Electronic Licensing, Approval, and Reporting for Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies — OJK — ID

To:

The Board of Directors of Insurance Companies;
The Board of Directors of Reinsurance Companies;
The Board of Directors of Sharia Insurance Companies; and
The Board of Directors of Sharia Reinsurance Companies,
in your respective locations.

COPY
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER: 10 /SEOJK.05/2018 CONCERNING ELECTRONIC LICENSING, APPROVAL, AND REPORTING FOR INSURANCE COMPANIES, SHARIA INSURANCE COMPANIES, REINSURANCE COMPANIES, AND SHARIA REINSURANCE COMPANIES

In accordance with the mandate of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies (State Gazette of the Republic of Indonesia Year 2016 Number 300, Supplement to the State Gazette of the Republic of Indonesia Number 5990), it is necessary to further regulate electronic licensing (e-licensing) applications for approval and reporting for insurance companies, Sharia insurance companies, reinsurance companies, and Sharia reinsurance companies in this Financial Services Authority Circular as follows:

I. GENERAL PROVISIONS
In this Financial Services Authority Circular, the following terms are defined:

Company means an insurance company, Sharia insurance company, reinsurance company, or Sharia reinsurance company.
Insurance Company means a general insurance company and a life insurance company.
Reinsurance Company means a company conducting reinsurance business.
Sharia Insurance Company means a Sharia general insurance company and a Sharia life insurance company.
Sharia Reinsurance Company means a company conducting Sharia reinsurance business.
Sharia Unit means a work unit at the head office of an Insurance Company or Reinsurance Company that functions as the parent office of branches outside the head office conducting business based on Sharia principles.
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.
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.
Reporting means the submission of any form of records providing information about specific activities conducted by the Company to the Financial Services Authority.
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 formed as limited liability companies or equivalent to GMS for Companies formed as cooperatives or joint ventures.
Board of Directors means the board of directors as referred to in Law Number 40 of 2007 concerning Limited Liability Companies for Companies formed as limited liability companies or equivalent to the Board of Directors for Companies formed as cooperatives or joint ventures.
Board of Commissioners means the board of commissioners as referred to in Law Number 40 of 2007 concerning Limited Liability Companies for Companies formed as limited liability companies or equivalent to the Board of Commissioners for Companies formed as cooperatives or joint ventures.
Sharia Supervisory Board, hereinafter abbreviated as SSB, is part of the Company's organ having the task and function of supervising the implementation of the Company's business activities to ensure compliance with Sharia Principles.

II. SCOPE OF LICENSING APPLICATIONS, APPROVALS, AND REPORTING BY COMPANIES

Applications for Licensing, Approvals, and Reporting as mandated in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies, submitted to the Financial Services Authority, are categorized as follows:
a. institutional category; and b. management category.
Applications for Licensing, Approvals, and Reporting included in the institutional category as referred to in item 1 letter a include:
a. For Insurance Companies and Reinsurance Companies, namely:
1) application for business license of Insurance Companies and Reinsurance Companies;
2) application for release of guarantee funds in the cancellation of business license applications for Insurance Companies and Reinsurance Companies;
3) Reporting on the implementation of business activities of Insurance Companies and Reinsurance Companies;
4) Reporting on the determination of controllers of Insurance Companies and Reinsurance Companies;
5) application for Approval to cease being a Controller of Insurance Companies and Reinsurance Companies;
6) Reporting on changes in controllers of Insurance Companies and Reinsurance Companies;
7) Reporting on the opening of branches outside the head office that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Companies and Reinsurance Companies;
8) Reporting on the opening of branches outside the head office that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Companies and Reinsurance Companies;
9) Reporting on the closure of branches outside the head office that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Companies and Reinsurance Companies;
10) Reporting on the closure of branches outside the head office that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Companies and Reinsurance Companies;
11) application for Approval of ownership changes causing changes in controlling shareholders of Insurance Companies and Reinsurance Companies;
12) application for Approval of ownership changes not causing changes in controlling shareholders of Insurance Companies and Reinsurance Companies;
13) Reporting on the implementation of ownership changes causing changes in controlling shareholders of Insurance Companies and Reinsurance Companies;
14) Reporting on the implementation of ownership changes not causing changes in controlling shareholders of Insurance Companies and Reinsurance Companies;
15) Reporting on name changes of Insurance Companies and Reinsurance Companies;
16) Reporting on changes in the domicile of the head office of Insurance Companies and Reinsurance Companies;
17) Reporting on reduction of paid-up capital of Insurance Companies and Reinsurance Companies formed as limited liability companies;
18) Reporting on increase of paid-up capital for Insurance Companies and Reinsurance Companies formed as limited liability companies;
19) Reporting on status changes of Insurance Companies and Reinsurance Companies formed as closed limited liability companies to open limited liability companies or vice versa;
20) Reporting on changes in the address of the head office of Insurance Companies and Reinsurance Companies;
21) Reporting on changes in the address of branches outside the head office of Insurance Companies and Reinsurance Companies that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
22) Reporting on changes in the address of branches outside the head office of Insurance Companies and Reinsurance Companies that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
23) application for Approval of plans for the implementation of mergers or consolidations of Insurance Companies and Reinsurance Companies;
24) Reporting on the implementation of GMS approving the merger of Insurance Companies and Reinsurance Companies;
25) Reporting on the implementation of mergers of Insurance Companies and Reinsurance Companies;
26) Reporting on the implementation of GMS approving the consolidation of Insurance Companies and Reinsurance Companies; and
27) Reporting on the implementation of consolidations of Insurance Companies and Reinsurance Companies.

b. For Sharia Insurance Companies and Sharia Reinsurance Companies, namely:
1) application for new establishment business license of Sharia Insurance Companies and Sharia Reinsurance Companies;
2) application for business license conversion from Insurance Company to Sharia Insurance Company or from Reinsurance Company to Sharia Reinsurance Company;
3) application for business license separation of Sharia Unit from Insurance Company or Reinsurance Company by establishing Sharia Insurance Company or Sharia Reinsurance Company;
4) application for release of guarantee funds in the cancellation of business license applications for Sharia Insurance Companies or Sharia Reinsurance Companies;
5) Reporting on receipt of portfolio transfer to Sharia Unit;
6) Reporting on the implementation of business activities of Sharia Insurance Companies and Sharia Reinsurance Companies;
7) Reporting on the determination of controllers of Sharia Insurance Companies and Sharia Reinsurance Companies;
8) application for Approval to cease being a controller of Sharia Insurance Companies and Sharia Reinsurance Companies;
9) Reporting on changes in controllers of Sharia Insurance Companies and Sharia Reinsurance Companies;
10) Reporting on the opening of branches outside the head office that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Companies and Sharia Reinsurance Companies;
11) Reporting on the opening of branches outside the head office that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Companies and Sharia Reinsurance Companies;
12) Reporting on the closure of branches outside the head office that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Companies and Sharia Reinsurance Companies;
13) Reporting on the closure of branches outside the head office that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Companies and Sharia Reinsurance Companies;
14) application for Approval of ownership changes causing changes in controlling shareholders of Sharia Insurance Companies and Sharia Reinsurance Companies;
15) application for Approval of ownership changes not causing changes in controlling shareholders of Sharia Insurance Companies and Sharia Reinsurance Companies;
16) Reporting on the implementation of ownership changes of Sharia Insurance Companies and Sharia Reinsurance Companies causing changes in controlling shareholders;
17) Reporting on the implementation of ownership changes of Sharia Insurance Companies and Sharia Reinsurance Companies not causing changes in controlling shareholders;
18) Reporting on name changes of Sharia Insurance Companies and Sharia Reinsurance Companies;
19) Reporting on changes in the domicile of the head office of Sharia Insurance Companies and Sharia Reinsurance Companies;
20) Reporting on reduction of paid-up capital for Sharia Insurance Companies and Sharia Reinsurance Companies formed as limited liability companies;
21) Reporting on increase of paid-up capital of Sharia Insurance Companies and Sharia Reinsurance Companies formed as limited liability companies;
22) Reporting on status changes of Sharia Insurance Companies and Sharia Reinsurance Companies formed as closed limited liability companies to open limited liability companies or vice versa;
23) Reporting on changes in the address of the head office of Sharia Insurance Companies and Sharia Reinsurance Companies;
24) Reporting on changes in the address of branches outside the head office of Sharia Insurance Companies and Sharia Reinsurance Companies that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
25) Reporting on changes in the address of branches outside the head office of Sharia Insurance Companies and Sharia Reinsurance Companies that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
26) application for Approval of plans for the implementation of mergers or consolidations of Sharia Insurance Companies and Sharia Reinsurance Companies;
27) Reporting on the implementation of GMS approving the merger of Sharia Insurance Companies and Sharia Reinsurance Companies;
28) Reporting on the implementation of mergers of Sharia Insurance Companies and Sharia Reinsurance Companies;
29) Reporting on the implementation of GMS approving the consolidation of Sharia Insurance Companies and Sharia Reinsurance Companies; and
30) Reporting on the implementation of consolidations of Sharia Insurance Companies and Sharia Reinsurance Companies.

c. For Insurance Companies and Reinsurance Companies that have Sharia Units, namely:
1) application for license to establish Sharia Unit;
2) application for Approval of transfer of portfolio of participants in Sharia Unit to Sharia Insurance Company or Sharia Reinsurance Company;
3) Reporting on the implementation of transfer of portfolio of participants in Sharia Unit and application for revocation of license to establish Sharia Unit;
4) Reporting on the implementation of business activities of Sharia Unit;
5) application for license to establish Sharia Unit previously owned by Company merging;
6) application for license to establish Sharia Unit previously owned by Company consolidating;
7) Reporting on the opening of branches outside the head office of Sharia Unit that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
8) Reporting on the opening of branches outside the head office of Sharia Unit that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
9) Reporting on cessation or closure of branches outside the head office of Sharia Unit that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
10) Reporting on cessation or closure of branches outside the head office of Sharia Unit that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims;
11) application for Approval of Reporting plan for closure of Sharia Unit; and
12) Reporting on the implementation of cessation of business activities of Sharia Unit.

Applications for Approval and Reporting included in the management category as referred to in item 1 letter b include:
a. For Insurance Companies and Reinsurance Companies, namely:
1) Reporting on changes in members of the Board of Directors and/or members of the Board of Commissioners of Insurance Companies and Reinsurance Companies;
2) Reporting on plans to employ foreign workers of Insurance Companies and Reinsurance Companies;
3) Reporting on appointment of foreign workers of Insurance Companies and Reinsurance Companies;
4) Reporting on termination of foreign workers of Insurance Companies and Reinsurance Companies;
5) Reporting on appointment of experts of Insurance Companies and Reinsurance Companies;
6) Reporting on appointment of actuaries and/or internal auditors of Insurance Companies and Reinsurance Companies; and
7) Reporting on termination of experts, actuaries, and/or internal auditors of Insurance Companies and Reinsurance Companies.

b. For Sharia Insurance Companies and Sharia Reinsurance Companies, namely:
1) Reporting on changes in members of the Board of Directors, members of the Board of Commissioners, and/or members of the SSB of Sharia Insurance Companies and Sharia Reinsurance Companies;
2) Reporting on plans to employ foreign workers of Sharia Insurance Companies and Sharia Reinsurance Companies;
3) Reporting on appointment of foreign workers of Sharia Insurance Companies and Sharia Reinsurance Companies;
4) Reporting on termination of foreign workers of Sharia Insurance Companies and Sharia Reinsurance Companies;
5) Reporting on appointment of experts of Sharia Insurance Companies and Sharia Reinsurance Companies;
6) Reporting on appointment of actuaries and/or internal auditors of Sharia Insurance Companies and Sharia Reinsurance Companies; and
7) Reporting on termination of experts, actuaries, and/or internal auditors of Sharia Insurance Companies or Sharia Reinsurance Companies.

c. For Insurance Companies and Reinsurance Companies that have Sharia Units, namely:
1) Reporting on changes in leadership of Sharia Unit;
2) Reporting on appointment and/or termination of experts of Sharia Unit; and
3) Reporting on changes in members of the SSB of Sharia Unit.

III. PROCEDURE FOR SUBMISSION OF LICENSING APPLICATIONS, APPROVALS, AND REPORTING

Companies must submit applications for Licensing, Approvals, and Reporting to the Financial Services Authority according to the format contained in the Appendix of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies, accompanied by required supporting documents.
Submission of applications for Licensing, Approvals, and Reporting as referred to in item 1 is accompanied by a self-assessment form signed by the Company's Board of Directors as contained in:
a. Appendix I which is an inseparable part of this Financial Services Authority Circular, for Insurance Companies and Reinsurance Companies; b. Appendix II which is an inseparable part of this Financial Services Authority Circular, for Sharia Insurance Companies and Sharia Reinsurance Companies; or
c. Appendix III which is an inseparable part of this Financial Services Authority Circular, for Insurance Companies having Sharia Units and Reinsurance Companies having Sharia Units.
Applications for Licensing, Approvals, and Reporting 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.
Supporting documents required as attachments for applications for Licensing, Approvals, and Reporting submitted online are color scans of original documents.
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 difficulties, submission of applications for Licensing, Approvals, and Reporting as referred to in item 1 is submitted to the Financial Services Authority offline.
With the submission of applications for Licensing, Approvals, and Reporting to the Financial Services Authority online as referred to in item 3 or offline as referred to in item 5, Companies are not required to submit printed documents (hard copy).
Companies must state that 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.
In the event of technical difficulties 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.
Applications for Licensing, Approvals, and Reporting by Companies offline as referred to in item 5 must be submitted in electronic data format consisting of color scans of original documents via compact disc (CD) or other electronic data storage media.
Submission of applications for Licensing, Approvals, and Reporting 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.
Submission of applications for Licensing, Approvals, and Reporting offline as referred to in item 5 is addressed to:
a. For Insurance Companies and Reinsurance Companies:
The Executive Head of Supervision of Insurance, Pension Funds, Financing Institutions, and Other Financial Service Institutions attention to Director of Institutional and Non-Bank Financial Products I Wisma Mulia 2 Building, 11th Floor Jalan Jenderal Gatot Subroto Number 42 Jakarta 12710; b. For Sharia Insurance Companies, Sharia Reinsurance Companies, Insurance Companies having Sharia Units, and Reinsurance Companies having Sharia Units:
The Executive Head of Supervision of Insurance, Pension Funds, Financing Institutions, and Other Financial Service Institutions attention to Director of Sharia Non-Bank Financial Products Wisma Mulia 2 Building, 15th Floor Jalan Jenderal Gatot Subroto Number 42 Jakarta 12710.
In the event of a change in the Financial Services Authority's office address for submission of reports as referred to in item 11, the Financial Services Authority will convey notification regarding the address change via letter or announcement.
Submission of applications for Licensing, Approvals, and Reporting offline as referred to in item 5 can be done by one of the following methods:
a. handed over directly to the Financial Services Authority office; or b. sent via courier service company, according to the address as referred to in item 11.
A Company is deemed to have submitted applications for Licensing, Approvals, and Reporting under the following conditions:
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 over 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 via courier service company as referred to in item 13 letter b.

IV. DATA STORAGE

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.
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.
The Financial Services Authority may verify and/or validate the truthfulness and reasonableness of printed documents (hard copy) of applications for Licensing, Approvals, and Reporting that have been submitted by Companies through the Financial Services Authority's data communication network system.

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This copy is consistent with the original Legal Director 1 Legal Department signed Yuliana
V. TRANSITIONAL PROVISIONS
Applications for Licensing, Approval, and Reporting that have been submitted to the Financial Services Authority in hard copy format before this Financial Services Authority Circular takes effect and have not yet received a license, Approval, and/or reporting recording letter from the Financial Services Authority do not need to be resubmitted online through the Financial Services Authority's data communication network system.
VI. CLOSING
The provisions in this Financial Services Authority Circular shall take effect after 2 (two) months from the date of establishment. Established in Jakarta on May 9, 2018 EXECUTIVE HEAD OF INSURANCE SUPERVISOR, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI

APPENDIX I
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 10 /SEOJK.05/2018 REGARDING ELECTRONIC LICENSING, APPROVAL AND REPORTING APPLICATIONS FOR INSURANCE COMPANIES, SHARIA INSURANCE COMPANIES, REINSURANCE COMPANIES AND SHARIA REINSURANCE COMPANIES

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TABLE OF CONTENTS APPENDIX
PART A: INSTITUTIONAL CATEGORY
No Description Application Page

Self-Assessment Form 1
Application for Business License of Insurance Company and Reinsurance Company 4
Self-Assessment Form 2
Application for release of guarantee funds in cancellation of business license application of Insurance Company or Reinsurance Company 28
Self-Assessment Form 3
Reporting on implementation of business activities of Insurance Company and Reinsurance Company 30
Self-Assessment Form 4
Reporting on determination of controller of Insurance Company and Reinsurance Company 32
Self-Assessment Form 5
Application for Approval to cease being controller of Insurance Company and Reinsurance Company 34
Self-Assessment Form 6
Reporting on change of controller of Insurance Company and Reinsurance Company 36
Self-Assessment Form 7
Reporting on opening offices outside the head office that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Company and Reinsurance Company 38
Self-Assessment Form 8
Reporting on opening offices outside the head office that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Company and Reinsurance Company 42
Self-Assessment Form 9
Reporting on closing offices outside the head office that have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Company and Reinsurance Company 45
Self-Assessment Form 10
Reporting on closing offices outside the head office that do not have the authority to make decisions regarding acceptance or rejection of coverage and/or claims of Insurance Company and Reinsurance Company 47
Self-Assessment Form 11
Application for Approval of ownership change causing change of controlling shareholder of Insurance Company and Reinsurance Company 49
Self-Assessment Form 12
Application for Approval of ownership change not causing change of controlling shareholder of Insurance Company and 65

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No Description Application Page Reinsurance Company

Self-Assessment Form 13
Reporting on implementation of ownership change causing change of controlling shareholder of Insurance Company and Reinsurance Company 80
Self-Assessment Form 14
Reporting on implementation of ownership change not causing change of controlling shareholder of Insurance Company and Reinsurance Company 83
Self-Assessment Form 15
Reporting on name change of Insurance Company and Reinsurance Company 86
Self-Assessment Form 16
Reporting on change of head office location of Insurance Company and Reinsurance Company 88
Self-Assessment Form 17
Reporting on reduction of paid-up capital of Insurance Company and Reinsurance Company that are limited liability companies 90
Self-Assessment Form 18
Reporting on increase of paid-up capital for Insurance Company and Reinsurance Company that are limited liability companies 93
Self-Assessment Form 19
Reporting on change of status of Insurance Company and Reinsurance Company that are limited liability closed company into public limited liability company or vice versa 99
Self-Assessment Form 20
Reporting on change of head office address of Insurance Company and Reinsurance Company 101
Self-Assessment Form 21
Reporting on change of address of office outside the head office of Insurance Company and Reinsurance Company that has the authority to make decisions regarding acceptance or rejection of coverage and/or claim 103
Self-Assessment Form 22
Reporting on change of address of office outside the head office of Insurance Company and Reinsurance Company that does not have the authority to make decisions regarding acceptance or rejection of coverage and/or claim 105
Self-Assessment Form 23
Application for Approval of plan for implementation of merger or consolidation of Insurance Company and Reinsurance Company 107
Self-Assessment Form 24
Reporting on implementation of GMS that approves merger of Insurance Company and Reinsurance Company 113
Self-Assessment Form 25
Reporting on implementation of merger of Insurance Company and Reinsurance Company 115

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No Description Application Page

Self-Assessment Form 26
Reporting on implementation of GMS that approves consolidation of Insurance Company and Reinsurance Company 117
Self-Assessment Form 27
Reporting on implementation of consolidation of Insurance Company and Reinsurance Company 119
PART B: MANAGEMENT CATEGORY
No Description Application Page
Self-Assessment Form 28
Reporting on change of Board of Directors members and/or Board of Commissioners members of Insurance Company and Reinsurance Company 121
Self-Assessment Form 29
Reporting on plan to employ foreign workforce of Insurance Company and Reinsurance Company 123
Self-Assessment Form 30
Reporting on appointment of foreign workforce of Insurance Company and Reinsurance Company 129
Self-Assessment Form 31
Reporting on dismissal of foreign workforce of Insurance Company and Reinsurance Company 131
Self-Assessment Form 32
Reporting on appointment of expert personnel of Insurance Company and Reinsurance Company 133
Self-Assessment Form 33
Reporting on appointment of actuary and/or internal auditor of Insurance Company and Reinsurance Company 137
Self-Assessment Form 34
Reporting on dismissal of expert personnel, actuary and/or internal auditor of Insurance Company and Reinsurance Company 140

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PART A: INSTITUTIONAL CATEGORY
SELF ASSESSMENT FORM 1 BUSINESS LICENSE APPLICATION FOR INSURANCE COMPANY AND REINSURANCE COMPANY FORM: 1 SELF ASSESSMENT FORM BUSINESS LICENSE APPLICATION FOR INSURANCE COMPANY AND REINSURANCE COMPANY Company Name :
Number of business license application letter :
Date of business license application letter :
Contact person (name, phone, email) :
Brief description of background of business license application :
Company Description :
(describe company history)
[......]
No. Shareholder Name Nominal (Rp) (%) Controller/Non- Controller 1 2 3 Total Company Group Structure Chart:
(up to ultimate controller)
[......]
Composition of Board of Directors, Board of Commissioners, expert personnel, actuaries, and internal auditors of the Company:
No. Position Name
Information
Regarding
Concurrent Positions
Nationality and Domicile
Type of Certification in risk management field (if any)

Chief Director

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2. Director
3. Director
4. Main Commissioner
5. Independent Commissioner
6. Commissioner
7. Expert Personnel
(including expert personnel per line of business, if any)
8. Company Actuary
9. Internal Auditor
10. Etc
(please elaborate further if the Company plans to use Foreign Workforce) NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES
1. Application is submitted
using Format 1
Appendix POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 10
paragraph (1)
POJK
Number
67/POJK.05
/2016
Deed of Establishment
2. Copy of the deed of establishment
of limited liability company or cooperative that is certified by the competent authority including copy of the deed of amendment of articles of association (if any) accompanied by copy of proof of approval, and/or copy of proof of receipt of notification letter from the competent authority.
Article 10
paragraph (2) letter a
POJK
Number
67/POJK.05
/2016
Company Establishment Data: [......]
Number and date of deed of establishment: [......] Number and date of proof of certification from competent authority:
[......]
Company Name:
[......]
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The competent authority.
The deed of establishment contains information among others:
a. name and place of headquarters; b. purpose and objective as well as business activities;
c. capital;
d. ownership; and e. authority, responsibility, and term of office of members of Board of Directors and members of Board of Commissioners. Place of headquarters:
[......]
Purpose and objective as well as business activities:
[......]
Paid-up capital amount:
[......]
Ownership data:
[......]
Authority, responsibility, and term of office of members of Board of Directors and members of Board of Commissioners:
[......]
Data of all amendments to the company's articles of association (if any):

Number and date
of deed: [......]
Number and date of proof of approval and/or receipt of notification from competent authority: [......] Substance of amendment to articles of association:
[......]
Etc.

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Organizational Structure

Organizational structure
that clearly illustrates:
a. separation of functions for risk management, function for financial management, and function for service b. existence of work units that handle functions:
1) underwriting;
2) actuarial;
3) claim administrative settlement;
4) marketing;
5) finance including
investment management;
6) risk management;
7) internal audit;
8) administration and
accounting;
9) compliance;
10) anti-money laundering and
prevention of terrorism financing; and
11) service and
complaint resolution.
Article 10
paragraph (2) letter b jo.
Article 48
POJK
Number
67/POJK.05
/2016
Proven by attaching an organizational structure chart containing all these functions.
4. Document containing
statement of duties, authority, responsibility, and working procedures in writing, which is established by the Board of Directors.
Article 10
paragraph (2) letter b jo.
Article 48
paragraph (3)
POJK
Number
67/POJK.05
/2016
Proven by attaching Standard Operating Procedure (SOP):
1. SOP No.: [......]
SOP Title: [......]
Effective date of SOP implementation:
[......]
Signed

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by: [......]

