Form and Structure of Periodic Reports for Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies

To:

1. Board of Directors of Insurance Brokerage Companies;
2. Board of Directors of Reinsurance Brokerage Companies; and
3. Board of Directors of Insurance Loss Assessing Companies,
   At their locations.

COPY

CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 3 /SEOJK.05/2018

ABOUT

FORM AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSING COMPANIES

In relation to the mandate of Article 6 of Financial Services Authority Regulation Number 55/POJK.05/2017 concerning Periodic Reports of Insurance Companies (State Gazette of the Republic of Indonesia Year 2017 Number 174, Supplement to the State Gazette of the Republic of Indonesia Number 6107), it is necessary to regulate the provisions on the form and structure of periodic reports for insurance brokerage companies, reinsurance brokerage companies, and insurance loss assessing companies in this Financial Services Authority Circular as follows:

I. GENERAL PROVISIONS

In this Financial Services Authority Circular, the following terms are meant:

1. Company means insurance brokerage company, reinsurance brokerage company, and insurance loss assessing company.

2. Insurance Brokerage Company means a company that conducts business of consulting and/or intermediary services in the closing of insurance or Sharia insurance and the handling and settlement of claims, acting on behalf of and for the policyholder, insured, or participant.

3. Reinsurance Brokerage Company means a Company that conducts business of consulting and/or intermediary services in the placement of reinsurance or Sharia reinsurance and the handling and settlement of claims, acting on behalf of and for insurance companies, Sharia insurance companies, guarantee companies, Sharia guarantee companies, reinsurance companies, or Sharia reinsurance companies that conduct reinsurance or Sharia reinsurance placement.

4. Insurance Loss Assessing Company means a company that conducts business of claim assessment services and/or consulting services regarding insurance objects.

5. Periodic Report means a report prepared by the Company for the benefit of the Financial Services Authority for a certain period.

6. Semi-Annual Report means a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant semester.

7. Annual Report means a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant year.

II. FORM AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSING COMPANIES

1. Periodic Reports of Insurance Brokerage Companies and Reinsurance Brokerage Companies consist of:
   a. Semi-Annual Report; and b. Annual Report.

2. Periodic Reports of Insurance Loss Assessing Companies consist of Annual Reports.

3. Annual Reports as referred to in item 1 letter b for Insurance Brokerage Companies and Reinsurance Brokerage Companies and Annual Reports as referred to in item 2 for Insurance Loss Assessing Companies consist of:
   a. financial aspects; and b. management aspects.

4. The form and structure of Semi-Annual Reports as referred to in item 1 letter a and Annual Reports for financial aspects as referred to in item 3 letter a are as set forth in Appendix I which is an inseparable part of this Financial Services Authority Circular, with the following provisions:
   a. for Insurance Brokerage Companies, as set forth in Format I A; b. for Reinsurance Brokerage Companies, as set forth in Format I B; and
   c. for Insurance Loss Assessing Companies, as set forth in Format I C.

5. The form and structure of Annual Reports for management aspects as referred to in item 3 letter b for Companies are as set forth in Appendix II which is an inseparable part of this Financial Services Authority Circular.

III. PROCEDURES FOR SUBMISSION OF PERIODIC REPORTS

1. Submission of Periodic Reports is conducted online through the Financial Services Authority's data communication network system.

2. In the event that the Financial Services Authority's data communication network system as referred to in item 1 is not yet available, Companies must submit Periodic Reports online via electronic mail to the Financial Services Authority.

3. The Financial Services Authority submits in writing to the Company regarding the electronic mail address used for the submission of Periodic Reports no later than 14 (fourteen) working days before the deadline for submission of Periodic Reports.

4. Companies must submit in writing to the Financial Services Authority the Company's electronic mail address used for the submission of Periodic Reports to the Financial Services Authority as referred to in item 2.

5. In the event that the Financial Services Authority's data communication network system as referred to in item 1 and item 2 experiences technical problems or the Company experiences disturbances so that it cannot submit Periodic Reports online, Periodic Reports are submitted offline accompanied by written notification and sent to the Financial Services Authority via a letter signed by the Board of Directors or equivalent and addressed to:
   Financial Services Authority u.p. Director of IKNB Support Services Wisma Mulia 2 Building, 12th Floor Jalan Jenderal Gatot Subroto Number 42 Jakarta 12710.

6. Submission of Periodic Reports offline as referred to in item 5 is conducted by one of the following methods:
   a. handed over directly; or b. sent through a courier service company.

7. Companies are deemed to have submitted Periodic Reports with the following provisions:
   a. for online submission via:

   1. the Financial Services Authority's data communication network system, proven by a receipt from the Financial Services Authority's data communication network system; or
   2. proof of sending electronic mail against reports sent to the Financial Services Authority's electronic mail address, in the event that submission through the data communication network cannot be performed; or
      b. for offline submission, proven by:
   3. a receipt letter from the Financial Services Authority, if the report is handed over directly; or
   4. a shipping receipt from the courier service company, if the report is sent through a courier service company.

IV. CLOSING PROVISIONS

1. The provisions in this Financial Services Authority Circular shall take effect on the date of determination.

This copy is in accordance with the original Director of Law 1 Law Department signed Yuliana

2. At the time this Financial Services Authority Circular takes effect, Financial Services Authority Circular Number 18/SEOJK.05/2014 concerning the Report on the Application of Good Corporate Governance for Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies, is revoked and declared invalid.

Determined in Jakarta on January 24, 2018 EXECUTIVE HEAD OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 3 /SEOJK.05/2018 ABOUT FORM AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSING COMPANIES

FORMAT I A
FORM AND STRUCTURE OF SEMI-ANNUAL REPORTS AND ANNUAL REPORTS FOR FINANCIAL ASPECTS FOR INSURANCE BROKERAGE COMPANIES

To
Yth. Directorate of IKNB Support Services Financial Services Authority

FINANCIAL REPORT
INSURANCE BROKERAGE COMPANY
Semester ... / Year ...

