Form and Structure of Periodic Reports for Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units

To:

Board of Directors of Sharia Insurance Companies;
Board of Directors of Sharia Reinsurance Companies;
Board of Directors of Insurance Companies having a Sharia Unit; and
Board of Directors of Reinsurance Companies having a Sharia Unit,
in their respective locations.

COPY
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 2 /SEOJK.05/2018 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

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

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

Company means a Sharia insurance company, a Sharia reinsurance company, a Sharia unit in an insurance company, and a Sharia unit in a reinsurance company.
Sharia Insurance Company means a general Sharia insurance company and a life Sharia insurance company.
Sharia Reinsurance Company means a company conducting risk management business based on Sharia principles over risks faced by Sharia Insurance Companies, Sharia guarantee companies, or other Sharia Reinsurance Companies.

Sharia Unit means a work unit at the head office of an insurance or reinsurance company functioning as the parent office of offices outside the head office that conduct business based on Sharia principles.
Periodic Report means a report prepared by the Company for the benefit of the Financial Services Authority within a certain period.
Monthly Report means a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant month.
Quarterly Report means a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant quarter.
Annual Report means a report prepared by the Company for the benefit of the Financial Services Authority, covering the period from January 1 to the end of the relevant year.
Other Reports mean reports prepared by the Company for the benefit of the Financial Services Authority other than Monthly Reports, Quarterly Reports, and Annual Reports, submitted within a certain period.

II. FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

The Periodic Reports of Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units consist of:
a. Monthly Reports; b. Quarterly Reports;
c. Annual Reports; and
d. Other Reports.
The Annual Report referred to in item 1 letter c for Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units consists of:
a. financial aspects; and b. management aspects.

The form and structure of Monthly Reports referred to in item 1 letter a, Quarterly Reports referred to in item 1 letter b, and Annual Reports for financial aspects referred to in item 2 letter a are as contained in Appendix I which is an inseparable part of this Financial Services Authority Circular with the following provisions:
a. for general Sharia insurance companies and Sharia Units in general insurance companies, as contained in Format I A; b. for Sharia Reinsurance Companies and Sharia Units in reinsurance companies, as contained in Format I B; and
c. for life Sharia insurance companies and Sharia Units in life insurance companies, as contained in Format I C.
The form and structure of Annual Reports for management aspects referred to in item 2 letter b for Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units are as contained in Format I D of Appendix I which is an inseparable part of this Financial Services Authority Circular.
The form and structure of Other Reports referred to in item 1 letter d for Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units are as contained in Appendix II which is an inseparable part of this Financial Services Authority Circular with the following provisions:
a. for corporate plan reports, as contained in Format II A; b. for business plan reports, as contained in Format II B;
c. for reinsurance/automatic retrocession program reports, as contained in Format II C;
d. for consumer complaint reports and follow-up on service and resolution of consumer complaints, as contained in Format II D;

e. for self-assessment reports on the implementation of integrated governance for financial conglomerates, as contained in Format II E; f. for annual reports on the implementation of integrated governance for financial conglomerates, as contained in Format II F; g. for integrated risk profile reports, as contained in Format II G; h. for integrated capital adequacy reports, as contained in Format II H;
i. for data updating activity plans and data updating realization reports, as contained in Format II I; and
j. for summaries of quarterly and/or annual financial reports, as contained in Format II J.

III. PROCEDURES FOR SUBMISSION OF PERIODIC REPORTS

Submission of Periodic Reports is done online through the Financial Services Authority's data communication network system.
In the event that the Financial Services Authority's data communication network system referred to in item 1 is not yet available, the Company must submit Periodic Reports online via electronic mail to the Financial Services Authority.
The Financial Services Authority submits in writing to the Company regarding the electronic mail address used for the submission of Periodic Reports no later than 14 (fourteen) working days before the deadline for submission of Periodic Reports.
The Company must submit in writing to the Financial Services Authority the Company's electronic mail address used for the submission of Periodic Reports to the Financial Services Authority as referred to in item 2.
In the event that the Financial Services Authority's data communication network system referred to in item 1 and item 2 experiences technical problems or the Company experiences disturbances so that it cannot submit Periodic Reports online, Periodic Reports are submitted offline accompanied by written notification and sent to the Financial Services Authority via a letter signed by the Board of Directors or equivalent and addressed to:
Financial Services Authority u.p. Director of Sharia Business Supervision Wisma Mulia 2 Building, 15th Floor Jalan Jenderal Gatot Subroto Number 42 Jakarta 12710.

Submission of Periodic Reports offline as referred to in item 5 is done in one of the following ways:
a. handed over directly; or b. sent through a courier service company.
The Company is deemed to have submitted Periodic Reports with the following provisions:
a. for online submission via:
1) the Financial Services Authority's data communication network system, evidenced by a receipt from the Financial Services Authority's data communication network system; or
2) proof of sending electronic mail against reports sent to the Financial Services Authority's electronic mail address, in the event that submission through the data communication network cannot be performed; or
b. for offline submission, evidenced by:
1) a receipt letter from the Financial Services Authority, if the report is handed over directly; or
2) a delivery receipt from the courier service company, if the report is sent through a courier service company.

IV. CLOSING PROVISIONS

The provisions in this Financial Services Authority Circular shall take effect on the date of determination.
At the time this Financial Services Authority Circular takes effect, Financial Services Authority Circular Number 4/SEOJK.05/2013 concerning Monthly Reports of Insurance and Reinsurance Companies Conducting All Their Businesses with Sharia Principles and Sharia Units of Insurance and Reinsurance Companies, is repealed and declared invalid.

This copy is in accordance with the original. Director of Legal Affairs 1 Legal Department signed Yuliana

All businesses conducted with Sharia Principles and Sharia Units of Insurance and Reinsurance Companies, determined in Jakarta on January 24, 2018 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed RISWINANDI

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 2 /SEOJK.05/2018 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

General Data
ASSY
Reporting Date
Company Code
Company Name
Reporting Period
Quarterly Reporting
Fiscal Year
Type of Reporting Period Monthly Report/Quarterly Report/Annual Report Board of Directors Name Board of Directors Position Company Address FORMAT I A FORM AND STRUCTURE OF MONTHLY/QUARTERLY/ANNUAL REPORTS FINANCIAL ASPECTS FOR GENERAL SHARIA INSURANCE COMPANIES AND SHARIA UNITS IN GENERAL INSURANCE COMPANIES -1-

Addressed To
Honorable Directorate of Sharia Business Supervision Financial Services Authority MONTHLY/QUARTERLY/ANNUAL REPORT GENERAL SHARIA INSURANCE -2-

PPAUS
Telephone
Fax
E-mail
Responsible Director
Name of Responsible Person
Position
Telephone
Fax
Email
PIC Financial Report
Report Compiler
Officer Name
Division
Number of Insured
External Auditor
Controller
License No. & Date
Number of Branches/Representative Offices Number of Employees Telephone and Fax E-mail NPWP Description Company Name Full Address Company Profile Per Quarter -3-

As of December 31, Year "Period" 1.
2.
3.
I, , registration number hereby declare that:

"Company Name" has presented all data fairly
I have reviewed the company's financial statements based on
based on regulations in the field of financial health of insurance companies Note: For annual reports only Thus this statement is made truthfully. "Place", "Date" "Actuary Name" "PAI Reg No" "Place", "Date" "Company Name" "Board of Directors Name" "Board of Directors Position" "Actuary Name" "PAI Reg No" Thus this statement is made truthfully. Statement Letter Financial Statements "Company Name" I, who signs below, declare that:
Responsible for the preparation and presentation of financial statements "Company Name" All information in the Company's financial statements has been presented completely according to actual conditions; The Company's financial statements do not contain incorrect material information or facts, and do not omit material information or facts. -4-

Per "Date" Quarter "Period" 1.
2.
3.
Note: For quarterly reports only "Place", "Date" "Company Name" "Board of Directors Name" "Board of Directors Position" "Company Name" All information in the Company's financial statements has been presented completely according to actual conditions; The Company's financial statements do not contain incorrect material information or facts, and do not omit material information or facts. Thus this statement is made truthfully. Responsible for the preparation and presentation of financial statements Statement Letter Financial Statements "Company Name" I, who signs below, declare that:
-5-

Jakarta, ......20xx
Member
Note: For annual reports only Chairman PT ... General Sharia Insurance Company STATEMENT OF THE SHARIA SUPERVISORY BOARD
Period......
After conducting research on the management of assets and liabilities of Tabarru' Funds, Tahud Funds, Company Funds, and Participant Investment Funds of PT ....., hereby the Sharia Supervisory Board of PT ..... declares that the management of assets and liabilities of Tabarru' Funds, Tahud Funds, Company Funds, and Participant Investment Funds has been carried out in accordance with Islamic Sharia principles.
Sharia Supervisory Board of PT ....
-6-

PPSA
USY
… - 0,0
0
%
10 - 0,0
0
%
9 - 0,0
0
%
8 - 0,0
0
%
7 - 0,0
0
%
6 - 0,0
0
%
5 - 0,0
0
%
4 - 0,0
0
%
3 - 0,0
0
%
2 - 0,0
0
%
1 - 0,0
0
%
N o
Line Number
Shareholder Name
Controlling Shareholder Rupiah Share Ownership Percentage Detail of Shareholders Per … -7-

PPU
A
US
1
…
0
2
3
4
5
6
7
8
9
N o
Line Number Name Position Start Date 1 Detail of Related Parties Per … -8-

0,00%
0,00%
0,00%
0,00%
0,00%
0,00%
0,00%
0,00%
0,00%
0,00%
0,00%

- - T
    otal
    … - -
    9 - -
    10 - -
    7 - -
    8 - -
    5 - -
    6 - -
    3 - -
    4 - -
    2 - -
    N o
    Line Number Description
    Budget Realization
    Education and Training Costs Percentage Training Ratio - I Per Quarter (in millions of rupiah) 1 - - -9-

0,00% 0,00%
Total Education Costs
Ratio of Education Costs and Employee Costs and
c. Commissioner Training - -
d. Sharia Supervisory Board Training - - Education and Training Costs a. Employee Training - - b. Board of Directors Training - - Description Budget Realization Employee and Management Costs - - Training Ratio - II Per Quarter (in millions of rupiah) - 1 0 -

-
-
-
-
-
-
-
-
-
-
-
-
-
-

-
-

Prohibited Assets - - - -
Difference between SAK Balance and SAP Balance - - - - Other Equity Components - - - - Profit Equilization Reserve - - - Retained Earnings Balance - - - Share Agio/Disagio - - - Accumulated Funds - - - - - Fund Equity Paid-in Capital - - - Provision for disaster risks - - - Qardh - - - - - Provision for uncollected contributions - - - Claim provision - - - PAYDI provision providing - - - Contribution provision - - - Technical Provisions Ujroh provision - - - Other liabilities - - - - Expenses to be Paid - - - - - - -

LIABILITIES AND EQUITY
Liabilities
Claims or investment benefit payables - - Non-Investment Property - - - Other Assets - - - -

Deferred acquisition costs - - - Reinsurance Assets - - - -

-
Receivables - - - - - - -
Not investments
Cash and Bank - - -
Other Investments - - -

Investment Property - - - - - - - Pure Gold - - - - - - - Sharia Financing with Rights - - - Direct Participation - - -

Financing Through Cooperation with - - - - - - - REPO - - - -

Sharia Real Estate Investment Funds - - - - - - - Sharia Asset-Backed Securities - - - -

Sharia Mutual Funds - - - -

Sharia Securities Issued - - - -

Sharia Securities Issued - - - - - - - Sharia Securities Issued - - - -

Sharia Government Securities - - - - - - - MTN Sharia - - -

Sukuk or Sharia Bonds - - - - Sharia Shares - - - SAK

Deposit Certificates - - - - - - - Balance Sheet Per Quarter (in millions of rupiah) Investments Adjustments Combined SAK ASSETS SAP Tabarru' Funds SAK SAP Participant Investment Funds DESCRIPTION SAK SAP Company Funds -11-

LKKUS

-
-

TOTAL PERFORMANCE OF ALL FUNDS - - - -
PROFIT AFTER TAX - - -
OTHER COMPREHENSIVE INCOME - - - PROFIT (LOSS) BEFORE TAX - - - Income Tax - - - - - Other Expenses - - - - Other Income - - - - TOTAL OPERATING EXPENSES - - - INSURANCE OPERATING PROFIT (LOSS) - - -
Other General and Administrative Expenses - - -
Increase (Decrease) in Ujroh Provision - - -
Employee and Management Expenses - - -
Education and Training Expenses - - - -
b. Acquisition Expenses - - -
c. General and Administrative Expenses:
-
OPERATING EXPENSES:
a. Marketing Expenses - - - b. Underwriting surplus for Participants - - - - a. Underwriting surplus for funds - - - - TOTAL UNDERWRITING EXPENSES - - - TOTAL SURPLUS (DEFICIT) - - - Net Claim Expenses Total - - - Adjuster Expenses - - - e. Withdrawal/Redemption of Investment Funds - - - -
c. Increase (Decrease) in Claim Provisions - - -
d. Withdrawal of Participant Investment Funds that - - - - -

b. Claim recovery - - -
EXPENSES
UNDERWRITING EXPENSES
Claim Expenses a. Gross Claims - UNDERWRITING INCOME - - - - Total Net Contribution Income - - - - b. Decrease (Increase) in PAKYBMP - - -
c. Decrease (Increase) in Provisions for - - -

-
Decrease (Increase) in Contribution Provisions a. Decrease (Increase) in Provisions - - - - Net Contributions - - - -

