Electronic Licensing, Approval, and Reporting for Insurance Brokerage, Reinsurance Brokerage, and Insurance Loss Assessment Companies

To:

1. The Board of Directors of Insurance Brokerage Companies;
2. The Board of Directors of Reinsurance Brokerage Companies; and
3. The Board of Directors of Insurance Loss Assessment Companies,
   At your location.

COPY

FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 9 /SEOJK.05/2018

CONCERNING

ELECTRONIC LICENSING, APPROVAL, AND REPORTING FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSMENT COMPANIES

In relation to the mandate of the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business and Institutional Licensing for Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies (State Gazette of the Republic of Indonesia Year 2016 Number 301, Supplement to the State Gazette of the Republic of Indonesia Number 5991), it is necessary to further regulate electronic licensing, approval, and reporting for insurance brokerage companies, reinsurance brokerage companies, and insurance loss assessment companies in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

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

1. Company means an insurance brokerage company, a reinsurance brokerage company, and an insurance loss assessment company.
2. Insurance Brokerage Company means a company that conducts insurance brokerage business.
3. Reinsurance Brokerage Company means a company that conducts reinsurance brokerage business.
4. Insurance Loss Assessment Company means a company that conducts insurance loss assessment business.
5. Licensing means the granting of legality in the form of a license from the Financial Services Authority to a specific legal entity to conduct business activities in the insurance field.
6. Approval means the granting of legality in the form of an approval letter from the Financial Services Authority to the Company to conduct specific activities in the insurance field.
7. Reporting means the submission of all forms of records providing information about specific activities conducted by the Company to the Financial Services Authority.
8. General Meeting of Shareholders, hereinafter abbreviated as GMS, is the general meeting of shareholders as referred to in Law Number 40 of 2007 concerning Limited Liability Companies for Companies in the form of a limited liability company or equivalent to the GMS for Companies in the form of a cooperative legal entity.
9. Board of Directors is the board of directors as referred to in Law Number 40 of 2007 concerning Limited Liability Companies for Companies in the form of a limited liability company or equivalent to the Board of Directors for Companies in the form of a cooperative legal entity.
10. Board of Commissioners is the board of commissioners as referred to in Law Number 40 of 2007 concerning Limited Liability Companies for Companies in the form of a limited liability company or equivalent to the Board of Commissioners for Companies in the form of a cooperative legal entity.

II. SCOPE OF LICENSING, APPROVAL, AND REPORTING FOR COMPANIES

The Licensing, Approval, and Reporting as mandated in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business and Institutional Licensing for Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies, which are submitted to the Financial Services Authority, are:

1. application for the Company's business license;
2. Reporting on the implementation of the Company's business activities;
3. Reporting on the Company's plan to employ foreign workers;
4. Reporting on the Company's appointment of foreign workers;
5. Reporting on the Company's termination of foreign workers;
6. application for registration of insurance brokers or reinsurance brokers;
7. Reporting on the appointment of insurance brokers or reinsurance brokers;
8. Reporting on the termination of insurance brokers or reinsurance brokers;
9. Reporting on the Company's appointment of expert personnel;
10. Reporting on the Company's termination of expert personnel;
11. Reporting on the opening of offices outside the Company's head office;
12. Reporting on the closure of offices outside the Company's head office;
13. application for Approval of changes in Company ownership that cause a change in the Company's controller;
14. application for Approval of ownership changes that do not cause a change in the Company's controller;
15. Reporting on changes in Company ownership;
16. Reporting on changes in the Company's name;
17. Reporting on changes in the location of the Company's head office;
18. Reporting on the reduction of paid-up capital for Companies in the form of a limited liability company;
19. Reporting on the increase of paid-up capital for Companies in the form of a limited liability company;
20. Reporting on changes in the status of Companies in the form of a closed limited liability company to an open limited liability company or vice versa;
21. Reporting on changes in the members of the Company's Board of Directors and/or members of the Company's Board of Commissioners;
22. Reporting on changes in the address of the Company's head office and/or offices outside the head office;
23. Reporting on Companies declared bankrupt by the court;
24. application for Approval of the Company's plan to cease business activities; and
25. Reporting on the implementation of the Company's cessation of business activities.

III. PROCEDURE FOR SUBMITTING LICENSING, APPROVAL, AND REPORTING APPLICATIONS

1. Companies must submit Licensing, Approval, and Reporting applications to the Financial Services Authority in accordance with the format contained in the Appendix of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business and Institutional Licensing for Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies, and accompanied by supporting documents as required.
2. The submission of Licensing, Approval, and Reporting applications as referred to in item 1 is accompanied by a self-assessment form signed by the Company's Board of Directors as contained in the Appendix which is an integral part of this Financial Services Authority Circular Letter.
3. The Licensing, Approval, and Reporting applications as referred to in items 1 and 2 are submitted to the Financial Services Authority online through the Financial Services Authority's data communication network system.
4. Supporting documents required as attachments for Licensing, Approval, and Reporting applications submitted online are color scans of the original documents.
5. In the event that the Financial Services Authority's data communication network system as referred to in item 3 is not yet available or experiences technical disturbances, the submission of Licensing, Approval, and Reporting applications as referred to in item 1 is submitted to the Financial Services Authority offline.
6. With the submission of Licensing, Approval, and Reporting applications to the Financial Services Authority online as referred to in item 3 or offline as referred to in item 5, Companies do not need to submit printed documents (hard copy).
7. Companies must state that the documents submitted online as referred to in item 3 or offline as referred to in item 5 are true and identical to their printed copies.
8. In the event of technical disturbances as referred to in item 5, the Financial Services Authority announces via the Financial Services Authority website and/or sends an email to the person in charge (PIC) of the Company.
9. Licensing, Approval, and Reporting applications for Companies submitted offline as referred to in item 5 must be submitted in electronic data form as color scans of original documents via compact disc (CD) or other electronic data storage media.
10. The submission of Licensing, Approval, and Reporting applications offline as referred to in item 5 is accompanied by a cover letter in printed form (hard copy) signed by the Company's Board of Directors.
11. The submission of Licensing, Approval, and Reporting applications offline as referred to in item 5 is addressed to:
    Executive Head of Insurance, Pension Fund, Financing Institutions, and Other Financial Service Institutions u.p. Director of IKNB Support Services Wisma Mulia 2 Building, 12th Floor Jalan Jenderal Gatot Subroto Number 42 Jakarta 12710.
12. In the event of a change in the address of the Financial Services Authority for the submission of Licensing, Approval, and Reporting applications as referred to in item 11, the Financial Services Authority will convey notification regarding the address change via letter or announcement.
13. The submission of Licensing, Approval, and Reporting applications offline as referred to in item 5 can be done in one of the following ways:
    a. handed in directly to the Financial Services Authority office; or b. sent through a courier service company, according to the address as referred to in item 11.
14. A Company is deemed to have submitted Licensing, Approval, and Reporting applications with the following provisions:
    a. for online submission through the Financial Services Authority's data communication network system, proven by a receipt from the Financial Services Authority's data communication network system; or b. for offline submission, proven by:

1. a receipt letter from the Financial Services Authority, if the report is handed in directly to the Financial Services Authority office as referred to in item 13 letter a; or
2. a shipping receipt from the courier service company, if the report is sent through a courier service company as referred to in item 13 letter b.

IV. DATA STORAGE

1. Companies must store printed documents of Licensing and Approval documents that have been submitted through the Financial Services Authority's data communication network system for as long as such Licensing and Approval remain valid.
2. Companies must store printed documents of Reporting documents that have been submitted through the Financial Services Authority's data communication network system for a minimum period of 5 (five) years from the date of Reporting.
3. The Financial Services Authority may conduct verification and/or validation of the truthfulness and reasonableness of printed documents (hard copy) of Licensing, Approval, and Reporting applications that have been submitted by Companies through the Financial Services Authority's data communication network system.

V. TRANSITIONAL PROVISIONS

Licensing, Approval, and Reporting applications that have been submitted to the Financial Services Authority in printed form (hard copy) before this Financial Services Authority Circular Letter takes effect and have not received a license, Approval, and/or reporting recording letter from the Financial Services Authority do not need to be submitted again online through the Financial Services Authority's data communication network system.

This copy is consistent with the original Director of Law 1 Legal Department signed Yuliana

VI. CLOSING

The provisions in this Financial Services Authority Circular Letter shall take effect after 2 (two) months from the date of establishment.

Established in Jakarta on 20 April 2018

EXECUTIVE HEAD OF INSURANCE,
PENSION FUNDS,
FINANCING INSTITUTIONS, AND
OTHER FINANCIAL SERVICE INSTITUTIONS
FINANCIAL SERVICES AUTHORITY, signed
RISWINANDI

APPENDIX
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 9 /SEOJK.05/2018 CONCERNING ELECTRONIC LICENSING, APPROVAL, AND REPORTING FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSMENT COMPANIES

• 1 -

TABLE OF CONTENTS OF APPENDIX

No. Description of Application Item

1. Self Assessment Format 1
   Application for Company's business license 3
2. Self Assessment Format 2
   Reporting on the implementation of the Company's business activities 25
3. Self Assessment Format 3
   Reporting on the Company's plan to employ foreign workers 27
4. Self Assessment Format 4
   Reporting on the Company's appointment of foreign workers 32
5. Self Assessment Format 5
   Reporting on the Company's termination of foreign workers 34
6. Self Assessment Format 6
   Application for registration of insurance brokers or reinsurance brokers 35
7. Self Assessment Format 7
   Reporting on the appointment of insurance brokers or reinsurance brokers 38
8. Self Assessment Format 8
   Reporting on the termination of insurance brokers or reinsurance brokers 40
9. Self Assessment Format 9
   Reporting on the Company's appointment of expert personnel 42
10. Self Assessment Format 10
    Reporting on the Company's termination of expert personnel 44
11. Self Assessment Format 11
    Reporting on the opening of offices outside the Company's head office 46
12. Self Assessment Format 12
    Reporting on the closure of offices outside the Company's head office 48
13. Self Assessment Format 13
    Application for Approval of changes in Company ownership that cause a change in the Company's controller 50
14. Self Assessment Format 14
    Application for Approval of ownership changes that do not cause a change in the Company's controller 62
15. Self Assessment Format 15
    Reporting on changes in Company ownership 73
16. Self Assessment Format 16
    Reporting on changes in the Company's name 76
17. Self Assessment Format 17
    Reporting on changes in the location of the Company's head office 78
18. Self Assessment Format 18
    Reporting on the reduction of paid-up capital for Companies in the form of a limited liability company 80
19. Self Assessment Format 19
    Reporting on the increase of paid-up capital for Companies in the form of a limited liability company 83
20. Self Assessment Format 20
    Reporting on changes in the status of Companies in the form of a closed limited liability company to an open limited liability company or vice versa 90
21. Self Assessment Format 21
    Reporting on changes in the members of the Company's Board of Directors and/or members of the Company's Board of Commissioners 92
22. Self Assessment Format 22
    Reporting on changes in the address of the Company's head office and/or offices outside the head office 94
23. Self Assessment Format 23
    Reporting on Companies declared bankrupt by the court 96
24. Self Assessment Format 24
    Application for Approval of the Company's plan to cease business activities 98
25. Self Assessment Format 25
    Reporting on the implementation of the Company's cessation of business activities 102

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SELF ASSESSMENT FORMAT 1 APPLICATION FOR COMPANY BUSINESS LICENSE

FORM: 1
SELF ASSESSMENT FORM
APPLICATION FOR COMPANY BUSINESS LICENSE

Company Name :
Application letter number for business license :
Date of application letter for business license :
Contact person (name, phone, email) :
Brief description of the background of the business license application :
Company Description :
(describe the company's history)
.......

No. Name of Shareholder Nominal (Rp) (%) Controller/Non-Controller 1 2 3 Total

Company Group Structure Chart:
(up to the ultimate controller)
[.........]

Composition of Board of Directors, Board of Commissioners, insurance brokers, reinsurance brokers, expert personnel, and foreign personnel:

No. Position Name Information Regarding Concurrent Positions Citizenship and Domicile Type of Certification (if any) 1 Main Director

• 4 -
  2 Director

3. Main Commissioner
4. Commissioner
5. Insurance Broker/Reinsurance Broker
6. Expert Personnel (including additional expert personnel, if any)
7. Foreign Workers (if any)
   (please elaborate if the Company plans to use foreign workers)

NO. DESCRIPTION OF LEGAL BASIS COMPLETENESS YES NO NOTES

1. Application for business license is submitted using Format 1 of the Appendix of POJK 68/POJK.05/2016 and signed by the Board of Directors.
   Article 9 paragraph (1) of POJK Number 68/POJK.05/2016
   Deed of Establishment
2. Copy of the deed of establishment of a limited liability company or cooperative including copies of the deed of amendment of the articles of association (if any) accompanied by copies of proof of approval, and/or copies of proof of receipt of notification from the competent authority.
   The deed of establishment contains information among others:
   a. name and location; b. purpose and business activities;
   c. capital;
   d. ownership;
   Article 9 paragraph (2) letter a of POJK Number 68/POJK.05/2016
   Number and date of deed of establishment:
   [.........]
   Number and date of proof of approval from competent authority:
   [.........]
   Company Name:
   [.........]