Etc.
Expertise certificate in
risk management field from Professional Certification Institution in risk management field for members of Board of Directors, members of Board of Commissioners, and officials 1 (one) level below the Board of Directors.
Article 49
paragraph (1)
POJK
Number
67/POJK.05
/2016
1. Name: [......]
Position: [......]
Certification type:
[......]
Institution issuing the certificate: [......]
Certificate number:
[......]
Certificate date:
[......]
2. Etc.
Paid-Up Capital
6. Copy of proof of
payment of paid-up capital in the form of cash deposit by shareholders to the Company and legalized with wet stamp by the bank party.
Article 10
paragraph (2) letter c
POJK
Number
67/POJK.05
/2016
Transaction date:
[.......]
Depositing bank: [.......]
Depositor name: [.......]
Receiving bank: [.......]
Receiver name: [.......]
Capital deposit nominal (original currency):
[.......]
Capital deposit nominal: Rp [.......]
7. Copy of proof of
placement of minimum paid-up capital in the form of time deposit and/or giro account in the name of the Company at one general bank, sharia general bank, or sharia business unit of a general bank in Indonesia and legalized by the receiving bank of the deposit which is still valid during the business license application process.
Article 10
paragraph (2) letter c
POJK
Number
67/POJK.05
/2016
Account number: [.......]
Bank name: [.......]
Date received:
[.......]

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Nominal capital deposit (original currency):
[.......]
Capital deposit nominal: Rp [.......]
Guarantee Fund

Initial report of guarantee fund
Article 10
paragraph (2) letter d
POJK
Number
67/POJK.05
/2016
Proof of placement of guarantee funds, consisting of:
a. guarantee fund of at least 20% of minimum paid-up capital;
Article 7 paragraph
(1) and
Article 10
paragraph (2) letter d
POJK
Number
67/POJK.05
/2016
Total guarantee fund amount of Rp [......] b. copy of time deposit slip with automatic renewal at general bank, sharia general bank, or sharia business unit of general bank in Indonesia that is not an affiliate of the relevant company; and
Article 7 paragraph
(2) and
Article 10
paragraph (2) letter d
POJK
Number
67/POJK.05
/2016
Bank name: [......]
Slip number: [......]
Guarantee fund nominal: [......]
c. agreement with
custodian bank registered at the Financial Services Authority regarding management of guarantee funds.
Article 38
and Article
39 POJK
Number
71/POJK.05
/2016
Custodian bank name
[......]
Number and date of agreement
[......]

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Ownership List

List of shareholders along with details of each shareholding size and entire group structure related to the Insurance Company or
Reinsurance Company and legal entity owner of the Insurance Company or Reinsurance Company up to the last owner, for limited liability companies.
Article 10
paragraph (2) letter e number 1 POJK Number 67/POJK.05 /2016 (explained in the form of chart and description) Last owner:
1. [......] amounting to
[......]%
2. Etc.
11. List of members along with basic savings and mandatory savings amounts for cooperative legal entities.
Article 10
paragraph (2) letter e number 2 POJK Number 67/POJK.05 /2016
1. Name: [......]
Basic savings amount: Rp[......]
Mandatory savings amount: Rp[......]
Membership start date: [......]
2. Etc.
Data of Shareholders or Members Other Than Controlling Shareholders
12. In case, shareholders or members other than controlling shareholders (PSP) are individuals:
a. copy of ID card in the form of KTP or passport that is still valid;
Article 10
paragraph (2) letter f number 1 letter a) POJK Number 67/POJK.05 /2016
1. Name: [......]
KTP/Passport Number:
[......]
Identity validity period: [......]
2. Etc.
b. copy of NPWP; Article 10 paragraph (2) letter f
1. Name: [......]
NPWP Number:

11 -
number 1 letter b)
POJK
Number
67/POJK.05
/2016
[......]

Etc.
c. copy of tax return (SPT) for the last 2 (two) years and other documents showing financial capability and source of funds for prospective individual shareholders;
Article 10
paragraph (2) letter f number 1 letter c) POJK Number 67/POJK.05 /2016 Copy 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 latest color photo sized 4 x 6 cm;
Article 10
paragraph (2) letter f number 1 letter d) POJK Number 67/POJK.05 /2016 Curriculum vitae and photo for Mr./Ms.:
[......]
Etc.
e. statement letter from prospective shareholders stating:
1) capital deposit does not come from loans;
2) capital deposit does not come from money laundering activities and
Statement letter signed by shareholders as follows:
Mr./Ms. [......]
Etc.
Completed with signatures above stamp duty.

12
- financial crimes;

does not have non-performing loans and/or financing;
is not included as a party prohibited from becoming shareholders or parties who manage, supervise, and/or have significant influence on financial services institutions;
has never been sentenced for committing criminal acts in the field of financial services business and/or economy based on court decisions that have had permanent legal force within the last 5 (five) years;
has never been sentenced for committing criminal acts based on court decisions that have had permanent legal force within the last 5 (five) years;
has never been declared bankrupt or guilty which caused a company to be declared bankrupt based on court decisions that have had permanent legal force within the last 5 (five) years; and
has never been a PSP, member of the Board of Directors, member of the Board of Commissioners, controller, or DPS member at a financial services company whose business license was revoked due to violations within the last 5 (five) years.

In case, shareholders or members other than PSP are legal entities:
a. copy of the deed of establishment of the legal entity including articles of association along with amendments (if any), accompanied by copies of proof of certification, proof of approval, and/or copies of proof of receipt of notification letter from the competent authority;
Article 10
paragraph (2) letter f number 2 letter a) POJK Number 67/POJK.05 /2016 Deed number: [......] Date: [......] Notary: [......] Substance: [......] Ministry of Law and Human Rights certification number:
[......]
Date: [......]
Data of all amendments to the company's articles

14 -
of association (if any):
1. Number and date
of deed: [......]
Number and date of proof of approval and/or receipt of notification from competent authority: [......] Substance of amendment to articles of association:
[......]
2. Etc.
b. financial statements that have been audited by public accountants accompanied by non-consolidated financial reports and the latest monthly financial reports;
Article 10
paragraph (2) letter f number 2 letter b) POJK Number 67/POJK.05 /2016 Financial report of shareholder [......] attached:
1. Audited financial report for period [......]
2. Non-consolidated financial report for period [......]
3. Latest monthly financial report for period [......]
c. documents of the Board of Directors and Board of Commissioners of the relevant legal entity:
1)copy of KTP or passport that is still valid;
Article 10
paragraph (2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Copy of identity of Board of Directors and Board of Commissioners members:
1. Name: [......]
Position: [......]
Number
15 -
KTP/Passport:
[......]
Identity validity period: [......]

Etc.
2)copy of NPWP; and Article 10 paragraph (2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Copy of NPWP of Board of Directors and Board of Commissioners members:
1. Name: [......]
NPWP Number:
[......]
2. Etc.
3)curriculum vitae completed with latest color photo sized 4 x 6 cm;
Article 10
paragraph (2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Curriculum vitae and photo for Mr./Ms.:
1. [......]
2. Etc.
d. statement letter from the Board of Directors or equivalent from the relevant legal entity stating that:
1) capital deposit does not come from loans;
2) capital deposit does not come 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 shareholders or parties who manage, supervise, and/or have significant influence on financial services institutions;
5) has never been sentenced for committing criminal acts in the field of financial services business and/or economy based on court decisions that have had permanent legal force within the last 5 (five) years;
6) has never been declared bankrupt or declared guilty which caused a company to be declared bankrupt based on court decisions having permanent legal force within the last 5 (five) years; and
7) has never been a PSP at a financial services company whose business license was revoked due to violations within the last 5 (five) years.
Article 10
paragraph (2) letter f number 2 letter d) POJK Number 67/POJK.05 /2016 Statement letter signed by the Board of Directors or equivalent authorized to represent the company as follows:
Mr./Ms. [......]
Etc.
Completed with signature above stamp duty.

16 -
e. rating result from internationally recognized rating agency, for shareholders in the form of foreign legal entities.
Article 10
paragraph (2) letter f number 2 letter e) POJK Number 67/POJK.05 /2016 Rated entity:
[......]
Rating agency:
[......]
Rating:
[......]
Other material information (if any):
[......]

In case the shareholder is the Republic of Indonesia, attach a copy of government regulations regarding state capital participation by the Republic of Indonesia for the establishment of the company.
Article 10
paragraph (2) letter f number 3 POJK Number 67/POJK.05 /2016 Government Regulation Number: [......] Date: [......] Nominal: [......]
In case the shareholder is the Regional Government, attach a copy of regional regulations regarding regional capital participation for the establishment of the company.
Article 10
paragraph (2) letter f number 4 POJK Number 67/POJK.05 /2016 Regional Regulation Number:
[......]
Date: [......]
Nominal: [......]
Controllers
List of controllers along with descriptions regarding the form of control.
Article 10
paragraph (2) letter g jo.
Article 30
POJK
Number
67/POJK.05
/2016
Controller name:
[......]
Number and date of Financial Services Authority approval regarding controller determination:
Number [......]
Date [......]
Rights and authorities:
[......]
Description regarding form of control:
[......]

18 -
Expert Personnel

Proof of employing expert personnel.
Article 10
paragraph (2) letter h jo.
Article 55,
Article 56,
and Article
57 POJK
Number
67/POJK.05
/2016
If necessary, the company can submit proof of employing expert personnel per line of business conducted by considering the complexity of the business.
Proof that expert personnel has met the following requirements:
a. expertise certification in life or general insurance with the highest level from the Professional Certification Institution in the insurance field; b. has work experience in the field of risk management for life insurance or general insurance for at least 3 (three) years; and
c. is not currently subject to sanctions from their professional association.
Article 55,
Article 56,
and Article
57 POJK
Number
67/POJK.05
/2016
1. Name: [......]
Certificate number:
[......]
Date: [......]
Issuer name: [......]
Work experience: [......]
Letter number from association: [......]
Date: [......]
2. Etc.
Work Plan
19. Work plan for the first 3 (three) years, at least containing:
a. feasibility study regarding market opportunities and economic potential as well as lines of business to be entered and target markets; b. steps taken to realize the intended plan; and
Article 10
paragraph (2) letter i
POJK
Number
67/POJK.05
/2016
Explanation in the form of description of each point:
a. [......] b. [......]
c. [......]

19 -
c. cash flow projections,
balance sheet, semi-annual profit/loss calculations and the health status of the Company and the assumptions underlying them, starting from when the Company begins operational activities. Annual Investment Management Plan

Investment plan
for the first 3 (three) years which must at least contain:
a. plan for the composition of investment types; b. estimated rate of investment return for each type of investment; and
c. considerations
underlying the plan for the composition of investment types.
Article 57
POJK
Number
73/POJK.05
/2016
Explanation consisting of descriptions of each point:
a. [......] b. [......]
c. [......]
Risk Management Guidelines
Photocopy of the
Company's risk management guidelines, which among others contain:
a. active supervision by the Board of Directors and Board of Commissioners; b. adequacy of policies, procedures, and setting of risk limits;
c. adequacy of processes
for identification, measurement, supervision, and risk control; d. risk management information system; and
Article 10
paragraph (2) letter j
POJK
Number
67/POJK.05
/2016 and
SEOJK
Number
10/SEOJK.
05/2016
Proven by risk management guidelines.
Guideline number:
[......]
Effective date of the guideline:
[......]
Signed by:
[......]
Explanation consisting of descriptions of each point:
a. [......] b. [......]
c. [......]
d. [......]

20 -
e. comprehensive internal control system. e. [......] Insurance Products

Specifications of the
insurance products to be marketed, accompanied by premium income projections and expenses linked to marketing new insurance products for a period of 3 (three) years and sample policies that will be used by the Insurance Company.
Article 10
paragraph (2) letter k
POJK
Number
67/POJK.05
/2016
Information regarding specifications of insurance products to be marketed in accordance with the scope of business and business lines. Agreements with Other Parties
Photocopy of agreements
with other parties and policies on partial delegation of functions in the conduct of business (if any).
Article 10
paragraph (2) letter l
POJK
Number
67/POJK.05
/2016
Name of Party: [......]
Function delegated:
[......]
Systems Used by the Company
Administrative systems and
data management infrastructure that support the preparation and submission of reports to the Financial Services Authority.
Article 10
paragraph (2) letter m
POJK
Number
67/POJK.05
/2016
Software: [......]
Hardware: [......]
Applications used by the company: [......]
Data processing systems that can
generate accurate and accountable information in decision making.
Article 48
paragraph (6)
POJK
Number
67/POJK.05
/2016
Data processing systems consist of:

spreadsheet
programs;
application-based
information systems; and/or
web-based
information systems.
Applications used by the Company: [......]
21 -
In Case of Direct Participation From Foreign Parties

Confirmation from the supervisory authority
in the country of origin of the foreign party.
Article 10
paragraph (2) letter n
POJK
Number
67/POJK.05
/2016
Country name: [......]
Institution name: [......]
Letter number: [......]
Date: [......]
Substance of confirmation:
[......]
Licensing Costs
Proof of payment of
licensing costs.
Article 10
paragraph (2) letter o
POJK
Number
67/POJK.05
/2016
OJK Information Receipt System Number (SIPO): [......] Payment date:
[......]
Amount paid:
[......]
Other Supporting Documents
Photocopy of initial/closing
financial position reports of the Company.
Article 10
paragraph (2) letter p number 1 POJK Number 67/POJK.05 /2016
Proof of operational readiness.
Article 10
paragraph (2) letter p number 2 POJK Number 67/POJK.05 /2016 Inventory list:
a. [......] b. [......]
c. Etc.
Head office domicile certificate Number: [......] Date:[......] Address: [......]
Proof of employing
actuaries and internal auditors.
Article 10
paragraph (2) letter p number 3
Actuary:
Name: [......]

22 -
POJK
Number
67/POJK.05
/2016
Appointment decree number:
[......]
Date: [......]

Internal auditor:
Name: [......]
Appointment decree number:
[......]
Date: [......]
Human resources field plan including
human resource development plans for at least the first 3 (three) years.
Article 10
paragraph (2) letter p number 4 POJK Number 67/POJK.05 /2016
Photocopy of guidelines for the implementation of
anti-money laundering programs and counter-terrorism financing prevention, which must at least cover:
a. active supervision by the Board of Directors and Board of Commissioners; b. policies and procedures;
c. internal controls;
d. management information systems; and e. human resources and training.
Article 10
paragraph (2) letter p number 5 POJK Number 67/POJK.05 /2016 and
Article 2
POJK
Number
39/POJK.05
/2015
Guideline number:
[......]
Effective date of the guideline:
[......]
Signed by:
[......]
Photocopy of good corporate governance guidelines
which contain provisions as follows:
a. execution of duties and responsibilities of members of the Board of Directors,
Article 10
paragraph (2) letter p number 6 POJK Number 67/POJK.05 /2016 jo. Guideline number:
[......]
Effective date of the guideline:
[......]

23 -
Board of Commissioners, and DPS; b. execution of duties of working units and committees that carry out internal control functions;
c. implementation of
compliance functions, internal auditors, and external auditors; d. implementation of risk management, including internal control systems and implementation of good corporate governance of information technology; e. implementation of remuneration policies; f. strategic plans; and g. transparency of financial and non-financial conditions.
Article 4
POJK
Number
73/POJK.05
/2016
Signed by:
[......]

Photocopy of investment governance guidelines
established by the Board of Directors, which contain investment policies and strategies which must at least contain:
a. profile of assets and liabilities of the Company; b. alignment between asset duration and liability duration of the Company;
c. investment objectives;
d. target rates of expected investment returns, including investment yield benchmarks (yield’s benchmark) used; e. basis for assessment and
Article 10
paragraph (2) letter p number 7 POJK Number 67/POJK.05 /2016 and Article 56 paragraph (3) POJK Number 73/POJK.05 /2016 Proven by Guidelines and Investment Strategies Guideline No.: [......] Effective Date of the Guideline:
[......]
Signed by:
[......]
Brief explanation regarding the aforementioned guidelines:
[......]

24 -
qualitative limits for each type of investment asset; f. maximum limits on investment allocation for each type of investment asset; g. maximum limit on the proportion of the Company's assets that can be placed with one party; h. maximum limit on the amount of assets not placed (idle assets) in the form of investment (15%);
i. prohibited investment objects
for 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, experts, and other service providers used in investment management; m. provisions on the use derivative instruments and other structured financial products for hedging purposes; n. restrictions
25 -
on investment transaction authorities for each level of management and their accountability; and o. actions to be taken against the Board of Directors for violations of investment policies.

Photocopy of information technology governance guidelines
which must at least contain:
a. organizational structure of the information system; b. guidelines for the use of information systems equipped with instructions or work orders for each function (standard operating procedure); and
c. data security management guidelines
and incident management guidelines (disaster recovery plan).
Article 65
POJK
Number
67/POJK.05
/2016
Proven by effective information technology governance guidelines. Guideline number:
[......]
Effective date of the guideline:
[......]
Signed by:
[......]
Photocopy of cooperation agreements between
shareholders in the form of foreign legal entity shareholders and Indonesian shareholders, which are made in Indonesian language and must at least contain:
a. capital composition and details of authorities, which must at least contain provisions regarding voting rights, profit sharing and
Article 10
paragraph (2) letter p number 8 POJK Number 67/POJK.05 /2016 Number: [......] Date: [......] Capital composition: [......] Obligations: [......]

26 -
losses, and appointment of members of the Board of Directors and members of the Board of Commissioners; and b. obligations of shareholders in the form of foreign legal entities to prepare and implement education and training programs according to their fields of expertise.

Automatic reinsurance support plan,
for Insurance Companies.
Article 10
paragraph (2) letter p number 9 POJK Number 67/POJK.05 /2016 Reinsurance support agreement letter number: [......] Date: [......] Reinsurance Company: [......] Type of reinsurance:
[......]
Line/Product: [......]
Retrocession support plan, for
Reinsurance Companies.
Article 10
paragraph (2) letter p number 10 POJK Number 67/POJK.05 /2016 Retrocession support agreement letter number: [......] Date: [......] Company: [......] Type of retrocession: [......] Line/Product: [......] Additional information (if needed):
We, the undersigned, declare that:
The Self Assessment Form above has been filled out according to the actual
conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are true and
identical to the printed documents.

27 -
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:

How to fill in: double-click in the box, then select “Checked”.
This Self Assessment Form is prepared based on the provisions of Financial Services Authority
Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

28 -
SELF ASSESSMENT FORM 2 APPLICATION FOR RELEASE OF GUARANTEE FUNDS IN CANCELLATION OF BUSINESS LICENSE APPLICATIONS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 2 SELF ASSESSMENT FORM APPLICATION FOR RELEASE OF GUARANTEE FUNDS IN CANCELLATION OF BUSINESS LICENSE APPLICATIONS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Application letter number :
Date of application letter :
Contact person (name, phone, email) :
Business license application letter number :
Date of business license application letter :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES
1. Application submitted
using format 7
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 26 paragraph
(2) POJK
Number
67/POJK.05/
2016
2. Reasons for release of guarantee funds.
Article 26 paragraph
(2) POJK
Number
67/POJK.05/
2016
Additional information (if needed):
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual
conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and
identical to the printed documents.
29 -
Jakarta, [......]
Board of Directors [......] signature [Full Name] Note:

How to fill in: double-click in the box, then select “Checked”.
This Self Assessment Form is prepared based on the provisions of Financial Services Authority
Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

30 -
SELF ASSESSMENT FORM 3 REPORTING ON THE IMPLEMENTATION OF BUSINESS ACTIVITIES OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 3 SELF ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF BUSINESS ACTIVITIES OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Date of reporting letter :
Contact person (name, phone, email) :
Number and date of Decision of the Commissioner Board of the Financial Services Authority regarding granting of business license to the Company :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report submitted
using format 8
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 27 paragraph (3)
POJK Number
67/POJK.05/2016
Proof of coverage activities already
conducted by the
Insurance Company.
Article 27 paragraph (4)
letter a POJK
Number
67/POJK.05/2016
Policy number:
[......]
Policy date:
[......]
Proof of reinsurance activities already
conducted by the
Insurance Company.
Article 27 paragraph (4)
letter a POJK
Number
67/POJK.05/2016
Number: [......]
Date:
[......]
Photocopy of residence permits and/or letters
permitting the use of foreign labor issued by the competent agency, for members of the Board of Directors and/or members of the Board of Commissioners who are foreign nationals.
Article 27 paragraph (4)
letter b POJK
Number
67/POJK.05/2016
Name: [......]
Position:
[......]
Permit letter number: [......]
Date:
[......]

31 -
Additional information (if needed):
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual
conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. How to fill in: double-click in the box, then select “Checked”.
2. This Self Assessment Form is prepared based on the provisions of Financial Services Authority
Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
32 -
SELF ASSESSMENT FORM 4 REPORTING ON THE DETERMINATION OF CONTROLLERS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 4 SELF ASSESSMENT FORM REPORTING ON THE DETERMINATION OF CONTROLLERS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Date of reporting letter :
Contact person (name, phone, email) :
Name of shareholder or controller recorded :
Name of prospective controller :
Reason for appointment of controller :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report submitted
using format 9
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 31
paragraph (2)
POJK
Number
67/POJK.05
/2016
List of controllers Article 31
paragraph (2)
POJK
Number
67/POJK.05
/2016
Controller name:
[.......]
Ownership percentage
(if controller is a shareholder): [.......]
Control relationship with the company (if controller is not a shareholder): [.......]

33 -
Determination/appointment letter number:
[......]
Determination/appointment letter date:
[......]

Information regarding
the form of control.
Article 31
paragraph (2)
POJK
Number
67/POJK.05
/2016
Rights and obligations of the controller:
[......]
Additional information (if needed):
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual
conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. How to fill in: double-click in the box, then select “Checked”.
2. This Self Assessment Form is prepared based on the provisions of Financial Services Authority
Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

34 -
SELF ASSESSMENT FORM 5 APPLICATION FOR APPROVAL TO CEASE BEING A CONTROLLER OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 5 SELF ASSESSMENT FORM APPLICATION FOR APPROVAL TO CEASE BEING A CONTROLLER OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Application letter number :
Date of application letter :
Contact person (name, phone, email) :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES
1. Application to cease being a
controller submitted by the
Board of Directors to the Financial Services Authority.
Article 32
paragraph (2)
POJK Number
67/POJK.05
/2016
2. Reasons for ceasing to be a
controller.
Article 32
paragraph (2)
POJK Number
67/POJK.05
/2016
Reason for ceasing as a controller:
[......]
3. Proof that the Insurance Company and
Reinsurance Company have appointed a new controller before submitting the application for approval to terminate a party as a controller in case the company only has 1 (one) controller.
Article 32
paragraph (3)
POJK Number
67/POJK.05
/2016
Name of new controller:
[......]
Number and date of decision on determination of results of suitability and propriety assessment for new controller:
[......] date [......]
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual
conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance
35 -
Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and

The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
How to fill in: double-click in the box, then select “Checked”.
This Self Assessment Form is prepared based on the provisions of Financial Services Authority
Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

36 -
SELF ASSESSMENT FORM 6 REPORTING ON CHANGES IN CONTROLLERS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 6 SELF ASSESSMENT FORM REPORTING ON CHANGES IN CONTROLLERS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Date of reporting letter :
Contact person (name, phone, email) :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report on changes in company
controllers signed by the Board of Directors and submitted to the Financial Services Authority.
Article 33
POJK
Number
67/POJK.05
/2016
List of shareholders
with details of each share ownership and all related business sector groups of the company and legal entities owning the company up to the ultimate owner accompanied by supporting documents.
Article 33
paragraph (1)
POJK
Number
67/POJK.05
/2016
Proof of change in controller Article 33
POJK
Number
67/POJK.05
/2016
New controller name: [......]
Ownership percentage (if controller is a shareholder): [......] Number and date of letter on determination/approval as a controller: [......]

37 -
Additional information (if needed):
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual
conditions and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. How to fill in: double-click in the box, then select “Checked”.
2. This Self Assessment Form is prepared based on the provisions of Financial Services Authority
Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Aspects of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
38 -
SELF ASSESSMENT FORM 7 REPORTING ON THE OPENING OF OFFICES OUTSIDE THE HEAD OFFICE THAT HAVE AUTHORITY TO MAKE DECISIONS ON ACCEPTANCE OR REJECTION OF COVERAGE AND/OR CLAIMS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 7 SELF ASSESSMENT FORM REPORTING ON THE OPENING OF OFFICES OUTSIDE THE HEAD OFFICE THAT HAVE AUTHORITY TO MAKE DECISIONS ON ACCEPTANCE OR REJECTION OF COVERAGE AND/OR CLAIMS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Date of reporting letter :
Contact person (name, phone, email) :
Purpose and objective of opening Office Outside Head Office :
List of opening of offices outside head office No. Office Name Address*) No. Phone/Fax Manager Effective Date Opening 1. 2. Etc. *) Address must be written completely, namely including Village/Sub-district name, District, City/Regency, and Postal Code. NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

Report submitted
using format 17
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 66 paragraph
(2) POJK
Number
67/POJK.05/
2016
Report has been accompanied
by documents as follows:
a. description of office name and office function;
Article 66 paragraph
(3) letter a
POJK Number
67/POJK.05/
2016
Office name:
[.......]
Office function:
[.......]

