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

To:

The Board of Directors of Insurance Brokerage Companies;
The Board of Directors of Reinsurance Brokerage Companies; and
The Board of Directors of Insurance Loss Assessing Companies,

at their respective locations.

COPY

CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020

CONCERNING

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

In relation to the mandate of regulations:
a. Article 6 of Financial Services Authority Regulation Number 55/POJK.05/2017 concerning Periodic Reports of Insurance Companies (State Gazette of the Republic of Indonesia Year 2017 Number 174, Supplement to the State Gazette of the Republic of Indonesia Number 6107); b. Article 7 paragraph (3), Article 14 paragraph (5), Article 15 paragraph (5), and Article 19 of Financial Services Authority Regulation Number 24/POJK.05/2019 concerning Business Plans of Non-Bank Financial Service Institutions (State Gazette of the Republic of Indonesia Year 2019 Number 175, Supplement to the State Gazette of the Republic of Indonesia Number 6392);
c. Financial Services Authority Regulation Number 13/POJK.05/2017 concerning the Use of Public Accountants and Public Accounting Firms in Financial Service Activities (State Gazette of the Republic of Indonesia Year 2017 Number 62, Supplement to the State Gazette of the Republic of Indonesia Number 6036); and
d. Financial Services Authority Regulation Number 12/POJK.01/2017 concerning the Implementation of Anti-Money Laundering and Counter-Terrorism Financing Programs in the Financial Service Sector (State Gazette of the Republic of Indonesia Year 2017 Number 57, Supplement to the State Gazette of the Republic of Indonesia Number 6035) as amended by Financial Services Authority Regulation Number 23/POJK.01/2019 concerning Amendments to Financial Services Authority Regulation Number 12/POJK.01/2017 concerning the Implementation of Anti-Money Laundering and Counter-Terrorism Financing Programs in the Financial Service Sector (State Gazette of the Republic of Indonesia Year 2019 Number 178, Supplement to the State Gazette of the Republic of Indonesia Number 6394), it is necessary to regulate the provisions on the scope, form, structure, and procedures for submitting periodic reports of insurance brokerage companies, reinsurance brokerage companies, and insurance loss assessing companies in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

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

Company means an insurance brokerage company, a reinsurance brokerage company, and an insurance loss assessing company.
Insurance Brokerage Company is a company that conducts business providing consulting and/or intermediary services in closing insurance or Sharia insurance and handling claim settlements, acting on behalf of and for the policyholder, insured, or participant.
Reinsurance Brokerage Company is a company that conducts business providing consulting and/or intermediary services in placing reinsurance or Sharia reinsurance and handling claim settlements, acting on behalf of and for insurance companies, Sharia insurance companies, guarantee companies, Sharia guarantee companies, reinsurance companies, or Sharia reinsurance companies that place reinsurance or Sharia reinsurance.
Insurance Loss Assessing Company is a company that conducts business providing claim assessment services and/or consulting services regarding insurance objects.
Periodic Report is a report prepared by the Company for the benefit of the Financial Services Authority for a specific period.
Semi-Annual Report is a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant semester.
Annual Report is a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant year.

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

Reports for Insurance Brokerage Companies consist of:
a. Periodic Reports consisting of:

Semi-Annual Reports; and
Annual Reports; and
b. in addition to Periodic Reports consisting of:
business plan;
business plan realization report;
business plan supervision report;
data updating activity report;
data updating realization report;
report on the appointment of public accountants and/or public accounting firms for the audit of annual historical financial information; and
report on the audit committee's evaluation of the implementation of audit services for annual historical financial information by public accountants and/or public accounting firms.

Reports for Reinsurance Brokerage Companies consist of:
a. Periodic Reports consisting of:

Semi-Annual Reports; and
Annual Reports; and
b. in addition to Periodic Reports consisting of:
business plan;
business plan realization report;
business plan supervision report;
report on the appointment of public accountants and/or public accounting firms for the audit of annual historical financial information; and
report on the audit committee's evaluation of the implementation of audit services for annual historical financial information by public accountants and/or public accounting firms.

Reports for Insurance Loss Assessing Companies consist of:
a. Periodic Reports which are Annual Reports; and b. in addition to Periodic Reports, consisting of:

report on the appointment of public accountants and/or public accounting firms for the audit of annual historical financial information; and
report on the audit committee's evaluation of the implementation of audit services for annual historical financial information by public accountants and/or public accounting firms.

The Annual Report as referred to in item 1 letter a item 2) for Insurance Brokerage Companies, as referred to in item 2 letter a item 2) for Reinsurance Brokerage Companies, and as referred to in item 3 letter a for Insurance Loss Assessing Companies consists of:
a. financial aspects; and b. management aspects.
The financial aspect as referred to in item 4 letter a is the Annual Report as referred to in the Financial Services Authority regulations concerning the conduct of business by Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies, which among other things contains financial statements audited by public accountants.
The financial statements audited by public accountants as referred to in item 5 are financial statements that have been approved by the General Meeting of Shareholders (GMS) or its equivalent.
The form and structure of the reports as referred to in items 1 to 3 are as set forth in the Appendix which is an integral part of this Financial Services Authority Circular Letter, with the following provisions:
a. the form and structure of the Semi-Annual Report as referred to in item 1 letter a item 1) for Insurance Brokerage Companies and item 2 letter a item 1) for Reinsurance Brokerage Companies, and the Annual Report for financial aspects as referred to in item 4 letter a for Companies are as set forth in Appendix I which is an integral part of this Financial Services Authority Circular Letter, with the following provisions:

for Insurance Brokerage Companies, as set forth in Format IA;
for Reinsurance Brokerage Companies, as set forth in Format IB; and
for Insurance Loss Assessing Companies, as set forth in Format IC;
b. the form and structure of the Annual Report for management aspects as referred to in item 4 letter b for Companies is as set forth in Appendix II which is an integral part of this Financial Services Authority Circular Letter; and
c. the form and structure of the business plan as referred to in item 1 letter b item 1) for Insurance Brokerage Companies and item 2 letter b item 1) for Reinsurance Brokerage Companies, the business plan realization report as referred to in item 1 letter b item 2) for Insurance Brokerage Companies and item 2 letter b item 2) for Reinsurance Brokerage Companies, and the business plan supervision report as referred to in item 1 letter b item 3) for Insurance Brokerage Companies and item 2 letter b item 3) for Reinsurance Brokerage Companies are as set forth in Appendix III which is an integral part of this Financial Services Authority Circular Letter, with the following provisions:
for the business plan, as set forth in Format IIIA;
for the business plan realization report, as set forth in Format IIIB; and
for the business plan supervision report, as set forth in Format IIIC;
d. the form and structure of the data updating activity report as referred to in item 1 letter b item 4) and the data updating realization report as referred to in item 1 letter b item 5) for Insurance Brokerage Companies are as set forth in Appendix IV which is an integral part of this Financial Services Authority Circular Letter; e. the form and structure of the report on the appointment of public accountants and/or public accounting firms for the audit of annual historical financial information as referred to in item 1 letter b item 6), item 2 letter b item 4), and item 3 letter b item 1) for Companies is as set forth in Appendix V which is an integral part of this Financial Services Authority Circular Letter; and f. the form and structure of the report on the audit committee's evaluation of the implementation of audit services for annual historical financial information by public accountants and/or public accounting firms as referred to in item 1 letter b item 7), item 2 letter b item 5), and item 3 letter b item 2) for Companies is as set forth in Appendix VI which is an integral part of this Financial Services Authority Circular Letter.

III. PROCEDURES FOR SUBMITTING REPORTS

Submission of reports is conducted online via the Financial Services Authority's data communication network system.
In the event that the Financial Services Authority's data communication network system as referred to in item 1 is not yet available or experiences technical disturbances, the Company must submit reports online via email to the Financial Services Authority.
In the event that the Company must submit reports online via email to the Financial Services Authority as referred to in item 2, the Financial Services Authority will provide written notice to the Company regarding the email address used for report submission no later than 14 (fourteen) working days before the report submission deadline.
In order to submit online via email as referred to in item 2, the Company must provide written notice to the Financial Services Authority of the Company's email address used for submitting reports to the Financial Services Authority.
In the event that the Financial Services Authority's data communication network system as referred to in items 1 and 2 experiences technical disturbances or the Company experiences disturbances preventing the online submission of Periodic Reports, reports are submitted offline accompanied by written notification and supporting documents in the form of reports on either compact disk (CD) or other electronic data storage media, and sent to the Financial Services Authority via mail signed by the Board of Directors or its equivalent, addressed to:
Financial Services Authority attn. Director of IKNB Support Services Wisma Mulia 2 Building, 12th Floor Jalan Jenderal Gatot Subroto Kav.40 Jakarta 12710.
Offline submission of reports as referred to in item 5 is conducted by one of the following methods:
a. handed in directly to the Financial Services Authority office; or b. sent via a courier service company.
The Company is deemed to have submitted the report with the following provisions:
a. for online submission via:

the Financial Services Authority's data communication network system, proven by a receipt from the Financial Services Authority's data communication network system; or
email to the Financial Services Authority, proven by an email sending receipt, in the event that sending via the data communication network cannot be performed; or
b. for offline submission, proven by a receipt from the Financial Services Authority.