• 5 -
  e. authority, responsibility, and term of office of members of the Board of Directors and members of the Board of Commissioners. Location:
  [.........]
  Purpose and Business Activities: [.........]
  Paid-up Capital Amount: [.........]
  Ownership Data:
  [.........]
  Authority, responsibility, and term of office of members of the Board of Directors and members of the Board of Commissioners:
  [.........]
  Data of all amendments to the articles of association of the Company (if any):

1. Number and date of deed:
   [.........]
   Number and date of proof of approval and/or receipt of notification from competent authority:

• 6 -
  [.........]
  Substance of amendment to articles of association:
  [.........]

2. Etc.
   Organizational Structure
3. Organizational structure that clearly describes the function:
   a. service; b. brokerage technical (for Insurance Brokerage Companies and Reinsurance Brokerage Companies)
   c. insurance loss assessment technical (for Insurance Loss Assessment Companies);
   and d. administration, finance, and internal audit.
   Article 9 paragraph (2) letter b, Article 13 paragraph (1) and paragraph (2) of POJK Number 68/POJK.05/2016
   Proven by attaching an organizational structure chart containing all these functions.
4. Documents containing written descriptions of duties, authority, responsibility, and work procedures, established by the Board of Directors.
   Article 9 paragraph (2) letter b, Article 13 paragraph (3) of POJK Number 68/POJK.05/2016
   Proven by attaching Standard Operating Procedure (SOP):
   No. SOP:
   [.........]
   Effective date of SOP implementation:
   [.........]
   Signed by:
   [.........]
5. Brokerage certificate with the lowest level 1 (one) level below the highest qualification from the Professional Certification Institution in the insurance field, for members of the Board of Directors of Insurance Brokerage
   Article 14 Paragraph (1) of POJK Number 68/POJK.05/2016
6. Name:
   [.........]
   Position:
   [.........]

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  Companies and Reinsurance Brokerage Companies. Type of certification:
  [.........]
  Institution issuing the certificate:
  [.........]
  Certificate number:
  [.........]
  Date of certificate:
  [.........]

2. Etc.
3. Insurance loss assessment expert certificate with the lowest level 1 (one) level below the highest qualification from the Professional Certification Institution in the insurance field, for members of the Board of Directors of Insurance Loss Assessment Companies.
   Article 14 Paragraph (2) of POJK Number 68/POJK.05/2016
   Type of certification:
   [.........]
   Institution issuing the certificate:
   [.........]
   Certificate number:
   [.........]
   Date of certificate:
   [.........]
   In the name of:
   [.........]
   Paid-up Capital
4. Copy of proof of paid-up capital settlement in the form of cash deposits by shareholders to the Company and legalized with a wet stamp by the bank.
   Article 9 paragraph (2) letter c of POJK Number 68/POJK.05/2016
   Transaction Date:
   [.......]
   Depositing Bank:
   [.......]
   Depositor Name:
   [.......]
   Receiving Bank:
   [.......]
   Recipient Name:
   [.......]
   Nominal of capital deposit (original currency): [.......]
   Nominal of capital deposit (Rupiah): [.......]
5. Copy of proof of placement of minimum paid-up capital in the form of time deposits and/or current accounts in the name of the Company at one of the commercial banks, commercial sharia banks, or sharia business units of commercial banks and legalized by the receiving bank of the deposit which is still valid during the process of applying for a business license.
   Article 9 paragraph (2) letter c of POJK Number 68/POJK.05/2016
   Account Number:
   [.......]
   Bank Name:
   [.......]
   Date Received: [.......]
   Nominal of capital deposit (Original Currency):
   [.......]
   Nominal of capital deposit (Rupiah): [.......]
   Ownership List
6. List of shareholders including details of the amount of each share ownership and the entire business group structure related to the Company and the legal entity owner of the Company up to the last owner, for Companies in the form of a limited liability company.
   Article 9 paragraph (2) letter d item 1 of POJK Number 68/POJK.05/2016
   (Explained in the form of a chart and description) Ultimate owner:
7. [.........]
   by [.........]%
8. Etc.

• 9 -

10. List of members including the amount of basic savings and mandatory savings, for Companies in the form of a cooperative legal entity.
    Article 9 paragraph (2) letter d item 2 of POJK Number 68/POJK.05/2016
11. Name:
    [.........]
    Amount of Basic Savings:
    Rp[.........]
    Amount of Mandatory Savings:
    Rp[.........]
    Date of membership start:
    [.........]
12. Etc.
    Data of Shareholders or Members Other Than Controllers
13. In the event that shareholders or members other than controllers are individuals:
    a. copy of identification in the form of ID card or passport that is still valid;
    Article 9 paragraph (2) letter e of POJK Number 68/POJK.05/2016
14. Name:
    [.........]
    Position:
    [.........]
    ID/Passport Number: [.........]
    Validity period of identity:
    [.........]
15. Etc.
    b. copy of Taxpayer Identification Number (NPWP);
    Article 9 paragraph (2) letter e of POJK Number 68/POJK.05/2016
16. Name:
    [.........]
    NPWP Number:
    [.........]
17. Etc.

c. copy of Tax Return (SPT) for the last 2 (two) years and other documents showing the financial capability and source of funds of prospective individual shareholders;
Article 9 paragraph (2) letter e of POJK Number 68/POJK.05/2016
Copy of SPT for Mr./Mrs.
[.........]:
SPT Period: year [.........]
Taxable Income:
Rp [.........]
Asset list:
[.........]
Total Assets:
Rp [.........]
Liability list:
[.........]
Total Liabilities:
Rp [.........] d. curriculum vitae list completed with the latest color passport-sized photo measuring 4 x 6 cm; and
Article 9 paragraph (2) letter e of POJK Number 68/POJK.05/2016
curriculum vitae list and passport photo in the name of:

1. Mr./Mrs.
   [.........]
2. Etc.
   e. statement letter from shareholders or members other than controllers stating:

1. capital deposits do not come from loans;
2. capital deposits do not come from money laundering activities and financial crimes;
3. do not have non-performing credits and/or financing;
4. are not included as Parties prohibited from becoming shareholders or Parties that manage, supervise, and/or have significant influence on financial service institutions;
5. have never been sentenced for committing criminal offenses in the field of financial service business and/or economy based on court decisions that have had permanent legal force in the last 5 (five) years;
6. have never been sentenced for committing criminal offenses based on court decisions that have had permanent legal force in the last 5 (five) years;
7. have never been declared bankrupt or guilty causing a company to be declared bankrupt based on court decisions that have had permanent legal force in the last 5 (five) years; and
8. have never been a PSP, member of the Board of Directors, member of the Board of Commissioners, or Controller, at a financial service company whose business license was revoked due to violations in the last 5 (five) years;
   Article 9 paragraph (2) letter e of POJK Number 68/POJK.05/2016
   Statement letter signed by shareholders or members other than controllers as follows:
   Mr./Mrs. ......
   Mr./Mrs. ......
   Completed with the relevant signatures above the stamp duty [.........]

12. In the event that shareholders or members other than controllers are legal entities:

• 11 -

• 12 -
  a. photocopy of the establishment deed of the legal entity including the articles of association and any amendments (if any), accompanied by a photocopy of the approval proof, photocopy of the approval letter, and/or photocopy of the receipt of notification from the competent authority;
  Article 9 paragraph (2) letter e
  POJK Number 68/POJK.05/2016
  No. Deed:
  [.........]
  Date:
  [.........]
  Notary:
  [.........]
  Substance:
  [.........]
  No. decision/letter from Ministry of Law and Human Rights:
  [.........]
  Date:
  [.........]
  Data of all amendments to the articles of association (if any):

1. No. and date
   of deed: [.........]
   No. and date of approval proof and/or receipt of notification from competent authority:
   [.........]
   Substance of amendment to articles of association:
   [.........]
2. Etc.

• 13 -
  b. financial statements that have been audited by a public accountant, accompanied by non-consolidated financial statements and the latest month-end financial statements;
  Article 9 paragraph (2) letter e
  POJK Number 68/POJK.05/2016
  Financial Statements of PT
  [.........] attached:

1. Audited financial statements
   for period
   [.........]

• Equity Amount
  Rp [.......]

2. Etc.
   c. the Board of Directors granted authority to represent the company attaches:

1. photocopy of valid identification in the form of an ID card (KTP) or passport;
   Article 9 paragraph (2) letter e
   POJK Number 68/POJK.05/2016
   Photocopy of identification of Board of Directors members and Board of Commissioners members:

1. Name:
   [.........]
   Position:
   [.........]
   ID/Passport No.:
   [.........]
   Validity period of identification:
   [.........]
2. Etc.

2. photocopy of the Taxpayer Identification Number (NPWP); and Article 9 paragraph (2) letter e
   POJK Number 68/POJK.05/2016
   Photocopy of NPWP of Board of Directors members and Board of Commissioners members:

• 14 -

1. Name:
   [.........]
   NPWP No.:
   [.........]
2. Etc.

3. curriculum vitae completed with the latest 4 x 6 cm color passport-size photo;
   Article 9 paragraph (2) letter e
   POJK Number 68/POJK.05/2016
   Curriculum vitae and passport photo in the name of:

1. Mr./Ms.
   [.........]
2. Etc.
   d. a statement letter from the Board of Directors or equivalent from the relevant legal entity stating that:

1. capital deposits do not originate from loans;
2. capital deposits do not originate from money laundering activities and
   financial crimes;
3. do not have non-performing loans and/or financing;
4. are not included as Parties prohibited from becoming
   shareholders or Parties that manage, supervise, and/or have significant influence on financial service institutions;
5. have never been sentenced for committing criminal offenses in the field of
   financial service business and/or economy based on court decisions that have permanent legal force within the last 5 (five) years;
   Article 9 paragraph (2) letter e
   POJK Number 68/POJK.05/2016
   Statement letter signed by the Board of Directors or equivalent authorized to represent the company as follows:

1. Mr./Ms. [.........]
2. Etc.
   Accompanied by signature above stamp duty.

• 15 -

6. have never been declared bankrupt or declared guilty
   which causes a company to be declared bankrupt based on court decisions that have permanent legal force within the last 5 (five) years; and
7. have never been controlling shareholders on
   financial service companies whose business licenses were revoked due to violations within the last 5 (five) years; e. rating results from internationally recognized rating agencies, for shareholders that are foreign legal entities.
   Article 9 paragraph (2) letter e
   POJK Number 68/POJK.05/2016
   Entity given rating:
   [.........]
   Rating Agency:
   [.........]
   Rating:
   [.........]
   Other material information (if any):
   [.........]

13. In the event that the shareholder is the Republic of Indonesia, attach
    a photocopy of the government regulation regarding state capital participation of the Republic of Indonesia for the establishment of the Company.
    Article 9 paragraph (2) letter e
    POJK Number 68/POJK.05/2016
    No. Government Regulation:
    [.........]
    Date: [.........]
    Nominal Amount:
    [.........]

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14. In the event that the shareholder is the Regional Government, attach
    a photocopy of the regional regulation regarding regional capital participation for the establishment of the Company.
    Article 9 paragraph (2) letter e
    POJK Number 68/POJK.05/2016
    No. Regional Regulation: [.........]
    Date: [.........]
    Nominal Amount:
    [.........]
    Controlling Party
15. List of Controlling Parties along with information regarding the form
    of their control.
    Article 9 paragraph (2) letter f
    POJK Number 68/POJK.05/2016
    Name of Controlling Party:
    [.........]
    No. and date of Financial Services Authority (OJK) Approval regarding Determination of Controlling Party:
    [.........] date
    [.........]
    Rights and authority:
    [.........]
    Description regarding form of control:
    [.........]
    Expert Personnel
16. Proof of employing expert personnel.
    Article 9 paragraph (2) letter g
    POJK Number 68/POJK.05/2016
17. Proof that expert personnel have met the following requirements:
    a. insurance brokerage expert certificate with the highest level from the Professional Certification Agency in the insurance field (for expert personnel of Insurance Brokerage Companies);
    Article 9 paragraph (2), Article
    32, Article
    35, and
    Article 38
    POJK Number 68/POJK.05/2016
18. Name:
    [.........]
    Certificate No.:
    [.........]
    Date:

• 17
• b. reinsurance brokerage expert certificate with the highest level from the Professional Certification Agency in the insurance field (for expert personnel of Reinsurance Brokerage Companies);
  c. insurance loss appraisal expert certificate with the highest qualification from the Professional Certification Agency in the insurance field (for expert personnel of Insurance Loss Appraisal Companies);
  d. have work experience in the technical brokerage and/or technical insurance field for at least 3 (three) years (for expert personnel of Insurance Brokerage Companies); e. have work experience in risk management for at least 3 (three) years (for expert personnel of Reinsurance Brokerage Companies); f. have work experience in loss appraisal for at least 3 (three) years (for expert personnel of Insurance Loss Appraisal Companies); and g. be members of professional associations in Indonesia. [.........] Name of certificate issuer:
  [.........]
  Work experience:
  [.........]
  No. letter of confirmation from Association:
  [.........]
  Date:
  [.........]

2. Etc.
   Work Plan
3. Work plan for the first 3 (three) years, at least containing:
   a. feasibility study regarding market opportunities and economic potential as well as business lines to be entered and their target markets; b. steps taken to realize the aforementioned plan; and
   c. cash flow projections, balance sheets, semi-annual profit/loss calculations, and the Company's health level
   Article 9 paragraph (2) letter h
   POJK Number 68/POJK.05/2016
   Explanation consisting of descriptions of each point:
   a. [.........] b. [.........]
   c. [.........]