39 -
b. letter of statement from relevant parties which must at least state the name and address of the company;
Article 66 paragraph
(3) letter b
POJK Number
67/POJK.05/
2016
Statement letter number:
[.......]
Statement letter date:
[.......]
Issuer of statement letter:
[.......]
c. manager's name
accompanied by a curriculum vitae list; and
Article 66 paragraph
(3) letter c
POJK Number
67/POJK.05/
2016
Curriculum vitae of:
a. Mr./Ms. [.......] b. Mr./Ms. [.......] d. description of duties and authorities of the office manager.
Article 66 paragraph
(3) letter d
POJK Number
67/POJK.05/
2016

The Company meets the provisions regarding
financial health for the last 4 (four) quarters.
Article 64 paragraph
(1) letter a
POJK Number
67/POJK.05/
2016
(Proven by stating and attaching solvency level data for the last 4 quarters).
The Company has a low or medium-low
risk level assessment.
Article 64 paragraph
(1) letter b
POJK Number
67/POJK.05/
2016
(Proven by stating and attaching risk level data reported to the Financial Services Authority.

40 -
5. The Company has expert personnel working full-time at the relevant office.
Proven by:
a. proof of employing expert personnel with a qualification level at least 1 (one) level below the highest qualification; b. professional degree certificate;
c. minimum work experience of 2 years in insurance risk management (proven by a curriculum vitae); and
d. not currently subject to sanctions from their professional association.
Article 64 paragraph (1) letter c jo. Article 58 POJK Number 67/POJK.05/2016
a. Appointment Decree Number: [.......]
Date: [.......] b. Certificate Number: [.......] Date: [.......]
c. Work experience in the insurance field: [.......]
d. Number: [.......]
Date: [.......]
6. The Company is not currently subject to administrative sanctions by the Financial Services Authority.
Article 64 paragraph (1) letter d
POJK Number 67/POJK.05/2016
Additional information (if necessary):
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors […………………] signature [Full Name]
41 -
Note:

Filling method: click twice on the box, then select "Checked".
This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

42 -
FORM SELF ASSESSMENT 8 REPORTING OF OPENING AN OFFICE OUTSIDE THE HEAD OFFICE THAT DOES NOT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 8 FORM SELF ASSESSMENT REPORTING OF OPENING AN OFFICE OUTSIDE THE HEAD OFFICE THAT DOES NOT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Reporting letter date :
Contact person (name, phone, email) :
Purpose and objective of opening an office outside the head office :
List of offices opened outside the head office No. Office Name Address*) Phone/Fax No. Leader Effective Date Opening 1. 2. Etc. *) Address must be written completely, including Village/Sub-district Name, District, City/Regency, and Postal Code. NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

The report is submitted using format 17 Appendix POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 66
paragraph (2)
POJK
Number
67/POJK.05
/2016
The report has been accompanied by the following documents:
a. description of office name and description of office function;
Article 66
paragraph (3) letter a
Office name:
[.......]

43 -
POJK
Number
67/POJK.05
/2016
Office function:
[.......] b. letter of confirmation from the relevant party stating at least the name and address of the company;
Article 66
paragraph (3) letter b
POJK
Number
67/POJK.05
/2016
Letter of confirmation number:
[.......]
Date of letter of confirmation:
[.......]
Issuer of letter of confirmation:
[.......]
c. leader's name completed with a curriculum vitae; and
Article 66
paragraph (3) letter c
POJK
Number
67/POJK.05
/2016
Curriculum vitae for:
a. Mr./Ms. [.......] b. Mr./Ms. [.......] d. description of duties and authority of the office leader.
Article 66
paragraph (3) letter d
POJK
Number
67/POJK.05
/2016
Additional information (if necessary) :
We, the undersigned, declare that:

The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are true and identical to the printed documents.

44 -
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:

Filling method: click twice on the box, then select
"Checked".
This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

45 -
FORM SELF ASSESSMENT 9 REPORTING OF CLOSURE OF AN OFFICE OUTSIDE THE HEAD OFFICE THAT HAS THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 9 FORM SELF ASSESSMENT REPORTING OF CLOSURE OF AN OFFICE OUTSIDE THE HEAD OFFICE THAT HAS THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Reporting letter date :
Contact person (name, phone, email) :
List of offices closed outside the head office No. Office Name Address*) Leader Effective Date Office Closure 1. 2. Etc. *) Address must be written completely, including Village/Sub-district Name, District, City/Regency, and Postal Code NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES
1. The report is submitted using format 18 Appendix POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 68
paragraph (2)
POJK
Number
67/POJK.
05/2016
2. Proof of notice of plan to close office outside the head office.
Article 67
paragraph (1) and Article
68 paragraph (2) letter a
POJK
Number
67/POJK.
05/2016
Date notice to policyholders: [.......]
3. Proof of transfer of services from the closed office outside the head office to the head office or the nearest office outside the head office.
Article 67
paragraph (1) and Article
68 paragraph (2) letter b
POJK
Number
67/POJK.
05/2016 to employees:
[.......]
Appointment Decree Number for transfer of leaders: [.......] Date of Decree: [.......] Appointment Decree Number for transfer of employees:
[.......]
Date: [.......]
Additional information (if necessary):
We, the undersigned, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
47 -
FORM SELF ASSESSMENT 10 REPORTING OF CLOSURE OF AN OFFICE OUTSIDE THE HEAD OFFICE THAT DOES NOT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 10 FORM SELF ASSESSMENT REPORTING OF CLOSURE OF AN OFFICE OUTSIDE THE HEAD OFFICE THAT DOES NOT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Reporting letter number :
Reporting letter date :
Contact person (name, phone, email) :
List of offices closed outside the head office No. Office Name Address*) Leader Effective Date Office Closure 1. 2. Etc. *) Address must be written completely, including Village/Sub-district Name, District, City/Regency, and Postal Code DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES Report is submitted using format 19 Appendix POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 69 paragraph
(2) POJK
Number
67/POJK.05/
2016
Additional information (if necessary):
We, the undersigned, declare that:

The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are true and identical to the printed documents.

48 -
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:

Filling method: click twice on the box, then select "Checked".
This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

49 -
FORM SELF ASSESSMENT 11 APPLICATION FOR APPROVAL OF OWNERSHIP CHANGES THAT RESULT IN CHANGES IN CONTROLLING SHAREHOLDERS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 11 FORM SELF ASSESSMENT APPLICATION FOR APPROVAL OF OWNERSHIP CHANGES OF COMPANIES THAT RESULT IN CHANGES IN CONTROLLING SHAREHOLDERS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Application letter number :
Application letter date :
Contact person (name, phone, email) :
Background of planned ownership change :
Form of ownership change
Ownership changes caused by the entry of a new shareholder becoming a controlling shareholder through the transfer of shares from existing shareholders or the issuance of new shares. Ownership changes caused by the transfer of shares among existing shareholders and resulting in the emergence of a new controlling shareholder. Capital increase by existing shareholders causing the addition/change of controlling shareholders. Others. Substance of ownership change:
Before Becoming
Shareholder Nominal (Rp) % Shareholder Nominal (Rp) % NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES Fulfillment of Requirements for Application for Approval of Planned Ownership Change

Ownership change has not been implemented until obtaining approval from the Financial Services Authority.
Article 74
paragraph (1)
POJK
Number
The Company
[...has not/yet...] implemented the ownership change

50 -
Financial Services Authority. 67/POJK.05 /2016 mentioned.

Fulfillment of ownership criteria requirements:
a. for Indonesian legal entities:
fully owned directly or indirectly by Indonesian citizens; or b. for foreign legal entities:
companies having similar business or parent companies where one of its subsidiaries operates in a similar insurance business field.
Article 3 paragraph
(1) POJK
Number
67/POJK.05
/2016
Ultimate shareholders of shareholders in the form of Indonesian legal entities:
1. PT [......] owned by [......];
2. Etc.
Data for shareholders in the form of foreign legal entities:
1. [......] operating in the field of
[......]
2. [......] has subsidiaries in the field of
business [..life insurance/general insurance/reinsurance..] as follows:
a) [......]; and b) [......].
3. Foreign ownership refers to Government Regulations regarding foreign ownership in Companies.
Article 6 paragraph
(4) POJK
Number
67/POJK.05
/2016
At the time of Company establishment, the following conditions were required:
a. direct participation by foreign parties in the Company up to a maximum of 80% (eighty percent) of paid-up capital; and b. having equity of at least 5 (five) times the amount of direct participation in the Insurance Company at the time of establishment. (Article 4 and Article 6 Government Regulation Number 14/2018)
4. Companies undergoing ownership changes through takeover and/or addition of new shareholders must adjust the minimum paid-up capital, namely:
a. Rp150,000,000,000.00 for insurance companies and b. Rp300,000,000,000.00 for reinsurance companies. (except for the entry of new shareholders due to inheritance results or ownership changes in the context of fulfilling financial health regulations).
Article 75 jo.
Article 6 paragraph
(1) and paragraph
(2) POJK
Number
67/POJK.05
/2016
Paid-up capital of the Company before planned ownership change:
Rp [......] for the period of financial report month [......] Paid-up capital of the Company after ownership change:
Rp [......] for the period of financial report month [......]
5. The amount of direct participation in the Company for shareholders in the form of Indonesian legal entities that are not financial service institutions under the supervision of the Financial Services Authority, the maximum is equal to the shareholder's equity.
Article 8 paragraph
(3) and paragraph
(6) POJK
Number
67/POJK.05
/2016
List of shareholder equities:
1. PT [......] equity amounting to Rp [......]
per (date of last financial report)
2. Etc.
Based on the equity amounts above, PT [......] and PT [......] meet/do not meet the maximum participation amount regulation. Completeness of Documents for Application for Approval of Ownership Change
6. The application is submitted using format 21 Appendix POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 76
paragraph (1)
POJK
Number
67/POJK.05
/2016
7. Planned ownership list. Article 76
paragraph (1) letter a
POJK
Number
67/POJK.05
/2016
Current list of names and composition of shareholders consists of:
a. [......] ownership amounting to [......] % b. [......] ownership amounting to [......] % Planned list of names and composition of shareholders consists of:
a. [......] ownership amounting to [......] % b. [......] ownership amounting to [......] %
8. In the event that the ownership change is caused by a new shareholder who is an individual, the company submits data of prospective shareholders or members other than controllers as follows:
a) photocopy of identification card (KTP) or valid passport;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point a) POJK Number 67/POJK.05 /2016
1. Name: [......]
Position: [......]
ID Card/Passport Number:
[......]
Validity period of identity: [......]
2. Etc.
b) photocopy of Taxpayer Identification Number (NPWP); Article 76 paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point b) POJK Number 67/POJK.05 /2016
1. Name: [......]
NPWP Number:
[......]
2. Etc.
c) photocopy of Income Tax Returns (SPT) for the last 2 (two) years and other documents showing financial capability and funding sources of the prospective individual shareholder;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point c) Photocopy of SPT for Mr./Ms. [......]:
1. SPT Period: year
[......]
Taxable Income:
Rp [......]

53 -
67/POJK.05
/2016
Asset list: [......]
Total assets: Rp
[......]
Liability list:
[......]
Total liabilities:
Rp [......]

Etc.
d) curriculum vitae completed with the latest color passport-sized photo measuring 4 x 6 cm;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point d) POJK Number 67/POJK.05 /2016 Curriculum vitae and passport photo for:
Mr./Ms. [......]
Etc.
e) statement letter from the prospective shareholder stating:
1) capital deposit does not originate from loans;
2) capital deposit does not originate from money laundering activities and financial crimes;
3) no bad credits and/or financing;
4) not included as a party prohibited from becoming a shareholder or a party managing, supervising, and/or having significant influence on financial service institutions;
5) never convicted for committing criminal acts in the financial service business and/or economy based on a court decision that has had permanent legal force within the last 5 (five) years;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point e) POJK Number 67/POJK.05 /2016 Statement letter signed by shareholders as follows:
Mr./Ms. [......]
Etc.
Completed with the signature of the concerned party above the stamp duty.

54 -
6) never convicted for committing criminal offenses based on a court decision that has had permanent legal force within the last 5 (five) years;
7) never declared bankrupt or guilty causing a company to be declared bankrupt based on a court decision that has had permanent legal force within the last 5 (five) years; and
8) never served as PSP, Board of Directors member, Board of Commissioners member, Controller, or DPS member at a financial service company whose business license was revoked due to violations within the last 5 (five) years.

In the event that the ownership change is caused by a new shareholder who is a legal entity, the company submits data of prospective shareholders as follows:
a. photocopy of the deed of establishment of the legal entity including the articles of association along with amendments (if any), accompanied by photocopies of approval proof, consent proof, and/or photocopies of receipt of notification from the competent authority;
Article 76
paragraph (1)
Data on company establishment:

55 -
letter b jo.
Article 10
paragraph (2) letter f number 2 point a) POJK Number 67/POJK.05 /2016 Deed Number: [......] 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):
1. Deed number and date: [......]
Number and date of approval proof and/or receipt of notification from competent authority:
[......]
Substance of amendment to articles of association: [......]
2. Etc.
b. financial reports audited by public accountants, completed with non-consolidated financial reports and the latest monthly financial reports;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point b) POJK Number 67/POJK.05 /2016 Financial Report of PT [......] attached:
1. Audited financial report for period [......]
2. Non-consolidated financial report for period [......]
3. Latest monthly financial report for period [......]
c. photocopy of identification card (KTP) or valid passport for directors and board of commissioners or equivalents thereof from the relevant legal entity;
Article 76
photocopy of identity
56 -
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point c) POJK Number 67/POJK.05 /2016 members of the Board of Directors and members of the Board of Commissioners :
1. Name: [......]
Position: [......]
ID Card/Passport Number:
[......]
Validity period of identity:
[......]
2. Etc.
d) photocopy of NPWP; Article 76 paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point c) POJK Number 67/POJK.05 /2016 Photocopy of NPWP for members of the Board of Directors and members of the Board of Commissioners :
1. Name: [......]
NPWP Number:
[......]
2. Etc.
e) curriculum vitae completed with the latest color passport-sized photo measuring 4 x 6 cm;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point c) POJK Number 67/POJK.05 /2016 Curriculum vitae and passport photo for:
1. Mr./Ms. [......]
2. Etc.
f) statement letter from the director or equivalent thereof of the relevant legal entity stating that:
1) capital deposit does not originate from loans;
2) capital deposit does not originate from money laundering activities
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point d) POJK Statement letter signed by:

Mr./Ms. [......]
Etc.

57 -
and financial crimes;

no bad credits and/or financing;
not included as a party prohibited from becoming a shareholder or a party managing, supervising, and/or having significant influence on financial service institutions;
never convicted for committing criminal acts in the financial service business and/or economy based on a court decision that has had permanent legal force within the last 5 (five) years;
never declared bankrupt or guilty causing a company to be declared bankrupt based on a court decision that has had permanent legal force within the last 5 (five) years; and
never served as PSP, Board of Directors member, Board of Commissioners member, controller, or DPS member at a financial service company whose business license was revoked due to violations within the last 5 (five) years.
Number
67/POJK.05
/2016 g. rating result from an internationally recognized rating agency, for shareholders in the form of foreign legal entities or subsidiaries operating in similar insurance businesses, showing a rating of at least A or equivalent.
Article 76
paragraph (1) letter b jo. Article 8 Entities rated:
[......]

58 -
paragraph (1) and paragraph (2) and Article 10 paragraph (2) letter f number 2 point e) POJK Number 67/POJK.05 /2016 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 foreign parties.
Article 76
paragraph (1) letter b jo. Article 8 paragraph (1) and paragraph (2) POJK Number 67/POJK.05 /2016 Confirmation letter number:
[......]
Date of confirmation letter: [......]
Country and institution:
[......]
Shareholder name:
[......]
Substance of letter: [......]

Draft minutes of the Annual General Meeting of Shareholders (RUPS).
Article 76
paragraph (1) letter c
POJK
Number
67/POJK.05
/2016
Draft minutes of RUPS contain substance before and after the planned ownership change and approval by shareholders. Other material information (if any):
[......]
Draft deed of transfer of rights over shares.
Article 76
paragraph (1) letter d
POJK
Number
67/POJK.05
/2016
Draft deed of transfer of rights over shares from:
Mr./Ms. [......]
PT [......] to:
Mr./Ms. [......]
PT [......]

59 -

Photocopy of Tax Returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of individual prospective shareholders.
Article 76
paragraph (1) letter e
POJK
Number
67/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
[......]
Photocopy of the Company's financial report which has been audited by a public accountant before paid-in capital addition, in the event that ownership change is caused by paid-in capital addition or will be carried out in the form of transfer of retained earnings, loan transfer, and/or stock dividends.
Article 76
paragraph (1) letter f
POJK
Number
67/POJK.05
/2016
Audited financial report of PT [......]
Year/period [......]
Photocopy of cooperation agreement between foreign legal entity shareholders and Indonesian shareholders, for applications for approval of ownership changes involving new foreign legal entity shareholders, which at least contains:
1) capital composition and details of authority, which at least contains provisions regarding voting rights, profit and loss distribution, and appointment of Board of Directors members and Board of Commissioners members;
Article 76
paragraph (1) letter g
POJK
Number
67/POJK.05
/2016
Number: [......]
Date: [......]
Capital composition:
[......]
Obligations: [......]

60 -
Commissioners of the company; and

obligations of foreign legal entity shareholders to prepare and implement education and training programs according to their field of expertise.

For ownership changes caused by cash paid-in capital additions:
a. shareholder statement letter stating that capital deposits do not originate from loans, money laundering activities, and financial crimes.
Article 78
paragraph (7) letter c
POJK
Number
67/POJK.05
/2016
Statement letter signed by shareholders as follows:
Mr./Ms.: [......]
Statement letter number:
[......]
Date of statement letter:
[......] b. photocopy of Tax Returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of individual shareholders. In the event that existing individual shareholders participate in the paid-in capital addition.
Article 78
paragraph (7) letter d
POJK
Number
67/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 [......]
Etc.
c. Financial report of the shareholder which has been audited by a public
Article 78
paragraph (7) letter e audited shareholder financial report as follows:

61 -
accountant and/or the latest financial report, in the event that the shareholder is a legal entity. POJK Number 67/POJK.05 /2016
1. Shareholder name:
[......]
Period of audited financial report:
[......]
Period of latest monthly financial report:
[......]
Total Equity:
[......]
2. Etc.
16. Business Plan. Article 68
paragraph (3)
POJK
Number
73/POJK.05
/2016
The capital addition plan has/is not included and is consistent with the Business Plan for year: [......] Background of capital increase:
[......]
Purpose of use of funds from capital addition results:
[......]
17. In the event that ownership change is caused by reduction of paid-in capital, the company's equity must not be less than:
a. IDR 100,000,000,000.00 for Insurance Companies; and b. IDR 200,000,000,000.00 for Reinsurance Companies.
Article 33
and Article
34 POJK
Number
71/POJK.05
/2016
Report period: as of
[......]
Equity: Rp[......]
18. In the event that ownership change is caused by transfer of subordinated loans, the transfer must not cause non-compliance with internal solvency ratio targets.
Article 24
POJK
Number
71/POJK.05
/2016
Solvency ratio for period [......] is [......]%. Projected solvency ratio for period [......] is [......]%.
62 -
19. Shareholder composition on the Financial Services Authority data communication network system.
Share composition in the company profile on the Financial Services Authority data communication network system [has/have not] complied with the composition before the planned ownership change. Assessment of Ability and Fit for Controllers
20. Existing controlling shareholders have obtained designation as controlling shareholders or controllers.
Article 2 paragraph
(1) and paragraph
(2) POJK
Number
27/POJK.03
/2016 as well as
SEOJK
Number
31/SEOJK.
05/2016
Number of designation/response decision:
[......]
Date of designation/response decision:
[......]
Name of Controller:
[......]
21. Insurance company or reinsurance company has submitted designation of new controller or has conducted ability and fit assessment at the Financial Services Authority against the new controller.
Article 10
paragraph (3) and paragraph (4) POJK Number 67/POJK.05 /2016 and
Article 2 paragraph
(1) and paragraph
(2) POJK
Number
27/POJK.03
/2016
Number of designation/response decision:
[......]
Date of designation/response decision:
[......]
Name of Controller:
[......]
Additional notes (if needed):
We who sign below hereby declare that:
1. 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………]
63 -
signature
[Full Name]
Notes:

Filling method: click twice on the box, then select "Checked".
This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

64 -
FORM SELF ASSESSMENT 12 APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE THAT DOES NOT RESULT IN CHANGE OF CONTROLLING SHAREHOLDER OF INSURANCE AND REINSURANCE COMPANIES FORM: 12 FORM SELF ASSESSMENT APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE OF COMPANY THAT DOES NOT RESULT IN CHANGE OF CONTROLLING SHAREHOLDER OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Application letter number :
Date of application letter :
Contact person (name, phone, email) :
Background of planned ownership change :
Form of ownership change
Ownership change caused by entry of new shareholders. Ownership change caused by loss of one or more existing shareholders. Ownership change caused by transfer of shares among existing shareholders, but there is no change in name and composition of shareholders. Capital addition by existing shareholders causing a change in percentage of share ownership. Others. Substance of ownership change:
Before Becoming
Shareholder Nominal (Rp) % Shareholder Nominal (Rp) %
65 -
NO DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES
1. Ownership change has not been implemented until obtaining approval from the Financial Services Authority.
Article 74
paragraph (1)
POJK
Number
67/POJK.05
/2016
Company
[...has not/has...] implemented the aforementioned ownership change.
2. Fulfillment of ownership criteria requirements:
a. for Indonesian legal entities:
directly or indirectly wholly owned by Indonesian citizens; or b. for foreign legal entities:
companies having similar business or parent companies where one of its subsidiaries operates in a similar insurance business.
Article 3 paragraph
(1) POJK
Number
67/POJK.05
/2016
Ultimate shareholders of shareholders in the form of Indonesian legal entities:
1. PT [......] owned by [......];
2. Etc.
Data of shareholders in the form of foreign legal entities:
1. [......] operating in the field of
[......]
2. [......] has subsidiaries in the field of
business [life insurance/general insurance/reinsurance..] as follows:
a) [......] ; and b) [......].
3. Foreign ownership refers to Government Regulations regarding
foreign ownership in Companies.
Article 3 paragraph
(3) POJK
Number
67/POJK.05
/2016
At the time of establishment of the Company, the following requirements were imposed:
a. direct participation of foreign parties in the Company at most 80% (eighty percent) of paid-in capital; and b. having equity of at least 5 (five) times the amount of direct participation in the Insurance Company at the time of establishment.
66 -
(Article 4 and Article 6
Government Regulation
Number 14/2018)

Companies undergoing ownership change through takeover and/or addition of new shareholders must adjust minimum paid-up capital, namely:
a. IDR 150,000,000,000.00 for
Insurance Companies and b. IDR 300,000,000,000.00 for Reinsurance Companies. (except for entry of new shareholders due to inheritance results or ownership changes in the context of meeting financial health regulations).
Article 75 jo.
Article 6 paragraph
(1) and paragraph
(2) POJK
Number
67/POJK.05
/2016
Paid-up capital of
Company before planned ownership change:
Rp [......] for reporting period month [......] Paid-up capital of Company after ownership change:
Rp [......] for reporting period month [......]
Total direct participation in the Company for shareholders in the form of
Indonesian legal entities that are not financial service institutions under the supervision of the Financial Services Authority, is at most equal to the equity of the shareholder.
Article 8 paragraph
(3) and paragraph
(6) POJK
Number
67/POJK.05
/2016
List of shareholder equities:
1. PT [......] equity worth Rp [......]
per (date of latest financial report)
2. Etc.
Completeness of Documents for Application for Approval of Ownership Change
6. Application is submitted using format 21
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 76
paragraph (1)
POJK
Number
67/POJK.05
/2016
7. Planned list of ownership. Article 76
paragraph (1) letter a
POJK
Number
67/POJK.05
/2016
List of names and composition of current shareholders in the form of foreign legal entities:
a) [......] ownership worth [......] % b) [......] ownership worth [......] % Planned list of names and composition of shareholders in the form of foreign legal entities:
a) [......] ownership worth [......] % b) [......] ownership worth [......] %.

67 -
in the form of foreign legal entities:
a) [......] ownership worth [......] % b) [......] ownership worth [......] %.