The Financial Services Authority may request original printed copies of reports that have been submitted by the Company through the Financial Services Authority's data communication network system.

This copy is consistent with the original Director of Legal Affairs 1 Legal Department signed Mufli Asmawidjaja

IV. CLOSING PROVISIONS

The provisions in this Financial Services Authority Circular Letter shall take effect on the date of determination.
Upon the effective date of this Financial Services Authority Circular Letter:
a. Financial Services Authority Circular Letter Number 3/SEOJK.05/2018 concerning the Form and Structure of Periodic Reports for Insurance Brokerage Companies, Reinsurance Brokerage Companies, and Insurance Loss Assessing Companies; and b. Item Roman II Number 5 letter b and Appendix IV in Financial Services Authority Circular Letter Number 10/SEOJK.05/2016 concerning Guidelines for the Implementation of Risk Management and Self-Assessment Results of Risk Management Implementation for Non-Bank Financial Service Institutions, are repealed and declared invalid.

Determined in Jakarta on December 22, 2020 EXECUTIVE HEAD OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed RISWINANDI

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020 CONCERNING THE FORM AND STRUCTURE OF REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSING COMPANIES

To:
Directorate of IKNB Support Services Financial Services Authority

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

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

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

Head Office Address

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

Telephone
Facsimile
Email
Website Address
Taxpayer Identification Number (NPWP)
Business License

Business License Number
Business License Date

Number of Offices Other Than Head Office
Number of Affiliated Companies
Number of Employees
(including management and staff)
Number of Partners in Business Acquisition

Individuals
Legal Entities

Auditor

Public Accounting Firm
Public Accountant
Registration Certificate Number (STTD)

OJK Liaison Officer

Name
Mobile Phone
Email

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

INSURANCE BROKERAGE COMPANY
FORM PP03
MANAGEMENT STRUCTURE LIST
Semester ... / Year ...
No. Name
Manager
Position OJK Fit and Proper Assessment Letter OJK Administration Letter LSP Expertise Certification Letter Date Number Number Date Number Date 1 President Director / Director / Chief Commissioner / Commissioner

INSURANCE BROKERAGE COMPANY
FORM PP04
EXPERTS AND BROKERS LIST
Semester ... / Year ...
No. Name Professional Title Position Appointment Letter OJK Registration Number LSP Expertise Certification Letter Date Number Number Date 1 CIIB / APAI / AAPAI / AAIK / AAAIK / AAIJ / AAAIJ Expert / Insurance Broker ...

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

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

Agriculture, forestry and fisheries 8. Transportation and warehousing 15. Public administration, defense and mandatory social security
Mining and quarrying 9. Accommodation and food and beverage services 16. Education services
Manufacturing 10. Information and communication 17. Health and social services
Electricity, gas, steam/hot water and
air conditioning supply
Financial services and insurance 18. Arts, entertainment and recreation
Water supply, waste management and
recycling, sewage and cleaning of waste and garbage
Real Estate 19. Other service activities
Construction 13. Professional, scientific and technical services 20. Personal and household services; activities that
generate goods and services by households used for own needs to meet needs
Wholesale and retail trade; repair and maintenance of cars and motorcycles
Rental and leasing services without option, labor services, travel agencies and other business support
Activities of international bodies and other extra-international bodies

INSURANCE BROKERAGE COMPANY
FORM PP07
FULFILLMENT OF CRITERIA FOR FOREIGN LEGAL ENTITIES BECOMING OWNERS/SHAREHOLDERS OF COMPANIES Semester ... / Year ...
PT ....
First Degree Direct Shareholder For Period... Name Shareholder Citizenship/ Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)
PT ....
Second Degree Indirect Shareholder For Period... Name Shareholder Name of First Degree Shareholder Citizenship / Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)
PT ....
Third Degree Indirect Shareholder (and onwards) For Period ... Name Shareholder Name of Second Degree Shareholder (and onwards) Citizenship / Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)

PT ....
Degree ... Direct Shareholder
For Period ...
Name of Shareholder
Degree
Citizenship/ Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)

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

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

INSURANCE BROKERAGE COMPANY
FORM LK02
STATEMENT OF COMPREHENSIVE INCOME Semester ... / Year ... (In Rupiah) Description Code Details Amount REVENUE Intermediary Service Revenue Formula= 4100 – 4110 +4200 Direct Intermediary Service Revenue 4100 LR01 -/- Portion of Intermediary Service Revenue of Other Companies – Member Cobroking Indirect Intermediary Service Revenue 4200 LR01 Consulting Service Revenue 4300 LR01 Claim Handling Service Revenue 4400 LR01 Other Revenue 4900 LR03 Total Revenue 4000 EXPENSES Operating Expenses Employee and Management Expenses 5100 LR04 Education and Training Expenses 5200 LR05 Marketing Expenses 5300 Commission Expenses 5400 LR06 Other Operating Expenses 5500 LR07 Non-Operating Expenses 5900 LR08 Total Expenses 5000 Profit (Loss) Before Tax 6100 Tax Expense 5600 Profit (Loss) After Tax 6200 Comprehensive Income (Expense) Increase (Decrease) in Fixed Asset Valuation 5710 Foreign Currency and Other Gains (Losses) 5720 Total Comprehensive Income (Expense) 5700 Comprehensive Profit (Loss) 6300

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

(in Rupiah)
Description Amount
Cash Flows from Financing Activities Cash Inflows from Financing Activities Cash Inflows from Capital Contributions Cash Inflows from Loans Cash Inflows from Other Financing Activities Cash Outflows for Financing Activities Cash Outflows for Dividend Payments Cash Outflows for Loan Repayments Cash Outflows for Other Financing Activities Total Cash Flows from Financing Activities Net Increase (Decrease) in Cash and Cash Equivalents Ending Cash-Bank Balance

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

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

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

INSURANCE BROKERAGE COMPANY
FORM PK02
PREMIUM ACCOUNT CHANGE REPORT
Semester ... / Year ...
(in Rupiah)
Description Amount
Beginning Balance of Premium Account Additions Receipt of Net Premiums Receipt of Brokerage Fees Receipt of Bank Interest Receipt of Claims from Insurance Companies Total Additions Deductions Premium deposits to insurance companies Transfer of brokerage fees to operational accounts Transfer for premium refunds Transfer of account interest to operational accounts Payment of claims to insured parties Total Deductions Increase (Decrease) in Premium Account Ending Balance of Premium Account

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

INSURANCE BROKERAGE COMPANY
FORM PK04
PREMIUM RECEIVABLES
Semester ... / Year ...
(in Rupiah)
No. Debit Note Number Insured Amount of Debit Note Business Line Status of Business Aging Amount 1 Property Individual / Company < 30 Days / 30 - 90 Days / > 90 Days 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life ... Combined Total Premium Receivables

INSURANCE BROKERAGE COMPANY
FORM PK05
BROKERAGE FEE RECEIVABLES
Semester ... / Year ...
(in Rupiah)
No. Name of Insured Insurance Company Type Status of Business Aging Amount 1 Direct/Indirect Individual / Company < 30 Days / 30 - 90 Days / > 90 Days ... Combined Total Brokerage Fee Receivables

INSURANCE BROKERAGE COMPANY
FORM PK06
CONSULTATION AND CLAIM HANDLING SERVICE RECEIVABLES Semester ... / Year ... (in Rupiah) No. Debtor Type of Receivable Status of Business Aging Amount 1 Consultation Receivable / Claim Handling Service Receivable Individual / Company < 30 Days / 30 - 90 Days / > 90 Days ... Total Brokerage Fee Receivables

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

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

INSURANCE BROKERAGE COMPANY
FORM PK09
PREMIUM PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Credit Note Number Insurance Company Amount of Credit Note Business Line Payment Status Insured Status of Business Aging Amount 1 Property Paid / Unpaid Individual / Company < 30 Days / 30 - 90 Days / > 90 Days 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life ... Combined Total Premium Payables

INSURANCE BROKERAGE COMPANY
FORM PK10
CLAIM PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Name of Insured Insurance Company Business Line Amount 1 Property 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life ... Combined Total Claim Payables

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

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

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

INSURANCE BROKERAGE COMPANY
FORM LR01
INCOME
Semester ... / Year ...
(in Rupiah)
No. Business Line Amount
Policy
Placement Process Placement Location Premium Brokerage Fee Income Consultation Service Income Claim Handling Service Income Direct Indirect 1 Property Digital/Non-Digital Domestic / ASEAN / NON-ASEAN 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total

INSURANCE BROKERAGE COMPANY
FORM LR02
TOP 30 INSURANCE PLACEMENT INCOME Semester ... / Year ... (in Rupiah) No. Insurer Amount Policy Placement Location Premium Brokerage Fee Income Consultation Service Income Claim Handling Service Income Direct Indirect 1 Domestic / ASEAN / NON-ASEAN ... Total

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

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

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

INSURANCE BROKERAGE COMPANY
FORM LR06
COMMISSION EXPENSES
Semester ... / Year ...
(in Rupiah)
No. Commission Recipient Status of Business Business Line Amount 1 Individual / Company Property 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total Commission Expenses

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

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

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

INSURANCE BROKERAGE COMPANY
FORM OP02
TOP 30 CLAIM HANDLING
Semester ... / Year ...
(in Rupiah)
No. Name of Insured Policy Number Business Line Sum Insured Date of Occurrence Estimated Loss Amount Insurance Company Claim Status Notes 1 Property Paid / In Process / Rejected 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total

INSURANCE BROKERAGE COMPANY
FORM OP03
CLAIM HANDLING DEVELOPMENT
Semester ... / Year ...
(in Rupiah)
No. Business Line Claim Status Total Claim Cases Total Loss Value 1 Property Paid / In Process / Rejected 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total

To
The Directorate of IKNB Support Services Financial Services Authority FINANCIAL STATEMENTS REINSURANCE BROKERAGE COMPANY Semester ... / Year ... FORMAT IB

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

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

Head Office Address

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

Telephone
Facsimile
Email
Website Address
Taxpayer Identification Number (NPWP)
Business License

Business License Number
Business License Date

Number of Offices Other Than Head Office
Number of Affiliated Companies
Number of Employees
(including executives and staff)
Number of Business Acquisition Partners

Individuals
Legal Entities

Auditor

Public Accounting Firm
Public Accountant
Registration Certificate Number (STTD)

OJK Liaison Officer

Name
Mobile Phone
Email

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

REINSURANCE BROKERAGE COMPANY
FORM PP03
EXECUTIVE STRUCTURE LIST
Semester ... / Year ...
No. Executive Name Position OJK Fit and Proper Assessment Letter OJK Administrative Letter LSP Expertise Certification Letter Date Number Number Date Number Date 1 President Director / Director / Supervisory Board Chairman / Supervisor

REINSURANCE BROKERAGE COMPANY
FORM PP04
EXPERTS AND BROKERS LIST
Semester ... / Year ...
No. Name Title Profession Position Appointment Letter OJK Registration Number LSP Expertise Certification Letter Date Number Number Date 1 CIIB / APAI / AAPAI / AAIK / AAAIK / AAIJ / AAAIJ Expert / Reinsurance Broker ...

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

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

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

REINSURANCE BROKERAGE COMPANY
FORM PP07
COMPLIANCE WITH CRITERIA FOR FOREIGN LEGAL ENTITIES THAT ARE OWNERS/SHAREHOLDERS OF THE COMPANY Semester ... / Year ...
PT ....
First Degree Direct Shareholder For Period... Shareholder Name Nationality/Country of Legal Entity Registration Business Type Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)
PT ....
Second Degree Indirect Shareholder For Period... Shareholder Name First Degree Shareholder Name Nationality/Country of Legal Entity Registration Business Type Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)
PT ....
Third Degree Indirect Shareholder (and subsequent) For Period ... Shareholder Name Second Degree Shareholder Name (and subsequent) Nationality/Country of Legal Entity Registration Business Type Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)

PT ....
Degree ... Direct Shareholder
For Period ...
Shareholder Name Degree Nationality/Country of Legal Entity Registration Business Type Name of Supervisory Authority Insurance Subsidiary Equity Total Nominal Shares (Rp) Ownership Percentage (%)

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

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

REINSURANCE BROKERAGE COMPANY
FORM LK02
COMPREHENSIVE INCOME STATEMENT Semester ... / Year ... (In Rupiah) Description Code Details Amount INCOME Brokerage Fee Income Direct Brokerage Fee Income 4100 LR01 Indirect Brokerage Fee Income 4200 LR01 Consultation Service Income 4300 LR01 Claim Handling Service Income 4400 LR01 Other Income 4900 LR03 Total Income 4000 EXPENSES Operational Expenses Employee and Executive Expenses 5100 LR04 Education and Training Expenses 5200 LR05 Marketing Expenses 5300 Commission Expenses 5400 LR06 Other Operational Expenses 5500 LR07 Non-Operational Expenses 5900 LR08 Total Expenses 5000 Profit (Loss) Before Tax 6100 Tax Expense 5600 Profit (Loss) After Tax 6200 Comprehensive Income (Expense)

Increase (Decrease) in Fixed Asset Valuation 5710
Foreign Currency and Other Gains (Losses) 5720 Total Comprehensive Income (Expense) 5700 Comprehensive Profit (Loss) 6300

REINSURANCE BROKERAGE COMPANY
FORM LK03
CASH FLOW STATEMENT
Semester ... / Year ...
(in Rupiah)
Description Amount
Beginning Cash-Bank Balance
Cash Flows from Operating Activities Cash Inflows for Operating Activities Cash Inflows from Premiums (Net) Cash Inflows from Direct Brokerage Services Cash Inflows from Indirect Brokerage Services Cash Inflows from Consultation Services Cash Inflows from Claim Handling Services Cash Inflows from Insurance Company Claims Cash Inflows from Other Operating Activity Income Cash Outflows for Operating Activities Cash Outflows for Premiums to Reinsurers Cash Outflows for Premium Refunds to Ceding Companies Cash Outflows for Employee and Executive Expenses Cash Outflows for Education Expenses Cash Outflows for Marketing Expenses Cash Outflows for Commission Expenses Cash Outflows for Claims to Ceding Companies Cash Outflows for Other Operating Activity Payments Total Cash from Operating Activities Cash Flows from Investing Activities Cash Inflows from Investing Activities Cash Inflows from Investment Returns Cash Inflows from Investment Liquidation Cash Inflows from Asset Sales Cash Inflows from Other Investing Activities Cash Outflows for Investing Activities Cash Outflows for Investment Placements Cash Outflows for Purchase of Fixed Assets Cash Outflows for Other Investing Activities Total Cash Flows from Investing Activities

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

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

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

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

REINSURANCE BROKERAGE COMPANY
FORM PK02
PREMIUM ACCOUNT CHANGE REPORT
Semester ... / Year ...
(in Rupiah)
Description Amount
Beginning Balance of Premium Account Additions Receipt of Net Premiums Receipt of Brokerage Fees Receipt of Bank Interest Receipt of Claims from Reinsurers Total Additions Deductions Premium deposits to Reinsurers Transfer of Brokerage Fees to Operational Accounts Transfer for Premium Refunds Transfer of Account Interest to Operational Accounts Payment of Claims to Ceding Companies Total Deductions Increase (Decrease) in Premium Account Ending Balance of Premium Account

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

REINSURANCE BROKERAGE COMPANY
FORM PK04
PREMIUM RECEIVABLES
Semester ... / Year ...
(in Rupiah)
No. Debit Note Number Ceding Company Amount of Debit Note Type of Reinsurance Business Line Aging Amount Treaty/Facultative 1 Property < 30 Days / 30 - 90 Days / > 90 Days 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life ... Combined Total Premium Receivables