General Data
Reporting Date
Company Code
Company Name
Company Address
Reporting Period
Reporting Month
Fiscal Year
Type of Reporting Period
Board of Directors Name
Board of Directors Position

INSURANCE BROKERAGE COMPANY
FORM PP01
GENERAL INFORMATION
Semester ... / Year ...
Description

1. Head Office Address 0

• Building Name and Floor
• Street Name and Number
• Village/Sub-district
• District
• Regency/City
• Province
• Postal Code

2. Telephone
3. Fax
4. Email
5. Website Address
6. Taxpayer Identification Number (NPWP)
7. Business License 0

• Business License Number
• Business License Date

8. Number of Offices Other Than Head Office
9. Number of Affiliated Companies
10. Number of Employees
    (including officials and staff)
11. Number of Partners in Business Acquisition #VALUE!

• Individuals
• Legal Entities

12. Auditor 0

• Public Accounting Firm
• Public Accountant
• Registered Certificate Number (STTD)

13. Employee liaison with OJK 0

• Name
• Mobile Phone
• Email

INSURANCE BROKERAGE COMPANY
FORM PP02
SHAREHOLDER LIST
Semester ... / Year ...
No. Shareholder Name Share Ownership OJK Fit and Proper Assessment SK OJK Approval Letter Nominal % Date Number Number Date ... Total

INSURANCE BROKERAGE COMPANY
FORM PP03
MANAGEMENT STRUCTURE LIST
Semester ... / Year ...
No. Management Name Position OJK Fit and Proper Assessment SK OJK Approval Letter Date Number Number Date 1 President Director / Director / Supervisory Board Chairman / Commissioner

INSURANCE BROKERAGE COMPANY
FORM PP04
LIST OF EXPERTS AND BROKERS
Semester ... / Year ...
No. Name Title Profession Position Appointment SK Registration Number Date Number 1 CIIB / APAI / AAPAI / AAIK / AAAIK / AAIJ / AAAIJ Expert / Insurance Broker ...

INSURANCE BROKERAGE COMPANY
FORM PP05
LIST OF OFFICES OTHER THAN HEAD OFFICE Semester ... / Year ... No. Operation Area / Territorial Scope Type of Office Address Regency/City Telephone Email Office Head Number of Employees 1 Branch / Representative / Marketing / Operational ... Total

INSURANCE BROKERAGE COMPANY
FORM PP06
LIST OF AFFILIATED COMPANIES
Semester ... / Year ...
No. Name of Affiliated Company Address Regency/City Telephone Email Type of Business Affiliation Relationship 1 Financial / Management / Family ... Type of Business:

1. Agriculture, forestry and fisheries 8. Transportation and warehousing 15. Public administration, defense and mandatory social security
2. Mining and quarrying 9. Accommodation and food and beverage provision
3. Education services
4. Processing industry 10. Information and communication 17. Health services and social activities
5. Electricity, gas, steam/hot water and
   air conditioning provision
6. Financial services and insurance 18. Arts, entertainment and recreation
7. Water supply, waste management and
   recycling, waste disposal and cleaning of waste and trash
8. Real Estate 19. Other service activities
9. Construction 13. Professional, scientific and technical services 20. Personal services serving households; activities
   that produce goods and services by households used for themselves to meet needs
10. Wholesale and retail trade; repair
    and maintenance of cars and motorcycles
11. Rental and leasing services without
    option rights, labor, travel agencies and other business support services
12. Activities of international bodies and other extra-international bodies

INSURANCE BROKERAGE COMPANY
FORM LK01
FINANCIAL POSITION REPORT
Semester ... / Year ...
(In Rupiah)
Description Code Details Semester ... / Year ... ASSETS 0 Cash and Cash Equivalents 1100 PK01

• Operational Account 1110
• Premium Account 1120 PK02
  Investments 1200 PK03
  Premium Receivables 1300 PK04
  Intermediation Service Receivables 1400 PK05 Consulting Receivables 1500 PK06 Claim Handling Service Receivables 1600 PK06 Fixed Assets 1700 PK07 Other Assets 1900 PK08 Total Assets 1000 LIABILITIES & EQUITY 0 Liabilities 0 Premium Payables 2100 PK09 Deferred Intermediation Service Revenue 2200 Claim Payables 2300 PK10 Commission Payables 2400 PK11 Tax Payables 2500 PK12 Other Payables 2900 PK13 Total Liabilities 2000 Equity 0 Paid-in Capital 3100 Additional Paid-in Capital 3200 Retained Earnings 3300 Current Year Profit 3400 Other Equity 3500
• Balance of Other Equity Components 3510
• Increase (Decrease) of Other Equity Components 3520
  Total Equity 3000
  Total Liabilities and Equity

INSURANCE BROKERAGE COMPANY
FORM LK02
COMPREHENSIVE INCOME STATEMENT Semester ... / Year ... (In Rupiah) Description Code Details Semester ... / Year ... REVENUE 0 Intermediation Service Revenue Direct Intermediation Service Revenue 4100 LR01 Indirect Intermediation Service Revenue 4200 LR01 Consulting Service Revenue 4300 LR01 Claim Handling Service Revenue 4400 LR01 Other Revenue 4900 LR03 Total Revenue 4000 EXPENSES Operating Expenses Employee and Management Expenses 5100 LR04 Education and Training Expenses 5200 LR05 Marketing Expenses 5300 Commission Expenses 5400 LR06 Other Operating Expenses 5500 LR07 Non-Operating Expenses 5900 LR08 Total Expenses 5000 Profit (Loss) Before Tax 6100 Tax Expense 5600 Profit (Loss) After Tax 6200 Comprehensive Income (Expense) Increase (Decrease) in Fixed Asset Valuation 5710 Foreign Currency and Other Gains (Losses) 5720 Total Comprehensive Income (Expense) 5700 Comprehensive Profit (Loss) 6300