• 18 -
  as well as the underlying assumptions, starting from when the Company begins operational activities. Risk Management Guidelines

19. Photocopy of the Company's risk management guidelines, including:
    a. active supervision by the Board of Directors and Board of Commissioners; b. adequacy of policies, procedures, and risk limit determinations;
    c. adequacy of risk identification, measurement, monitoring,
    and control processes; d. risk management information systems; and; and e. comprehensive internal control systems.
    Article 9 paragraph (2) letter i
    POJK Number 68/POJK.05/2016,
    SEOJK Number 10/SEOJK.05/2016
    Proven by
    Risk Management
    Guidelines
    No. guidelines:
    [.........]
    Effective Date of guidelines:
    [.........]
    Signed by: [.........]
    Explanation consisting of descriptions of each point:
    a. [.........] b. [.........]
    c. [.........]
    d. [.........] e. [.........]
    Agreements with Other Parties
20. Photocopy of agreements with other parties (if any) and policies for partial delegation of functions in business operations (if any).
    Article 9 paragraph (2) letter j
    POJK Number 68/POJK.05/2016
    Name of Party:
    [.........]
    Delegated Function:
    [.........]
    Systems Used by the Company
21. Administrative systems and data management infrastructure supporting the preparation and submission of reports to the Financial Services Authority.
    Article 9 paragraph (2) letter k
    POJK Number 68/POJK.05/2016
    Software:
    [.........]
    Hardware:
    [.........]

• 19 -
  Applications used by the Company:
  [.........]

22. Data processing systems that can generate
    accurate information and can be accountable in decision-making.
    Article 13
    paragraph (6)
    POJK Number 68/POJK.05/2016
    Data processing system in the form of:

• spreadsheet programs;
• application-based information systems;
  and/or
• web-based information systems.
  Applications used by the Company:
  [.........]
  In the Event of Direct Investment from Foreign Parties

23. Confirmation from the supervisory authority in the home country
    of the foreign party, in the event of direct investment from Foreign Parties.
    Article 9 paragraph (2) letter l
    POJK Number 68/POJK.05/2016
    Country name:
    [.........]
    Institution name:
    [.........]
    Letter No.:
    [.........]
    Date:
    [.........]
    Substance of confirmation:
    [.........]
24. Proof of payment of licensing fees.
    Article 9 paragraph (2) letter m
    POJK Number 68/POJK.05/2016
    No. OJK Payment System:
    [.........]

• 20 -
  Date of payment:
  [.........]
  Amount paid:
  [.........]
  Other Documents

25. Photocopy of the Company's initial/opening financial position report.
    Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016
26. Proof of operational readiness. Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016
    Inventory list:
    a. [.........] b. [.........]
    c. Etc.
    Letter of Confirmation of Head Office Address No.:
    [.........]
    Date: [.........]
    Address:
    [.........]
27. Proof of having valid professional indemnity insurance with an insured amount of at least equal to the paid-up capital.
    Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016
28. Human resources plan including human resource development plans for at least the first 3 (three) years.
    Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016

• 21 -

29. Photocopy of guidelines for implementing anti-money laundering and counter-terrorism financing programs.
    Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016
    Proven by
    Anti-Money Laundering and
    Counter-Terrorism Financing
    Program Implementation
    Guidelines
    No. Guidelines:
    [.........]
    Effective Date of SOP:
    [.........]
    Signed by:
    [.........]
    Explanation consisting of descriptions of each point:
    a... b... c...
    d....
    e...
30. Photocopy of good corporate governance guidelines, containing provisions as follows:
    Proven by good corporate governance guidelines No. guidelines:
    [.........]
    Effective Date of guidelines:
    [.........]
    Signed by: [.........] a. execution of duties and responsibilities of the Board of Directors and Board of Commissioners;
    Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016 and
    Article 4
    POJK Number 73/POJK.05/2016 b. execution of duties of units and committees performing internal control functions
    Article 9 paragraph (2) letter n
    POJK Number

• 22

Company; and 68/POJK.05/2016 and
Article 4
POJK Number 73/POJK.05/2016
c. application of compliance functions, internal auditors, and external auditors.
Article 9 paragraph (2) letter n
POJK Number 68/POJK.05/2016 and
Article 4
POJK Number 73/POJK.05/2016
31.
Photocopy of investment governance guidelines established by the Board of Directors, containing investment policies and strategies, at least containing:
a. the Company's asset and liability profile; b. the match between asset duration and liability duration of the Company;
c. investment objectives;
d. target levels of expected investment returns, including yield benchmarks used; e. valuation basis and qualitative limits for each type of investment asset; f. maximum allocation limits for investment for each type of investment asset; g. maximum proportion limits of the Company's assets that can be placed with one party; h. maximum limits on idle assets not placed in investment forms;
i. investment objects prohibited for
Article 9 paragraph (2) letter n
POJK Number 68/POJK.05/2016
Proven by good corporate governance guidelines No. guidelines:
[.........]
Effective Date of guidelines:
[.........]
Signed by:
[.........]
Brief explanation regarding the guidelines:
[.........]
Proven by guidelines and investment strategies No.

• 23
• investment placement;
  j. minimum liquidity level of the Company's investment portfolio to support fund availability for insurance benefit payments; k. supervision and reporting systems for the implementation of investment management;
  l. provisions regarding the use of investment managers, investment advisors, expert personnel, and other service providers used in investment management;
  m. provisions on the use of derivative instruments and other structured financial products for hedging purposes; n. transaction authority limits for investment for each management level and their accountability; and o. actions to be taken against the Board of Directors for violations of investment policies. guidelines:
  [.........]
  Effective Date of guidelines:
  [.........]
  Signed by:
  [.........]

32. Photocopy of cooperation agreements between foreign legal entity shareholders and Indonesian shareholders, made in Indonesian language and at least containing:
    a. capital composition and detailed authorities, at least containing provisions regarding voting rights, profit and loss distribution, and appointment of Board of Directors and Board of Commissioners members of the Company; and b. obligations of foreign legal entity shareholders
    Article 9 paragraph (2) letter n
    POJK Number 68/POJK.05/2016
    No.:
    [.........]
    Date: [.........]
    Capital composition:
    [.........]
    Obligations:
    [.........]

• 24 -
  to formulate and implement education and training programs according to their fields of expertise. We, the undersigned, hereby declare that:

1. The aforementioned Self Assessment Form has been filled out according to the actual conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
3. Filling method: double-click in the box, then select
   ”Checked”.
4. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies,
   and Insurance Loss Appraisal Companies.

• 25 -
  FORM SELF ASSESSMENT 2 BUSINESS ACTIVITY EXECUTION REPORTING COMPANY FFOORRMM:: 22 FORM SELF ASSESSMENT BUSINESS ACTIVITY EXECUTION REPORTING COMPANY Company Name :
  Report letter No. :
  Report letter Date :
  Contact person (name, phone, email)
  :
  No. and date of Financial Services Authority (OJK) Commissioners' Decision regarding business license :
  LEGAL BASIS DESCRIPTION
  COMPLETENESS
  YES NO DESCRIPTION

1. Reports are submitted using
   format 2 Attachment of POJK
   Number 68/POJK.05/2016 and signed by the Board of Directors. Report Date :
   [.........]
   Policy Date:
   [.........]
2. Proof of insurance placement for Insurance Brokerage Companies, proof of reinsurance placement for Reinsurance Brokerage Companies, or proof of work order letters for Insurance Loss Appraisal Companies.
   Article 11 paragraph (4)
   letter a POJK
   68/POJK.05/2016
   Policy No.:
   [.........]
   Date: [.........]
3. Photocopy of residence permits and/or permits for using foreign labor
   issued by the competent authority, for
   Board of Directors members and/or Board of Commissioners members who are foreign nationals.
   Article 11 paragraph (4)
   letter b POJK
   68/POJK.05/2016
4. Name:
   [.........]
   Position:
   [.........]
   Permit No.:
   [.........]
   Date: [.........]
5. Etc.

• 26 -
  Additional notes (if necessary):
  We, the undersigned, hereby declare that:

1. The aforementioned Self Assessment Form has been filled out according to the actual conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies,
   Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
3. Filling method: double-click in the box, then select
   ”Checked”.
4. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies,
   and Insurance Loss Appraisal Companies.

• 27 -
  FORM SELF ASSESSMENT 3 REPORTING PLANS TO EMPLOY FOREIGN WORKERS OF THE COMPANY FORM: 3 FORM SELF ASSESSMENT REPORTING PLANS TO EMPLOY FOREIGN WORKERS OF THE COMPANY Company Name :
  Report letter No. :
  Contact person (name, phone, email)
  :
  Report letter Date :
  Name of foreign worker :
  Position of foreign worker : Expert personnel with job level one level below Board of Directors/consultant Functions handled by foreign workers : Technical brokerage/technical loss appraisal insurance/marketing/information systems Duration of foreign worker usage :
  Name of Indonesian accompanying worker :
  NO LEGAL BASIS REQUIREMENTS
  COMPLETENESS
  YES NO DESCRIPTION
  Requirements for Using Foreign Workers

1. Foreign workers are employed as:
   a. expert personnel with job level 1 level below Board of Directors; or b. consultants.
   Article 15 paragraph (2) POJK Number
   68/POJK.05/
   2016
   Position of foreign workers employed
   [.........]
2. Foreign workers handle functions:
   a. technical brokerage for
   Insurance Brokerage Companies and
   Reinsurance Brokerage Companies; b. technical insurance loss appraisal, for Insurance Loss Appraisal Companies;
   c. marketing; and/or
   d. information systems.
   Article 15 paragraph (3) POJK Number
   68/POJK.05/
   2016
   Functions of foreign workers employed:
   [.........]

• 28 -

3. Foreign workers as experts/consultants meet the requirements:
   a. employed to execute specific projects or programs related to operational activities in the insurance field (for foreign workers as consultants);
   Article 15 paragraph (5) letter a
   POJK Number 68/POJK.05/
   2016
   Projects or programs related to operational activities in the insurance field [.........] b. employed for a maximum duration of 5 (five) years (for foreign workers as expert personnel) or duration for specific projects or programs related to operational activities in the insurance field for a maximum of 5 (five) years (for foreign workers as consultants);
   Article 15 paragraph (4) letter a and
   paragraph (5) letter b
   POJK Number 68/POJK.05/
   2016
   Duration of usage of foreign workers or duration of projects [.........]
   c. accompanied by Indonesian workers in the context of knowledge, expertise, and technology transfer;
   Article 15 paragraph (4) letter a and paragraph (5) letter c
   POJK Number 68/POJK.05/
   2016
   Letter of confirmation of appointment of Indonesian accompanying workers [.........] d. possess expertise according to the field of duties that will be their responsibility; and
   Article 15 paragraph (6) letter a
   POJK Number 68/POJK.05/
   2016 e. foreign workers hold positions that cannot yet be filled by Indonesian workers.
   Article 15 paragraph (6) letter b
   POJK Number 68/POJK.05/
   2016
   Written statement letter from the Board of Directors regarding reasons for using foreign workers [.........]
4. Meet the provisions of labor laws and regulations.
   Article 15 paragraph (6) letter c
   POJK Number 68/POJK.05/
   2016

• Letter of confirmation
  of having education that matches job requirements [.........]

• competence certificates
  or work experience matching the position to be held for at least 5 (five) years

• letter of confirmation
  of transferring expertise to Indonesian accompanying workers

• letters/documents
  explaining the background of education of Indonesian accompanying workers matching the position to be held by foreign workers (Article 36 Menaker 16/2015)

• 29 -
  Completeness of Documents for Request to Employ Foreign Workers

5. Reports on plans to employ foreign workers are submitted by the Company's Board of Directors to the Financial Services Authority according to format 3 attachment of POJK Number 68/POJK.05/2016 and signed by the Board of Directors.
   Article 16 paragraph (2) POJK Number
   68/POJK.05/
   2016
6. Curriculum vitae of foreign workers employed.
   Article 16 paragraph (3) letter a
   POJK Number 68/POJK.05/
   2016
   Completed with descriptions of their work along with photocopies of passports and the latest 4x6 cm color passport photos
7. Photocopy of documents reflecting their fields of expertise.
   Article 16 paragraph (3) letter a
   POJK Number 68/POJK.05/
   2016
   No.:
   [.........]
   Date: [.........]
8. Annual education and training program plans during the employment of the aforementioned foreign workers.
   Article 16 paragraph (3) letter b
   POJK Number 68/POJK.05/
   2016
9. Plans for placement and fields of responsibility of foreign workers.
   Article 16 paragraph (3) letter c
   POJK Number 68/POJK.05/
   2016
   Descriptions regarding plans for education and training programs during the employment of foreign workers that describe the process of knowledge, expertise and technology transfer along with expected results and implementation time. Additional notes (if necessary):
   We, the undersigned, hereby declare that:
10. The aforementioned Self Assessment Form has been filled out according to the actual conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
11. The documents submitted online are true and identical to the printed documents.
    Jakarta, [………………………....]
    Board of Directors [……………………….] signature [Full Name] Note:
12. Filling method: double-click in the box, then select ”Checked”.
13. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 30 -
  SELF ASSESSMENT 4 REPORTING ON THE APPOINTMENT OF FOREIGN WORKERS OF THE COMPANY FORM: 4 FORM SELF ASSESSMENT REPORTING ON THE APPOINTMENT OF FOREIGN WORKERS OF THE COMPANY Company Name :
  Report letter No. :
  Contact person (name, phone, email)
  Report letter Date :
  Name of foreign worker :
  Position of foreign worker : Expert personnel with job level one level below Board of Directors/consultant Functions handled by foreign workers : Technical brokerage/technical loss appraisal insurance/marketing/information systems Duration of foreign worker usage :
  Name of Indonesian accompanying workers :
  NO LEGAL BASIS REQUIREMENTS
  COMPLETENESS
  YES NO DESCRIPTION

1. Photocopy of proof of appointment
   of foreign workers.
   Article 17 paragraph (2)
   letter a POJK Number
   68/POJK.05/2016
   No.: [.........]
   Date: [.........]
2. Photocopy of residence permits. Article 17 paragraph (2)
   letter b POJK Number
   68/POJK.05/2016
   No.: [.........]
3. Photocopy of permits for using foreign workers.
   Article 17 paragraph (2)
   letter c POJK Number
   68/POJK.05/2016
   No.: [.........]
4. Photocopy of NPWP (Taxpayer Identification Number). Article 17 paragraph (2)
   letter d POJK Number
   68/POJK.05/2016
   No.: [.........]

