FORM MIGRASI PESERTA JENIS PESERTA PESERTA NAMA INSTANSI/BADAN/PERUSAHAAN KODE VIRTUAL ACCOUNT BANK TEMPAT PEMBAYARAN IURAN TANGGAl REGISTRASI NOMOR PKS KODE PKS MASA BERLAKU KODE TANGGUNGAN KODE KC KODE DATI
P=PESERTA S=SUAMI I=ISTRI A=ANAK T=TAMBAHAN (ANAK KE4 DST) BELUM 1 LAKI KAWIN PEREMPU CERAI HI DERAI M
1 '$l 5 0!+& (67"#*8*6,+* 9 "%"')
HUBKEL
N!
1
N! KK
NIK/KITAS/KITAP
N"#" L$%&'"
4
1=P =S =I 4=A 0=T
0
T&l L"*+
T$#", $#", L"* L"*+ + --/##/. --/##/.... ...
2
J$%*6 K$1"#*%
S,",76 ":*%
1=LK =PRM
1=BK8 =K8 =CH8 4=CM 0 = TDK TAU TAU
3
AWIN DIISI PETUGAS BPJS
DUP ATI
l"#", T$#", T*%&& RT
1
11
RW
K!-$ P!6
1
1
-"l"# 6",7 '$l7"+&" -*$+>!l$'"% >$+>$-" ?"6'$6
DIISI PETUGAS BPJS
DIISI PETUGAS BPJS
K!-$ K!-$ D$6" K$;"#","% N"#" K$;"#","% (-**6* (-**6* $,7&"6) $,7&"6)
N"#" D$6"
K!-$ F"6'$6 T'
N"#" F"6'$6 T'
12
13
1
14
10
1
DIISI KANTOR PUSAT
S,",76 K!-$ F"6'$6 D!',$+ G*&*
N"#" F"6'$6 D!',$+ G*&*
N!#!+ T$l$!% P$6$+,"
E#"*l
NPP (NOPEG)
1
4
1=T$,"8 J">","% =K!%,+"'8 =P"+7 :"',7 4=P$%$+*#" P$%6*7%
0
K$l"6 R":",
1=K$l"6 I8 =K$l"6 II8 =K$l"6 III
2
TMT K$+@" (K"+.< A',*?)
3
Kewarga Negaraan
G"@* P!'!' T7%@< T$," 1=WNI, (K"+.< 2=WNA A',*?)
A67+"%6* L"*%%."
N!< P!l*6
N"#" A67+"%6*
1
N!< NPWP
N! P"66!+ ,
4