INSURANCE BROKERAGE COMPANY
FORM LK03
CASH FLOW STATEMENT
Semester ... / Year ...
(in Rupiah)
Description Semester ... / Year ...
Beginning Cash-Bank Balance
Cash Flows from Operating Activities Cash Inflows for Operating Activities Cash Inflows from Premiums (Net) Cash Inflows from Direct Intermediation Service Revenue Cash Inflows from Indirect Intermediation Service Revenue Cash Inflows from Consulting Services Cash Inflows from Claim Handling Service Revenue Cash Inflows from Insurance Company Claims Cash Inflows from Other Operating Activity Revenue Cash Outflows for Operating Activities Cash Outflows for Premiums to Insurance Companies Cash Outflows for Premium Refunds to Insured Cash Outflows for Employee and Management Expenses Cash Outflows for Education Expenses Cash Outflows for Marketing Expenses Cash Outflows for Commission Expenses Cash Outflows for Claims to Insured Cash Outflows for Other Operating Activity Payments Total Cash Flows from Operating Activities Cash Flows from Investing Activities Cash Inflows from Investing Activities Cash Inflows from Investment Returns Cash Inflows from Investment Withdrawals Cash Inflows from Asset Sales Cash Inflows from Other Investing Activities Cash Outflows for Investing Activities Cash Outflows for Investment Placements Cash Outflows for Purchase of Fixed Assets Cash Outflows for Other Investing Activities Total Cash Flows from Investing Activities

(in Rupiah)
Description Semester ... / Year ...
Cash Flows from Financing Activities Cash Inflows from Financing Activities Cash Inflows from Deposits Cash Inflows from Loans Cash Inflows from Other Financing Activities Cash Outflows for Financing Activities Cash Outflows for Dividend Payments Cash Outflows for Loan Repayments Cash Outflows for Other Financing Activities Total Cash Flows from Financing Activities Net Increase (Decrease) in Cash and Cash Equivalents Ending Cash-Bank Balance

INSURANCE BROKERAGE COMPANY
FORM LK04
STATEMENT OF CHANGES IN EQUITY Semester ... / Year ... (In Rupiah) Description Amount Beginning Equity Balance Additions

• Paid-in Capital
• Additional Paid-in Capital
• Current Year Profit
• OCI Gains
• Other Additions
  Total Additions
  Deductions
• Dividend Distribution
• Additional Paid-in Capital
• Current Year Loss
• OCI Losses
• Other Deductions
  Total Deductions
  Ending Equity Balance

INSURANCE BROKERAGE COMPANY
FORM PK01
CASH AND CASH EQUIVALENTS
Semester ... / Year ...
(in Rupiah)
No. Account Number Type of Cash and Cash Equivalents Amount 1 Petty Cash / Operational Account / Premium Account ... Total Cash and Cash Equivalents

INSURANCE BROKERAGE COMPANY
FORM PK02
PREMIUM ACCOUNT CHANGE REPORT
Semester ... / Year ...
(in Rupiah)
Description Semester ...
Beginning Premium Account Balance Additions Net Premium Receipts Service Fee Receipts Bank Interest Receipts Claim Receipts from Insurance Companies Total Additions Deductions Premium Deposits to Insurance Companies Service Fee Transfers to Operational Accounts Premium Refund Transfers Account Interest Transfers to Operational Accounts Claim Payments to Insured Total Deductions Increase (Decrease) in Premium Account Ending Premium Account Balance

INSURANCE BROKERAGE COMPANY
FORM PK03
INVESTMENTS
Semester ... / Year ...
(in Rupiah)
No. Type of Investment Amount
1 Property
2 Deposits
3 Government Bonds
4 Bonds
5 Stocks
6 Others
...
Total Investments

INSURANCE BROKERAGE COMPANY
FORM PK04
PREMIUM RECEIVABLES
Semester ... / Year ...
(in Rupiah)
No. Invoice Number Insured Debtor Invoice Amount Business Line Debtor Status Aging Amount 1 Property Individuals / Companies < 30 Days/ 30 - 90 Days / > 90 Days 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous ... Combined Total Premium Receivables

INSURANCE BROKERAGE COMPANY
FORM PK05
INTERMEDIATION SERVICE RECEIVABLES Semester ... / Year ... (in Rupiah) No. Insured Name Insurance Company Type Status Debtor Aging Amount 1 Direct/Indirect Individuals / Companies < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Total Intermediation Service Receivables

INSURANCE BROKERAGE COMPANY
FORM PK06
CONSULTING AND CLAIM HANDLING SERVICE RECEIVABLES Semester ... / Year ... (in Rupiah) No. Debtor Name Type of Receivable Debtor Status Aging Amount 1 Consulting Receivables / Claim Handling Service Receivables Individuals / Companies < 30 Days/ 30 - 90 Days / > 90 Days ... Total Intermediation Service Receivables

INSURANCE BROKERAGE COMPANY
FORM PK07
FIXED ASSETS
Semester ... / Year ...
(in Rupiah)
No. Type of Asset Acquisition Cost Accumulated Depreciation Book Value 1 Land / Buildings / Vehicles / Office Equipment / Other Fixed Assets ... Total Fixed Assets

INSURANCE BROKERAGE COMPANY
FORM PK08
OTHER ASSETS
Semester ... / Year ...
(in Rupiah)
No. Asset Name Type of Asset Balance 1 Employee Receivables / Prepaid Expenses / Deferred Taxes / Others ... Total Other Assets

INSURANCE BROKERAGE COMPANY
FORM PK09
PREMIUM PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Invoice Number
Insurance Company Creditor
Invoice Amount Business Line Insured Status Debtor Payment Status Aging Amount 1 Property Paid / Unpaid Individuals / Companies < 30 Days/ 30 - 90 Days /

90 Days
2 Motor Vehicles
3 Transportation
4 Ship Hulls
5 Aircraft Hulls
6 Satellites
7 Offshore Energy
8 Onshore Energy
9 Engineering
10 Liability
11 Personal Accident and
Health
12 Credit
13 Suretyship
14 Miscellaneous
...
Combined
Total Premium Payables

INSURANCE BROKERAGE COMPANY
FORM PK10
CLAIM PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Insured Name Insurance Company Name Business Line Amount 1 Property 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous ... Combined Total Claim Payables

INSURANCE BROKERAGE COMPANY
FORM PK11
COMMISSION PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Commission Recipient Type of Business Amount 1 Individuals / Companies ... Total Commission Payables

INSURANCE BROKERAGE COMPANY
FORM PK12
TAX PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Type of Tax Amount
1 PPh 21
2 PPh 25
3 ...
4 ...
5 ...
6 ...
7 ...
8 ...
9 ...
...
Others
Total Tax Payables

INSURANCE BROKERAGE COMPANY
FORM PK13
OTHER PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Creditor Amount
...
Combined
Total Other Payables

INSURANCE BROKERAGE COMPANY
FORM LR01
REVENUE
Semester ... / Year ...
(in Rupiah)
No. Business Line Amount
Policy
Placement Location Premium Intermediation Service Revenue Consulting Service Revenue Claim Handling Service Revenue Direct Indirect 1 Property Domestic / ASEAN / NON-ASEAN 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship ... Miscellaneous Total

INSURANCE BROKERAGE COMPANY
FORM LR02
TOP 30 INSURANCE PLACEMENT REVENUE Semester ... / Year ... (in Rupiah) No. Insurer Amount Policy Placement Location Premium Intermediation Service Revenue Consulting Service Revenue Claim Handling Service Revenue Direct Indirect 1 Domestic / ASEAN / NON-ASEAN ... Total

INSURANCE BROKERAGE COMPANY
FORM LR03
OTHER REVENUE
Semester ... / Year ...
(in Rupiah)
No. Description Amount
...
Total Other Revenue

INSURANCE BROKERAGE COMPANY
FORM LR04
EMPLOYEE AND MANAGEMENT EXPENSES Semester ... / Year ... (in Rupiah) Description Amount Management Salaries Management Allowances Employee Salaries Employee Allowances Other Management Expenses Other Employee Expenses Total Employee and Management Expenses

INSURANCE BROKERAGE COMPANY
FORM LR05
EDUCATION AND TRAINING EXPENSES Semester ... / Year ... (in Rupiah) No. Activity Name Activity Period Activity Location Amount ... Total Education and Training Expenses

INSURANCE BROKERAGE COMPANY
FORM LR06
COMMISSION EXPENSES
Semester ... / Year ...
(in Rupiah)
No. Commission Recipient Debtor Status Business Line Amount 1 Individuals / Companies Property 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship ... Miscellaneous Total Commission Expenses

INSURANCE BROKERAGE COMPANY
FORM LR07
OTHER OPERATING EXPENSES
Semester ... / Year ...
(in Rupiah)
Description Amount
Water and Electricity
Telephone and Internet
Transportation
Depreciation
Rent
Maintenance and Repair
Other Operating Expenses
Total Other Operating Expenses

INSURANCE BROKERAGE COMPANY
FORM LR08
OTHER NON-OPERATING EXPENSES
Semester ... / Year ...
(in Rupiah)
No. Description Amount
Total Other Non-Operating Expenses

INSURANCE BROKERAGE COMPANY
FORM OP1
PROFESSIONAL INDEMNITY INSURANCE POLICY Semester ... / Year ... (in Rupiah) No. Insurer Name Policy Number Coverage Amount Premium Deductible Coverage Period Notes ...

INSURANCE BROKERAGE COMPANY
FORM OP02
TOP 30 CLAIM HANDLING
Semester ... / Year ...
(in Rupiah)
No. Insured Name
Policy Number
Business Line Coverage Amount
Date of
Incident
Estimated Loss Amount
Insurance Company
Claim Status Notes
1 Property Paid / In
Process / Rejected
2 Motor Vehicles
3 Transportation
4 Ship Hulls
5 Aircraft Hulls
6 Satellites
7 Offshore Energy
8 Onshore Energy
9 Engineering
10 Liability
11 Personal Accident and
Health
12 Credit
13 Suretyship
...
Miscellaneous
Total

INSURANCE BROKERAGE COMPANY
FORM OP03
CLAIM HANDLING DEVELOPMENT
Semester ... / Year ...
(in Rupiah)
No. Business Line Claim Status Total Claim Cases Total Loss Value 1 Property Paid / In Process / Rejected 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship ... Miscellaneous Total

FORMAT I B
FORM AND STRUCTURE OF SEMI-ANNUAL REPORTS AND ANNUAL REPORTS FOR FINANCIAL ASPECTS FOR REINSURANCE BROKERAGE COMPANIES

To
Yth. Directorate of IKNB Support Services Financial Services Authority

FINANCIAL REPORT
REINSURANCE BROKERAGE COMPANY
Semester ... / Year ...

General Data
Reporting Date
Company Code
Company Name
Company Address
Reporting Period
Reporting Month
Fiscal Year
Type of Reporting Period
Board of Directors Name
Board of Directors Position

FORMAT C
STRUCTURE AND ARRANGEMENT OF SEMI-ANNUAL AND ANNUAL REPORTS FOR FINANCIAL ASPECTS FOR INSURANCE LOSS ASSESSORS

To
Directorate of IKNB Supporting Services Financial Services Authority

FINANCIAL STATEMENTS
INSURANCE LOSS ASSESSOR
Year ...

General Data
Reporting Date
Company Code
Company Name
Company Address
Reporting Period
Reporting Month
Fiscal Year
Type of Reporting Period
Board of Directors Name
Board of Directors Position

INSURANCE LOSS ASSESSOR
FORM PP01
GENERAL INFORMATION
Year ...
Description

1. Head Office Address 0

• Building Name and Floor
• Street Name and Number
• Village/Sub-district
• District
• Regency/City
• Province
• Postal Code

2. Telephone
3. Fax
4. Email
5. Website Address
6. Taxpayer Identification Number (NPWP)
7. Business License 0

• Business License Number
• Business License Date

8. Number of Offices Other Than Head Office
9. Number of Affiliate Companies
10. Number of Employees
    (including directors and staff)
11. Number of Partners in Business Acquisition #VALUE!

• Individuals
• Legal Entities

12. Auditor 0

• Public Accounting Firm
• Public Accountant
• Registration Certificate Number (STTD)

13. OJK Liaison Officer 0

• Name
• Mobile Phone
• Email

INSURANCE LOSS ASSESSOR
FORM PP02
SHAREHOLDER LIST
Year ...
No. Shareholder Name Share Ownership SK of Competency and Fit Test OJK Approval Letter Nominal % Date Number Number Date ... Total

INSURANCE LOSS ASSESSOR
FORM PP03
BOARD OF DIRECTORS LIST
Year ...
No. Director Name Position SK of Competency and Fit Test OJK Approval Letter Date Number Number Date 1 President Director / Director / Commissioner / Commissioner

INSURANCE LOSS ASSESSOR
FORM PP04
EXPERTS LIST
Year ...
No. Name Degree Profession Appointment SK OJK Registration Letter Registration Number Date Number Date Number 1 ICAP / ANZIIF ...

INSURANCE LOSS ASSESSOR
FORM PP05
OFFICES OTHER THAN HEAD OFFICE LIST Year ...
No. Operational Area/
Territorial Coverage
Type of Office Address Regency/City Telephone Email Office Head Number of Employees 1 Branch / Representative / Marketing / Operational ... Total

INSURANCE LOSS ASSESSOR
FORM PP06
AFFILIATED COMPANIES LIST
Year ...
No. Affiliate Company Name Address Regency/City Telephone Email Business Type Affiliation Relationship 1 Financial / Management / Family ... Business Type:

1. Agriculture, forestry and fisheries 8. Transportation and warehousing 15. Government administration, defense and mandatory social security
2. Mining and quarrying 9. Accommodation and food and beverage services 16. Education services
3. Manufacturing industry 10. Information and communication 17. Health and social services
4. Electricity, gas, steam/hot water and air conditioning supply 11. Financial and insurance services 18. Arts, entertainment and recreation
5. Water supply, waste management and recycling, disposal and cleaning of waste and garbage 12. Real Estate 19. Other service activities
6. Construction 13. Professional, scientific and technical services 20. Personal services for households; activities producing goods and services by households used for own needs
7. Wholesale and retail trade; repair and maintenance of cars and motorcycles 14. Rental and leasing services without option, employment, travel agencies and other business support services 21. Activities of international bodies and other extra-international bodies

INSURANCE LOSS ASSESSOR
FORM LK01
STATEMENT OF FINANCIAL POSITION Year ...
(In Rupiah)
Description Code Details Year ...
Cash and Cash Equivalents 1100 PK01 Investments 1200 PK02 Claims Handling Service Receivables 1300 PK03 Advance Funds Receivables 1400 PK04 Consulting Service Receivables 1600 PK05 Fixed Assets 1600 PK06 Other Assets 1900 PK07 Total Assets 1000 LIABILITIES & EQUITY 0 Liabilities 0 Commission Payable 2100 PK08 Tax Payable 2200 PK09 Other Payables 2300 PK10 Total Liabilities 2000 Equity 0 Paid-in Capital 3100 Additional Paid-in Capital 3200 Retained Earnings 3300 Current Year Profit 3400 Other Equity 3500

• Balance of Other Equity Components 3510
• Increase (Decrease) of Other Equity Components 3520
  Total Equity 3000
  Total Liabilities and Equity

INSURANCE LOSS ASSESSOR
FORM LK02
COMPREHENSIVE INCOME STATEMENT Year ...
(In Rupiah)
Description Code Details Year ...
Consulting Service Revenue 4200 LR01 Other Revenue 4900 LR03 Total Revenue 4000 EXPENSES Operating Expenses Employee and Director Expenses 5100 LR04 Education and Training Expenses 5200 LR05 Marketing Expenses 5300 Commission Expenses 5400 LR06 Other Operating Expenses 5500 LR07 Non-Operating Expenses 5900 LR08 Total Expenses 5000 Profit (Loss) Before Tax 6100 Tax Expense 5600 Profit (Loss) After Tax 6200 Comprehensive Income (Expense) Increase (Decrease) in Fixed Asset Valuation 5710 Foreign Currency and Other Gains (Losses) 5720 Total Comprehensive Income (Expense) 5700 Comprehensive Profit (Loss) 6300

INSURANCE LOSS ASSESSOR
FORM LK03
CASH FLOW STATEMENT
Year ...
(In Rupiah)
Description Year ...
Cash Flow from Operating Activities Cash Inflows for Operating Activities Cash Inflows from Claims Valuation Services Cash Inflows from Consulting Services Cash Inflows from Advance Funds Return Cash Inflows from Other Operating Activity Revenue Cash Outflows for Operating Activities Cash Outflows for Employee and Director Expenses Cash Outflows for Education Expenses Cash Outflows for Marketing Expenses Cash Outflows for Commission Expenses Cash Outflows for Other Operating Activity Payments Total Cash Flow from Operating Activities Cash Flow from Investment Activities Cash Inflows from Investment Activities Cash Inflows from Investment Income Receipt Cash Inflows from Investment Liquidation Cash Inflows from Asset Sales Cash Inflows from Other Investment Activities Cash Outflows for Investment Activities Cash Outflows for Investment Placement Cash Outflows for Fixed Asset Purchases Cash Outflows for Other Investment Activities Total Cash Flow from Investment Activities

Description Year ...
Cash Flow from Financing Activities Cash Inflows from Financing Activities Cash Inflows from Deposits Cash Inflows from Loans Cash Inflows from Other Financing Activities Cash Outflows for Financing Activities Cash Outflows for Dividend Payments Cash Outflows for Loan Repayments Cash Outflows for Other Financing Activities Total Cash Flow from Financing Activities Net Increase (Decrease) in Cash and Cash Equivalents Ending Cash - Bank Balance