---

• 33 -
  Additional information (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
3. Filling method: double-click the box, then select “Checked”.
4. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 34 -
  FORM SELF ASSESSMENT 5 REPORTING ON TERMINATION OF FOREIGN WORKERS COMPANY FORM: 5 FORM SELF ASSESSMENT REPORTING ON TERMINATION OF FOREIGN WORKERS COMPANY Company Name :
  Report letter number
  Contact person (name, phone, email)
  Foreign worker name :
  Report letter date :
  LEGAL BASIS DESCRIPTION
  COMPLETENESS
  YES NO NOTES
  Termination report of foreign workers accompanied by reasons for termination.
  Article 17 paragraph (3)
  POJK Number
  68/POJK.05/2016
  Additional information (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been in accordance with the provisions of the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature (Full Name) Note:
3. Filling method: double-click the box, then select
   ”Checked”.
4. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 35 -
  FORM SELF ASSESSMENT 6 APPLICATION FOR REGISTRATION OF INSURANCE BROKER OR REINSURANCE BROKER FORM: 6 FORM SELF ASSESSMENT APPLICATION FOR REGISTRATION OF INSURANCE BROKER OR REINSURANCE BROKER Company name :
  Number and date
  Application letter
  :
  Broker name :
  Type of broker : Insurance Broker / Reinsurance Broker Professional title :
  Place and date of birth :
  Nationality :
  Contact person (name, tel/email)
  :
  NO BASIC REQUIREMENTS
  LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. The report is submitted
   using format 4 (insurance broker) or format 7 (reinsurance broker) Annex POJK 68/POJK.05/2016 and signed by the Board of Directors.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
2. Photocopy of brokerage certificate
   with the lowest level of 2
   (two) levels below the highest qualification from the Professional Certification Body or a brokerage certificate from abroad after first obtaining recognition from the Professional Certification Body.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
   Name of Professional
   Certification Body:
   [.........]
   Certificate Number:
   [.........]
3. Proof of work experience in
   the field of brokerage technical and/or insurance technical for at least 3 (three) years.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
   Company
   Name:
   [.........]
   Position:
   [.........]
   Job Description:
   [.........]

• 36

4. Proof of membership in an
   insurance/reinsurance broker association in Indonesia.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
5. Photocopy of identification card
   in the form of an ID card or valid passport.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
   Identity Number:
   [.........]
6. Photocopy of Taxpayer Identification
   Number (NPWP). Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
   NPWP Number: [.........]
7. Curriculum vitae with the latest
   4 x 6 cm colored passport photo.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
8. Statement letter from the
   concerned party stating:
   a. has never been sentenced for committing criminal acts in the field of financial services business and/or economy based on a court decision that has obtained permanent legal force within the last 5 (five) years; b. has never been sentenced for committing criminal acts based on a court decision that has obtained permanent legal force within the last 5 (five) years; and
   c. has never been declared
   bankrupt or guilty which causes a corporation/company to be declared bankrupt based on a court decision that has obtained permanent legal force within the last 5 (five) years.
   Article 22 paragraph
   (2) and Article
   28 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
   Date of Statement
   Letter:
   [.........]

• 37 -
  Additional information (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual conditions
   and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
3. Filling method: double-click the box, then select “Checked”.
4. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 38 -
  FORM SELF ASSESSMENT 7 REPORTING ON APPOINTMENT OF INSURANCE BROKER OR REINSURANCE BROKER FORM: 7 FORM SELF ASSESSMENT REPORTING ON APPOINTMENT OF INSURANCE BROKER OR REINSURANCE BROKER Company Name :
  Number and date application letter
  :
  Broker name :
  Type of broker : Insurance Broker / Reinsurance Broker Professional title :
  Place and date of birth :
  Nationality :
  Contact person (name, tel/email) :
  NO BASIC REQUIREMENTS
  LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. The report is submitted
   using format 5
   (insurance broker) or format
   8 (reinsurance broker)
   Annex POJK 68/POJK.05/
   2016 and signed by the
   Board of Directors.
   Article 25 paragraph (2)
   and Article 31 paragraph
   (2) POJK Number
   68/POJK.05/2016
2. Certificate of registration of
   insurance broker or reinsurance broker.
   Article 25 paragraph (2)
   and Article 31 paragraph
   (2) POJK Number
   68/POJK.05/2016
   Registration number:
   [.........]
   Additional information (if necessary):
   We, the undersigned, hereby declare that:
3. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and

• 39 -

2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [……………………….]
   Board of Directors [...........................] signature [Full Name] Note:
3. Filling method: double-click the box, then select “Checked”.
4. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 40 -
  FORM SELF ASSESSMENT 8 REPORTING ON TERMINATION OF INSURANCE BROKER OR REINSURANCE BROKER FORM: 8 FORM SELF ASSESSMENT REPORTING ON TERMINATION OF INSURANCE BROKER OR REINSURANCE BROKER Company Name :
  Number and date application letter
  :
  Broker name :
  Type of broker : Insurance Broker / Reinsurance Broker Professional title :
  Place and date of birth :
  Nationality :
  Contact person (name, tel/email)
  :
  LEGAL BASIS DESCRIPTION
  COMPLETENESS
  YES NO NOTES
  The report is submitted using format 6
  (insurance broker) or format 9 (reinsurance broker)
  Annex POJK
  68/POJK.05/ 2016 and signed by the Board of Directors.
  Article 25 paragraph (3)
  and Article 31 paragraph (3) POJK
  Number
  68/POJK.05/201
  6
  Additional information (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and
   identical to the printed documents.

• 41 -
  Jakarta, […………………]
  Board of Directors [……………….] signature
  [Full Name]
  Note:

1. Filling method: double-click the box, then select “Checked”.
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 42 -
  FORM SELF ASSESSMENT 9 REPORTING ON APPOINTMENT OF EXPERT PERSONNEL COMPANY FORM: 9 FORM SELF ASSESSMENT REPORTING ON APPOINTMENT OF EXPERT PERSONNEL COMPANY Company Name :
  Type and business line of expert personnel : PPA/PPR/PPKA Registration number from the Financial Services Authority :
  (If already registered previously)
  Contact person (name, phone, email)
  :
  Placement of expert personnel : Head Office / Office Outside Head Office Name of expert personnel :
  Place and date of Birth :
  Professional title of expert personnel :
  Report letter number :
  Report letter date :
  LEGAL BASIS DESCRIPTION
  COMPLETENESS
  YES NO NOTES
  The report is submitted using format 10 (for Insurance Brokerage Company) or format 12 (for Reinsurance Brokerage Company) or format 14 (for Insurance Loss Appraisal Company) Annex POJK Number 68/POJK.05/2016.
  Article 34 paragraph
  (2);
  Article 37 paragraph
  (2);
  Article 40 paragraph
  (2);
  POJK Number
  68/POJK.05
  /2016
  Additional information (if necessary):

• 43 -
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and
   identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
3. Filling method: double-click the box, then select
   ”Checked”.
4. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies and Insurance Loss Appraisal Companies.

• 44 -
  FORM SELF ASSESSMENT 10 REPORTING ON TERMINATION OF EXPERT PERSONNEL COMPANY FORM: 10 FORM SELF ASSESSMENT REPORTING ON TERMINATION OF EXPERT PERSONNEL COMPANY Company Name :
  Report letter number :
  Contact person (name, phone, email)
  :
  Name of expert personnel :
  Place and date of Birth :
  Professional title of expert personnel :
  Status of expert personnel : Expert Personnel / Additional Expert Personnel Report letter date :
  BASIC REQUIREMENTS
  LEGAL BASIS
  COMPLETENESS
  YES NO NOTES
  The report is submitted using format 11 (for Insurance Brokerage Company) or format 13 (for Reinsurance Brokerage Company) or format 15 (for Insurance Loss Appraisal Company) Annex POJK Number 68/POJK.05/2016.
  Article 34 paragraph
  (3);
  Article 37 paragraph
  (3);
  Article 40 paragraph
  (3);
  POJK Number
  68/POJK.05/
  2016
  Additional information (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and
   identical to the printed documents.

• 45 -
  Jakarta, [………………………....]
  Board of Directors [……………………….] signature [Full Name] Note:

1. Filling method: double-click the box, then select
   ”Checked”.
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies and Insurance Loss Appraisal Companies.

• 46 -
  FORM SELF ASSESSMENT 11 REPORTING ON OPENING OF OFFICE OUTSIDE HEAD OFFICE OF COMPANY FORM: 11 FORM SELF ASSESSMENT REPORTING ON OPENING OF OFFICE OUTSIDE HEAD OFFICE OF COMPANY Company Name :
  Report letter number :
  Report letter date :
  Contact person (name, phone, email)
  :
  Purpose and objectives of opening office outside head office :
  List of Opening Offices Outside Head Office No. Office Name Address*) Tel No. Manager Date of Effective Opening 1. 2. Etc. *) Address must be written in full, namely including the name of the Village/Sub-district, District, City/Regency, and Postal Code. NO LEGAL BASIS DESCRIPTION COMPLETENESS YES NO NOTES

1. The report is submitted
   using format 16
   Annex POJK
   68/POJK.05/2016 and signed by the Board of Directors.
   Article 42 paragraph
   (2) POJK
   Number
   68/POJK.05/
   2016
2. The report has been accompanied
   by documents as follows:
   a. office name and function of the office;
   Article 42 paragraph
   (3) letter a
   POJK Number
   68/POJK.05/
   2016
   Office Name:
   [.......]
   Office Function:
   [.......] b. office address supported by a letter of statement from the relevant party stating at least the name of the Company;
   Article 42 paragraph
   (3) letter b
   POJK Number
   68/POJK.05/
   2016
   Letter number statement:
   [.......]
   Date of letter statement:
   [.......]
   Issuing agency of statement letter:
   [.......]

• 47 -
  c. name of office manager
  accompanied by a curriculum vitae; and
  Article 42 paragraph
  (3) letter c
  POJK Number
  68/POJK.05/
  2016
  Curriculum Vitae of:

1. Mr./Ms. [.........]
2. Mr./Ms. [.........]
   d. description of duties and authority of the office manager.
   Article 42 paragraph
   (3) letter d
   POJK Number
   68/POJK.05/
   2016
   Additional information: (if necessary)
   We, the undersigned, hereby declare that:
3. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
4. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
5. Filling method: double-click the box, then select “Checked”.
6. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 48 -
  FORM SELF ASSESSMENT 12 REPORTING ON CLOSURE OF OFFICE OUTSIDE HEAD OFFICE OF COMPANY FORM: 12 FORM SELF ASSESSMENT REPORTING ON CLOSURE OF OFFICE OUTSIDE HEAD OFFICE OF COMPANY Company Name :
  Report letter number :
  Report letter date :
  Contact person (name, phone, email)
  :
  List of closure of offices outside head office No. Office Name Address*) Manager Date of Effective Closure Office 1. 2. Etc. *) Address must be written in full, namely including the name of the Village/Sub-district, District, City/Regency, and Postal Code NO LEGAL BASIS DESCRIPTION COMPLETENESS YES NO NOTES

1. The report is submitted
   using format
   17 Annex POJK Number
   68/POJK.05/2016 and signed by the Board of Directors.
   Article 44 paragraph
   (2) POJK
   Number
   68/POJK.05/
   2016
2. Proof of notification of
   planned closure of office outside head office.
   Article 44 paragraph
   (2) letter a
   POJK Number
   68/POJK.05/
   2016
   Date of notification to policyholders:
   [.......]
3. Proof of transfer of services
   from the closed office outside head office to the head office or the nearest office outside head office.
   Article 44 paragraph
   (2) letter b
   POJK Number
   68/POJK.05/
   2016
   Date of notification to employees:
   [.......]
   Number of SK transfer of manager:
   [.......]
   Date of SK:
   [.......]

• 49 -
  Number of SK transfer of employees:
  [.......]
  Date:
  [.......]
  Additional information (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
3. Filling method: double-click the box, then select “Checked”.
4. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority
   Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Appraisal Companies.