Reinsurance/Retrocession Contributions - - - - Total Gross Contributions/Ujroh Received/Allocated - - - - b. Indirect Contribution Allocation: - - - -

-
UNDERWRITING INCOME
Gross Contributions/Ujroh Received/Allocated a. Direct Contribution Allocation: - - - - - - Total Investment Income and - - - - Total Investment Management Ujroh - - - Total Investment Returns - - - - Investment Returns Distributed to Funds - - - - - -

Financial Performance Report For the Period Ended (in millions of rupiah) INCOME INVESTMENT INCOME AND UJROH Investment Returns - - Mudharabah Agreement Participant Investment Funds Combined Adjustments Description Company Funds Tabarru' Funds Wakalah Bil Ujrah Agreement

-12-

Dividend Payments -
Qardh Payments -
Others - -

-
b. Cash Outflows
Subordinated Loan Payments - Qardh Receipts - Others - - CASH FLOWS FROM FINANCING ACTIVITIES a. Cash Inflows Capital/Capital Work Deposits - Subordinated Loans - Others - - - - Payment of ujroh/fees to the Company - - - Purchase of Fixed Assets - - Investment Returns Distributed to Funds - - - b. Cash Outflows Investment Placements - - - Others - - - -

Sale of Fixed Assets -
Receipt of Investment Profit Sharing from Funds - Receipt of Investment Profit Sharing from Funds - Investment Liquidation - Receipt of Investment Returns - - - -

CASH FLOWS FROM INVESTMENT ACTIVITIES a. Cash Inflows Zakat Payments - Tax Payments - Others - - Reinsurance Contributions Paid - - Rent Payments - Marketing Expenses - Reinsurance Ujroh Payments - Insurance Ujroh Payments Distribution of UW Surplus Payment to - Distribution of UW Surplus Payment to - Acquisition Expenses - Withdrawal of Participant Investment Funds that have been - - Withdrawal/Redemption of Investment Funds - -

-
b. Cash Outflows
Claims Paid - - -
Underwriting Surplus Distribution Receipts - Others - - Tabarru' Fund Surplus Allocation Receipts - - - Reinsurance Claims Received - -

Received Ujroh -
INCREASE (DECREASE) IN CASH BALANCE CASH END BALANCE CASH FLOWS FROM OPERATING ACTIVITIES a. Cash Inflows Participant Contributions BEGINNING BALANCE - - - - Description Company Funds Tabarru' Funds Wakalah Bil Ujrah Agreement Cash Flow Statement For the Period Ended (in millions of rupiah) Mudharabah Agreement Participant Investment Funds Combined -13-

LPDS
-

- - - IV. Ending Fund Balance

Dividend Payments -
Other Deductions - - -
III. Deductions
Comprehensive loss for the current period - Decrease in accumulated tabarru'/fund -

-
Other Additions - - -
Paid-in Capital -
Comprehensive income for the current period - Increase in accumulated tabarru'/investment funds
I. Beginning Fund Balance - - -
II. Additions
DESCRIPTION Company Funds Tabarru' Funds Investment Funds Combined STATEMENT OF CHANGES IN FUNDS For the Period Ended (in millions of rupiah) - 1 4 -

DPUS

-
-
-
-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

Other Assets -
Total Non-Investments
TOTAL WEALTH (I+II)

-
Non-Investment Property - - - - - Deferred Acquisition Costs - - - - - Reinsurance Assets - - - - - - Investment Receivables - - - - Investment Return Receivables - - - - - - Indirect Closing Ujroh Receivables - - - - Direct Closing Ujroh Receivables - - - - - - -
II. Non-Investments
Cash and Bank - - -
-
Other Investments -
Total Investments
Pure Gold - - - -
-
-
-
Investment Property - - - - - - Direct Participation - - - - - Sharia Financing with Liens - - - - - - Financing Through Cooperation With Parties - - - - - REPO - - - - - - Sharia Real Estate Investment Funds - - - - - Sharia Asset-Backed Securities - - - - - - Sharia Mutual Funds - - - - - Sharia Securities of Multinational Institutions - - - - - - Sharia Securities of Countries Other Than RI - - - - - Sharia Securities of Bank Indonesia - - - - - - Sharia Securities of RI Government - - - - - MTN Sharia - - - - Sukuk or Sharia Bonds - - - - - Sharia Shares - - - - Deposit Certificates - - - - Deposits - - - - - - Description Ledger Balance (SAK) Valuation Based on SAP Difference Based on Valuation Based on SAK and SAP COMPANY FUNDS ANALYSIS CALCULATION OF COMPANY FUND ASSETS AND LIABILITIES (in millions of rupiah) AYD After Per-Company Limits AYD After Per-Asset Type Limits AYD After Affiliation Limits AYD After Foreign Limits (SAP Balance)
I. Investments
-
1
5
-

DPUS-1
-
-
-

- - TOTAL LIABILITIES (I+II+III)
    II. Ujroh Provisions - -
    III. Provisions for Guarantee Over Principal - -
    Description Ledger Balance (SAK) Valuation Based on SAP Difference SAK and SAP Valuation
    I. Payables - -
    COMPANY FUNDS ANALYSIS
    CALCULATION OF COMPANY FUND LIABILITIES (in millions of rupiah) - 1 6 -

DTUS

-
-
-
-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

Total Non-Investments
TOTAL ASSETS (I+II)
Other Assets - - -
-
-
Reinsurance Assets - - - - - - Investment Receivables - - - - - Investment Return Receivables - - - - - - Reinsurance Claim Recovery Receivables - - - - - Co-insurance Contribution Receivables - - - - - - Total Investments
II. Non-Investments
Cash and Bank - -
Other Investments - - -
-
-
-
Pure Gold - - - - - -
Financing Through Cooperation With Parties - - - - - REPO - - - - - - Sharia Real Estate Investment Funds - - - - - Sharia Asset-Backed Securities - - - - - - Sharia Mutual Funds - - - - - Sharia Securities of Multinational Institutions - - - - - - Sharia Securities of Countries Other Than RI - - - - - Sharia Securities of Bank Indonesia - - - - - - Sharia Securities of RI Government - - - - - MTN Sharia - - - - Sukuk or Sharia Bonds - - - - - Sharia Shares - - - - Deposit Certificates - - - - Deposits - - - - - - Description Ledger Balance (SAK) Valuation Based on SAP Difference Based on Valuation Based on SAK and SAP AYD After Per-Company Limits TABARRU' FUNDS ANALYSIS CALCULATION OF TABARRU' FUND ASSETS AND LIABILITIES (in millions of rupiah) AYD After Per-Asset Type Limits AYD After Affiliation Limits AYD After Foreign Limits (SAP Balance)
I. Investments
-
1
7
-

DTUS-1
-
-
-
-
-

- - Total Liabilities
    Claim Provision - -
    Catastrophic Risk Provision - - Contribution Provision - - Provision for Contributions Not Yet Revenue - - Description Ledger Balance (SAK) Valuation Based on SAP Difference SAK and SAP Valuation Liabilities - - TABARRU FUND ANALYSIS TABARRU FUND LIABILITY CALCULATION (in millions of rupiah) - 1 8 -

DIPUS

Other Assets - -
Total Non-Investment
TOTAL WEALTH ( I + II )
Investment Receivables - - - - Investment Income Receivables - - - - cash and Bank - - - - Other Investments - - Total Investment
II. Non-Investment
Pure Gold - - - -
Financing Through Cooperation with Parties - - - - REPO - - - - Sharia Real Estate Investment Fund - - - - Sharia Asset-Backed Securities - - - - Sharia Mutual Funds - - - - Sharia Securities Issued by Multinational Institutions - - - - Sharia Securities Issued by Countries Other than RI - - - - Sharia Securities Issued by Bank Indonesia - - - - Sharia Securities Issued by the State of RI - - - - MTN Sharia - - - - Sukuk or Sharia Bonds - - - - Sharia Stocks - - - - Certificate of Deposit - - - -
I. Investment
Deposits - -
Description Ledger Balance (SAK) Valuation Based on SAP Difference Valuation Based on SAK and SAP Guaranteed PAYDI Assets ANALYSIS OF PARTICIPANT INVESTMENT FUNDS CALCULATION OF ASSETS AND LIABILITIES OF PARTICIPANT INVESTMENT FUNDS IN GUARANTEED PAYDI (in millions of rupiah) - 1 9 -

DIPUS-2
-
-
-

- - TOTAL LIABILITIES
    Accumulation of Participant Investment Funds - - Provision for PAYDI providing guarantee - - Description Ledger Balance (SAK) Valuation Based on SAP Difference SAK and SAP Valuation Liabilities - - ANALYSIS OF PARTICIPANT INVESTMENT FUNDS CALCULATION OF LIABILITIES OF PARTICIPANT INVESTMENT FUNDS IN GUARANTEED PAYDI (in millions of rupiah) - 2 0 -

RPTSAUS

-
-
-
-
-
-
0.00% 0.00%

-
0.00% 0.00%
Assets Available for Qardh that A. Deficiency (surplus) of solvency level B. Insufficiency of investment, cash and bank - Ratio of Solvency Level of Tabarru' Fund and Fund Solvency Level Ratio before Internal Target Solvency Level Ratio 0.00% 0.00% Solvency Level Ratio with DTMBR/MMBR 0.00% 0.00%
c. Market Risk -
2. Guaranteed PAYDI Assets -
3. Guaranteed PAYDI Liabilities -
F. MMBR for Guaranteed PAYDI

Guaranteed PAYDI Risk
a. Credit Risk - b. Liquidity Risk - D. Insurance Risk - E. Operational Risk - - B. Liquidity Risk - -
C. Market Risk - -
B. Liabilities, other than Qardh from Corporate Fund - - DTMBR/MMBR A. Credit Risk - - Description Tabarru' Fund Corporate Fund Solvency Level A. Permitted Assets (AYD) - - FINANCIAL RATIOS ACHIEVEMENT OF SOLVENCY LEVEL (in millions of rupiah) - 2 1 -

RIKSTSU

-
0.00% 0.00% 0.00% 0.00%

0.00% - - 0.00%

-
0.00% 0.00% 0.00% 0.00%

0.00% - - 0.00%

-
-

0.00% 0.00% 0.00% 0.00%

-
-
-
0.00% 0.00% 0.00% 0.00%

- - - Total Required Qardh (a-b)
      Calculation of Required Qardh for Fund A. Total Obligations other than Qardh - B. Total Assets -
      C. Corporate Insurance Fund Assets - - -
      D. Ratio (a+b) : (a+b+c)

B. Participant Investment Fund Assets - - -
C. Change in funds (a-b)
D. Ratio (c:b)
Asset Ratio of Sharia Unit
A. Tabarru Fund Assets -
-
B. Last year/quarter/month funds - - -
C. Ratio (a:b)
Fund change ratio
A. Current year/quarter/month funds - -
C. Ratio (a:b)
Claim expense ratio
A. Net claim expense -
B. Net contribution -

-
B. Average investment - - -
C. Own retention claim liabilities -
D. Ratio [a:(b+c)]
Net investment income ratio A. Net investment income - Investment to liability balance ratio A. Investment, cash and bank - B. Technical provisions - B. Current liabilities - - -
C. Ratio (a:b)
Liquidity Ratio
A. Current wealth - - -
Description
Tabarru' Fund Corporate Fund Participant Investment Fund Indicator Combined FINANCIAL RATIOS OTHER THAN SOLVENCY LEVEL (in millions of rupiah) - 2 2 -

RKUS
-

- - Total Credit Risk
    Credit Risk (a) - - -
    Credit Risk (b) - -
    Description
    Tabarru Fund Corporate Fund Total Deviation PAYDI (guaranteed) MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK (in millions of rupiah) - 2 3 -

1.20% - - -
2.10% - - -
3.00% - - -
4.50% - - -
9.00% - - -

1.60% - - -
2.80% - - -
4.00% - - -
6.00% - - -
12.00% - - -

1.00% - - -

1.60% - - -
2.80% - - -
4.00% - - -
6.00% - - -

2.80% - - -
4.00% - - -

5.60% - - -
8.00% - - -
12.00% - - -

8.00% - - -

30.00% - - -

2.80% - - -

2.80% - - -
4.00% - - -
6.00% - - -
12.00% - - -
15.00% - - -

2.80% - - -

2.80% - - -
4.00% - - -
6.00% - - -
12.00% - - -
15.00% - - -

2.80% - - -

2.80% - - -
4.00% - - -
6.00% - - -
12.00% - - -
15.00% - - -

2.00% - - -
25.00% - - -
2.00% - - -

Investment Income Receivables - - - Total a. Undistributed investments - - - b. Failed investments on date - - - e. Cluster rating 5 - - - Investment Receivables
c. Cluster rating 3 - - -
d. Cluster rating 4 - - - a. Cluster rating 1 - - - b. Cluster rating 2 - - - Domestic - - - Foreign:
Cluster Rating 5 - - -
Reinsurance Claim Receivables Cluster Rating 3 - - - Cluster Rating 4 - - - Cluster Rating 1 - - - Cluster Rating 2 - - - Domestic - - - Foreign:
e. Cluster rating 5 - - -
Reinsurance Contribution Receivables
c. Cluster rating 3 - - -
d. Cluster rating 4 - - - a. Cluster rating 1 - - - b. Cluster rating 2 - - - Domestic - - - Foreign:
b. assets sourced from agreements - - - Co-insurance Claim Receivables Reinsurance Assets a. assets sourced from estimated value - - - cash and Bank - - - Direct Closing Contribution Receivables - - - Unused Property - - - Non-Investment a. LTV < 65% - - - b. 65% < LTV < 75% - - - b. 65% < LTV < 75% - - - Other commercial property Residential property a. LTV < 65% - - - d.Unhealthy - - - Loans Secured by Mortgage Rights b.Healthy - - - c.Less healthy - - - Financing Through Cooperation with Parties a.Very healthy - - - Securities issued by Institutions - - - REPO - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
Securities Issued by the State a. Cluster rating 1 - - - Sharia Securities Issued by the State - - - Securities Issued by Banks - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
MTN Sharia a. Cluster rating 1 - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
Sukuk / Corporate Sharia Bonds a. Cluster rating 1 - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - -
-
-
Other Categories, according to Bank rating:
a. Cluster rating 1 - - -
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK - FAILURE OR INABILITY OF DEBTOR OR OTHER PARTIES (in millions of rupiah) Investment Term Deposits and Certificates of Deposit Special Category (up to 2 billion per - - Factor Tabarru Fund Corporate Fund Total Deviation PAYDI (guaranteed) Description Tabarru Fund Corporate Fund PAYDI (guaranteed) Total AYD -24-