REINSURANCE BROKERAGE COMPANY
FORM PK05
BROKERAGE FEE RECEIVABLES
Semester ... / Year ...
(in Rupiah)
No. Name of Ceding Company Type Aging Amount 1 Direct/Indirect < 30 Days / 30 - 90 Days / > 90 Days ... Combined Total Brokerage Fee Receivables

REINSURANCE BROKERAGE COMPANY
FORM PK06
CONSULTATION AND CLAIM HANDLING SERVICE RECEIVABLES Semester ... / Year ... (in Rupiah) No. Debtor Type of Receivable Aging Amount 1 Consultation Receivable / Claim Handling Service Receivable < 30 Days / 30 - 90 Days / > 90 Days ... Total Brokerage Fee Receivables

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

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

REINSURANCE BROKERAGE COMPANY
FORM PK09
PREMIUM PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Credit Note Number Reinsurer Amount of Credit Note Type of Reinsurance Business Line Payment Status Ceding Company Aging Amount Treaty/Facultative 1 Property Paid / Unpaid < 30 Days / 30 - 90 Days / > 90 Days 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life ... Combined Total Premium Payables

REINSURANCE BROKERAGE COMPANY
FORM PK10
CLAIM PAYABLES
Semester ... / Year ...
(in Rupiah)
No. Ceding Company Name of Reinsurer Aging Amount 1 < 30 Days / 30 - 90 Days / > 90 Days ... Combined Total Premium Payables

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

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

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

REINSURANCE BROKERAGE COMPANY
FORM LR01
INCOME
Semester ... / Year ...
(in Rupiah)
No.
Business Line
Amount Slip
Reinsurance
Process
Placement
Location
Placement
Premium Brokerage Fee Income
Consultation Service Income
Claim Handling Service Income
Direct Indirect
1 Property Digital/Non-Digital Domestic / ASEAN / NON-ASEAN 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total

REINSURANCE BROKERAGE COMPANY
FORM LR02
TOP 30 INSURANCE PLACEMENT INCOME Semester ... / Year ... (in Rupiah) No. Reinsurance Amount Slip Reinsurance Placement Location Premium Brokerage Fee Income Consultation Service Income Claim Handling Service Income Direct Indirect 1 Domestic / ASEAN / NON-ASEAN ... Total

REINSURANCE BROKERAGE COMPANY
FORM LR03
OTHER INCOME
Semester ... / Year ...
(in Rupiah)
No. Description Amount
...
Total Other Income

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

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

REINSURANCE BROKERAGE COMPANY
FORM LR06
COMMISSION EXPENSES
Semester ... / Year ...
(in Rupiah)
No. Commission Recipient Status of Business Business Line Amount 1 Individual / Company Property 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft Hulls 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total Commission Expenses

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

REINSURANCE BROKERAGE COMPANY
FORM LR08
OTHER NON-OPERATIONAL EXPENSES Semester ... / Year ... (in Rupiah) No. Description Amount Total Other Non-Operational Expenses

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

REINSURANCE BROKER COMPANY
FORM OP02
TOP 30 CLAIM HANDLING
Semester ... / Year ...
(in Rupiah)
No. Name
Ceding Company
Register Number
Claim Line of Business
Date of Occurrence
Estimated Value of Loss
Reinsurance Company
Claim Status Remarks
1 Property Paid / In Process / Rejected 2 Motor Vehicles 3 Cargo 4 Hull 5 Aircraft 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total

REINSURANCE BROKER COMPANY
FORM OP03
CLAIM HANDLING DEVELOPMENT
Semester ... / Year ...
(in Rupiah)
No. Line of Business Claim Status Total Number of Claims Total Value of Losses 1 Property Paid / In Process / Rejected 2 Motor Vehicles 3 Cargo 4 Hull 5 Aircraft 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship 14 Miscellaneous 15 Life Total

TO
Honorable Directorate of Supporting Services for Non-Banking Financial Institutions Financial Services Authority FINANCIAL REPORT INSURANCE LOSS ASSESSOR COMPANY Year ... FORMAT IC General Data Reporting Date Company Code Company Name Company Address Reporting Period Reporting Month Fiscal Year Type of Reporting Period Board of Directors Name Directors' Positions

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

Head Office Address

Building Name and Floor
Street Name and Number
Village/Sub-district (Kelurahan)
District (Kecamatan)
Regency/City (Kabupaten/Kota)
Province
Postal Code

Telephone
Facsimile
Email
Website Address
Taxpayer Identification Number (NPWP)
Business License

Business License Number
Business License Date

Number of Offices Other Than Head Office
Number of Affiliated Companies
Number of Employees
(including directors and staff)
Number of Partners in Business Acquisition

Individuals
Legal Entities

Auditor

Public Accounting Firm
Public Accountant
Registration Certificate Number (STTD)

OJK Liaison Officer

Name
Mobile Phone
Email

INSURANCE LOSS ASSESSOR COMPANY FORM PP02 SHAREHOLDER LIST Year ... No. Shareholder Name Share Ownership Ability and Fitness Assessment SK OJK Approval Letter Nominal % Date Number Number Date ... Total

INSURANCE LOSS ASSESSOR COMPANY FORM PP03 MANAGEMENT STRUCTURE LIST Year ... No. Name Management Position Ability and Fitness Assessment SK Administrative Letter Certification Letter LSP Expertise Date Number Number Date Number Date 1 President Director / Director / Chief Commissioner / Commissioner

INSURANCE LOSS ASSESSOR COMPANY FORM PP04 EXPERTS LIST Year ... No. Name Title Profession Appointment SK OJK Registration Letter OJK Registration Number Expertise Certification Letter LSP Date Number Date Number Number Date 1 ICAP / ANZIIF ...

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

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

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

INSURANCE LOSS ASSESSOR COMPANY FORM PP07 FULFILLMENT OF CRITERIA FOR FOREIGN LEGAL ENTITIES THAT ARE OWNERS/SHAREHOLDERS OF THE COMPANY Semester ... / Year ...
PT ....
First Degree Direct Shareholders For Period... Name Shareholder Citizenship/ Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Number of Shares Nominal (Rp) Ownership Percentage (%)
PT ....
Second Degree Indirect Shareholders For Period... Name Shareholder Name of First Degree Shareholder Citizenship / Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Number of Shares Nominal (Rp) Ownership Percentage (%)
PT ....
Third Degree Indirect Shareholders (and subsequent) For Period ... Name Shareholder Name of Second Degree Shareholder (and subsequent) Citizenship / Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Number of Shares Nominal (Rp) Ownership Percentage (%)

PT ....
Degree ... Direct Shareholders For Period ... Name of Shareholder Degree Citizenship/ Country of Legal Entity Registration Type of Business Name of Supervisory Authority Insurance Subsidiary Equity Number of Shares Nominal (Rp) Ownership Percentage (%)

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

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

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

INSURANCE LOSS ASSESSOR COMPANY FORM LK03 CASH FLOW STATEMENT Year ... (in Rupiah) Description Amount Cash Flows from Operating Activities Cash Inflows for Operating Activities Cash Inflows from Claims Assessment Services Cash Inflows from Consultation Services Cash Inflows from Advances Fund Returns Cash Inflows from Other Operating Activity Revenue Cash Outflows for Operating Activities Cash Outflows for Employee and Management Expenses Cash Outflows for Education Expenses Cash Outflows for Marketing Expenses Cash Outflows for Commission Expenses Cash Outflows for Other Operating Activity Payments Total Cash Flows from Operating Activities Cash Flows from Investing Activities Cash Inflows from Investing Activities Cash Inflows from Investment Income Receipts Cash Inflows from Investment Liquidations Cash Inflows from Asset Sales Cash Inflows from Other Investing Activities Cash Outflows for Investing Activities Cash Outflows for Investment Placements Cash Outflows for Fixed Asset Purchases Cash Outflows for Other Investing Activities Total Cash Flows from Investing Activities

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

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

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

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

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

INSURANCE LOSS ASSESSOR COMPANY FORM PK03 CLAIMS HANDLING SERVICE RECEIVABLES Year ... (in Rupiah) No. Assignment Letter Number Assignor Status Business Entity Aging Amount 1 Individual / Company < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Combined Total Claims Assessment Service Receivables

INSURANCE LOSS ASSESSOR COMPANY FORM PK04 ADVANCES FUND RECEIVABLES Year ... (in Rupiah) No. Assignor Status Business Entity Aging Amount 1 Individual / Company < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Total Advances Fund Receivables