• 50 -
  FORM SELF ASSESSMENT 13 APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE THAT CAUSES CHANGE OF CONTROLLING SHAREHOLDER OF COMPANY FORM: 13 FORM SELF ASSESSMENT APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE THAT CAUSES CHANGE OF CONTROLLING COMPANY SHAREHOLDER Company Name :
  Application letter number :
  Application letter date :
  Contact person (name, phone, email)
  :
  Background of planned ownership change
  Type of Ownership Change Ownership change caused by the entry of a new shareholder becoming a controlling shareholder through the transfer of shares from existing shareholders or issuance of new shares. Ownership change caused by the transfer of shares among existing shareholders and causing the emergence of a new controlling shareholder. Capital increase by existing shareholders that causes the existence of additional/change of controlling shareholders. Others. Substance of Ownership Change Before Becomes Shareholder Nominal (Rp) % Shareholder Nominal (Rp) % BASIC REQUIREMENTS LEGAL BASIS COMPLETENESS YES NO NOTES Fulfillment of Ownership Provisions for Insurance Brokerage Companies, Reinsurance Brokerage Companies and Insurance Loss Appraisal Companies

1. Ownership change
   has not been implemented until
   Article 46 paragraph
   (1) POJK
   Company
   [...has not/has...]

• 51 -
  with obtaining approval from the Financial Services Authority. Number 68/POJK.05/ 2016 implementing the aforementioned ownership change.

2. Fulfillment of ownership
   criteria requirements:
   a. for Indonesian legal entities, namely directly or indirectly wholly owned by Indonesian citizens; or b. for Foreign legal entities, namely companies that have similar business or parent companies that one of its subsidiaries operates in the field of similar insurance business.
   Article 3 paragraph
   (1) POJK
   Number
   68/POJK.05/
   2016
   Ultimate shareholders of shareholders in the form of Indonesian legal entities:
3. PT [.........] owned by [.........] ;
4. Etc.
   Data of shareholders in the form of foreign legal entities:
5. [.........] operates in the field of
   [.........]
6. [.........] has subsidiaries in the field of
   business [..life insurance/general insurance /reinsurance..] as follows:
   a. [.........] ; and b. [.........]
7. Foreign ownership refers to
   Government Regulations on foreign ownership in Companies.

Article 3 paragraph (3)
POJK Number
68/POJK.05/
2016
At the time of establishment of the Company, direct participation of foreign parties in the Company is at most 80% (eighty percent) (Article 6 Government Regulation Number 73/1992)
4. The total direct participation
in the Company for shareholders in the form of Indonesian legal entities that are not LJKs under the supervision of the Financial Services Authority, the highest is equal to the equity of the shareholder.
Article 7 paragraph (3)
POJK Number
68/POJK.05/
2016
List of shareholder equity:

1. PT [.........] equity
   amounting to Rp [.........] per (last financial report date)
2. PT [.........] equity
   amounting to Rp [.........] per (last financial report date) Based on the equity amount above, PT... and PT.... meet/do not meet the maximum participation provisions.
3. The total direct participation
   in the Company for shareholders in the form of Indonesian legal entities that are LJKs under the supervision of the Financial Services Authority, is carried out in accordance with the provisions of legislation governing investment and/or participation.
   Article 7 paragraph (5)
   POJK Number
   68/POJK.05/
   2016
   List of shareholder equity:
   PT [.........] equity amounting to Rp [.........] per (last financial report date) Based on the equity amount above, PT [.........] and PT [.........] meet/do not meet the maximum participation provisions. Completeness of Documents for Application for Approval of Ownership Change
4. The application is submitted
   using format 18
   Annex POJK Number
   68/POJK.05/2016 and signed by the Board of Directors of the company.
   Article 46 paragraph
   (3) POJK
   Number
   68/POJK.05/
   2016
5. Draft ownership list. Article 46 paragraph
   (3) letter a
   POJK Number
   68/POJK.05/
   2016
   List of names and composition of existing shareholders in the form of:
   a. [.........] ownership amounting to [.........] % b. [.........] ownership amounting to [.........] % Draft list of names and composition of shareholders in the form of:
   a. [.........] ownership amounting to [.........] % b. [.........] ownership amounting to [.........] %

---

• 53 -

8. In the event that a change in ownership is caused by a new shareholder who is an individual, the company submits data on the prospective shareholder or member other than the controller as follows:
   a. photocopy of an identity document in the form of an ID card (KTP) or valid passport; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016
9. Name: [.........]
   Position: [.........]
   ID/Passport Number: [.........]
   Validity period of identity: [.........]
10. Etc.
    b. photocopy of the Taxpayer Identification Number (NPWP); Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016
11. Name: [.........]
    NPWP Number: [.........]
12. Etc.
    c. photocopy of tax returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of the prospective individual shareholder;
    Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Photocopy of SPT for Mr./Ms. [.........]:
    SPT Period: year [.........]
    Taxable Income: Rp [.........]
    Asset list: [.........]
    Total assets Rp [.........]
    Liability list [.........]
    Total Liabilities Rp [.........] d. curriculum vitae completed with the latest 4 x 6 cm color passport photo; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Curriculum vitae and passport photo for:
13. Mr./Ms. [.........]
14. Etc.

• 54 -
  e. a statement letter from the prospective shareholder stating:

1. capital deposits do not originate from loans;
2. capital deposits do not originate from money laundering activities and financial crimes;
3. does not have non-performing loans and/or financing;
4. is not included as a party prohibited from becoming a shareholder or a party that manages, oversees, and/or has significant influence on a financial services institution;
5. has never been sentenced for committing criminal acts in the field of financial services business and/or the economy based on a court decision that has had permanent legal force in the last 5 (five) years;
6. has never been sentenced for committing criminal acts based on a court decision that has had permanent legal force in the last 5 (five) years;
7. has never been declared bankrupt or guilty causing a company to be declared bankrupt based on a court decision that has had permanent legal force in the last 5 (five) years; and
   Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Statement letter signed by shareholders as follows:

1. Mr./Ms. [.........]
2. Mr./Ms. [.........]
3. Etc.
   Accompanied by the relevant signature above the stamp duty.

• 55 -

8. has never been a PSP, Board of Directors member, Board of Commissioners member, and Controller at a financial services company whose business license was revoked due to violations in the last 5 (five) years.

9. In the event that a change in ownership is caused by a new shareholder who is a legal entity, the company submits data on the prospective shareholder as follows:
   a. photocopy of the establishment deed of the legal entity including the articles of association and any amendments thereto, accompanied by photocopies of proof of approval, proof of consent, and/or photocopies of proof of receipt of notification from the competent authority; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Company Establishment Data:
   Deed No.: [.........]
   Date: [.........]
   Notary: [.........]
   Substance: [.........]
   Ministry of Law and Human Rights decision/letter number: [.........] Date: [.........] Business activities: [.........] Data on all Amendments to the Company's Articles of Association (if any):
10. Deed number and date: [.........]
    Number and date of proof of consent and/or receipt of notification from the competent authority:

• 56 -
  [.........]
  Substance of articles of association amendment:
  [.........]

2. Etc.
   b. financial reports audited by a public accountant, completed with non-consolidated financial reports and the latest monthly financial report; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Financial report of PT [.........] attached:
   Audited financial report for period [.........]
   c. photocopy of identity document in the form of an ID card (KTP) or valid passport for the directors or equivalent to directors of the relevant legal entity;
   Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Photocopy of identity of Board of Directors members and Board of Commissioners members:
3. Name: [.........]
   Position: [.........]
   ID/Passport Number: [.........]
   Validity period of identity:
4. Etc.
   d. photocopy of the taxpayer identification number (NPWP) of directors or equivalent to directors; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Attached photocopy of NPWP of Board of Directors members:
5. Name: [.........]
   NPWP Number: [.........]
6. Etc.
   e. curriculum vitae of directors or equivalent, completed with the latest 4 x 6 cm color passport photo; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Attached curriculum vitae and passport photo for:
7. Mr./Ms. [.........]
8. Mr./Ms. [.........]
9. Etc.
   f. a statement letter from the directors or equivalent of the relevant legal entity, stating that:

1. capital deposits do not originate from loans;
2. capital deposits do not
   Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Attached statement letter signed by:

1. Mr./Ms. [.........]
2. Mr./Ms. [.........]
3. Etc.

• 57 -
  originate from money laundering activities and financial crimes;

3. does not have non-performing loans and/or financing;
4. is not included as a party prohibited from becoming a shareholder or a party that manages, oversees, and/or has significant influence on a financial services institution;
5. has never been sentenced for committing criminal acts in the field of financial services business and/or the economy based on a court decision that has had permanent legal force in the last 5 (five) years;
6. has never been declared bankrupt or guilty causing a company to be declared bankrupt based on a court decision that has had permanent legal force in the last 5 (five) years; and
7. has never been a PSP, Board of Directors member, Board of Commissioners member, and Controller at a financial services company whose business license was revoked due to violations in the last 5 (five) years.
   g. rating results from an internationally recognized rating agency, for shareholders in the form of foreign legal entities or their subsidiaries that operate in similar insurance businesses, showing a rating of at least A or equivalent. Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e jo. Pasal 7 ayat (1) dan ayat (2) POJK Nomor 68/POJK.05/2016 Entity rated:

• 58 -
  [.........]
  Rating Agency:
  [.........]
  Rating:
  [.........]
  Other material information (if any):
  [.........] h. confirmation from the supervisory authority in the country of origin of the foreign party, in the event of direct participation by a foreign party; Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Confirmation letter number:
  [.........]
  Date of confirmation letter: [.........]
  Country and agency:
  [.........]
  Shareholder name:
  [.........]
  Substance of letter: [.........]
  i. photocopy of a cooperation agreement between the shareholder in the form of a foreign legal entity and the Indonesian shareholder, for applications for approval of ownership changes involving a new shareholder in the form of a foreign legal entity, which at least contains:

1. capital composition and details of authority, at least containing provisions regarding voting rights, profit and loss distribution, and appointment of Board of Directors members and Board of Commissioners members
   Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf n angka 8 POJK Nomor 68/POJK.05/2016 Number: [.........] Date: [.........] Capital composition:
   [.........]
   Obligations: [.........]

• 59 -
  of the Company; and

2. obligations of the shareholder in the form of a foreign legal entity to prepare and implement education and training programs according to their field of expertise.

10. Draft minutes of the General Meeting of Shareholders (RUPS).
    Pasal 46 ayat (3) huruf c POJK Nomor 68/POJK.05/2016 Draft minutes of the RUPS contain the substance before and after the planned change in share ownership and the approval of the shareholders. Other material information (if any):
    [.........]
11. Draft deed of transfer of rights over shares.
    Pasal 46 ayat (3) huruf d POJK Nomor 68/POJK.05/2016 Draft deed of transfer of rights over shares from:

• Mr./Ms. [.........]
• PT [.........]
  to:
• Mr./Ms. [.........]
• PT [.........]

12. Photocopy of tax returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of individual shareholders.
    Pasal 46 ayat (3) huruf e POJK Nomor 68/POJK.05/2016 Attached photocopy of SPT for: Mr./Ms. [.........] SPT Period: Year [.........] Taxable Income: Rp [.........]
    Asset list: ....
    Total assets: Rp [.........]
    Liability list:
    [.........]
    Total liabilities: Rp [.........]
13. Photocopy of the Company's financial report audited by a public accountant before the addition of Paid-up Capital, in the event that the change in ownership is caused by the addition of Paid-up Capital or will be carried out in the form of transfer of retained earnings, transfer of loans, and/or stock dividends.
    Pasal 46 ayat (3) huruf f POJK Nomor 68/POJK.05/2016 Attached audited financial report of PT [.........] year/period [.........]

• 60 -
  Assessment of Competence and Propriety for Controllers

14. The current controller has obtained a determination as a controller.
    Pasal 2 ayat (1) dan ayat (2) POJK 27/POJK.03/2016 serta SEOJK Nomor 31/SEOJK.05/2016 Number of determination/decision response:
    [.........]
    Date of determination/decision response: [.........]
    Controller Name:
    [.........]
15. Results of the competence and propriety assessment in the event of a change in ownership that causes the existence of a new Controller of the Insurance Company.
    Pasal 9 ayat (3) dan ayat (4) POJK Nomor 68/POJK.05/2016 dan Pasal 2 ayat (1) dan (2) POJK 27/POJK.03/2016 serta SEOJK Nomor 31/SEOJK.05/2016 We, the undersigned, hereby declare that:
16. The Self Assessment Form above has been filled out according to the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
17. The documents submitted online are true and identical to the printed documents.
    Jakarta, [………………………....]
    Board of Directors [……………………….] signature [Full Name]

• 61 -
  Notes:

1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 62 -
  FORM SELF ASSESSMENT 14 APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE THAT DOES NOT CAUSE A CHANGE IN CONTROLLER OF THE COMPANY FORM: 14 FORM SELF ASSESSMENT APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE THAT DOES NOT CAUSE A CHANGE IN CONTROLLER OF THE COMPANY Company Name :
  Letter of application number :
  Date of application letter :
  Contact person (name, phone, email) :
  Background of the planned change in share ownership :
  Type of ownership change Ownership change caused by the entry of a new shareholder Ownership change caused by the loss of one or more existing shareholders Ownership change caused by the transfer of shares among existing shareholders, but there is no change in the name and composition of shareholders Additional paid-up capital by existing shareholders causing a change in share ownership percentage Others Substance of ownership change Before Becoming Shareholder Nominal (Rp) % Shareholder Nominal (Rp) % Total Total

• 63 -
  BASIC REQUIREMENTS
  LEGAL
  COMPLETENESS
  YES NO NOTES
  Compliance with Ownership Provisions for Insurance Brokerage, Reinsurance Brokerage and Insurance Loss Assessment Companies