RKRAUS1

0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
0.00% -
- - - Total
      …

10 - - -
9 - - -
8 - - -
7 - - -
6 - - -
5 - - -
4 - - -
3 - - -
MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK - FAILURE/INABILITY OF REINSURER (in millions of rupiah) 2 - - - Net Reinsurance Exposure ((2)-(3)) Factor Total Deviation 1 - - - Row Number Type of Reinsurer Name of Reinsurer Technical Provisions Reinsurance Expense Deposit and/or Contributions withheld by Company - 2 5 -

RKLAUS

-
-
LIABILITY AND ASSET DIFFERENCE DEVIATION (4% X (Max (Li - AYDi), 0))

- - - - Accumulation of Participant Investment Funds - - - -
        -
        Provision for catastrophic risk - - - - - Claim provision - - - - - Provision for contributions not yet revenue - - - - - - Contribution provision - - - Provision for principal guarantee of PAYDI - - - - - Technical Provisions Ujroh provision - - - - - - Other Liabilities - - - - - - - - - - - - - -

Expenses Payable - - - - - - - - - - - - - - Tax Payable - - - - - - - - - Ujroh Payable - - - - - - - - - - - - - - - - Reinsurance Payable - - - - - - - - - - - - - -

- - - - Co-insurance Payable - - -
        -
        Liabilities and Equity
        Liabilities
        Liabilities
        Claims Payable or investment benefits - - - - - - - - - -
- - - - Other Assets - - - -

-
Other Fixed Assets - - - -
Deferred Acquisition Costs - - - - - Non-Investment Property - - - - - - Investment Income Receivables - - - - - - - - - - - - - - - Investment Receivables - - - - - - - - - - - - - -

Reinsurance Claim Recovery Receivables - - - - - - -
-
-
Co-insurance Claim Receivables - - -
Reinsurance Contribution/Ujroh Receivables - - - -

Reinsurance Assets - - - - - - - -

Direct Closing Contribution/Ujroh Receivables - - - - - - - - - - Non-Investment cash and Bank - - - - - - - - - - - - - - - - - Other Investments - - - - - - - - - - - - - -

Sharia Financing with Mortgage Rights - - - - -

- Pure Gold - - - -
  -
  Investment Property - - - - - Direct Participation - -

Financing Through Cooperation with Other Parties - - - - - - - - - - - - - - - REPO - - - - - - - -

Real Estate Investment Fund - - - - - - - - - - - - - - - Sharia Asset-Backed Securities -

Sharia Mutual Funds - - - - - - - - - - - - - - - Securities Issued by Institutions - - - - - - - -

Securities Issued by Countries Other Than - - - - - - - - - - - - - - - Securities Issued by Bank Indonesia -

Sharia Securities Issued by the State - - - - - - - - - - - - - - - MTN Sharia - - - - - - - -

Sukuk / Corporate Sharia Bonds - - - - - - - - - - - - - - - Sharia Stocks -

Certificate of Deposit - - - - - - - - More than 1 year up to 3 years More than 3 years up to 5 years More than 5 years up to 10 years More than 3 years up to 5 years More than 5 years up to 10 years

Assets
Investment
Term Deposits - - - - - -
Description
Up to 1 year More than 1 year up to 3 years More than 3 years up to 5 years More than 5 years up to 10 years MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND LIQUIDITY RISK (in millions of rupiah) More than 10 years Total Tabarru' Fund More than 10 years Total Corporate Fund Up to 1 year More than 1 year up to 3 years Tabarru' Fund PAYDI (guaranteed) Total More than 10 years Tabarru' Fund Up to 1 year - 2 6 -

RPSYA
-
-
-

Market Risk (C) - - -
Total Market Risk
Market Risk (A) - - -
Market Risk (B) - - -
Description
Corporate Fund Tabarru Fund PAYDI (guaranteed) Total Deviation Total MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND MARKET RISK (in millions of rupiah) - 2 7 -

RPAS

15% - - -
20% - - -
30% - - -
20% - - -
30% - - -

0% - - -
6% - - -
16% - - -

1.60% - - -
2.80% - - -
4% - - -
6% - - -
12% - - -
10% - - -

10% - - -
20% - - -

7% - - -
15% - - -
40% - - -
3% - - -

4% - - -

Non-Investment Property - - - TOTAL Pure gold - - - NON-INVESTMENT Investment Result 2% - 4% - - - Investment Result less than 2% - - - Investment Property Investment Result 4% or more - - - Under OJK Supervision - - - Not Under OJK Supervision - - - Real Estate Investment Fund - - - Direct Participation d. Cluster rating 4 - - - e. Cluster rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
Sharia Asset-Backed Securities a. Cluster rating 1 - - - PAYDI (guaranteed) - - - - Tabarru' Fund - - - - Corporate Fund - - - - Entirely equity securities - - - Mixed*) Entirely government debt securities - - - Entirely private debt securities and - - - Other Stocks - - - Sharia Mutual Funds Stocks traded on foreign exchanges - - - Stocks constituting main index of main exchange - - - - Stocks traded on Indonesian exchange - - - Investment Sharia Stocks Including IDX30 or JII - - MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND MARKET RISK - MARKET PRICE CHANGES (in millions of rupiah) Factor Corporate Fund Tabarru' Fund Total Deviation PAYDI (guaranteed) Description Corporate Fund Tabarru' Fund PAYDI (guaranteed) Total AYD -28-

- - - - #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! - #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! -

#VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! - #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! - #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! -

- - - - Total Deviation
        -
        Total Permitted Assets in Rupiah Total Liabilities in Rupiah Difference Between Permitted Assets over Liabilities Factor

-
Total Liabilities
Exchange Rate - - -
- - - - Provision for catastrophic risk - - - -

- - - - Provision for claims - - - -
- - - - Provision for contributions not yet revenue - - - -

- - - - Provision for contributions - - - -

Provision for investment principal guarantee - - - - - - - - Ujroh provision - - - -

-
Other liabilities - - - - - - - - - - - - - -

Expenses Payable - - - - - - - - - - - - -

Tax Payable - - - - - - - - - - -

-
Co-insurance Payable - - - - - - - -

Non-Investment Property - - - -

Reinsurance Payable - - -
Ujroh Payable - - - - - - - -

Total Permitted Assets
Liabilities
Claims payable - -

Deferred Acquisition Costs - - - - - - - -

- - - - Investment Receivables - - - -
- - - - Investment Income Receivables - - - -

-
-
Reinsurance Claim Receivables - - - - - - - - - - - - - -

Reinsurance Assets - - - -

Co-insurance Claim Receivables - - - - - - - - - - - - - -

- - - - Reinsurance Contribution Receivables - - - -
- - - - Direct Closing Contribution Receivables - - - -

- cash and Bank - - - - - - - - - - - - - -

-
-
Direct Participation - - - - Other investments - - - - - - - -

Pure gold - - - -

Investment Property - - - - - - -

Sharia Financing with Mortgage Rights - - - -

- - - - Sharia Financing Through Cooperation with Other Parties. - - - -

REPO - - - -

- - - - Sharia Real Estate Investment Fund - - - -

Sharia Asset-Backed Securities - - - -

- - - - Sharia Mutual Funds - - - -

Sharia Securities Issued by Multinational Institutions - - - -

- - - - Sharia Securities Issued by Countries Other Than the Republic of Indonesia - - - -

Sharia Securities Issued by Bank Indonesia - - - -

- - - - Sharia Securities Issued by the State - - - -

MTN Sharia - - - -

- - - - Sukuk or Sharia Bonds - - - -

Sharia Stocks - - - -

-
Certificate of Deposit - - - - - - - - - - - - - -

Permitted Assets
Deposits - -
EUR SGD GBP Others IDR
PAYDI (guaranteed)
Total USD JPY AUD EUR SGD
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND MARKET RISK - FOREIGN EXCHANGE RATE CHANGES (in millions of rupiah) SGD GBP Others IDR Total DESCRIPTION USD JPY AUD EUR Corporate Fund GBP Others IDR Total Tabarru' Fund USD JPY AUD - 2 9 -

-
-
15% 15%

-
PUo -
Max((PUrf-PUo),0) fPTB
PTPI
PKo -
Max((PKrf-PKo),0)
PUrf -
Description Corporate Fund Tabarru' Fund PKrf - MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND MARKET RISK - INVESTMENT YIELD RATE CHANGE RISK (in millions of rupiah) - 3 0 -

RSAS-
-
III. Total ((PKli - ARi)fpkli) -
IV. Total ((PRBi - ARi)fpbi) -
Total Deviation
Description Total Deviation
I. Total max ((PK* - PK), 0) -
II. Total ((PAKYBMPi - ARi)fpki -
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND INSURANCE RISK (in millions of人寿) - 3 1 -

-
-
-
-
-
-
-
-
-
-
-
-
-

Life*) - -
Total max ((PK* - PK), 0)
Health - -
Personal Accident - -
Liability - -
Miscellaneous - -
Offshore Energy (Oil and Gas) - - Engineering - - Satellite - - Onshore Energy (Oil and Gas) - - Marine Hull - - Aviation Hull - - Motor Vehicles (Own Damage, Third Party - - Transportation (Marine Cargo) - - PK PK* Total Deviation Property - - MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND INSURANCE RISK - CONTRIBUTION PROVISION (in millions of rupiah) - 3 2 -

RSAS2
25% -
25% -
30% -
30% -
30% -
25% -
35% -
35% -
25% -
35% -
25% -
25% -
25% -
10% -

- - Total
    Personal Accident - -
    Life*) - -
    Miscellaneous - -
    Health - -
    Engineering - -
    Liability - -
    Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Aviation Hull - - Satellite - - Marine Cargo - - Marine Hull - - Property - - Motor Vehicles (Own Damage, Third Party - - PAKYBMP AR fpk Total Deviation PAKYBMP ((2) - (3)) x (4) MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND INSURANCE RISK - PROVISION FOR CONTRIBUTIONS NOT YET REVENUE (in millions of rupiah) - 3 3 -

20% -
20% -
25% -
25% -
25% -
20% -
30% -
30% -
20% -
30% -
20% -
20% -
20% -
10% -

- - - Total
      Personal Accident - -
      Life*) - -
      Miscellaneous - -
      Health - -
      Engineering - -
      Liability - -
      Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Aviation Hull - - Satellite - - Marine Cargo - - Marine Hull - - Property - - Motor Vehicles (Own Damage, Third Party - - Claim Provision AR fpk Total Deviation Claim Provision((2) - (3)) x (4) MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND INSURANCE RISK - CLAIM PROVISION (in millions of rupiah) - 3 4 -

RSAS4
25% -
25% -
30% -
30% -
30% -
25% -
35% -
35% -
25% -
35% -
25% -
25% -
25% -
10% -

- - - Total
      Personal Accident - -
      Life*) - -
      Miscellaneous - -
      Health - -
      Engineering - -
      Liability - -
      Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Aviation Hull - - Satellite - - Marine Cargo - - Marine Hull - - Property - - Motor Vehicles (Own Damage, Third Party - - Catastrophic Risk Provision AR fpk Total Deviation Catastrophic Risk Provision ((2) - (3)) x (4) MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND INSURANCE RISK - PROVISION FOR CATASTROPHIC RISK (in millions of rupiah) - 3 5 -

RSOS

-
-
-

-
- Total Deviation (f+h+j)
  h. Sub Total Operational Risk PAYDI (ROPAYDI Operational Risk Tabarru' Fund (RODT)
  i. Tabarru' Fund Investment -
  j. Sub Total RODT = (1‰*i) e. Operational Risk =(50%d) f. Sub Total Corporate Operational Risk (c+e) Operational Risk PAYDI (ROPAYDI) g. PAYDI Fund Assets - b. Education and Training Expenses -
  c. Operational Risk = (1%(a-b))
  d. Deferred Acquisition Cost Balance - Description Tabarru' Fund Corporate Fund Corporate Operational Risk a. General and Administrative Expenses - MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU FUND OPERATIONAL RISK (in millions of rupiah) - 3 6 -

RA110
Rating Name Rating Category Business Sector Economic Location Special Relationship Ownership Purpose Ownership Share (%)

- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
- - - - 0.00%
        Return Rate
        0.00%
        0.00%
        0.00%
        0.00%
        0.00%
        0.00%
        0.00%
        0.00%
        0.00%
        0.00%
        0.00% - - - - - - - - -

…

9 - - - - - -

10
Row Number
1
2
3
4
5
6

8 - - - - - -

-
7
8
9
10

-
7 - - - - - -

- - - 6 - -

5 - - - - - -

4 - - - - - -

-
3 - - - - - -

2 - -

1 - - - - -
Investment Receivables Total Investment Return Investment Return That Has Not Yet Due Book Balance Valuation Balance SAP AYD Investment Return Running Investment Receivables Currency Type Return Rate Collectibility DD/MM/YY Start DD/MM/YY Maturity Date