In the event that ownership change is caused by new shareholders who are individuals, the Company submits data of prospective shareholders as follows:
a) photocopy of identification in the form of ID card (KTP) or valid passport;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point a) POJK Number 67/POJK.05 /2016
1. Name: [......]
ID Card/Passport Number:
[......]
Validity period of identity:
[......]
2. Etc.
b) photocopy of Taxpayer Identification Number (NPWP); Article 76 paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point b) POJK Number 67/POJK.05 /2016
1. Name: [......]
NPWP Number:
[......]
2. Etc.
c) photocopy of Tax Returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of individual prospective shareholders;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point c) POJK Number 67/POJK.05 Fotocopy of SPT for Mr./Ms. [......]:
1. SPT Period: year
[......]
Taxable Income:
Rp [......]
Asset List: [......]

68 -
/2016 Total Assets: Rp
[......]
Liability List:
[......]
Total Liabilities :
Rp [......]

Etc.
d) curriculum vitae list accompanied by the latest color passport photo sized 4 x 6 cm; and
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point d) POJK Number 67/POJK.05 /2016 Curriculum vitae list and passport photo for the name of:
Mr./Ms. [......]
Etc.
e) statement letter from prospective shareholders 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 bad credits and/or financing;
4) is not included as a party prohibited from becoming a shareholder or a party managing, supervising, and/or having significant influence on financial service institutions;
5) has never been sentenced for committing criminal offenses in the field of financial service business and/or economy
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 1 point e) POJK Number 67/POJK.05 /2016 Statement letter signed by shareholders as follows:
Mr./Ms. [......]
Etc.
Accompanied by signature of the relevant party above on stamp duty.

69 -
based on court decisions that have had permanent legal force within the last 5 (five) years;

has never been sentenced for committing criminal offenses based on court decisions that have had permanent legal force within the last 5 (five) years;
has never been declared bankrupt or guilty causing a company to be declared bankrupt based on court decisions that have had permanent legal force within the last 5 (five) years; and
has never become PSP, Board of Directors members, Board of Commissioners members, Controllers, or DPS members at financial service companies whose business licenses were revoked due to violations within the last 5 (five) years.

In the event that ownership change is caused by new shareholders who are legal entities, the Company submits data of prospective shareholders as follows:
a. photocopy of the deed of establishment of the legal entity including the articles of association together with amendments (if any), accompanied by photocopies of proof of approval, proof of permission, and/or photocopies of proof of notification receipt from competent authorities;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point a) POJK Data of company establishment:
Deed No.: [......]
Date: [......]
Notary: [......]

70 -
from competent authorities;
Number
67/POJK.05
/2016
Substance: [......]
Number of Kemenkumham decision/letter: [......] Date: [......] Business activities: [......] Data of all amendments to the company's articles of association (if any):
1. Number and date of deed: [......]
Number and date of proof of approval and/or notification receipt from competent authorities:
[......]
Substance of amendment to articles of association:
[......]
2. Etc.
b. financial report which has been audited by a public accountant accompanied by non-consolidated financial reports and the latest monthly financial report;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point b) POJK Number 67/POJK.05 /2016 Financial report of PT [......] attached:
1. Audited financial report for period [......]
2. Non-consolidated financial report for period [......]
3. Latest monthly financial report for period [......]
c. photocopy of identification in the form of ID card (KTP) or valid passport for directors or those equivalent to directors and board of commissioners of the respective legal entity;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point c) POJK Photocopy of identity of Board of Directors members and Board of Commissioners members:
71 -
commissioners of the respective legal entity; huruf f angka 2 poin c) POJK Number 67/POJK.05 /2016
1. Name: [......]
Position: [......]
ID Card/Passport Number:
[......]
Validity period of identity:
[......]
2. Etc.
d) photocopy of NPWP; Article 76 paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point c) POJK Number 67/POJK.05 /2016 Photocopy of NPWP of Board of Directors members and Board of Commissioners members:
1. Name: [......]
NPWP Number:
[......]
2. Etc.
e) curriculum vitae list accompanied by the latest color passport photo sized 4 x 6 cm;
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point c) POJK Number 67/POJK.05 /2016 Curriculum vitae list and passport photo for the name of:
1. Mr./Ms. [......]
2. Etc.
f) statement letter from directors or those equivalent to directors of the respective 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 bad credits
Article 76
paragraph (1) letter b jo.
Article 10
paragraph (2) letter f number 2 point d) POJK Number 67/POJK.05 /2016 statement letter signed by:

Mr./Ms. [......]
Etc.

72 -
and/or financing;

is not included as a party prohibited from becoming a shareholder or a party managing, supervising, and/or having significant influence on financial service institutions;
has 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 within the last 5 (five) years;
has never been declared bankrupt or guilty causing a company to be declared bankrupt based on court decisions that have had permanent legal force within the last 5 (five) years; and
has never become PSP, Board of Directors members, Board of Commissioners members, Controllers, or DPS members at financial service companies whose business licenses were revoked due to violations within the last 5 (five) years.
g. rating results from internationally recognized rating agencies, for shareholders in the form of foreign legal entities or subsidiaries operating in similar insurance businesses, showing a lowest rating of A or equivalent.
Article 76
paragraph (1) letter b jo. Article 8 paragraph (1) and paragraph (2) Entity rated:
[......]
Rating agency:
[......]

73 -
similar insurance businesses, showing a lowest rating of A or equivalent. huruf f angka 2 poin e) POJK Number 67/POJK.05 /2016 Rating:
[......]
Other material information (if any):
[......] h. confirmation from the supervisory authority in the home country of the Foreign Party, in the event of direct participation from Foreign Parties.
Article 76
paragraph (1) letter b jo. Article 8 paragraph (1) and paragraph (2) POJK Number 67/POJK.05 /2016 Confirmation letter number:
[......]
Date of confirmation letter: [......]
Country and institution:
[......]
Shareholder name:
[......]
Substance of letter: [......]

Draft minutes of the Annual General Meeting of Shareholders (RUPS). Article 76
paragraph (1) letter c
POJK
Number
67/POJK.05
/2016
Draft minutes of RUPS contain substance before and after the planned ownership change of shares and approval by shareholders. Other material information (if any):
[......]
Draft deed of transfer of share rights.
Article 76
paragraph (1) letter d
POJK
Number
67/POJK.05
/2016
Draft deed of transfer of share rights from:
Mr./Ms. [......]
PT [......] to:
Mr./Ms. [......]
PT [......]
Photocopy of Tax Returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of prospective individual shareholders.
Article 76
paragraph (1) letter e
POJK
Number
Photocopy of SPT for: Mr./Ms.
[......]
SPT Period: Year
[......]
Taxable Income:

74 -
individual shareholders.
67/POJK.05
/2016
Rp [......]
Asset List: ....
Total Assets: Rp
[......]
Liability List:
[......]
Total Liabilities:
Rp [......]

Etc.
Photocopy of the Company's financial report which has been audited by a public accountant before paid-in capital addition, in the event that ownership change is caused by paid-in capital addition or will be carried out in the form of transfer of retained earnings, loan transfer, and/or stock dividends.
Article 76
paragraph (1) letter f
POJK
Number
67/POJK.05
/2016
Audited financial report of PT [......]
Year/period [......]
Photocopy of cooperation agreement between foreign legal entity shareholders and Indonesian shareholders, for applications for approval of ownership changes involving new foreign legal entity shareholders, which at least contains:
1) capital composition and details of authority, which at least contains provisions regarding voting rights, profit and loss distribution, and appointment of Board of Directors members and Board of Commissioners members of the company; and
2) obligations of foreign legal entity shareholders to prepare and implement education and training programs according to their field of expertise.
Article 76
paragraph (1) letter g
POJK
Number
67/POJK.05
/2016
Number: [......]
Date: [......]
Capital composition:
[......]
Obligations: [......]

75 -
15. For ownership changes caused by cash paid-in capital additions:
a. shareholder statement letter stating that capital deposits do not originate from loans, money laundering activities, and financial crimes.
Article 78
paragraph (7) letter c
POJK
Number
67/POJK.05
/2016
Statement letter signed by shareholders as follows:
1. Mr./Ms. [......]
Statement letter number:
[......]
Date of statement letter:
[......]
2. Etc.
b. photocopy of Tax Returns (SPT) for the last 2 (two) years and other documents showing the financial capacity and funding sources of individual shareholders. In the event that existing individual shareholders participate in the paid-in capital addition.
Article 78
paragraph (7) letter d
POJK
Number
67/POJK.05
/2016
Photocopy of SPT for Mr./Ms.
[......]:
1. SPT Period: Year
[......]
Taxable Income:
Rp [......]
Asset List: [......]
Total Assets: Rp
[......]
Liability List:
[......]
Total Liabilities:
Rp [......]
2. Etc.
c. financial report of the shareholder which has been audited by a public accountant and/or the latest financial report, in the event that the shareholder is a legal entity.
Article 78
paragraph (7) letter e
POJK
Number
67/POJK.05
/2016
Financial report of shareholder as follows:
1. Shareholder name:
[......]
Period of audited financial report:
[......]
Period of latest monthly financial report:
[......]
76 -
Total Equity:
[......]

Etc.
Business Plan. Article 68
paragraph (3)
POJK
Number
73/POJK.05
/2016
The capital addition plan has/is not included and is consistent with the Business Plan for year: [......] Background of capital addition:
[......]
Purpose of use of funds from capital addition results:
[......]
In the event that ownership change is caused by reduction of paid-in capital, the company's equity must not be less than:
a. IDR 100,000,000,000.00 for
Insurance Companies; and b. IDR 200,000,000,000.00 for Reinsurance Companies.
Article 33
and Article
34 POJK
Number
71/POJK.05
/2016
Report period: as of
[......]
Equity: Rp[......]
In the event that ownership change is caused by transfer of subordinated loans, the transfer must not cause non-compliance with internal solvency ratio targets.
Article 24
POJK
Number
71/POJK.05
/2016
Solvency ratio for period [......] is [......]%. Projected solvency ratio for period [......] is [......]%.
Shareholder composition on the Financial Services Authority data communication network system.
Share composition in the company profile on the Financial Services Authority data communication network system [has/have not] complied with the composition before the planned ownership change. Additional notes (if needed):

77 -
We, the undersigned below, declare that:
1. 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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors […………………] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies,
and Sharia Reinsurance Companies.
78 -
FORM SELF ASSESSMENT 13 REPORTING IMPLEMENTATION OF OWNERSHIP CHANGES THAT CAUSE CHANGES IN CONTROLLING SHAREHOLDERS OF INSURANCE AND REINSURANCE COMPANIES FORM: 13 FORM SELF ASSESSMENT REPORTING IMPLEMENTATION OF OWNERSHIP CHANGES THAT CAUSE CHANGES IN CONTROLLING SHAREHOLDERS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Number and date of
Financial Services Authority approval letter regarding the ownership change plan :
Contact person (name, phone, email) :
Substance of ownership change
Before Becoming
Shareholder Nominal (Rp) % Shareholder Nominal (Rp) % NO. LEGAL BASIS COMPLETENESS DESCRIPTION YES NO

Report submitted
using format 22
Appendix POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 77 paragraph (2)
POJK Number
67/POJK.05/2016
Copy of the deed of amendment
of the Company's Articles of Association containing ownership changes and shareholder composition, and accompanied by proof of approval, consent and/or letter
Article 77 paragraph (2)
letter a POJK
Number
67/POJK.05/2016
Deed No.: [.......]
Date: [.......]
Notary: [.......]
Approval/letter number

79 -
receipt notification from the competent authority. receipt notification Ministry of Law and Human Rights:
[.......]
Date: [.......]
Substance: [.......]

Deed of transfer of rights over
shares, in case there is transfer of rights over shares.
Article 77 paragraph (2)
letter b POJK
Number
67/POJK.05/2016
Deed No.: [.......]
Date: [.......]
Notary: [.......]
Substance: [.......]
Copy of proof of settlement
of paid-up capital in the form of cash deposits at one of the general banks, sharia general banks, or sharia business units of general banks legalized by the bank, in case there is increase in paid-up capital carried out in the form of cash.
Article 77 paragraph (2)
letter c POJK
Number
67/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: Rp [.......]
Copy of proof
of placement of paid-up capital at one of the general banks, sharia general banks, or sharia business units of general banks legalized by the bank, in case there is increase in paid-up capital carried out in the form of cash.
Article 77 paragraph (2)
letter c POJK
Number
67/POJK.05/2016
Account No.: [.......]
Bank Name: [.......]
Date received:
[.......]
Paid-up capital deposit nominal (original currency): [.......] Paid-up capital deposit nominal : Rp [.......]

80 -
Additional notes (if any):
We, the undersigned below, declare that:
1. The Self Assessment Form above has been filled out according to the actual
situation and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
81 -
FORM SELF ASSESSMENT 14 REPORTING IMPLEMENTATION OF OWNERSHIP CHANGES THAT DO NOT CAUSE CHANGES IN CONTROLLING SHAREHOLDERS OF INSURANCE AND REINSURANCE COMPANIES FORM: 14 FORM SELF ASSESSMENT REPORTING IMPLEMENTATION OF OWNERSHIP CHANGES THAT DO NOT CAUSE CHANGES IN CONTROLLING SHAREHOLDERS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Financial Services Authority approval letter number regarding the ownership change plan :
Financial Services Authority approval letter date regarding the ownership change plan :
Contact person (name, phone, email) :
Substance of ownership change
Before Becoming
Shareholder Nominal (Rp) % Shareholder Nominal (Rp) % NO. LEGAL BASIS COMPLETENESS DESCRIPTION YES NO

Report submitted
using format 22
Appendix POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 77 paragraph (2)
POJK Number
67/POJK.05/2016
Copy of the deed of amendment
of the Articles of Association
Pasal 77 ayat (2) huruf a POJK
No. Akta: [.......]

82 -
Company containing ownership changes and shareholder composition, and accompanied by proof of approval, proof of consent and/or proof of letter receipt notification from the competent authority. Number 67/POJK.05/2016 Date: [.......] Notary: [.......] No. Consent/letter receipt notification Ministry of Law and Human Rights:
[.......]
Date: [.......]
Substance: [.......]

Deed of transfer of rights
over shares, in case there is transfer of rights over shares.
Article 77 paragraph (2)
letter b POJK
Number
67/POJK.05/2016
Deed No.: [.......]
Date: [.......]
Notary: [.......]
Substance: [.......]
Copy of proof of settlement
of paid-up capital in the form of cash deposits at one of the general banks, sharia general banks, or sharia business units of general banks legalized by the bank, in case there is increase in paid-up capital carried out in the form of cash.
Article 77 paragraph (2)
letter c POJK
Number
67/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: Rp [.......]
Copy of proof
of placement of paid-up capital at one of the general banks, sharia general banks, or sharia business units of general banks legalized by the bank, in case there is increase in paid-up capital carried out in the form of cash.
Article 77 paragraph (2)
letter c POJK
Number
67/POJK.05/2016
Account No.: [.......]
Bank Name: [.......]

83 -
Date received:
[.......]
Paid-up capital deposit nominal (original currency): [.......] Paid-up capital deposit nominal: Rp [.......] Additional notes (if any):
We, the undersigned below, declare that:
1. The Self Assessment Form above has been filled out according to the actual
situation and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
84 -
FORM SELF ASSESSMENT 15 REPORTING CHANGE OF NAME OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 15 FORM SELF ASSESSMENT REPORTING CHANGE OF NAME OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name before change :
Company Name after change
:
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Brief description regarding background of name change :
NO. LEGAL BASIS
COMPLETENESS DESCRIPTION
YES NO

Report
submitted using format 23 Appendix POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 78 paragraph (2)
POJK Number
67/POJK.05/2016
Copy of the deed of amendment
of the Company's Articles of Association accompanied by proof of approval from the competent authority for Companies that are limited liability companies.
Article 78 paragraph (2)
POJK Number
67/POJK.05/2016
Deed No.: [.......]
Date: [.......]
Notary: [.......]
No. Kemenkumham
Approval:
[.......]
Date: [.......]
Substance: [......]

85 -
3. Copy of NPWP under
the new name of the Company.
Article 78 paragraph (2)
POJK Number
67/POJK.05/2016
Name on NPWP :
[.......]
NPWP No.: [.......]
Address: [.......]
Additional notes (if necessary):
We, the undersigned below, declare that:
1. The Self Assessment Form above has been filled out according to the actual
situation and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
86 -
FORM SELF ASSESSMENT 16 REPORTING CHANGE OF LOCATION OF HEAD OFFICE OF INSURANCE AND REINSURANCE COMPANIES FORM: 16 FORM SELF ASSESSMENT REPORTING CHANGE OF LOCATION OF HEAD OFFICE OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Date of relocation :
Data of change of location
Description Old New
Location
Office Address
City/District Name
Phone and Fax No.
NO. LEGAL BASIS
COMPLETENESS DESCRIPTION
YES NO

Report submitted
using format 24 Appendix
POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 78
paragraph (3)
POJK
Number
67/POJK.05
/2016
Copy of the deed of amendment of the articles of association
that is accompanied by proof of approval from the competent authority for Companies that are limited liability companies.
Article 78
paragraph (3) letter a
POJK
Number
67/POJK.05
/2016
Deed No.:
[......]
Date:
[......]
Notary:
[......]
Number
Kemenkumham:
[......]

87 -
Date:
[......]
Substance:
[......]

Copy of NPWP containing
the new location of the Company.
Article 78
paragraph (3) letter b
POJK
Number
67/POJK.05
/2016
NPWP: [......]
Name: [......]
Address:
[......]
Additional notes (if necessary):
We, the undersigned below, declare that:
1. The Self Assessment Form above has been filled out according to the actual
situation and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

88 -
FORM SELF ASSESSMENT 17 REPORTING REDUCTION OF PAID-UP CAPITAL OF INSURANCE AND REINSURANCE COMPANIES THAT ARE LIMITED LIABILITY COMPANIES FORM: 17 FORM SELF ASSESSMENT REPORT OF REDUCTION OF PAID-UP CAPITAL OF INSURANCE AND REINSURANCE COMPANIES THAT ARE LIMITED LIABILITY COMPANIES Company Name :
Report letter number :
Report letter date :
Brief background description of paid-up capital reduction :
Contact person (name, phone, email) :
Substance of paid-up capital reduction Before Becoming Shareholder Name Nominal (Rp) % Shareholder Name Nominal (Rp) % NO. LEGAL BASIS COMPLETENESS DESCRIPTION YES NO

Report submitted
using format 25
Appendix POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 78 paragraph
(5) POJK
Number
67/POJK.05/
2016
Report only for reduction of paid-up capital that does not cause changes in share composition.
Copy of the deed of amendment
of the Company's Articles of Association containing reduction of paid-up capital and shareholder composition
Article 78 paragraph
(5) POJK
Number
67/POJK.05/
2016
Deed No.: [......]
Date: [......]
Notary: [......]

89 -
and accompanied by proof of approval from the authority agency. Letter of approval number:
[......]
Date: [......]
Substance: [......]

Business Plan. Article 68 paragraph
(3) POJK
Number
73/POJK.05/
2016
Reduction plan has/not yet been included and is consistent with Business Plan year: [......] Background of capital reduction: [......]
Foreign ownership refers to
Government Regulations concerning foreign ownership in Companies.
Article 3 paragraph
(3) POJK
Number
67/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 4 and Article 6 of Government Regulation Number 14/2018)
Company equity
after reduction of paid-up capital is not less than:
a. Rp100,000,000,000.00
(one hundred billion rupiah) for Insurance Companies; and b. Rp200,000,000,000.00 (two hundred billion rupiah) for Reinsurance Companies.
Article 33 and
Article 34 POJK
Number
71/POJK.05/
2016
Reporting Period:
per [......]
Equity:
Rp[......]
Reduction of paid-up capital
does not cause failure to meet the financial health level of the Company.
Article 3 paragraph
(1) POJK
Solvency Ratio

90 -
of the Company.
Number
71/POJK.05/
2016 after capital reduction is done:
[......]
Reporting period:
[......]
Furthermore, other aspects can be described regarding financial health aspects [......] Additional notes (if necessary):
We, the undersigned below, declare that:
1. The Self Assessment Form above has been filled out according to the actual
situation and has been completed with documents as referred to in Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
91 -
FORM SELF ASSESSMENT 18 REPORTING INCREASE OF PAID-UP CAPITAL FOR INSURANCE AND REINSURANCE COMPANIES THAT ARE LIMITED LIABILITY COMPANIES FORM: 18 FORM SELF ASSESSMENT REPORTING INCREASE OF PAID-UP CAPITAL FOR INSURANCE AND REINSURANCE COMPANIES THAT ARE LIMITED LIABILITY COMPANIES Company Name :
Report letter number :
Report letter date :
Brief background description of increase in paid-up capital :
Contact person (name, phone, email) :
Form of increase in paid-up capital (for increases in paid-up capital that do not cause changes in share composition takeover, and/or addition of new shareholders) Cash capital deposit. Transfer of retained earnings into paid-up capital. Transfer of loans. Dividends in the form of shares distributed proportionally to all shareholders. Substance of increase in paid-up capital Before Becoming Shareholder Name Nominal (Rp) % Shareholder Name Nominal (Rp) % NO. LEGAL BASIS COMPLETENESS DESCRIPTION YES NO
1. Foreign ownership refers to
Government Regulations concerning foreign ownership in Companies.
Article 3 paragraph (3)
POJK Number
67/POJK.05/
2016
At the time of establishment of the Company, the following conditions are required:
a. direct participation of foreign parties in the Company is at most 80% (eighty percent) of paid-up capital; and b. Has Equity of at least 5 (five) times the amount of direct participation in Insurance Companies at the time of establishment. (Article 4 and Article 6 of Government Regulation Number 14/2018)
2. Total direct participation in
Companies for shareholders who are Indonesian legal entities who are not Financial Service Institutions that are under supervision of the Financial Services Authority, is at most equal to the equity of the shareholder.
Article 8 paragraph (3)
and paragraph (6)
POJK Number
67/POJK.05/
2016
List of shareholder equity:
1. PT [......] equity
amounting to Rp [......] per (date of last financial report)
2. Etc.
Based on the equity amounts above, PT [......] and PT [......] meet/do not meet the maximum participation limit. Completeness of Documents for Ownership Change Approval Application
3. Report submitted
using format
26 Appendix POJK
Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 78 paragraph
(7) POJK Number
67/POJK.05/
2016
4. Copy of the deed of amendment
of the Company's Articles of Association containing increase in paid-up capital and shareholder composition,
Article 78 paragraph
(7) letter a
POJK Number
67/POJK.05/
2016
Deed No.: [......]
Date: [......]
Notary: [......]
93 -
and accompanied by proof of letter receipt notification from the competent authority. Letter of receipt notification number: [......] Date: [......] Substance: [......]

Copy of proof
of capital deposit at one of the general banks, sharia general banks, or sharia business units of general banks in Indonesia and legalized by the receiving bank of the deposit, in case increase in paid-up capital is carried out in the form of cash.
Article 78 paragraph
(7) letter b
POJK Number
67/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:
Rp [......]
Financial statements of
insurance companies or reinsurance companies that have been audited by public accountants before increase in paid-up capital, in case increase in paid-up capital is carried out in the form of transfer of retained earnings, transfer of loans and/or stock dividends.
Article 78 paragraph
(7) letter b
POJK Number
67/POJK.05/
2016
In case increase in paid-up capital is carried out in the form of transfer of retained earnings:
1. Retained Earnings balance before
increase in paid-up capital: Rp [......]
2. Paid-up capital
before increase in paid-up capital: Rp [......] In case increase in paid-up capital is carried out in the form of transfer of loans:
1. Total liabilities before
increase in paid-up capital: Rp [......]
2. Paid-up capital
before increase in paid-up capital: Rp [......]
3. Total equity before
increase in paid-up capital: Rp [......]
4. Solvency ratio before
increase in paid-up capital: Rp [......]
In case increase in paid-up capital is carried out in the form of distribution of stock dividends:
1. Retained earnings balance before
increase in paid-up capital: Rp [......]
2. Paid-up capital
before increase in paid-up capital: Rp [......] Total equity before increase in paid-up capital: Rp [......]
7. Statement letter
from shareholders stating that the capital deposit does not come from loans, money laundering activities (money laundering) and financial crimes, in case increase in paid-up capital is carried out in the form of cash.
Article 78 paragraph
(7) letter c
POJK Number
67/POJK.05/
2016
Statement letter signed by shareholders as follows:
Mr./Ms. [......]
PT [......]
8. Copy of Tax Return (SPT) for the last
2 (two) years and other documents showing financial capability and source of funds
Article 78 paragraph
(7) letter d
POJK Number
67/POJK.05/
2016
Copy of SPT for:
Mr./Ms. [......]
1. SPT Period: Year
[......]
Taxable Income

95 -
of individual shareholders.
Tax:
Rp [......]
Asset list: [......]
Total assets Rp
[......]
Liability list
[......]
Total liabilities
Rp [......]

Etc.
Financial statements
of shareholders that have been audited by public accountants and/or the latest financial statements, in case shareholders are legal entities.
Article 78 paragraph
(7) letter e
POJK Number
67/POJK.05/
2016
Shareholder financial statements, as follows:
1. Shareholder name: [......]
Audited financial statement reporting period:
[......]
Last month financial statement reporting period:
[......]
Total equity:
[......]
2. Etc.
10. Business Plan. Article 68 paragraph
(3) POJK Number
73/POJK.05/
2016
Increase in capital has/not yet been included and is consistent with Business Plan year:
[......]
Background of capital increase:
[......]
Purpose of use of funds resulting from capital increase

96 -
deposited: [......]

Company Equity
after additional paid-in capital is not less than:
a. Rp100,000,000,000.00 (one hundred billion rupiah) for Insurance Companies; and b. Rp200,000,000,000.00 (two hundred billion rupiah) for Reinsurance Companies.
Article 33 and
Article 34 POJK
Number
71/POJK.05/
2016
Company Name: PT
[......]
Reporting Period: as of
[......]
Equity: Rp [......]
In the event that
the addition of paid-in capital constitutes the conversion of subordinated loans, such conversion does not cause failure to meet the internal solvency ratio target.
Article 24 POJK
Number
71/POJK.05/2016
Solvency ratio for period [......] amounting to [......] %. Projected solvability ratio for period [......] amounting to [......]%. Additional information (if necessary):
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs

97 -
Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
98 -
FORM SELF ASSESSMENT 19 REPORTING ON CHANGE OF STATUS OF INSURANCE AND REINSURANCE COMPANIES THAT ARE CLOSED LIMITED LIABILITY COMPANIES BECOMING OPEN LIMITED LIABILITY COMPANIES OR VICE VERSA FORM: 19 FORM SELF ASSESSMENT REPORTING ON CHANGE OF STATUS OF INSURANCE AND REINSURANCE COMPANIES THAT ARE CLOSED LIMITED LIABILITY COMPANIES BECOMING OPEN LIMITED LIABILITY COMPANIES OR VICE VERSA Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report submitted using format 27
Annex POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 78 paragraph
(8) POJK
Number
67/POJK.05/
2016
Copy of the deed of amendment of the articles of association containing the substance of the change of status of the Company from a closed company to an open company or vice versa.
Article 78 paragraph
(8) POJK
Number
67/POJK.05/
2016
Deed No.: [......]
Date: [......]
Notary: [......]
Copy of proof of approval from the competent authority regarding the change of status of the Company from a closed company to an open company or vice versa.
Article 78 paragraph
(8) POJK
Number
67/POJK.05/
2016
Approval letter No. from Kemenkumham:
[......]
Date: [......]
Additional information (if necessary):

99 -
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
100 -
FORM SELF ASSESSMENT 20 REPORTING ON CHANGE OF HEAD OFFICE ADDRESS FOR INSURANCE AND REINSURANCE COMPANIES FORM: 20 FORM SELF ASSESSMENT REPORTING ON CHANGE OF HEAD OFFICE ADDRESS FOR INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
Purpose and objective of change :
Change of head office address
Old address and phone number
New address and phone number
Effective date of change of head office address Address*):
Phone No.:
Address*):
Phone No.:
*) Address must be written completely, namely including the name of the Village/Sub-district, District, City/Regency, and Postal Code. NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

Report submitted using format 29
Annex POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 80 paragraph
(2) POJK
Number
67/POJK.05/
2016
Letter of confirmation from the relevant party stating at least the name and address of the Company.
Article 80 paragraph
(2) POJK
Number
67/POJK.05/
2016
Letter confirmation No.:
[......]
Date of letter confirmation:
[......]
Issuer of the letter confirmation:
[......]

101 -
Additional information (if necessary):
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
102 -
FORM SELF ASSESSMENT 21 REPORTING ON CHANGE OF OFFICE ADDRESS OUTSIDE THE HEAD OFFICE OF INSURANCE AND REINSURANCE COMPANIES THAT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FORM: 21 FORM SELF ASSESSMENT REPORTING ON CHANGE OF OFFICE ADDRESS OUTSIDE THE HEAD OFFICE OF INSURANCE AND REINSURANCE COMPANIES THAT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
Purpose and objective of change :
List of changes of office addresses outside the head office No. Office Name Address*) and Phone Number Old Record Number and Date Office Outside Head Office Address*) and Phone Number New Effective Date Change of Office Address 1. 2. Etc. *) Address must be written completely, namely including the name of the Village/Sub-district, District, City/Regency, and postal code. NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

Report submitted using format 29 Annex
POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 80 paragraph
(2) POJK
Number
67/POJK.05/
2016
Letter of confirmation from the relevant party stating at least the name and address of the Company.
Article 80 paragraph
(2) POJK
Number
67/POJK.05/
2016
Letter confirmation No.:
[......]
Date of letter confirmation:

103 -
[......]
Issuer of the letter confirmation:
[......]
Additional information (if necessary):
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
104 -
FORM SELF ASSESSMENT 22 REPORTING ON CHANGE OF OFFICE ADDRESS OUTSIDE THE HEAD OFFICE OF INSURANCE AND REINSURANCE COMPANIES THAT DO NOT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS FORM: 22 FORM SELF ASSESSMENT CHANGE OF OFFICE ADDRESS OUTSIDE THE HEAD OFFICE OF INSURANCE AND REINSURANCE COMPANIES THAT DO NOT HAVE THE AUTHORITY TO MAKE DECISIONS REGARDING ACCEPTANCE OR REJECTION OF UNDERWRITING AND/OR CLAIMS Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
Purpose and objective of change :
List of changes of office addresses outside the head office No. Office Name Address*) and Phone Number Old Record Number and Date Office Outside Head Office Address*) and Phone Number New Effective Date Change of Office Address 1. 2. Etc. *) Address must be written completely, namely including the name of the Village/Sub-district, District, City/Regency, and postal code. NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

Report submitted using format 29
Annex POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 80 paragraph
(2) POJK
Number
67/POJK.05/
2016
Letter of confirmation from the relevant party stating at least the name and address of the Company.
Article 80 paragraph
(2) POJK
Number
67/POJK.05/
2016
Letter confirmation No.: [......]
Date of letter confirmation: [......]
Issuer of the letter confirmation:
[......]

105 -
Additional information (if necessary):
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
106 -
FORM SELF ASSESSMENT 23 APPLICATION FOR APPROVAL OF PLANNED IMPLEMENTATION OF MERGER OR CONSOLIDATION OF INSURANCE AND REINSURANCE COMPANIES FORM: 23 FORM SELF ASSESSMENT APPLICATION FOR APPROVAL OF PLANNED IMPLEMENTATION OF MERGER OR CONSOLIDATION OF INSURANCE AND REINSURANCE COMPANIES Company Name to be implementing merger or consolidation :
Company Name after merger or consolidation :
Application letter number :
Date of application letter :
Contact person (name, phone, email) :
Brief description of background of merger or consolidation :
Merger or consolidation does not reduce rights of policyholders, insured parties, or participants. : Yes / No Financial condition of the resulting company after merger or consolidation meets the financial health standards. : Yes / No NO. Original NO. Becomes Name Shareholder Nominal (Rp) (%) Name Shareholder Nominal (Rp) (%)

PT [ ...... ] 1. PT [ ...... ]
Shareholder
Shareholder
Shareholder
Shareholder
Total
PT [ ...... ]
Shareholder
Shareholder
Total Total
Substance of merger or consolidation

107 -
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Application submitted using format 30
Annex POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 82
paragraph (3)
POJK
Number
67/POJK.
05/2016
Documents submitted by the Company applying for permission have complied with applicable laws and regulations:
a. draft minutes of the General Meeting of Shareholders which has approved the merger or consolidation;
Article 82
paragraph (3) letter a
POJK
Number
67/POJK.
05/2016 b. draft deed of merger or consolidation, which contains the following substance:
1) rights and obligations arising from all coverage of insurance objects conducted by the Company conducting the merger or consolidation, become the responsibility of the new resulting Company of the merger or consolidation.
2) the merger or consolidation does not reduce the rights of policyholders, insured parties, or participants.
3) the financial condition of the resulting Company of the merger or consolidation meets the financial health standards.
Article 82
paragraph (2) and paragraph
(3) letter b POJK
Number
67/POJK.
05/2016

108 -
c. plan list of ownership of the resulting Company of the merger or consolidation;
Article 82
paragraph (3) letter c
POJK
Number
67/POJK.
05/2016 d. data of shareholders or members other than PSP of the resulting Company of the merger or consolidation;
Article 82
paragraph (3) letter d
POJK
Number
67/POJK.
05/2016 e. latest audited financial statements of the Company conducting the merger or consolidation;
Article 82
paragraph (3) letter e
POJK
Number
67/POJK.
05/2016 f. proforma financial statements of the resulting Company of the merger or consolidation;
Article 82
paragraph (3) letter f
POJK
Number
67/POJK.
05/2016 g. work plan for the first 3 (three) years of the resulting Company of the merger or consolidation; and
Article 82
paragraph (3) letter g
POJK
Number
67/POJK.
05/2016 h. organizational structure of the resulting Company of the merger or consolidation.
Article 82
paragraph (3) letter h
POJK
Number
67/POJK.
05/2016

Merger or consolidation results in foreign ownership not exceeding the provisions of applicable laws and regulations.
Article 82
paragraph (3)
POJK
Number
67/POJK.
05/2016
Explain the share ownership structure and percentage of each share up to the ultimate shareholder.

109 -
Latest Financial Statements and Proforma Financial Statements Resulting from Merger or Consolidation

Financial condition of the resulting Company of the merger or consolidation continues to meet the provisions regarding the financial health of insurance companies:
a. RBC ratio; Article 82 paragraph (3) letter e and letter f POJK Number 67/POJK. 05/2016 a. RBC achievement ratio for the last 3 (three) quarters of the Company to be conducting the merger or consolidation. b. RBC achievement ratio of the resulting Company of the merger. b. investment balance ratio; Article 82 paragraph (3) letter e and letter f POJK Number 67/POJK. 05/2016 a. Achievement ratio of the investment balance ratio for the last 3 (three) quarters of the Company to be conducting the merger or consolidation. b. Achievement ratio of the investment balance ratio of the resulting Company of the merger or consolidation.
c. liquidity ratio; and Article 82
paragraph (3) letter e and letter f POJK Number 67/POJK. 05/2016 a. Achievement ratio of Liquidity for the last 3 (three) quarters of the Company to be conducting the merger. b. Achievement ratio of Liquidity of the resulting Company of the merger

110 -
or consolidation. d. own funds amount. Article 82 paragraph (3) letter e and letter f POJK Number 67/POJK. 05/2016 a. Own funds for the last quarter of the Company to be conducting the merger or consolidation. b. Own funds of the resulting Company of the merger or consolidation. Changes in Board of Directors and Board of Commissioners

Merger or consolidation results in changes to the composition of members of the Board of Directors, members of the Board of Commissioners, and/or PSP of the Company.
Description regarding the results of the suitability and propriety assessment for members of the Board of Directors, members of the Board of Commissioners, and/or PSP of the resulting Company of the merger or consolidation.
Application for approval of the planned implementation of Merger or Consolidation is submitted simultaneously with the application for suitability and propriety assessment for prospective members of the Board of Directors, members of the Board of Commissioners, members of DPS, and/or PSP of the Company.
If the intended merger or consolidation results in changes to members of the Board of Directors, members of the Board of Commissioners, and/or PSP of the Company. Additional information (if necessary):
We, who sign below, declare that:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are true and identical to the printed documents.

111 -
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:

Filling method: click twice on the box, then select "Checked".
This Self Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

112 -
FORM SELF ASSESSMENT 24 REPORTING ON EXECUTION OF GMS WHICH APPROVED MERGER OF INSURANCE AND REINSURANCE COMPANIES FORM: 24 FORM SELF ASSESSMENT REPORTING ON EXECUTION OF GMS WHICH APPROVED MERGER OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
Financial Services Authority approval letter number :
Date of Financial Services Authority approval letter :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report submitted using format 31
Annex POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 84 paragraph (2)
POJK Number
67/POJK.05/2016
Copy of the minutes of the GMS approving the Merger.
Article 84 paragraph (2)
letter a POJK
Number
67/POJK.05/2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]
Copy of the Deed of Merger.
Article 84 paragraph (2)
letter b POJK
Number
67/POJK.05/2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]
Document stating that the Company has no tax debts from the competent authority.
Article 84 paragraph (2)
letter c POJK
Number
67/POJK.05/2016
No.: [......]

113 -
Date: [......]
Signed by: [......]
Additional information (if necessary):
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
114 -
FORM SELF ASSESSMENT 25 REPORTING ON EXECUTION OF MERGER OF INSURANCE AND REINSURANCE COMPANIES FORM: 25 FORM SELF ASSESSMENT REPORTING ON EXECUTION OF MERGER OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
Financial Services Authority approval letter number :
Date of Financial Services Authority approval letter :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report submitted to the Financial Services Authority and signed by the Board of Directors.
Article 85 POJK
Number
67/POJK.05/2016
Copy of the deed of amendment of the articles of association resulting from the Merger.
Article 85 POJK
Number
67/POJK.05/2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]
Copy of proof of approval from the competent authority.
Article 85 POJK
Number
67/POJK.05/2016
Kemenkumham approval proof No.:
[......]
Date: [......]
Additional information (if necessary):

115 -
We, who sign below, 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs
of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
116 -
FORM SELF ASSESSMENT 26 REPORTING ON EXECUTION OF GMS WHICH APPROVED CONSOLIDATION OF INSURANCE AND REINSURANCE COMPANIES FORM: 26 FORM SELF ASSESSMENT REPORTING ON EXECUTION OF GMS WHICH APPROVED CONSOLIDATION OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Date of report letter :
Contact person (name, phone, email) :
Financial Services Authority approval letter number :
Date of Financial Services Authority approval letter :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS YES NO NOTES

Report submitted using format
33 Annex POJK
Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 86 paragraph (2) POJK
Number
67/POJK.05/2016
Copy of the minutes of the GMS approving the consolidation.
Article 86 paragraph (2) letter
a POJK Number
67/POJK.05/2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]
Copy of the deed of consolidation.
Article 86 paragraph (2) letter
b POJK Number
67/POJK.05/2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]

117 -
4. Document stating that the Company has no tax debts from the competent authority.
Article 86 paragraph (2) letter c
POJK Number
67/POJK.05/2016
Number: [......]
Date: [......]
Signed by: [......]
Additional notes (if necessary):
We, who sign below, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are correct and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
118 -
FORM SELF ASSESSMENT 27 REPORTING ON THE IMPLEMENTATION OF MERGER OF INSURANCE AND REINSURANCE COMPANIES FORM: 27 FORM SELF ASSESSMENT REPORTING ON THE IMPLEMENTATION OF MERGER OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Approval letter number from the Financial Services Authority :
Approval letter date from the Financial Services Authority :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

Report submitted
to the Financial Services
Authority and signed by the
Board of Directors.
Article 87 POJK Number
67/POJK.05/2016
Copy of the deed of amendment
of the articles of association resulting from the Merger.
Article 87 POJK Number
67/POJK.05/2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]
Copy of the approval proof from the
competent authority.
Article 87 POJK Number
67/POJK.05/2016
Ministry of Law and Human Rights approval certificate number:
[......]
Date: [......]
Additional notes (if necessary):

119 -
We, who sign below, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are correct and identical to their printed versions.
Jakarta, [………………]
Board of Directors [......] signature [Full Name] Note:
1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
120 -
B. MANAGEMENT CATEGORY
FORM SELF ASSESSMENT 28 REPORTING ON CHANGES IN MEMBERS OF THE BOARD OF DIRECTORS AND/OR MEMBERS OF THE BOARD OF COMMISSIONERS OF INSURANCE AND REINSURANCE COMPANIES FORM: 28 FORM SELF ASSESSMENT REPORTING ON CHANGES IN MEMBERS OF THE BOARD OF DIRECTORS AND/OR MEMBERS OF THE BOARD OF COMMISSIONERS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

Report submitted using format 28
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 79 paragraph
(2) POJK
Number
67/POJK.05/
2016
Copy of the minutes of the general meeting of members for Companies
in the form of a cooperative legal entity.
Article 79 paragraph
(2) letter b
POJK Number
67/POJK.05/
2016
Number: [......]
Date:
[......]
Notary Name:
[......]
Copy of the minutes of the General Meeting of Shareholders
for Companies in the form of a limited liability company.
Article 79 paragraph
(2) letter b
POJK Number
67/POJK.05/
2016
Number:
[......]
Date:
[......]
Notary Name:
[......]
Location of Notary:
[......]

121 -
4. Proof of recording changes
in Board of Directors members and/or Board of Commissioners members in the shareholders' list. Ministry of Law and Human Rights receipt and recording certificate number:
[......]
Date: [......]
Additional notes (if necessary):
We, who sign below, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are correct and
identical to their printed versions.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
122 -
FORM SELF ASSESSMENT 29 REPORTING ON PLANS TO EMPLOY FOREIGN WORKERS OF INSURANCE AND REINSURANCE COMPANIES FORM: 29 FORM SELF ASSESSMENT REPORTING ON PLANS TO EMPLOY FOREIGN WORKERS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Name of foreign worker :
Name of accompanying Indonesian worker :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES
Requirements for Use of Foreign Workers (FW)

Foreign workers are employed as:
a. experts with a job level one level below the Board of Directors; b. actuaries; or
c. consultants.
Article 50 paragraph
(2) POJK Number
67/POJK.05/
2016
Job title of the foreign worker employed [......]
Foreign workers handle functions:
a. underwriting; b. actuarial;
c. marketing; and/or
d. information systems.
Article 50 paragraph
(3) POJK Number
67/POJK.05/
2016
Description of work at the position to be occupied by the foreign worker:
[......]
Foreign workers as
experts/consultants meet the provisions:
a. employed to carry out specific projects or programs related to operational activities in the insurance field (for foreign workers as Consultants);
Article 50 paragraph
(5) letter a
POJK Number
67/POJK.05/
2016
Project or program related to operational activities in the insurance field [......]

123 -
Consultant); b. employed for a maximum period of 5 (five) years (for foreign workers as experts) or a period 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 50 paragraph
paragraph (4), and paragraph (5) POJK Number 67/POJK.05/ 2016 Duration of use of foreign workers or project duration [......]
c. accompanied by Indonesian workers in the context of knowledge transfer,
skills, and technology.
Article 50 paragraph
paragraph (4), and paragraph (5) POJK Number 67/POJK.05/ 2016
Letter of
appointment of accompanying
Indonesian workers and accompanied by job titles and main duties and functions of the Indonesian workers [......]
Explanation
of language that will be used by foreign workers and accompanying Indonesian workers in communication accompanied by supporting evidence [......]
124 -
d. possess expertise appropriate to the scope of work that will be their responsibility; and
Article 50 paragraph
paragraph (6) letter a
POJK Number
67/POJK.05/
2016 e. foreign workers occupy positions that cannot yet be filled by Indonesian workers.
Article 50 paragraph
paragraph (6) letter b
POJK Number
67/POJK.05/
2016
Written statement letter from the Board of Directors regarding reasons for using foreign workers [......]

Meet the provisions of legislation in the field
of manpower.
Article 50 paragraph
paragraph (6) letter c
POJK Number
67/POJK.05/
2016

Statement letter
of foreign workers to transfer their expertise to accompanying Indonesian workers (Article 36 Permenaker 16/2015) Completeness of Documents for Application Plan to Employ Foreign Workers

Report submitted using format 14
Appendix of POJK Number 67/POJK.05/2016 and
signed by the Board of Directors.
Article 51 paragraph
(2) POJK Number
67/POJK.05/
2016
Curriculum vitae of the foreign worker
employed.
Article 51 paragraph
(3) letter a
POJK Number
67/POJK.05/
2016
Has been completed with description of their work along with photocopy of passport and recent colored photo size 4x6 cm.

125 -
7. Photocopy of documents reflecting the field
of expertise of the foreign worker.
Article 50 paragraph
(6) letter a and
51 paragraph (3) letter a POJK
Number
67/POJK.05/
2016
Number:
[......]
Date:
[......]
8. Annual education and training program plan
while the aforementioned foreign worker is employed.
Article 51 paragraph
(3) letter b
POJK Number
67/POJK.05/
2016
Description regarding the plan for education and training while the foreign worker is employed which describes the process of knowledge transfer, skills and technology accompanied by expected results and time implementation.
9. Placement plan and scope of work that becomes
the responsibility of the foreign worker.
Article 51 paragraph
(3) letter c
POJK Number
67/POJK.05/
2016
Description
regarding the plan for placement and scope of work that becomes responsibility of foreign workers [......]
List of the number of
foreign workers working at the
Company accompanied by details of job titles and descriptions of their duties. [......]
Organization
structure document of the
Company
[......]
Additional notes (if necessary):
We, who sign below, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are correct and identical to their printed versions.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
127 -
FORM SELF ASSESSMENT 30 REPORTING ON APPOINTMENT OF FOREIGN WORKERS OF INSURANCE AND REINSURANCE COMPANIES FORM: 30 FORM SELF ASSESSMENT REPORTING ON APPOINTMENT OF FOREIGN WORKERS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Name of foreign worker :
Job title of foreign worker : expert with a job level one level below the Board of Directors/actuarial/consultant Functions handled by foreign worker : underwriting/actuarial/ marketing/information systems Duration of use of foreign worker :
Name of accompanying Indonesian worker :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

Photocopy of proof of appointment
of foreign worker.
Article 52 paragraph
(2) letter a
POJK Number
67/POJK.05/
2016
Number: [......]
Date: [......]
Photocopy of residence permit letter. Article 52 paragraph
(2) letter b
POJK Number
67/POJK.05/
2016
Number: [......]
Date: [......]
Photocopy of letter of permission
to use foreign labor.
Article 52 paragraph
(2) letter c
POJK Number
67/POJK.05/
2016
Number: [......]
Date: [......]
Photocopy of Taxpayer Identification Number (NPWP). Article 52 paragraph
(2) letter d
POJK Number
67/POJK.05/
2016
Number: [......]

128 -
Additional notes (if necessary):
We, who sign below, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are correct and
identical to their printed versions.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
129 -
FORM SELF ASSESSMENT 31 REPORTING ON TERMINATION OF FOREIGN WORKERS OF INSURANCE AND REINSURANCE COMPANIES FORM: 31 FORM SELF ASSESSMENT REPORTING ON TERMINATION OF FOREIGN WORKERS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Name of foreign worker :
DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES
Report submitted by the Board of Directors of the Company to the Financial Services Authority and has been accompanied by reasons for termination.
Article 52
paragraph (3)
POJK Number
67/POJK.05
/2016
Additional notes (if necessary):
We, who sign below, declare that:

The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are correct and identical to their printed versions.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name]

130 -
Note:

Filling method: click twice on the box, then select "Checked"
This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

131 -
FORM SELF ASSESSMENT 32 REPORTING ON APPOINTMENT OF EXPERTS OF INSURANCE AND REINSURANCE COMPANIES FORM: 32 FORM SELF ASSESSMENT REPORTING ON APPOINTMENT OF EXPERTS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Name of expert :
Professional degree of expert :
Type and line of business of expert :
Placement of expert : head office / branch office*) *) If the expert is placed at a branch office, please also describe the name and address of the branch office in question. NO DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

Requirements for Use of Experts:
a. the expert possesses a certificate of expertise for general insurance or life insurance with the highest level from the Professional Certification Body in the insurance field.
Article 55, Article
56, and Article
57 each paragraph (2) letter a POJK Number 67/POJK.05/ 2016 Certificate number:
[......]
Date of certificate:
[......]
Body issuing the certificate:
[......] b. the expert possesses work experience in the field of risk management according to the line of business (general insurance/life insurance/reinsurance) for at least 3 (three) years.
Article 55, Article
56, and Article
57 each paragraph (2) letter b POJK Number 67/POJK.05/ 2016 Company:
[......]
Position:
[......]
Period: [......]

12 -
Company:
[......]
Position [......]
Period:.
[......]
c. the expert is not currently subject to sanctions
from their professional association.
Article 55, Article
56, and Article
57 each paragraph (2) letter c POJK Number 67/POJK.05/ 2016 Letter number:
[......]
Date of letter:
[......]
Body issuing the letter: [......]