1. Ownership change has not been implemented until approval is obtained from the Financial Services Authority.
   Pasal 46 ayat (1) POJK Nomor 68/POJK.05/2016 The Company [...has not/has...] implemented the aforementioned ownership change.
2. Fulfillment of ownership criteria requirements for insurance companies:
   a. for Indonesian legal entities, namely directly or indirectly wholly owned by Indonesian citizens; or b. for Foreign legal entities, namely companies that have similar businesses or a parent company that one of its subsidiaries operates in a similar Insurance Business field. Pasal 3 ayat (1) POJK Nomor 68/POJK.05/2016 Ultimate shareholders of shareholders in the form of Indonesian legal entities:
3. PT [.........] owned by [.........] ;
4. Etc.
   Data on shareholders in the form of foreign legal entities:
5. [.........]
   operates in the field of [.........]
6. [.........] has subsidiaries in the business field of [..insurance brokerage/reinsurance brokerage/insurance loss assessment..] as follows:
   a. [.........] ; and b. [.........]
7. Foreign ownership refers to Government Regulations regarding foreign ownership in Companies.
   Pasal 3 ayat (3) POJK Nomor 68/POJK.05/2016 At the time of the Company's establishment, direct participation by foreign parties in the Company was at most 80% (eighty percent) (Article 6 of Government Regulation Number 73/1992)

• 64 -

4. The amount of direct participation in the Company for shareholders in the form of Indonesian legal entities that are not Financial Services Institutions (LJK) under the supervision of the Financial Services Authority, is at most equal to the shareholder's equity.
   Pasal 7 ayat (3) POJK Nomor 68/POJK.05/2016 List of shareholder equity:
5. PT [.........] equity amounting to Rp [.........] per (date of latest financial report)
6. PT [.........] equity amounting to Rp [.........] per (date of latest financial report)
   Based on the equity amounts above, PT... and PT.... meet/do not meet the maximum participation amount regulations.
7. The amount of direct participation in the Company for shareholders in the form of Indonesian legal entities that are financial services institutions under the supervision of the Financial Services Authority, is carried out in accordance with provisions of legislation governing investment and/or participation.
   Pasal 7 ayat (5) POJK Nomor 68/POJK.05/2016 (to be filled by the Financial Services Authority) Completeness of Documents for Application for Approval of Ownership Change
8. The application is submitted using format 18 Attachment of POJK Number 68/POJK.05/2016 and signed by the Company's Board of Directors.
   Pasal 46 ayat (3) POJK Nomor 68/POJK.05/2016
9. Planned ownership list.
   Pasal 46 ayat (3) huruf a POJK Nomor 68/POJK.05/2016 Planned ownership list before and after the ownership change.

• 65 -

8. In the event that a change in ownership is caused by a new shareholder who is an individual, the company submits data on the prospective shareholder as follows:
   a) photocopy of an identity document in the form of an ID card (KTP) or valid passport; Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016
9. Name: [.........]
   Position: [.........]
   ID/Passport Number: [.........]
   Validity period of identity: [.........]
10. Etc.
    b) photocopy of NPWP; Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016
11. Name: [.........]
    NPWP Number: [.........]
12. Etc.
    c) photocopy of tax returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of the prospective individual shareholder; Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Photocopy of SPT for Mr./Ms. [.........]:
    SPT Period: year [.........]
    Taxable Income:
    Rp [.........]
    Asset list: [.........]
    Total assets Rp [.........]
    Liability list [.........]
    Total Liabilities Rp [.........] d) curriculum vitae completed with the latest 4 x 6 cm color passport photo; and Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Curriculum vitae and passport photo for:
13. Mr./Ms. [.........]
14. Mr./Ms. [.........]
    e) a statement letter from the prospective shareholder stating:

1. capital deposits do not originate from loans;
2. capital deposits do not originate from money laundering activities and financial crimes;
3. does not have non-performing loans and/or financing;
4. is not included as a party prohibited from becoming a shareholder or a party that manages, oversees, and/or has significant influence on a financial services institution;
5. has never been sentenced for committing criminal acts in the field of financial services business and/or the economy based on a court decision that has had permanent legal force in the last 5 (five) years;
6. has never been sentenced for committing criminal acts based on a court decision that has had permanent legal force in the last 5 (five) years;
7. has never been declared bankrupt or guilty causing a company to be declared bankrupt based on a court decision that has had permanent legal force in the last 5 (five) years; and
   Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Statement letter signed by:

1. Mr./Ms. [.........]
2. Mr./Ms. [.........]
3. Etc.

• 67 -

8. has never been a PSP, Board of Directors member, Board of Commissioners member, and Controller at a financial services company whose business license was revoked due to violations in the last 5 (five) years.

9. In the event that a change in ownership is caused by a new shareholder who is a legal entity, the company submits data on the prospective shareholder as follows:
   a. photocopy of the establishment deed of the legal entity including the articles of association and any amendments thereto (if any), accompanied by photocopies of proof of approval, proof of consent, and/or photocopies of proof of receipt of notification from the competent authority; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Company Establishment Data:
   Deed No.: [.........]
   Date: [.........]
   Notary: [.........]
   Substance: [.........]
   Ministry of Law and Human Rights decision/letter number: [.........] Date: [.........] Business activities: [.........] Data on all amendments to the company's articles of association (if any):
10. Deed number and date: [.........]
    Number and date of proof of consent and/or receipt of notification from the competent authority: [.........] Substance of articles of association amendment: [.........]
11. Etc.
    b. financial reports audited by a public accountant, completed with non-consolidated financial reports and the latest monthly financial report; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Financial report of PT [.........] attached:
12. Audited financial report for period [.........]
13. Etc.
    c. photocopy of identity document in the form of an ID card (KTP) or valid passport for directors or equivalent to directors of the relevant legal entity;
    Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Photocopy of identity of Board of Directors members:
14. Name: [.........]
    Position: [.........]
    ID/Passport Number: [.........]
    Validity period of identity:
15. Etc.
    d. photocopy of NPWP of Directors or equivalent to directors; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Photocopy of NPWP of Board of Directors members:
16. Name: [.........]
    NPWP Number: [.........]
17. Etc.

e. curriculum vitae of directors or equivalent, completed with the latest 4 x 6 cm color passport photo; Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Curriculum vitae and passport photo for:

1. Mr./Ms. [.........]
2. Mr./Ms. [.........]
3. Etc.
   f. a statement letter from the directors or equivalent of the relevant legal entity, stating that:

1. capital deposits do not originate from loans;
2. capital deposits do not originate from money laundering activities and financial crimes;
3. does not have non-performing loans and/or financing;
4. is not included as a party prohibited from becoming a shareholder or a party that manages, oversees, and/or has significant influence on a financial services institution;
5. has never been sentenced for committing criminal acts in the field of financial services business and/or the economy based on a court decision that has had permanent legal force in the last 5 (five) years;
6. has never been declared bankrupt or guilty causing a company to be declared bankrupt based on a court decision that has had permanent legal force in the last 5 (five) years; and
7. has never been a PSP, Board of Directors member, Board of Commissioners member, and Controller at a financial services company whose business license was revoked due to violations in the last 5 (five) years.
   Pasal 46 ayat (3) huruf b jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Statement letter signed by:

1. Mr./Ms. [.........]
2. Etc.

g. rating results from an internationally recognized rating agency, for shareholders in the form of foreign legal entities or their subsidiaries that operate in similar insurance businesses, showing a rating of at least A or equivalent; Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e jo. Pasal 7 ayat (1) dan ayat (2) POJK Nomor 68/POJK.05/2016 Entity rated:
[.........]
Rating Agency:
[.........]
Rating:
[.........]
Other material information (if any):
[.........] h. confirmation from the supervisory authority in the country of origin of the foreign party, in the event of direct participation by a foreign party; and Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf e POJK Nomor 68/POJK.05/2016 Confirmation letter number: [.........] Date of confirmation letter: [.........] Country and agency:
[.........]
Shareholder name: [.........]
Substance of letter: [.........]
i. photocopy of a cooperation agreement between the shareholder in the form of a foreign legal entity and the Indonesian shareholder, for applications for approval of ownership changes involving a new shareholder in the form of a foreign legal entity,
Pasal 46 ayat (3) jo. Pasal 9 ayat (2) huruf n angka 8 POJK Nomor 68/POJK.05/2016 Date of agreement:
(date-month-year)
Parties to the agreement:

1. [.........]
2. [.........]

• 71 -
  foreign legal entity, which must contain at least:

1. capital composition and details of authority, which must contain at least provisions regarding voting rights, profit and loss distribution, and the appointment of Directors and Commissioners of the Company; and
2. the obligation of foreign legal entity shareholders to prepare and implement education and training programs in their field of expertise.

3. Etc.
   Substance of the agreement:
4. [.........]
5. [.........]
6. Etc.
7. Draft minutes of the General Meeting of Shareholders (RUPS). Article 46 paragraph (3) letter c
   POJK Number 68/POJK.05/2016
   Draft minutes of the RUPS contain substance before and after the planned change in share ownership and the approval of the shareholders. Other material information (if any):
   [.........]
8. Draft deed of transfer of share rights.
   Article 46 paragraph (3) letter d
   POJK Number 68/POJK.05/2016
   Draft deed of transfer of share rights from:

• Mr./Mrs. [.........]
• PT [.........]
  to:
• Mr./Mrs. [.........]
• PT [.........]

12. Photocopy of Tax Returns (SPT) for the last 2 (two) years and other documents showing financial capacity and funding sources of individual shareholders.
    Article 46 paragraph (3) letter e
    POJK Number 68/POJK.05/2016
    Attached photocopy of SPT for: Mr./Mrs. [.........]
    SPT Period: Year [.........]

• 72 -
  Taxable Income:
  Rp [.........]
  Asset list: [.........]
  Total assets: Rp [.........]
  Liability list:
  [.........]
  Total liabilities:
  Rp [.........]

13. Photocopy of the Company's financial statements audited by a public accountant before the addition of Paid-up Capital, in the event that the change in ownership is caused by an addition of Paid-up Capital or will be carried out in the form of transfer of retained earnings, loan transfer, and/or stock dividends.
    Article 46 paragraph (3) letter f
    POJK Number 68/POJK.05/2016
    Audited financial statements of PT [.........] year/period [.........] We, the undersigned, hereby declare that:
14. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
15. The documents submitted online are true and identical to the printed documents.
    Jakarta, [……………………….]
    Board of Directors [……………………….] signature [Full Name] Note:
16. Filling method: click twice on the box, then select "Checked".
17. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 73 -
  FORMAT SELF ASSESSMENT 15 REPORTING OF CHANGE IN COMPANY OWNERSHIP FORM: 15 FORM SELF ASSESSMENT REPORTING OF CHANGE IN COMPANY OWNERSHIP Company Name :
  Report letter number :
  Report letter date :
  Contact person (name, tel/email)
  :
  Financial Services Authority approval letter number regarding the planned change in ownership :
  Financial Services Authority approval letter date regarding the planned change in ownership :
  Substance of ownership change
  *) Strike out what is not needed
  Report Document Completeness
  Before After
  Shareholder Nominal (Rp) % Shareholder Nominal (Rp) % Total Total NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Report submitted using format 19
   Appendix of POJK Number
   68/POJK.05/2016 and signed by the Board of Directors.
   Article 47 paragraph (2)
   POJK Number
   68/POJK.05/
   2016
2. Photocopy of the deed of amendment to the Articles of Association
   of the company containing change in ownership and composition of shareholders, and accompanied by proof of approval and/or proof of receipt of notification from the competent authority.
   Article 47 paragraph (2)
   letter a POJK
   Number
   68/POJK.05/
   2016
   Deed No.: [.......]
   Date: [.......]
   Notary: [.......]
   Approval No./

• 74 -
  receipt of notification letter
  Ministry of Law and Human Rights:
  [.......]
  Date: [.......]
  Substance: [.......]

