102 INDRATI ISTRI 03/03/1957 KEL. RAWA SARI146 AKTIF 0 59,5003171054303570003 01/09/2014

0001341250694 0103 HUSEN A HALIM PESERTA 04/07/1948 KEC. TANAH ABANG147 AKTIF 0 59,5003171070407480002 01/09/2014

0001341250705 0103 ANI TENGKU IDRIS ISTRI 18/08/1956 KEC. TANAH ABANG148 AKTIF 0 59,5003171075808560003 01/09/2014

0001341250716 0104 IRNI ROSIAH PESERTA 04/04/1955 KEL. PETAMBURAN149 AKTIF 0 59,5003171074404550003 01/09/2014

0001341250727 0105 RUCHIJATU SUNNAH PESERTA 10/04/1948 KEL. PETOJO UTARA150 AKTIF 0 59,5003171015004480001 01/09/2014

0001341250738 0106 WILLY FICTOR KAUROW PESERTA 04/10/1933 KEL. PETOJO UTARA151 AKTIF 0 59,5003171010410330001 01/09/2014

0001341250749 0107 HERMIN LARASATI PESERTA 27/01/1940 KEL. KEBON KOSONG I152 AKTIF 0 59,5003175026701400003 01/09/2014

0001341250751 0108 H.MARDJONO PESERTA 13/09/1939 KEL. PETAMBURAN153 AKTIF 0 59,5003171071309390001 01/09/2014

0001341250762 0109 JUARSA INSAN PUTRA PESERTA 01/06/1958 KEL. PETAMBURAN154 AKTIF 0 59,5003171070106580005 01/09/2014

0001341250773 0109 NENI NURAINI ISTRI 24/03/1959 KEL. PETAMBURAN155 AKTIF 0 59,5003171076403590002 01/09/2014

0001341250784 0110 DYAH PURWANTI SULASIKIN PESERTA 21/08/1952 KEL. BENDUNGAN HILIR156 AKTIF 0 59,5003171076108520003 01/09/2014

0001341250795 0111 ELLY WAHYUNINGSIH PESERTA 29/05/1956 KEL. CIPINANG BESAR SELATAN I157 AKTIF 0 59,5003175066905560003 01/09/2014

0001341250806 0112 H. SULISTIYO PESERTA 17/02/1957 KEC. JOHAR BARU158 AKTIF 0 59,5003175011702570002 01/09/2014

0001341250817 0112 DRA. SRI WINARYANTI ISTRI 04/01/1961 KEC. MATRAMAN159 AKTIF 0 59,5003175014401610002 01/09/2014

0001341250828 0113 H. SUPARYO PESERTA 17/09/1949 KEL. LUBANG BUAYA160 AKTIF 0 59,5003175101709490005 01/09/2014

0001341250839 0113 HJ. NIKMATUL BAROKAH ISTRI 14/06/1950 KEL. LUBANG BUAYA161 AKTIF 0 59,5003175105406500003 01/09/2014

0001341250841 0114 ENDAH HASANAH, SE PESERTA 07/03/1955 KEL. BATU AMPAR162 AKTIF 0 59,5003175044703550002 01/09/2014

0001341250852 0115 LIHARTO KOESNI PESERTA 01/03/1954 KEL. PULO GEBANG163 AKTIF 0 59,5003175070103540002 01/09/2014

0001341250863 0116 JOHN MARISI TUA SIHOMBING PESERTA 03/09/1957 KEL. PONDOK KELAPA164 AKTIF 0 59,5003175070309571001 01/09/2014

Page 7 of 4512/5/14 2:21 PM

Page 8: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341250874 0116 NURHAIDA NAINGGOLAN ISTRI 04/08/1957 KEL. PONDOK KELAPA165 AKTIF 0 59,5003175074408571001 01/09/2014

0001341250885 0117 WARTINI PESERTA 14/12/1945 KEL. PAL MERIEM166 AKTIF 0 59,5003175015412450003 01/09/2014

0001341250896 0118 ANTON SIMAMORA R.M PESERTA 21/11/1935 KEL. KAYU PUTIH167 AKTIF 0 59,5003175022111350003 01/09/2014

0001341250907 0119 LIBERTY PESERTA 05/07/1955 KEC. MATRAMAN168 AKTIF 0 59,5003175014507550001 01/09/2014

0001341250918 0120 E.KURNIASIH PESERTA 14/07/1954 KEL. CILILITAN169 AKTIF 0 59,5003175045407540002 01/09/2014

0001341250929 0121 ENDANG RETNO GUNDARI PESERTA 20/10/1957 KEL. PONDOK BAMBU II170 AKTIF 0 59,5003175076910570006 01/09/2014

0001341250931 0122 HJ.TUTY PARTUTY PESERTA 15/05/1942 KEL. MALAKA SARI171 AKTIF 0 59,5003175025505420005 01/09/2014

0001341250942 0123 BUDININGSIH PESERTA 07/07/1955 KEL. CIPINANG CEMPEDAK172 AKTIF 0 59,5003175034707550006 01/09/2014

0001341251087 0123 IBDU SUGRATA PESERTA 29/09/1953 KEL. CIPINANG CEMPEDAK173 AKTIF 0 59,5003175032909530003 01/09/2014

0001341250953 0124 CHAIRUNNISA NASUTION PESERTA 28/07/1948 KEC. PULO GADUNG174 AKTIF 0 59,5003175026807480002 01/09/2014

0001341250964 0125 ALEX C TUMIMOMOR PESERTA 09/08/1936 KEL. KAYU MANIS175 AKTIF 0 59,5003175010908360001 01/09/2014

0001341250975 0125 TIOFAN L SIMAMORA ISTRI 18/04/1938 KEL. KAYU MANIS176 AKTIF 0 59,5003175015804380001 01/09/2014

0001341250986 0126 AMIR HASAN PESERTA 22/02/1943 KEL. KAYU MANIS177 AKTIF 0 59,5003174022202430002 01/09/2014

0001341250997 0126 NURSEHA ISTRI 17/08/1948 KEL. KAYU MANIS178 AKTIF 0 59,5003174025708490002 01/09/2014

0001341251008 0127 NURHAYATI PESERTA 29/01/1957 KEL. MALAKA JAYA179 AKTIF 0 59,5003175076901570005 01/09/2014

0001341251019 0128 LILI ROSALI PESERTA 28/05/1954 KEL. CAWANG180 AKTIF 0 59,5003175042805540001 01/09/2014

0001341251021 0128 REENI VD BERG ISTRI 01/07/1960 KEL. CAWANG181 AKTIF 0 59,5003175044107600007 01/09/2014

0001341251032 0129 FRODINE SATRIATI AEK PESERTA 24/09/1957 KEL. SETU182 AKTIF 0 59,5003175106409570001 01/09/2014

0001341251043 0129 LIPURRATY NORON ISTRI 23/01/1943 KEL. KAMPUNG TENGAH183 AKTIF 0 59,5000954056301430075 01/09/2014

0001341251054 0130 TURMUDI PESERTA 13/08/1941 KEL. PISANGAN TIMUR II184 AKTIF 0 59,5003175021308410001 01/09/2014

0001341251065 0130 SRI SUMARTI ISTRI 24/09/1944 KEL. PISANGAN TIMUR II185 AKTIF 0 59,5003175026409440002 01/09/2014

0001341251076 0131 SUNARTO PESERTA 02/02/1954 KEC. CIRACAS186 AKTIF 0 59,5003175090202540007 01/09/2014

0001341251098 0133 SUWARTO BT SUMAWIREJA PESERTA 31/12/1939 KEL. PENGGILINGAN I187 AKTIF 0 59,5003175063112390019 01/09/2014

0001341251109 0133 HJ. SULIYATMI ISTRI 24/10/1955 KEL. PENGGILINGAN I188 AKTIF 0 59,5003175066410550001 01/09/2014

Page 8 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341251111 0274 LEGIATI PESERTA 24/01/1942 KEL. CAWANG189 AKTIF 0 42,5003175046401420002 01/09/2014

0001341251122 0275 AMANI PESERTA 30/12/1950 KEL. PULO GEBANG190 AKTIF 0 42,5003175067012500011 01/09/2014

0001341251133 0276 MININ ININ PESERTA 16/12/1933 KEL. CAWANG191 AKTIF 0 42,5003175045612330001 01/09/2014

0001341251144 0277 SOEGINO PESERTA 07/05/1936 KEL. GROGOL SELATAN192 AKTIF 0 42,5003174050705360002 01/09/2014

0001341251155 0278 SAKIMAN PESERTA 07/10/1949 KEL. JAGAKARSA II193 AKTIF 0 42,5003174090710490002 01/09/2014

0001341251166 0278 NY.DELIANA TOBING S. ISTRI 26/09/1942 KEL. JAGAKARSA II194 AKTIF 0 42,5003174096609420001 01/09/2014

0001341251177 0279 ELIS DJAMILAH PESERTA 22/06/1957 KEL. PASAR MANGGIS195 AKTIF 0 42,5003174026206570001 01/09/2014

0001341251188 0280 SUKANDA PESERTA 31/12/1954 KEL. PONDOK LABU I196 AKTIF 0 42,5003174061501098810 01/09/2014

0001341251199 0280 SOFIATUN ISTRI 03/04/1958 KEL. PONDOK LABU I197 AKTIF 0 42,5003174067004580002 01/09/2014

0001341251201 0281 SUKIMAN PESERTA 13/10/1954 KEL. GROGOL UTARA II198 AKTIF 0 42,5003174051310540003 01/09/2014

0001341251212 0281 RUTASIH ISTRI 10/10/1965 KEL. GROGOL UTARA II199 AKTIF 0 42,5003174055010650006 01/09/2014

0001341251223 0282 SUWARTI PESERTA 03/07/1944 KEL. PETUKANGAN SELATAN200 AKTIF 0 42,5003174104307440001 01/09/2014

0001341251234 0283 KOMARIYAH PESERTA 31/07/1967 KEL. GROGOL UTARA II201 AKTIF 0 42,5003174057107670002 01/09/2014

0001341251245 0284 SUDARMI PESERTA 20/10/1940 KEL. KOJA202 AKTIF 0 42,5003172036010400003 01/09/2014

0001341251256 0285 MUHAMADDIN PESERTA 24/03/1957 KEC. KELAPA GADING203 AKTIF 0 42,5003172022403570003 01/09/2014

0001341251267 0285 SAHARANI ISTRI 12/05/1964 KEL. SUNGAI BAMBU204 AKTIF 0 42,5003172025205640013 01/09/2014

0001341251278 0286 ARWIYATI PESERTA 01/12/1950 KEL. KEBON BAWANG III205 AKTIF 0 42,5003172024112500009 01/09/2014

0001341251289 0287 YAMIN PESERTA 21/09/1940 KEL. WARAKAS206 AKTIF 0 42,5003172022109400002 01/09/2014

0001341251291 0288 RUKIYAH BONTHA PESERTA 10/11/1945 KEL. KOJA207 AKTIF 0 42,5003172035011450004 01/09/2014

0001341251302 0289 DAMARIS SINLAE LOE PESERTA 11/11/1945 KEL. KEBON BAWANG III208 AKTIF 0 42,5003172025111450001 01/09/2014

0001341251313 0290 ALWI BIN BASIR PESERTA 17/12/1933 KEL. PAPANGGO II209 AKTIF 0 42,5003172021712330003 01/09/2014

0001341251324 0290 EMAH ISTRI 17/12/1941 KEL. PAPANGGO II210 AKTIF 0 42,5003172025712410002 01/09/2014

0001341251335 0291 NELLY DURANDT PESERTA 01/03/1938 KEL. KEBON BAWANG III211 AKTIF 0 42,5003172024103380001 01/09/2014

0001341251346 0292 MACHMUD S PESERTA 01/02/1934 KEC. TANJUNG PRIOK212 AKTIF 0 42,5003172030102340002 01/09/2014

Page 9 of 4512/5/14 2:21 PM

Page 10: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341251357 0293 ABU BAKAR PESERTA 30/06/1939 KEL. LAGOA213 AKTIF 0 42,5003172033006390002 01/09/2014

0001341251368 0293 OCIH ISTRI 23/06/1943 KEL. LAGOA214 AKTIF 0 42,5003172036306430001 01/09/2014

0001341251379 0294 LANTAWI PESERTA 08/06/1941 KEC. TANJUNG PRIOK215 AKTIF 0 42,5003172030806410001 01/09/2014

0001341251381 0295 KURIYAH PESERTA 16/12/1955 KEL. LAGOA216 AKTIF 0 42,5003172035612550003 01/09/2014

0001341251392 0296 SAHANAH PESERTA 04/06/1948 KEL. TANJUNG PRIOK217 AKTIF 0 42,5003172024406480003 01/09/2014

0001341251403 0297 H.AMIR PESERTA 02/04/1946 KEL. LAGOA218 AKTIF 0 42,5003172030204460001 01/09/2014

0001341251414 0297 SITI MARIYAM ISTRI 03/05/1952 KEL. LAGOA219 AKTIF 0 42,5003172034305520005 01/09/2014

0001341251425 0298 SANE PESERTA 30/12/1940 KEL. SUNGAI BAMBU220 AKTIF 0 42,5003172027012400003 01/09/2014

0001341251436 0299 AMINAH PESERTA 29/12/1950 KEC. TANJUNG PRIOK221 AKTIF 0 42,5003172036912500003 01/09/2014

0001341251447 0300 NY. NASEHA PESERTA 25/11/1938 KEL. WARAKAS222 AKTIF 0 42,5003172026511380002 01/09/2014

0001341251458 0301 HJ. RABANANG PESERTA 24/04/1953 KEL. LAGOA223 AKTIF 0 42,5003172036404530001 01/09/2014

0001341251469 0302 NY. SUIRAH PESERTA 26/10/1955 KEL. PAPANGGO II224 AKTIF 0 42,5003172026610550002 01/09/2014

0001341251471 0303 LAODE MUMUAN PESERTA 20/04/1941 KEL. TUGU SELATAN225 AKTIF 0 42,5003172032004410004 01/09/2014

0001341251482 0304 DUKUT PESERTA 18/07/1950 KEL. SUNGAI BAMBU226 AKTIF 0 42,5003172021607500002 01/09/2014

0001341251493 0304 NY. ASMAGDALENA ISTRI 06/12/1953 KEL. SUNGAI BAMBU227 AKTIF 0 42,5003172024612530001 01/09/2014

0001341251504 0305 H. EWOD RUSWANDI PESERTA 15/03/1941 KEL. TANJUNG PRIOK228 AKTIF 0 42,5003172021503410002 01/09/2014

0001341251515 0305 NY. ROMLAH ISTRI 11/11/1954 KEL. TANJUNG PRIOK229 AKTIF 0 42,5003172025111540003 01/09/2014

0001341251526 0306 BASRI YUNUS PESERTA 31/12/1950 Puskesmas Rusun Marunda230 AKTIF 0 42,5003172043112500088 01/09/2014

0001341251537 0306 NY. SAWIYAH ISTRI 09/11/1961 Puskesmas Rusun Marunda231 AKTIF 0 42,5003172044811610004 01/09/2014

0001341251548 0307 NY. SUKIRAH PESERTA 31/12/1939 KEL. PADEMANGAN TIMUR232 AKTIF 0 42,5003172057112390003 01/09/2014

0001341251559 0308 SYARIFUDIN IDRIS PESERTA 01/05/1935 KEL. TANJUNG PRIOK233 AKTIF 0 42,5000951030105350102 01/09/2014

0001341251561 0308 NY. RAHMAH ISTRI 10/02/1943 KEL. TANJUNG PRIOK234 AKTIF 0 42,5000951030105350102 01/09/2014

0001341251572 0309 NY.N.THOMAS BENENDYK PESERTA 30/05/1939 KEL. LAGOA235 AKTIF 0 42,5002472001700530000 01/09/2014

0001341251583 0310 NY. ROSIANAH HUTAPEA PESERTA 16/12/1937 KEL. TUGU UTARA I236 AKTIF 0 42,5003172035612370001 01/09/2014

Page 10 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341251616 0312 NY. SUMARNI PESERTA 26/10/1956 KEL. SEMPER BARAT III237 AKTIF 0 42,5003172046610560002 01/09/2014

0001341251627 0313 ISMAIL SJAHRONI PESERTA 06/08/1941 KEL. LAGOA238 AKTIF 0 42,5003172030608410001 01/09/2014

0001341251638 0313 ASMAH ISTRI 30/12/1953 KEL. LAGOA239 AKTIF 0 42,5003172037012530010 01/09/2014

0001341251649 0314 HALIDJAH BA MASRI PESERTA 22/12/1951 KEL. TANJUNG PRIOK240 AKTIF 0 42,5003172026212510005 01/09/2014

0001341251651 0315 NY. ZALEHA PESERTA 21/06/1956 KEL. WARAKAS241 AKTIF 0 42,5003172026106560001 01/09/2014

0001341251662 0316 SABENI PESERTA 26/09/1937 KEL. KALI BARU242 AKTIF 0 42,5003172042609370001 01/09/2014

0001341251673 0317 MOH YUNUS PESERTA 05/12/1935 KEL. KEBON BAWANG I243 AKTIF 0 42,5003172020512350006 01/09/2014

0001341251684 0318 HJ. WARSINAH PESERTA 01/10/1948 KEL. KEBON BAWANG I244 AKTIF 0 42,5003172024110480002 01/09/2014

0001341251695 0319 NY, OTJIH SUKARSIH PESERTA 09/12/1951 KEL. TANJUNG PRIOK245 AKTIF 0 42,5003172024912510001 01/09/2014

0001341251706 0320 NY. MIMI PESERTA 29/12/1942 KEL. WARAKAS246 AKTIF 0 42,5003172026912420011 01/09/2014

0001341251717 0321 NY. ARTI PESERTA 28/12/1947 KEL. WARAKAS247 AKTIF 0 42,5003172026812470004 01/09/2014

0001341251728 0322 NY. HATIJAH PESERTA 22/12/1941 KEL. WARAKAS248 AKTIF 0 42,5003172026212410004 01/09/2014

0001341251739 0323 M. AMIR PESERTA 31/12/1942 KEL. PEGANGSAAN DUA249 AKTIF 0 42,5003172063112420010 01/09/2014

0001341251741 0324 HASAN BASRI BIN BATJO PESERTA 18/11/1937 KEC. TANJUNG PRIOK250 AKTIF 0 42,5003172031811310004 01/09/2014

