Circular Letter of the Financial Services Authority Number 31/SEOJK.05/2015 Concerning Own Retention Limits, Amount of Reinsurance Support, and Automatic Reinsurance/Retrosession Program Reports

To:

Board of Directors of General Insurance Companies;
Board of Directors of Shariah General Insurance Companies;
Board of Directors of Life Insurance Companies;
Board of Directors of Shariah Life Insurance Companies;
Board of Directors of Reinsurance Companies; and
Board of Directors of Shariah Reinsurance Companies,

at your address.

CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 31/SEOJK.05/2015

CONCERNING
OWN RETENTION LIMITS, AMOUNT OF REINSURANCE SUPPORT, AND REPORTS ON AUTOMATIC REINSURANCE/RETROSESSION PROGRAMS

In accordance with the mandate of Article 3, Article 10 paragraph (4), Article 18 paragraph (4), and Article 32 of the Financial Services Authority Regulation Number 14/POJK.5/2015 concerning Own Retention and Domestic Reinsurance Support (State Gazette of the Republic of Indonesia Year 2015 Number 265, Supplement to the State Gazette of the Republic of Indonesia Number 5754), it is necessary to regulate own retention limits, the minimum amount of automatic and facultative reinsurance support placement with priority to domestic reinsurers, as well as the form, structure, and procedures for submitting automatic reinsurance/retrosession program reports, in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

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

Company means an insurance company, a Shariah insurance company, a reinsurance company, and a Shariah reinsurance company.
Insurance Company means a general insurance company and a life insurance company as referred to in Law Number 40 of 2014 concerning Insurance.
Shariah Insurance Company means a Shariah general insurance company and a Shariah life insurance company as referred to in Law Number 40 of 2014 concerning Insurance.
General Insurance Company means a company conducting general insurance business, and/or reinsurance business for risks of other General Insurance Companies as referred to in Law Number 40 of 2014 concerning Insurance.
Life Insurance Company means a company conducting life insurance business as referred to in Law Number 40 of 2014 concerning Insurance.
Shariah General Insurance Company means a company conducting Shariah general insurance business and/or Shariah reinsurance business for risks of other Shariah General Insurance Companies as referred to in Law Number 40 of 2014 concerning Insurance and/or General Insurance Companies conducting part of their business using Shariah principles.
Shariah Life Insurance Company means a company conducting Shariah life insurance business as referred to in Law Number 40 of 2014 concerning Insurance and/or Life Insurance Companies conducting part of their business using Shariah principles.
Reinsurance Company means a company conducting reinsurance business as referred to in Law Number 40 of 2014 concerning Insurance.
Shariah Reinsurance Company means a company conducting Shariah reinsurance business as referred to in Law Number 40 of 2014 concerning Insurance and/or Reinsurance Companies conducting part of their business using Shariah principles.
Financial Services Authority, hereinafter abbreviated as OJK, is the Financial Services Authority as referred to in Law Number 21 of 2011 concerning the Financial Services Authority.

II. OWN RETENTION LIMITS

Companies are required to have and apply own retention for every risk managed.
The application of own retention as referred to in item 1 is carried out with the following provisions:
a. for Insurance Companies and Reinsurance Companies, according to the own retention limits as stated in Appendix I Table 1.A; and b. for Shariah Insurance Companies and Shariah Reinsurance Companies, according to the own retention limits as stated in Appendix I Table 1.B, which are an inseparable part of this OJK Circular Letter.

III. MINIMUM AMOUNT OF DOMESTIC REINSURANCE SUPPORT PLACEMENT

The minimum amount of automatic reinsurance support placement with priority to domestic reinsurers for Insurance Companies and Shariah Insurance Companies is at least 25% (twenty-five percent) of the automatic reinsurance capacity of each respective insurance business line or the amount as attached in Appendix II Table 2.A which is an inseparable part of this OJK Circular Letter, whichever is larger.
The minimum amount of facultative reinsurance support placement with priority to domestic reinsurers for Insurance Companies and Shariah Insurance Companies is at least 25% (twenty-five percent) of the sum insured per risk of each respective insurance business line or the amount as attached in Appendix II Table 2.B which is an inseparable part of this OJK Circular Letter, whichever is larger.