3. Photocopy of the deed of transfer of share rights in the event
   of transfer of share rights.
   Article 47 paragraph (2)
   letter b POJK
   Number
   68/POJK.05/
   2016
   Deed No.: [.......]
   Date: [.......]
   Notary: [.......]
   Substance: [.......]
4. Photocopy of proof of settlement of paid-up capital in the form of cash deposit or
   Photocopy of proof of placement of paid-up capital in one of the general banks or sharia general banks legalized by the bank, in the event there is an addition of paid-up capital.
   Article 47 paragraph (2)
   letter c POJK
   Number
   68/POJK.05/
   2016
   Transaction Date:
   [.......]
   Depositing Bank:
   [.......]
   Depositor Name:
   [.......]
   Receiving Bank:
   [.......]
   Recipient Name:
   [.......]
   Paid-up capital deposit nominal (Original Currency): [.......] Paid-up capital deposit nominal (Rupiah):
   [.......]
5. Photocopy of government regulations regarding
   state capital participation
   Republic of Indonesia, in the event of change in ownership due to addition of Paid-up Capital from central government shareholders.
   Article 47 paragraph (2)
   letter d POJK
   Number
   68/POJK.05/
   2016

• 75 -

6. Photocopy of regional regulations regarding regional capital participation in the event
   of change in ownership due to addition of Paid-up Capital from regional government shareholders.
   Article 47 paragraph (2)
   letter e POJK
   Number
   68/POJK.05/
   2016
   Account No.: [.......]
   Bank Name: [.......]
   Date received:
   [.......]
   Paid-up capital deposit nominal (original currency): [.......] Paid-up capital deposit nominal (Rupiah):
   [.......]
   Additional notes: (if any)
   We, the undersigned, hereby declare that:
7. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
8. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
9. Filling method: click twice on the box, then select "Checked".
10. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68 /POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 76 -
  FORM SELF ASSESSMENT 16 REPORTING OF CHANGE IN COMPANY NAME FORM: 16 FORM SELF ASSESSMENT REPORTING CHANGE IN COMPANY NAME Company Name before change :
  Company Name after change
  :
  Report letter number :
  Report letter date :
  Contact person (name, phone, email)
  :
  Brief description of the background of the name change :
  NO REQUIREMENT LEGAL BASIS
  FULFILLMENT
  YES NO NOTES

1. Report submitted using format 20
   Appendix of POJK Number
   68/POJK.05/2016 and signed by the Board of Directors.
   Article 48 paragraph
   (2) POJK
   Number
   68/POJK.05/
   2016
2. Photocopy of the deed of amendment to the Articles of Association
   of the Company, which states the change of name with the Company's name that is appropriate for the Company's business type, accompanied by proof of approval from the competent authority.
   Article 5 paragraph
   (1) Jo.
   Article 48 paragraph
   (2) letter a
   POJK Number
   68/POJK.05/
   2016
   Deed No.: [.......]
   Date: [.......]
   Notary: [.......]
   Ministry of Law and Human Rights Approval No.:
   [.......]
   Date: [.......]
   Substance: [.........]
3. Photocopy of the Tax Identification Number (NPWP) under the new name of the Company.
   Article 48 paragraph
   (2) letter b
   POJK Number
   68/POJK.05/
   2016
   Name on NPWP :
   NPWP No.:
   [.......]
   Address: [.......]
   Additional notes: (if necessary)

• 77 -
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [……………………….]
   Board of Directors [...........................] signature [Full Name] Note:
3. Filling method: click twice on the box, then select "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 78 -
  FORM SELF ASSESSMENT 17 REPORTING OF CHANGE IN HEAD OFFICE LOCATION OF THE COMPANY FORM: 17 FORM SELF ASSESSMENT REPORTING OF CHANGE IN HEAD OFFICE LOCATION OF THE COMPANY Company name :
  Report letter number :
  Date of relocation :
  Contact person (name, tel/email) :
  Date of relocation :
  Head office location change data:
  Old New Description
  Location
  Office Address
  Name
  City/Regency
  Phone and Fax No.
  NO DESCRIPTION LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. Report submitted using format 21
   Appendix of POJK
   68/POJK.05/2016 and signed by the Board of Directors.
   Article 48
   paragraph (3) letter a
   POJK
   68/POJK.05
   /2016
2. Photocopy of the deed of amendment to the Articles of Association accompanied
   by proof of approval from the competent authority for Companies in the form of limited liability companies.
   Article 48
   paragraph (3) letter a
   POJK
   68/POJK.05
   /2016
   Deed No.:
   [.........]
   Date
   [.........]:
   Notary: [.........]
   Ministry of Law and Human Rights No. : [.........]
   Date:
   [.........]
   Substance:
   [.........]
3. Photocopy of NPWP for the new location of the
   Company.
   Article 48
   paragraph (3) letter b
   POJK
   68/POJK.05
   /2016
   NPWP: [.........]
   Name: [.........]

• 79 -
  Address: [.........]

4. Data regarding the office address supported by a letter of statement from the relevant party stating at least the Company's name.
   Article 50
   paragraph (2)
   POJK
   68/POJK.05
   /2016
   We, the undersigned, hereby declare that:
5. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
6. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Note:
7. Filling method: click twice on the box, then select "Checked".
8. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 80 -
  FORM SELF ASSESSMENT 18 REPORTING OF REDUCTION OF PAID-UP CAPITAL OF COMPANIES IN THE FORM OF LIMITED LIABILITY COMPANIES FORM: 18 FORM SELF ASSESSMENT REPORTING OF REDUCTION OF PAID-UP CAPITAL OF COMPANIES IN THE FORM OF LIMITED LIABILITY COMPANIES Company Name :
  Report letter number :
  Report letter date :
  Contact person (name, phone, email) :
  Brief description of the background of the reduction of paid-up capital :
  Substance of Reduction of Paid-up Capital Before Becoming Shareholder Name Nominal (Rp) % Shareholder Name Nominal (Rp) % Total Total NO REQUIREMENT LEGAL BASIS COMPLETENESS YES NO NOTES

1. Report submitted using format 22 Appendix of POJK
   Number 68/POJK.05/2016 and signed by the Board of Directors.
   Article 48
   paragraph (5)
   POJK
   Number
   68/POJK.
   05/2016
   Report is only for reduction of paid-up capital that does not cause a change in share composition.
2. Photocopy of the deed of amendment to the Company's Articles of Association
   containing reduction of paid-up capital and composition of shareholders, and accompanied by proof of approval from the competent authority.
   Article 48
   paragraph (5)
   POJK
   Number
   68/POJK.
   05/2016
   Deed No.:
   [.........]
   Date:
   [.........]
   Notary: [.........]
   Approval Letter No.:
   [.........]
   Date:
   [.........]
   Substance:
   [.........]
3. Foreign ownership refers to Government Regulations regarding
   foreign ownership in the Company.
   Article 3
   paragraph (3)
   POJK
   Number
   68/POJK.
   05/2016
   At the time of establishment of the
   Company, direct participation of foreign parties in the Company is at most 80% (eighty percent) (Article 6 of Government Regulation Number 73/1992)
4. Company equity after reduction of paid-up capital is not less than:
   a. Rp 2,000,000,000.00 (two billion rupiah) for Insurance Brokerage Companies; b. Rp 3,000,000,000.00 (three billion rupiah) for Reinsurance Brokerage Companies; and
   c. Rp 500,000,000.00 (five hundred million rupiah) for
   Insurance Loss Assessors.
   Article 56,
   Article 57,
   and Article
   58 POJK
   Number
   70/POJK.
   05/2016
   Report Period: as of
   [.........]
   Equity:
   Rp[.........]
   Additional notes (if necessary):

• 81 -
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, […………………….]
   Board of Directors [...........................] signature [Full Name] Note:
3. Filling method: click twice on the box, then select
   "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 82 -
  FORM SELF ASSESSMENT 19 REPORTING OF ADDITION OF PAID-UP CAPITAL OF COMPANIES IN THE FORM OF LIMITED LIABILITY COMPANIES FORM: 19 FORM SELF ASSESSMENT REPORTING OF ADDITION OF PAID-UP CAPITAL OF COMPANIES IN THE FORM OF LIMITED LIABILITY COMPANIES Company Name :
  Report letter number :
  Report letter date :
  Contact person (name, phone, email)
  :
  Brief description of the background of the addition of paid-up capital :
  Form of addition of paid-up capital (for addition of paid-up capital that does not cause a change in share composition, takeover, and/or addition of new shareholders) Cash capital deposit Transfer of retained earnings to paid-up capital Loan transfer Stock dividends distributed proportionally to all shareholders Substance of addition of paid-up capital Before Becoming Shareholder Name Nominal (Rp) % Shareholder Name Nominal (Rp) % Total Total NO REQUIREMENT LEGAL BASIS COMPLETENESS YES NO NOTES

1. Foreign ownership refers to
   Government Regulations regarding foreign ownership in the Company.
   Article 3 paragraph (3)
   POJK Number
   68/POJK.05/
   2016
   At the time of establishment of the
   Company, direct participation of foreign parties in the Company is at most

• 83 -
  80% (eighty percent)
  (Article 6 of
  Government Regulation
  Number
  73/1992)

2. Total direct participation in
   the Company for
   Indonesian legal entity shareholders who are not Financial Service Institutions under the supervision of the Financial Services Authority, shall not exceed the shareholder's equity.
   Article 7 paragraph (3)
   POJK Number
   68/POJK.05/
   2016
   Shareholder equity list:
3. PT [.........]
   equity amounting to Rp
   [.........] as of (date of last financial statement)
4. Etc.
   Based on the equity amounts above, PT
   [.........] and PT
   [.........] meet/do not meet the maximum participation limit. Completeness of Documents for Approval Request for Change in Ownership
5. Report submitted
   using format 23 Appendix of POJK
   Number 68/POJK.05/2016 and signed by the Board of Directors.
   Article 48 paragraph
   (7) POJK
   Number
   68/POJK.05/
   2016
6. Photocopy of the deed of amendment to the Articles of Association
   of the company containing addition of paid-up capital and composition of shareholders, and accompanied by proof of receipt of notification from the competent authority.
   Article 48 paragraph
   (7) letter a
   POJK Number
   68/POJK.05/
   2016
   Deed No.:
   [.........]
   Date:
   [.........]
   Notary:
   [.........]
   Notification receipt letter No.:
   [.........]
   Date:
   [.........]
   Substance:
   [.........]
7. Photocopy of proof of capital deposit in one of the
   general banks or sharia general banks in Indonesia and legalized by the receiving bank, in the event the addition of paid-up capital is carried out in the form of cash.
   Article 48 paragraph
   (7) letter b item 1 POJK
   Number
   68/POJK.05/
   2016
   Transaction Date:
   [.........]
   Depositing Bank:
   [.........]
   Depositor Name:
   [.........]
   Receiving Bank:
   [.........]
   Recipient Name:
   [.........]
   Paid-up capital deposit nominal
   (original currency):
   [.........]
   Paid-up capital deposit nominal
   (Rupiah):
   [.........]
8. Company financial statements that have been
   audited by a public
   Accountant before the addition of capital, in the event the addition of Paid-up Capital is carried out in the form of transfer of retained earnings, loan transfer and/or stock dividends for Companies in the form of limited liability companies.
   Article 48 paragraph
   (6) and paragraph (7) letter b item
   2 POJK Number
   68/POJK.05/
   2016
   Audited financial statements
   PT:
   [.........]
   Year/period:
   [.........]
9. Photocopy of shareholder or cooperative member statement
   stating that the capital deposit does not originate from loans, money laundering activities, and financial crimes in the event the addition of capital is carried out in the form of cash.
   Article 48 paragraph
   (7) letter c
   POJK Number
   68/POJK.05/
   2016
   Statement letter signed by the shareholder as follows:

• Mr./Mrs. [.........]
• PT [.........]

8. Photocopy of Tax Returns (SPT) for the last
   2 (two) years and documents showing financial capacity and funding sources of prospective individual shareholders.
   Article 48 paragraph
   (7) letter d
   POJK Number
   68/POJK.05/
   2016
   Photocopy of SPT for: Mr./Mrs.
   [.........]
   SPT Period:
   Year [.........]
   Taxable Income:
   Rp [.........]
   Asset list:
   [.........]
9. Financial statements of the shareholder that have been
   audited by a public accountant and/or the latest financial statements, in the event the shareholder is in the form of a legal entity.
   Article 48 paragraph
   (7) letter e
   POJK Number
   68/POJK.05/
   2016
   Financial statements of the shareholder, as follows:
   Shareholder
   Name: [.........]
   Financial Statement
   Period
   Audited:
   [.........]
   Financial Statement
   Period
   Last Month:
   [.........]
10. Photocopy of the Company's financial
    statements audited by a public accountant before the addition of paid-up capital, in the event the addition of paid-up capital is carried out in the form of transfer of retained earnings, loan transfer and/or stock dividends.
    Article 46 paragraph
    (3) letter f
    POJK Number
    68/POJK.05/
    2016
    In the event the addition of paid-up capital is carried out in the form of transfer of retained earnings:
11. Retained Earnings
    balance before addition of paid-up capital: Rp [.........]
12. Paid-up capital
    before addition of paid-up capital: Rp
    [.........]
    In the event the addition of paid-up capital is carried out in the form of loan transfer:
13. Total
    liabilities before addition of paid-up capital: Rp [.........]
14. Paid-up capital
    before

• 84 -
  addition of paid-up capital: Rp
  [.........]

3. Total equity
   before addition of paid-up capital: Rp
   [.........]
   In the event the addition of paid-up capital is carried out in the form of stock dividend distribution:
4. Retained Earnings
   balance before addition of paid-up capital: Rp [.........]
5. Paid-up capital
   before addition of paid-up capital: Rp
   [.........]
6. Total equity
   before addition of paid-up capital: Rp
   [.........]
7. Equity of insurance and reinsurance companies
   after addition of paid-up capital is not less than:
   a. Rp 2,000,000,000.00
   (two billion rupiah)
   Article 56, 57,
   58 POJK
   Number
   70/POJK.05/
   2016
   Company Name: PT
   [.........]
   Report Period: as of
   [.........]