Requirements for Adjustment of Experts According to Type and Line of Business
(to be filled if the reported appointment is an adjustment of Experts according type and line of business):
a. the expert possesses a certificate of expertise for general insurance or life insurance with a level at least 1 level below the highest qualification from the Professional Certification Body in the insurance field.
Article 55, Article
56, and Article
57 each paragraph (4) letter a POJK Number 67/POJK.05/ 2016 Certificate number:
[......]
Date of certificate:
[......]
Body issuing the certificate:
[......] b. the expert possesses a certificate of expertise according to the line of business conducted from the Professional Certification Body in the field of insurance.
Article 55, Article
56, and Article
57 each paragraph (4) letter b POJK Number 67/POJK.05/ 2016 Certificate number:
[......]
Date of certificate:
[......]
Body issuing the certificate:
[......]
c. the expert possesses work experience in the field of risk management
for at least 3 (three)
Article 55, Article
56, and Article
57 each paragraph (4)
Company:
[......]
Position:

133 -
years. letter c POJK
Number
67/POJK.05/
2016
[......]
Period: [......] d. the expert is not currently subject to sanctions from their professional association.
Article 55 paragraph
(4) letter d
POJK Number
67/POJK.05/
2016
Letter number:
[......]
Date of letter:
[......]
Body issuing the letter: [......]

Requirements for Use of Experts at Branch Offices that Have Authority to Make Decisions Regarding Acceptance or Rejection of Coverage and/or Claims
(to be filled if the reported appointment is an appointment of Experts at Branch Offices):
a. the expert possesses a certificate of expertise according to the scope of business with a level at least 1 level below the highest qualification from the Professional Certification Body in the field of insurance;
Article 58 paragraph
(2) letter a
POJK Number
67/POJK.05/
2016
Certificate number:
[......]
Date of certificate:
[......]
Body issuing the certificate:
[......] b. the expert possesses work experience in the field of insurance risk management for at least 2 (two) years; and
Article 58 paragraph
(2) letter b
POJK Number
67/POJK.05/
2016
Company:
[......]
Position:
[......]
Period: [......]
c. the expert is not currently subject to sanctions
from their professional association.
Article 58 paragraph
(2) letter c
POJK Number
67/POJK.05/
2016
Letter number:
[......]
Date: [......]
Body issuing the letter:
[......]

134 -
4. Administrative Requirements for Appointment of Experts
a. Report submitted using format 15
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 62 paragraph
(2) POJK Number
67/POJK.05/
2016 b. photocopy of valid ID card or passport;
Article 62 paragraph
(2) letter b
POJK Number
67/POJK.05/
2016
ID Card Number:
[......]
c. curriculum vitae
accompanied by a recent colored photo size 4 x 6 cm;
Article 62 paragraph
(2) letter c
POJK Number
67/POJK.05/
2016
Has been completed with description of their work. d. Board of Directors decision letter regarding the appointment of Experts. Number: [......] Date: [......] Additional notes (if necessary):
We, who sign below, declare that:
1. The Self Assessment Form above has been filled out according to the actual conditions and has been completed with documents as referred to in the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are correct and
identical to their printed versions Jakarta, [………………] Board of Directors [………………] signature [Full Name] Note:
1. Filling method: click twice on the box, then select "Checked".
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
135 -
FORM SELF ASSESSMENT 33 REPORTING ON APPOINTMENT OF ACTUARIES AND/OR INTERNAL AUDITORS OF INSURANCE AND REINSURANCE COMPANIES FORM: 33 FORM SELF ASSESSMENT REPORTING ON APPOINTMENT OF COMPANY ACTUARIES, ACTUARIES ACCORDING TO TYPE AND LINE OF BUSINESS AND/OR INTERNAL AUDITORS OF INSURANCE AND REINSURANCE COMPANIES Company Name :
Name of company actuary/actuary according to type and line of business/internal auditor :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Degree of company actuary/actuary according to type and line of business /internal auditor :
Type and line of business of actuary :
NO DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO REQUIREMENTS

Requirements for Use of Company Actuary (Appointed Actuary)
(to be filled if the reported appointment is the appointment of Company Actuary) The company actuary has obtained approval from the Financial Services Authority to become a Company Actuary.
Article 2 POJK
Number
27/POJK.03/
2016
Decision Number
Financial Services
Authority:
[......]
Date of Decision
Financial Services
Authority:
[......]
Requirements for Adjustment of Actuaries According to Type and Line of Business
(to be filled if the reported appointment is Adjustment of Actuaries According to Type and Line of Business) a. photocopy of expertise certificate from the Professional Certification Body;
Article 62 paragraph
(2) letter a
POJK Number
67/POJK.05/
2016
Certificate number:
[......]
Date

136 -
certificate:
[......]
Body issuing the certificate:
[......] b. photocopy of valid ID card;
Article 62 paragraph
(2) letter b
POJK Number
67/POJK.05/
2016
ID Card Number:
[......]
c. curriculum vitae
accompanied by the latest colored photo size 4 x 6 cm;
Article 62 paragraph
(2) letter c
POJK Number
67/POJK.05/
2016
Has been completed with description of their work. d. letter of confirmation from the relevant professional association that they are not currently subject to sanctions;
Article 62 paragraph
(2) letter d
POJK Number
67/POJK.05/
2016
Letter Number
[......]
Date of Letter
[......]

Requirements for Use of Internal Auditors
(to be filled if what is being reported is the appointment of Internal Auditor) The Internal Auditor has obtained approval from the Financial Services Authority.
Article 2 POJK
Number
27/POJK.03/
2016
Decision Number
Financial Services
Authority:
[......]
Date of Decision
Financial Services
Authority:
[......]
Administrative Requirements for Appointment of Actuaries and/or Internal Auditors
a. report on the appointment of Company Actuary, actuary according to type and line of business and/or internal auditor submitted using format 15
Appendix of POJK Number 67/POJK.05/2016 and
signed by the Board of Directors.
62 paragraph (2)
POJK Number
67/POJK.05/
2016 b. Board of Directors decision letter regarding the appointment Number: [......]

137 -
actuaries of the Company, actuaries according to type and business line and/or internal auditors. Date: [......] Additional information (if necessary):
We, the undersigned, declare that:
1. The aforementioned Self Assessment Form 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to their printed versions.
Jakarta, [………………]
Board of Directors [………………] signature [Clear Name] Note:
1. Filling method: click twice on the box, then select “Checked”.
2. This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
138 -
FORM SELF ASSESSMENT 34 REPORTING ON THE DISMISSAL OF EXPERTS, ACTUARIES AND/OR INTERNAL AUDITORS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES FORM: 34 FORM SELF ASSESSMENT REPORTING ON THE DISMISSAL OF EXPERTS, ACTUARIES, AND/OR INTERNAL AUDITORS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES Company Name :
Report letter number :
Report letter date :
Contact person (name, phone, email) :
Name of expert, actuary, and/or internal auditor :
Professional title :
Type and business line of the expert (for experts) :
Placement : headquarters / office outside headquarters Reason for dismissal of expert, actuary, and/or internal auditor :
LEGAL BASIS DESCRIPTION
COMPLETENESS
YES NO NOTES
Report submitted using format 16 Attachment to POJK Number 67/POJK.05/2016 and signed by the Board of Directors.
Article 62 paragraph (3)
POJK Number
67/POJK.05/
2016
Additional information (if necessary):
We, the undersigned, declare that:

The aforementioned Self Assessment Form 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 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are true and identical to their printed versions.

139 -
This copy is consistent with the original Legal Director 1 Legal Department signed Yuliana Jakarta, [………………] Board of Directors [………………] signature [Clear Name] Note:

Filling method: click twice on the box, then select “Checked”
This Self Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Affairs of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
Established in Jakarta on May 9, 2018 CHIEF EXECUTIVE OFFICER OF SUPERVISOR OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 10 /SEOJK.05/2018 CONCERNING ELECTRONIC APPLICATION FOR LICENSING, APPROVAL AND REPORTING FOR INSURANCE COMPANIES, SHARIA INSURANCE COMPANIES, REINSURANCE COMPANIES AND SHARIA REINSURANCE COMPANIES

1 -
TABLE OF CONTENTS OF APPENDIX
PART A: INSTITUTIONAL CATEGORY
No Description Application Page

Self Assessment
Form 1
Application for new establishment business license Sharia Insurance Company and Sharia Reinsurance Company 5
Self Assessment
Form 2
Application for business license conversion from Insurance Company to Sharia Insurance Company or conversion from Reinsurance Company to Sharia Reinsurance Company 31
Self Assessment
Form 3
Application for business license separation of Sharia units from Insurance Company or Reinsurance Company carried out by establishing Sharia Insurance Company or Sharia Reinsurance Company 53
Self Assessment
Form 4
Application for disbursement of guarantee funds in the context of cancellation of business license application Sharia Insurance Company or Sharia Reinsurance Company 76
Self Assessment
Form 5
Reporting receipt of transfer of membership portfolio in Sharia Unit 78
Self Assessment
Form 6
Reporting implementation of business activities Sharia Insurance Company and Sharia Reinsurance Company 80
Self Assessment
Form 7
Reporting determination of controller of Sharia Insurance Company and Sharia Reinsurance Company 82
Self Assessment
Form 8
Application for Approval to cease being controller of Sharia Insurance Company and Sharia Reinsurance Company 84
Self Assessment
Form 9
Reporting change of controller of Sharia Insurance Company and Sharia Reinsurance Company 86
Self Assessment
Form 10
Reporting opening of office outside headquarters that has authority to make decisions regarding acceptance or rejection of coverage and/or decisions regarding acceptance or rejection of claims of Sharia Insurance Company and Sharia Reinsurance Company 88
Self Assessment
Form 11
Reporting opening of office outside headquarters that does not have authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Company and Sharia Reinsurance Company 91

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No Description Application Page Insurance Company and Sharia Reinsurance Company

Self Assessment
Form 12
Reporting closure of office outside headquarters that has authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Company and Sharia Reinsurance Company 93
Self Assessment
Form 13
Reporting closure of office outside headquarters that does not have authority to make decisions regarding acceptance or rejection of coverage and/or claims of Sharia Insurance Company and Sharia Reinsurance Company 95
Self Assessment
Form 14
Application for Approval of change of ownership causing change of controlling shareholder of Sharia Insurance Company and Sharia Reinsurance Company 113
Self Assessment
Form 15
Application for Approval of change of ownership that does not cause change of controlling shareholder of Sharia Insurance Company and Sharia Reinsurance Company 128
Self Assessment
Form 16
Reporting implementation of change of ownership of Sharia Insurance Company and Sharia Reinsurance Company causing change of controlling shareholder 131
Self Assessment
Form 17
Reporting implementation of change of ownership of Sharia Insurance Company and Sharia Reinsurance Company that does not cause change of controlling shareholder 134
Self Assessment
Form 18
Reporting name change of Sharia Insurance Company and Sharia Reinsurance Company 136
Self Assessment
Form 19
Reporting change of domicile of headquarters office of Sharia Insurance Company and Sharia Reinsurance Company 138
Self Assessment
Form 20
Reporting reduction of paid-up capital for Sharia Insurance Company and Sharia Reinsurance Company in the form of limited liability company 141
Self Assessment
Form 21
Reporting increase of paid-up capital Sharia Insurance Company and Sharia Reinsurance Company in the form of limited liability company 149

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No Description Application Page

Self Assessment
Form 22
Reporting change of status of Sharia Insurance Company and Sharia Reinsurance Company in the form of closed limited liability company to open limited liability company or vice versa 151
Self Assessment
Form 23
Reporting change of address of headquarters office of Sharia Insurance Company and Sharia Reinsurance Company 153
Self Assessment
Form 24
Reporting change of address of office outside headquarters for Sharia Insurance Company and Sharia Reinsurance Company that has authority to make decisions regarding acceptance or rejection of coverage and/or and claims 155
Self Assessment
Form 25
Reporting change of address of office outside headquarters for Sharia Insurance Company and Sharia Reinsurance Company that does not have authority to make decisions regarding acceptance or rejection of coverage and/or and claims 157
Self Assessment
Form 26
Application for approval of plan for implementation of merger or consolidation of Sharia Insurance Company and Sharia Reinsurance Company 163
Self Assessment
Form 27
Reporting Implementation of GMS That Approved Merger of Sharia Insurance Company And Sharia Reinsurance Company 165
Self Assessment
Form 28
Reporting implementation of merger of Sharia Insurance Company and Sharia Reinsurance Company 167
Self Assessment
Form 29
Reporting Implementation of GMS that approved consolidation of Sharia Insurance Company and Sharia Reinsurance Company 169
Self Assessment
Form 30
Reporting implementation of consolidation of Sharia Company and Sharia Reinsurance Company BAGIAN B : MANAGEMENT CATEGORY No Description Application Page
Self Assessment
Form 31
Reporting Change of members of the Board of Directors, Members of the Board of Commissioners and/or Members of DPS Sharia Insurance Company And Sharia Reinsurance Company 171

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No Description Application Page

Self Assessment
Form 32
Reporting plan to employ foreign workers of Sharia Insurance Company and Sharia Reinsurance Company 173
Self Assessment
Form 33
Reporting appointment of foreign workers Sharia Insurance Company and Sharia Reinsurance Company 179
Self Assessment
Form 34
Reporting dismissal of foreign workers for Sharia Insurance Company and Sharia Reinsurance Company 181
Self Assessment
Form 35
Reporting appointment of experts of Sharia Insurance Company and Sharia Reinsurance Company 183
Self Assessment
Form 36
Reporting appointment of actuaries and/or internal auditors of Sharia Insurance Company and Sharia Reinsurance Company 187
Self Assessment
Form 37
Reporting dismissal of experts, actuaries, and/or internal auditors of Sharia Insurance Company or Sharia Reinsurance Company 190

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PART A : INSTITUTIONAL CATEGORY
SELF ASSESSMENT FORM 1 APPLICATION FOR NEW ESTABLISHMENT BUSINESS LICENSE SHARIA INSURANCE COMPANY AND REINSURANCE COMPANY FORM: 1 FORM SELF ASSESSMENT APPLICATION FOR NEW ESTABLISHMENT BUSINESS LICENSE SHARIA INSURANCE COMPANY AND SHARIA REINSURANCE COMPANY Company Name :
Number of application letter for business license :
Date of application letter for business license :
Contact person (name, phone, email) :
Brief description of background of business license application :
Company Description :
(describe company history)
[......]
No. Name of Shareholder Nominal (Rp) (%) Controlling/Non- Controlling 1 2 3 Total Company Group Structure Chart:
(up to ultimate controller)
......
Composition of Board of Directors, Board of Commissioners, DPS, experts, actuaries, and internal auditors of the company:
No. Position Name
Brief
Description
Responsibility
Information
Regarding
Concurrent
Positions
Nationality and Domicile
Type of Certifica te in field of risk management (if any)

Director

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Main

Director
Director
Commissioner
Main
Commissioner
Independent
Commissioner
Sharia
Supervisory Board
Expert
(including expert per business line, if any)
Company Actuary
Internal Auditor
Etc
(please elaborate also if the Company plans to use Foreign Workers) NO LEGAL BASIS DESCRIPTION COMPLETENESS YES NO NOTES
Application submitted
using format 2
Attachment to POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 13
paragraph (1)
POJK Number
67/POJK.05
/2016
Deed of Establishment
Copy of deed of establishment
of limited liability company or cooperative including copy of deed of amendment of articles of association (if any) accompanied by copy of proof of approval, and/or copy of proof of notification receipt from the competent authority. The deed of establishment
Article 10
paragraph (2) letter a
POJK Number
67/POJK.05
/2016
Data of company establishment:
number and date of deed of establishment:
[......]
Number and date of proof of approval from authority

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contains information among others:
a. name and place of domicile; b. purpose and objectives as well as business activities;
c. capital;
d. ownership; and e. authority, responsibility, and term of office of members of the Board of Directors and members of the Board of Commissioners. competent authority:
[......]
Company
Name:
[......]
Place of domicile:
[......]
Purpose and objectives as well as business activities:
[......]
Amount of paid- up capital: [......]
Ownership data:
[......]
Authority, responsibility, and term of office of members of board of directors and members of board of commissioners:
[......]
Data of all changes of articles of association of the company (if any):

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

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[......]
Substance of amendment of articles of association: [......]

Etc.
Organizational Structure
Organizational structure that
illustrates clearly:
a. separation of functions of risk management, function of financial management, and service function. b. existence of work units that handle functions:
1) underwriting;
2) actuarial;
3) claim administration
settlement;
4) marketing;
5) finance including
investment management;
6) risk management;
7) internal audit;
8) administration and
accounting;
9) compliance;
10) anti money laundering
and prevention of terrorism financing; and
11) service and
complaint resolution.
Article 10
paragraph (2) letter b jo.
Article 48
paragraph (1) and paragraph (2) POJK Number 67/POJK.05 /2016 Proven by attaching organizational structure chart that contains all functions thereof.
4. Documents containing
description of duties, authority, responsibility, and procedures of work in writing, which are established by the Board of Directors.
Article 10
paragraph (2) letter b jo.
Article 48
paragraph (3)
POJK Number
67/POJK.05
/2016
Proven by attaching
Standard Operating
Procedure (SOP):
1. SOP No.:
[......]
Title of SOP:

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[......]
Effective date of implementation of SOP: [......] Signed by: [......]

Etc.
Expertise certification in the field of
risk management from Professional Certification Institution in the field of risk management for members of the Board of Directors, members of the Board of Commissioners, and officials 1 (one) level below the Board of Directors.
Article 49
paragraph (1)
POJK Number
67/POJK.05
/2016
1. Name: [......]
Position:
[......]
Type of certification:
[......]
Institution issuing the certificate:
[......]
Certificate number:
[......]
Date of certificate:
[......]
2. Etc.
Paid-Up Capital
6. Copy of proof of settlement
of paid-up capital in the form of cash deposit by Shareholders to the Company and legalized with wet stamp by general bank sharia or sharia business unit of general bank in Indonesia.
Article 10
paragraph (2) letter c
POJK Number
67/POJK.05
/2016
Transaction date: [.......]
Depositing bank:
[.......]
Name of depositor:
[.......]
Receiving bank:
[.......]

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Name of recipient:
[.......]
Nominal amount of capital deposit (original currency): [.......] Nominal amount of capital deposit: Rp [.......]

Copy of proof of placement
of minimum paid-up capital in the form of time deposit and/or checking account in the name of the Company at one of the general sharia banks or sharia business unit of general bank in Indonesia and legalized by the receiving bank which remains valid during the process of business license application.
Article 10
paragraph (2) letter c
POJK Number
67/POJK.05
/2016
Account number:
[.......]
Bank name:
[.......]
Date received:
[.......]
Nominal amount of capital deposit (original currency): [.......] Nominal amount of capital deposit: Rp [.......] Guarantee Funds
Initial report of guarantee funds Article 10
paragraph (2) letter d
POJK Number
67/POJK.05
/2016
Proof of placement of guarantee
funds, consisting of:
a. guarantee funds of at least 20% (twenty percent) of the minimum paid-up capital;
Article 7 paragraph
(1) and Article
10 paragraph (2)
POJK Number
67/POJK.05
/2016
Total amount of guarantee funds equal to Rp [......] b. copy of time deposit slip with automatic renewal at sharia general bank, or sharia business unit of general bank in Indonesia that is not affiliated with the relevant Company; and
Article 7 paragraph
(3) and Article 10 paragraph (2) POJK Number 67/POJK.05 /2016
Name of sharia
bank:
[......]
Slip number:
[......]
Nominal amount of
guarantee funds:

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[......]
c. agreement with custodian bank registered at
Financial Services Authority regarding management of guarantee funds.
Article 41 and
Article 42
POJK Number
72/POJK.05
/2016
Name of custodian bank
[......]
Number and date of agreement
[......]
Ownership List

List of shareholders along with details of each share ownership and entire group structure related to
Sharia Insurance Company or Sharia Reinsurance Company and legal entity owner of Sharia Insurance Company or Sharia Reinsurance Company up to last owner, for Company in the form of limited liability company.
Article 10
paragraph (2) letter e number 1 POJK Number 67/POJK.05 /2016 (explained in chart form and description) Last owner:
1. [......]
by
[......]%
2. Etc.
11. List of members along with amount of
principal savings and mandatory savings for Company in the form of cooperative legal entity.
Article 10
paragraph (2) letter e number 2 POJK Number 67/POJK.05 /2016
1. Name: [......]
Amount of principal savings:
Rp[......]
Amount of mandatory savings:
Rp[......]
Date of start of membership:
[......]
2. Etc.
Data of Shareholders or Members Other Than Controlling Shareholders
12. In case, shareholders
or members other than Controlling Shareholder (CS) is individual:

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a. copy of identification card consisting of ID card or passport that is still valid;
Article 10
paragraph (2) letter f number 1 letter a) POJK Number 67/POJK.05 /2016
1. Name: [......]
ID Card/Passport
Number:
[......]
Validity period of identity:
[......]
2. Etc.
b. copy of Taxpayer Identification Number (NPWP); Article 10 paragraph (2) letter f number 1 letter b) POJK Number 67/POJK.05 /2016
1. Name:
[......]
NPWP Number:
[......]
2. Etc.
c. copy of tax return (SPT) for 2 (two)
years last and documents showing financial capability and source of funds of prospective shareholder individual;
Article 10
paragraph (2) letter f number 1 letter c) POJK Number 67/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 latest color photo size 4 x 6 cm; and
Article 10
paragraph (2) letter f number 1 letter d) POJK Number Curriculum vitae list and photo for name:
1. Mr./Mrs. [......]
2. Etc.
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67/POJK.05
/2016 e. statement letter from prospective shareholder stating:
1) capital deposit does not
originate from loans;
2) capital deposit does not
originate from money laundering activities (money laundering) and financial crime;
3) does not have non-performing credit
and/or financing;
4) not included as
Party prohibited from becoming shareholder or Party that manages, supervises, and/or has significant influence on financial service institution;
5) never sentenced
for committing criminal offense in the field of financial service business and/or economy based on court decision that has had permanent legal force within 5 (five) years last;
6) never sentenced
for committing criminal offense based on court decision that has had permanent legal force within 5 (five) years last;
7) never declared bankrupt or guilty that causes a
company declared bankrupt based on court decision
Article 10
paragraph (2) letter f number 1 letter e) POJK Number 67/POJK.05 /2016 Statement letter that is signed by shareholder as follows:

Mr./Mrs. [......]
Etc.
Completed with signature of the party above the stamp duty

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that has had permanent legal force within 5 (five) years last; and

never became
CS, member of Board of Directors, member of Board of Commissioners, controller, or member of DPS on financial service company whose business license is revoked due to violation within 5 (five) years last.

In case, shareholder
or member other than CS is legal entity:
a. copy of deed of establishment of legal entity including articles of association along with its amendments (if any), accompanied by copy of proof of approval, copy of proof of approval, and/or copy of proof of notification receipt from competent authority;
Article 10
paragraph (2) letter f number 2 letter a) POJK Number 67/POJK.05 /2016 Deed number: [......] Date: [......] Notary: [......] Substance:
[......]
Number of approval Kemenkumham:
[......]
Date: [......]
Business Activity:
[......]
Data of all changes of articles of association of the company (if any):
Number and
date of deed:
[......]
Number and date of proof of approval

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and/or receipt of notification from authority competent:
[......]
Substance of amendment of articles of association: [......]

Etc.
b. financial report that has been audited by public accountant completed with non-consolidated financial report and monthly financial report last;
Article 10
paragraph (2) letter f number 2 letter b) POJK Number 67/POJK.05 /2016 Financial report of shareholder [......] attached:
Financial report
that has been audited period
[......]
Financial report
non-consolidated period [......]
Financial report
monthly last period [......]
c. documents of Board of Directors
and Board of Commissioners from legal entity relevant:
1) copy of identification card
consisting of ID card or passport that is still valid;
Article 10
paragraph (2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Copy of identity of members of Board of Directors and members of Board of Commissioners :
Name:
[......]

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Position:
[......]
ID Card/Passport
Number:
[......]
Validity period of identity:
[......]

Etc.

copy of NPWP; and Article 10
paragraph (2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Copy of NPWP of members of Board of Directors and members of Board of Commissioners :

Name:
[......]
NPWP Number:
[......]
Etc.
3) curriculum vitae list
completed with color photo latest size 4 x 6 cm;
Article 10
paragraph (2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Curriculum vitae list and photo for name:
Mr./Mrs. [......]
Etc.
d. statement letter of director or equivalent from legal entity relevant stating that:
1) capital deposit does not
originate from loans;
2) capital deposit does not
originate from money laundering activities (money laundering) and financial crime;
3) does not have non-performing credit
and/or financing;
4) not included as
Party prohibited
Article 10
paragraph (2) letter f number 2 letter d) POJK Number 67/POJK.05 /2016 Statement letter that is signed by director or equivalent that is given authorization to represent the company as follows:
Mr./Mrs. [......]
Etc.
Completed with signature of the party above

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to become a shareholder or party that manages, supervises, and/or has significant influence on financial services institutions;

never convicted
for committing a criminal offense in the field of financial services business and/or the economy based on a court decision that has had final legal force within the last 5 (five) years;
never declared bankrupt or found guilty which
caused a company to be declared bankrupt based on a court decision that has final legal force within the last 5 (five) years; and
never served as a PSP in a financial services company whose business license was revoked due to violations within the last 5 (five) years.
above the stamp. e. rating results from an internationally recognized rating agency, for shareholders in the form of foreign legal entities.
Article 10
paragraph (2) letter f number 2 letter e) POJK Number 67/POJK.05 /2016 Entity rated:
[......]
Rating Agency:
[......]
Rating:
[......]
Other material information
(if any):

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[......]

In the event that the shareholder is the Republic of Indonesia, accompanied by a photocopy of government regulations regarding state capital participation for the establishment of the Company.
Article 10
paragraph (2) letter f number 3 POJK Number 67/POJK.05 /2016 jo.
Article 3 paragraph
(1) Government Regulation No.
44 Year
2005
No. Government Regulation:
[......]
Date: [......]
Nominal Amount: [......]
In the event that the shareholder is the Regional Government, accompanied by a photocopy of regional regulations regarding regional capital participation for the establishment of the Company.
Article 10
paragraph (2) letter f number 4 POJK Number 67/POJK.05 /2016 No. Regional Regulation: [......] Date: [......] Nominal Amount: [......] Controller
List of controllers along with descriptions regarding the form of control.
Article 10
paragraph (2) letter g jo.
Article 30
POJK Number 67/POJK.05
/2016
Name of controller:
[......]
Number and date of Financial Services Authority approval related to the determination of controller:
Number [......]
Date [......]
Rights and authority:
[......]
Description regarding the form of control [......] Sharia Supervisory Board
Evidence that the DPS does not violate dual office rules
Article 41
POJK Number

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on financial services institutions, in the form of a DPS statement that it does not hold dual offices at more than 4 (four) financial services institutions. 73/POJK.05 /2016

Photocopy of the minutes of the Extraordinary General Meeting of Shareholders regarding the appointment of DPS members.
Article 13
paragraph (2) jo.
Article 30
POJK Number 67/POJK.05
/2016
Evidence of approval by the National Sharia Council regarding the appointment of DPS members.
Article 13
paragraph (2) jo.
Article 30
POJK Number 67/POJK.05
/2016
Evidence of DPS approval for Sharia Insurance products to be marketed, which at least includes:
a. basis for calculating contribution rates, contribution reserves, and asset share or profit testing, for Sharia Life Insurance Companies;
Article 13
paragraph (2) jo.
Article 30
POJK Number 67/POJK.05
/2016 b. basis for calculating contribution rates, contribution reserves, and underwriting projections, for Sharia General Insurance Companies;
Article 13
paragraph (2) jo.
Article 30
POJK Number 67/POJK.05
/2016
c. marketing methods; Article 13
paragraph (2) jo.
Article 30
POJK Number 67/POJK.05
/2016 d. automatic reinsurance support plan for Sharia Insurance Companies and retrocession support plan for Sharia Reinsurance Companies; and
Article 13
paragraph (2) jo.
Article 30
POJK Number 67/POJK.05
/2016 e. sample policies, insurance application forms (SPPA), and brochures.
Article 13
paragraph (2) jo.
Article 30
POJK Number

20 -
67/POJK.05
/2016

Evidence of fulfillment of competency and suitability assessment requirements for DPS members.
Article 36
paragraph (5) letter e
POJK
Number
67/POJK.05
/2016
Experts
Evidence of employing experts.
Article 10
paragraph (2) letter h jo.
Article 55,
Article 56,
and Article 57
POJK Number 67/POJK.05
/2016
If necessary, the company can submit evidence of employing experts per business line organized by considering the complexity of the business.
Evidence that Experts have met the following provisions:
a. highest level certificate of Sharia life insurance or Sharia general insurance from the Professional Certification Body in the insurance field; b. work experience in risk management for at least 3 (three) years; and
c. not currently subject to sanctions from their professional association.
PAU:
Article 55
paragraph (2)
POJK Number 67/POJK.05
/2016
PAJ:
Article 56
paragraph (2)
POJK Number 67/POJK.05
/2016
PAR:
Article 57
paragraph (2)
POJK Number 67/POJK.05
/2016
Name: [......]
Certificate
Number:
[......]
Date:
[......]
Certifying body name:
[......]
Work experience:
[......]
Number of letter from association:
[......]

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Date:
[......]

Etc.
Supporting evidence that employed Experts have expertise in Sharia Insurance and/or Sharia economics.
Article 13
paragraph (2) letter e jo.
Article 30
POJK Number 67/POJK.05
/2016
Work Plan
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 Company health levels and underlying assumptions, starting from when the Company conducts operational activities.
Article 10
paragraph (2) letter i
POJK Number 67/POJK.05
/2016
Explanation in the form of description for each point:
a. [......] b. [......]
c. [......]
Annual Investment Management Plan
Investment plan for the first 3 (three) years, at least containing:
a. plan for the composition of investment types; b. estimated rate of return for each type of investment; and
c. considerations underlying the plan for the composition of investment types.
Article 57
POJK Number
73/POJK.05
/2016
Explanation in the form of description for each point:
a. [......] b. [......]
c. [......]
Risk Management Guidelines

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Photocopy of the Company's risk management guidelines, among others containing:
a. active supervision by the Board of Directors and Board of Commissioners; b. adequacy of policies, procedures, and Risk limit determinations;
c. adequacy of processes for risk identification, measurement, monitoring,
and control; d. risk management information systems; and e. comprehensive internal control systems.

Article 10
paragraph (2) letter j
POJK Number
67/POJK.05
/2016 and
SEOJK
Number
10/SEOJK.0
5/2016
Proven by risk management guidelines.
Guideline number:
[......]
Effective date of guideline: [......]
Signed by: [......]
Explanation in the form of description for each point:
a. [......] b. [......]
c. [......]
d. [......] e. [......]
Insurance Products
28. Specifications of insurance products to be marketed, accompanied by premium income projections and expenses linked to the marketing of new insurance products for a period of 3 (three) years and sample policies to be used by Insurance Companies.
Article 10
paragraph (2) letter k
POJK Number 67/POJK.05
/2016
Information regarding specifications of insurance products that will be marketed in accordance with the scope of business and business lines. Agreements With Other Parties
29. Photocopy of agreements with other parties and policies on outsourcing of certain functions in the conduct of business (if any).
Article 10
paragraph (2) letter l
POJK Number 67/POJK.05
/2016
Name of party:
[......]
Functions outsourced:
[......]
Systems Used by the Company
30. Administration systems and data management infrastructure
Article 10
paragraph (2)
Software: [......]
Hardware:

23 -
that support the preparation and submission of reports to the Financial Services Authority. letter m POJK Number 67/POJK.05 /2016 [......] Applications used by the company:
[......]

Data processing systems that can generate accurate and accountable information in decision-making.
Article 48
paragraph (6)
POJK Number 67/POJK.05
/2016
Data processing system consisting of:

spreadsheet
programs;
application-based
information systems; and/or
web-based
information systems.
Applications used by the Company:
[......]
In Case of Direct Participation From Foreign Parties

Confirmation from the supervisory authority in the country of origin of the foreign party.
Article 10
paragraph (2) letter n
POJK Number 67/POJK.05
/2016
Country name:
[......]
Institution name
[......]
Letter number:
[......]
Date: [......]
Substance of confirmation:
[......]
Licensing Costs
Proof of payment of licensing costs.
Article 10
paragraph (2) letter o
POJK Number 67/POJK.05
/2016
Financial Services Authority Information Receipt System Number (SIPO): [......] Payment date:

24 -
[......]
Amount paid:
[......]
Other Supporting Documents

Photocopy of initial/opening financial position report of the Company.
Article 10
paragraph (2) letter p number 1 POJK Number 67/POJK.05 /2016
Evidence of operational readiness. Article 10
paragraph (2) letter p number 2 POJK Number 67/POJK.05 /2016 Inventory list:
a. [......] b. [......]
c. Etc.
Office domicile letter
Number: [......]
Date:[......]
Address: [......]
Evidence of employing actuaries and internal auditors.
Article 10
paragraph (2) letter p number 3 POJK Number 67/POJK.05 /2016
Actuary:
Name: [......]
Appointment letter
Number:
[......]
Date:
[......]
Internal
auditor:
Name: [......]
Appointment letter
Number:
[......]
Date: [......]

25
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Human resources plan including human resource development plan for at least the first 3 (three) years.
Article 10
paragraph (2) letter p number 4 POJK Number 67/POJK.05 /2016
Photocopy of guidelines for implementing anti-money laundering and counter-terrorism financing programs, at least covering:
a. active supervision by the Board of Directors and Board of Commissioners; b. policies and procedures;
c. internal controls;
d. management information systems; and e. human resources and training.
Article 10
paragraph (2) letter p number 5 POJK Number 67/POJK.05 /2016 and
Article 2
POJK Number
39/POJK.05
/2015
Guideline number:
[......]
Effective date of guideline: [......]
Signed by: [......]

26
-

Photocopy of good corporate governance guidelines for the Company, containing the following provisions:
a. implementation of duties and responsibilities of members of the Board of Directors, Board of Commissioners, and DPS; b. implementation of duties of working units and committees carrying out internal control functions of the Insurance Company;
c. application of compliance functions, internal auditors, and external auditors;
d. application of risk management, including internal control systems and application of information technology governance; e. application of remuneration policies; f. strategic plan of the Insurance Company; and g. transparency of financial and non-financial conditions of the Insurance Company.
Article 10
paragraph (2) letter p number 6 POJK Number 67/POJK.05 /2016 and
Article 4
POJK Number
73/POJK.05
/2016
Guideline number:
[......]
Effective date of guideline: [......]
Signed by: [......]
Photocopy of investment governance guidelines established by the Board of Directors, containing investment policies and strategies, at least containing:
a. profile of the Company's assets and liabilities; b. matching between asset duration and liability duration of the Company;
c. investment objectives;
d. expected rate of return targets, including yield benchmark used as
Article 10
paragraph (2) letter p number 7 POJK Number 67/POJK.05 /2016 and
Article 56
paragraph (3)
POJK Number
73/POJK.05
/2016
Proven by guidelines and investment strategies No. guideline:
[......]
Effective date of guideline: [......]
Signed by: [......]
Brief explanation against the guidelines

27
- 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 limit of the Company's assets that can be placed with one party; h. maximum limit of idle assets not placed in the form of investment;
i. prohibited investment objects for investment placement;
j. minimum liquidity ratio 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, experts, 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. restrictions on investment transaction authority for each management level and accountability; and o. actions to be applied to the Board of Directors for violations of investment policies. thereof: [......]
28 -

Photocopy of information technology governance guidelines, at least containing:
a. information system organizational structure; b. guidelines for using information systems equipped with instructions or work orders for each function (standard operating procedure); and
c. data security management guidelines and incident management guidelines (disaster recovery plan).
Article 65
POJK Number
73/POJK.05
/2016
Proven by effective information technology governance guidelines. Guideline number:
[......]
Effective date of guideline: [......]
Signed by: [......]
Photocopy of cooperation agreements between shareholders in the form of foreign legal entities and Indonesian shareholders, for Companies that include participation from foreign legal entities, 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 members of the Board of Directors and members of the Board of Commissioners of the Company; and b. obligations of shareholders in the form of foreign legal entities to formulate and implement education and training programs according to their fields of expertise.
Article 10
paragraph (2) letter p number 8 POJK Number 67/POJK.05 /2016 Number: [......] Date: [......] Capital composition:
[......]
Obligations:
[......]
Automatic reinsurance support plan, for Sharia Insurance Companies.
Article 10
paragraph (2) letter p number 9 POJK Number 67/POJK.05 Letter number reinsurance support agreement:
[......]

29 -
/2016 Date: [......]
Reinsurance Company:
[......]
Type of reinsurance:
[......]
Line/Product:
[......]

Retrocession support plan, for Sharia Reinsurance Companies.
Article 10
paragraph (2) letter p number 10 POJK Number 67/POJK.05 /2016 Letter number retrocession support agreement: [......] Date: [......] Company:
[......]
Type of retrocession:
[......]
Line/Product:
[......]
Photocopy of financial management guidelines in accordance with Sharia Principles, at least regulating investment placement including limits, types, and amounts.
Article 16
paragraph (2) letter f
POJK Number 67/POJK.05
/2016
Photocopy of guidelines for conducting Insurance Business in accordance with Sharia Principles, at least regulating risk spreading.
Article 16
paragraph (2) letter g
POJK Number 67/POJK.05
/2016
Additional information (if needed):
We who sign below declare that:

30 -
1. 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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
2. The documents submitted online are true and identical to the printed documents.
Jakarta, [………………]
Board of Directors [………………] signature [Full Name] Note:
1. How to fill out: click twice on the box, then select "Checked".
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.
31 -
FORM SELF ASSESSMENT 2 APPLICATION FOR BUSINESS LICENSE CONVERSION FROM INSURANCE COMPANY TO SHARIA INSURANCE COMPANY OR CONVERSION FROM REINSURANCE COMPANY TO SHARIA REINSURANCE COMPANY FORM: 2 FORM SELF ASSESSMENT APPLICATION FOR BUSINESS LICENSE CONVERSION FROM INSURANCE COMPANY TO SHARIA INSURANCE COMPANY OR CONVERSION FROM REINSURANCE COMPANY TO SHARIA REINSURANCE COMPANY Company Name :
Application letter number for business license :
Date of application letter for business license :
Contact person (name, tel/email) :
Brief description of background of business license application :
Company description :
(describe company 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, DPS, experts, actuaries, and internal auditors of the company:
No. Position Name
Brief
Description
Responsibility
Information
Regarding
Dual Office
Citizenship and
Domicile
Type of Certification in risk management field (if any)

Chief Director

32 -
2. Director
3. Director
4. Chief Commissioner
5. Independent Commissioner
6. Commissioner
7. Sharia Supervisory Board
8. Expert
(including expert per business line, if any)
9. Company Actuary
10. Internal Auditor
11. Etc.
(please elaborate if the company plans to use Foreign Workers) NO. DESCRIPTION OF LEGAL BASIS COMPLETENESS YES NO NOTES
1. Conversion license application
submitted using format 3
Appendix of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 16 paragraph
(1) POJK
Number
67/POJK.05
/2016
Organizational Structure
2. Organizational structure that clearly depicts:
a. separation of risk management functions, financial management functions, and service functions; and b. existence of working units handling functions:
1) underwriting;
2) actuarial;
3) claim settlement
Article 10 paragraph
(2) letter b jo. Article 48 paragraph (1) and paragraph (2) POJK Number 67/POJK.05 /2016 Proven by attaching an organizational structure chart containing all functions.
33 -
administration;

marketing;
finance including investment management;
risk management;
internal audit;
administration and accounting;
compliance;
anti-money laundering and counter-terrorism financing; and
service and complaint resolution.

Documents containing descriptions of duties, authorities, responsibilities, and written work procedures, established by the Board of Directors.
Article 10 paragraph
(2) letter b jo. Article 48 paragraph (3) POJK Number 67/POJK.05 /2016 Proven by attaching Standard Operating Procedures (SOP):
1. SOP No.: [......]
SOP Title: [......]
Effective date of SOP implementation:
[......]
Signed by:
[......]
2. Etc.
Guarantee Fund
4. Initial guarantee fund report. Article 10 paragraph
(2) POJK
Number
67/POJK.05
/2016
5. Evidence of guarantee fund placement, consisting of:
Article 10 paragraph
(2) POJK
Number
67/POJK.05
/2016 a. guarantee fund of at least 20% (twenty percent) of the minimum paid-up capital;
Article 7 paragraph
(1) and Article
10 paragraph (2)
POJK Number 67/POJK.05
/2016
Total guarantee fund amount is Rp [......]

34 -
b. photocopy of fixed-term deposit certificates with automatic renewal at Sharia commercial banks, or Sharia business units of commercial banks in Indonesia that are not affiliates of the relevant Sharia Insurance Company or Sharia Reinsurance Company; and
Article 7 paragraph
(3) and Article
10 paragraph (2)
POJK Number 67/POJK.05
/2016
1. Name of Sharia bank:
[......]
2. Certificate No.: [......]
3. Nominal amount of
guarantee funds: [......]
c. agreement with a custodian bank registered with the Financial Services Authority regarding the administration of guarantee funds.
Article 41 and
Article 42
POJK Number
72/POJK.05
/2016
Custodian bank name
[......]
Number and date of agreement [......]
Ownership List
6. List of shareholders along with details of each share ownership and the entire group structure related to the Sharia Insurance Company or Sharia Reinsurance Company and the legal entity owner of the Sharia Insurance Company or Sharia Reinsurance Company up to the last owner, for Companies in the form of limited liability companies.
Article 10 paragraph
(2) POJK
Number
67/POJK.05
/2016
(elaborated in chart form and description) Last owner:
1. [......] amounting to
[......]%
2. Etc.
7. List of members along with the amount of basic deposits and mandatory deposits for Companies in the form of cooperative legal entities.
Article 10 paragraph
(2) POJK
Number
67/POJK.05
/2016
1. Name: [......]
Amount of basic deposit: Rp[......]
Amount of mandatory deposit: Rp[......]
Date of membership start: [......]
2. Etc.
Shareholder or Member Data Other Than Controlling Shareholders
8. In the event that shareholders
35 -
or members other than CSPs are individuals:
a. photocopy of identification cards such as ID card or passport that is still valid;
Article 10 paragraph
(2) letter f number 1 letter a) POJK Number 67/POJK.05 /2016
1. Name: [......]
ID Card/Passport Number:
[......]
Validity period of identity: [......]
2. Etc.
b. photocopy of Taxpayer Identification Number (NPWP); Article 10 paragraph (2) letter f number 1 letter b) POJK Number 67/POJK.05 /2016
1. Name: [......]
NPWP Number:
[......]
2. Etc.
c. photocopy of tax returns for the last 2 (two) years and other documents showing financial capability and source of funds for prospective individual shareholders;
Article 10 paragraph
(2) letter f number 1 letter c) POJK Number 67/POJK.05 /2016 Attached photocopy of tax return for Mr./Ms. [......]:
Tax Return Period: year
[......]
Taxable Income:
Rp [......]
Asset list: [......]
Total assets:
Rp [......]
Liability list:
[......]
Total liabilities: Rp
[......] d. curriculum vitae list completed with latest color photos sized 4 x 6 cm; and
Article 10 paragraph
(2) letter f number 1 letter d) POJK Number 67/POJK.05 /2016 Attached curriculum vitae list and photo for:
1. Mr./Ms. [......]
2. Mr./Ms. [......]
e. statement letter from the concerned party stating:
Article 10 paragraph
(2) letter f number 1
Attached statement letter signed by
36 -
letter e)
POJK Number
67/POJK.05
/2016 shareholders as follows:
Mr./Ms. [......]
Mr./Ms. [......]
Completed with signatures of the concerned parties above the stamp.
37 -
within the last 5 (five) years; and

has never been a PSP, member of the Board of Directors,
member of the Board of Commissioners, controller, or member of the DPS in a financial services company whose license was revoked due to violations within the last 5 (five) years.

In the event that shareholders
or members other than PSPs are legal entities:
a. photocopy of the establishment deed of the legal entity including the articles of association together with its amendments (if any), accompanied by photocopies of proof of approval, photocopy of proof of consent, and/or photocopy of proof of receipt of notice from the competent authority;
Article 10 paragraph
(2) letter f number 2 letter a) POJK Number 67/POJK.05 /2016 Deed No.: [......] Date: [......] Notary: [......] Substance: [......] Ministry of Law and Human Rights approval number:
[......]
Date: [......]
Data on all changes to the company's articles of association (if any):
Deed number and date
[......]
Number and date of proof of consent and/or receipt of notice from competent authorities: [......] Substance of the change to the articles of association:

38 -
[......]

Etc.
b. financial reports that have been audited by a public accountant supplemented with non-consolidated financial reports and the latest monthly financial report;
Article 10 paragraph
(2) letter f number 2 letter b) POJK Number 67/POJK.05 /2016 Financial report of the shareholder [......] which is attached:
Audited financial report
for period [......]
Non-consolidated financial report
for period [......]
Latest monthly financial report
for period [......]
c. documents of the Board of Directors and
Board of Commissioners of the relevant legal entity:
1) photocopy of identification in the form of an ID card
or passport that is still valid;
Article 10 paragraph
(2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Attached photocopies of identity of members of the Board of Directors and members of the Board of Commissioners:
Name: [......]
Position: [......]
ID Card/Passport Number:
[......]
Validity period of identity: [......]
Etc.
2) photocopy of the Taxpayer Identification Number (NPWP); and Article 10 paragraph
(2) letter f number 2 letter c) POJK Number 67/POJK.05 /2016 Attached photocopies of NPWP of members of the Board of Directors and members of the Board of Commissioners:
Name: [......]
NPWP Number:
[......]
Etc.
3) curriculum vitae list
completed with color passport photos measuring 4 x 6 cm;
Article 10 paragraph
(2) letter f number 2 letter c) Attached curriculum vitae list and passport photo in the name of:
Mr./Ms. [......]

39 -
latest size 4 x 6 cm;
POJK Number
67/POJK.05
/2016

Etc.
d. Letter of statement from the directors or equivalent thereof 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) does not have bad credits 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 convicted for committing criminal acts in the field of financial services business and/or the economy based on court decisions that have permanent legal force within the last 5 (five) years;
6) has never been declared bankrupt or declared guilty causing a company to be declared bankrupt based on court decisions having permanent legal force within the last 5
Article 10 paragraph
(2) letter f number 2 letter d) POJK Number 67/POJK.05 /2016 Attached letter of statement signed by the directors as follows:
Mr./Ms. [......]
Etc.
Completed with the respective signature above the stamp duty.

40 -
(five) years; and

has never served as a PSP in a financial services company whose license was revoked due to violations within the last 5 (five) years.
e. rating results from internationally recognized rating agencies, for foreign legal entity shareholders.
Article 10 paragraph
(2) letter f number 2 letter e) POJK Number 67/POJK.05 /2016 Entity rated:
[......]
Rating agency:
[......]
Rating:
[......]
Other material information (if any):
[......]

In the case of shareholders being the State of the Republic of Indonesia:
photocopy of government regulations regarding state capital participation for the establishment of Sharia Insurance Companies or Sharia Reinsurance Companies.
Article 10 paragraph
(2) letter f number 3
POJK Number
67/POJK.05
/2016 jo.
Article 3 paragraph
(1) Government Regulation Number 44 Year 2005 No. Government Regulation: [......] Date: [......] Nominal Amount: [......]
In the case of Regional Government shareholders:
photocopy of regional regulations regarding regional capital participation for the establishment of Sharia Insurance Companies or Sharia Reinsurance Companies.
Article 10 paragraph
(2) letter f number 4
POJK Number
67/POJK.05
/2016
No. Regional Regulation:
[......]
Date: [......]
Nominal Amount: [......]
Controllers
List of controllers along with descriptions regarding the form of control. Article 10 paragraph
(2) letter g jo. Article 30
Controller Name:
[......]