IV. FORM AND STRUCTURE OF AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORTS

Automatic reinsurance/retrosession program reports for General Insurance Companies and Reinsurance Companies consist of:
a. automatic reinsurance/retrosession program report for all insurance business lines; b. automatic reinsurance/retrosession program report for each insurance business line;
c. projection of underwriting surplus calculation for all business lines;
d. projection of underwriting surplus calculation for each business line; and e. proof of rejection of automatic reinsurance support from domestic reinsurers (if any).
Automatic reinsurance/retrosession program reports for Shariah General Insurance Companies and Shariah Reinsurance Companies consist of:
a. automatic reinsurance/retrosession program report for all insurance business lines; b. automatic reinsurance/retrosession program report for each insurance business line;
c. projection of underwriting surplus calculation for all business lines;
d. projection of underwriting surplus calculation for each business line; and e. proof of rejection of automatic reinsurance support from domestic reinsurers (if any).
Automatic reinsurance program reports for Life Insurance Companies and Shariah Life Insurance Companies consist of:
a. automatic reinsurance program report for all insurance business lines; b. automatic reinsurance program report for each insurance business line; and
c. proof of rejection of automatic reinsurance support from domestic reinsurers (if any).
The form and structure of automatic reinsurance/retrosession program reports for General Insurance Companies and Reinsurance Companies are as stated in Appendix III which is an inseparable part of this OJK Circular Letter.
The form and structure of automatic reinsurance/retrosession program reports for Shariah General Insurance Companies and Shariah Reinsurance Companies are as stated in Appendix IV which is an inseparable part of this OJK Circular Letter.
The form and structure of automatic reinsurance program reports for Life Insurance Companies and Shariah Life Insurance Companies are as stated in Appendix V which is an inseparable part of this OJK Circular Letter.

V. PROCEDURES FOR SUBMISSION OF AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORTS

Companies are required to submit automatic reinsurance/retrosession program reports to OJK annually every year according to the form and structure as referred to in Appendix III, Appendix IV, or Appendix V which are inseparable parts of this OJK Circular Letter.
Automatic reinsurance/retrosession program reports as referred to in item 1 are submitted to OJK online through the OJK data communication network system.
In the event that the OJK data communication network system as referred to in item 2 is not yet available or a technical disturbance occurs at the time of the deadline for submitting automatic reinsurance/retrosession program reports, Companies are required to submit the said automatic reinsurance/retrosession program reports offline in the form of electronic data via compact disc (CD) or other electronic data storage media.
In the event of a technical disturbance at the time of the deadline for submitting automatic reinsurance/retrosession program reports as referred to in item 3, Companies are required to submit the automatic reinsurance/retrosession program reports no later than on the first working day following the occurrence of the technical disturbance.
In the event that the technical disturbance as referred to in item 4 is experienced by OJK, OJK announces in writing to the Companies on the same day following the occurrence of the technical disturbance.
Submission of automatic reinsurance/retrosession program reports offline in the form of electronic data as referred to in item 3 is accompanied by a cover letter signed by the Company's Board of Directors or equivalent and prepared in spreadsheet format.
Submission of automatic reinsurance/retrosession program reports offline as referred to in item 6 is addressed to:
Financial Services Authority a. for General Insurance Companies, Life Insurance Companies, Reinsurance Companies:
u.p. Directorate of Insurance Supervision and BPJS Kesehatan Menara Merdeka Building Mailing Room 12th Floor Jl. Budi Kemuliaan I No.2 Central Jakarta b. for Shariah General Insurance Companies, Shariah Life Insurance Companies, Shariah Reinsurance Companies:
u.p. Shariah IKNB Directorate Menara Merdeka Building Mailing Room 12th Floor Jl. Budi Kemuliaan I No.2 Central Jakarta
Submission of automatic reinsurance/retrosession program reports offline as referred to in item 6 can be done in one of the following ways:
a. handed in directly to the OJK office as referred to in item 7; b. sent via registered post office; or
c. sent via courier/courier service company.
Companies are deemed to have submitted automatic reinsurance/retrosession program reports with the following provisions:
a. for online submission via the OJK data communication network system, proven by a receipt from OJK; b. for offline submission, proven by:
1. a receipt letter from OJK, if the report is handed in directly to the OJK office as referred to in item 8 letter a; or
2. a shipping receipt from the post office or courier/courier service company, if the report is sent via post office or courier/courier service company as referred to in item 8 letter b and letter c.
In the event of a change in the OJK office address for report submission as referred to in item 8, OJK will convey notification regarding the address change via letter or announcement.

VI. CLOSING

The provisions in this Financial Services Authority Circular Letter shall take effect on January 1, 2016.