-
-
Timeframe
Name Group Company Type
/ Issuer
Fund Type Supervisor Investment Type Row Number Instrument Identity Investment Guarantee Fund In The Context Of Infrastructure Financing Issuer Name / Party DETAILS A-110. Investment and Property Details (in millions of rupiah) … Row Number 1 2 3 4 5 6 7 8 9 10 … - 3 7 -

…

- - - - 10 - - -
        -
        9 - - - - - - - -
- - - 8 - - -
      -
      7 - - - - - - - -
- - - 6 - - -
      -
      5 - - - - - - - -
- - - 4 - - -
      -
      3 - - - - - - - -
- - - 2 - - -
      DETAILS A-120. Receivables Details (in millions of rupiah) AYD (Million Rp) 1 - - - - - - - - DD/MM/YY Start Currency Debtor Rating Book Balance (Million Rp) Valuation Balance SAP (Million Rp) Row Number Debtor Name Business Category Receivable Type Fund Type - 3 8 -

… - -
9 - -
8 - -
7 - -
6 - -
5 - -
4 - -
3 - -
2 - -
1 - -
N o m or Baris Asset Name Market Value / Appraisal Bal ance Million (R p) Note DET AIL S A-130. Other Assets Details (in millions of rupiah) -39-

…

-
- - - 10 - -

9 - - - - - -
8 - -

7 - - - - - -
6 - -

5 - - - - - -
4 - -

3 - - - - - -
2 - -
1 - - - - - -
DETAILS A-210. Liabilities Details (in millions of rupiah) Country Currency Book Balance (Million Rp) Valuation Balance SAP (Million Rp) Row Number Name Liability Type Fund Type DD/MM/YY Start Period - 4 0 -

Miscellaneous - -
Life*) - -
Credit (Credit) - -
Suretyship - -
Accident - - - -
Liability (Liability) - -
Health - -
Offshore Energy (Oil and Gas) - - Engineering (Engineering) - - Satellite - - Onshore Energy (Oil and Gas) - - Hull (Marine Hull) - - Aviation Hull (Aviation Hull) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal - - Transportation (Marine Cargo) - - Life*) - -
II. PKYBMP
Property (Property) - -
Suretyship - -
Miscellaneous - -
-
Health - -
Credit (Credit) - -
Liability (Liability) - -
Accident - - -
Offshore Energy (Oil and Gas) - - Engineering (Engineering) - - Satellite - - Onshore Energy (Oil and Gas) - - Hull (Marine Hull) - - Aviation Hull (Aviation Hull) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal - - Transportation (Marine Cargo) - - Property (Property) - - Risk Provision Risk Provision on Amount Tabarru' Funds Risk Provision Insurance Branch Ujroh Provision Ujroh Provision on Amount Company Funds DETAILS A-220. UJROH PROVISION, CONTRIBUTION PROVISION, AND PROVISION ON CONTRIBUTIONS THAT ARE NOT YET INCOME (in millions of rupiah) Risk Provision on Combined Amount
I. Ujroh/Contribution Provision
-
4
1
-

RA221
-
-
-
-
-
-
-
-
-
-
-
-
-
-

- - - Total
      Accident - - -
      Life*) - - -
      Miscellaneous - - -
      Health - - -
      Credit (Credit) - - -
      Suretyship - - -
      Engineering (Engineering) - - - Liability (Liability) - - - Onshore Energy (Oil and Gas) - - - Offshore Energy (Oil and Gas) - - - Aviation Hull (Aviation Hull) - - - Satellite - - - Transportation (Marine Cargo) - - - Hull (Marine Hull) - - - Property (Property) - - - Motor Vehicles (Own Damage, Third Party Liability, and Personal - - - Insurance Branch Provision for Claims in Process IBNR Claims Provision Payment Claims Provision Tabarru' Funds Total Claims Provision DETAILS A-221. CLAIMS PROVISION - 4 2 -

Life*) - -
T otal II
Suretyship - -
Miscellaneous - -
He alth - -
Cre dit (Cre dit) - -
Ta ngung
Gugat (Liability) - -
Ac cident - -
Offshore Energy (Oil and
Gas) - -
En gineering (Engine eering) - - Satellite - - Onshore Energy (Oil and Gas) - - Hull (Marine Hull) - - Aviation Hull (A viation Hull) - - Mo tor Ve hicl e (O wn Damag e, Third Party - - Transportation (Marine Carg o) - - Insurance Branch R etention Self Tabarru' Funds Reinsurance Prop er ty) - - DET AIL S A-222 Risk Provision Disaster -43-

RA310

- 0.00% 0.00% 0.00%
- 0.00% 0.00% 0.00%
- 0.00% 0.00% 0.00%
- 0.00% 0.00% 0.00%
- - - - 0.00% 0.00% 0.00% Total

= 10 years - -
-
-
-
5 years = age < 10 years - - - - 1 year < age < 5 years - - <= 1 year - - Foreign Currency Asset to Liability Ratio2) Total Rupiah Foreign Currency Total Liabilities1) Rupiah Age

Total
Assets1)
Rupiah Foreign Currency
DETAILS A-310
Recapitulation of Assets and Liabilities by Currency and Maturity Date - 4 4 -

Current Liability Ratio Against Non-Current Liabilities - -
Description Rupiah Foreign Currency Total Current Asset Ratio Against Non-Current Assets - - DETAILS A-310 Recapitulation of Assets and Liabilities by Currency and Maturity Date (in percentage) - 4 5 -

RB110
…

…

-
Row Number
1
2
3
4
5
6
7
8
9
10 - - - -
-

10 - - - - - - - - - - -

9 - - - - - - - - - - - -

8 - - - - - - - - - - - -
-

- - - - 7 - - - -

6 - - - - - - - - - - -

-
5 - - - - - - - - - - - -
4 - - - - - - - - - - - -
-
-

-
- - - - 3 - - - -
        -

-
-

1 - - - - - - - - - - - -

2 - - - - - - - - - - -

DETAILS B-110
Contributions and Claims by Business Line Adjuster Expense Commission Expense Withdrawal/Redemption Participant Investment Funds Not Yet Due Gross Contribution - Direct Gross Contribution - Indirect Contribution Reinsurance/retrocession Gross Claims Gross Claims Recovery Withdrawal of Participant Investment Funds That Have Matured Allocation For DIP Allocation For Ujrah Allocation For Tabarru' Number of Policies Claimed Number of Participants Who Claimed Allocation For Ujrah Allocation For Tabarru' Distribution Channel Number Marketing Number of Inforce Policies Number of Participants Row Number Business Line Location Currency - 4 6 -

RC110
-
-
-
-
-
-
-
-
-
-
-
-
C-110. GUARANTEE FUND REPORT Summary of Guarantee Fund Development and Calculation of Guarantee Fund Adequacy Note: *) Net premium and reinsurance premium amounts are as presented in Description Amount

Summary of Guarantee Fund Development
Beginning Balance of Guarantee Fund - New Guarantee Fund Placements:
a. Guarantee Fund in the Form of Deposits - b. Guarantee Fund in the Form of SUN/Government Securities Other Securities Issued by the State (SBN) - Total New Guarantee Fund Placements (3 + 4) Withdrawal of Guarantee Fund:
a. Guarantee Fund in the Form of Deposits - b. Guarantee Fund in the Form of SUN/Government Securities Other Securities Issued by the State (SBN) - Total withdrawal of Guarantee Fund (7 + 8) Ending Balance of Guarantee Fund (1 + 5 – 9)
Annual Calculation of Guarantee Fund Adequacy
Required minimum Equity -
Net Contribution Amount*) - Reinsurance Contribution Amount*) - Provision Amount for Guaranteed PAYDI - Minimum Guarantee Fund Limit I (20% x 1) Minimum Guarantee Fund Limit II ((1% x 2) + (0.25% x 3 ) + (2% x 4)) Used Minimum Guarantee Fund Limit ( The greater value between 5 and 6) Guarantee Fund Owned Excess (Deficiency) of Guarantee Fund (8 - 7) -47-

RD110
…

…

Row Number
1
2
3
4
5
6
7
8
9
10 - - - - -
-

10 - - - - - - - - - - -

- - - - 9 - - -

8 - - - - - - - - - - -

- - - - 7 - - -

6 - - - - - - - - - - -

- - - - 5 - - -

4 - - - - - - - - - - -

- - - - 3 - - -

2 - - - - - - - - - - -
Row Number
Product Name Policy Type
(Group/Individual)
Business Line
DETAILS D-110
Micro Insurance Marketing Performance by Micro Insurance Product Type -

- - - - 1 - - -

Number of Memberships Ended Due to Claims Number of Active Participants at End of Reporting Period Gross Premium/ Contribution (Rp) Number of Active Participants at End of Reporting Period Gross Premium/ Contribution (Rp) Gross Claims (Rp) Not Compliant with OJK SE NO. 9/SEOJK.05/2017 Participants Who Claimed Compliant with OJK SE NO. 9/SEOJK.05/2017 Number of Active Participants at Start of Reporting Period Number of New Participants In the Reporting Period Number of Memberships Renewed in the Reporting Period Number of Memberships Ended Due to Maturity

Gross Claims (Rp) Participants Who Claimed Number of Active Participants at Start of Reporting Period Number of New Participants In the Reporting Period Number of Memberships Renewed in the Reporting Period Number of Memberships Ended Due to Maturity Number of Memberships Cancelled Number of Memberships Ended Due to Claims - 4 8 -

RD-120
…

10 - - - - - - -
9 - - - -

8 - - - - - - -
7 - - - -

6 - - - - - - -
5 - - - -

4 - - - - - - -
3 - - - -

2 - - - - - - -
1 - - - -
DETAILS D-120. Micro Insurance Marketing Channel Performance (in millions of rupiah) Number of Legal Entities Marketer Legal Entity Number of Individual Marketers Product Name Being Marketed Number of Participants/Insured Gross Premium/ Contribution (Rp) Row Number Marketing Channel Type Marketing Region Legal Entity Category - 4 9 -

B
LB
RSY
General Data
ASSYR
1Reporting Date
NCompany Code
Company Name
Reporting Period
Reporting Month April
Fiscal Year
Type of Reporting Period Monthly/Quarterly/Annual Report Board of Directors Name Director Position Company Address FORMAT I B FORM AND STRUCTURE OF MONTHLY/QUARTERLY/ANNUAL FINANCIAL ASPECT REPORTS FOR SHARIA REINSURANCE COMPANIES AND SHARIA UNITS IN REINSURANCE COMPANIES -50-

To
The Directorate of Sharia Financial Services Financial Services Authority MONTHLY/QUARTERLY/ANNUAL REPORT SHARIA REINSURANCE -51-

PPUSY
Company Profile
As of 31-Jan-1900
Description
Company Name
Full Address
Telephone and Fax
E-mail
Tax ID (NPWP)
License No. & Date
Number of Branches/Representatives Number of Employees Number of Insured External Auditor Controller PIC Financial Reporting Report Compiler Officer Name Division Telephone Fax Email Responsible Director Responsible Person Name Position Telephone Fax E-mail -52-

As of December 31, "Period" Year 1.
2.
3.
I, , registration number hereby declare that:

"Company Name" has fairly presented all data
I have reviewed the company's financial statements based on
based on regulations in the field of corporate health of the insurance industry Note: For annual reports only Thus this statement is made truthfully. Statement Letter Financial Statements "Company Name" I, the undersigned, hereby declare that:
Responsible for the preparation and presentation of financial statements "Company Name" All information in the company's financial statements has been presented completely according to actual conditions; The company's financial statements do not contain untrue material information or facts, and do not omit material information or facts. "Place", "Date" "Company Name" "Board of Directors Name" "Director Position" "Actuary Name" "PAI Reg No" Thus this statement is made truthfully. "Place", "Date" "Actuary Name" "PAI Reg No" -53-

As of "Date" Quarter "Period" 1.
2.
3.
Note: For quarterly reports only Responsible for the preparation and presentation of financial statements Statement Letter Financial Statements "Company Name" I, the undersigned, hereby declare that:
"Place", "Date"
"Company Name"
"Board of Directors Name"
"Director Position"
"Company Name"
All information in the company's financial statements has been presented completely according to actual conditions; The company's financial statements do not contain untrue material information or facts, and do not omit material information or facts. Thus this statement is made truthfully. -54-

Jakarta, ......20xx
Member
Note: For annual reports only
Sharia Supervisory Board PT ....
Chairman
PT ...
Sharia Reinsurance Company
STATEMENT
OF THE SHARIA SUPERVISORY BOARD After conducting research on the management of assets and liabilities of Tabarru' Funds, Tanahud Funds, Company Funds, and Participant Investment Funds of PT ....., then hereby the Sharia Supervisory Board of PT ..... declares that the management of assets and liabilities of Tabarru' Funds, Tanahud Funds, Company Funds, and Participant Investment Funds has been carried out in accordance with Islamic Sharia principles. -55-

PPSRESU
N o m or Baris
Shareholder Name
Shareholder Controller Rupiah Share Ownership Percentage Shareholder Details As of 31-Jan-1900 2 - 0.0 0 % 1 - 0.0 0 % 4 - 0.0 0 % 3 - 0.0 0 % 6 - 0.0 0 % 5 - 0.0 0 % 8 - 0.0 0 % 7 - 0.0 0 % 10 - 0.0 0 % 9 - 0.0 0 % -56-