0001341251752 0324 H.HAMDANAH ISTRI 20/05/1949 KEC. TANJUNG PRIOK251 AKTIF 0 42,5003172036005490002 01/09/2014

0001341251763 0351 KURNELLIA PESERTA 02/03/1950 KEL. CIRACAS252 AKTIF 0 42,5003175094203500001 01/09/2014

0001341253989 0351 FX SUYADI PESERTA 08/10/1947 KEL. CIRACAS253 AKTIF 0 42,5003175090810470001 01/09/2014

0001341251774 0325 SUHAEBAH PESERTA 03/05/1953 KEL. WARAKAS254 AKTIF 0 42,5003172024305530002 01/09/2014

0001341251785 0326 AMINAH PESERTA 29/12/1945 KEL. TUGU UTARA I255 AKTIF 0 42,5003172031806111005 01/09/2014

0001341251796 0327 GABRIEL MEKA PESERTA 04/11/1940 KEL. PAPANGGO II256 AKTIF 0 42,5003172020701099783 01/09/2014

0001341251807 0327 RASMI ISTRI 18/11/1953 KEL. PAPANGGO II257 AKTIF 0 42,5003172025811530001 01/09/2014

0001341251818 0328 DAHLAN DJUNTAK PESERTA 30/06/1942 KEL. KEBON BAWANG III258 AKTIF 0 42,5003172023006420001 01/09/2014

0001341251829 0328 MURNI ISTRI 01/08/1960 KEL. KEBON BAWANG III259 AKTIF 0 42,5003172024108600007 01/09/2014

0001341251831 0329 ALWI SANGGERANG PESERTA 17/03/1942 Puskesmas Rawa Badak Selatan260 AKTIF 0 42,5003172031703420002 01/09/2014

Page 11 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341251842 0329 AISYAH BT.MAHMUD ISTRI 11/07/1952 Puskesmas Rawa Badak Selatan261 AKTIF 0 42,5003172035107520001 01/09/2014

0001341251853 0330 TARI BINTI CASWAN PESERTA 23/10/1943 KEL. TUGU UTARA I262 AKTIF 0 42,5003172036310430005 01/09/2014

0001341251864 0331 D.FIRDAUS PESERTA 11/10/1958 KEL. PETAMBURAN263 AKTIF 0 42,5003171071110580002 01/09/2014

0001341251875 0331 NETTY ISTRI 27/11/1963 KEL. PETAMBURAN264 AKTIF 0 42,5003171076711630003 01/09/2014

0001341251886 0332 SURATNO PESERTA 11/12/1959 KEL. BINTARO265 AKTIF 0 42,5003174101112590008 01/09/2014

0001341251897 0332 SUPARTI ISTRI 07/05/1958 KEL. BINTARO266 AKTIF 0 42,5003174104705580008 01/09/2014

0001341251908 0334 MAMAT HAMDANI PESERTA 13/05/1946 KEL. GEDONG267 AKTIF 0 42,5003175051305460001 01/09/2014

0001341251919 0334 NINI ROHANI ISTRI 11/12/1952 KEL. GEDONG268 AKTIF 0 42,5003175055112520003 01/09/2014

0001341251921 0335 MARLAN PESERTA 31/12/1933 KEL. PENGGILINGAN I269 AKTIF 0 42,5003175063112330003 01/09/2014

0001341251932 0335 NGADIMAH ISTRI 24/01/1942 KEL. PENGGILINGAN I270 AKTIF 0 42,5003175066401420001 01/09/2014

0001341251943 0336 ARI BIN AMENAN PESERTA 12/05/1942 KEL. LAGOA271 AKTIF 0 42,5003172031205420005 01/09/2014

0001341251954 0337 MATTITUS RIWU MENYI PESERTA 25/09/1930 KEL. KOJA272 AKTIF 0 42,5003172032509300001 01/09/2014

0001341251965 0337 ERLIN ELIPAS RIWU ISTRI 29/07/1935 KEL. KOJA273 AKTIF 0 42,5003172036907350001 01/09/2014

0001341251976 0338 SAHDIYAH PESERTA 30/12/1946 KEL. TANJUNG PRIOK274 AKTIF 0 42,5003172027012460020 01/09/2014

0001341251987 0340 CRISTINA LUMI PESERTA 15/07/1943 KEL. WARAKAS275 AKTIF 0 42,5003172025507430005 01/09/2014

0001341251998 0341 LENNY R.HALIWELA PESERTA 11/11/1953 KEL. KEBON BAWANG III276 AKTIF 0 42,5003172051115300010 01/09/2014

0001341252009 0342 MARTHA PESERTA 27/12/1949 KEL. TANJUNG PRIOK277 AKTIF 0 42,5003172026712490004 01/09/2014

0001341252011 0343 ISMAIL SAMAD PESERTA 03/06/1942 KEL. SEMPER BARAT III278 AKTIF 0 42,5003172040308420001 01/09/2014

0001341252022 0343 SALMAH ISTRI 06/03/1951 KEL. SEMPER BARAT III279 AKTIF 0 42,5003172044603510002 01/09/2014

0001341252033 0344 LAMRAH PESERTA 09/12/1942 KEL. WARAKAS280 AKTIF 0 42,5003172024912420003 01/09/2014

0001341252044 0345 SAHAT SITOMPUL PESERTA 02/10/1940 KEL. KEBON BAWANG III281 AKTIF 0 42,5003172020210400004 01/09/2014

0001341252055 0345 ERNI HUTABARAT ISTRI 08/07/1950 KEL. KEBON BAWANG III282 AKTIF 0 42,5003172024807500001 01/09/2014

0001341252066 0346 NARIYAH PESERTA 23/07/1946 KEL. TUGU UTARA I283 AKTIF 0 42,5003172036307460001 01/09/2014

0001341252077 0347 SUTIAH SUMASARAH PESERTA 10/08/1936 KEL. TUGU UTARA I284 AKTIF 0 42,5003172035008360002 01/09/2014

Page 12 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341252088 0348 WARIN PESERTA 11/03/1942 KEL. PAPANGGO II285 AKTIF 0 42,5003172021103420005 01/09/2014

0001341252099 0348 ASNI ISTRI 28/12/1950 KEL. PAPANGGO II286 AKTIF 0 42,5003172026812500022 01/09/2014

0001341252101 0349 PARNI PESERTA 20/05/1963 KEL. TANJUNG PRIOK287 AKTIF 0 42,5003172026005630008 01/09/2014

0001341252112 0350 ASMAH PESERTA 27/12/1956 KEL. KOTA BAMBU SELATAN288 AKTIF 0 42,5003173076712560009 01/09/2014

0001341252257 0387 MIESKE RAMBING PESERTA 07/05/1952 CIPAYUNG289 AKTIF 0 42,5003276014705520001 01/09/2014

0001341252134 0387 IRMA FITRIA PESERTA 04/07/1980 TANAH SAREAL290 AKTIF 0 42,5003271064407800016 01/09/2014

0001341252145 0388 GRIETYE M MAGDALENA PESERTA 25/12/1951 BABELAN I291 AKTIF 0 42,5003216026512510004 01/09/2014

0001341252268 0388 GRIETYE M MAGDALENA PESERTA 25/12/1951 BABELAN I292 AKTIF 0 42,5003216026512510004 01/09/2014

0001341252167 0390 SUYADI PESERTA 08/02/1957 TAMBUN293 AKTIF 0 42,5003216060802570007 01/09/2014

0001341252189 0392 RIKA SRI REJEKI PESERTA 07/01/1975 CILEUBUT294 AKTIF 0 42,5003271024701750061 01/09/2014

0001341252202 0394 R DEKA SUHASTATI PESERTA 26/09/1948 AREN JAYA295 AKTIF 0 59,5003275016609480005 01/09/2014

0001341252213 0395 MARIAH PESERTA 15/09/1959 KEL. TANJUNG PRIOK296 AKTIF 0 42,5003172025509590008 01/09/2014

0001341252224 0396 O.Y ROHAYATI PESERTA 19/01/1951 KEL. WARAKAS297 AKTIF 0 42,5003172025901510005 01/09/2014

0001341252235 0397 A KAMARUZAMAN PESERTA 06/07/1923 KEL. TEBET TIMUR298 AKTIF 0 59,5003174010607230001 01/09/2014

0001341252281 0419 ZULAIHA BULWAFA PESERTA 09/12/1955 ABADI JAYA299 AKTIF 0 42,5003276054912550005 01/09/2014

0001341252325 0134 FX. PUTUT ABJL PESERTA 25/08/1950 KEL. CAKUNG BARAT300 AKTIF 0 59,5003175062508500002 01/09/2014

0001341252336 0134 MTH SRI DEWIWAHYUNINGSIH

ISTRI 16/06/1952 KEL. CAKUNG BARAT301 AKTIF 0 59,5003175065609520001 01/09/2014

0001341252347 0135 EMPONG SUWARSIH PESERTA 25/02/1957 KEL. KAYU MANIS302 AKTIF 0 59,5003175016502570003 01/09/2014

0001341252358 0136 DRS. M M SAMSIDIK TARMAN PESERTA 28/07/1946 KEL. BATU AMPAR303 AKTIF 0 59,5003175042807460001 01/09/2014

0001341252369 0136 TRI MURTI SAMSIDIK BSC ISTRI 16/06/1947 KEL. BATU AMPAR304 AKTIF 0 59,5003175045606470003 01/09/2014

0001341252371 0137 NY. SRI SUKARNI PESERTA 07/12/1946 KEL. PISANGAN TIMUR I305 AKTIF 0 59,5003175024712460003 01/09/2014

0001341252382 0138 WAGIMIN PESERTA 23/03/1956 KEC. CIRACAS306 AKTIF 0 59,5003175092303560002 01/09/2014

0001341252393 0138 RIYANA PURBA ISTRI 15/09/1961 KEC. CIRACAS307 AKTIF 0 59,5003175095509610008 01/09/2014

Page 13 of 4512/5/14 2:21 PM

Page 14: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341252404 0139 WILLEM TUMANGKENG PESERTA 25/12/1937 KEL. UTAN KAYU UTARA308 AKTIF 0 59,5003175012512370008 01/09/2014

0001341252415 0140 NY. IVONNE KANSIL M.RAINARD

PESERTA 30/05/1946 KEC. PULO GADUNG309 AKTIF 0 59,5003175027005480001 01/09/2014

0001341252426 0141 SAUT S TAMPUBOLON PESERTA 16/01/1956 KEL. PENGGILINGAN I310 AKTIF 0 59,5003175061601560002 01/09/2014

0001341252437 0141 TIURMA BR TAMBUN ISTRI 01/05/1960 KEL. PENGGILINGAN I311 AKTIF 0 59,5003175064105600008 01/09/2014

0001341252448 0142 NY. MARYANI PESERTA 04/03/1952 KEL. KEBON PALA312 AKTIF 0 59,5003175084403520004 01/09/2014

0001341252459 0143 NY. LILY PORY PRANCIEN PESERTA 20/01/1934 KEL. CAWANG313 AKTIF 0 59,5003175026001340003 01/09/2014

0001341252461 0144 YANTI SUTJIADI PESERTA 20/04/1946 KEL. CIPINANG CEMPEDAK314 AKTIF 0 59,5003175036004460002 01/09/2014

0001341252472 0145 SOEDIJANTO KERTMAN PESERTA 26/12/1934 KEL. JATI II315 AKTIF 0 59,5003175022612340003 01/09/2014

0001341252483 0145 SETIATI ISTRI 10/04/1949 KEL. JATI II316 AKTIF 0 59,5003175025004490001 01/09/2014

0001341252494 0146 TJAHYO WIDONO PESERTA 11/04/1950 KEL. PONDOK KOPI I317 AKTIF 0 59,5003175071104500004 01/09/2014

0001341252505 0146 LUPI LAKSMINI ISTRI 29/01/1956 KEL. PONDOK KOPI I318 AKTIF 0 59,5003175076901560003 01/09/2014

0001341252516 0147 NY. NETTY HUTAGAOLTAMBUNAN

PESERTA 16/03/1941 KEL. PONDOK KOPI I319 AKTIF 0 59,5003175025603410001 01/09/2014

0001341252527 0148 PAULUS RUWIJO PESERTA 27/04/1950 KEL. BATU AMPAR320 AKTIF 0 59,5003175042704500001 01/09/2014

0001341252538 0148 SRI SUMIARSIH ISTRI 01/10/1958 KEL. BATU AMPAR321 AKTIF 0 59,5003175044110580006 01/09/2014

0001341252549 0149 IWAN HUTABARAT PESERTA 22/12/1950 KEC. PULO GADUNG322 AKTIF 0 59,5003175022212500008 01/09/2014

0001341252551 0149 ARTHA TAMPUBOLON ISTRI 02/01/1956 KEC. PULO GADUNG323 AKTIF 0 59,5003175024201560002 01/09/2014

0001341252562 0150 RAZNY HERAWATY RAZALI PESERTA 07/10/1952 KEL. PONDOK BAMBU II324 AKTIF 0 59,5003175074710520001 01/09/2014

0001341252573 0151 HJ.MARTATI PESERTA 23/12/1949 KEL. KLENDER I325 AKTIF 0 59,5003175076312490002 01/09/2014

0001341252584 0152 SUDIARTI PESERTA 31/07/1956 KEL. GEDONG326 AKTIF 0 59,5003173087107560003 01/09/2014

0001341252595 0153 RANTI PESERTA 17/02/1957 KEL. MAKASAR327 AKTIF 0 59,5003175085702570001 01/09/2014

0001341252606 0154 DEWI AISYAH PESERTA 25/07/1942 KEL. Cipinang Besar Selatan II328 AKTIF 0 59,5003175036507420002 01/09/2014

0001341252617 0155 NI NYOMAN SUMARNI PESERTA 12/10/1952 KEL. CIBUBUR329 AKTIF 0 59,5003175095210520003 01/09/2014

0001341252628 0156 WALTER SINAGA PESERTA 20/09/1940 KEL. KLENDER I330 AKTIF 0 59,5000954072009400171 01/09/2014

Page 14 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341252639 0157 SAMY DUNDA PESERTA 12/05/1953 KEL. BATU AMPAR331 AKTIF 0 59,5003175041205530003 01/09/2014

0001341252641 0157 SAMSIH SUNDA ISTRI 11/07/1953 KEL. BATU AMPAR332 AKTIF 0 59,5003175045107530001 01/09/2014

0001341252652 0158 FARIDA ROSNAINI PESERTA 25/09/1950 KEL. PENGGILINGAN I333 AKTIF 0 59,5003175066509500001 01/09/2014

0001341252663 0159 RUMANA DUNDA PESERTA 03/11/1933 KEL. BATU AMPAR334 AKTIF 0 59,5003175044311330004 01/09/2014

0001341252674 0160 TOTOM MARTAPRADJA PESERTA 20/11/1952 KEL. CILILITAN335 AKTIF 0 59,5003175042011520003 01/09/2014

0001341252685 0160 TJUTJU RISMAWATY ISTRI 03/01/1956 KEL. CILILITAN336 AKTIF 0 59,5003175044301560002 01/09/2014

0001341252696 0161 JOHANA ANALIST LAHENGKO PESERTA 06/12/1930 KEL. CIPINANG CEMPEDAK337 AKTIF 0 59,5003175034612300002 01/09/2014

0001341252707 0162 NY.M.LOPPIES MOJO PESERTA 21/05/1941 KEL. JATI II338 AKTIF 0 59,5003175026105410001 01/09/2014

0001341252718 0163 PAULINA WATIMENA PESERTA 23/03/1944 KEL. DUKUH339 AKTIF 0 59,5003175046303440003 01/09/2014

0001341252729 0164 NURAENI PESERTA 11/02/1958 KEL. KEBON JERUK340 AKTIF 0 59,5003173055102580005 01/09/2014

0001341252731 0165 TUTI SURYANTINAH PESERTA 16/04/1950 KEL. KELAPA DUA341 AKTIF 0 59,5003173055604500002 01/09/2014

0001341252742 0166 PRAYITNO SE PESERTA 08/06/1956 KEL. MERUYA SELATAN I342 AKTIF 0 59,5003173080806560005 01/09/2014

0001341252753 0166 RUZANNA ISTRI 30/07/1961 KEL. MERUYA SELATAN II343 AKTIF 0 59,5003173087007610001 01/09/2014

0001341252764 0167 DR.LIEK SARI HANDIKIN PESERTA 26/02/1942 KEL. JOGLO I344 AKTIF 0 59,5003173082602420001 01/09/2014

0001341252775 0167 DR.NURYNUSDWINURINGTYAS

ISTRI 09/05/1954 KEL. JOGLO I345 AKTIF 0 59,5003173084905540001 01/09/2014

0001341252786 0168 NYOMAN SUWASTINI PESERTA 18/05/1951 KEL. KEMANGGISAN346 AKTIF 0 59,5003173075805510003 01/09/2014

0001341252797 0169 SUTIAH PESERTA 12/07/1967 KEL. KEBON JERUK347 AKTIF 0 59,5003173055207570006 01/09/2014

0001341252808 0170 KASMINAH PESERTA 19/09/1931 KEL. SLIPI I348 AKTIF 0 59,5003173075909310001 01/09/2014

0001341252819 0171 DJIYO GUNANTO PESERTA 02/01/1957 KEL. SLIPI I349 AKTIF 0 59,5003173070201570006 01/09/2014

0001341252821 0171 SURANTI ISTRI 22/11/1959 KEL. SLIPI I350 AKTIF 0 59,5003173076211590005 01/09/2014

0001341252832 0172 ABDUL GANI SARRO PESERTA 07/05/1949 KEL. TOMANG351 AKTIF 0 59,5003173020705490001 01/09/2014

0001341252843 0172 SO TIEN TIEN ISTRI 17/05/1960 KEL. TOMANG352 AKTIF 0 59,5003173025705800002 01/09/2014

0001341252854 0173 KETUT SARINI PESERTA 22/02/1954 KEL. SLIPI I353 AKTIF 0 59,5003173076202540002 01/09/2014

Page 15 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341252865 0174 MONGGO SITORUS PESERTA 01/12/1956 KEC. PAL MERAH354 AKTIF 0 59,5003173074112560009 01/09/2014

0001341252876 0175 SUWARNI PESERTA 02/10/1933 KEL. SLIPI I355 AKTIF 0 59,5003173074210330001 01/09/2014

0001341252887 0176 YUNIAR DWIHARINI PESERTA 05/06/1957 KEL. DURI KEPA356 AKTIF 0 59,5003173054506570009 01/09/2014

0001341252898 0177 SAHENI ALIASA PESERTA 29/09/1951 KEL. SLIPI II357 AKTIF 0 59,5003173076909510002 01/09/2014

0001341252922 0179 JULISMAN ASMOENA PESERTA 30/07/1951 KEL. SLIPI II358 AKTIF 0 59,5003173073007510001 01/09/2014

0001341252933 0180 CHAERONI PESERTA 17/01/1946 KEL. KOTA BAMBU UTARA359 AKTIF 0 59,5003173075701460001 01/09/2014

0001341252944 0181 HJ. EMMY FARIDA BSC PESERTA 11/01/1950 KEL. KEBON JERUK360 AKTIF 0 59,5003173055101500001 01/09/2014

0001341252955 0182 MUSRIPAH PESERTA 10/10/1943 KEL. SRENGSENG361 AKTIF 0 59,5003173085010430002 01/09/2014

0001341252966 0183 KAROLINA TOBING PESERTA 25/12/1945 KEL. SUKABUMI UTARA362 AKTIF 0 59,5003173056512450005 01/09/2014

0001341252977 0184 SOEBIJAKTO BERNARD PESERTA 23/01/1937 KEL. TANJUNG DUREN UTARA363 AKTIF 0 59,5003173022301370001 01/09/2014

0001341252988 0184 SUMIYATI ISTRI 12/08/1944 KEL. TANJUNG DUREN UTARA364 AKTIF 0 59,5003173025208440001 01/09/2014

0001341252999 0185 T NGUDININGSIH PESERTA 30/05/1945 KEL. KOTA BAMBU SELATAN365 AKTIF 0 59,5003173074104440003 01/09/2014

0001341253001 0186 MIMIN RUSMINI PESERTA 08/01/1951 KEL. TOMANG366 AKTIF 0 59,5003173024801510003 01/09/2014

0001341253012 0187 KUWAT PESERTA 05/02/1957 KEL. PAL MERAH II367 AKTIF 0 59,5003173070502570001 01/09/2014

0001341253023 0187 NY.LILI KARLINAH ISTRI 06/03/1966 KEL. PAL MERAH II368 AKTIF 0 59,5003173074603660003 01/09/2014

0001341253034 0188 DARMINI S.E MM PESERTA 01/01/1955 KEL. KEBON JERUK369 AKTIF 0 59,5003173054101550001 01/09/2014

0001341253045 0189 NY. NORA MIENEE TANAMAL PESERTA 22/11/1936 KEL. KEDAUNG KALI ANGKE370 AKTIF 0 59,5003173016211360002 01/09/2014

0001341253056 0190 DARYANTO PESERTA 23/11/1951 KEL. SLIPI I371 AKTIF 0 59,5003173072311510002 01/09/2014

0001341253067 0191 DAYAT HIDAYAT PESERTA 19/03/1953 KEL. KOTA BAMBU SELATAN372 AKTIF 0 59,5003173071903530003 01/09/2014

0001341253078 0191 ETI KOMALASARI ISTRI 28/10/1962 KEL. KOTA BAMBU SELATAN373 AKTIF 0 59,5003173076810620003 01/09/2014

0001341253089 0192 SAKIMAN PESERTA 04/12/1955 KEL. DURI KOSAMBI I374 AKTIF 0 59,5003173010412550004 01/09/2014

0001341253091 0192 SUPINI ISTRI 30/12/1955 KEL. DURI KOSAMBI I375 AKTIF 0 59,5003173017012550008 01/09/2014

0001341253102 0193 DRS. MANAHAN SIAHAAN PESERTA 19/12/1930 KEL. SLIPI II376 AKTIF 0 59,5003173071912300003 01/09/2014

0001341253113 0193 R MARJATI TAMPUBOLON ISTRI 29/03/1940 KEL. SLIPI II377 AKTIF 0 59,5003173076903400001 01/09/2014

Page 16 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341253124 0194 H. ASNAN PESERTA 16/07/1932 KEL. SLIPI II378 AKTIF 0 59,5003173071607320002 01/09/2014

0001341253135 0195 AKUWAN PESERTA 20/04/1958 KEL. SLIPI II379 AKTIF 0 59,5003173072004580008 01/09/2014

0001341253168 0197 MURSIDAH SKP PESERTA 24/12/1953 KEL. KEMANGGISAN380 AKTIF 0 59,5003173076412530001 01/09/2014

0001341253179 0198 R.CHRYS HARYONO PESERTA 01/08/1944 KEL. KOTA BAMBU SELATAN381 AKTIF 0 59,5003173070108440002 01/09/2014

0001341253181 0198 M.M SUWARTI ISTRI 04/02/1948 KEL. KOTA BAMBU SELATAN382 AKTIF 0 59,5003173074402480001 01/09/2014

0001341253192 0199 DRA. SETIAWATI PESERTA 15/01/1951 KEL. SUKABUMI SELATAN383 AKTIF 0 59,5003173055501510004 01/09/2014

0001341253203 0200 DRS.BUDIARTO SUKEMI PESERTA 16/06/1935 KEL. SLIPI I384 AKTIF 0 59,5000952061606350230 01/09/2014

0001341253214 0200 ENY SUHASTIFA ISTRI 07/03/1958 KEL. SLIPI I385 AKTIF 0 59,5003173074703580002 01/09/2014

0001341253225 0201 LADJUMAH PESERTA 28/04/1956 KEL. KAMAL I386 AKTIF 0 59,5003173062804560002 01/09/2014

0001341253236 0201 HOLIFAH ISTRI 10/02/1966 KEL. KAMAL I387 AKTIF 0 59,5003173065002660002 01/09/2014

0001341253247 0202 MUCHOLIFATUN PESERTA 03/03/1958 KEL. SUKABUMI UTARA388 AKTIF 0 59,5003173054303590004 01/09/2014

0001341253258 0203 DR. NIKEN PARMANTO PESERTA 25/12/1942 KEL. GROGOL UTARA I389 AKTIF 0 59,5003174056512420013 01/09/2014

0001341253269 0204 SUMARTONO PESERTA 31/01/1940 KEL. GROGOL UTARA I390 AKTIF 0 59,5003174053101400001 01/09/2014

0001341253271 0204 NY.ATIEK SUMARTONO ISTRI 17/07/1943 KEL. GROGOL UTARA I391 AKTIF 0 59,5003174055707430002 01/09/2014

0001341253282 0205 NY.NIEKE B SENEWE PESERTA 10/03/1940 KEL. BUKIT DURI392 AKTIF 0 59,5003174015003400006 01/09/2014

0001341253293 0206 WIDJIASIH PESERTA 31/01/1956 KEL. MANGGARAI393 AKTIF 0 59,5003174017101560001 01/09/2014

0001341253304 0207 ZAYADI PESERTA 18/12/1951 KEC. PASAR MINGGU394 AKTIF 0 59,5003174041812510000 01/09/2014

0001341253315 0208 AGUSTINE RUMSARI PESERTA 14/08/1956 KEL. KARET395 AKTIF 0 59,5003174025408560003 01/09/2014

0001341253326 0209 DR. SRI MURTININGSIH PESERTA 07/11/1944 KEL. TEBET TIMUR396 AKTIF 0 59,5003174014711440003 01/09/2014

0001341253337 0210 NY. NIKMAH PESERTA 31/05/1949 KEL. KEBON BARU397 AKTIF 0 59,5003174017105490002 01/09/2014

0001341253348 0211 NY.SUSIRAH SOETARDJO PESERTA 11/01/1939 KEL. PELA MAMPANG II398 AKTIF 0 59,5003174035101390001 01/09/2014

0001341253359 0212 RM.RAHARDJO PESERTA 04/10/1935 KEL. RAWA BARAT399 AKTIF 0 59,5003174070410350002 01/09/2014

0001341253361 0212 RR.SITI ASIJAH ISTRI 02/10/1935 KEL. RAWA BARAT400 AKTIF 0 59,5003174074210350001 01/09/2014

0001341253372 0213 RR . HENDRORINI DCN PESERTA 16/12/1950 KEL. GANDARIA UTARA I/PLT401 AKTIF 0 59,5003174075612500001 01/09/2014

Page 17 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341253383 0214 BUDI HERAWATI PESERTA 01/05/1950 KEL. MANGGARAI402 AKTIF 0 59,5003174014105500001 01/09/2014

0001341253394 0215 NY.JEANNETTE E. SENDUK PESERTA 04/11/1935 KEL. KEBAYORAN LAMA UTARA403 AKTIF 0 59,5000953054411350180 01/09/2014

0001341253405 0216 DR.DJANG JUSI PESERTA 12/12/1929 KEL. RAWA BARAT404 AKTIF 0 59,5003174051212290001 01/09/2014

0001341253416 0216 ZULEICHA JUSI ISTRI 25/03/1939 KEL. RAWA BARAT405 AKTIF 0 59,5003174056503390001 01/09/2014

0001341253427 0217 H.TAPIARA SIAGIAN PESERTA 22/11/1947 KEL. KEBON BARU406 AKTIF 0 59,5003174016211470002 01/09/2014

0001341253438 0218 SITI ATIKA PESERTA 10/04/1948 KEL. JAGAKARSA II407 AKTIF 0 59,5003174095004480006 01/09/2014

0001341253449 0219 RATNA G TURNIP PESERTA 14/07/1952 KEL. PETUKANGAN UTARA408 AKTIF 0 59,5003174105407520003 01/09/2014

0001341253451 0220 SUKASNI PESERTA 11/05/1939 KEL. MENTENG DALAM I409 AKTIF 0 59,5003174015105390003 01/09/2014

0001341253462 0221 NY.HILWIAH ALI MUCHTAR PESERTA 17/08/1922 KEL. GROGOL UTARA I410 AKTIF 0 59,5003174055708220002 01/09/2014

0001341253473 0222 DIDI SUANDI ADIMIHARDJA PESERTA 14/07/1939 KEL. BUKIT DURI411 AKTIF 0 59,5003174011407390001 01/09/2014

0001341253484 0223 NY.SRI SUDEWI PESERTA 05/03/1941 KEC. PASANGGRAHAN412 AKTIF 0 59,5003174104503410001 01/09/2014

0001341253495 0224 SUIT B ASERI PESERTA 25/12/1940 KEL. GROGOL UTARA I413 AKTIF 0 59,5000953052512400190 01/09/2014

0001341253506 0224 TINI BT.HR.SIDUP ISTRI 07/06/1954 KEL. GROGOL UTARA I414 AKTIF 0 59,5003174054706540001 01/09/2014

0001341253517 0225 WINARNI KOESOEMOPRODJO PESERTA 02/06/1942 KEL. BUKIT DURI415 AKTIF 0 59,5003174014206420008 01/09/2014

0001341253528 0226 NY.KALSUM A. BARMANSYAH PESERTA 03/05/1945 KEL. PONDOK PINANG416 AKTIF 0 59,5003174054305450003 01/09/2014

0001341253539 0227 DRA.SUHARSINI SARJONO PESERTA 24/05/1950 KEL. GROGOL SELATAN417 AKTIF 0 59,5003174056405500001 01/09/2014

0001341253541 0228 MUDIATI EOH PESERTA 01/01/1941 KEL. PASAR MANGGIS418 AKTIF 0 59,5003174024101410001 01/09/2014

0001341253552 0229 NY.HISWATI SOEKARSO PESERTA 23/06/1936 KEL. TEBET TIMUR419 AKTIF 0 59,5003174016306360006 01/09/2014

0001341253697 0230 DR.HARJANTOKARTOKOESOEMO

PESERTA 09/04/1940 KEL. GROGOL UTARA I420 AKTIF 0 59,5003174050904400001 01/09/2014

0001341253563 0230 NY.CHRISMINTARTIHARJANTO

PESERTA 17/09/1950 KEL. GROGOL UTARA II421 AKTIF 0 59,5003174055709500001 01/09/2014

0001341253574 0231 NY.FAUZAH PESERTA 03/05/1953 KEL. KEBON BARU422 AKTIF 0 59,5003174014305530001 01/09/2014

0001341253585 0232 VENNY VERONICA BOLUNG PESERTA 18/06/1950 KEL. LENTENG AGUNG I423 AKTIF 0 59,5003174095806500001 01/09/2014

0001341253596 0233 SUDARMI PESERTA 10/06/1945 KEC. JAGAKARSA424 AKTIF 0 59,5003174095006450004 01/09/2014

Page 18 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341253607 0234 ALFRED SOMPIE PESERTA 03/10/1928 KEL. TEBET BARAT425 AKTIF 0 59,5003174010310280001 01/09/2014

0001341253618 0234 ELISABETH L.E. LOLONG ISTRI 17/12/1944 KEL. TEBET BARAT426 AKTIF 0 59,5003174015712440001 01/09/2014

0001341253629 0235 OERIP TJAHYADI PESERTA 11/12/1937 KEL. DUREN TIGA427 AKTIF 0 59,5003174081112370002 01/09/2014

0001341253631 0235 RUKMIYATI ISTRI 22/01/1944 KEL. DUREN TIGA428 AKTIF 0 59,5003174084201440001 01/09/2014

0001341253642 0236 NICOLAAS C.RUMANGKAY PESERTA 11/11/1935 KEC. JAGAKARSA429 AKTIF 0 59,5003174091701097358 01/09/2014

0001341253653 0236 JOHANA J.C. MAWUNTU ISTRI 27/06/1939 KEC. JAGAKARSA430 AKTIF 0 59,5003174096706390001 01/09/2014

0001341253664 0237 R.M ARKO SIDARDJO PESERTA 19/12/1931 KEL. TEBET TIMUR431 AKTIF 0 59,5003174011912310001 01/09/2014

0001341253675 0238 DOLLY J BOLANGRONDONUWU

PESERTA 14/05/1942 KEL. PONDOK PINANG432 AKTIF 0 59,5003174055405420002 01/09/2014

0001341253686 0239 SITI ROENDJANI SADIYO PESERTA 05/03/1946 KEL. PELA MAMPANG II433 AKTIF 0 59,5003174034503460001 01/09/2014

0001341253708 0241 MARIAH FATIMAH PESERTA 05/08/1935 KEC. JOHAR BARU434 AKTIF 0 59,5000950084508350007 01/09/2014

0001341253719 0242 H.M NASRUL GAUS SE PESERTA 15/06/1954 KEC. TANJUNG PRIOK435 AKTIF 0 59,5003172021506540007 01/09/2014

0001341253721 0242 HJ. JULIATI NINGSIH ISTRI 07/07/1960 KEC. TANJUNG PRIOK436 AKTIF 0 59,5003172024107600004 01/09/2014

0001341253732 0243 RR LIES HANDAYANI PESERTA 23/03/1956 KEC. JOHAR BARU437 AKTIF 0 59,5003175016303560005 01/09/2014

0001341253743 0244 S.SANADI PESERTA 12/12/1948 KEL. MALAKA JAYA438 AKTIF 0 59,5003175071212480008 01/09/2014

0001341253754 0245 MUSA NIMAN PESERTA 30/11/1942 KEL. KAMPUNG TENGAH439 AKTIF 0 59,5000954053011420314 01/09/2014

0001341253765 0246 SUHARSIH PESERTA 28/05/1958 KEL. SUKABUMI UTARA440 AKTIF 0 42,5003173056805580006 01/09/2014

0001341253776 0247 NY.GRAY MARLENEWATTIMENA

PESERTA 31/10/1940 KEL. KEDAUNG KALI ANGKE441 AKTIF 0 42,5003173017110400001 01/09/2014

0001341253787 0248 NYAMIN PESERTA 11/09/1957 KEL. JOGLO I442 AKTIF 0 42,5003174081109570004 01/09/2014

0001341253798 0249 SUKRA BIN KANI PESERTA 06/04/1942 KEL. KELAPA DUA443 AKTIF 0 42,5003173050604420003 01/09/2014

0001341253809 0249 RODEMAH ISTRI 16/05/1945 KEL. KELAPA DUA444 AKTIF 0 42,5003173055605450001 01/09/2014

0001341253811 0250 RUSMINI PESERTA 12/09/1950 KEL. SLIPI I445 AKTIF 0 42,5003173075209500002 01/09/2014

0001341253822 0251 SUHANAH PESERTA 05/10/1952 KEL. KOTA BAMBU UTARA446 AKTIF 0 42,5003173074510520004 01/09/2014

0001341253833 0252 SIMAN ROHADI PESERTA 22/12/1945 KEL. TOMANG447 AKTIF 0 42,5003173022212450001 01/09/2014

Page 19 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341253844 0252 TITIK SURYATI ISTRI 27/06/1951 KEL. TOMANG448 AKTIF 0 42,5003173026706511001 01/09/2014

0001341253855 0253 SALI PESERTA 31/12/1951 KEL. SLIPI I449 AKTIF 0 42,5003173073112510009 01/09/2014

0001341253866 0253 KARIYATI ISTRI 25/08/1958 KEL. SLIPI I450 AKTIF 0 42,5003173076508580004 01/09/2014

0001341253877 0254 HANAPI PESERTA 02/12/1953 KEL. RAWA SARI451 AKTIF 0 42,5003171050212530001 01/09/2014

0001341253888 0255 SUMARYA PESERTA 25/12/1951 KEL. RAWA SARI452 AKTIF 0 42,5003171052512510001 01/09/2014

0001341253899 0257 NY.SINTAN PESERTA 06/06/1947 KEL. JOHAR BARU I453 AKTIF 0 42,5003171084606470001 01/09/2014

0001341253901 0258 TASEM K PESERTA 03/04/1935 KEL. SERDANG454 AKTIF 0 42,5003171034304350002 01/09/2014

0001341253912 0259 BEATRIX MANUSIWA R PESERTA 07/03/1946 KEL. JOHAR BARU III455 AKTIF 0 42,5003171084703460001 01/09/2014

0001341253923 0260 L.M. WISMAN PESERTA 23/05/1928 KEL. GALUR456 AKTIF 0 42,5000950086305280015 01/09/2014

0001341253934 0261 HARYANTO PESERTA 28/09/1955 PONDOK BENDA457 AKTIF 0 42,5003674062809550004 01/09/2014

0001341252303 0261 SUMARTINI ISTRI 04/04/1955 PONDOK BENDA458 AKTIF 0 42,5003674064404550008 01/09/2014

0001341253945 0262 OPSAH PESERTA 01/03/1935 KEL. JOHAR BARU III459 AKTIF 0 42,5003171084103350001 01/09/2014

0001341253956 0263 HUSMAYANI PESERTA 26/06/1957 KEL. RAWA SARI460 AKTIF 0 42,5003171056606570003 01/09/2014

0001341253967 0264 SUKARSIH PESERTA 22/07/1962 KEL. RAWA SARI461 AKTIF 0 42,5003171056207620002 01/09/2014

0001341253978 0265 DJUMIARTI PESERTA 10/04/1945 KEL. PISANGAN BARU462 AKTIF 0 42,5003175015004450003 01/09/2014

0001341253991 0267 PONTIAH RESMI PESERTA 19/10/1942 KEL. KAYU MANIS463 AKTIF 0 42,5003175015910420001 01/09/2014

0001341254002 0268 IBRAHIM ARIYANTO PESERTA 15/06/1938 KEL. JATI I464 AKTIF 0 42,5003175021506380005 01/09/2014

0001341254013 0268 ANI SUHENI ISTRI 21/01/1946 KEL. JATI I465 AKTIF 0 42,5003175026101460001 01/09/2014

0001341254024 0269 SITI NURHAEDAH PESERTA 31/12/1949 KEL. MALAKA SARI466 AKTIF 0 42,5003175077112490021 01/09/2014

0001341254035 0270 SUMARNI PESERTA 27/11/1944 KEL. PISANGAN BARU467 AKTIF 0 42,5003175016711440001 01/09/2014

0001341254046 0271 HUSIN RUDI P PESERTA 04/01/1965 KEL. UTAN KAYU UTARA468 AKTIF 0 42,5003175011601094326 01/09/2014

0001341254057 0271 SUHARTINI ISTRI 27/06/1969 KEL. UTAN KAYU UTARA469 AKTIF 0 42,5003175016706690003 01/09/2014

0001341254068 0272 SAMI PESERTA 09/11/1942 KEL. PISANGAN BARU470 AKTIF 0 42,5003175014911420001 01/09/2014

0001341254079 0273 YOOPIE YACOBUS TEROK PESERTA 26/01/1936 KEL. PONDOK KELAPA471 AKTIF 0 42,5003175072601360001 01/09/2014