Determined in Jakarta on the date

EXECUTIVE HEAD OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, FIRDAUS DJAELANI 16 November 2015

signed

Copy in accordance with the original Director of Legal Affairs 1 Legal Department

signed
Sudarmaji

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 31/SEOJK.05/2015 CONCERNING OWN RETENTION LIMITS, AMOUNT OF REINSURANCE SUPPORT, AND AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORTS

Minimum Own Retention per Risk (specific percentage of own capital) 1 Property*) <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 2 Motor Vehicles 150 Million 3 Marine <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 4 Hull <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 0.6% OC 0.45% OC min 3 Billion 0.3% OC min 4.5 Billion 6 Billion 5 Aircraft 0.375% OC 6 Satellite 0.075% OC 7 Onshore Energy <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 8 Offshore Energy <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 0.75% OC 0.56% OC min 3.75 Billion 0.375% OC min 5.625 Billion
7.5 Billion
9 Engineering
<500 Billion

500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 10 Liability 750 Million 11 Death 150 Million 12 Personal Accident 150 Million 13 Health 150 Million 14 Credit 750 Million 15 Suretyship 750 Million 16 Miscellaneous 750 Million

Notes*):

High risk occupation:
a. chemical, oil, gas b. paper, leather, rubber
c. wood, bamboos, rattan
d. motor vehicle repair shops
Construction Class 3 is as referred to in OJK Circular Letter Number 21/SEOJK.05/2015 concerning the Determination of Premium Rates or Contributions for Property Insurance and Motor Vehicle Insurance Business Lines in 2015.

Table 1.A. Own Retention Limits
Insurance Companies and Reinsurance Companies

Bad risk as referred to in item 1 is risk for buildings with high risk occupation and construction class 3.

No. Insurance Business Line Own Capital (OC) Maximum Limit 1 Property 10% OC 2 Motor Vehicles 10% OC

The minimum own retention limit for the property insurance business line for bad risks is set at least 30% of the minimum own retention limit.

Minimum Own Retention per Risk (specific percentage of own capital*) 1 Property*) <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 2 Motor Vehicles 100 Million 3 Marine <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 4 Hull <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 0.6% OC 0.45% OC min 3 Billion 0.3% OC min 4.5 Billion 6 Billion 5 Aircraft 0.375% OC 6 Satellite 0.075% OC 7 Onshore Energy <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 8 Offshore Energy <500 Billion >500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 0.75% OC 0.56% OC min 3.75 Billion 0.375% OC min 5.625 Billion
7.5 Billion
9 Engineering
<500 Billion

500 Billion – 1 Trillion >1 Trillion-2 Trillion >2 Trillion 1.5% OC 1.125% OC min 7.5 Billion 0.75% OC min 11.25 Billion 15 Billion 10 Liability 500 Million 11 Death 100 Million 12 Personal Accident 100 Million 13 Health 100 Million 14 Credit 500 Million 15 Miscellaneous 500 Million

Notes):

High risk occupation:
a. chemical, oil, gas b. paper, leather, rubber
c. wood, bamboos, rattan
d. motor vehicle repair shops

Determined in Jakarta on the date

EXECUTIVE HEAD OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, FIRDAUS DJAELANI

For Shariah Insurance Companies having tabarru' funds not yet reaching Rp50,000,000,000 (fifty billion rupiah) and for Shariah Reinsurance Companies having tabarru' funds not yet reaching Rp100,000,000,000 (one hundred billion rupiah), the calculation of minimum and maximum own retention limits is calculated from the sum of own capital plus accumulated tabarru' funds; and the sum of OC plus accumulated tabarru' funds as referred to, is used until the amount reaches a maximum of Rp50,000,000,000 (fifty billion rupiah) for Shariah Insurance Companies and Rp100,000,000,000 (one hundred billion rupiah) for Shariah Reinsurance Companies.

Table 1.B. Own Retention Limits
Shariah Insurance Companies and Shariah Reinsurance Companies

No. Insurance Business Line Own Capital (OC)* Maximum Limit 1 Property 10% OC* 2 Motor Vehicles 10% OC*

Notes *):
The use of own capital as the standard for calculating minimum own retention limits and maximum retention limits for Shariah Insurance Companies and Shariah Reinsurance Companies applies the following provisions:
For Shariah Insurance Companies having tabarru' funds of at least Rp50,000,000,000 (fifty billion rupiah) and for Shariah Reinsurance Companies having tabarru' funds of at least Rp100,000,000,000 (one hundred billion rupiah), the calculation of minimum and maximum own retention limits is calculated from tabarru' funds;

The minimum own retention limit for the property insurance business line for bad risks is set at least 30% of the minimum own retention limit. Bad risk as referred to in item 1 is risk for buildings with high risk occupation and construction class 3.

Example:
Calculation of the minimum retention rate for a Shariah Insurance Company for the property business line is:
If the company has tabarru' funds of Rp100,000,000,000 then the minimum retention rate = 1.5% x Rp100,000,000,000 If the company has tabarru' funds of Rp 40,000,000,000 (and own capital Rp55,000,000,000) then the minimum retention rate is calculated from tabarru' funds and own capital = Rp40,000,000,000+Rp55,000,000,000; maximum Rp50,000,000,000, so the company's minimum retention rate = 1.5% x Rp 50,000,000,000

Construction Class 3 is as referred to in OJK Circular Letter Number 21/SEOJK.05/2015 concerning the Determination of Premium Rates or Contributions for Property Insurance and Motor Vehicle Insurance Business Lines in 2015

16 November 2015 signed

Copy in accordance with the original Director of Legal Affairs 1 Legal Department

signed
Sudarmaji

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 31/SEOJK.05/2015 CONCERNING OWN RETENTION LIMITS, AMOUNT OF REINSURANCE SUPPORT, AND AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORTS

Proportional Non-Proportional 1 Property 210,000,000,000 185,000,000,000 2 Marine 150,000,000,000 140,000,000,000 3 Hull 80,000,000,000 75,000,000,000 4 Aircraft 75,000,000,000 60,000,000,000 5 Satellite 40,000,000,000 40,000,000,000 6 Onshore Energy 100,000,000,000 100,000,000,000 7 Offshore Energy 170,000,000,000 170,000,000,000 8 Engineering 210,000,000,000 185,000,000,000 9 Liability 85,000,000,000 100,000,000,000 10 Miscellaneous 125,000,000,000 100,000,000,000

Table 2.A. Minimum Amount of Domestic Automatic Reinsurance Support Placement

The minimum amount of domestic automatic reinsurance support placement for the property business line does not include the special session for earthquakes, volcanoes, and tsunamis. For motor vehicle, death, personal accident, health, credit, and suretyship insurance business lines, 100% (one hundred percent) reinsurance support from domestic reinsurers applies.

No. Insurance Business Line Amount of Automatic Reinsurance Support in the Form of Priority Treaty in Domestic Currency (in rupiah)

No. Insurance Business Line Amount of Facultative Reinsurance Support for Insurance Companies (in rupiah) Amount of Facultative Reinsurance Support for Shariah Insurance Companies (in rupiah) 1 Property 620,000,000,000 150,000,000,000 2 Marine 250,000,000,000 50,000,000,000 3 Hull 140,000,000,000 50,000,000,000 4 Aircraft 180,000,000,000 50,000,000,000 5 Satellite 40,000,000,000 40,000,000,000 6 Onshore Energy 640,000,000,000 150,000,000,000 7 Offshore Energy 620,000,000,000 150,000,000,000 8 Engineering 620,000,000,000 150,000,000,000 9 Liability 175,000,000,000 175,000,000,000 10 Miscellaneous 300,000,000,000 75,000,000,000

Determined in Jakarta on the date

EXECUTIVE HEAD OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, FIRDAUS DJAELANI

Notes:
The minimum amount of domestic facultative reinsurance support placement for the property business line does not include the special session for earthquakes, volcanoes, and tsunamis. For motor vehicle, death, personal accident, health, credit, and suretyship insurance business lines, 100% (one hundred percent) reinsurance support from domestic reinsurers applies.

Table 2.B. Minimum Amount of Domestic Facultative Reinsurance Support Placement

16 November 2015 signed

Copy in accordance with the original Director of Legal Affairs 1 Legal Department

signed
Sudarmaji

APPENDIX III
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 31/SEOJK.05/2015 CONCERNING OWN RETENTION LIMITS, AMOUNT OF REINSURANCE SUPPORT, AND AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORTS

Respected Directorate of Insurance Supervision and BPJS Kesehatan Financial Services Authority Menara Merdeka Jalan Budi Kemuliaan I No.2 Central Jakarta

General Insurance Company / Reinsurance Company Year ……….. (fill in company name and address)

, 20xx

Director
(Company Stamp)

Clear Name
Position

AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORT

AUTOMATIC REINSURANCE/RETROSESSION PROGRAM REPORT YEAR 20XX GENERAL INSURANCE COMPANY / REINSURANCE COMPANY

Title

Cover 1
Table of Contents 2
List of Marketed Insurance Business Lines 3
Determination of Own Retention 4

A. Automatic Reinsurance/Retrosession Program Report A - All Insurance Business Lines 5 A - 1 Property 6 A - 2 Motor Vehicles 7 A - 3 Marine 8 A - 4 Hull 9 A - 5 Aircraft 10 A - 6 Satellite 11 A - 7 Onshore Energy 12 A - 8 Offshore Energy 13 A - 9 Engineering 114 A - 10 Liability 15 A- 11 Death 16 A - 12 Personal Accident 17 A - 13 Health 18 A - 14 Credit 19 A - 15 Suretyship 20 A - 16 Miscellaneous 21

B. Projection of Underwriting Surplus Calculation B - All Insurance Branches 22 B - 1 Property 23 B - 2 Motor Vehicles 24 B - 3 Marine 25 B - 4 Hull 26 B - 5 Aircraft 27 B - 6 Satellite 28 B - 7 Onshore Energy 29 B - 8 Offshore Energy 30 B - 9 Engineering 31 B - 10 Liability 32 B- 11 Death 33 B - 12 Personal Accident 34 B - 13 Health 35 B - 14 Credit 36 B - 15 Suretyship 37 B - 16 Miscellaneous 38

C. Proof of Rejection of Automatic Reinsurance Support (if any)

Table of Contents

No. Insurance Branch
1 Property
2 Motor Vehicles
3 Marine
4 Hull
5 Aircraft
6 Satellite
7 Onshore Energy
8 Offshore Energy
9 Engineering
10 Liability
11 Death
12 Personal Accident
13 Health
14 Credit
15 Suretyship
16 Miscellaneous

Notes:

Only Insurance Branches whose products are marketed are included in this report
Mark "√" for insurance branches whose products are marketed

List
Insurance Business Lines

Own Capital :
Total %
(1) (2) (3) (4)
1 Property
2 Motor Vehicles
3 Marine
4 Hull
5 Aircraft
6 Satellite
7 Onshore Energy
8 Offshore Energy
9 Engineering
10 Liability
11 Death
12 Personal Accident
13 Health
14 Credit
15 Suretyship
16 Miscellaneous

Own Retention
Determination of Own Retention Year 20xx No. Insurance Business Line

Sheet A
All Insurance Business Lines (in millions of rupiah) No. Description QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 Own Retention 2 Reinsurer Support A. Domestic B. Foreign

Automatic Reinsurance/Retrosession Program Report Year 20xx Proportional Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Non-Proportional

Sheet A-1
Insurance Business Line: Property (in millions of rupiah) No. Description
Rating QS Surplus Surplus.... QS Surplus Surplus.....
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total

Priority
Non-Proportional

Automatic Reinsurance/Retrosession Program Report Year 20xx Proportional Catastrophe X/L Non-Priority Working X/L Stop Loss

Sheet A-2
Insurance Business Line: Motor Vehicles (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-3
Insurance Business Line: Transportation (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-4
Insurance Business Line: Ship Hull (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-5
Insurance Business Line: Aircraft Hull (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-6
Insurance Business Line: Satellite (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-7
Insurance Business Line: Energy - Onshore (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-8
Insurance Business Line: Energy - Offshore (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-9
Insurance Business Line: Engineering (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-10
Insurance Business Line: Liability (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-11
Insurance Business Line: Death (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Proportional Non-Proportional Priority Non-Priority Working X/L Stop Loss Catastrophe X/L

Sheet A-12
Insurance Business Line: Personal Accident (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-13
Insurance Business Line: Health (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Proportional Non-Proportional Priority Non-Priority Working X/L Stop Loss Catastrophe X/L

Sheet A-14
Insurance Business Line: Credit (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet A-15
Insurance Business Line: Suretyship (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Proportional Non-Proportional Catastrophe X/L Priority Non-Priority Working X/L Stop Loss

Sheet A-16
Insurance Business Line: Miscellaneous (in millions of rupiah) No Description QS Rating QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Automatic Reinsurance/Retrocession Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Sheet B
All Insurance Business Lines (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-1
Insurance Business Line: Property (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-2
Insurance Business Line: Motor Vehicles (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Business Line B-3
Insurance Business Line: Transportation (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-4
Insurance Business Line: Ship Hull (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-5
Insurance Business Line: Aircraft Hull (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-6
Insurance Business Line: Satellite (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-7
Insurance Business Line: Energy - Onshore (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-8
Insurance Business Line: Energy - Offshore (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-9
Insurance Business Line: Engineering (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-10
Insurance Business Line: Liability (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-11
Insurance Business Line: Death (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE Enter Exit

Sheet B-12
Insurance Business Line: Personal Accident (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-13
Insurance Business Line: Health (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE Enter Exit

Sheet B-14
Insurance Business Line: Credit (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-15
Insurance Business Line: Suretyship (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Enter Exit
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Sheet B-16
Insurance Business Line: Miscellaneous (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Premium 2 Commission 3 Reserve for Premiums Not Yet Earned:
a. Previous Year b. Current Year 4 Earned Premium (1 - 2 + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Reserve/Outstanding Claims:
a. Previous Year b. Current Year 8 Claim Expense (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the place where the company was established as a legal entity
Determined in Jakarta
On the date
EXECUTIVE HEAD OF SUPERVISOR INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, FIRDAUS DJAELANI Enter Exit PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE 16 November 2015 signed Copy matches the original Legal Director 1 Legal Department signed Sudarmaji

APPENDIX IV
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER /SEOJK.05/2015 REGARDING OWN RETENTION LIMITS, REINSURANCE SUPPORT AMOUNTS, AND REINSURANCE/RETROCESSION REPORTS