• 85 -
  for Insurance Brokerage Companies; b. Rp 3,000,000,000.00 (three billion rupiah) for Reinsurance Brokerage Companies; and
  c. Rp 500,000,000.00
  (five hundred million rupiah) for
  Insurance Loss Assessors.
  Equity: Rp
  [.........]
  Additional notes (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, […………………]
   Board of Directors [……………] signature
   [Full Name]
   Note:
3. Filling method: click twice on the box, then select
   "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

• 86 -
  FORM SELF ASSESSMENT 20 REPORTING OF CHANGE IN STATUS OF COMPANIES IN THE FORM OF LIMITED LIABILITY COMPANIES CLOSED TO OPEN LIMITED LIABILITY COMPANIES OR VICE VERSA FORM: 20 FORM SELF ASSESSMENT REPORTING OF CHANGE IN STATUS OF COMPANIES IN THE FORM OF LIMITED LIABILITY COMPANIES CLOSED TO OPEN LIMITED LIABILITY COMPANIES OR VICE VERSA Company Name :
  Report letter number :
  Report letter date :
  Contact person (name, tel/email)
  :
  Substance of status change :
  DESCRIPTION LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. Report submitted using format 24
   Appendix of POJK
   68/POJK.05/2016 and signed by the
   Board of Directors.
   Article 48 paragraph (8)
   POJK Number
   68/POJK.05/
   2016
2. Photocopy of the deed of amendment to the Articles of Association that
   contains the substance of the aforementioned.
   Article 48 paragraph (8)
   POJK Number
   68/POJK.05/
   2016
   Deed No.: [.........]
   Date: [.........]
   Notary: [.........]
   Ministry of Law and Human Rights Approval No.:
   [.........]
   Date: [.........]
3. Photocopy of proof of
   approval from the competent authority for the transaction changing the status of the Company from closed company to open company.
   Article 48 paragraph (8)
   POJK Number
   68/POJK.05/
   2016
   Ministry of Law and Human Rights Approval Letter No.:
   [.........]
   Date: [.........]
   Additional notes (if necessary):
   We, the undersigned, hereby declare that:
4. The Self Assessment Form above has been filled out in accordance with the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors; and
5. The documents submitted online are true and identical to the printed documents.
   Jakarta, [……………………….]
   Board of Directors [...........................] signature [Full Name] Note:
6. Filling method: click twice on the box, then select
   "Checked".
7. This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessors.

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  FORM SELF ASSESMENT 21 REPORTING CHANGES IN BOARD OF DIRECTORS AND/OR BOARD OF COMMISSIONERS MEMBERS OF THE COMPANY FORM: 21 FORM SELF ASSESSMENT REPORTING CHANGES IN BOARD OF DIRECTORS AND/OR BOARD OF COMMISSIONERS MEMBERS OF THE COMPANY Company Name :
  Report Letter Number :
  Report Letter Date :
  Contact Person (Name, Phone, Email) :
  NO REQUIREMENTS
  LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. Report submitted using
   format 25
   Appendix of OJK Regulation
   Number
   68/POJK.05/2016.
   Article 49
   paragraph (2)
   OJK Regulation
   Number
   68/POJK.05
   /2016
2. Photocopy of the minutes of the
   members' meeting for Companies in the form of a legal entity cooperative.
   Article 49
   paragraph (2) letter a
   OJK Regulation
   Number 68/POJK.05
   /2016
   Number:
   [.........]
   Date:
   [.........]
   Notary Name:
   [.........]
3. Minutes of the General Meeting
   of Shareholders for
   Companies in the form of a limited liability company.
   Article 49
   paragraph (2) letter b
   OJK Regulation
   Number 68/POJK.05
   /2016
   Number:
   [.........]
   Date:
   [.........]
   Notary Name:
   [.........]
4. Proof of recording changes in
   Board of Directors and/or
   Board of Commissioners members in the company's register.
   Number:
   [.........]
   Date:
   [.........]

• 93 -
  Additional notes (if necessary):
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Notes:
3. Filling method: click twice in the box, then select "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services
   Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies.

• 94 -
  FORM SELF ASSESSMENT 22 REPORTING CHANGES IN HEAD OFFICE ADDRESS AND/OR OFFICES OUTSIDE THE HEAD OFFICE OF THE COMPANY FORM: 22 FORM SELF ASSESSMENT REPORTING CHANGES IN HEAD OFFICE ADDRESS AND/OR OFFICES OUTSIDE THE HEAD OFFICE OF THE COMPANY Company Name :
  Report Letter Number :
  Report Letter Date :
  Contact person (name, phone/email) :
  Purpose and reason for change :
  Change of head office address
  Address*) & Phone No.
  Old
  Address*) & Phone No.
  New
  Effective Date of Address Change*)
  Head Office
  Address:
  Phone No.:
  Address:
  Phone No.:
  *)Address must be written in full, including the Village/Sub-district, District, Regency/City, and postal code. NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Report submitted
   using format 26
   Appendix of OJK Regulation
   Number 68/POJK.05/2016 and signed by the Board of Directors.
   Article 50
   paragraph (2)
   OJK
   Regulation
   Number
   68/POJK.
   05/2016
2. Data on the address of the head office
   and/or offices outside the head office.
   Article 50
   paragraph (2)
   OJK
   Regulation
   Number 68/POJK.
   05/2016
3. Office address supported
   by a letter of confirmation from the relevant party stating at least the Company's name.
   Article 50
   paragraph (2)
   OJK
   Regulation
   Number 68/POJK.
   05/2016
   Letter confirmation number:
   [.........]
   Date of letter confirmation:
   [.........]

• 95 -
  Issuer of the letter confirmation:
  [.........]
  Additional notes: (if necessary)
  We, the undersigned, hereby declare that:

1. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies; and
2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Notes:
3. Filling method: click twice in the box, then select "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services
   Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies.

• 96 -
  FORM SELF ASSESSMENT 23 REPORTING COMPANIES DECLARED BANKRUPT BY THE COURT FORM: 23 FORM SELF ASSESSMENT REPORTING COMPANIES DECLARED BANKRUPT BY THE COURT Company Name :
  Report Letter Number :
  Report Letter Date :
  Contact Person (Name,
  Phone/Email)
  :
  NO DESCRIPTION
  LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. Report submitted
   using format 27
   Appendix of OJK Regulation
   Number 68/POJK.05/2016 and signed by the Board of Directors.
   Article 52
   paragraph (2)
   OJK
   Regulation
   Number 68/POJK.
   05/2016
2. Photocopy of documents serving as
   the basis for the bankruptcy ruling.
   Article 52
   paragraph (2) letter a
   OJK
   Regulation
   Number 68/POJK.
   05/2016
3. Original copy of the decision regarding
   the issuance of the business license of the Company or a photocopy of the decision regarding the issuance of the business license that has been legalized and a director's statement that the original copy of the decision is lost.
   Article 52
   paragraph (2) letter b
   OJK
   Regulation
   Number 68/POJK.
   05/2016
   Letter confirmation number:
   [.........]
   Date of letter confirmation:
   [.........]
   Issuing agency of the letter confirmation:
   [.........]
   Additional notes: (if necessary)
   We, the undersigned, hereby declare that:
4. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business

• 97 -
  and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies; and

2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Notes:
3. Filling method: click twice in the box, then select "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services
   Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies.

• 98 -
  FORM SELF ASSESSMENT 24 REQUEST FOR APPROVAL OF PLANNED BUSINESS CESSATION OF THE COMPANY FORM: 24 FORM SELF ASSESSMENT APPROVAL OF PLANNED BUSINESS CESSATION OF THE COMPANY Company Name :
  Report Letter Number :
  Report Letter
  Date :
  Contact person (name, phone/email)
  :
  Type of transaction :
  Background of the
  Planned Business
  Cessation
  :
  DESCRIPTION LEGAL BASIS
  COMPLETENESS
  YES NO NOTES
  Substantive Analysis of the Planned Business Cessation (PKBU)

1. Reasons for business
   cessation.
   Article 53 paragraph (2) letter
   a OJK Regulation Number
   68/POJK.05/2016
   Explain briefly the reasons for business
   cessation: ....
2. Description of the
   Company's condition, including data on the number of in-force policies, number of policyholders, insured, or participants, number of obligations of the Company to policyholders, insured, or participants, and other obligations.
   Article 53 paragraph (2) letter
   b OJK Regulation Number 68/POJK.05/2016
   Based on the planned business cessation of PT xxx, the following information regarding the condition of PT xxx is known:
3. Number of policies:
   [.........]
4. Summary of
   Financial
   Report:
   [.........]
5. Plan for
   settlement of obligations
   Article 53 paragraph (2) letter
   c OJK Regulation Number 68/POJK.05/2016
   Settlement of obligations as follows:

• 99 -
  of the Company to all creditors.

1. [.........]
2. [.........]
3. Plan for
   dissolution or other plans after the Company has settled obligations to all creditors and the business license of the Company has been revoked by the Financial Services Authority.
   Article 53 paragraph (2) letter
   d OJK Regulation Number 68/POJK.05/2016
   Explain the dissolution plan or other plans:
   [.........]
   Analysis of Supporting Documents for PKBU
4. Request for
   approval of the planned business cessation is submitted using format 28
   Appendix of OJK
   Regulation
   Number
   68/POJK.05/2016 and signed by the Board of Directors.
   Article 53 paragraph (3) OJK
   Regulation
   Number
   68/POJK.05/2016
5. Original copy of the
   decision regarding the issuance of the business license of the Company or if the original copy of the decision is lost, it must be accompanied by a photocopy of the decision regarding the issuance of the business license that has been legalized and a director's statement that the original copy of the decision is lost.
   Article 53 paragraph (3) letter
   a OJK Regulation Number 68/POJK.05/2016
   Copy of the
   Decision of the
   Minister of
   Finance/
   Copy of the
   Decision of the Board of
   Commissioners number
   [.........] dated
   [.........] concerning
   [.........]
6. Photocopy of Article 53 paragraph (3) letter
   the RUPS decision regarding approval of the planned business cessation of the Company. b OJK Regulation Number 68/POJK.05/2016 RUPS Decision:
   [.........]
   Number: [.........]
   Date: [.........]
7. Latest financial
   report of the Company.
   Article 53 paragraph (3) letter
   c OJK Regulation Number 68/POJK.05/2016
   Financial
   Report of the company that has been audited as of [.........], as follows:
8. Total assets:
   Rp[.........]
9. Total liabilities:
   Rp[.........]
10. Paid-up capital:
    Rp[.........]
11. Equity:
    Rp[.........]
12. Gross premiums:
    Rp[.........]
13. Net profit:
    Rp[.........]
14. Proof of tax settlement
    and other obligations to the State.
    Article 53 paragraph (3) letter
    d OJK Regulation Number 68/POJK.05/2016
    Tax payment proof:
15. Proof of settlement
    of Financial Services Authority levies and administrative fines payable.
    Article 53 paragraph (3) letter
    e OJK Regulation Number 68/POJK.05/2016
    Payment proof:
    Nominal:
    Rp[.........]
    Date: [.........]
    Additional notes: (if necessary)
    We, the undersigned, hereby declare that:
16. The Self Assessment Form above has been filled out in accordance with the actual
    conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies; and

• 101 -

2. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name] Notes:
3. Filling method: click twice in the box, then select
   "Checked".
4. This Self Assessment Form is prepared based on the provisions of Financial Services
   Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies.

• 102 -
  FORM SELF ASSESSMENT 25 REPORTING ON THE EXECUTION OF BUSINESS CESSATION FORM: 25 FORM SELF ASSESSMENT REPORTING ON THE EXECUTION OF BUSINESS CESSATION OF THE COMPANY Company Name :
  Report Letter Number :
  Report Letter Date :
  Contact person (name, phone/email) :
  OJK Approval Letter Number :
  OJK Approval Letter Date :
  Type of transaction :
  NO REQUIREMENTS
  LEGAL BASIS
  COMPLETENESS
  YES NO NOTES

1. Proof that the Company has
   ceased all business activities of the Company.
   Article 55 letter a
   OJK Regulation Number
   68/POJK.05/2016
2. Proof of announcement
   of business cessation and settlement of the Company's obligations in a Newspaper for 3 (three) consecutive days at most 10 (ten) days from the date of the letter of approval of the planned business cessation.
   Article 55 letter b
   OJK Regulation Number 68/POJK.05/2016
   Proof of cornerstone announcement containing the following items:
   [.........]
3. Company's statement
   that it has settled all obligations of the Company within a period of at most 4 (four) months from the date of the letter of approval of the planned business cessation.
   Article 55 letter c
   OJK Regulation Number 68/POJK.05/2016
   Settlement of all obligations as follows:
   [.........]
4. Final balance sheet of the Company Article 55 letter d Final balance sheet

• 103 -
  that has been audited by an independent auditor.
  OJK Regulation Number
  68/POJK.05/2016 of the company that has been audited as of [.........] as follows:

1. Total assets:
   [.........]
2. Total liabilities:
   [.........]
3. Total equity:
   [.........]
4. Statement letter from
   shareholders or equivalent to shareholders in a legal entity in the form of a cooperative stating that all obligations of the Company have been settled and if there are claims at a later date, they become the responsibility of the shareholders or equivalent to shareholders in a legal entity in the form of a cooperative.
   Article 55 letter e
   OJK Regulation Number 68/POJK.05/2016
   Additional notes: (if necessary)
   We, the undersigned, hereby declare that:
5. The Self Assessment Form above has been filled out in accordance with the actual
   conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies; and
6. The documents submitted online are true and identical to the printed documents.
   Jakarta, [………………………....]
   Board of Directors [……………………….] signature [Full Name]

• 104 -
  This copy is in accordance with the original Director of Law 1 Legal Department signed Yuliana Notes:

1. Filling method: click twice in the box, then select
   "Checked".
2. This Self Assessment Form is prepared based on the provisions of Financial Services
   Authority Regulation Number 68/POJK.05/2016 concerning Licensing of Business and Institutions of Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessment Companies. Issued in Jakarta on 20 April 2018 EXECUTIVE HEAD OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI