| Insured Name | Policy No | Payment Status | Claim No | Transaction No | In Payment Of | Payee Name | Summary Amount |
|---|---|---|---|---|---|---|---|
| ANTI ARCHIVE CO., LTD | PA/PPI/C-48690 |
Full Payment | CL/PA/PPI/3996 | CL/PA/PPI/3996-01 |
ACCIDENTAL MEDICAL EXPENSE | ANTI ARCHIVE CO., LTD | 21.25 |