PPU
RES
N o m or Baris Name Position Start Date 1 Details of Related Parties As of 31-Jan-1900 2 3 4 5 6 7 8 9 10 -57-

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
Education and Training Ratio - I As of 31-Jan-1900 (in millions of rupiah) 1 - - 2 - - N o m or Baris Description Bud get Reali zation Education and Training Costs Percentage 5 - - 6 - - 3 - - 4 - - 9 - - 10 - - 7 - - 8 - - T otal … - - -58-

RPPRES-2

0.00% 0.00%
Education and Training Ratio - II As of 31-Jan-1900 (in millions of rupiah) Description Budget Realization Employee and Management Costs - - Education and Training Costs a. Employee Training - - b. Board of Directors Training - - Total Training Costs Training Cost Ratio and Employee and Management
c. Board of Commissioners Training - -
d. Sharia Supervisory Board Training - - -5 9 -

LPKREU-SY

-
-
-
-
-
-
-
-
-
-
-
-
-

-
-

Laporan Posisi Keuangan
As of 31-Jan-1900
(in millions of rupiah)
Investment
Deposits - - -
Adjustments
Combined
SAK
ASSETS
SAP
Tabarru' Funds
SAK SAP
Participant Investment Funds DESCRIPTION SAK SAP Company Funds SAK

Deposit Certificates - - - - - - -

Sharia Sukuk or Bonds - - - - - - - Sharia Stocks - - - -

Sharia Government Securities - - - - - - - Sharia MTN - - - -

Sharia Securities Issued - - - - - - - Sharia Securities Issued - - - -

Sharia Mutual Funds - - - - - - - Sharia Securities Issued - - - -

Sharia Real Estate Investment Funds - - - - - - - Sharia Asset-Backed Securities - - - - Sharia Financing With Rights - - - Direct Participation - - -

Financing Through Cooperation With - - - - - - - REPO - - - - - Investment Properties - - - Pure Gold - - - - - - - Non-investment Cash and Banks - - - Other Investments - - -

Receivables - - - - - - -
-
Deferred Acquisition Costs - - - Reinsurance Assets - - - - LIABILITIES AND EQUITY Liabilities Claims Payable or Investment Benefits - - Non-Investment Property - - - Other Assets - - - -

Expenses Incurred But Not Yet Paid - - - - - - -

Technical Provisions
Ujroh provision - - -
Other payables - - -
Provision for contributions that have not yet - - - Claims provision - - - PAYDI provision that provides - - - Contribution provision - - - Fund Equity Paid-in Capital - - - Provision for disaster risk - - - Qardh - - - - Profit Equilization Reserve - - - Retained Earnings Balance - - Stock Agio/Disagio - - - Accumulated Funds - - - - - Forbidden Wealth - - - -

Difference Between SAK Balance and SAP Balance - - - - Other Equity Components - - - - -60-

LKKREU

Financial Performance Report For the Period Ending 31-Jan-1900 (in millions of rupiah) INCOME INVESTMENT RETURN AND UJROH INCOME Investment Return - - Mudharabah Contract Participant Investment Funds Combined Adjustments Description Company Funds Tabarru' Funds Wakalah Bil Ujrah Contract

Investment Return Distributed to Funds - - - - - - - Total Investment Management Ujroh - - Total Investment Return - - - - b. Indirect Contribution Allocation: - - - - - UNDERWRITING INCOME Gross Contribution/Ujroh Received/Allocation a. Direct Contribution Allocation: - - - - - - Total Income from Investment Return and - - - - - Reinsurance/Retrocession Contribution - - - - Total Gross Contribution/Ujroh - - - - b. Decrease (Increase) in PKYBMP Provision - - -
c. Decrease (Increase) in Provision for - - -
-
Decrease (Increase) in Contribution Provision a. Decrease (increase) in Provision for - - - - Net Contribution - - - - Total Net Contribution Income - - - UNDERWRITING INCOME - - - - - b. Claims recovery - - - EXPENSES UNDERWRITING EXPENSES Claims Expense a. Gross Claims -
c. Increase (Decrease) in Provision for - - -
d. Withdrawal of Participant Investment Funds that have - - - - - Total Net Claims Expense - - - Adjuster Expense - - - e. Withdrawal/Redemption of Investment Funds - - - - a. Underwriting surplus for funds - - - - TOTAL UNDERWRITING EXPENSES - - - TOTAL UNDERWRITING SURPLUS (DEFICIT) - - - b. Acquisition Expense - - -
c. General and Administrative Expenses:
-
BUSINESS EXPENSES:
a. Marketing Expense - - - b. Underwriting surplus for Participants - - - -

Employee and Management Expense - - -
Education and Training Expense - - - -
TOTAL BUSINESS EXPENSES - - - INSURANCE OPERATING PROFIT (LOSS) - - -
Other General and Administrative Expenses - - -
Increase (decrease) in Ujroh Provision - - - Other Expenses - - - - Other Income - - - - PROFIT (LOSS) BEFORE TAX - - - Income Tax - - - - - -
- TOTAL ENTIRE FUNDS PERFORMANCE - - - -
  PROFIT AFTER TAX - - -
  OTHER COMPREHENSIVE INCOME - - - - -61-

LAK-R
-

-
Cash Flow Statement
For the Period Ending 31-Jan-1900 (in millions of rupiah) Mudharabah Contract Participant Investment Funds Combined BEGINNING BALANCE - - - - Description Company Funds Tabarru' Funds Wakalah Bil Ujrah Contract

Ujroh received -
INCREASE (DECREASE) IN CASH BALANCE ENDING CASH BALANCE CASH FLOWS FROM OPERATING ACTIVITIES a. Cash Inflows Participant Contributions Others - - - - Receipt of Tabarru' Fund Surplus Allocation - Reinsurance Claims Received - Distribution Surplus Receipts - Withdrawal of Participant Investment Funds that have - - Withdrawal/Redemption of Investment Funds - - b. Cash Outflows Claims Paid - - - Marketing Expense - Reinsurance Ujroh Payment - Insurance Ujroh Payment Payment of UW Surplus Distribution to - Payment of UW Surplus Distribution to - Acquisition Expense - Zakat Payment - Tax Payment - Others - - Reinsurance Contribution Paid - - Rent Payment - Investment Return Receipt - - - -

CASH FLOWS FROM INVESTMENT ACTIVITIES a. Cash Inflows -

Sale of Fixed Assets -
Receipt of Investment Profit Sharing for Funds - Receipt of Investment Profit Sharing for Funds - Investment Liquidation - b. Cash Outflows Investment Placement - - - Others - - - - Payment of ujroh/fee to Company - - - Purchase of Fixed Assets - - Investment Return Distributed to Funds - - - CASH FLOWS FROM FINANCING ACTIVITIES a. Cash Inflows Capital Injection/Working Capital - Subordinated Loan - Others - - - b. Cash Outflows Subordinated Loan Repayment - Qardh Receipt - Others - - - Dividend Payment - Qardh Payment - Others - - -62-

LPDR
-

STATEMENT OF CHANGES IN FUNDS For the Period Ending 31-Jan-1900 (in millions of rupiah) DESCRIPTION Company Funds Tabarru' Funds Combined
I. Beginning Fund Balance - -
II. Additions
Paid-in Capital -
Comprehensive income for the current period - Increase in accumulated tabarru' funds / funds - Other additions - -
III. Deductions
Comprehensive loss for the current period - Decrease in accumulated tabarru' funds / funds -
IV. Ending Fund Balance
-
Dividend Payment -
Other deductions - -
-
6
3
-

DP-R

-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

COMPANY FUNDS ANALYSIS
CALCULATION OF COMPANY FUNDS ASSETS AND LIABILITIES As of 31-Jan-1900 (in millions of rupiah) AYD After Limits Per Asset Type AYD After Affiliation Limits AYD After Foreign Limits (SAP Balance)
I. Investment
Deposits - - - - - -
Description Book Balance (SAK) Valuation Based on SAP Difference Based on Valuation Based on SAK and SAP AYD After Limits Per Company

-
Sharia Stocks - - - - - -
Deposit Certificates - - - -

Sharia MTN - - - - - -
Sharia Sukuk or Bonds - - -

-
Sharia Bank Indonesia Securities - - - - - - Sharia Government Securities RI - - - -

Sharia Multilateral Institution Securities - - - - - - Sharia Securities Other Than RI - - - -

-
Sharia Asset-Backed Securities - - - - - - Sharia Mutual Funds - - - -

REPO - - - - - -
Sharia Real Estate Investment Funds - - - -

-
Sharia Financing With Collateral Rights - - - - - - Financing Through Cooperation With Parties - - - -

Investment Properties - - - - - - Direct Participation - - - - Total Investment
II. Non-Investment
Cash and Banks - -

-
Other Investments - - - -
Pure Gold - - - -

Direct Closing Ujroh Receivables - - - - - -

-
Investment Return Receivables - - - - - - Indirect Closing Ujroh Receivables - - - -

Reinsurance Assets - - - - - - Investment Receivables - - - - Total Non-Investment TOTAL WEALTH (I+II) Other Assets - - - - - - Non-Investment Property - - - - - - Deferred Acquisition Costs - - - - - 6 4 -

DP-R-1
-
-
-

COMPANY FUNDS ANALYSIS
CALCULATION OF COMPANY FUNDS LIABILITIES As of 31-Jan-1900 (in millions of rupiah) Description Book Balance (SAK) Valuation Based on SAP Difference SAK and SAP Valuation
I. Payables - -
TOTAL LIABILITIES (I+II+III)
II. Ujroh Provision - -
III. Provision for Guarantee Over Principal - -
-
6
5
-

DTUR

-
-
-
-
-
-
-
-
-
-
-
-
-
-

-
-
-
-

ANALYSIS OF TABARRU FUND
CALCULATION OF ASSETS AND LIABILITIES OF THE TABARRU' FUND As of Jan 31, 1900 (in millions of rupiah) AYD After Limit Per Asset Type AYD After Affiliation Limit AYD After Foreign Limit (SAP Balance)
I. Investment
Deposits - - - - - -
Description Ledger Balance (SAK) Valuation Based on SAP Difference Based on SAK and SAP Valuation AYD After Limit Per Company

-
Shariah Stocks - - - - - -
Certificates of Deposit - -

Shariah MTN - - - - - -
Shariah Sukuk or Bonds - - - -

-
Shariah Securities Bank Indonesia - - - - - - Shariah Securities State RI - - - -

Shariah Securities Multinational Institutions - - - - - - Shariah Securities Countries Other Than RI - - - -

-
Shariah Asset-Backed Securities - - - - - - Shariah Mutual Funds - - -

REPO - - - - - -
Shariah Real Estate Investment Fund - - - - - - - Pure Gold - - - - - - Financing Through Cooperation With Parties - - - - Total Investments
II. Non-Investment
Cash and Banks - -
Other Investments - - -

Reinsurance Contribution Receivables - - - - - -

-
Investment Income Receivables - - - - - - Reinsurance Claim Recovery Receivables - - - - Total Non-Investments TOTAL WEALTH (I+II) Other Assets - - - - - - Reinsurance Assets - - - - - - Investment Receivables - - - - - 6 6 -

DTUR-1
-
-
-
-

ANALYSIS OF TABARRU FUND
CALCULATION OF LIABILITIES OF THE TABARRU' FUND As of Jan 31, 1900 (in millions of rupiah) Description Ledger Balance (SAK) Valuation Based on SAP Difference in SAK and SAP Valuation Payables - - Contribution Reserves - - Reserves for Contributions That Have Not Yet Become - - TOTAL LIABILITIES Claim Reserves - - Catastrophic Risk Reserves (Catastrophic - - - 6 7 -

RPTSRES

-
-
-
-
-
0,00% 0,00%

-
0,00% 0,00%
FINANCIAL RATIOS
SOLVENCY LEVEL ACHIEVEMENT
As of Jan 31, 1900
(in millions of rupiah)
Description Tabarru Fund Company Fund Solvency Level A. Permitted Assets (AYD) - - B. Liabilities other than Qardh from the Company Fund - - DTMBR/MMBR A. Credit Risk - - B. Liquidity Risk - -
C. Market Risk - -
D. Insurance Risk -
E. Operational Risk - -
F. MMBR over Guaranteed PAYDI

Guaranteed PAYDI Risk
a. Credit Risk - b. Liquidity Risk -
c. Market Risk -
Guaranteed PAYDI Assets -
Guaranteed PAYDI Liabilities -
Solvency Level Ratio before considering Assets Internal Target Solvency Level Ratio (annual) 0,00% 0,00% Solvency Level Ratio with DTMBR/MMBR that 0,00% 0,00% Assets Available For Considered Qardh A. Deficiency (Surplus) of solvency level from target B. Insufficiency of investments, cash and banks - Tabarru Fund and Tanahud Fund Solvency Level Ratio - 6 8 -

RIKSTSRU

-
0,00% 0,00% 0,00%

0,00% - 0,00%

-
-
0,00% 0,00% 0,00%

0,00% - 0,00%

-
-

0,00% 0,00% 0,00%

-
-
-
0,00% 0,00% 0,00%

FINANCIAL RATIO
SOLVENCY LEVEL
ASIDE
As of Jan 31, 1900
(in millions of rupiah)
Description
Tabarru Fund Company Fund
Combined Indicator
Liquidity Ratio
A. Current Wealth - -
B. Current Obligations - -
C. Ratio (a:b)
Ratio of investment balance with liabilities A. Investments, cash and banks - B. Technical reserves -
C. Retention claim payables -
D. Ratio [a:(b+c)]
Net investment income ratio A. Net investment income - - B. Average investments - -
C. Ratio (a:b)
Claim expense ratio
A. Net claim expenses -
B. Net contributions -
C. Ratio (a:b)
Fund change ratio
A. Current year/quarter/month funds - - B. Previous year/quarter/month funds - -
C. Fund changes (a-b)
D. Ratio (c:b)
Sharia Unit Asset Ratio
A. Tabarru Fund Assets - -
B. Participant Investment Fund Assets - -
C. Company Insurance Fund Assets - -
D. Ratio (a+b) : (a+b+c)
Calculation of Required Qardh Funds A. Total Obligations other than Qardh - B. Total Assets - Total Required Qardh (a-b) -69-