Page 20 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001341254081 0273 IDA SENGO ISTRI 15/03/1946 KEL. PONDOK KELAPA472 AKTIF 0 42,5003175075503460006 01/09/2014

0001446728286 R.SOEHARTO PESERTA 25/02/1929 KEL. PETAMBURAN473 AKTIF 0 59,5003171072502290001 06/10/2014

0001446729377 NY.SARDJUNI ISTRI 07/07/1947 KEL. PETAMBURAN474 AKTIF 0 59,5003171074707470002 06/10/2014

0001446738142 CHRISTINE RISAKOTTA PESERTA 18/03/1936 KEL. GROGOL UTARA I475 AKTIF 0 42,50006/10/2014

0001446746545 EMPUD PESERTA 08/05/1942 KEC. KEMAYORAN476 AKTIF 0 42,5003171030805420001 06/10/2014

0001446756805 FIENCE MANASE PESERTA 23/02/1942 KEL. SUNGAI BAMBU477 AKTIF 0 59,5003172026302420001 06/10/2014

0001446788349 SUHAERI PESERTA 04/01/1981 KEL. KEBON BAWANG I478 AKTIF 0 42,5003172020401810022 06/10/2014

0001446793301 SUNIAH PESERTA 20/11/1944 KEL. KEBON BAWANG I479 AKTIF 0 42,5003172026011440002 06/10/2014

0001446798082 ROSMAH PESERTA 01/12/1941 KEL. LAGOA480 AKTIF 0 59,5003172034112410004 06/10/2014

0001446815057 SAGIYAN PESERTA 17/11/1958 KEL. SRENGSENG481 AKTIF 0 59,5003173081711580005 06/10/2014

0001446823203 SIGIT PALGUNADI PESERTA 03/06/1966 PEKAYON JAYA482 AKTIF 0 59,5003275040306660013 06/10/2014

0001446842463 LUSTINA PURBA PESERTA 20/06/1956 CIMANGGIS483 AKTIF 0 59,5003276056006560009 06/10/2014

0001446852497 AMELIA PESERTA 17/11/1951 ABADI JAYA484 AKTIF 0 59,5003276055711510001 06/10/2014

0001446858009 AMAN TRI SAPUTRA PESERTA 22/07/1945 SEYEGAN485 AKTIF 0 59,5003404052207450001 06/10/2014

0001446921641 SOEWARTI PESERTA 21/04/1956 CIMANGGIS486 AKTIF 0 59,5003276026104560009 06/10/2014

0001446929943 SOPIAH PESERTA 31/12/1943 KEL. TANJUNG PRIOK487 AKTIF 0 42,5003172027112430019 06/10/2014

0001446937817 SURATMI PESERTA 25/10/1953 KEL. LAGOA488 AKTIF 0 42,5003172036510530003 06/10/2014

0001451973644 DR PARMANTOSETJOHUSODO

PESERTA 12/06/1940 KEL. GROGOL UTARA I489 AKTIF 0 59,5003174051206400003 16/10/2014

0001451979819 SRI HARTATI N PESERTA 15/01/1942 CILEUNGSI490 AKTIF 0 59,5003203145501421405 16/10/2014

0001451981147 ERIKA HUTABARAT PESERTA 17/02/1953 BAKTI JAYA491 AKTIF 0 59,5003276055702530001 16/10/2014

0001451982611 JOCEBETH BAWOTONG PESERTA 28/12/1947 BAKTI JAYA492 AKTIF 0 59,5003276056812470001 16/10/2014

0001451984016 MARDJOKO SE PESERTA 05/08/1955 COLOMADU I493 AKTIF 0 59,5003313120508550003 16/10/2014

0001451984365 BETTY TAKIM ISTRI 19/06/1961 COLOMADU I494 AKTIF 0 59,5003313125906610001 16/10/2014

Page 21 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001451986457 NISMAN PESERTA 15/12/1955 CIPONDOH495 AKTIF 0 59,5003671051512550003 16/10/2014

0001451986907 FUASIH ISTRI 30/12/1962 CIPONDOH496 AKTIF 0 59,5003671057012620002 16/10/2014

0001451988437 YULIANA COLOAY PESERTA 28/09/1949 TUGU497 AKTIF 0 59,5003276026809490003 16/10/2014

0001451989361 ARIFIN AMIR PESERTA 02/04/1944 BOJONG GEDE498 AKTIF 0 59,5003201130204440001 16/10/2014

0001451989787 DESMINAR.S ISTRI 10/10/1949 BOJONG GEDE499 AKTIF 0 59,5003201135010490001 16/10/2014

0001451991756 H.AWANG DJUARSAH PESERTA 09/07/1954 TELUK PUCUNG500 AKTIF 0 59,5003275030907540019 16/10/2014

0001451992533 HJ.NURAENI ISTRI 09/09/1959 TELUK PUCUNG501 AKTIF 0 59,5003275034909590020 16/10/2014

0001451993793 MUHAMAD APIN SUGANDA PESERTA 04/07/1949 BABELAN I502 AKTIF 0 59,5003216020407490007 16/10/2014

0001451994129 MURTINAH ISTRI 25/11/1957 BABELAN I503 AKTIF 0 59,5003216026511570002 16/10/2014

0001451996188 DRASUHATRIDJAS S K EP PESERTA 01/05/1958 DURENJAYA504 AKTIF 0 59,5003275014105580028 16/10/2014

0001451999621 MANAN EFENDI PESERTA 08/03/1950 DR. DAHLIA/KLINIK SUKAMAJU505 AKTIF 0 59,5003276050803500001 16/10/2014

0001451999946 SARIFAH ISTRI 10/04/1957 DR. DAHLIA/KLINIK SUKAMAJU506 AKTIF 0 59,5003276055004570007 16/10/2014

0001452000879 DJUMIRIN PESERTA 16/04/1949 AREN JAYA507 AKTIF 0 59,5003275011604490008 16/10/2014

0001452001116 SUHARTI ISTRI 17/05/1947 AREN JAYA508 AKTIF 0 59,5003275015705470005 16/10/2014

0001452006707 SITI TOENSIJAH PESERTA 29/03/1933 BAKTI JAYA509 AKTIF 0 59,5003276056293330001 16/10/2014

0001452008024 ABDUL RASYID PESERTA 28/10/1942 BAKTI JAYA510 AKTIF 0 59,5003276052810420006 16/10/2014

0001452011117 HJ. POPON ANDAWATI PESERTA 03/08/1950 BOJONGLOA511 AKTIF 0 59,5003204284308500002 16/10/2014

0001452014594 SLAMET SUTAMTO PESERTA 06/10/1952 DR. DAHLIA/KLINIK SUKAMAJU512 AKTIF 0 59,5003276050610520001 16/10/2014

0001452015988 RUDDY SULU RUNTU PESERTA 26/03/1956 TELUK PUCUNG513 AKTIF 0 59,5003275032603560011 16/10/2014

0001452016506 IVONNE LENGKONG ISTRI 08/10/1961 TELUK PUCUNG514 AKTIF 0 59,5003275034810610014 16/10/2014

0001452017733 SUDIBYO EKO BUDIARSO,BA PESERTA 06/05/1950 BOJONG GEDE515 AKTIF 0 59,5003201130605500001 16/10/2014

0001452018025 SITI KHALIJAH ISTRI 23/04/1963 BOJONG GEDE516 AKTIF 0 59,5003201136304630004 16/10/2014

0001452019847 NYAI TARI SARINAH. HJ PESERTA 31/12/1954 CIKARANG517 AKTIF 0 59,5003216087112540002 16/10/2014

0001452021478 HJ.SUDIRAH PESERTA 05/05/1959 CIKARANG518 AKTIF 0 59,5003216084505590003 16/10/2014

Page 22 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452023223 WATI PESERTA 10/10/1960 DURENJAYA519 AKTIF 0 59,5003275015010600047 16/10/2014

0001452026845 SRI NING MARDIYANTI PESERTA 08/01/1951 MEKARSARI520 AKTIF 0 59,5003276024801610003 16/10/2014

0001452028882 ESTHER A.WOY PESERTA 12/12/1957 BAKTI JAYA521 AKTIF 0 59,5003276055212570016 16/10/2014

0001452030333 MIHARJA RIKIN PESERTA 10/09/1952 Klinik SAPTA MITRA PONDOK GEDE522 AKTIF 0 59,5003275121009520003 16/10/2014

0001452030849 YUMINAH NIMAN ISTRI 15/11/1953 Klinik SAPTA MITRA PONDOK GEDE523 AKTIF 0 59,5003275125511530004 16/10/2014

0001452035182 ABDUL RACHMAN PESERTA 29/11/1944 AREN JAYA524 AKTIF 0 59,5003275012911440003 16/10/2014

0001452035463 SITI PARWITI ISTRI 31/12/1952 AREN JAYA525 AKTIF 0 59,5003275017112520033 16/10/2014

0001452036587 SURADI PESERTA 16/09/1956 JATIMULYA526 AKTIF 0 59,5003216061609560005 16/10/2014

0001452037184 ESTI SULASTRI ISTRI 25/07/1961 JATIMULYA527 AKTIF 0 59,5003216066507610003 16/10/2014

0001452038319 AGUS MURAYA PESERTA 27/02/1958 DURENJAYA528 AKTIF 0 59,5003275012702580012 16/10/2014

0001452038782 SUPRIYATINI ISTRI 18/01/1966 DURENJAYA529 AKTIF 0 59,5003275015801660007 16/10/2014

0001452040525 BAMBANG SUHARSO PESERTA 14/08/1953 KEL. KRAMAT JATI I530 AKTIF 0 59,5003175041408530002 16/10/2014

0001452040896 ELLYANA DUANI ISTRI 16/04/1956 KEL. KRAMAT JATI I531 AKTIF 0 59,5003175045604560001 16/10/2014

0001452043833 KOMUSIAM PESERTA 16/01/1958 LEUWILIANG532 AKTIF 0 59,5003201141601580001 16/10/2014

0001452044226 ANITA ROCHYATI.S ISTRI 03/12/1962 LEUWILIANG533 AKTIF 0 59,5003201144312620001 16/10/2014

0001452046544 ARSIAH PESERTA 24/04/1958 BAKTI JAYA534 AKTIF 0 59,5003276056404580006 16/10/2014

0001452048085 HJ. NURSITI HIDAYATI PESERTA 19/09/1954 CIPADU535 AKTIF 0 59,5003671135909530002 16/10/2014

0001452049514 DRS KUSNAN SUDJA'I PESERTA 27/12/1943 LARANGAN UTARA536 AKTIF 0 59,5003174062712430002 16/10/2014

0001452050807 D A R Y A T U N PESERTA 24/01/1964 KEL. KOTA BAMBU UTARA537 AKTIF 0 59,5003173076401640005 16/10/2014

0001452052912 SRI ISMIYATI ISTRI 13/01/1962 KEL. KOTA BAMBU UTARA538 AKTIF 0 59,5003671065301620003 16/10/2014

0001452055285 ALAMSYAH PASARIBU PESERTA 26/08/1954 LALADON539 AKTIF 0 59,5003201292608540001 16/10/2014

0001452055847 AGUSTINI RAHMAH ISTRI 17/08/1958 LALADON540 AKTIF 0 59,5003201295708580004 16/10/2014

0001452060461 AGUSTINE PESERTA 05/08/1959 KUNCIRAN541 AKTIF 0 59,5003671140508590005 16/10/2014

0001452063069 BAMBANG TRI SUJONO PESERTA 05/11/1952 PONDOK PUCUNG542 AKTIF 0 59,5003603240511520001 16/10/2014

Page 23 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452064307 M.M.SUNARSIH PESERTA 13/12/1942 BP Thamrin Serdang (JST)543 AKTIF 0 59,5003171035312420001 16/10/2014

0001452065321 ALVIN PUTRA WARDHANU PESERTA 11/01/2010 BOJONGSARI544 AKTIF 0 59,5003276111101100003 16/10/2014

0001452066118 SUTIRMAN PESERTA 30/04/1959 LARANGAN UTARA545 AKTIF 0 59,5003671133004590003 16/10/2014

0001452066658 MUSRIPAH ISTRI 28/11/1961 LARANGAN UTARA546 AKTIF 0 59,5003671136811610005 16/10/2014

0001452068201 RAMLI PESERTA 12/08/1954 KEC. MENTENG547 AKTIF 0 59,5003171061208540002 16/10/2014

0001452068559 TJITJIH SUWARSIH ISTRI 22/02/1957 KEC. MENTENG548 AKTIF 0 59,5003171066202570001 16/10/2014

0001452070708 TISNAWATI PESERTA 20/12/1956 BINONG549 AKTIF 0 59,5003603176012560001 16/10/2014

0001452072407 DRS. JENAL MIFTAH, SKM PESERTA 03/01/1963 PONDOK BENDA550 AKTIF 0 59,50016/10/2014

0001452076615 H.M.YUSUF PESERTA 04/04/1934 KEL. KAYU PUTIH551 AKTIF 0 59,5003175020404340001 16/10/2014

0001452078033 HARIJATMI BUDI RAHAYU PESERTA 06/12/1952 LARANGAN552 AKTIF 0 59,5003671134612520002 16/10/2014

0001452084028 HJ. MURSINAH PESERTA 28/08/1938 KEL. KAYU PUTIH553 AKTIF 0 59,5003176026808380001 16/10/2014

0001452084851 SEHATINA BARUS PESERTA 11/05/1954 CIPADU554 AKTIF 0 59,5003671135105540001 16/10/2014

0001452086651 NINING HENING PRAMESTY PESERTA 15/06/1958 PAMULANG555 AKTIF 0 59,5003674060302109023 16/10/2014

0001452088181 NENY SUMARNI PESERTA 30/09/1950 CILEUBUT556 AKTIF 0 59,5003201047009500001 16/10/2014

0001452089272 RACHMATIAH PESERTA 28/11/1958 JATIBENING557 AKTIF 0 59,5003275086811580017 16/10/2014

0001452090611 EDDY YANTO PESERTA 22/02/1952 KLINIK PALA MEDIKA558 AKTIF 0 59,5003276062202520003 16/10/2014

0001452091522 ARI ASTUTI ISTRI 12/09/1954 KLINIK PALA MEDIKA559 AKTIF 0 59,5003276065209540001 16/10/2014

0001452094525 SAHANG J T HUTAGALUNG PESERTA 15/05/1937 PKM KEC. GROGOL PETAMBURAN560 AKTIF 0 59,5003173021505370002 16/10/2014

0001452094942 ASNATH NAPITUPULU ISTRI 10/03/1951 PKM KEC. GROGOL PETAMBURAN561 AKTIF 0 59,5003173025003510006 16/10/2014

0001452097067 AMINAH PESERTA 11/12/1944 AREN JAYA562 AKTIF 0 59,5003275015112440000 16/10/2014

0001452097866 YUSMIATI BOER PESERTA 12/05/1957 AREN JAYA563 AKTIF 0 59,5003275015205570021 16/10/2014

0001452100331 ANTONIUS TONY BAMBANG.P PESERTA 03/10/1952 PONDOK KACANG TIMUR564 AKTIF 0 59,5003674030310520001 16/10/2014

0001452101207 C. KATHARINA PESERTA 21/01/1956 PONDOK KACANG TIMUR565 AKTIF 0 59,5003674036101560004 16/10/2014

0001452104482 SINTO PESERTA 12/12/1958 KEL. DURI KOSAMBI I566 AKTIF 0 59,50016/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452105966 RUDJITO PESERTA 09/11/1950 RAWA TEMBAGA567 AKTIF 0 59,5003275040911500002 16/10/2014

0001452106337 SRI SURYATI ISTRI 08/08/1958 RAWA TEMBAGA568 AKTIF 0 59,5003275044808580017 16/10/2014

0001452108418 WARDI SYAMSUDDIN PESERTA 05/01/1948 PONDOK AREN569 AKTIF 0 59,50016/10/2014

0001452108892 NIRWANA ISTRI 30/09/1950 PONDOK AREN570 AKTIF 0 59,50016/10/2014

0001452111107 ACIM AL TASIM PESERTA 03/02/1952 DARMARAJA571 AKTIF 0 59,5003211030302520002 16/10/2014

0001452111513 CICIH BARIAH ISTRI 13/08/1964 DARMARAJA572 AKTIF 0 59,5003211035308640004 16/10/2014

0001452112997 KOMINA SARAGIH PESERTA 10/10/1949 KEC. CENGKARENG573 AKTIF 0 59,5003173015010490002 16/10/2014

0001452115563 SUMAENI PESERTA 28/08/1967 KELAPA DUA574 AKTIF 0 59,5003603286808670001 16/10/2014

0001452121029 HJ.SUTINAH PESERTA 16/11/1948 KEL. KEBON BAWANG I575 AKTIF 0 59,50016/10/2014

0001452122032 HJ.YUNIAR PESERTA 06/06/1953 JATIWARNA576 AKTIF 0 59,5003275124606530001 16/10/2014

0001452125889 IDA MAHIDA PESERTA 20/12/1950 RANGKAPAN JAYA577 AKTIF 0 59,5003276016012500001 16/10/2014

0001452126835 R.SOELAXMO WIDODO PESERTA 26/01/1950 KEC. MATRAMAN578 AKTIF 0 59,5003175012601500002 16/10/2014

0001452127667 NY TUTI SUDARTINI ISTRI 30/07/1958 KEC. MATRAMAN579 AKTIF 0 59,5003175017007580001 16/10/2014

0001452130391 MUFIZAR ILYAS PESERTA 23/05/1958 BOJONG GEDE580 AKTIF 0 59,5003201132305580001 16/10/2014

0001452134002 NY. F E LENGKEY PESERTA 30/12/1935 KEL. LAGOA581 AKTIF 0 59,5003172037012350006 16/10/2014

0001452136623 RODIAH SALSAWATI PESERTA 05/05/1940 KEL. MANGGARAI582 AKTIF 0 59,5003174012501110051 16/10/2014

0001452137602 SIMON TUHUMENA PESERTA 19/09/1935 PONDOK BENDA583 AKTIF 0 59,5003674061909350002 16/10/2014

0001452138197 D. NOORTJE SALENDU ISTRI 26/11/1954 PONDOK BENDA584 AKTIF 0 59,5003674066611540001 16/10/2014

0001452139536 JOHN DAULIMA PESERTA 14/10/1938 BAKTI JAYA585 AKTIF 0 59,5003276051410380001 16/10/2014

0001452139975 INEKE DAULIMA ISTRI 20/03/1945 BAKTI JAYA586 AKTIF 0 59,5003276056003450004 16/10/2014

0001452141854 JOKE SIMANJUNTAK SENDUK PESERTA 14/01/1943 KEL. SUNTER AGUNG I587 AKTIF 0 59,5003172025401430001 16/10/2014