INSURANCE LOSS ASSESSOR COMPANY FORM PK05 CONSULTATION SERVICE RECEIVABLES Year ... (in Rupiah) No. Assignor Status Business Entity Aging Amount 1 Individual / Company < 30 Days/ 30 - 90 Days / > 90 Days ... Combined Total Consultation Service Receivables

INSURANCE BROKER COMPANY
FORM PK06
FIXED ASSETS
Year ...
(in Rupiah)
No. Type of Asset Acquisition Cost Accumulated Depreciation Book Value 1 Land / Building / Vehicles / Office Equipment / Other Fixed Assets ... Total Fixed Assets

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

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

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

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

INSURANCE LOSS ASSESSOR COMPANY FORM LR01 REVENUE Year ... (in Rupiah) No. Line of Business Amount Assignment Letter Number Sum Insured Claim Value Type of Revenue Revenue 1 Property Loss Assessor Services / Consultation Services 2 Motor Vehicles 3 Cargo 4 Hull 5 Aircraft 6 Satellites 7 Offshore Energy 8 Onshore Energy 9 Engineering 10 Liability 11 Personal Accident and Health 12 Credit 13 Suretyship ... Miscellaneous Total

INSURANCE LOSS ASSESSOR COMPANY FORM LR02 TOP 30 REVENUE Year ... (in Rupiah) No. Assignor Amount Assignment Letter Number Sum Insured Claim Value Type of Revenue Revenue 1 Loss Assessor Services / Consultation Services ... Total

INSURANCE LOSS ASSESSOR COMPANY FORM LR03 OTHER REVENUE Year ... (in Rupiah) No. Description Amount ... Total Other Revenue

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

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

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

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

This copy is consistent with the original Legal Director 1 Legal Department signed Mufli Asmawidjaja INSURANCE LOSS ASSESSOR COMPANY FORM LR08 OTHER NON-OPERATING EXPENSES Year ... (in Rupiah) No. Description Amount Total Other Non-operating Expenses Established in Jakarta on December 22, 2020 CHIEF EXECUTIVE SUPERVISOR OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed RISWINANDI

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKER COMPANIES, REINSURANCE BROKER COMPANIES, AND INSURANCE LOSS ASSESSOR COMPANIES

Report on the Implementation of Good Corporate Governance for Insurance Broker Companies, Reinsurance Broker Companies, and Insurance Loss Assessor Companies

Transparency of Good Corporate Governance Implementation
a. General Meeting of Shareholders (GMS) Execution Execution of annual GMS and extraordinary GMS as well as decisions resulting from each GMS No. Time of Execution Agenda Participants Decision Notary Deed Number Note 1. 2. Etc. b. Board of Directors

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

Etc.
Etc.
4) Frequency of Board of Directors meetings held within 1 (one) year.
No Name Position Number of Board Meetings (... times meeting) % Attendance Physical Attendance Teleconference/Video/Conference/Other Electronic Media Facilities 1. 2. Etc
5) Disclosure of share ownership by Board of Directors members reaching 5% (five percent) or more of paid-up capital, including type and number of shares.
No Name Position Board of Directors Member Share Ownership Reaching 5% (five percent) or More of Paid-up Capital A B C D Note:
Indonesia/Overseas Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership 1. 2. Etc. Note:
A. The company itself;
B. other insurance companies;
C. financial services companies other than insurance companies; and
D. other companies located both inside and outside the country, including shares obtained through the stock exchange.
6) Financial relationships and family relationships of Board of Directors members with other Board of Directors members, Commissioners, and/or shareholders of the company where the Board of Directors member serves.
No. Name Financial Relationship With Other Directors Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc No. Name Family Relationship With Other Directors Commissioners Shareholders Yes No Note* Yes No Note* Yes No Note* 1. 2.

Note:
*) Form of financial relationship: debt-receivable, business cooperation, etc. ) Form of family relationship: husband/wife/child/parent/sibling/in-law, etc.
c. Board of Commissioners

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

Etc.
Etc.
4) Frequency of Board of Commissioners meetings held within 1 (one) year.
No Name Position Number of Board of Commissioners Meetings (... times meeting) % Attendance Physical Attendance Teleconference/Video/Conference/Other Electronic Media Facilities 1. 2. Etc
5) Board of Commissioners Meetings with the Board of Directors
No Name Position Number of Board of Commissioners Meetings (... times meeting) % Attendance Physical Attendance Teleconference/Video/Conference/Other Electronic Media Facilities 1. 2. Etc
6) Board of Commissioners Meetings with External Auditors
No Name Position Number of Board of Commissioners Meetings (... times meeting) % Attendance Physical Attendance Teleconference/Video/Conference/Other Electronic Media Facilities 1. 2. Etc (Resume of Meeting Results) (Resume of Meeting Results)
7) Disclosure of share ownership by Board of Commissioners members reaching 5% (five percent) or more of paid-up capital, including type and number of shares.
No Name Position Board of Directors Member Share Ownership Reaching 5% (five percent) or More of Paid-up Capital A B C D Note:
Indonesia/Overseas Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership 1. 2. Etc. Note:
A. The company itself;
B. other insurance companies;
C. financial services companies other than insurance companies; and
D. other companies located both inside and outside the country, including shares obtained through the stock exchange.
8) Financial relationships and family relationships of Board of Commissioners members with other Board of Commissioners members, Board of Directors members, and/or shareholders of the company where the Board of Commissioners member serves

N o . Name Financial Relationship With Other Commissioners Directors Shareholders Yes No Note* Yes No Note* Yes No Note*

Etc
No. Name Family Relationship With Other Commissioners Directors Shareholders Yes No Note* Yes No Note* Yes No Note* 1. 2. (Resume of Meeting Results)

Note:
*) Form of financial relationship: debt-receivable, business cooperation, etc. ) Form of family relationship: husband/wife/child/parent/sibling/in-law, etc. d. Board of Commissioners Supervision Results Report Summary of Supervision Results Recommendations e. Implementation of external auditor functions. No. Description Year n-2 Year n-1 Year n

Name of Public Accounting Firm
Name of Public Accountant
Audit Period
GMS Number
f. Implementation of remuneration policies and other facilities for Board of Directors, Board of Commissioners, Number of Board of Directors, Board of Commissioners, and employees receiving remuneration packages in 1 (one) year grouped according to income level as follows:
Individual Remuneration Amount in 1 year *) Number of Directors Number of Commissioners Employees Above Rp2 billion Above Rp1 billion up to Rp2 billion Above Rp500 million up to Rp1 billion Below Rp500 million Note:
*) requested in cash g. Information Technology Governance No. Description Checklist *) If Yes, Explain. Yes No 1. Does the company have an information system organizational structure?
Does the company have guidelines for the use of information systems equipped
No. Description Checklist *) If Yes, Explain. Yes No with instructions or work orders for each function (standard operating procedure)? 3. Does the company have data security management guidelines (data back-up)? 4. Does the company have incident management guidelines (disaster recovery plan)? *) marked with a checkmark h. Number of internal deviations (internal fraud) Disclosure regarding internal deviations must at least include:
Internal Deviations in Year
Number of cases committed by Board of Commissioners and Board of Directors Members Permanent Employees Non-permanent Employees T-1 T T-1 T T-1 T Total deviations Already resolved In the process of internal resolution Resolution not yet attempted Already followed up through legal processes.
i. Legal issues
Legal Issues Number of Cases Civil Criminal Has received a final and binding decision In the process of resolution in court and in Alternative Dispute Resolution Institutions for civil cases Total

j. Functions of the Company outsourced to third parties (outsourcing) No Function Outsourced Name of Third Party Business License Contract Duration 1. 2. Etc. k. Disclosure of other important matters No. Description Checklist *) If Yes, Explain. Yes No 1. Resignation or dismissal of external auditors
2. Material transactions with related parties
3.
Material claims filed by and/or against Insurance Companies 4. Conflicts of Interest currently ongoing and/or likely to occur 5. Other material information regarding Insurance Companies
6. The company has a compliance function
7. The company has an internal auditor
8. The company has a risk management function
9.
The company has an investment management function/unit 10. The company has a special work unit and/or appoints a Company official responsible for the implementation of AML and CFT programs *) choose one answer by placing a “√” mark ) Related Parties are individuals or companies/entities that have control relationships with the Company, either directly or indirectly, through ownership, management, and/or financial relationships
2. Self-Assessment on the Implementation of Good Corporate Governance for Insurance Broker Companies, Reinsurance Broker Companies, and Insurance Loss Assessor Companies.
☑ Self-assessment on the implementation of Good Corporate Governance for Insurance Broker Companies and Reinsurance Broker Companies is conducted based on the Guidelines for Good Corporate Governance and the self-assessment checklist prepared by the National Committee for Governance Policy (KNKG) as a committee formed by the government

This copy matches the original Legal Director 1 Legal Department signed Mufli Asmawidjaja who is responsible for formulating good corporate governance policies.

Self-assessment (self assessment) of the implementation of Good Corporate Governance for Insurance Loss Assessors has not yet taken effect until the issuance of the Guidelines on Good Corporate Governance for Insurance Loss Assessors and the self-assessment checklist by the National Governance Policy Committee (KNKG), a committee formed by the government responsible for formulating good corporate governance policies.

Action Plan.
No. Corrective Action
Target
Completion Date
Obstacles
Completion Notes

...
Determined in Jakarta on December 22, 2020 EXECUTIVE HEAD OF SUPERVISOR INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed RISWINANDI

APPENDIX III
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020 ON THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSORS

FORMAT III A
FORM AND STRUCTURE OF REPORTS OTHER THAN PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES AND REINSURANCE BROKERAGE COMPANIES Business Plan in accordance with the provisions of Article 7 paragraph (3), Article 15 paragraph (5) and
Article 19 regarding the Business Plan of Non-Bank Financial Services Institutions with a submission deadline of no later than November 30 of the previous year.

BUSINESS PLAN
Year ...............................
(fill in company name and address) Approved, Board of Commissioners (Company Stamp) N a m e C l e a r Position 20xx Director, (Company Stamp) N a m e C l e a r Position

BUSINESS PLAN
FOR INSURANCE BROKERAGE COMPANIES AND REINSURANCE BROKERAGE COMPANIES 1 : Executive Summary 2 : Evaluation of the Implementation of the Previous Period's Business Plan 3 : Vision, Mission, and Business Strategy 4 : Business Activity Plan 5 : Business Development or Expansion Plan 6 : Capital Plan 7 : Funding Plan 8 : Office Network Development and/or Change Plan 9 : Organization, Human Resources, and/or Information Technology Development Plan 10 : Financial Statement Projections, Ratio Projections, and Other Specific Items, and Assumptions Used 11 :
Other Information

Executive Summary
Plans and Strategic Steps to be Taken by the Company *)
...........................................................................................................
...........................................................................................................
...........................................................................................................
Note:
*) Plans and Strategic Steps for a period of 1 (one) year, taking into account the 3 (three) year medium-term plan and the 5 (five) year long-term plan. Matters that can be disclosed in the aforementioned plans and strategic steps include:

Business brokerage development strategy,
Changes in the composition of key parties,
Office network expansion,
Capital strengthening, and
Governance implementation.
a. Financial Indicators
Filled in Rupiah
No. Financial Indicator
Performance
Jun X1
Performance
Sept X1
Projection
Dec
X-1
June X Dec X
1 Assets
2 Premium Receivables
3 Brokerage Service Receivables 4 Premium Payables 5 Equity 6 Operational Revenue 7 Operational Expenses 8 Comprehensive Income (Loss) Note:
Operational revenue consists of brokerage service revenue, consultation service revenue, and claim handling service revenue

b. Financial Ratios
%
No. Description
Performance
Jun X1
Performance
Sept X1
Projection
Dec X1
June X Dec X
Return on Asset (ROA) : (net profit after tax/total asset) Return on Equity (ROE): (net profit after tax/total equity) Operational Expense to Operational Revenue Ratio (BOPO) Deferred Premium Ratio ((premium payable – premium receivable)/ premium payable) Deferred Premium Fund Adequacy Ratio (total premium accounts/(premium payable-premium receivable)) Commission Expense to Operational Revenue Ratio (Commission Expense/Operational Revenue)
2. Evaluation of the Implementation of the Previous Period's Business Plan
Briefly describe the plans and realization of corporate actions listed in the previous period's business plan. (Ignore if your company is a new company or first implementation in the industry). No. Corporate Action Business Plan Realization Obstacles Problem Solving Efforts 1 Business Development 2 Capital 3 Funding

Plans regarding brokerage service business activities in business lines previously implemented by the Company with reference to the provisions of legislation regarding the conduct of the Company's business and business licenses as well as approval of the Company's business activities to OJK. Can be added with reasons and considerations in formulating the aforementioned plan and strategies to realize the plan. 4 Office Network Development 5 Human Resources Development
3. Vision, Mission, and Business Strategy
a. Company Vision
Vision is the description of the company's condition in the future and is the company's aspiration. Vision is a statement answering the question of the company's direction ahead. b. Company Mission Mission is the elaboration of the vision that describes the existing environmental conditions and market conditions as well as the Company's anticipation ahead.
c. Company Business Strategy

analysis of the Company's position in facing business competition
...................................................................................................
...................................................................................................
Company policy direction
...................................................................................................
...................................................................................................
management policy (policy statements)
...................................................................................................
..................................................................................................
business development strategy
...................................................................................................
Business Activity Plan
Business Development or Expansion Plan
No. Type of Business Line
General Description
Business Activity
Time of Implementation
Business Activity
Reasons
And
Considerations
Business Expansion Strategy
Capital Plan
The capital plan must at least include plans for capital changes including plans for capital additions from existing shareholders or new shareholders, plans for capital additions through the capital market, and plans for other capital additions. Capital Change Plan

Description Regarding Capital Change Plans
(filled with plans for capital changes accompanied by nominal size plans and implementation time plans for the aforementioned capital changes)
Reasons and Considerations
(filled with reasons/considerations in formulating the capital change plan)
Strategy
(filled with strategies to realize the capital change plan)

Funding Plan
a) Description Regarding Funding Plans
.....................................................................................................
.....................................................................................................
...........................................................

filled with plans based on funding sources to be obtained by the Company in the next 1 year. The funding sources mentioned can come from subordinated loans or the issuance of securities through public offerings.

b) Reasons and Considerations
.....................................................................................................
.....................................................................................................
...........................................................

filled with reasons/considerations in formulating the funding plan
c) Strategy
.....................................................................................................
.....................................................................................................
...........................................................
filled with strategies to realize the funding plan

Office Network Development and/or Change Plan
Office network development and/or change plans must at least include plans for opening and merging offices outside the head office. No. Type of Office Time Implementation 1 Location 2 Notes 3 A. Opening B. Address Change ...
C. Closing
...
Note:
Filled with the month of the planned implementation time.
For locations in the DKI Jakarta province, at least mention the name of the DKI Jakarta province. For locations outside the DKI Jakarta province, at least include the name of the Regency/City.
Detailed notes can be attached in a separate sheet.
Specifically for offices that have the authority to accept or reject insurance closures, information on experts who will fill those offices must be provided.
Organization, Human Resources, and/or Information Technology Development Plan
a. Organization Development Plan

Description Regarding Organization Development Plans
(filled with explanations regarding organization development plans, including plans for the formation of work units/divisions, plans for changes to work units/divisions, and plans for committee formation, adjusted to the size and complexity of the Company's business)
Reasons and Considerations
(filled with reasons/considerations in formulating the organization development plan)
Strategy
(filled with strategies to realize the organization development plan) b. Human Resources Development Plan
Description Regarding Human Resources Fulfillment Plans
No. Type of Fulfillment
Actual
Number
Human Resources
Human Resources Fulfillment Plan Number (+/-) Time 1 Board of Directors Fulfillment 2 Board of Commissioners Fulfillment 3 Broker Fulfillment 4 Expert Personnel Fulfillment 5 Internal Audit Fulfillment (function) ... Total *) filled with additions and reductions in the number of employees
Reasons and Considerations
(filled with reasons/considerations in formulating the human resources fulfillment plan)
Strategy
(filled with strategies to realize the human resources fulfillment plan)

c. Human Resources Education and Training Implementation Plan for Directors, Board of Commissioners, and Employees

Human Resources Education and Training Plan Table
No. Material Candidate
Participants
Time
Training Place
Speaker/
Training Institution
Training Cost
...
Reasons and Considerations
(filled with reasons/considerations in formulating the human resources development plan)
Strategy
(filled with strategies to realize the human resources development plan) d. Foreign Workforce Utilization Plan
Foreign Workforce Utilization Plan Table
No.
Name of Foreign
Workforce
(if any)
/ Number of
Foreign Workforce
Position
Job Title
Field of
Work
Assignment
Duration
Name of
Accompanying Personnel
Planned
Knowledge Transfer Program
Reason 1)

...
Note:

filled with reasons for utilizing foreign workforce and reasons why Indonesian workforce is not/has not yet been used
Reasons and Considerations
(filled with reasons/considerations in formulating the foreign workforce utilization plan)
Strategy
(filled with strategies to realize the foreign workforce utilization plan)

e. Outsourced Workforce Utilization Plan

Outsourced Workforce Utilization Plan Table
No. Field of
Task
Reasons
Utilization of
Outsourced
Workforce
Number of
Outsourced
Workforce
Name of
Outsourced
Workforce
Provider
Company
(if any)
Duration
Contract with
Outsourced
Workforce
Company

...
2) Reasons and Considerations
(filled with reasons/considerations in formulating the outsourced workforce utilization plan)
3) Strategy
(filled with strategies to realize the outsourced workforce utilization plan) f. Information Technology Development Plan

Describe the information technology usage plans used by the company to support business activities.
No.
Type/Name
Application
Ownership
(Inhouse/vendor)
Name of
Vendor
Application Function
Reasons and Considerations
(filled with reasons/considerations in formulating the fundamental information technology development and procurement plan)
Strategy
(filled with strategies to realize the fundamental information technology development and procurement plan)

Financial Statement Projections, Ratio Projections, and Other Specific Items, and Assumptions Used

Financial Position Projections for Insurance Brokerage Companies and Reinsurance Brokerage Companies
(in Rupiah)
DESCRIPTION
Actual as of Jun 30
20XX-1
Prognosis as of Dec 31 20xx-1 as of Dec 31 20XX-1 as of Jun 30 20XX as of Dec 31 20XX ASSETS Cash and Cash Equivalents

Operating Accounts
Premium Investment Accounts
Premium Receivables
Brokerage Service
Receivables
Consultation Receivables
Claim Handling Service
Receivables

Fixed Assets -
Other Assets -
Total Assets -
LIABILITIES & EQUITY -
Liabilities -
Premium Payables -
Deferred Brokerage Service
Revenue -
Claim Payables -
Commission Payables -
Tax Payables -
Other Payables -
Total Liabilities -
Equity -
Paid-in Capital
Additional Paid-in Capital

Retained Earnings -
Current Year Profit -
Other Equity - Balance of Other Equity Components - Increase (Loss) of Other Equity Components -

DESCRIPTION
Actual as of Jun 30
20XX-1
Prognosis as of Dec 31 20xx-1 as of Dec 31 20XX-1 as of Jun 30 20XX as of Dec 31 20XX Total Equity - TOTAL LIABILITIES AND EQUITY
2) Comprehensive Income/Loss Projections for Insurance Brokerage Companies and Reinsurance Brokerage Companies
(in Rupiah)
DESCRIPTION
Actual
As of Jun 30
20XX-1
Prognosis as of Dec 31 20xx-1 as of Dec 31 20XX-1 as of Jun 30 20XX as of Dec 31 20XX REVENUE Brokerage Service Revenue Direct Brokerage Service Revenue Indirect Brokerage Service Revenue Consultation Service Revenue Claim Handling Service Revenue Other Revenue Total Revenue EXPENSES Operational Expenses Employee and Executive Expenses Education and Training Expenses Marketing Expenses Commission Expenses Other Operational Expenses Non-Operational Expenses Total Expenses Profit (Loss) Before Tax Tax Expenses Profit (Loss) After Tax Comprehensive Income (Expense) Increase (Decrease) in Fixed Asset Valuation

DESCRIPTION
Actual
As of Jun 30
20XX-1
Prognosis as of Dec 31 20xx-1 as of Dec 31 20XX-1 as of Jun 30 20XX as of Dec 31 20XX Foreign Currency and Other Gains (Losses) Total Comprehensive Income (Expense) Comprehensive Income (Loss)
3) Ratio and Other Specific Item Projections for Insurance Brokerage Companies and Reinsurance Brokerage Companies
(in Rupiah)
(ratios in percentage)
DESCRIPTION
Actual As of
Jun 30
20XX
Projection
As of Dec 31
20XX-1
As of Jun 30
20XX
As of Dec 31
20XX
Return on Asset (ROA) a. Profit (Loss) After Tax b. Total Assets
c. Ratio a:b
Return on Equity (ROE) a. Profit (Loss) After Tax b. Equity
c. Ratio a:b
BOPO (Operational Cost Operational Revenue)

DESCRIPTION
Actual As of
Jun 30
20XX
Projection
As of Dec 31
20XX-1
As of Jun 30
20XX
As of Dec 31
20XX a. Operational Expenses b. Operational Revenue
c. Ratio a:b
Deferred Premium Ratio (%) a. Premium Liabilities- Premium Receivables b. Premium Liabilities
c. Deferred Premium = a : b
Deferred Premium Fund Adequacy Ratio a. Total Premium Accounts b. Premium Payables- Premium Receivables
c. Deferred Premium Fund Adequacy Ratio = a:b
Commission Expense to Operational Revenue Ratio a. Commission Expenses b. Operational Revenue
c. Ratio a:b
11. Other Information
Other information includes information that needs to be disclosed because it affects the company's business activities, which is not mentioned in the scope of the Business Plan. Examples:

merger, acquisition, and consolidation plans;
insurance portfolio transfer plans;
insurance business field change plans;
business activity change plans not based on Sharia principles to Sharia-based principles.
Sustainable Finance Action Plan based on POJK regarding the Implementation of Sustainable Finance for Financial Services Institutions, Issuers, and Public Companies.

FORMAT III B
FORM AND STRUCTURE OF REPORTS OTHER THAN PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES AND REINSURANCE BROKERAGE COMPANIES Business Realization Report in accordance with the provisions of Article 7 paragraph (3),
Article 15 paragraph (5) and Article 19 of POJK Number 24/POJK.05/2019 regarding the Business Plan of Non-Bank Financial Services Institutions with a submission deadline of no later than one month after the relevant semester ends

BUSINESS REALIZATION REPORT
Year ...............................
(fill in company name and address) Approved, Board of Commissioners (Company Stamp) N a m e C l e a r Position 20xx Director, (Company Stamp) N a m e C l e a r Position

A. Explanation Regarding Business Plan Achievement Filled with explanations regarding Business Plan achievement, including Business Plan achievement and the comparison of plans and realizations which must at least include:

Business Activity Plan
No. Type of Business Line
Business Plan Realization Deviation (%) Explanation of Follow-up Plan Per Semester I Year 1900 Premium Revenue Brokerage Service Premium Revenue Brokerage Service Premium Revenue Brokerage Service 1 Property 2 Motor Vehicles 3 Transportation 4 Ship Hulls 5 Aircraft 6 Satellites 7 Energy Offshore 8 Energy Onshore 9 Engineering 10 Liability 11 Transportation 12 Ship Hulls 13 Aircraft 14 Satellites
Business Development or Expansion Plan
No. Type of New Business Line
Business Plan Realization Deviation (%) Explanation of Follow-up Plan Per Semester I Year Time of Implementation New Business Activity Time of Implementation New Business Activity
Capital Plan
No. Plan for
Capital Change
Business Plan Realization Deviation (%) Explanation of Follow-up Plan Per Semester I Year 1900 Nominal Size Time of Implementation Nominal Size Time of Implementation Nominal Size Time of Implementation 1 Plan for Capital Addition from Existing Shareholders 2 Plan for Capital Addition from New Shareholders 3 Plan for Capital Addition through Capital Market 4 Plan for Other Capital Addition
Office Network Development and/or Change Plan
a. Office Network Opening
No. A. Office Network Opening
Business Plan Realization Explanation of Follow-up Plan Per Semester I Year Type of Office Time Implementation Location Time Implementation Location b. Address Transfer No. B. Address Transfer Business Plan Realization Explanation of Follow-up Plan Per Semester I Year Type of Office Time Implementation Location Time Implementation Location
c. Office Closing
No. C. Office Closing
Business Plan Realization Explanation of Follow-up Plan Per Semester I Year Type of Office Time Implementation Location Time Implementation Location
Organization, Human Resources, and/or Information Technology Development Plan
a. Organization Development Plan Organization Development Plan Business Plan Realization Explanation of Follow-up Plan Per Semester I Year
Plan for Formation of Work Units/Divisions
Plan for Change of Work Units/Divisions
Plan for Committee Formation
…
b. Human Resources Fulfillment Plan No. Type of Fulfillment Business Plan Human Resources Fulfillment Realization Deviation (%) Explanation of Follow-up Plan Per Semester I Year 1900 Number (+/-) Time Number (+/-) Time Number (+/-) Time 1 Board of Directors Fulfillment 2 Board of Commissioners Fulfillment 3 Broker Fulfillment 4 Expert Personnel Fulfillment 5 Internal Audit (function)
c. Human Resources Education and Training Implementation Plan for
Directors, Board of Commissioners, and Employees Material/ Topic Business Plan Realization Explanation of Follow-up Plan Per Semester I Year 1900 Candidate Participants Time Training Participants Time Training

d. Foreign Workforce Utilization Plan Name of Foreign Workforce (if any) / Number of Foreign Workforce Business Plan Position Job Title Field of Work Assignment Duration Name of Accompanying Personnel Planned Knowledge Transfer Program Realization Explanation of Follow-up Plan Per Semester I Year 1900 Name of Foreign Workforce / Number of Foreign Workforce Position Job Title Field of Work Assignment Duration Name of Accompanying Personnel Realization Knowledge Transfer Program e. Outsourced Workforce Utilization Plan Field of Task Business Plan Realization Explanation of Follow-up Plan Per Semester I Year 1900 Number of Outsourced Workforce Name of Outsourced Workforce Provider Company (if any) Duration Contract with Outsourced Workforce Company Number of Outsourced Workforce Name of Outsourced Workforce Provider Company Duration Contract with Outsourced Workforce Company f. Information Technology Development Plan Type/ Name Application Business Plan Realization Explanation of Follow-up Plan Per Semester I Year 1900 Ownership (Inhouse/ vendor) Name of Vendor Function Application Ownership (Inhouse/ vendor) Name of Vendor Function Application

Financial Realization Report
Description Business Plan
Realization
Semester I Year
Deviation (Rupiah) Deviation (%) ASSETS Cash and Cash Equivalents

Operating Accounts
Premium Investment Accounts
Premium Receivables
Brokerage Service Receivables
Consultation Receivables
Claim Handling Service Receivables Fixed Assets Other Assets Total Assets LIABILITIES & EQUITY 0 0 Liabilities 0 0 Premium Payables Deferred Brokerage Service Revenue Claim Payables Commission Payables Tax Payables Other Payables Total Liabilities Equity Paid-in Capital Additional Paid-in Capital Retained Earnings Current Year Profit Other Equity
Balance of Other Equity Components
Increase (Loss) of Other Equity Components
Total Equity
Total Liabilities and Equity

Comprehensive Income/Loss Realization
Description Deviation
Plan Realization Rupiah %
REVENUE
Brokerage Service Revenue
Brokerage Service Revenue
Direct Brokerage Service Revenue Indirect Brokerage Service Revenue Consultation Service Revenue Claim Handling Service Revenue Other Revenue Total Revenue

EXPENSES
Operational Expenses
Employee and Executive Expenses Education and Training Expenses Marketing Expenses Commission Expenses Other Operational Expenses Non-Operational Expenses Total Expenses Profit (Loss) Before Tax Tax Expenses Profit (Loss) After Tax Comprehensive Income (Expense) Increase (Decrease) in Fixed Asset Valuation Foreign Currency and Other Gains (Losses) Total Comprehensive Income (Expense) Comprehensive Income (Loss)
8. Realization of Ratios and Other Specific Items
Description Actual Projection Deviation

Return on Asset (ROA)
a. Profit (Loss) after Tax b. Total Assets
c. Ratio a : b
Return on Equity (ROE)
a. Profit (Loss) after Tax b. Total Equity
c. Ratio a : b
BOPO
a. Operational Expenses b. Operational Revenue
c. Ratio a : b
Deferred Premium Ratio
a. Premium Liabilities – Premium Receivables b. Premium Liabilities
c. Ratio a : b
Deferred Premium Fund Adequacy Ratio
a. Total Premium Accounts b. Premium Payables- Premium Receivables
c. Ratio a : b
Commission Expense to Operational Revenue Ratio
a. Commission Expenses b. Operational Revenue
c. Ratio a : b
Other Information
Corporate Action Business Plan Realization Explanation
Merger, acquisition, and consolidation plans
Insurance portfolio transfer plans
Insurance business field change plans
Business activity change plans not based on Sharia principles to Sharia-based principles
Sustainable Finance Action Plan

FORMAT III C

FORMAT AND STRUCTURE OF REPORTS OTHER THAN PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES AND REINSURANCE BROKERAGE COMPANIES

Business Plan Supervision Report in accordance with the provisions of Article 7 paragraph (3), Article 15 paragraph (5), and Article 19 of POJK Number 24/POJK.05/2019 concerning Business Plans of Non-Bank Financial Service Institutions, with a submission deadline no later than November 30 of the preceding year.

BUSINESS PLAN SUPERVISION REPORT

Year ...............................
(fill in company name and address)

, 20xx
Board of Commissioners
(Company Stamp)

Full Name
Position

This copy is consistent with the original Legal Director 1 Legal Department signed Mufli Asmawidjaja

Assessment Aspects Explanation

Realization of business plan both
quantitatively and qualitatively
Factors affecting
Company performance:
a. Good corporate governance factors; b. Risk profile factors;
c. Profitability factors; and
d. Capitalization factors.
Board of Directors' efforts to
improve Company performance

Established in Jakarta on December 22, 2020 EXECUTIVE HEAD OF SUPERVISOR INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed RISWINANDI

APPENDIX IV
LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020 CONCERNING THE FORMAT AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSORS

This copy is consistent with the original Legal Director 1 Legal Department signed Mufli Asmawidjaja

FORMAT AND STRUCTURE OF REPORTS OTHER THAN PERIODIC REPORTS DATA UPDATE ACTIVITY PLAN REPORT AND DATA UPDATE REALIZATION REPORT FOR INSURANCE BROKERAGE COMPANIES

Data Update Activity Plan Report and Data Update Realization Report as referred to in the Financial Services Authority Regulation concerning the Implementation of Anti-Money Laundering and Counter-Terrorism Financing Programs in the Financial Services Sector

APPENDIX V
LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020 CONCERNING THE FORMAT AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSORS

This copy is consistent with the original Legal Director 1 Legal Department signed Mufli Asmawidjaja

FORMAT AND STRUCTURE OF REPORTS OTHER THAN PERIODIC REPORTS PUBLIC ACCOUNTANT AND/OR PUBLIC ACCOUNTING FIRM APPOINTMENT REPORT FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSORS

The format and structure of the public accountant and/or public accounting firm appointment report in the context of audits of annual historical financial information as referred to in the Financial Services Authority Regulation concerning the Use of Public Accountant and Public Accounting Firm Services in Financial Services activities refers to the format and structure as contained in the Appendix of the Financial Services Authority Letter concerning Procedures for the Use of Public Accountant and Public Accounting Firm Services in Financial Services Activities.

APPENDIX VI
LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 25 /SEOJK.05/2020 CONCERNING THE FORMAT AND STRUCTURE OF PERIODIC REPORTS FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSORS

This copy is consistent with the original Legal Director 1 Legal Department signed Mufli Asmawidjaja

FORMAT AND STRUCTURE OF REPORTS OTHER THAN PERIODIC REPORTS AUDIT COMMITTEE EVALUATION RESULTS REPORT ON THE IMPLEMENTATION OF AUDIT SERVICES FOR ANNUAL HISTORICAL FINANCIAL INFORMATION BY PUBLIC ACCOUNTANT AND/OR PUBLIC ACCOUNTING FIRM FOR INSURANCE BROKERAGE COMPANIES, REINSURANCE BROKERAGE COMPANIES, AND INSURANCE LOSS ASSESSORS

The format and structure of the audit committee evaluation results report on the implementation of audit services for annual historical financial information by public accountant and/or public accounting firm as referred to in the Financial Services Authority Regulation concerning the Use of Public Accountant and Public Accounting Firm Services in Financial Services activities refers to the format and structure as contained in the Appendix of the Financial Services Authority Letter concerning Procedures for the Use of Public Accountant and Public Accounting Firm Services in Financial Services Activities

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

Lineage: Superseded

Timeline

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