To
Yth. Sharia IKNB Directorate Financial Services Authority Menara Merdeka Building Jalan Budi Kemuliaan I No.2 Central Jakarta Sharia General Insurance Company / Sharia Reinsurance Company Year ……….. (company name and address to be filled in) , 20xx Director (Company Stamp) Full Name Position AUTOMATIC REINSURANCE/RETROCESSION PROGRAM REPORT

Title

Cover 1
Table of Contents 2
List of Insurance Business Lines Marketed 3
Determination of Own Retention 4
A. Automatic Reinsurance/Retrocession Program Report A - All Insurance Business Lines 5 A - 1 Property 6 A - 2 Motor Vehicles 7 A - 3 Transportation 8 A - 4 Ship Hull 9 A - 5 Aircraft Hull 10 A - 6 Satellite 11 A - 7 Onshore Energy 12 A - 8 Offshore Energy 13 A - 9 Engineering 14 A - 10 Liability 15 A- 11 Death 16 A - 12 Personal Accident 17 A - 13 Health 18 A - 14 Credit 19 A - 15 Miscellaneous 20 B. Projection of Underwriting Surplus Calculation B - All Insurance Branches 21 B - 1 Property 22 B - 2 Motor Vehicles 23 B - 3 Transportation 24 B - 4 Ship Hull 25 B - 5 Aircraft Hull 26 B - 6 Satellite 27 B - 7 Onshore Energy 28 B - 8 Offshore Energy 29 B - 9 Engineering 30 B - 10 Liability 31 B- 11 Death 32 B - 12 Personal Accident 33 B - 13 Health 34 B - 14 Credit 35 B - 15 Miscellaneous 36
C. Evidence of Rejection of Automatic Reinsurance Support (if any)
Table of Contents
SHARIA GENERAL INSURANCE COMPANY / SHARIA REINSURANCE COMPANY AUTOMATIC REINSURANCE/RETROCESSION PROGRAM REPORT YEAR 20XX

No. Insurance Branch
1 Property
2 Motor Vehicles
3 Transportation
4 Ship Hull
5 Aircraft Hull
6 Satellite
7 Onshore Energy
8 Offshore Energy
9 Engineering
10 Liability
11 Death
12 Personal Accident
13 Health
14 Credit
15 Miscellaneous
Notes:

Only Insurance Branches whose products are marketed are included in this report
Mark with a "√" for insurance branches whose products are marketed
List
Insurance Business Lines

Own Capital *) :
Total %
(1) (2) (3) (4)
1 Property
2 Motor Vehicles
3 Transportation
4 Ship Hull
5 Aircraft Hull
6 Satellite
7 Onshore Energy
8 Offshore Energy
9 Engineering
10 Liability
11 Death
12 Personal Accident
13 Health
14 Credit
15 Miscellaneous
*) Note:
The use of own capital as the standard for calculating the minimum and maximum own retention limits on this form refers to regulations regarding the determination of own retention for Sharia Insurance Companies and Sharia Reinsurance Companies. Own Retention Determination of Own Retention Year 20xx No. Insurance Business Line

Sheet A
All Insurance Business Lines (in millions of rupiah) No Description QS Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 Own Retention 2 Reinsurer Support A. Domestic B. Foreign Automatic Sharia Reinsurance/Retrocession Program Report Year 20xx Proportional Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Non-Proportional

Sheet A-1
Insurance Business Line: Property (in millions of rupiah) No Description
QS Rating QS Surplus Surplus.... QS Surplus Surplus.....
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Subtotal
B. Foreign
…..
…..
…..
…..
Subtotal
Priority
Non-Proportional
Automatic Sharia Reinsurance/Retrocession Program Report Year 20xx Proportional Catastrophe X/L Non-Priority Working X/L Stop Loss

Lembar A-2
Insurance Business Line: Motor Vehicles (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-3
Insurance Business Line: Transportation (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-4
Insurance Business Line: Ship Hull (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-5
Insurance Business Line: Aircraft Hull (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-6
Insurance Business Line: Satellite (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-7
Insurance Business Line: Energy - Onshore (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-8
Insurance Business Line: Energy - Offshore (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-9
Insurance Business Line: Engineering (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-10
Insurance Business Line: Liability (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-11
Insurance Business Line: Death (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Proportional Non-Proportional Priority Non-Priority Working X/L Stop Loss Catastrophe X/L

Lembar A-12
Insurance Business Line: Personal Accident (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-13
Insurance Business Line: Health (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Proportional Non-Proportional Priority Non-Priority Working X/L Stop Loss Catastrophe X/L