INSURANCE LOSS ASSESSOR
FORM LK04
STATEMENT OF CHANGES IN EQUITY Year ...
(In Rupiah)
Description Amount
Increases

• Paid-in Capital
• Additional Paid-in Capital
• Current Year Profit
• OCI Gain
• Other Increases
  Total Increases
  Decreases
• Dividend Distribution
• Additional Paid-in Capital
• Current Year Loss
• OCI Loss
• Other Decreases
  Total Decreases
  Ending Equity Balance

INSURANCE LOSS ASSESSOR
FORM PK01
CASH AND CASH EQUIVALENTS
Year ...
(In Rupiah)
No. Account Number Type of Cash and Cash Equivalents Amount 1 Petty Cash / Bank ... Total Cash and Cash Equivalents

INSURANCE LOSS ASSESSOR
FORM PK02
INVESTMENTS
Year ...
(In Rupiah)
No. Investment Type Amount
1 Property
2 Deposits
3 Government Bonds
4 Bonds
5 Stocks
6 Others
...
Total Investments

INSURANCE LOSS ASSESSOR
FORM PK03
CLAIMS HANDLING SERVICE RECEIVABLES Year ...
(In Rupiah)
No. Work Order Number Client Business Type Status Aging Amount 1 Individual / Company < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Total Claims Valuation Service Receivables

INSURANCE LOSS ASSESSOR
FORM PK04
ADVANCE FUNDS RECEIVABLES
Year ...
(In Rupiah)
No. Client Business Type Status Aging Amount 1 Individual / Company < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Total Advance Funds Receivables

INSURANCE LOSS ASSESSOR
FORM PK05
CONSULTING SERVICE RECEIVABLES Year ...
(In Rupiah)
No. Client Business Type Status Aging Amount 1 Individual / Company < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Total Consulting Service Receivables

INSURANCE LOSS ASSESSOR
FORM PK06
FIXED ASSETS
Year ...
(In Rupiah)
No. Asset Type Acquisition Cost Accumulated Depreciation Book Value 1 Land / Buildings / Vehicles / Office Equipment / Other Fixed Assets ... Total Fixed Assets

INSURANCE LOSS ASSESSOR
FORM PK07
OTHER ASSETS
Semester ... / Year ...
(In Rupiah)
No. Asset Name Asset Type Balance 1 Employee Receivables / Prepaid Expenses / Deferred Taxes / Others ... Total Other Assets

INSURANCE LOSS ASSESSING COMPANY FORM PK08 COMMISSION PAYABLES Year ... (in Rupiah) No. Commission Recipient Type of Business Entity Amount 1 Individual / Company ... Total Commission Payables

INSURANCE LOSS ASSESSING COMPANY FORM PK09 TAX PAYABLES Year ... (in Rupiah) No. Type of Tax Amount 1 PPh 21 2 PPh 25 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... ... Others Total Tax Payables

INSURANCE LOSS ASSESSING COMPANY FORM PK10 OTHER PAYABLES Year ... (in Rupiah) No. Creditor Amount ... Combined Total Other Payables

INSURANCE LOSS ASSESSING COMPANY FORM LR01 INCOME Year ... (in Rupiah) No. Business Line Amount Assignment Order Value Insured Value Claim Value Type of Income Income 1 Property Damage / Loss Assessing Services / Consulting Services 2 Motor Vehicles 3 Transportation 4 Hull of Ships 5 Hull of Aircraft 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship ... Miscellaneous Total

INSURANCE LOSS ASSESSING COMPANY FORM LR02 TOP 30 INCOME Year ... (in Rupiah) No. Assignor Amount Assignment Order Value Insured Value Claim Value Type of Income Income 1 Loss Assessing Services / Consulting Services ... Total

INSURANCE LOSS ASSESSING COMPANY FORM LR03 OTHER INCOME Year ... (in Rupiah) No. Description Amount ... Total Other Income

INSURANCE LOSS ASSESSING COMPANY FORM LR04 EMPLOYEE AND MANAGEMENT EXPENSES Year ... (in Rupiah) Description Amount Management Salaries Management Allowances Employee Salaries Employee Allowances Other Management Expenses Other Employee Expenses Total Employee and Management Expenses

INSURANCE LOSS ASSESSING COMPANY FORM LR05 EDUCATION AND TRAINING EXPENSES Year ... (in Rupiah) No. Activity Name Activity Period Activity Location Amount ... Total Education and Training Expenses

INSURANCE LOSS ASSESSING COMPANY FORM LR06 COMMISSION EXPENSES Year ... (in Rupiah) No. Commission Recipient Business Entity Status Business Line Amount 1 Individual / Company Property Damage 2 Motor Vehicles 3 Transportation 4 Hull of Ships 5 Hull of Aircraft 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship ... Miscellaneous Total Commission Expenses

INSURANCE LOSS ASSESSING COMPANY FORM LR07 OTHER OPERATIONAL EXPENSES Year ... (in Rupiah) Description Amount Water and Electricity Telephone and Internet Transportation Depreciation Rent Maintenance and Repair Other Operational Expenses Total Other Operational Expenses

INSURANCE LOSS ASSESSING COMPANY FORM LR08 OTHER NON-OPERATIONAL EXPENSES Year ... (in Rupiah) No. Description Amount Total Other Non-Operational Expenses

This copy is in accordance with the original Legal Director 1 Legal Department signed Yuliana Established in Jakarta on January 24, 2018 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 3 /SEOJK.05/2018 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSING COMPANIES

I. Report on the Implementation of Good Corporate Governance for Insurance
Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies

1. Transparency of Good Corporate Governance Implementation
   a. Implementation of the General Meeting of Shareholders (GMS) Implementation of annual GMS and extraordinary GMS, as well as decisions produced at each GMS No. Time Implementation Agenda Participants GMS Decisions Notary Deed Number Notes 1. 2. Etc. b. Board of Directors

1. Number, names, positions, criteria, date of appointment by GMS,
   term of office, nationality, and domicile of Board of Directors members No Name Position Criteria Date Appointment by GMS Term of Office Nationality Domicile Last Formal Education and Professional Title Competency and Fit and Proper Test 1. 2. Etc.
2. In the event that there are changes in the composition of Board of Directors
   members during the reporting year, the previous Board of Directors composition must be stated with a table as follows:
   No. Name Position Date of Appointment by GMS Date of Dismissal by GMS
3. Concurrent positions of Board of Directors members
   No. Name
   Position in
   Company
   Position in
   Other Company
   Name of
   Other Company
   Business Field

Etc.
2.
1.
2.
Etc.
Etc

4. Frequency of Board of Directors meetings held in 1 (one) year.
   No Name Position
   Number of Board of Directors Meetings (... meetings) % Attendance Physical Attendance Teleconference/Video/ Conference/Other Electronic Media Facilities 1. 2. Etc
5. Disclosure of share ownership by Board of Directors members reaching 5%
   (five percent) or more of paid-up capital, including the type and number of share certificates. No Name Position Board of Directors member share ownership reaching 5% (five percent) or more of paid-up capital A B C D Note:
   Indonesia
   /Foreign
   Total
   Nominal
   Shares
   %
   Ownership
   Total
   Nominal
   Shares
   %
   Ownership
   Total
   Nominal
   Shares
   %
   Ownership
   Total
   Nominal
   Shares
   %
   Ownership

Etc.
Notes:
A. The company itself;
B. other insurance companies;
C. financial service companies other than insurance companies; and
D. other companies located both domestically and abroad, including shares obtained through the stock exchange.
6) Financial relationships and family relationships of Board of Directors members with
other Board of Directors members, Board of Commissioners members, and/or shareholders of the company where the Board of Directors member serves. No. Name Financial Relationship With Other Directors Board of Commissioners Shareholders Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc No. Name Family Relationship With Other Directors Board of Commissioners Shareholders Yes No Note* Yes No Note* Yes No Note * 1. 2.

Notes:
*) Form of financial relationship: debt-credit, business cooperation, etc. ) Form of family relationship: spouse/children/parents/siblings/ in-laws, etc.
c. Board of Commissioners

1. Number, names, positions, criteria, date of appointment by GMS,
   term of office, nationality, and domicile of Board of Commissioners members No Name Position Criteria Date Appointment by GMS Term of Office Nationality Domicile Last Formal Education and Professional Title Competency and Fit and Proper Test 1. 2. Etc.
2. In the event that there are changes in the composition of Board of Commissioners
   members during the reporting year, the previous Board of Commissioners composition must be stated with a table as follows:
   No. Name Position
   Date
   Appointment by
   GMS
   Date of Dismissal by GMS
3. Concurrent positions of Board of Commissioners members
   No. Name
   Position in
   Company
   Position in
   Other Company
   Name of
   Other Company
   Business Field

Etc.
2. 1.
2.
Etc.
Etc.
4) Frequency of Board of Commissioners meetings held in 1
(one) year.
No Name Position
Number of Board of Directors Meetings (... meetings) % Attendance Physical Attendance Teleconference/Video/ Conference/Other Electronic Media Facilities

Etc
5) Board of Commissioners meetings with the Board of Directors
No
Name Position
Number of Commissioners Meetings (... meetings) % Attendance Physical Attendance Teleconference/Video/ Conference/Other Electronic Media Facilities 1. 2. Etc
6) Disclosure of share ownership by Board of Commissioners members
reaching 5% (five percent) or more of paid-up capital, including the type and number of share certificates. No Name Position Board of Directors member share ownership reaching 5% (five percent) or more of paid-up capital A B C D Note:
Indonesia
/Foreign
Total
Nominal
Shares
%
Ownership
Total
Nominal
Shares
%
Ownership
Total
Nominal
Shares
%
Ownership
Total
Nominal
Shares
%
Ownership
1.
2.
Etc.
Notes:
A. The company itself;
B. other insurance companies;
C. financial service companies other than insurance companies; and
D. other companies located both domestically and abroad, including shares obtained through the stock exchange.
7) Financial relationships and family relationships of Board of Commissioners
members with other Board of Commissioners members, Board of Directors members, and/or shareholders of the company where the Board of Commissioners member serves Name Financial Relationship With Other Board of Commissioners Directors Shareholders Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc

No. Name
Family Relationship With
Other Board of Commissioners
Directors Shareholders
Yes No Note* Yes No Note* Yes No Note* 1.
2.
Etc
Notes:
*) Form of financial relationship: debt-credit, business cooperation, etc. ) Form of family relationship: spouse/children/parents/siblings/ in-laws, etc. d. Board of Commissioners Supervision Results Report Summary of Supervision Results Recommendations e. Implementation of external auditor functions. No. Description Year n-2 Year n-1 Year n

1. Name of Public Accounting Firm
2. Name of Public Accountant
3. Audit Period
4. GMS Number
   f. Implementation of remuneration policies and other facilities for Board of Directors members, Board of Commissioners members, Number of Board of Directors, Board of Commissioners, and employees receiving remuneration packages in 1 (one) year, grouped according to income level as follows:
   Total Remuneration per person in 1 year *) Total Directors Total Board of Commissioners Employees Above Rp2 billion Above Rp1 billion to Rp2 billion Above Rp500 million to Rp1 billion Below Rp500 million Notes:
   *) requested in cash g. Information Technology Governance No. Description Checklist *) If Yes, Explain. Yes No
5. Does the company have an information system
   organizational structure?

Does the company have guidelines for the use of information systems equipped with instructions or work orders for each function (standard operating procedure)?
3. Does the company have guidelines for
data security management (data back-up)?
4. Does the company have guidelines for
incident management (disaster recovery plan)? h. Number of internal deviations (internal fraud) Disclosure of internal deviations must at least include:
Internal deviations in
Year
Number of cases committed by
Board of Commissioners and
Board of Directors Members
Permanent
Employees
Non-permanent
Employees
T-1 T T-1 T T-1 T
Total deviations
Resolved
In the process of internal resolution Resolution not yet attempted Followed up through legal processes.
i. Legal issues
Legal Issues Number of Cases
Civil Criminal
Has obtained a final and binding judgment In the process of resolution in court and in Alternative Dispute Resolution Institutions Disputes for civil cases Total j. Company functions outsourced to other parties (outsourcing) No. Function Outsourced Name of Other Party Business License Contract Duration 1. 2. Etc. k. Disclosure of other important matters No. Description Checklist *) If Yes, Explain. Yes No

1. Resignation or dismissal of external
   auditor
2. Material transactions with related parties
3. Material claims filed by and/or
   against the Insurance Company
4. Conflicts of Interest currently ongoing
   and/or likely to occur
5. Other material information regarding the
   Insurance Company
6. The company has a compliance function
7. The company has an internal auditor
8. The company has a risk management function
9. The company has an investment management
   function/unit

The company has a special work unit and/or appoints a Financial Service Institution official responsible for the implementation of AML and CFT programs *) choose one answer by placing a “√” sign ) Related Parties are individuals or companies/entities that have a control relationship with the Company, directly or indirectly, through ownership, management, and/or financial relationships
2. Self-Assessment of Good Corporate Governance Implementation for Insurance
Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies. ☑ Self-assessment of Good Corporate Governance implementation for Insurance Brokerage Companies and Reinsurance Brokerage Companies is conducted based on the Guidelines for Good Corporate Governance and the self-assessment checklist (self assessment) prepared by the National Governance Policy Committee (KNKG) as a committee formed by the government tasked with formulating good corporate governance policies. ☑ Self-assessment of Good Corporate Governance implementation for Insurance Loss Assessing Companies is not yet in effect until the Guidelines for Good Corporate Governance for Insurance Loss Assessing Companies and the self-assessment checklist (self assessment) by the National Governance Policy Committee (KNKG) as a committee formed by the government tasked with formulating good corporate governance policies are established.
3. Action Plan.
No. Corrective Action Target
Resolution
Resolution Obstacles Notes
1.
Etc
II. Report on the Implementation of Risk Management for Insurance Brokerage Companies,
Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies

1. Overview of General Risk Management Implementation
   a) Active Supervision by the Board of Directors and Board of Commissioners (To be filled with a description of the roles of the Board of Directors and Board of Commissioners in Risk Management and the Risk Management organizational structure) b) Adequacy of Policies, Procedures, and Risk Limit Setting (To be filled with a description of risk appetite, risk tolerance, and risk limit setting)

c) Adequacy of the Risk Identification, Measurement, Monitoring, and Control Process (To be filled with a description of the Risk Identification, Measurement, Monitoring, and Control Process) d) Risk Management Information System (To be filled with a description of how the company's information system supports Risk Management implementation) e) Comprehensive Internal Control System (To be filled with a description of how internal control including the compliance function is conducted by the company)
2) Risk Management Implementation for Each Type of Risk
a) Strategic Risk
Scope of Risk Management
Implementation
Description
Active Supervision by the Board of Directors and Board of Commissioners (To be filled with a description of active supervision by the Board of Directors and Board of Commissioners over Strategic Risk) Adequacy of Policies, Procedures, and Risk Limit Setting (To be filled with a description of risk appetite, risk tolerance, and limit setting for Strategic Risk) Adequacy of the Process for Identification, Measurement, Monitoring, and (To be filled with a description of the identification process, measurement, monitoring, and control for Strategic Risk) Risk Management Information System (To be filled with a description of how the company's information system supports Risk Management implementation for Strategic Risk) Comprehensive Internal Control System (To be filled with a description of how internal control including the compliance function is conducted by the company for Strategic Risk)

b) Operational Risk
Scope of Risk Management
Implementation
Description
Active Supervision by the Board of Directors and Board of Commissioners (To be filled with a description of active supervision by the Board of Directors and Board of Commissioners over Operational Risk) Adequacy of Policies, Procedures, and Risk Limit Setting (To be filled with a description of risk appetite, risk tolerance, and limit setting for Operational Risk) Adequacy of the Process for Identification, Measurement, Monitoring, and Risk Control (To be filled with a description of the identification process, measurement, monitoring, and control for Operational Risk) Risk Management Information System (To be filled with a description of how the company's information system supports Risk Management implementation for Operational Risk) Comprehensive Internal Control System (To be filled with a description of how internal control including the compliance function is conducted by the company for Operational Risk) c) Management Risk Scope of Risk Management Implementation Description Active Supervision by the Board of Directors and Board of Commissioners (To be filled with a description of active supervision by the Board of Directors and Board of Commissioners over Operational Risk) Adequacy of Policies, Procedures, and Risk Limit Setting (To be filled with a description of risk appetite, risk tolerance, and limit setting for Operational Risk) Adequacy of the Process for Identification, Measurement, Monitoring, and (To be filled with a description of the identification process, measurement, monitoring, and control for Operational Risk) Risk Management Information System (To be filled with a description of how the company's information system supports Risk Management implementation for Operational Risk) Comprehensive Internal Control System (To be filled with a description of how internal control including the compliance function is conducted by the company for Operational Risk) d) Governance Risk Scope of Risk Management Implementation Description Active Supervision by the Board of Directors and Board of Commissioners (To be filled with a description of active supervision by the Board of Directors and Board of Commissioners over Governance Risk)

Scope of Risk Management
Implementation
Description
Adequacy of Policies,
Procedures, and Risk Limit
Setting
(To be filled with a description of risk appetite, risk tolerance, and limit setting for Governance Risk) Adequacy of the Process for Identification, Measurement, Monitoring, and (To be filled with a description of the identification process, measurement, monitoring, and control for Governance Risk) Risk Management Information System (To be filled with a description of how the company's information system supports Risk Management implementation for Governance Risk) Comprehensive Internal Control System (To be filled with a description of how internal control including the compliance function is conducted by the company for Governance Risk) Established in Jakarta on January 24, 2018 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI This copy is in accordance with the original Legal Director 1 Legal Department signed Yuliana