41 -
of their control. POJK Number
67/POJK.05
/2016
Number and date of Financial Services Authority approval related to the determination of controllers:
Number [......] date
[......]
Rights and authorities:
[......]
Description regarding the form of control:
[......]
Sharia Supervisory Board

Proof that the DPS does not violate dual position regulations at financial services institutions, in the form of a DPS statement that they do not hold dual positions at more than 4 (four) financial services institutions.
Article 41
POJK Number
73/POJK.05
/2016
Photocopy of the Minutes of the General Meeting of Shareholders regarding the appointment of DPS members.
Article 13 paragraph
(2) jo. Article
30 POJK
Number
67/POJK.05
/2016
Proof of approval from the National Sharia Council regarding the appointment of DPS members.
Article 13 paragraph
(2) jo. Article
30 POJK
Number
67/POJK.05
/2016
Proof of approval of the DPS regarding Sharia Insurance products to be marketed which at least includes:
a. basis for calculating contribution rates, provision of contributions, and asset share or profit testing, for Sharia Life Insurance Companies;
Article 13 paragraph
(2) jo. Article
30 POJK
Number
67/POJK.05
/2016 b. basis for calculating contribution rates, provision of
Article 13 paragraph
(2) jo. Article
30 POJK

42 -
contributions, and underwriting projections, for Sharia General Insurance Companies; Number 67/POJK.05 /2016
c. marketing methods; Article 13 paragraph
(2) jo. Article
30 POJK
Number
67/POJK.05
/2016 d. automatic reinsurance support plan for Sharia Insurance Companies and retrocession support plan for Sharia Reinsurance Companies; and
Article 13 paragraph
(2) jo. Article
30 POJK
Number
67/POJK.05
/2016 e. sample policies, insurance application letters (SPPA), and brochures.
Article 13 paragraph
(2) jo. Article
30 POJK
Number
67/POJK.05
/2016

Proof of fulfillment of competency and suitability assessment requirements for DPS members
Article 36
paragraph (5) letter e
POJK Number
67/POJK.05
/2016
Expert Personnel
Proof of employing expert personnel.
Article 10 paragraph
(2) letter h jo. Article 55,
Article 56, and
Article 57
POJK Number
67/POJK.05
/2016
If necessary, the company may submit proof of employing expert personnel per business line operated considering the complexity of the business.
Proof that Expert Personnel has met the following provisions:
a. insurance certification for life or general insurance with the highest level from the Professional Certification Agency in the insurance sector; b. has work experience in the field of managing life insurance or
Article 55,
Article 56, and
Article 57
POJK Number
67/POJK.05
/2016
Name: [......]
Certificate number:
[......]
Date: [......]
Name of certifier: [......]

43 -
general insurance for at least 3 (three) years; and
c. is not currently subject to sanctions from their professional association.
Work experience:
[......]
Number of letter of confirmation from association: [......] Date: [......]

Etc.
Supporting proof that employed Expert Personnel has expertise in the field of Sharia Insurance and/or Sharia economics.
Article 13 paragraph
(2) letter e jo.
Article 30
POJK Number
67/POJK.05
/2016
Work Plan
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 company health levels and their underlying assumptions, starting from when the Sharia Insurance Company or Sharia Reinsurance Company commences operational activities.
Article 10 paragraph
(2) letter i
POJK Number
67/POJK.05
/2016
Explanation in the form of description of each point:
a. [......] b. [......]
c. [......]
Risk Management Guidelines
Photocopy of the Company's risk management guidelines, among others containing:
a. active supervision by the Board of Directors
Article 10 paragraph
(2) letter j
POJK Number
67/POJK.05
/2016 and
Proven with risk management guidelines Guideline Number:
[......]

44 -
and Board of Commissioners; b. adequacy of policies, procedures, and Risk limit determinations;
c. adequacy of processes for identifying, measuring, monitoring,
and controlling Risks; d. risk management information systems; and e. comprehensive internal control systems. SEOJK Number 10/SEOJK.0 5/2016 Effective date of guideline implementation:
[......]
Signed by:
[......]
Explanation in the form of description of each point:
a. [......] b. [......]
c. [......]
d. [......] e. [......]
Agreements with Other Parties

Photocopy of agreements with other parties (if any) and policies on the transfer of partial functions in the conduct of business.
Article 10 paragraph
(2) letter l
POJK Number
67/POJK.05
/2016
Party Name: [......]
Function transferred:
[......]
Systems Used by the Company
Administrative systems and data management infrastructure supporting the preparation and submission of reports to the Financial Services Authority.
Article 10 paragraph
(2) letter m
POJK Number
67/POJK.05
/2016
Software: [......]
Hardware: [......]
Applications used by the company: [......]
Data processing systems that can generate accurate and accountable information in decision-making.
Article 48 paragraph
(6) paragraph (2)
POJK Number
67/POJK.05
/2016
Data processing system consists of:

spreadsheet programs;
application-based information systems;
and/or
web-based information systems.
Applications used by the company: [......]
In Case of Direct Participation From Foreign Parties
45 -
26. Confirmation from the supervisory authority in the country of origin of the foreign party.
Article 10 paragraph
(2) letter n
POJK Number
67/POJK.05
/2016
Country name: [......]
Letter Number: [......]
Date: [......]
Substance of confirmation:
[......]
Licensing Costs
27. Proof of payment of licensing costs.
Article 10 paragraph
(2) letter o
POJK Number
67/POJK.05
/2016
OJK Information Receipt System (SIPO) Number: [......] Payment date:
[......]
Amount paid:
[......]
Other Supporting Documents
28. Photocopy of initial/opening financial position reports of the Company.
Article 10 paragraph
(2) letter p number 1
POJK Number
67/POJK.05
/2016
29. Proof of operational readiness. Article 10 paragraph
(2) letter p number 2
POJK Number
67/POJK.05
/2016
Inventory list:
a. [......] b. [......]
c. Etc.
Head Office Domicile Certificate Letter Number: [......] Date: [......] Address: [......]
30. Proof of employing actuaries and internal auditors.
Article 10 paragraph
(2) letter p number 3
POJK Number
67/POJK.05
/2016
1. Actuary:
Name: [......]
Appointment Letter Number
46 -
/2016 appointment:
[......]
Date: [......]

Internal Auditor:
Name: [......]
Appointment Letter Number
[......]
Date: [......]
Manpower plan including human resource development plans for at least the first 3 (three) years.
Article 10 paragraph
(2) letter p number 4
POJK Number
67/POJK.05
/2016
Photocopy of guidelines for implementing anti-money laundering and counter-terrorism financing programs, at least covering:
a. active supervision by the Board of Directors and Board of Commissioners; b. policies and procedures;
c. internal controls;
d. management information systems; and e. human resources and training.
Article 2 POJK
Number
39/POJK.05
/2015
Guideline No.:
[......]
Effective date of guideline implementation:
[......]
Signed by:
[......]
Photocopy of good corporate governance guidelines for the Company, containing provisions as follows:
a. execution of duties and responsibilities of the Board of Directors, Board of Commissioners, and DPS; b. execution of duties of working units and committees carrying out internal control functions of the
Article 10 paragraph
(2) letter p number 6
POJK Number
67/POJK.05
/2016 and
Article 4 POJK
Number
73/POJK.05
/2016
Guideline No.:
[......]
Effective Date of guideline implementation:
[......]
Signed by:
[......]

47 -
Insurance Industry Company;
c. implementation of compliance functions, internal auditors, and external auditors;
d. implementation of risk management, including internal control systems and implementation of information technology governance; e. implementation of remuneration policies; f. strategic plan of the Insurance Industry Company; and g. transparency of the financial and non-financial conditions of the Insurance Industry Company.

Photocopy of investment governance guidelines established by the Board of Directors, containing investment policies and strategies which at least contain:
a. profile of the Company's assets and liabilities; b. alignment between asset duration and liability duration of the Company;
c. investment objectives;
d. expected investment return targets, including yield benchmarks used; e. valuation basis and qualitative limits for each type of investment asset; f. maximum allocation limits for investment in each type of investment asset; g. maximum proportion limit of the Company's assets that can be placed with one party; h. maximum limit of the number
Article 10 paragraph
(2) letter p number 7
POJK Number
67/POJK.05
/2016 and
Article 56 paragraph
(3) POJK
Number
73/POJK.05
/2016
Proven with
Guidelines and Investment Strategy Guideline No.:
[......]
Effective Date of Guideline Implementation:
[......]
Signed by:
[......]
Brief explanation regarding the guidelines:
[......]

48 -
of idle assets not placed (idle assets) in the form of investments;
i. prohibited investment objects for 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. restrictions on investment transaction authorities for each management level and their accountability; and o. actions to be applied to the Board of Directors for violations of investment policies.
49 -

Information technology governance guidelines which at least contain:
a. information system organizational structure; b. guidelines for using information systems equipped with instructions or work orders for each function (standard operating procedure); and
c. data security management guidelines and incident management guidelines (disaster recovery plan).
Article 10 paragraph
(2) POJK
Number
67/POJK.05
/2016
Proven with effective information technology governance guidelines Guideline No.: [......] Effective date of guideline implementation:
[......]
Signed by:
[......]
Photocopy of cooperation agreements between foreign legal entity shareholders and Indonesian shareholders, for Companies that include participation from foreign legal entities, made in Indonesian language and at least containing:
a. capital composition and details of authorities, at least containing provisions regarding voting rights, profit and loss distribution, and appointment of members of the Board of Directors and members of the Board of Commissioners of the Sharia Insurance Company or Sharia Reinsurance Company; and b. obligations of foreign legal entity shareholders to formulate and implement education and training programs according to their fields of expertise.
Article 10 paragraph
(2) letter p number 8
POJK Number
67/POJK.05
/2016
Number: [......]
Date: [......]
Capital Composition: [......]
Obligations: [......]

50 -

Automatic reinsurance support plan, for Sharia Insurance Companies.
Article 10 paragraph
(2) letter p number 9
POJK Number
67/POJK.05
/2016
Number of reinsurance support agreement letter:
[......]
Date: [......]
Reinsurance Company: [......]
Type of Reinsurance:
[......]
Line/Product: [......]
Retrocession support plan, for Sharia Reinsurance Companies.
Article 10 paragraph
(2) letter p number 10
POJK Number
67/POJK.05
/2016
Number of retrocession support agreement letter:
[......]
Date: [......]
Company: [......]
Type of retrocession: [......]
Line/Product: [......]
Business license as an Insurance Company or Reinsurance Company.
Article 16 paragraph
(2) letter f
POJK Number
67/POJK.05
/2016
Photocopy of the deed of amendment to the articles of association stating:
Article 16 paragraph
(2) POJK
Number
67/POJK.05
/2016 a. one of the purposes and objectives of the Company is to conduct business activities based on Sharia Principles; and
Article 16 paragraph
(2) POJK
Number
67/POJK.05
/2016 b. authorities and responsibilities of the DPS, accompanied by proof of approval, proof of consent, and/or proof of receipt of notice
Article 16 paragraph
(2) POJK
Number
67/POJK.05
/2016

51 -
from the competent authority.

Photocopy of the Minutes of the General Meeting of Shareholders approving the conversion.
Article 16 paragraph
(2) POJK
Number
67/POJK.05
/2016
Photocopy of guidelines for financial management implementation according to Sharia principles which at least regulates investment placement including limits, types, and amounts.
Article 16 paragraph
(2) POJK
Number
67/POJK.05
/2016
Photocopy of guidelines for conducting Insurance Business according to Sharia Principles which at least regulates risk spreading.
Article 16 paragraph
(2) letter g
POJK Number
67/POJK.05
/2016
Supporting proof that employed Expert Personnel has expertise in the field of Sharia Insurance and/or Sharia economics.
Article 16 paragraph
(2) letter h
POJK Number
67/POJK.05
/2016
Plan for settling the rights of policyholders or insured parties who are unwilling to become policyholders or participants of the resulting Sharia Insurance Company or Sharia Reinsurance Company from the conversion.
Article 16 paragraph
(2) letter j
POJK Number
67/POJK.05
/2016
Additional notes (if needed):
We, the undersigned, declare that:
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 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies; and
The documents submitted online are true and identical to the printed documents.

52 -
Jakarta, [………………]
Directors [………………] signature
[Full Name]
Notes:

Filling method: click twice on the box, then select "Checked".
This Self-Assessment Form is prepared based on the provisions of Financial Services Authority Regulation Number 67/POJK.05/2016 concerning Business Licensing and Institutional Structure of Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies.

53 -
FORM SELF ASSESSMENT 3 APPLICATION FOR BUSINESS LICENSE SEPARATION OF SHARIA UNIT FROM INSURANCE COMPANY OR REINSURANCE COMPANY BY ESTABLISHING A SHARIA INSURANCE COMPANY OR SHARIA REINSURANCE COMPANY FORM: 3 FORM SELF ASSESSMENT APPLICATION FOR BUSINESS LICENSE SEPARATION OF SHARIA UNIT FROM INSURANCE COMPANY OR REINSURANCE COMPANY BY ESTABLISHING A SHARIA INSURANCE COMPANY OR SHARIA REINSURANCE COMPANY Company Name :
Business license application letter number :
Date of business license application letter :
Contact person (name, phone, email) :
Brief description of background of business license application :
Company description :
(describe company history)
[.......]
No. Name of Shareholder Nominal (Rp) (%) Controller/Non- Controller 1 2 3 Total Company group structure diagram:
(up to ultimate controller)
......
Composition of Directors, Board of Commissioners, DPS, expert personnel, actuaries, and internal auditors of the company:
No. Position Name
Brief Description
Responsibility
Information Regarding
Dual Positions
Citizenship and
Domicile
Certification Type field of risk management (if any) 1 Director
54 -
Main
2 Director
3 Director
4 Commissioner
Main
5 Independent
Commissioner
6 Commissioner
7 Sharia
Supervisory Board
8 Expert Personnel
(including expert personnel per business line, if any) 9 Actuary Company 10 Internal Auditor Etc (please elaborate if the company plans to use foreign workers) NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

Application submitted using format 4 Appendix
of POJK Number
67/POJK.05/2016 and signed by the Board of Directors.
Article 20 paragraph
(4) POJK
Number
67/POJK.05/
2016
Photocopy of the deed of minutes of the GMS approving the Separation.
Article 20 paragraph
(5) letter a
POJK Number
67/POJK.05/
2016
Deed No.: [......]
Date: [......]
Notary: [......]
Substance:
[......]
Photocopy of the Separation Deed. Article 20 paragraph
(5) letter b
POJK Number
67/POJK.05/
2016
Deed No.: [......]
Date: [......]
Notary: [......]

55 -
Substance:
[......]
Ministry of Law and Human Rights approval number/letter:
[......]
Date: [......]

Photocopy of the establishment deed of a limited liability company or cooperative including
photocopy of the deed of amendment to the articles of association (if any) accompanied by photocopy of proof of consent, and/or photocopy of proof of receipt of notice from the competent authority. The establishment deed contains information among others:
a. name and domicile; b. purpose and objectives as well as business activities;
c. capital;
d. ownership; and e. authorities, responsibilities, and term of office of members of the Board of Directors and members of the Board of Commissioners.
Article 10 paragraph
(2) letter a
POJK Number
67/POJK.05/
2016
Company establishment data:
Number and date of establishment deed:
[......]
Number and date of proof of approval from competent authorities:
[......]
Name of Company:
[......]
Place of domicile:
[......]
Purpose and objectives as well as business activities:
[......]
Total settled capital: [......]
Purpose and data on ownership:
[......]
Authorities, responsibilities, and term of office of members

56 -
of the Board of Directors and members of the Board of Commissioners:
[......]
Data on all changes to the company's articles of association (if any):
1. Number and
date of deed:
[......]
Number and date of proof of consent and/or receipt of notice from competent authorities:
[......]
Substance of the change to the articles of association:
[......]
2. Etc.
Organizational Structure
5. Organizational structure that clearly depicts:
a. separation of risk management functions, financial management functions, and service functions. b. existence of working units handling functions:
1) underwriting;
2) actuarial;
3) claims administration settlement;
4) marketing;
5) finance including investment management;
6) risk management;
Article 10 paragraph
(2) letter b jo.
Article 48 paragraph
(1) and paragraph
(2) POJK
Number
67/POJK.05/
2016
Proven by attaching an organizational structure diagram containing all these functions.
57 -

7) internal audit;
8) administration and accounting;
9) compliance;
10) anti-money laundering and
prevention of terrorist financing; and
11) service and complaint resolution.

Documents containing descriptions of duties, authorities, responsibilities, and written work procedures, established by the Board of Directors.

Pasal 10 ayat (2) huruf b jo. Pasal 48 ayat (3) POJK Nomor 67/POJK.05/2016

Proven by attaching Standard Operating Procedure (SOP):

No. SOP: [......]
Title of SOP: [......]
Effective date of SOP implementation: [......] Signed by: [......]
Etc.

Guarantee Fund

Initial report on guarantee funds

Pasal 10 ayat (2) POJK Nomor 67/POJK.05/2016

Proof of placement of guarantee funds, consisting of:
a. guarantee funds of at least 20% (twenty percent) of the minimum paid-up capital;

Pasal 7 ayat (1) dan Pasal 10 ayat (2) POJK Nomor 67/POJK.05/2016

Total amount of guarantee funds is Rp [......] b. photocopy of time deposit certificates with automatic renewal at a general Islamic bank, or the Islamic business unit of a general bank in Indonesia that is not an affiliate of the relevant Sharia Insurance Company or Sharia Reinsurance Company; and

Pasal 7 ayat 1. Nama bank syariah: [......]

2. No. certificate: [......]
3. Nominal guarantee funds: [......]
c. agreement with a custodian bank registered with the Financial Services Authority regarding the management of guarantee funds.

Pasal 41 dan Pasal 42 POJK Nomor 72/POJK.05/2016

Name of custodian bank [......]
Number and date of agreement [......]

Shareholder List

List of shareholders including details of each share ownership and the entire group structure related to the Sharia Insurance Company or Sharia Reinsurance Company and the legal entity owner of the Sharia Insurance Company or Sharia Reinsurance Company up to the ultimate owner, for companies in the form of limited liability companies.

Pasal 10 ayat (2) POJK Nomor 67/POJK.05/2016 (explained in the form of charts and descriptions)

Ultimate Owner:
1. [......] amounting to [......]%
2. Etc.

10. List of members including the amount of principal savings and mandatory savings for companies in the form of cooperative legal entities.

Pasal 10 ayat (2) POJK Nomor 67/POJK.05/2016

Name: [......]
Principal Savings Amount: Rp[......]
Mandatory Savings Amount: Rp[......]
Date of membership start: [......]

58 -

Etc.

Data of Shareholders or Members Other than Controlling Shareholders

In the event that shareholders or members other than the Controlling Shareholder (PSP) are individuals.
a. photocopy of valid identification cards such as ID card (KTP) or passport;

Pasal 10 ayat (2) huruf f angka 1 huruf a) POJK Nomor 67/POJK.05/2016

Name: [......]
ID Card/Passport Number: [......]
Validity period of identity: [......]
Etc.

b. photocopy of Taxpayer Identification Number (NPWP);

Pasal 10 ayat (2) huruf f angka 1 huruf b) POJK Nomor 67/POJK.05/2016

Name: [......]
NPWP Number: [......]
Etc.

c. photocopy of tax returns (SPT) for the last 2 (two) years and other documents showing financial capability and funding sources of prospective individual shareholders;

Pasal 10 ayat (2) huruf f angka 1 huruf c) POJK Nomor 67/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 [......]

59 -

d. curriculum vitae list completed with the latest color passport-sized photo measuring 4 x 6 cm; and

Pasal 10 ayat (2) huruf f angka 1 huruf d) POJK Nomor 67/POJK.05/2016

Attached curriculum vitae list and passport photos for:

Mr./Ms. [......]
Etc.

e. statement letter from the concerned party 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 credits 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 financial service institutions;
5) has never been sentenced for committing criminal offenses in the field of financial service businesses and/or the economy based on court decisions that have had permanent legal force within the last 5 (five) years;
6) has never been sentenced for committing criminal offenses based on court decisions that have had permanent legal force within the last 5 (five) years;
7) has never been declared bankrupt or found guilty causing a company to be declared bankrupt

Pasal 10 ayat (2) huruf f angka 1 huruf e) POJK Nomor 67/POJK.05/2016

Statement letter signed by the shareholder as follows:

Mr./Ms. [......]
Etc.

Completed with the signature of the concerned party above the stamp duty.

60 -

based on court decisions that have had permanent legal force within the last 5 (five) years; and
8) has never become a Controlling Shareholder (PSP), member of the Board of Directors, member of the Board of Commissioners, Controller, or member of the Sharia Supervisory Board (DPS) at a financial service company whose business license was revoked due to violations within the last 5 (five) years.

In the event that shareholders or members other than the Controlling Shareholder (PSP) are legal entities:

Pasal 10 ayat (2) POJK Nomor 67/POJK.05/2016

a. photocopy of the establishment deed of the legal entity including the articles of association along with its amendments (if any), accompanied by photocopies of proof of approval, proof of consent, and/or photocopies of proof of receipt of notification letters from competent authorities;

Pasal 10 ayat (2) huruf f angka 2 huruf a) POJK Nomor 67/POJK.05/2016

Deed No.: [......]
Date: [......]
Notary: [......]
Substance: [......]
Ministry of Law and Human Rights Approval Number: [......] Date: [......] Data of all changes to the articles of association of the company (if any):

Number and date of deed: [......]
Number and date of proof of consent and/or receipt of notification from competent authority: [......] Substance of changes to articles of association: [......]
Etc.

61 -

b. financial reports audited by public accountants, supplemented with non-consolidated financial reports and the latest monthly financial reports;

Pasal 10 ayat (2) huruf f angka 2 huruf b) POJK Nomor 67/POJK.05/2016

Financial report of shareholder [......] attached:

Audited financial report for period [......]
Non-consolidated financial report for period [......]
Latest monthly financial report for period [......]

c. documents from the Board of Directors of the relevant company:
1) photocopy of valid identification cards such as ID card (KTP) or passport;

Pasal 10 ayat (2) huruf f angka 2 huruf c) POJK Nomor 67/POJK.05/2016

Photocopy of identity of Board of Directors members and Board of Commissioners members:

Name: [......]
Position: [......]
ID Card/Passport Number: [......]
Validity period of identity: [......]
Etc.
```
 2) photocopy of NPWP; and
```

Pasal 10 ayat (2) huruf f angka 2 huruf c) POJK Nomor 67/POJK.05/2016

Photocopy of NPWP of Board of Directors members and Board of Commissioners members:

Name: [......]
NPWP Number: [......]

Etc.

 3) curriculum vitae list completed with the latest color passport-sized photo measuring 4 x 6 cm.

Pasal 10 ayat (2) huruf f angka 2 huruf c) POJK Nomor 67/POJK.05/2016

Curriculum vitae list and passport photos for:

Mr./Ms. [......]
Etc.

62 -

d. statement letter from the director or equivalent thereof 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) does not have non-performing credits and/or financing;

Pasal 10 ayat (2) huruf f angka 2 huruf d) POJK Nomor 67/POJK.05/2016

Statement letter signed by the director as follows:

Mr./Ms. [......]
Etc.

Completed with the signature of the concerned party above the stamp duty.

is not included as a Party prohibited from becoming a shareholder or a Party that manages, oversees, and/or has significant influence on financial service institutions;
has never been sentenced for committing criminal offenses in the field of financial service businesses and/or the economy based on court decisions that have had permanent legal force within the last 5 (five) years;
has never been declared bankrupt or found guilty causing a company to be declared bankrupt based on court decisions having permanent legal force within the last 5 (five) years; and
has never become a Controlling Shareholder (PSP) at a financial service company whose business license was revoked due to violations within the last 5 (five) years.

e. rating results from internationally recognized rating agencies, for shareholders in the form of foreign legal entities.

Pasal 10 ayat (2) huruf f angka 2 huruf e) POJK Nomor 67/POJK.05/2016

Entity rated: [......]
Rating Agency: [......]
Rating: [......]
Other material information (if any): [......]

In the event that the shareholder is the Republic of Indonesia, attach a photocopy of government regulations regarding state capital participation

63 -

for the establishment of the Company.

Pasal 10 ayat (2) huruf f angka 3 POJK Nomor 67/POJK.05/2016 jo. Pasal 3 ayat (1) PP Nomor 44 Tahun 2005

No. Government Regulation: [......]
Date: [......]
Nominal: [......]

In the event that the shareholder is the Regional Government, attach a photocopy of regional regulations regarding regional capital participation for the establishment of the Company.

Pasal 10 ayat (2) huruf f angka 4 POJK Nomor 67/POJK.05/2016 jo. Pasal 173 Undang-undang Nomor 32 Tahun 2004

No. Regional Regulation: [......]
Date: [......]
Nominal: [......]

Controller

List of Controllers along with information regarding the form of control.

Pasal 10 ayat (2) huruf g jo. Pasal 30 POJK Nomor 67/POJK.05/2016

Name of Controller: [......]
Number and date of Otoritas Jasa Keuangan Decision Letter regarding Determination of Controller: Number [......] date [......] Rights and authorities: [......] Description regarding the form of control: [......]

Sharia Supervisory Board (Dewan Pengawas Syariah)

Proof that DPS members do not violate conflict of interest provisions at financial service institutions, in the form of a DPS statement that they do not hold concurrent positions at more than 4 (four) financial service institutions.

Pasal 41 POJK Nomor 73/POJK.05/2016

64 -

Photocopy of minutes of the Annual General Meeting of Shareholders (RUPS) regarding the appointment of DPS members.