Lembar A-14
Insurance Business Line: Credit (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar A-15
Insurance Business Line: Miscellaneous (in millions of rupiah) No Description QS Rating Surplus QS Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 Gross Own Retention 2 Reinsurer Support A. Domestic

…..
…..
…..
…..
Sub Total
B. Foreign
…..
…..
…..
…..
Sub Total
Automatic Reinsurance/Retrocession Sharia Program Report Year 20xx Catastrophe X/L Priority Non-Priority Working X/L Stop Loss Proportional Non-Proportional

Lembar B
All Insurance Business Lines (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-1
Insurance Business Line: Property (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-2
Insurance Business Line: Motor Vehicles (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-3
Insurance Business Line: Transportation (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-4
Insurance Business Line: Ship Hull (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-5
Insurance Business Line: Aircraft Hull (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-6
Insurance Business Line: Satellite (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-7
Insurance Business Line: Energy - Onshore (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-8
Insurance Business Line: Energy - Offshore (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-9
Insurance Business Line: Engineering (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-10
Insurance Business Line: Liability (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-11
Insurance Business Line: Death (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE In Out

Lembar B-12
Insurance Business Line: Personal Accident (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-13
Insurance Business Line: Health (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE In Out

Lembar B-14
Insurance Business Line: Credit (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
In Out
PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE

Lembar B-15
Insurance Business Line: Miscellaneous (in millions of rupiah) Total Total No. Description Direct Position Current Year Previous Year Domestic ASEAN *) Non ASEAN Domestic ASEAN *) Non ASEAN (3+4+5+6-7-8-9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Tabarru' Contribution 2 Provision for Contributions Not Yet Earned :
a. Previous Year b. Current Year 3 Contribution Provision a. Previous Year b. Current Year 4 Contribution Revenue (1 + 2a - 2b + 3a - 3b) 5 Claims Paid 6 Adjuster Costs 7 Claims Provision :
a. Previous Year b. Current Year 8 Claim Expenses (5 + 6 + 7b - 7a) 9 Underwriting Surplus (4 - 8)

Separation is based on the location where the company was established as a legal entity
Determined in Jakarta
On the date
EXECUTIVE HEAD OF SUPERVISOR INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, FIRDAUS DJAELANI In Out PROJECTION OF UNDERWRITING SURPLUS CALCULATION Period January 1 to December 31 ….. REINSURANCE 16 November 2015 signed Copy in accordance with the original Legal Director 1 Legal Department signed Sudarmaji

APPENDIX V
CIRCULAR OF THE FINANCIAL SERVICES AUTHORITY NUMBER /SEOJK.05/2015 CONCERNING OWN RETENTION LIMITS, REINSURANCE SUPPORT AMOUNTS, AND REINSURANCE/RETROCESSION REPORTS

To
The Director of Insurance Supervision and BPJS Kesehatan Financial Services Authority Menara Merdeka Building Jalan Budi Kemuliaan I No.2 Central Jakarta AUTOMATIC REINSURANCE PROGRAM REPORT Life Insurance Company With Conventional Principles / With Sharia Principles
Year....
(company name and address to be filled) _________, ________________________ 20xx (Company Stamp) Full Name Position Director

Title

Cover 1
Table of Contents 2
A Automatic Reinsurance Program Report A All Life Insurance and Annuity Business Lines 3 A-1 Insurance Business Line: Term 4 A-2 Insurance Business Line: Term Death Other Than Term 5 A-3 Insurance Business Line: Endowment 6 A-4 Insurance Business Line: Combined Endowment 7 A-5 Insurance Business Line: Whole Life 8 A-6 Insurance Business Line: Combined Whole Life 9 A-7 Insurance Business Line: General Annuity 10 A-8 Insurance Business Line: Pension Fund Annuity 11 A-9 Insurance Business Line: Non-Traditional 12 A-10 Insurance Business Line: Health (Quota Share & Surplus Treaty Reinsurance ) 13 A-11 Insurance Business Line: Personal Accident (Quota Share & Surplus Treaty Reinsurance ) 14 A-12 Insurance Business Line: Personal Accident (Excess of Loss Treaty Reinsurance ) 15 A-13 Insurance Business Line: Health (Excess of Loss Treaty Reinsurance ) 16 B Evidence of Reinsurance Support Rejection (if any)
Table of Contents
AUTOMATIC REINSURANCE PROGRAM REPORT YEAR 20XX LIFE INSURANCE COMPANY

Company Name :
Year 20xx
All Life Insurance and Annuity Business Lines. No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Reinsurer Support A. Domestic

...........................
..................... etc.
B. Foreign
A S E A N
a. ...........................
b. ...........................
c. ..................... etc.
NON ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
AUTOMATIC REINSURANCE PROGRAM REPORT

Company Name :
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Term No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Reinsurer Support A. Domestic

...........................
..................... etc.
B. Foreign
A S E A N
a. ...........................
b. ...........................
c. ..................... etc.
NON ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name :
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Term Death Other Than Term No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Reinsurer Support A. Domestic

...........................
..................... etc.
B. Foreign
A S E A N
a. ...........................
b. ...........................
c. ..................... etc.
NON ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Mixed No. Description Reinsurance Type Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Support Reinsurers A. Domestic

...........................
..................... etc.
B. Foreign
ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
NON-ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Mixed Combination No. Description Reinsurance Type Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Support Reinsurers A. Domestic

...........................
..................... etc.
B. Foreign
ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
NON-ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Combination Whole Life No. Description Reinsurance Type Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Support Reinsurers A. Domestic

...........................
..................... etc.
B. Foreign
ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
NON-ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: General Annuity No. Description Reinsurance Type Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Support Reinsurers A. Domestic

...........................
..................... etc.
B. Foreign
ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
NON-ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Pension Fund Annuity No. Description Reinsurance Type Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Support Reinsurers A. Domestic

...........................
..................... etc.
B. Foreign
ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
NON-ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Non-Traditional No. Description Reinsurance Type Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I Own Retention II Support Reinsurers A. Domestic

...........................
..................... etc.
B. Foreign
ASEAN
a. ...........................
b. ...........................
c. ..................... etc.
NON-ASEAN
a. ...........................
b. ...........................
c. ..................... etc.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Health (In millions of rupiah) No. Description Q.S. (a) S.I (b) S.II ....................... (c) (1) (2) (3) (4) (5) (6) I Own Retention (d) II Support Reinsurers A. Domestic

............... (Rp / %) (e)
........ etc.
B. Foreign
ASEAN
a. ...... (Rp / %) (e)
b. ......
c. ...... etc.
NON-ASEAN
a. ...... (Rp / %) (e)
b. ......
c. ...... etc.
Notes:
(a). Q.S. = Quota Share Treaty Reinsurance. (b). S = Surplus Treaty Reinsurance. (c). Filled as needed. (d). Own Retention = includes X/L reinsurance support if any. (e). Strike out what is not needed.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Personal Accident (In millions of rupiah) No. Description Q.S. (a) S.I (b) S.II ....................... (c) (1) (2) (3) (4) (5) (6) I Own Retention (d) II Support Reinsurers A. Domestic

............... (Rp / %) (e)
........ etc.
B. Foreign
ASEAN
a. ...... (Rp / %) (e)
b. ......
c. ...... etc.
NON-ASEAN
a. ...... (Rp / %) (e)
b. ......
c. ...... etc.
Notes:
(a). Q.S. = Quota Share Treaty Reinsurance. (b). S = Surplus Treaty Reinsurance. (c). Filled as needed. (d). Own Retention = includes X/L reinsurance support if any. (e). Strike out what is not needed.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Personal Accident. (In millions of rupiah) No. Description X/L 1 (a) X/L 2 ....................... (b) (1) (2) (3) (4) (5) I Own Retention (c) II Support Reinsurers A. Domestic

............... (Rp / %) (d)
........ etc.
B. Foreign
ASEAN
a. ...... (Rp / %) (d)
b. ......
c. ...... etc.
NON-ASEAN
a. ...... (Rp / %) (d)
b. ......
c. ...... etc.
Notes:
(a). X/L = Excess of Loss Treaty Reinsurance. (b). Filled as needed. (c). R.S. = Does not include X/L reinsurance support. (d). Strike out what is not needed.

Company Name:
AUTOMATIC REINSURANCE PROGRAM REPORT Year 20xx Insurance Business Line: Health (In millions of rupiah) No. Description X/L 1 (a) X/L 2 ....................... (b) (1) (2) (3) (4) (5) I Own Retention (c) II Support Reinsurers A. Domestic

............... (Rp / %) (d)
........ etc.
B. Foreign
ASEAN
a. ...... (Rp / %) (d)
b. ......
c. ...... etc.
NON-ASEAN
a. ...... (Rp / %) (d)
b. ......
c. ...... etc.
Notes:
(a). X/L = Excess of Loss Treaty Reinsurance. (b). Filled as needed. (c). R.S. = Does not include X/L reinsurance support. Determined in Jakarta (d). Strike out what is not needed. on the date EXECUTIVE HEAD OF INSURANCE SUPERVISOR, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, FIRDAUS DJAELANI 16 November 2015 signed Copy matches the original Legal Director Legal Department signed Sudarmaji

Circular Letter of the Financial Services Authority Number 31/SEOJK.05/2015 Concerning Own Retention Limits, Amount of Reinsurance Support, and Automatic Reinsurance/Retrosession Program Reports

Lineage: In force

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