0001452143158 FREDDY TOMASOA PESERTA 20/02/1942 TAJUR HALANG588 AKTIF 0 59,5003201372002420003 16/10/2014

0001452145443 ELISABETH TOMASOA P ISTRI 14/10/1962 TAJUR HALANG589 AKTIF 0 59,50016/10/2014

0001452148075 PANTAS SITOMPUL PESERTA 13/07/1934 KEL. LAGOA590 AKTIF 0 59,5003172031307340001 16/10/2014

Page 25 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452148345 ANNA MARIE MANGENTE ISTRI 12/02/1939 KEL. LAGOA591 AKTIF 0 59,5003172035202390002 16/10/2014

0001452149605 ULI BASA PINTORIASIHOMBING

PESERTA 24/08/1947 KEL. PASEBAN592 AKTIF 0 59,5003171046408470001 16/10/2014

0001452151034 M.HAMILI PESERTA 06/06/1956 PANCORAN MAS593 AKTIF 0 59,5003276010606560006 16/10/2014

0001452151372 AAN NURLAILA ISTRI 31/03/1960 PANCORAN MAS594 AKTIF 0 59,5003276017103600002 16/10/2014

0001452152619 DJAIYAR PESERTA 30/06/1942 BAKTI JAYA595 AKTIF 0 59,5003276057006420001 16/10/2014

0001452154781 ARISMAN PESERTA 15/12/1958 KEDUNG BADAK596 AKTIF 0 59,5003271061512280003 16/10/2014

0001452156502 SUGIHARSI ISTRI 14/08/1944 KEDUNG BADAK597 AKTIF 0 59,5003271065408440001 16/10/2014

0001452157874 MOHAMMAD FUAD PESERTA 27/07/1951 BAKTI JAYA598 AKTIF 0 59,5003276052707510003 16/10/2014

0001452158278 FARIDAH ISTRI 10/03/1961 BAKTI JAYA599 AKTIF 0 59,5003276055003610003 16/10/2014

0001452161687 NURUL KOMAR PESERTA 27/02/1955 TELUK PUCUNG600 AKTIF 0 59,5003275036702550012 16/10/2014

0001452162363 MOCH SALEH PESERTA 08/02/1940 SETU601 AKTIF 0 59,5003674040802400001 16/10/2014

0001452163779 SITI ISNAENI RIAH ISTRI 08/06/1943 SETU602 AKTIF 0 59,5003674044808430003 16/10/2014

0001452166209 MARTINAH PESERTA 31/12/1940 BOJONG RAWALUMBU603 AKTIF 0 59,5003275057112400016 16/10/2014

0001452167561 I KETUT WINDHU PESERTA 30/12/1955 BAKTI JAYA604 AKTIF 0 59,5003276053012550006 16/10/2014

0001452167831 YESNI MARSUSI ISTRI 01/01/1955 BAKTI JAYA605 AKTIF 0 59,5003276054101550009 16/10/2014

0001452170226 RATNA NINGSIH LAGONAH PESERTA 11/11/1954 MEKARSARI606 AKTIF 0 59,5003276025111540009 16/10/2014

0001452171295 WAAD RAKJANI PESERTA 14/02/1938 JATIASIH607 AKTIF 0 59,5003275091402380006 16/10/2014

0001452172588 SRIE UTAMI WAAD ISTRI 01/07/1947 JATIASIH608 AKTIF 0 59,5003275094107470035 16/10/2014

0001452174243 SUWARTO PESERTA 12/06/1937 PEJAGOAN609 AKTIF 0 59,5003305131206370001 16/10/2014

0001452174693 SUTARNI ISTRI 18/11/1943 PEJAGOAN610 AKTIF 0 59,5003305135811430001 16/10/2014

0001452181915 CAPT.B.SUMARDI MSC PESERTA 01/06/1955 KEL. KLP GADING TIMUR II611 AKTIF 0 59,5003172060106550002 16/10/2014

0001452182477 LENNY KUSUMA ISTRI 27/11/1955 KEL. KLP GADING TIMUR II612 AKTIF 0 59,5003172066711550001 16/10/2014

0001452183862 A.C.H.H.LATUKOLAN BETTY PESERTA 09/03/1943 BAKTI JAYA613 AKTIF 0 59,5003276054903430002 16/10/2014

Page 26 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452185651 SINTAN PESERTA 06/06/1947 KEC. JOHAR BARU614 AKTIF 0 59,5003171080502110016 16/10/2014

0001452186933 H.MAMAN DARMANSYAH PESERTA 07/03/1958 JATIMULYA615 AKTIF 0 59,50016/10/2014

0001452187449 SUKARDINAH SUBONTO ISTRI 15/03/1958 JATIMULYA616 AKTIF 0 59,5003216065503580016 16/10/2014

0001452186977 SUWIRUDIN PESERTA 12/01/1952 CIBARUSAH617 AKTIF 0 42,5003216221201620004 16/10/2014

0001452195088 HASANAH ISTRI 15/06/1964 CIBARUSAH618 AKTIF 0 42,50016/10/2014

0001452189475 HERMINE J PANGGABEAN SH PESERTA 04/10/1943 KEL. KLP GADING TIMUR I619 AKTIF 0 59,5003172064410430001 16/10/2014

0001452192772 SUHARTO PESERTA 06/10/1962 PONDOK KACANG TIMUR620 AKTIF 0 59,5003674030610620005 16/10/2014

0001452206092 ERNI LESTARI ISTRI 11/08/1968 PONDOK KACANG TIMUR621 AKTIF 0 59,5003674035108680006 16/10/2014

0001452199004 PAULA TAKENDARE PESERTA 02/04/1940 PANCORAN MAS622 AKTIF 0 42,5003276014204400005 16/10/2014

0001452208511 ABD. MADYID PESERTA 12/05/1951 MEKAR SARI623 AKTIF 0 42,5003216061205510006 16/10/2014

0001452210467 SYOFIARTI ISTRI 26/06/1956 MEKAR SARI624 AKTIF 0 42,50016/10/2014

0001452210535 ASRIL UMAR PESERTA 24/09/1936 BINTARA JAYA625 AKTIF 0 59,50016/10/2014

0001452211323 ALIDA DJOESAN ISTRI 15/12/1944 BINTARA JAYA626 AKTIF 0 59,50016/10/2014

0001452213617 FERRY DIDI PUNU PESERTA 03/01/1958 CIBINONG627 AKTIF 0 59,5003201010301580007 16/10/2014

0001452214146 LINDA SUALANG ISTRI 05/07/1962 CIBINONG628 AKTIF 0 59,5003201014507620004 16/10/2014

0001452215913 I GUSTI AYU SANTI PESERTA 21/03/1957 BAKTI JAYA629 AKTIF 0 59,5003276056103570001 16/10/2014

0001452216745 SURTIMAH TAMPUBOLON PESERTA 16/03/1956 PANCORAN MAS630 AKTIF 0 59,5003276015603560004 16/10/2014

0001452219693 ABDUL RADJAK HAMID PESERTA 31/12/1938 KALIABANG TENGAH631 AKTIF 0 42,5003275033112380012 16/10/2014

0001452220334 DAHLIA RADJAK ISTRI 30/10/1947 KALIABANG TENGAH632 AKTIF 0 42,5003275037010470005 16/10/2014

0001452219884 MALTAN RIKIN PESERTA 29/02/1956 JATIMAKMUR633 AKTIF 0 59,5003275122902560004 16/10/2014

0001452220481 YUNA HANUM ISTRI 01/01/1961 JATIMAKMUR634 AKTIF 0 59,5003275124101610010 16/10/2014

0001452221504 PUDJI M.N KANSIL PESERTA 26/03/1957 BAKTI JAYA635 AKTIF 0 59,5003276056603570004 16/10/2014

0001452222562 ROCHIMAH PESERTA 28/10/1954 KEL. MENTENG DALAM I636 AKTIF 0 59,5003174016810540009 16/10/2014

0001452225497 SOENARYO PESERTA 18/06/1953 SETU637 AKTIF 0 59,5003603361806530001 16/10/2014

Page 27 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452226667 SOETINI ISTRI 03/03/1959 SETU638 AKTIF 0 59,5003603364303590001 16/10/2014

0001452227692 BARKAH PESERTA 09/09/1947 KEL. KALI BARU639 AKTIF 0 59,5003275064909470002 16/10/2014

0001452229942 NINING HENING PRANESTI PESERTA 15/06/1958 PAMULANG640 AKTIF 0 59,5003674065506580008 16/10/2014

0001452230482 M.J.F RUGEBREGT PESERTA 09/09/1935 BAKTI JAYA641 AKTIF 0 42,5003276050909350003 16/10/2014

0001452231145 M.B. MAMANGKEY ISTRI 12/10/1944 BAKTI JAYA642 AKTIF 0 42,5003276055210440003 16/10/2014

0001452231235 H. JAYA SAPUTRA PESERTA 12/08/1949 CIPADU643 AKTIF 0 59,5003671131208490002 16/10/2014

0001452233766 FARIDA PESERTA 15/10/1975 SETIA MEKAR644 AKTIF 0 42,5003216065510750031 16/10/2014

0001452236758 EMID ENDJUM PESERTA 13/09/1951 BANTARGEBANG645 AKTIF 0 42,5003275071309510002 16/10/2014

0001452237399 ILLOH ISTRI 20/04/1963 BANTARGEBANG646 AKTIF 0 42,5003275076004630006 16/10/2014

0001452238176 SEDJO PESERTA 04/06/1955 CILEDUG647 AKTIF 0 59,5003671060406550001 16/10/2014

0001452239741 MAGDALENA PESERTA 11/02/1941 JATIWARNA648 AKTIF 0 42,5003275125102410001 16/10/2014

0001452241192 AI SURTIKA PESERTA 15/07/1957 PAMULANG649 AKTIF 0 59,5003603255507570003 16/10/2014

0001452242981 MARDIK, BSC. PESERTA 17/08/1945 CIPADU650 AKTIF 0 59,5003671131708450002 16/10/2014

0001452243497 MARIAM ISTRI 22/01/1951 CIPADU651 AKTIF 0 59,5003671136201510001 16/10/2014

0001452247389 ABU SURAHMAN PESERTA 09/07/1961 BINONG652 AKTIF 0 59,5003603170907610002 16/10/2014

0001452249358 WAGINO, SE PESERTA 05/03/1954 PONDOK PUCUNG653 AKTIF 0 59,5003603240503540002 16/10/2014

0001452252295 NELTY ISTRI 19/04/1954 PONDOK PUCUNG654 AKTIF 0 59,5003603245904540001 16/10/2014

0001452251294 CHRISTINA LAKENA PESERTA 27/06/1945 SUKMAJAYA655 AKTIF 0 42,5003276056706450002 16/10/2014

0001452253599 MEUTIA RANI PESERTA 31/07/1956 PONDOK AREN656 AKTIF 0 59,5003674037107560003 16/10/2014

0001452253869 DJASEM PESERTA 23/12/1950 BINTARA JAYA657 AKTIF 0 42,5003275026312500007 16/10/2014

0001452256751 WA MASIRA PESERTA 13/12/1948 SEROJA658 AKTIF 0 42,5003275035312480008 16/10/2014

0001452262149 SUYATI PESERTA 07/11/1949 CIPADU659 AKTIF 0 59,5003671134711490001 16/10/2014

0001452265356 MUSTIAROH PESERTA 05/10/1956 DRAMAGA660 AKTIF 0 42,50016/10/2014

0001452282502 SUYATTO PESERTA 31/12/1956 LARANGAN UTARA661 AKTIF 0 59,5003671133112560002 16/10/2014

Page 28 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452282862 AGATHA SUPARNI ISTRI 14/08/1963 LARANGAN UTARA662 AKTIF 0 59,5003671135408630001 16/10/2014

0001452284908 SIMON FEOH ANIN PESERTA 16/08/1955 BOGOR UTARA663 AKTIF 0 42,5003271051608550005 16/10/2014

0001452287103 SURMIATI FEOH ANIN ISTRI 05/09/1963 BOGOR UTARA664 AKTIF 0 42,50016/10/2014

0001452286552 ALICE GERALDINE SIMON PESERTA 06/08/1954 PONDOK PUCUNG665 AKTIF 0 59,5003603244608540002 16/10/2014

0001452290117 H.SURITNO PESERTA 02/02/1953 MANGUNJAYA666 AKTIF 0 42,5003216060202530004 16/10/2014

0001452291243 HJ.TRI PUJI ASTUTI ISTRI 09/06/1962 MANGUNJAYA667 AKTIF 0 42,5003216064906620007 16/10/2014

0001452293987 E T T I PESERTA 04/06/1943 CIKARANG668 AKTIF 0 42,5003216194406430002 16/10/2014

0001452294898 NANI RUKMINI PESERTA 30/06/1952 RENGAS669 AKTIF 0 59,5003603347006520001 16/10/2014

0001452296777 H. CHAIRUL DJAMAL PESERTA 01/05/1949 RAWA BUNTU670 AKTIF 0 59,5003674010105490001 16/10/2014

0001452297071 HJ. SRI HARYATI ISTRI 14/06/1953 RAWA BUNTU671 AKTIF 0 59,5003674015406530003 16/10/2014

0001452296867 ALBERT LOMBONAUNG PESERTA 20/04/1952 PABUARAN INDAH672 AKTIF 0 42,5003201012004520003 16/10/2014

0001452297554 NURJANAH ISTRI 15/12/1959 PABUARAN INDAH673 AKTIF 0 42,5003201015512590003 16/10/2014

0001452351227 HARTADI PESERTA 31/03/1954 CILEDUG674 AKTIF 0 59,50016/10/2014

0001452351407 YUN HIDAYATI ISTRI 31/10/1959 CILEDUG675 AKTIF 0 59,5003671067110590001 16/10/2014

0001452352072 YUYUN PESERTA 17/04/1967 LARANGAN UTARA676 AKTIF 0 59,50016/10/2014

0001452353376 ALOYSIUS R.G PESERTA 04/09/1948 PAMULANG677 AKTIF 0 59,5003603250409480001 16/10/2014

0001452354039 MARIA ROHANI B. ISTRI 01/12/1951 PAMULANG678 AKTIF 0 59,5003603254112510001 16/10/2014

0001452355345 SUNARTI PESERTA 25/11/1949 AREN JAYA679 AKTIF 0 42,5003275016511490005 16/10/2014

0001452356807 SARAH AMINAH PESERTA 20/12/1940 BAKTI JAYA680 AKTIF 0 42,5003276056012400002 16/10/2014

0001452357303 EUIS NETTY SURYATI PESERTA 17/07/1958 BINONG681 AKTIF 0 59,5003603175707580003 16/10/2014

0001452358304 ARENS MOHA PESERTA 15/10/1945 TELUK PUCUNG682 AKTIF 0 42,5003275031510450004 16/10/2014

0001452358967 SOPHIA BAKARI ISTRI 01/12/1957 TELUK PUCUNG683 AKTIF 0 42,5003275034112570006 16/10/2014

0001452358833 NANI SUMARNI PESERTA 15/03/1958 JATIUWUNG684 AKTIF 0 59,5003671092908071034 16/10/2014

0001452359889 HJ. TATI SUGIARTI PESERTA 26/06/1958 JATIUWUNG685 AKTIF 0 59,5003603286606580002 16/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452360802 SADIAH PESERTA 05/05/1952 CIPAYUNG686 AKTIF 0 42,5003201264505520001 16/10/2014

0001452360835 A.SUMIYEM PESERTA 31/12/1950 PONDOK PUCUNG687 AKTIF 0 59,5003603247112500003 16/10/2014

0001452361432 MASDIANA HUTAGALUNG PESERTA 30/03/1958 PAMULANG688 AKTIF 0 59,5003674067003580002 16/10/2014

0001452361847 TATI HARTATI PESERTA 19/04/1958 JATIUWUNG689 AKTIF 0 59,5003603175904580003 16/10/2014

0001452362174 C.E.M.TUMUNDO LENGKONG PESERTA 06/10/1942 BAKTI JAYA690 AKTIF 0 42,5003276054610420001 16/10/2014

0001452362477 DAFRIL ADLIN PESERTA 22/04/1954 BINONG691 AKTIF 0 59,5003603172204540001 16/10/2014

0001452363074 HAMDANI PESERTA 30/12/1954 BOJONG NANGKA692 AKTIF 0 59,5003603283012540003 16/10/2014

0001452363715 TATI HERAWATI ISTRI 03/04/1967 BOJONG NANGKA693 AKTIF 0 59,5003603284304670003 16/10/2014

0001452363985 NURSIAH PESERTA 05/05/1945 PABUARAN INDAH694 AKTIF 0 42,5003201014505450007 16/10/2014

0001452365223 SUMARYONO PESERTA 18/05/1958 LARANGAN UTARA695 AKTIF 0 42,5003671131805580002 16/10/2014

0001452365752 INA SULASTRI ISTRI 02/08/1962 LARANGAN UTARA696 AKTIF 0 42,5003671134208620002 16/10/2014

0001452366731 SUMEISEY RICHARDINE H PESERTA 29/03/1937 CIPUTAT697 AKTIF 0 59,5003674046903370003 16/10/2014

0001452367135 DJUBAEDAH PESERTA 10/01/1952 KEL. PADEMANGAN BARAT I698 AKTIF 0 42,5003172055001520005 16/10/2014

0001452367517 YUSMAWARTI PESERTA 16/07/1956 PONDOK KACANG TIMUR699 AKTIF 0 59,50016/10/2014

0001452368068 HJ NINGRUM PESERTA 27/11/1943 KEL. KOTA BAMBU SELATAN700 AKTIF 0 42,5003173076711430007 16/10/2014

0001452368147 LOESSIANA PESERTA 26/03/1947 KARANG TENGAH701 AKTIF 0 59,5003671126603470001 16/10/2014

0001452369069 MAIMUNAH PESERTA 20/06/1955 KEL. KRAMAT JATI I702 AKTIF 0 42,5003175046006550006 16/10/2014

0001452370026 TRI WALUYO PESERTA 05/05/1956 BENDA BARU703 AKTIF 0 59,5003674060505560020 16/10/2014

0001452370779 MAMI SULASMI ISTRI 08/07/1958 BENDA BARU704 AKTIF 0 59,5003674064897580010 16/10/2014

0001452370601 DJONNIE PIETER KEREH PESERTA 18/02/1958 PENGASINAN705 AKTIF 0 42,5003275051802580005 16/10/2014

0001452370961 VENNY Y MOUNTUNG ISTRI 22/07/1963 PENGASINAN706 AKTIF 0 42,5003275056207630005 16/10/2014

0001452372311 H.DJAMIDDIN PESERTA 13/12/1943 KEC. TANJUNG PRIOK707 AKTIF 0 42,5003172021312430004 16/10/2014

0001452372794 SITTI SYAMSIAH ISTRI 22/12/1952 KEC. TANJUNG PRIOK708 AKTIF 0 42,5003172026212520001 16/10/2014

0001452373964 SURADJI PESERTA 09/10/1958 KEL. JAGAKARSA I709 AKTIF 0 42,5003174090910580002 16/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452374785 WARSIAH BIN JAYA PESERTA 01/12/1954 KEL. KEBON BAWANG I710 AKTIF 0 42,5003172024112540004 16/10/2014

0001452379713 H. IING SOLIHIN PESERTA 11/08/1949 KADUHEJO711 AKTIF 0 42,5003601191108490002 16/10/2014

0001452380049 HJ. E. SUNARTI ISTRI 05/02/1959 KADUHEJO712 AKTIF 0 42,5003601194502590001 16/10/2014

0001452383223 KIRYANTO PESERTA 11/05/1954 KUNCIRAN713 AKTIF 0 59,5003671111105540002 16/10/2014

0001452384011 SITI AMINAH ISTRI 01/01/1962 KUNCIRAN714 AKTIF 0 59,5003671114101620001 16/10/2014

0001452383706 MUHAMAD MADO PESERTA 07/05/1956 KEL. SEMPER BARAT I715 AKTIF 0 42,5003172040705560002 16/10/2014

0001452384325 IDA FARIDA ISTRI 19/12/1959 KEL. SEMPER BARAT I716 AKTIF 0 42,5003172045912590002 16/10/2014

0001452384999 TENTREM RAHAYU PESERTA 27/01/1952 CIPADU717 AKTIF 0 59,5003671136701520001 16/10/2014

0001452386046 AMBOTUO TAEPO PESERTA 13/03/1957 TAMBUN718 AKTIF 0 42,5003216051303570002 16/10/2014

0001452386204 SYAFE'I SA'ID PESERTA 29/09/1948 WAY HALIM719 AKTIF 0 59,5001871012909480001 16/10/2014

0001452386518 ZURIAH ISTRI 05/12/1952 WAY HALIM720 AKTIF 0 59,5001871014512520001 16/10/2014

0001452387587 MAESAROH PESERTA 01/01/1953 KEL. WARAKAS721 AKTIF 0 59,5003172024101530013 16/10/2014

0001452388937 DRA TIEM FATIMAH PESERTA 02/04/1954 KEL. RAWA SARI722 AKTIF 0 59,5003171054204540002 16/10/2014

0001452389545 EDWARD WATTIMURY PESERTA 08/01/1937 KEC. TANJUNG PRIOK723 AKTIF 0 59,50016/10/2014

0001452390153 SITI JUWALIYAH PESERTA 28/06/1968 KEL. LAGOA724 AKTIF 0 59,5003172036806680003 16/10/2014

0001452392717 JAJAT DURADJAT PESERTA 03/10/1949 KLINIK AVIATI725 AKTIF 0 59,50016/10/2014

0001452394023 AGUSTINE PESERTA 07/08/1963 TAMBUN726 AKTIF 0 42,50016/10/2014

0001452394978 SUHIEF SUGIANA PESERTA 21/11/1942 MANGUNJAYA727 AKTIF 0 59,5003216062111420001 16/10/2014

0001452395193 ZAINAL TJABBA PESERTA 05/06/1953 KEL. RAWA BADAK II728 AKTIF 0 42,5003172030506530006 16/10/2014

0001452395608 SUNARTI ISTRI 03/05/1961 KEL. RAWA BADAK II729 AKTIF 0 42,5003172034305610002 16/10/2014

0001452395981 ROHIBI MACHMUD PESERTA 24/01/1958 TEGAL GUNDIL730 AKTIF 0 59,5003271052401580003 16/10/2014

0001452396317 LILIS HERAWATY,SE ISTRI 13/11/1962 TEGAL GUNDIL731 AKTIF 0 59,50016/10/2014

0001452396767 ASDJAYA PESERTA 25/05/1934 KEL. WARAKAS732 AKTIF 0 42,5003172022505340001 16/10/2014

0001452397239 MARDIYAH ISTRI 19/12/1944 KEL. WARAKAS733 AKTIF 0 42,5003172025912440001 16/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452397724 ADE ARYANI PESERTA 10/10/1956 WISMA JAYA734 AKTIF 0 59,5003275015010560031 16/10/2014

0001452398343 ALI RUSLAN PESERTA 16/08/1945 Klinik Semper Ssma Mdika (JST)735 AKTIF 0 42,5003172031608450002 16/10/2014

0001452399535 WASIMUN PESERTA 20/03/1958 KOTA BARU736 AKTIF 0 59,5003275022003580004 16/10/2014

0001452399794 SUPIAH ISTRI 01/06/1963 KOTA BARU737 AKTIF 0 59,5003275024106630021 16/10/2014

0001452400615 H. SUMARDI PESERTA 06/05/1953 WISMA JAYA738 AKTIF 0 42,5003275010605530021 16/10/2014

0001452401177 HJ ALIMAH ISTRI 23/03/1954 WISMA JAYA739 AKTIF 0 42,5003275016303540008 16/10/2014

0001452401212 JOHANA JACOBA LOE PESERTA 29/10/1942 TELUK PUCUNG740 AKTIF 0 59,5003275036910420001 16/10/2014

0001452402775 MARTHIN TAHALELE PESERTA 17/05/1949 TELUK PUCUNG741 AKTIF 0 59,50016/10/2014

0001452403135 PURNAWATI TAHALELE ISTRI 23/12/1961 TELUK PUCUNG742 AKTIF 0 59,50016/10/2014

0001452404474 L MUSILA PESERTA 21/07/1949 DEPOK JAYA743 AKTIF 0 59,50016/10/2014

0001452406882 I KETUT DANGIN SILAADNYANA

PESERTA 04/02/1954 MANGKUBUMI744 AKTIF 0 59,5003278080402540006 16/10/2014

0001452412315 DRA. ERLINA POEDJIWATISOEBIARSIH

ISTRI 08/03/1967 MANGKUBUMI745 AKTIF 0 59,5003278084803670003 16/10/2014

0001452414161 MUDJIONO PESERTA 22/10/1953 CILEDUG746 AKTIF 0 59,5003671062210530002 16/10/2014

0001452414442 SUKARNI ISTRI 23/07/1959 CILEDUG747 AKTIF 0 59,50016/10/2014

0001452415094 NAHILAH PESERTA 13/12/1958 KELAPA DUA748 AKTIF 0 42,50016/10/2014

0001452416444 RETNO HANDOKO PESERTA 16/03/1958 JOMBANG749 AKTIF 0 59,5003674041603580001 16/10/2014

0001452416872 ENDANG RATNA NINGSIH ISTRI 04/09/1960 JOMBANG750 AKTIF 0 59,5003674044409600001 16/10/2014

0001452417131 HAYATI PESERTA 27/04/1958 KELAPA DUA751 AKTIF 0 42,50016/10/2014

0001452418424 KETTY DAPU PESERTA 02/01/1937 TELUK PUCUNG752 AKTIF 0 59,5000951034201370027 16/10/2014

0001452419381 H.CHOIRUL HOTI PESERTA 18/03/1943 KEL. KEBON BAWANG I753 AKTIF 0 59,5003172025803430002 16/10/2014

0001452419662 MAD SARI PESERTA 02/01/1943 BOJONGSARI754 AKTIF 0 42,5003276030201430002 16/10/2014

0001452420167 YOYOH ISTRI 02/01/1952 BOJONGSARI755 AKTIF 0 42,5003276034201520002 16/10/2014

0001452420022 ARIFUDDIN BILI PESERTA 15/05/1958 KEL. TUGU SELATAN756 AKTIF 0 59,5003172031505580009 16/10/2014

Page 32 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452420358 SADARIA ISTRI 11/12/1973 KEL. TUGU SELATAN757 AKTIF 0 59,5003172035112730011 16/10/2014

0001452421506 SEBASTIANUS OPAT PESERTA 20/01/1956 Klinik SAPTA MITRA PONDOK GEDE758 AKTIF 0 59,5003275122001560002 16/10/2014

0001452421822 CHRISCENTIA SRI YUNIATI ISTRI 07/06/1960 Klinik SAPTA MITRA PONDOK GEDE759 AKTIF 0 59,5003275124706600003 16/10/2014

0001452422518 HASANAH RIVAI PESERTA 08/12/1942 MEKARSARI760 AKTIF 0 59,5003276024812420003 16/10/2014

0001452423341 POERHADI PESERTA 20/03/1950 BAKTI JAYA761 AKTIF 0 59,50016/10/2014

0001452423598 ANITA LUMANAUW ISTRI 10/04/1960 BAKTI JAYA762 AKTIF 0 59,50016/10/2014

0001452424162 TINAH PESERTA 14/04/1940 MEGAMENDUNG763 AKTIF 0 42,50016/10/2014

0001452425218 SUPRAPTO ISMAIL PESERTA 27/08/1952 BAKTI JAYA764 AKTIF 0 59,5003276052708520005 16/10/2014

0001452425354 SULISTYASIH SUPRAPTO ISTRI 09/09/1955 BAKTI JAYA765 AKTIF 0 59,5003276054909550005 16/10/2014

0001452425264 MURTADHO PESERTA 25/05/1954 ADIWERNA766 AKTIF 0 42,5003328112505540002 16/10/2014

0001452425635 SITI MUNTAMAH ISTRI 10/02/1957 ADIWERNA767 AKTIF 0 42,5003328115002570004 16/10/2014

0001452426175 FITRI HERAWATI KS PESERTA 19/04/1962 TELUK PUCUNG768 AKTIF 0 59,5003275035904620014 16/10/2014

0001452426761 SYARIF PHONEO PESERTA 01/12/1952 JATIRAHAYU769 AKTIF 0 59,5003275120112520004 16/10/2014

0001452426941 ETI KARWATI ISTRI 03/03/1962 JATIRAHAYU770 AKTIF 0 59,5003275124303620004 16/10/2014

0001452427075 MARSIPAH PESERTA 24/05/1952 KEL. TUGU SELATAN771 AKTIF 0 42,5003172036405520002 16/10/2014

0001452427942 WASIAH PESERTA 05/12/1961 SETIA MEKAR772 AKTIF 0 59,5003216064512610005 16/10/2014

0001452428651 YENNI CHADIJAH PESERTA 03/05/1960 KALIABANG TENGAH773 AKTIF 0 42,5003275034305600019 16/10/2014

0001452428853 ALWI PESERTA 15/04/1954 WISMA JAYA774 AKTIF 0 59,5003275011504540025 16/10/2014

0001452430438 ALMI ISTRI 23/08/1956 WISMA JAYA775 AKTIF 0 59,5003275016308560015 16/10/2014

0001452431349 DJONO SUMANTRI PESERTA 22/02/1956 TAJUR776 AKTIF 0 59,5003671062202560001 16/10/2014

0001452431744 ETTY BUDHIANTI ISTRI 27/05/1964 TAJUR777 AKTIF 0 59,5003671066705640003 16/10/2014

0001452432418 NY.TITI BT SUKATMA PESERTA 19/10/1940 KEL. PISANGAN BARU778 AKTIF 0 42,5003175015910400001 16/10/2014

0001452433149 MURSINTO WATI PESERTA 16/02/1958 PEKAYON JAYA779 AKTIF 0 59,5003275045602580007 16/10/2014

0001452434005 L J G HUTASOIT PESERTA 14/10/1936 JATI SAMPURNA780 AKTIF 0 59,5003275105410360003 16/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452434714 DJANATI PESERTA 25/12/1944 KEL. KEBON BAWANG I781 AKTIF 0 42,5003172036512440007 16/10/2014

0001452435715 JON LISTER BUSMINBATUBARA

PESERTA 17/06/1953 BAKTI JAYA782 AKTIF 0 59,50016/10/2014

0001452436198 ESMIN BR PANJAITAN ISTRI 23/12/1956 BAKTI JAYA783 AKTIF 0 59,50016/10/2014

0001452436154 AMINAH PESERTA 10/02/1950 KEL. KEBON BAWANG I784 AKTIF 0 42,5003172025002500003 16/10/2014

0001452437256 JOOTJE PALANDENG SAMAD PESERTA 24/12/1943 PEKAYON JAYA785 AKTIF 0 59,5003275046412430001 16/10/2014

0001452437662 PAINO PESERTA 07/07/1954 JOMBANG786 AKTIF 0 42,5003674040707540007 16/10/2014

0001452438178 WARSINI ISTRI 04/03/1966 JOMBANG787 AKTIF 0 42,5003674044403660001 16/10/2014

0001452439967 PARIMAN PESERTA 09/07/1957 LARANGAN UTARA788 AKTIF 0 42,5003671130907570001 16/10/2014

0001452440463 SUGINEM ISTRI 05/04/1964 LARANGAN UTARA789 AKTIF 0 42,5003671134504640001 16/10/2014

0001452440428 ELLI PESERTA 29/03/1960 Klinik YAKESTI BEKASI (JST)790 AKTIF 0 59,50016/10/2014

0001452441249 NYOMAN SARIANI NOYA PESERTA 21/04/1955 BAKTI JAYA791 AKTIF 0 59,5003276056104550002 16/10/2014

0001452442149 ASIAH PESERTA 26/12/1934 KELAPA DUA792 AKTIF 0 42,5003603286612340001 16/10/2014

0001452442882 MARLINA ASNAWI PESERTA 26/03/1957 JATIMAKMUR793 AKTIF 0 59,5003275086603570005 16/10/2014

0001452443894 WARSITO PESERTA 14/08/1952 BAKTI JAYA794 AKTIF 0 59,50016/10/2014

0001452444265 SRI RATMINI ISTRI 18/01/1955 BAKTI JAYA795 AKTIF 0 59,50016/10/2014

0001452445885 H.S.L. NASUTION PESERTA 22/09/1940 WISMA JAYA796 AKTIF 0 59,5003275012209400006 16/10/2014

0001452446774 MA'TENE ISTRI 23/06/1947 WISMA JAYA797 AKTIF 0 59,5003275016036470002 16/10/2014

0001452447156 ONIH PESERTA 20/07/1951 CIPUTAT798 AKTIF 0 42,50016/10/2014

0001452447628 WATIMAN PESERTA 01/02/1956 CIPAYUNG799 AKTIF 0 59,5003276010102560002 16/10/2014

0001452447843 SUMIYATI ISTRI 20/09/1963 CIPAYUNG800 AKTIF 0 59,5003276016009630002 16/10/2014

0001452448563 SALIM ARSYAD PESERTA 17/12/1954 BOJONG GEDE801 AKTIF 0 59,5003201131712540003 16/10/2014

0001452448754 MARNI SYARIF ISTRI 18/03/1956 BOJONG GEDE802 AKTIF 0 59,5003201135803560004 16/10/2014

0001452448631 SUYAMTI PESERTA 12/07/1958 LARANGAN UTARA803 AKTIF 0 42,5003671135207580003 16/10/2014

Page 34 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452450587 TRI BUDI ASMARA PESERTA 27/06/1953 JOMBANG804 AKTIF 0 42,50016/10/2014

0001452452411 SUTARMI ISTRI 12/12/1960 JOMBANG805 AKTIF 0 42,50016/10/2014

0001452450892 ESMAN SANUSI PESERTA 27/01/1950 JATIMULYA806 AKTIF 0 59,5003216062701500001 16/10/2014

0001452452163 KASNAP EFFENDI PESERTA 31/03/1953 AREN JAYA807 AKTIF 0 59,50016/10/2014

0001452452591 MARTIASIH ISTRI 31/03/1959 AREN JAYA808 AKTIF 0 59,50016/10/2014

0001452462377 SYAFRIAL PESERTA 09/10/1955 KEDUNG BADAK809 AKTIF 0 59,50016/10/2014

0001452464267 HJ.CAHYA HIDAYAH ISTRI 15/07/1964 KEDUNG BADAK810 AKTIF 0 59,50016/10/2014

0001452465325 BAMBANG EDY HUDIYANTO PESERTA 14/06/1954 CIMANGGIS811 AKTIF 0 59,5003276021406540006 16/10/2014

0001452465663 NUR ISNAENI ISTRI 25/06/1957 CIMANGGIS812 AKTIF 0 59,5003276026506570006 16/10/2014

0001452466304 KIAGUS MUCHSIN PESERTA 06/12/1936 AREN JAYA813 AKTIF 0 59,50016/10/2014

0001452466642 FISWAYNI ISTRI 30/05/1952 AREN JAYA814 AKTIF 0 59,50016/10/2014

0001452467957 DR.H.NOTO PALGUNO PESERTA 01/03/1944 Klinik Semper Ssma Mdika (JST)815 AKTIF 0 59,5003172041401099468 16/10/2014

0001452468677 NY. HJ.SRI WAHYUNI ISTRI 24/09/1951 Klinik Semper Ssma Mdika (JST)816 AKTIF 0 59,5003172046409510001 16/10/2014

0001452469779 TJARMI PESERTA 13/12/1948 JOMBANG817 AKTIF 0 59,5003674045312480003 16/10/2014

0001452470589 SRI HARTININGSIH PESERTA 13/04/1954 PONDOK PUCUNG818 AKTIF 0 59,5003674035304540002 16/10/2014

0001452471074 MAKMUN PESERTA 11/09/1956 CILEDUG819 AKTIF 0 59,5003671061109560001 16/10/2014

0001452471388 RULIYANI ISTRI 05/02/1957 CILEDUG820 AKTIF 0 59,5003671064502570001 16/10/2014

0001452471939 HELMI YUSUF PESERTA 21/01/1939 CIPUTAT821 AKTIF 0 59,50016/10/2014

0001452472209 NINO ROSITA LUBIS ISTRI 11/11/1945 CIPUTAT822 AKTIF 0 59,50016/10/2014

0001452473886 SRI WAHYU WIDAYATI PESERTA 14/04/1945 PANUNGGANGAN823 AKTIF 0 59,5003671115404450001 16/10/2014

0001452474292 MASTINA PESERTA 24/09/1955 PONDOK PUCUNG824 AKTIF 0 59,5003674036409550002 16/10/2014

0001452475089 FRENKY USMAN PESERTA 14/03/1934 PONDOK PUCUNG825 AKTIF 0 59,5003603241403340001 16/10/2014

0001452475596 DOLLY FRENKY USMAN ISTRI 11/12/1936 PONDOK PUCUNG826 AKTIF 0 59,5003603245112360001 16/10/2014

0001452477036 PANGEMANAN COLOAY PESERTA 09/06/1945 BENDA BARU827 AKTIF 0 59,5003674060906450001 16/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452477745 NANING PESERTA 27/11/1956 KEL. HARAPAN MULYA828 AKTIF 0 59,5003171031801098436 16/10/2014

0001452478037 R.L.LUMMY PESERTA 19/11/1936 KEC. TANJUNG PRIOK829 AKTIF 0 59,5003172021911360003 16/10/2014

0001452478487 SUNARMI PESERTA 29/12/1961 KEC. KOJA830 AKTIF 0 59,50016/10/2014

0001452478937 IDA SIMPAN SEMBIRING PESERTA 27/11/1956 Puskesmas Rawa Badak Selatan831 AKTIF 0 59,5003172036711560002 16/10/2014

0001452479365 DRA EMILIANA DJUNAEDI PESERTA 30/09/1940 KEL. DURI KEPA832 AKTIF 0 59,5003173057009400001 16/10/2014

0001452480873 NY.SARTJE SAMALLO PESERTA 05/05/1931 KEL. PALMARIAM833 AKTIF 0 59,50016/10/2014

0001452482054 ROYANI ABDULLAH PESERTA 02/10/2014 BOGOR SELATAN834 AKTIF 0 59,5003171041808560003 16/10/2014

0001452482302 YAYOEK SRI RAHAYU ISTRI 25/09/1958 BOGOR SELATAN835 AKTIF 0 59,5003271046509580002 16/10/2014

0001452482875 NY. MIMIN COLOAY PESERTA 27/08/1942 MUSTIKA JAYA836 AKTIF 0 59,5003275016708420006 16/10/2014

0001452483393 PROKORUS HONTONG PESERTA 21/06/1956 Klinik TIARA BUNDA837 AKTIF 0 59,5003275032106560010 16/10/2014

0001452483584 NORMA LAIDA ISTRI 12/04/1965 Klinik TIARA BUNDA838 AKTIF 0 59,5003275035204650024 16/10/2014

0001452484102 BINTAN ANDO PANJAITAN PESERTA 11/12/1956 TELUK PUCUNG839 AKTIF 0 59,5003275031112560010 16/10/2014

0001452484293 GRIETJE BARNETJE SHIRLEY ISTRI 16/09/1963 TELUK PUCUNG840 AKTIF 0 59,5003275035609630019 16/10/2014

0001452484978 WENDELL ALFONS TUHUTERU PESERTA 26/11/1956 SAWANGAN841 AKTIF 0 59,5003276032611560001 16/10/2014

0001452485215 IDA WAHYUNINGSYATI ISTRI 12/01/1970 SAWANGAN842 AKTIF 0 59,5003276035201700004 16/10/2014

0001452486903 S.ZULKARNAIN PESERTA 22/07/1955 BAKTI JAYA843 AKTIF 0 59,5003276052312070627 16/10/2014

0001452614545 USUP HANDJOKO PESERTA 04/12/1950 RANGKASBITUNG844 AKTIF 0 42,5003602140412500001 17/10/2014

0001452615085 TINI SUPARTINI ISTRI 10/02/1955 RANGKASBITUNG845 AKTIF 0 42,5003602145002550001 17/10/2014

0001452617447 TEKADIYANTO PESERTA 11/12/1956 CILEDUG846 AKTIF 0 42,5003671061112560002 17/10/2014

0001452618202 SUPARMI ISTRI 21/12/1961 CILEDUG847 AKTIF 0 42,5003671066112610001 17/10/2014

0001452619629 SITI COBARIAH PESERTA 02/01/1973 CIKUYA848 AKTIF 0 42,5003603314201730001 17/10/2014

0001452621137 LENNY MARLEN KAUNANGLETLORA

PESERTA 09/11/1947 KLINIK INDOSEHAT PASAR KEMIS849 AKTIF 0 42,5003603124911470001 17/10/2014

0001452622555 MULYONO PESERTA 15/08/1955 PAMULANG850 AKTIF 0 42,5003674061508550009 17/10/2014

Page 36 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452623264 WIDARTI ISTRI 14/01/1963 PAMULANG851 AKTIF 0 42,5003674065401630012 17/10/2014

0001452624827 SUDJIYO PESERTA 06/02/1957 JOMBANG852 AKTIF 0 42,5003674040602570001 17/10/2014

0001452625413 TURIYAH ISTRI 06/06/1964 JOMBANG853 AKTIF 0 42,5003674044606640003 17/10/2014

0001452638215 IWAN RACHMAT PESERTA 10/08/1955 PAMULANG854 AKTIF 0 42,5003674061008550004 17/10/2014

0001452638834 BALGIS NURLAILI ISTRI 20/09/1968 PAMULANG855 AKTIF 0 42,5003674066009680002 17/10/2014

0001452640577 YATI KARYATI PESERTA 16/08/1956 JOMBANG856 AKTIF 0 42,5003674045608560004 17/10/2014

0001452642366 ANIM PESERTA 15/01/1957 KLINIK INDOSEHAT PASAR KEMIS857 AKTIF 0 42,5003603121501570002 17/10/2014

0001452642849 ICIH SULAESIH ISTRI 08/09/1961 KLINIK INDOSEHAT PASAR KEMIS858 AKTIF 0 42,5003603124809610001 17/10/2014

0001452644447 BAMBANG KUNTOYO PESERTA 01/12/1953 CILEDUG859 AKTIF 0 42,5003671060112530005 17/10/2014

0001452646416 EDI HARYOKO PESERTA 12/10/1957 CILEDUG860 AKTIF 0 42,5003671061210570005 17/10/2014

0001452646991 ALFIAH ISTRI 11/11/1964 CILEDUG861 AKTIF 0 42,5003671065111640001 17/10/2014

0001452648521 CICIH SUWARSIH PESERTA 13/11/1938 PONDOK AREN862 AKTIF 0 42,5003674035311380002 17/10/2014

0001452652885 CHRISTIANUS SALINDEHO PESERTA 04/08/1925 PEDURENAN863 AKTIF 0 42,5007172070408250001 17/10/2014

0001452655067 WASTI DOALY PESERTA 07/06/1963 PEDURENAN864 AKTIF 0 42,5007172074706630001 17/10/2014

0001452657194 ROYANI MACHMUD PESERTA 27/09/1948 PAMULANG865 AKTIF 0 42,5003173072709480001 17/10/2014

0001452657789 NURHASANAH ISTRI 20/09/1955 PAMULANG866 AKTIF 0 42,5003173076009550001 17/10/2014

0001452659387 SUBARDI RAHARJO PESERTA 23/07/1952 LARANGAN UTARA867 AKTIF 0 42,5003671132307520003 17/10/2014

0001452660164 LASMI ESTHER ISTRI 23/06/1956 LARANGAN UTARA868 AKTIF 0 42,5003671136306560001 17/10/2014

0001452664967 HAYATI PESERTA 27/04/1958 KELAPA DUA869 AKTIF 0 42,50017/10/2014

0001452670874 HARIS PESERTA 21/08/1942 KEL. PETUKANGAN SELATAN870 AKTIF 0 42,5003204092108420001 17/10/2014

0001452676544 ANWAR SALEH PESERTA 10/05/1940 KEC. KOJA871 AKTIF 0 42,5003172031005400004 17/10/2014

0001452678906 SUNARSIH ISTRI 11/08/1964 KEC. KOJA872 AKTIF 0 42,50017/10/2014

0001452682282 ABDIUL HAFID PESERTA 01/09/1951 WISMA JAYA873 AKTIF 0 42,50017/10/2014

0001452684317 SITI HAWA ISTRI 04/03/1953 WISMA JAYA874 AKTIF 0 42,50017/10/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001452691214 MIYO PESERTA 10/01/1953 CILEDUG875 AKTIF 0 42,50017/10/2014

0001452697446 SUPRIYATI ISTRI 31/12/1960 CILEDUG876 AKTIF 0 42,50017/10/2014

0001792094152 BUDIMAN SRI SUMARTINI PESERTA 13/08/1939 PEKAYON JAYA877 AKTIF 0 59,5003275041308390010 01/09/2014

0001792260573 SRIEUTAMI WAAD PESERTA 01/07/1947 JATIASIH878 AKTIF 0 59,5003275094107470003 01/12/2014

0001792273342 ROSMERRY PESERTA 26/05/1958 KELAPA DUA879 AKTIF 0 59,5003603286605580001 01/12/2014

0001792279315 KARTIKAH PESERTA 17/04/1955 CIPADU880 AKTIF 0 59,5003671135704550002 01/12/2014

0001792282364 ULFAH KUSNAN PESERTA 12/12/1947 LARANGAN UTARA881 AKTIF 0 59,5003174065212470005 01/12/2014

0001792285042 SITI ACHYANI PESERTA 11/11/1958 PONDOK PUCUNG882 AKTIF 0 59,5003603245111580001 01/12/2014

0001792287099 HANDJOJO KERTADIPRADJA PESERTA 04/02/1955 PONDOK PUCUNG883 AKTIF 0 59,5003674030402550002 01/12/2014

0001792288326 NUR'AIN ISTRI 12/11/1965 PONDOK PUCUNG884 AKTIF 0 59,5003674035211650009 01/12/2014

0001792294468 TB A TASYFIN PESERTA 08/01/1958 CIPUTAT885 AKTIF 0 59,5003674040905120001 01/12/2014

0001792296347 RATU ROZIQOH ISTRI 11/03/1970 CIPUTAT886 AKTIF 0 59,5003674045103700002 01/12/2014

0001793049827 NY. TUTY HARYATI PESERTA 01/05/1955 KEL. KLP GADING TIMUR II887 AKTIF 0 59,5003172064105550005 03/12/2014

0001793056746 HJ.DAHNIAR GAZALI PESERTA 01/01/1935 KEL. PETOJO UTARA888 AKTIF 0 59,5003171014101350001 03/12/2014

0001793062732 E.SUNARTI PESERTA 05/02/1959 KADUHEJO889 AKTIF 0 59,5003601190502590001 03/12/2014

0001793087818 NAHILAH PESERTA 13/12/1958 KELAPA DUA890 AKTIF 0 42,5003603287112580005 03/12/2014

0001793136341 LILIEK SETIAWAN PESERTA 04/05/1956 GEMBOR891 AKTIF 0 59,5003671080405560002 03/12/2014

0001793161462 H.KANAD PESERTA 20/01/1939 KEL. KEBON KELAPA892 AKTIF 0 59,5003171082001390002 03/12/2014

0001793190082 DJUMASIH PESERTA 29/11/1951 MEGAMENDUNG893 AKTIF 0 42,5003201266911510001 03/12/2014

0001793193816 M. SIDIK SUHARJO PESERTA 06/03/1937 SEROJA894 AKTIF 0 42,5003275030603370003 03/12/2014

0001793416307 SITI MUTMAINAH ISTRI 05/01/1939 SEROJA895 AKTIF 0 42,5003275034501390005 03/12/2014

0001793204728 DJOKO MARYONO PESERTA 10/11/1950 SIMPANG KAWAT896 AKTIF 0 59,5001571081011500042 03/12/2014

0001793417264 SUHERMI ISTRI 11/01/1954 SIMPANG KAWAT897 AKTIF 0 59,5001571085101540022 03/12/2014

0001793208723 F.W.A LAWALATA PESERTA 27/08/1938 ABADI JAYA898 AKTIF 0 59,5003276052708380002 03/12/2014

Page 38 of 4512/5/14 2:21 PM

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793418344 ELLY KAMALI LAWALATA.T ISTRI 12/04/1944 ABADI JAYA899 AKTIF 0 59,5003276055204440008 03/12/2014

0001793211952 LOUSA D.KROMA PESERTA 27/08/1953 KEL. PETOJO UTARA900 AKTIF 0 59,5003171016708530004 03/12/2014

0001793218656 MOH DJUHARRY HARUN PESERTA 25/08/1955 KEC. KEMAYORAN901 AKTIF 0 59,5003173032508550003 03/12/2014

0001793419975 HERNASTI TAMBAHAN 27/10/1958 KEC. KEMAYORAN902 AKTIF 0 59,5003171036710580007 03/12/2014

0001793222199 CHAIRUMAN PESERTA 17/12/1934 KEL. UTAN PANJANG903 AKTIF 0 59,5003171031712340001 03/12/2014

0001793421551 CHAIRIYAH ISTRI 21/04/1942 KEL. UTAN PANJANG904 AKTIF 0 59,5003171036104420003 03/12/2014

0001793229434 SAUL. LONTAAN PESERTA 29/12/1940 KEL. SEMPER BARAT I905 AKTIF 0 59,5003172042912400009 03/12/2014

0001793235881 ZALBIAH HANOUM SARDJONO PESERTA 04/06/1935 KEL. SLIPI I906 AKTIF 0 59,5003173074406350003 03/12/2014

0001793238491 H.DJOKO SOEPOLO SE PESERTA 10/03/1951 KEL. TEGAL PARANG907 AKTIF 0 59,5003174031003510002 03/12/2014

0001793428108 LITA FIANA SOEPOLO ISTRI 09/12/1954 KEL. TEGAL PARANG908 AKTIF 0 59,5003174034912540001 03/12/2014

0001793247153 JOHANIS PANGALO PESERTA 22/06/1944 PABUARAN INDAH909 AKTIF 0 42,5003201012206440003 03/12/2014

0001793252529 LINEKE PARENGKUAN PESERTA 01/11/1946 PABUARAN INDAH910 AKTIF 0 42,5003201014111460003 03/12/2014

0001793255253 YUSUF WAKID PESERTA 03/06/1953 CITEUREUP911 AKTIF 0 59,5003201030306530001 03/12/2014

0001793260462 SITI SAHARA SIREGAR PESERTA 31/01/1966 CITEUREUP912 AKTIF 0 59,5003201037101660001 03/12/2014

0001793325475 RUWANTO PESERTA 16/06/1956 KOTABATU913 AKTIF 0 42,5003201291606260004 03/12/2014

0001793430944 MAE SALHA TAMBAHAN 21/06/1962 KOTABATU914 AKTIF 0 42,5003201296106620002 03/12/2014

0001793333092 ELUN PESERTA 10/05/1950 Klinik Kimia Farma Gunung Jati915 AKTIF 0 42,5003209211006600002 03/12/2014

0001793335803 ELSYE MAWUNTU PESERTA 04/04/1943 JATIMULYA916 AKTIF 0 42,5003216064404430001 03/12/2014

0001793336826 H.HERU SUNARYONO PESERTA 17/12/1942 SEMPUR917 AKTIF 0 42,5003271031712420001 03/12/2014

0001793431844 HJ.LATIFAH SUNARYONO ISTRI 04/05/1946 SEMPUR918 AKTIF 0 42,5003271034405460002 03/12/2014

0001793338165 YUS RUSWIATI PESERTA 15/08/1947 TANAH SAREAL919 AKTIF 0 42,5003271065508470001 03/12/2014

0001793339493 TITING MARIATIN PESERTA 12/12/1946 TANAH SAREAL920 AKTIF 0 42,5003271065212460006 03/12/2014

0001793341991 ENDANG SUHENDAR PESERTA 12/04/1955 DURENJAYA921 AKTIF 0 42,5003275011204550018 03/12/2014

0001793433374 YUNIZAR TAMBAHAN 08/06/1959 DURENJAYA922 AKTIF 0 42,5003275014806590019 03/12/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793345141 NYAK DJOHAN PESERTA 27/08/1954 DURENJAYA923 AKTIF 0 59,5003275012708540015 03/12/2014

0001793436456 SRI SULASTRI ISTRI 22/11/1954 DURENJAYA924 AKTIF 0 59,5003275016211540005 03/12/2014

0001793346399 YAMIN SYAMHARI PESERTA 06/10/1945 TELUK PUCUNG925 AKTIF 0 59,5003275030610450003 03/12/2014

0001793347964 NURHAYATI PESERTA 05/10/1952 TELUK PUCUNG926 AKTIF 0 59,5003275034510520011 03/12/2014

0001793350664 SUNARNO PESERTA 11/09/1953 KALIABANG TENGAH927 AKTIF 0 59,5003275031109530007 03/12/2014

0001793438728 L SETIAWATI ISTRI 08/08/1955 KALIABANG TENGAH928 AKTIF 0 59,5003275034808550017 03/12/2014

0001793354242 GUTENG SETYO LAKSONO PESERTA 29/08/1957 TELUK PUCUNG929 AKTIF 0 59,5003275032908570006 03/12/2014

0001793440787 NINIEK SULIS TIYANI ISTRI 19/01/1959 TELUK PUCUNG930 AKTIF 0 59,5003275035901590002 03/12/2014

0001793364568 MUNDJINAH PESERTA 06/04/1942 PERUMNAS II931 AKTIF 0 59,5003275044604420007 03/12/2014

0001793370892 KARNOTO PESERTA 01/01/1936 PEJUANG932 AKTIF 0 42,5003275061013460001 03/12/2014

0001793441981 ROYANI TAMBAHAN 05/12/1946 PEJUANG933 AKTIF 0 42,5003275064512460003 03/12/2014

0001793375291 BANUARAN HARAHAP PESERTA 14/06/1949 PONDOKGEDE934 AKTIF 0 42,5003275081406490011 03/12/2014

0001793443386 NURHAIDA SIREGAR ISTRI 01/12/1954 PONDOKGEDE935 AKTIF 0 42,5003275084112540015 03/12/2014

0001793377135 ASEP SUPARMAN PESERTA 15/01/1961 JATIBENING936 AKTIF 0 42,5003275081501610015 03/12/2014

0001793379431 HJ. RINA HERLINA PESERTA 10/05/1966 JATIBENING937 AKTIF 0 42,5003275085005660020 03/12/2014

0001793382434 RINI INDIATI PESERTA 28/01/1956 JATIASIH938 AKTIF 0 42,5003276026801560008 03/12/2014

0001793386168 SOEKIRNO PESERTA 31/05/1955 JATIWARNA939 AKTIF 0 42,5003275123105550002 03/12/2014

0001793444681 DSK. WIDAYATI ISTRI 28/08/1958 JATIWARNA940 AKTIF 0 42,5003275126808580008 03/12/2014

0001793391129 SURADI PESERTA 05/10/1952 JATIJAJAR941 AKTIF 0 42,5003276020510520001 03/12/2014

0001793395596 MAIMUNAH PESERTA 28/06/1966 JATIJAJAR942 AKTIF 0 42,5003276026806660001 03/12/2014

0001793397789 PARWOTO PESERTA 01/11/1934 KEDAUNG943 AKTIF 0 42,5003276030111340001 03/12/2014

0001793415159 PRAWOTO PESERTA 26/02/1956 BAKTI JAYA944 AKTIF 0 59,5003276052602560001 03/12/2014

0001793426927 SOPHIA ROLOS PESERTA 15/09/1943 KEL. SEMPER BARAT I945 AKTIF 0 59,5003172045509430001 03/12/2014

0001793460868 MAX JOHNY TAMPI PESERTA 05/05/1950 BAKTI JAYA946 AKTIF 0 59,5003276050505500002 03/12/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793461522 SUCIYAH TAMPI ISTRI 16/10/1949 BAKTI JAYA947 AKTIF 0 59,5003276055610490001 03/12/2014

0001793466628 FARIDA MARGARETACORPUTTY

PESERTA 22/12/1945 BAKTI JAYA948 AKTIF 0 42,5003276056212450006 03/12/2014

0001793467923 HENNY SUHAENNY PESERTA 06/10/1957 SUKMAJAYA949 AKTIF 0 42,5003276054610570009 03/12/2014

0001793469598 ELISABETH PONDA'AG PESERTA 20/12/1946 BAKTI JAYA950 AKTIF 0 42,5003276056012460001 03/12/2014

0001793471152 MONIYONG WOLTHERJOHANES

PESERTA 12/01/1931 ABADI JAYA951 AKTIF 0 42,5003276051201310001 03/12/2014

0001793471534 WAWORUNTU LOUISE JETJE ISTRI 21/08/1932 ABADI JAYA952 AKTIF 0 42,5003276056108320001 03/12/2014

0001793475044 KARTIKA ATMAJA PESERTA 05/10/1946 CILANGKAP953 AKTIF 0 59,5003276104510460001 03/12/2014

0001793488105 GRACE R. MAILANGKAY PESERTA 21/08/1956 BENDA BARU954 AKTIF 0 59,5003674066108560001 03/12/2014

0001793488882 SOEMIRAT PESERTA 16/04/1934 BOGOR TIMUR955 AKTIF 0 59,5003174011604340001 03/12/2014

0001793489332 NY NANI SUMIRAT ISTRI 14/09/1945 BOGOR TIMUR956 AKTIF 0 59,5003174015409450002 03/12/2014

0001793490906 DR FAISAL HAQ PESERTA 24/02/1939 KEL. PONDOK PINANG957 AKTIF 0 59,5003174052402390001 03/12/2014

0001793496126 DARWATI PESERTA 11/03/1961 TAMBUN958 AKTIF 0 42,5003216065103610005 03/12/2014

0001793499996 sri SUMIYATI HARUN PESERTA 12/03/1947 KEL. KEBON BAWANG II959 AKTIF 0 42,5003172025203470002 03/12/2014

0001793505521 HJ . RD. DEDEN SOFIA PESERTA 28/11/1939 KLINIK RAGUNAN960 AKTIF 0 42,5001053016811390001 03/12/2014

0001793510155 MH HEYDEMANS PESERTA 11/08/1937 BAKTI JAYA961 AKTIF 0 42,5000951035103370020 03/12/2014

0001793513349 IDA MURTINI PESERTA 14/05/1930 KEL. KARTINI962 AKTIF 0 59,5003171025405301001 03/12/2014

0001793515353 USMAN WALUYO PESERTA 12/10/1950 KEL. PETAMBURAN963 AKTIF 0 59,5003171071210500001 03/12/2014

0001793518503 SUPARMI PESERTA 25/11/1951 KEL. SUNGAI BAMBU964 AKTIF 0 42,5003172026511510008 03/12/2014

0001793520088 KLUMPUK PESERTA 30/12/1941 KEL. LAGOA965 AKTIF 0 42,5003172037012410004 03/12/2014

0001793520944 H. RACHMAT SOEBANDRIO PESERTA 20/09/1946 KEL. TUGU UTARA I966 AKTIF 0 42,5003172032009460002 03/12/2014

0001793522068 MANUNG PESERTA 12/11/1957 KEC. KOJA967 AKTIF 0 42,5003172031211570003 03/12/2014

0001793523475 BUTJE PANGEMANAN PESERTA 30/08/1957 KEL. TUGU UTARA I968 AKTIF 0 42,5003172033008570002 03/12/2014

0001793524138 HERMINA ELYANA HUTAJULU ISTRI 09/06/1953 KEL. TUGU UTARA I969 AKTIF 0 42,5003172034906530004 03/12/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793525962 ABD RAHMAN PESERTA 01/05/1958 KEL. CILINCING I970 AKTIF 0 42,5003172040105580004 03/12/2014

0001793527086 HJ.S.INDRALANG PESERTA 15/02/1950 KEC. CILINCING971 AKTIF 0 42,5003172045502500004 03/12/2014

0001793528425 NY LIES B SOEMARTO PESERTA 03/07/1945 KEL. MUNJUL972 AKTIF 0 42,5003172064307450002 03/12/2014

0001793529707 DJAIMAN PESERTA 05/07/1935 NAYAKA ERA HUSADA 09 (JST)973 AKTIF 0 42,5003175020507350002 03/12/2014

0001793530113 SIAMINARTI ISTRI 05/09/1944 NAYAKA ERA HUSADA 09 (JST)974 AKTIF 0 42,5003175024509440001 03/12/2014

0001793533757 SULAMI PESERTA 18/06/1939 KEL. TEBET TIMUR975 AKTIF 0 59,5003174015806390001 03/12/2014

0001793534668 SUKARSIH PESERTA 27/12/1956 KEL. KLENDER I976 AKTIF 0 59,5003175076712560006 03/12/2014

0001793536323 MASBI THALIB PESERTA 11/11/1949 PABUARAN INDAH977 AKTIF 0 59,5003201011111490002 03/12/2014

0001793537469 SRI MARTINI TAMBAHAN 17/12/1955 PABUARAN INDAH978 AKTIF 0 59,5003201015712550006 03/12/2014

0001793541554 SUTISNA PESERTA 01/01/1941 PAGADEN979 AKTIF 0 42,5003213070101410002 03/12/2014

0001793542026 HJ. SITI LATIFAH ISTRI 22/04/1947 PAGADEN980 AKTIF 0 42,5003213076204470002 03/12/2014

0001793549081 RUKANTI PESERTA 23/03/1959 DURENJAYA981 AKTIF 0 59,5003275016303590015 03/12/2014

0001793551948 ABDUL ROHMAN PESERTA 06/07/1957 TELUK PUCUNG982 AKTIF 0 59,5003275030607570006 03/12/2014

0001793552185 MARLYN S MARINGKA ISTRI 31/03/1965 TELUK PUCUNG983 AKTIF 0 59,5003275037103650019 03/12/2014

0001793553063 ELSYE BR.SIAGIAN PESERTA 19/06/1952 BINTARA JAYA984 AKTIF 0 59,5003275085906520006 03/12/2014

0001793553535 RAM KASIM PESERTA 17/10/1951 JATIBENING985 AKTIF 0 59,5003275085710510015 03/12/2014

0001793554481 AMSAH KARYATIN PESERTA 30/10/1953 JATIWARNA986 AKTIF 0 42,5003275123010530005 03/12/2014

0001793554661 SRI RATU BUDI MAHYATI ISTRI 21/04/1961 JATIWARNA987 AKTIF 0 42,5003275126104610018 03/12/2014

0001793555177 ABDULLAH KAINAN PESERTA 15/02/1939 PANCORAN MAS988 AKTIF 0 59,5003276011502390002 03/12/2014

0001793555684 ARSIUS HELMA DALUAS PESERTA 28/09/1939 BAKTI JAYA989 AKTIF 0 59,5003276052809390001 03/12/2014

0001793556461 JUNETT TATIMU DALUAS ISTRI 06/06/1952 BAKTI JAYA990 AKTIF 0 59,5003277731008118417 03/12/2014

0001793558709 MURSINAH PESERTA 17/11/1942 SUKMAJAYA991 AKTIF 0 42,5003276055711420002 03/12/2014

0001793559036 ROBERT GULTOM PESERTA 10/04/1955 BAKTI JAYA992 AKTIF 0 42,5003276051004550004 03/12/2014

0001793559238 ROSMERY TAMBUNAN ISTRI 07/11/1956 BAKTI JAYA993 AKTIF 0 42,5003276054711560002 03/12/2014

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YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793559969 SUKENDA HF PESERTA 08/05/1958 BOJA I994 AKTIF 0 59,5003324070805580002 03/12/2014

0001793560252 MEIRINA LISTYA NINGSIH ISTRI 15/05/1958 BOJA I995 AKTIF 0 59,5003324075505500001 03/12/2014

0001793561332 FRANCISCUS SOEKIRNO PESERTA 23/11/1946 PAMULANG996 AKTIF 0 59,5003674062311460001 03/12/2014

0001793562917 SRI WIDJI ISTRI 03/09/1952 PAMULANG997 AKTIF 0 59,5003674064309520001 03/12/2014

0001793563637 ITA BINTI ALI PESERTA 31/12/1944 KEL. SLIPI I998 AKTIF 0 42,5000952067112440368 03/12/2014

0001793565235 GUSDI WARMAN H, SH PESERTA 18/08/1953 LUBUK BEGALUNG999 AKTIF 0 59,5003573051808530009 03/12/2014

0001793565382 HJ.SYAFRIDA ISTRI 12/07/1958 LUBUK BEGALUNG1,000 AKTIF 0 59,5003573055207580005 03/12/2014

0001793566361 ANIM KUSNAEDI PESERTA 06/06/1953 KEL. WARAKAS1,001 AKTIF 0 59,5003172020606530015 03/12/2014

0001793566574 ONAH ISTRI 19/09/1958 KEL. WARAKAS1,002 AKTIF 0 59,5003172025909580011 03/12/2014

0001793567316 SUJANA PESERTA 09/11/1954 KEL. TANJUNG PRIOK1,003 AKTIF 0 59,5003172020911540004 03/12/2014

0001793567507 LINDA ISTRI 14/08/1961 KEL. TANJUNG PRIOK1,004 AKTIF 0 59,5003172025408610003 03/12/2014

0001793568497 IMAM SUPANDI PESERTA 12/07/1955 KEL. PAPANGGO I1,005 AKTIF 0 42,5003172021207550001 03/12/2014

0001793568611 SAHARIYA ISTRI 22/04/1962 KEL. PAPANGGO I1,006 AKTIF 0 42,5003172026204620004 03/12/2014

0001793569735 MARIA MARTHA N.G. PESERTA 16/10/1953 KEC. TANJUNG PRIOK1,007 AKTIF 0 59,5003172025610530001 03/12/2014

0001793570163 H. SADIKIN PESERTA 12/06/1940 KEL. SUNGAI BAMBU1,008 AKTIF 0 59,5003172021206400001 03/12/2014

0001793570758 S A I A H PESERTA 05/11/1950 KEL. KOJA1,009 AKTIF 0 59,5003172034511500003 03/12/2014

0001793571715 LUSIA HERY PESERTA 17/12/1943 KEC. KOJA1,010 AKTIF 0 42,5000951045712430217 03/12/2014

0001793572086 HJ. SITI AMINAH PESERTA 21/10/1945 KEL. LAGOA1,011 AKTIF 0 59,5003172036110450001 03/12/2014

0001793572391 SYAMSIAR PESERTA 28/12/1943 Klinik Syifa Medical Center1,012 AKTIF 0 59,5003172036812430004 03/12/2014

0001793573144 SUWARMAN PESERTA 19/09/1958 KEL. KELAPA DUA1,013 AKTIF 0 42,5003173051909580001 03/12/2014

0001793573425 PARSINI ISTRI 07/11/1961 KEL. KELAPA DUA1,014 AKTIF 0 42,5003173055109700003 03/12/2014

0001793573818 H.ZAINI PESERTA 31/10/1945 KEL. KELAPA DUA1,015 AKTIF 0 59,5003173053110450004 03/12/2014

0001793573932 ASMANAH ISTRI 27/07/1950 KEL. KELAPA DUA1,016 AKTIF 0 59,5003173056707500002 03/12/2014

0001793574292 ALI PESERTA 28/02/1963 KEL. KOTA BAMBU UTARA1,017 AKTIF 0 42,5003173072802630001 03/12/2014

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Page 44: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793574382 SRI HARTINI ISTRI 20/07/1966 KEL. KOTA BAMBU UTARA1,018 AKTIF 0 42,5003173076007660002 03/12/2014

0001793574865 GUFRANI B ARRASULI PESERTA 22/12/1960 KEC. KEBON JERUK1,019 AKTIF 0 59,5003173076212600001 03/12/2014

0001793576801 RM. HARDJONO PESERTA 17/02/1932 LARANGAN UTARA1,020 AKTIF 0 59,5003174011702320003 03/12/2014

0001793577014 RA.ISYE ISMUDIWARTI ISTRI 22/05/1940 LARANGAN UTARA1,021 AKTIF 0 59,5003174016205400001 03/12/2014

0001793577429 H NURMISIH PESERTA 27/04/1940 KEL. PASAR MANGGIS1,022 AKTIF 0 59,5003174026704400003 03/12/2014

0001793577802 SOETARMONO PESERTA 10/09/1938 KEL. KEBAYORAN LAMA UTARA1,023 AKTIF 0 59,5003174051009380003 03/12/2014

0001793577936 MARIA.M.INDRAWARDANI ISTRI 29/09/1948 KEL. KEBAYORAN LAMA UTARA1,024 AKTIF 0 59,5003174056909480001 03/12/2014

0001793578533 FERRY YATI HARIS PESERTA 28/01/1952 BAKTI JAYA1,025 AKTIF 0 59,5003174076801520001 03/12/2014

0001793579231 ERIKA PESERTA 25/07/1948 KEL. BIDARA CINA III1,026 AKTIF 0 59,5003175036507480003 03/12/2014

0001793579589 RAMA YULIS YUSUF,SE.MM PESERTA 30/07/1951 KEL. MALAKA SARI1,027 AKTIF 0 59,5003175077007510004 03/12/2014

0001793579905 NURSIAM PESERTA 02/02/1950 JONGGOL1,028 AKTIF 0 59,5003201064202500001 03/12/2014

0001793580399 EDIH SUHENDI PESERTA 30/12/1954 LEUWILIANG1,029 AKTIF 0 42,5003201163012540001 03/12/2014

0001793580524 MARYATI ISTRI 27/12/1969 LEUWILIANG1,030 AKTIF 0 42,5003201166712690001 03/12/2014

0001793581121 ACE RAHMAN PESERTA 24/10/1948 CIMALAKA1,031 AKTIF 0 59,5003211222410480004 03/12/2014

0001793581378 AMINAH ABUSALAM ISTRI 15/02/1969 CIMALAKA1,032 AKTIF 0 59,5003211225502690011 03/12/2014

0001793582021 DALIONO WAGIRIN PESERTA 30/03/1957 AREN JAYA1,033 AKTIF 0 59,5003275013003570006 03/12/2014

0001793582199 SUYANTI ISTRI 27/12/1961 AREN JAYA1,034 AKTIF 0 59,5003275016712610018 03/12/2014

0001793582649 BURHAN SUKIRNO PESERTA 17/12/1938 DURENJAYA1,035 AKTIF 0 42,5003275011712380001 03/12/2014

0001793582785 SUIDAH ISTRI 01/05/1950 DURENJAYA1,036 AKTIF 0 42,5003275014105500013 03/12/2014

0001793583189 MIMI PESERTA 17/06/1950 BINTARA1,037 AKTIF 0 42,5003275025706500007 03/12/2014

0001793583551 NINA NIRWANA PESERTA 27/10/1955 TELUK PUCUNG1,038 AKTIF 0 59,5003275036710550010 03/12/2014

0001793583933 RADEN WIKKY KOESARIOMAN

PESERTA 08/01/1955 TELUK PUCUNG1,039 AKTIF 0 59,5003275030801550006 03/12/2014

0001793584798 KASIYEM PESERTA 01/02/1943 SEROJA1,040 AKTIF 0 42,5003275034102430007 03/12/2014

Page 44 of 4512/5/14 2:21 PM

Page 45: Data e-id Kepesertaan BPJS Kesehatan Pensiunan PT. PELNI Persero

YAYASAN KESEHATAN PENSIUNAN PT.PELNI (01143409)Nama Entitas :YAYASAN KESEHATAN PENSIUNAN PT.PELNISub Entitas :

No. Kartu NPP/Nopeg Nama Hub. Keluarga Tgl. Lahir Nama Faskes Tingkat INo. Status Peserta Gaji IuranNIK Nama Faskes Gigi TMT

0001793585485 RAMLAH TANGAHU PESERTA 08/07/1946 SEROJA1,041 AKTIF 0 59,5003275034607460001 03/12/2014

0001793585744 TARMAT PESERTA 27/09/1940 PANCORAN MAS1,042 AKTIF 0 42,5003276012709400002 03/12/2014

0001793585979 RATMAH ISTRI 21/10/1948 PANCORAN MAS1,043 AKTIF 0 42,5003276016110480004 03/12/2014

0001793586587 LATINAR SOFION PESERTA 16/06/1941 KLINIK AZZAHRA1,044 AKTIF 0 59,5003276025606410002 03/12/2014

0001793586824 H.WAWANG SUWARDI PESERTA 16/07/1940 CIMANGGIS1,045 AKTIF 0 59,5003276051607400002 03/12/2014

0001793586947 HJ. AISYAH PRATERNITI ISTRI 21/04/1951 CIMANGGIS1,046 AKTIF 0 59,5003276056104510003 03/12/2014

0001793587329 ROCHMAH PESERTA 21/04/1936 KEMIRI MUKA1,047 AKTIF 0 42,5003276066104360001 03/12/2014

0001793587915 IRWAN PESERTA 29/07/1957 dr. AM Sajarwadi1,048 AKTIF 0 59,5003404102907570002 03/12/2014

0001793588264 FARIDA IRIANA WURYANTI ISTRI 12/12/1963 dr. AM Sajarwadi1,049 AKTIF 0 59,5003404105212630000 03/12/2014

0001793588512 SUNARTI PESERTA 15/01/1955 CILEDUG1,050 AKTIF 0 59,5003671065501550003 03/12/2014

0001793588905 CHADIR NURFAKIH PESERTA 04/12/1948 KARANG TENGAH1,051 AKTIF 0 59,5003671120412480001 03/12/2014

0001793589063 KASMUNI ISTRI 10/12/1956 KARANG TENGAH1,052 AKTIF 0 59,5003671125012560002 03/12/2014

0001793589636 ZULFA HASAN RIFA'AH PESERTA 30/12/1956 LARANGAN UTARA1,053 AKTIF 0 59,5003671137012560004 03/12/2014

56,907,500Iuran per Tgl 05/12/2014

Page 45 of 4512/5/14 2:21 PM