RKUS-RE
-

-
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK As of Jan 31, 1900 (in millions of rupiah) Credit Risk (b) - Total Credit Risk Description Tabarru Fund Total Deviation Company Fund Credit Risk (a) - - - 7 0 -

RKRKRES

1,20% - - -
2,10% - - -
3,00% - - -
4,50% - - -
9,00% - - -

1,60% - - -
2,80% - - -
4,00% - - -
6,00% - - -
12,00% - - -

1,00% - - -

1,60% - - -
2,80% - - -
4,00% - - -
6,00% - - -

2,80% - - -
4,00% - - -

5,60% - - -
8,00% - - -
12,00% - - -

8,00% - - -

30,00% - - -

2,80% - - -

2,80% - - -
4,00% - - -
6,00% - - -
12,00% - - -
15,00% - - -

2,80% - - -

2,80% - - -
4,00% - - -
6,00% - - -
12,00% - - -
15,00% - - -

2,80% - - -

2,80% - - -
4,00% - - -
6,00% - - -
12,00% - - -
15,00% - - -

2,00% - - -
25,00% - - -
2,00% - - -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK - DEFAULT OR INABILITY RISK OF DEBTOR OR OTHER PARTY As of Jan 31, 1900 (in millions of rupiah) Factor Tabarru Fund Company Fund Total Deviation PAYDI (guaranteed) Description Tabarru Fund Company Fund PAYDI (guaranteed) Total AYD Special Category (up to 2 billion per - - - Other Categories, according to Bank Rating:
Investment
Time Deposits and Certificates of Deposit - - -
c. Cluster rating 3 - - -
d. Cluster rating 4 - - - a. Cluster rating 1 - - - b. Cluster rating 2 - - - a. Cluster rating 1 - - - b. Cluster rating 2 - - - e. Cluster rating 5 - - - Shariah Corporate Sukuk / Bonds e. Cluster rating 5 - - - Shariah MTN
c. Cluster rating 3 - - -
d. Cluster rating 4 - - -
c. Cluster rating 3 - - -
d. Cluster rating 4 - - - a. Cluster rating 1 - - - b. Cluster rating 2 - - - Securities Issued by Banks - - - Securities Issued by States e. Cluster rating 5 - - - Shariah Securities State - - -
c. Cluster rating 3 - - -
d. Cluster rating 4 - - - a. Cluster rating 1 - - - b. Cluster rating 2 - - - REPO - - - Financing Through Cooperation with Parties e. Cluster rating 5 - - - Securities issued by Institutions - - - c.Unhealthy - - - d.Not healthy - - - a.Very healthy - - - b.Healthy - - - - b. 65% < LTV < 75% - - - Loans Secured by Rights Residential Property a. LTV < 65% - - b. 65% < LTV < 75% - - - Unused Properties - - - Other Commercial Properties a. LTV < 65% - - - Direct Closing Contribution Receivables - - - Reinsurance Assets Non-Investment Cash and Banks - - - Co-insurance Claim Receivables Domestic - - - a. assets sourced from estimated value - - - b. assets sourced from agreements - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
Foreign:
a. Cluster rating 1 - - -
Reinsurance Contribution Receivables Domestic - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - Cluster Rating 2 - - - Cluster Rating 3 - - - Foreign Cluster Rating 1 - - - Reinsurance Claim Receivables Domestic - - - Cluster Rating 4 - - - Cluster Rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
Foreign:
a. Cluster rating 1 - - -
Investment Receivables a. Investments not yet received - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - Total b. Investments defaulted on date - - - Investment Income Receivables - - - -71-

RKRKRES1

0,00% -
0,00% -
0,00% -
0,00% -
0,00% -
0,00% -
0,00% -
0,00% -
0,00% -
0,00% -
MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK - FAILURE/INABILITY OF REINSURER As of Jan 31, 1900 (in millions of rupiah) 2 - - - Reinsurance Exposure Net ((2)-(3)) Factor Total Deviation 1 - - - Row Number Type of Reinsurer Name of Reinsurer Technical Reserves Expenses Reinsurer Deposit and/or Contributions withheld 4 - - - 3 - - - 6 - - - 5 - - - 8 - - - 7 - - - 10 - - - 9 - - - - 7 2 -

RKLRES

Description
Up to 1 year
More than 1 year up to 3
More than 3 years up to 5
More than 5 years up to 10
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND LIQUIDITY RISK As of Jan 31, 1900 (in millions of rupiah) More than 10 years Total Tabarru' Fund More than 10 years Total Company Fund Up to 1 year More than 1 year up to 3 Tabarru' Fund PAYDI (guaranteed) Total More than 10 years Tabarru' Fund Up to 1 year Assets Investments Time Deposits - - - - - - More than 1 year up to 3 More than 3 years up to 5 More than 5 years up to 10 More than 3 years up to 5 More than 5 years up to 10

Certificates of Deposit - - - - - - - - - - - - - - -

Shariah Corporate Sukuk / Bonds - - - - - - - - - - - - - - - Shariah Stocks -

Shariah Securities State - - - - - - - - - - - - - - - Shariah MTN -

Securities Issued by Countries Other Than Country - - - - - - - - - - - - - - - Securities Issued by Bank Indonesia -

Shariah Mutual Funds - - - - - - - - - - - - - - - Securities Issued by Institutions -

Shariah Real Estate Investment Fund - - - - - - - - - - - - - - - Shariah Asset-Backed Securities -

Financing Through Cooperation with Other Parties - - - - - - - - - - - - - - - REPO - Shariah Financing with Mortgage Rights - - - - -

Pure Gold - - - -
-
Property Investments - - - - - Direct Participation - - - - - Other Investments - - - - - - - - - - - - - -

-
Non-Investment
Cash and Banks - - - - - - - - - - - - - - - Contribution/Ujroh Receivables Direct Closing - - - - - - - -

Contribution/Ujroh Receivables Reinsurance - - - -

Reinsurance Assets - - - - - - - - - Reinsurance Claim Recovery Receivables - - - - - - - -

Co-insurance Claim Receivables - - - -
-
Investment Receivables - - - - - - - - - - - - - -

-
Non-Investment Property - - - - - - Investment Income Receivables - - - - - - - - - - - - - - - Other Fixed Assets - - - - - Deferred Acquisition Costs - - - -

- - - - Other Assets - - - -
- Co-insurance Payables - - - -
  -
  Liabilities and Equity
  Liabilities
  Payables
  Claim Payables or Investment Benefits - - - - - - - - - -

-
Reinsurance Payables - - - - - - - - - - - - - -

-
Ujroh Payables - - - - - - - - - - - - - - -

Expenses Incurred But Not Yet Paid - - - - - - - - - - - - - - Tax Payables - - Technical Reserves Ujroh Reserves - - - - - - Other Payables - - - - - - - - - - - - - -

-
Reserves for contributions that have not become - - - - - - Contribution Reserves - - - PAYDI Reserves Providing Principal Guarantee - - - - - Catastrophic Risk Reserves - - - - - Claim Reserves - - - - - DIFFERENCE BETWEEN LIABILITIES AND ASSETS DEVIATION (4% X (Max (Li - AYDi), 0))
- - - - Accumulation of Participant Investment Funds - - - -
        -
        7
        3
        -

RPSYA-R
-
-

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND MARKET RISK As of Jan 31, 1900 (in millions of rupiah) Description Company Fund Tabarru Fund PAYDI (guaranteed) Total Deviation Total Market Risk (A) - - - Market Risk (B) - - - Market Risk (C) - - - Total Market Risk - 7 4 -

RPARES

15% - - -
20% - - -

20% - - -
30% - - -

0% - - -
6% - - -
16% - - -

1,6% - - -
2,8% - - -
4% - - -
6% - - -
12% - - -
10% - - -

10% - - -
20% - - -

7% - - -
15% - - -
40% - - -
3% - - -

4% - - -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND MARKET RISK - MARKET PRICE CHANGES As of Jan 31, 1900 (in millions of rupiah) Factor Company Fund Tabarru' Fund Total Deviation PAYDI (guaranteed) Description Company Fund Tabarru' Fund PAYDI (guaranteed) Total AYD - Stocks traded on Indonesian exchange - - - Investments Shariah Stocks Including IDX30 or JII - - Other Stocks - - - Shariah Mutual Funds Stocks traded on foreign exchanges - - - Main index constituent stocks of main exchanges - - - Entirely equity securities - - - Mixed*) Entirely government debt securities - - - Entirely private debt securities and - - - - Tabarru' Fund - - - - Company Fund - - - - Shariah Asset-Backed Securities a. Cluster rating 1 - - - PAYDI (guaranteed) - - - d. Cluster rating 4 - - - e. Cluster rating 5 - - - b. Cluster rating 2 - - -
c. Cluster rating 3 - - -
Under OJK Supervision - - - Not Under OJK Supervision - - - Real Estate Investment Funds - - - Direct Participation Investment Results 2% - 4% - - - Investment Results less than 2% - - - Property Investments Investment Results 4% or more - - - Non-Investment Properties - - - TOTAL Pure gold - - - NON-INVESTMENT - 7 5 -

RPSB-R

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND MARKET RISK - FOREIGN CURRENCY VALUE CHANGES As of Jan 31, 1900 (in millions of rupiah) EUR EUR SGD IDR Others Total DESCRIPTION USD JPY GBP AUD Company Fund Permitted Assets Deposits - - - SGD IDR Others PAYDI (guaranteed) Total USD JPY GBP AUD EUR SGD IDR Others Total Tabarru' Fund USD JPY GBP AUD

Certificates of Deposit - - - - - - - - - - - - - -

Shariah Sukuk or Bonds - - - -

- - - - Stocks - - - -

Shariah Securities State - - - -

- - - - MTN Syariah - - - -

Shariah Securities Issued by Countries Other Than Republic of Indonesia

- - - - Securities Issued by
        Bank Indonesia

Shariah Mutual Funds - - - -

- - - - Securities Issued by
        Multinational Institutions

Shariah Real Estate Investment Fund - - - -

- - - Asset-Backed Securities - - - -

Financing Through Cooperation with Parties - - - -

- - - - REPO - - - -

-
Direct Participation - - - - Shariah Financing with Mortgage Rights - - - -

Pure gold - - - -
Property Investments - - -

Cash and Banks - - - -

- - - - Other Investments - - - -

Reinsurance Contribution Receivables - - - -

- - - Direct Closing Contribution Receivables - - - -

-
-
-
-

-
Reinsurance Assets - - - -
-

-
Co-insurance Claim Receivables - - - - - - - - - - - -

-
-
Reinsurance Claim Receivables - - - - - - - - - - - - - -

Investment Income Receivables - - - -

- - - - Receivables - - - -

Deferred Acquisition Costs - - - - Non-Investment Property - - - -

-
-
Co-insurance Payables - - - - Total Permitted Assets Liabilities Claim Payables - - Ujroh Payables - - - - Reinsurance Payables - - -

Tax Payables - - - - - - - - - - -

Expenses Incurred But Not Yet Paid - - - - - - - - - - - -

Other Payables - - - - - - - - - - - - -

-
-
Ujroh Reserves - - - -

Contribution Reserves
Reserves for contributions that have not yet Claim Reserves Catastrophic Risk Reserves Total Liabilities Principal Investment Guarantee Reserves - - -

Total Permitted Assets in Rupiah Total Liabilities in Rupiah Difference Between Permitted Assets and Liabilities Factor Total Deviation

- - - - Exchange Rate - - - -
        -
        7
        6
        -

RPSC-R
-
-
15% 15%

-
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND MARKET RISK - INVESTMENT YIELD RATE CHANGE RISK As of Jan 31, 1900 (in millions of rupiah) Description Company Fund Tabarru' Fund PKrf - PKo - Max((PKrf-PKo),0) PUrf - PUo - Max((PUrf-PUo),0) fPTB PTPI - 7 7 -

RSAS-R
-
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND INSURANCE RISK As of Jan 31, 1900 (in millions of rupiah) Description Total Deviation
I. Total max ((PK* - PK), 0) -
II. Total ((PAKYBMPi - ARi)fpki -
III. Total ((PKli - ARi)fpkli) -
IV. Total ((PRBi - ARi)fpbi) -
Total Deviation
-
7
8
-

RSAS1-R
-
-
-
-
-
-
-
-

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND INSURANCE RISK - CONTRIBUTION RESERVES As of Jan 31, 1900 (in millions of rupiah) PK PK* Total Deviation Property - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - - Ship Hull - - Aviation Hull - - Satellite - - Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Engineering - - Liability - - Miscellaneous - - Life*) - -
I. Total max ((PK* - PK), 0)
Health - -
Personal Accident - -
-
7
9
-

RSAS2-R
25% -
25% -
30% -
30% -
30% -
25% -
35% -
35% -
25% -
35% -
25% -
25% -
25% -
10% -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND INSURANCE RISK - RESERVES FOR CONTRIBUTIONS THAT HAVE NOT YET BECOME INCOME As of Jan 31, 1900 (in millions of rupiah) PAKYBMP AR fpk Total Deviation PAKYBMP ((2) - (3)) x (4) Property - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - - Ship Hull - - Aviation Hull - - Satellite - - Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Engineering - - Liability - - Miscellaneous - - Health - - Total Personal Accident - - Life*) - - - 8 0 -

RSAS3-R
20% -
20% -
25% -
25% -
25% -
20% -
30% -
30% -
20% -
30% -
20% -
20% -
20% -
10% -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND INSURANCE RISK - CLAIM RESERVES As of Jan 31, 1900 (in millions of rupiah) Claim Reserves AR fpk Total Deviation Claim Reserves ((2) - (3)) x (4) Property - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - - Ship Hull - - Aviation Hull - - Satellite - - Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Engineering - - Liability - - Miscellaneous - - Health - - Total Personal Accident - - Life*) - - - 8 1 -

RSAS4-R
25% -
25% -
30% -
30% -
30% -
25% -
35% -
35% -
25% -
35% -
25% -
25% -
25% -
10% -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND INSURANCE RISK - CATASTROPHIC RISK RESERVES As of Jan 31, 1900 (in millions of rupiah) Catastrophic Risk Reserves AR fpk Total Deviation Catastrophic Risk Reserves ((2) - (3)) x (4) Property - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - - Ship Hull - - Aviation Hull - - Satellite - - Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Engineering - - Liability - - Miscellaneous - - Health - - Total Personal Accident - - Life*) - - - 8 2 -

RSOS-R
-
-
-
-

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND OPERATIONAL RISK As of Jan 31, 1900 (in millions of rupiah) Description Tabarru Fund Company Fund Company Operational Risk a. General and Administrative Expenses - b. Education and Training Expenses -
c. Operational Risk = (1%*(a-b))
d. Deferred Acquisition Cost Balance - e. Operational Risk =(50%*d) f. Sub Total Company Operational Risk (c+e) PAYDI Operational Risk (ROPAYDI) g. PAYDI Fund Assets - Total Deviation (f+h+j) h. Sub Total PAYDI Operational Risk (ROPAYDI Tabarru' Fund Operational Risk (RODT)
i. Tabarru' Fund Investments -
j. Sub Total RODT = (1‰*i)
-
8
3
-

RA110-R
(in millions of rupiah)
Rank Name Rating Agency Business Category Economic Sector Location Special Relationship Ownership Purpose Ownership Share (%) Currency Type Level Rate of Return (%)

- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
- - - - 0.00% - - 0.00%
        Collectibility Book Balance Assessment Balance SAP AYD Investment Results Current Received Cash Investment Receivables Investment Receivables Previous Period Received Cash Current Period Total Investment Results Investment Results Ready for Distribution

DD/MM/YY Start DD/MM/YY Maturity Timeframe Name Group Category Company / Fund Type Regulator Investment Type Number Line Instrument Identity Fund Guarantee Investment In the Name of Issuer / Party

- - - 2 - -
      1 - - - - - -
      4 - - - - - -
      3 - - - - - -
- - - 6 - -
      5 - - - - - -
      8 - - - - - -
      7 - - - - - -
- - - 10 - -
      9 - - - - - -
      DETAILS A-110. Investment and Property Details As of Jan 31, 1900 Number Line 1 2 3 4 5 6 7 8 9 10 6 7 8 9 10 N 1 2 3 4 5 umber Line - 8 4 -

RA120-R
DETAILS A-120. Receivables Details As of Jan 31, 1900 (in millions of rupiah) AYD (Million Rp) 1 - - - - - - - - DD/MM/YY Start Currency Debtor Rank Book Balance (Million Rp) Assessment Balance SAP (Million Rp) Line Number Debtor Name Business Category Receivable Type Fund Type - 3 - - - - - - - -

- - - 2 - - -
      -
      5 - - - - - - - -
- - - 4 - - -
      -
      7 - - - - - - - -
- - - 6 - - -
      -
      9 - - - - - - - -
- - - 8 - - -
- - - - 10 - - -
        -
        8
        5
        -

R
A130-R
N o m or Line Asset Name Market Value / Appraisal Bal Million (Rp) Notes RIN CIA N A-130. Other Assets Details As of Jan 31, 1900 (in millions of rupiah) 2 - - 1 - - 4 - - 3 - - 6 - - 5 - - 8 - - 7 - - 10 - - 9 - - -86-

RA210-RU
DETAILS A-210. Liabilities Details As of Jan 31, 1900 (in millions of rupiah) Country Currency Book Balance (Million Rp) Assessment Balance SAP (Million Rp) Line Number Name Liability Type Fund Type DD/MM/YY Start Period 1 - - - - - -

3 - - - - - -
2 - -

5 - - - - - -
4 - -

7 - - - - - -
6 - -

9 - - - - - -
8 - -

- - - 10 - -
      -
      8
      7
      -

RA220-R

DETAILS A-220. PROVISION FOR UJROH, PROVISION FOR CONTRIBUTION, AND PROVISION FOR CONTRIBUTIONS THAT ARE NOT YET REVENUE Quarterly (in millions of rupiah) Risk Provision for Combined Total
I. Ujroh/Contribution Provision
Property Assets - -
Risk Provision Risk Provision for Total Tabarru' Fund Insurance Branch Ujroh Provision Ujroh Provision for Total Marine Hull Fund - - Aviation Hull - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - - Offshore Energy (Oil and Gas) - - Engineering - - Satellite - - Onshore Energy (Oil and Gas) - - - Health - - Credit (Credit) - - Liability - - Personal Accident - - - Life*) - -
II. PKYBMP
Property Assets - -
Suretyship - -
Miscellaneous - -
Marine Hull - -
Aviation Hull - -
Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

Transportation (Marine Cargo) - - Offshore Energy (Oil and Gas) - - Engineering - - Satellite - - Onshore Energy (Oil and Gas) - - Personal Accident - - - - Liability - - Health - - Miscellaneous - - Life*) - - Credit (Credit) - - Suretyship - - - 8 8 -

RA221-R
-
-
-
-
-
-
-
-
-
-
-
-
-
-

DETAILS A-221.
CLAIM PROVISION
As of Jan 31, 1900
Insurance Branch
Provision for Claims in Process IBNR Claim Provision Provision for Periodic Payment Claims Tabarru' Fund Total Claim Provision Property Assets - - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

Transportation (Marine Cargo) - - - Marine Hull - - - Aviation Hull - - - Satellite - - - Onshore Energy (Oil and Gas) - - - Offshore Energy (Oil and Gas) - - - Engineering - - - Liability - - - Credit (Credit) - - - Suretyship - - - Miscellaneous - - - Health - - - Total Personal Accident - - - Life*) - - - - 8 9 -

R
A222-R

-
RIN
CIA
N
A-222
Risk Provision
Disaster
As of Jan 31, 1900
Branch
Insurance
Self Retention
Tabarru' Fund
Reinsurance
Property Assets (Pro p erty) - - Motor Vehicles (O wn Damag e, Third Party - - Transportation (Marine Carg o) - - Marine Hull - - Aviation Hull - - Satellite - - Onshore Energy (Oil and Gas) - - Offshore Energy (Oil and Gas) - - Engine ering) - - Tang ung Gugat (Liability) - - Personal Accident - - Health - - Cre dit (Cre dit) - - Life*) - - T otal Suretyship - - Miscellaneous - - -90-

RA310-R

- #DIV/0! #DIV/0! #DIV/0!
- #DIV/0! #DIV/0! #DIV/0!
- #DIV/0! #DIV/0! #DIV/0!
- #DIV/0! #DIV/0! #DIV/0!
- - - - #DIV/0! #DIV/0! #DIV/0!
        Rupiah
        Age

Total
Assets
DETAILS A-310
Asset and Liability Recapitulation Details by Currency and Maturity As of Jan 31, 1900 Foreign Currency Asset Ratio Against Liabilities Total Rupiah Foreign Currency Total Liabilities Rupiah Foreign Currency 1 year < age < 5 years - - <= 1 year - -

-
-
5 years = age < 10 years - - - - Total >= 10 years - - - - 9 1 -

RA310-1-R
Details A310-1
Asset and Liability Recapitulation Details by Currency and Maturity As of Jan 31, 1900 (in percentage) Current Liability Ratio Against Non-Current Liabilities 0.00% 0.00% 0.00% Description Rupiah Foreign Currency Total Current Asset Ratio Against Non-Current Assets 0.00% 0.00% 0.00% - 9 2 -

RB110-R
Total Policies With Claims Total Participants Who Allocation For Ujrah Allocation For Tabarru Distribution Channel Marketing Volume Inforce Policies Volume Participants Line Number Business Location Currency DETAILS B-110 Contributions and Claims by Business Line As of Jan 31, 1900

- - - - 1 - - - -
        Contributions Gross Claims Claims Recovery Adjuster Expense Commission Expense Allocation For DIP Contributions Bruto - Direct Allocation For Ujrah Allocation For Tabarru Contributions Bruto - Indirect
- - - - 2 - - - -

-
-

- - - 3 - - - -

-
-

- - - 4 - - - -

-
-

- - - 5 - - - -

-
-

- - - 6 - - - -

-
-

- - - 7 - - - -

-
-

- - - 8 - - - -

-
-

- - - 9 - - - -

-
-

- - - 10 - - - -

10
N
5
6
7
8
9 umber
Line
1
2
3
4

-
9
3
-

RC110-RE
-
-
-
-
-
-
-
-
-
-
-
C-110. GUARANTEE FUND REPORT Summary of Guarantee Fund Development and Calculation of Guarantee Fund Adequacy As of Jan 31, 1900 Description Amount

Summary of Guarantee Fund Development
Beginning Balance of Guarantee Fund - New Guarantee Fund Placement:
a. Guarantee Fund in Deposit Form - b. Guarantee Fund in SUN/Surat Form - Total New Guarantee Fund Placement (3 + 4) Guarantee Fund Withdrawal:
a. Guarantee Fund in Deposit Form - b. Guarantee Fund in SUN/Surat Form - Total Guarantee Fund Withdrawal (7 + 8) Ending Balance of Guarantee Fund (1 + 5 – 9)
Annual Calculation of Guarantee Fund Adequacy
Required minimum Equity -
Net Contribution Total*) -
Reinsurance Contribution Total*) - Provision Total for PAYDI Guaranteed - Minimum Guarantee Fund Limit I (20% x 1) Minimum Guarantee Fund Limit II ((1% x 2) + Minimum Guarantee Fund Used ( Guarantee Fund Owned Excess (Deficiency) of Guarantee Fund (8 - 7) - 9 4 -

RD110-R
Line Number
Product Name Policy Type
(Group/Individual)
Business Line
DETAILS D-110
Micro Insurance Marketing Performance by Product Type As of Jan 31, 1900 According to SEOJK No. 9/SEOJK.05/2017 Total Active Participants at Beginning of Period Total New Participants During Reporting Period Total Membership Renewed at Total Membership Terminated Due to Maturity Not According to SEOJK No. 9/SEOJK.05/2017 Total Claim Participants Total Membership Terminated Due to Claim Total Active Participants at End of Period Premium / Gross Contribution (Rp) Gross Claims (Rp) Total Claim Participants Total Active Participants at Beginning of Period Total New Participants During Reporting Period Total Membership Renewed at Total Membership Terminated Due to Maturity Total Membership Terminated Due to Cancellation

- - - - 1 - - -
        Not According to Grand
        Design Micro Insurance
        Total Membership Terminated Due to Claim Total Active Participants at End of Period Premium / Gross Contribution (Rp) Gross Claims (Rp)

2 - - - - - - - - -

3 - - - - - - -
-
-

- - - - 4 - - -

5 - - - - - - - - - -

6 - - -
-
-

- - - - 7 - - -

8 - - - - - - - - - -

9 - - -
-

10 - - -

6
7
8
9
10
1
2
3
4
5
Line Number

-
9
5
-

RD120
_
R
R
DETAILS D-120. Micro Insurance Marketing Channel Performance As of Jan 31, 1900 (in millions of rupiah) Total Legal Entity Marketer Legal Entity Total Marketer Individual Product Name Being Marketed Volume Participants/Insured Premium/Gross Contribution (Rp) Line Number Marketing Channel Type Marketing Region Legal Entity Category

2 - - - - - - -
1 - - - -

4 - - - - - - -
3 - - - -

6 - - - - - - -
5 - - - -

8 - - - - - - -
7 - - - -

10 - - - - - - -
9 - - - - -9
6
-

BL
BAJSC
General Data
AJSSY
1Reporting Date
NCompany Code
Company Name
Reporting Period
Reporting Month
Fiscal Year
Type of Reporting PeriodMonthly/Quarterly/Annual Directorate Name Director Position Company Address FORMAT I C FORM AND STRUCTURE OF MONTHLY/QUARTERLY/ANNUAL REPORTS ON FINANCIAL ASPECTS FOR SHARIA LIFE INSURANCE COMPANIES AND SHARIA UNITS WITHIN LIFE INSURANCE COMPANIES -97-

K e p a d a
To
Yth.Direktorat IKNB Syariah Sharia IKNB Directorate Financial Services Authority MONTHLY/QUARTERLY/ANNUAL REPORT SHARIA LIFE INSURANCE COMPANY Month Year 1900 -98-

E-mail
Report Compiler
Officer Name
Division
Telephone
Fax
Email
Management Person in Charge Person in Charge Name Position Telephone Fax PIC Financial Report Company Name Full Address Telephone and Fax E-mail NPWP License No. & Date Number of Branches/Representatives Number of Employees Number of Insured External Auditor Controller Notes Company Profile -99-

As of Dec 31, Year "Period" 1.
2.
3.
I, , registration number hereby declare that:

"Company Name" has presented all data
fairly
I have reviewed the company's financial statements based on
based on regulations in the field of corporate health finance insurance Note: For annual reports only Thus this statement is made truthfully. Statement Letter Financial Statements "Company Name" I, the undersigned, declare that:
Responsible for the preparation and presentation of financial statements "Company Name" All information in the company's financial statements has been presented completely according to actual conditions; The company's financial statements do not contain incorrect material information or facts, and do not omit material information or facts. "Place", "Date" "Company Name" "Directorate Name" "Director Position" "Actuary Name" "PAI Reg No" Thus this statement is made truthfully. "Place", "Date" "Actuary Name" "PAI Reg No" -100-

Per "Date" Quarter "Period" 1.
2.
3.
Note: For annual reports only Responsible for the preparation and presentation of financial statements Statement Letter Financial Statements "Company Name" I, the undersigned, declare that:
"Place", "Date"
"Company Name"
"Directorate Name"
"Director Position"
"Company Name"
All information in the company's financial statements has been presented completely according to actual conditions; The company's financial statements do not contain incorrect material information or facts, and do not omit material information or facts. Thus this statement is made truthfully. -101-

Jakarta, ......20xx
Member
Note: For annual reports only
Sharia Supervisory Board PT ....
Chairman
PT ...
Sharia Life Insurance Company STATEMENT SHARIA SUPERVISORY BOARD After conducting research on the management of assets and liabilities of Tabarru' Fund, Tanahud Fund, Company Fund, and Participant Investment Fund PT ....., hereby the Sharia Supervisory Board of PT ..... declares that the management of assets and liabilities of Tabarru' Fund, Tanahud Fund, Company Fund, and Participant Investment Fund has been carried out in accordance with Islamic Sharia principles. -102-

Shareholder Name Shareholder Rupiah Percentage

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
7
8
9
10
1
2
3
4
5
6
Shareholder Details
No Share Ownership
-
1
0
3
-

P
P
U
AJ
S
7
8
9
10
1
2
3
4
5
6
Rin cia n
Pih a k
Uta m a
N o
N a m a
J a b a t a n
T a n g g a l
M u l a i
-104-

RPPAJS-1
Description
Budget Realization Percentage

- 0.00%
- 0.00%
- 0.00%
- 0.00%
- 0.00%
- 0.00%
- 0.00%
- 0.00%
- 0.00%
- 0.00%
  7
  8
  9
  10
  1
  2
  3
  4
  5
  6
  Education and Training Ratio - I (in millions of rupiah) No Education and Training Costs - 1 0 5 -

RPPAJS-2

0.00% 0.00%
Total Training Costs
Training Cost Ratio and Employee Costs Employee and Management Costs Education and Training Costs a. Employee Training b. Directorate Training
c. Commissioner Training
d. Sharia Supervisory Board Training Description Budget Realization Education and Training Ratio - II (in millions of rupiah) - 1 0 6 -

Combined
SAK SAP SAK DT SAK DTH SAP SAK SAP Adjustment SAK

Difference Between SAK Balances and Balance Assets Not Permitted Paid-in Capital Share Premium/Discount Accumulated Funds Profit Equilization Reserve Retained Earnings Other Equity Components Fund Equity Claim and Benefit Liabilities Expenses Still Payable Other Liabilities Technical Provisions Ujroh Provision PAYDI Provision Contribution Provision Provision for contributions that are not yet revenue Claim Provision Provision for risk disaster Qardh Liabilities Investment Properties Pure Gold Other Investments Non-Investment Cash and Bank Receivables Reinsurance Assets Deferred Acquisition Costs Non-Investment Property Other Assets LIABILITIES AND EQUITY Direct Participation Shariah MTN Shariah Securities Shariah Securities Issued by Banks Shariah Securities Issued by the State Shariah Securities Issued by Institutions Shariah Mutual Funds Shariah Asset-Backed Securities Shariah Real Estate Investment Funds REPO Financing Through Cooperation with Parties Shariah Financing With Collateral Rights Sukuk or Shariah Bonds Balance Sheet (in millions of rupiah) DESCRIPTION Fund Company Fund Tabarru' and Tanahud Funds Participant Investment Fund ASSETS Investments Deposits Deposit Certificates Shariah Stocks -107-

LKK-J
Fund
Company Fund
Fund
Tabarru'
Fund
Tanahud
Contract
Wakalah
Bil Ujrah
Contract
Mudharabah
Combined Adjustment

TOTAL PERFORMANCE ENTIRETY - - - - - - - Other Income Other Expenses PROFIT (LOSS) BEFORE TAX Income Tax PROFIT AFTER TAX COMPREHENSIVE INCOME OTHER INSURANCE BUSINESS PROFIT (LOSS) b. Underwriting surplus for Participants EXPENSES:
a. Marketing Expenses b. Acquisition Expenses
c. General and Administrative Expenses:

Employee Expenses
Education and
Training Expenses
Other General and
Administrative Expenses
Increase (decrease)
Ujroh Provision
Increase (decrease)
PAYDI Provision
TOTAL EXPENSES a. Underwriting surplus for Company Fund UNDERWRITING EXPENSES Claim Expenses a. Gross Claims b. Claims recovery
c. Increase (Decrease)
Claim Provision d. Withdrawal of Participant Investment Fund that has matured e. Withdrawal / Redemption Participant Investment Fund Total Net Claim Expenses Adjuster Expenses TOTAL EXPENSES TOTAL SURPLUS (DEFICIT) UNDERWRITING EXPENSES Total Investment Results Income and Ujroh UNDERWRITING INCOME Tabarru' Contribution / Tanahud Contribution / Ujroh / Reinsurance Contribution / Retrocession Net Contributions Decrease (Increase) Contribution Provision and a. Decrease (increase) Contribution Provision b. Decrease (increase) PAKYBMP
c. Decrease (Increase)
Provision for Risk
Total Revenue
Net Contributions
UNDERWRITING INCOME
Total Ujroh for Investment Management Financial Performance Statement For the Period Ending On (in millions of rupiah) Description Participant Investment Fund INCOME INVESTMENT INCOME AND UJROH MANAGEMENT Investment Results Investment Results Distributed to Fund Total Investment Results -108-

LAK-J
Fund
Company Fund
Fund
Tabarru'
Fund
Tanahud
Contract
Wakalah Bil
Ujrah
Contract
Mudharabah
Combined

Dividend Payments
Qardh Payments
Others
Capital Injection / Working Capital Subordinated Loans Qardh Receipts Others Cash Outflows Loan Repayments Subordinated Cash Inflows Investment Profit Sharing Participant Investment Fund Investment Withdrawals Sale of Fixed Assets Others Cash Outflows Investment Placements Investment Results Distributed to Company Fund Payment of ujroh/fee to Company Purchase of Fixed Assets Others CASH FLOW FROM FINANCING ACTIVITIES Investment Profit Sharing Tabaru' Fund Marketing Expenses Reinsurance Ujroh Payments Insurance Ujroh Payments Reinsurance Contributions Paid Rent Payments Zakat Payments Tax Payments Others CASH FLOW FROM INVESTMENT ACTIVITIES Cash Inflows Investment Results Receipts Acquisition Expenses Ujroh Received Surplus Allocation Receipts Tabarru' Fund Reinsurance Claims Received Underwriting Surplus Distribution Receipts Other - Last Cash Outflows Claims Paid Withdrawal of Participant Investment Fund that has matured Withdrawal / Redemption of Participant Investment Fund not yet matured Payment of UW Surplus Distribution to Company Payment of UW Surplus Distribution to Participants / Holders Contribution Para Participants CASH FLOW CALCULATION For the Period Ending On (in millions of rupiah) Description Participant Investment Fund BEGINNING BALANCE INCREASE (DECREASE) CASH BALANCE ENDING CASH BALANCE CASH FLOW FROM OPERATING ACTIVITIES Cash Inflows -109-

- - - - IV. Ending Fund Balance
        Other additions
        III. Reductions
        Comprehensive loss for current period Decrease in accumulated tabarru' funds Dividend Payments Other reductions Increase in accumulated tabarru' funds / STATEMENT OF CHANGES IN FUNDS For the Period Ending On (in millions of rupiah) Description Fund Company Fund Fund Tabarru' Fund Tanahud Participant Investment Fund Combined
        I. Beginning Fund Balance
        II. Additions
        Paid-in Capital
        Comprehensive profit for current period - 1 1 0 -

DPJS

......
Shariah Securities
Other than Indonesian State TOTAL WEALTH (I+II)
II. Non-Investment
Cash and Bank
Ujroh Receivables Closing
Direct
Claims Recovery Receivables Reinsurance Investment Results Receivables Investment Receivables Reinsurance Assets Deferred Acquisition Costs Non-Investment Property Other Assets Total Non-Investment Total Investments Shariah Securities Multinational Institutions Shariah Mutual Funds Shariah Asset-Backed Securities Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Pure Gold Financing With Collateral Rights Investment Properties Direct Participation Other Investments AYD After Foreign Limit (SAP Balance)
I. Investments
Deposits
AYD After
Per Company Limit
Shariah Securities Bank
Indonesia
Shariah Stocks
Sukuk or Shariah Bonds
Shariah MTN
Shariah Securities
Indonesian State
Deposit Certificates
Description Book Balance
Large (SAK)
Assessment
Based on
SAP
Difference Based on
Assessment Based on SAK and SAP AYD After Per Category Limit Asset Type AYD After Affiliation Limit ANALYSIS OF COMPANY FUNDS CALCULATION OF ASSETS AND LIABILITIES SAP FOR COMPANY FUNDS (in millions of rupiah) - 1 -

DPJS-1

I. Liabilities
II. Ujroh Provision
III. Provision for Guarantee Over
TOTAL OBLIGATIONS (I+II+III) ANALYSIS OF COMPANY FUNDS CALCULATION OF SAP LIABILITIES FOR COMPANY FUNDS (in millions of rupiah) Description Book Balance Large (SAK) Assessment Based on SAP Difference Between SAK and SAP Assessment - 1 1 2 -

DTJS

Non-Investment Total
TOTAL WEALTH
Receivables from Contribution Coinsurance Receivables Recovery Receivables Reinsurance Claims Receivables Investment Income Receivables Investment Receivables Reinsurance Assets Other Assets Sharia Securities Bank Indonesia Sharia Receivables Contribution Receivables Direct Closing Sharia Securities Sharia Mutual Fund Institutions Sharia Asset-Backed Securities Sharia Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Pure Gold Other Investments Total Investments
II. Non-Investments
Cash and Banks
State Sharia Securities
Outside of RI
AYD After Limits Per Asset Type AYD After Affiliation Limits AYD After Foreign Limits (SAP Balance)
I. Investments
Deposits
AYD After Limits Per Company Sharia Stocks Sharia Sukuk or Bonds Sharia MTN State RI Sharia Securities Certificate of Deposits Description of Ledger Balances (SAK) Valuation Based on SAP Difference Based on SAK and SAP Valuation (in millions of rupiah) ANALYSIS OF TABARRU' AND TANAHUD FUNDS CALCULATION OF ASSETS AND LIABILITIES OF TABARRU' AND TANAHUD FUNDS -113-

DTJS-1

- - Total Liabilities
    ANALYSIS OF TABARRU' AND TANAHUD FUNDS CALCULATION OF ASSETS AND LIABILITIES OF TABARRU' AND TANAHUD FUNDS (in millions of rupiah) Description of Ledger Balances (SAK) Valuation Based on SAP SAK and SAP Valuation Difference Payables Contribution Provisions Provisions for Contributions Not Yet Recognized as Revenue Claim Provisions Provisions for Catastrophic Risks
1
1
4
-

Other Assets
Total Non-Investments
TOTAL WEALTH (I+II)
Reinsurance Claims Recovery Receivables Investment Income Receivables Investment Receivables Reinsurance Assets Deferred Acquisition Costs Non-Investment Property Direct Closing Ujrah Receivables Sharia Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Pure Gold Financing with Mortgage Rights Investment Properties Direct Participation Other Investments Total Investments
II. Non-Investments
Cash and Banks
Sharia Asset-Backed Securities
I. Investments
Deposits
Certificates of Deposits
Sharia Stocks
Sharia Sukuk or Bonds
Sharia MTN
State RI Sharia Securities
Bank Indonesia Sharia Securities Sharia Securities of Countries Other Than RI Sharia Securities of Multinational Institutions Sharia Mutual Funds ANALYSIS OF PARTICIPANT INVESTMENT FUNDS CALCULATION OF ASSETS AND LIABILITIES OF PARTICIPANT INVESTMENT FUNDS AT GUARANTEED PAYDI (in millions of rupiah) Description of Ledger Balances (SAK) Valuation Based on SAP SAK and SAP Valuation Difference Guaranteed PAYDI Assets -115-

DIPJS-2

Payables
Accumulation of Participant Investment Funds Provisions for PAYDI Providing Investment Principal Guarantees TOTAL LIABILITIES ANALYSIS OF PARTICIPANT INVESTMENT FUNDS CALCULATION OF LIABILITIES FOR DIP AT GUARANTEED PAYDI (in millions of rupiah) Description of Ledger Balances (SAK) Valuation Based on SAP SAK and SAP Valuation Difference

1
1
6
-

RPTSAJSC

0.00% 0.00%
0.00% 0.00%
0.00% 0.00%

0.00% 0.00%
Solvency Ratio Level with DTMBR/MMBR Required by Regulation (percentage per POJK 72) Assets Available for Qardh Counted as Additions to Tabarru' and Tanahud Fund AYD A. Deficiency (surplus) in solvency level from internal target B. Insufficient investments, cash and banks Solvency Ratio Level for Tabarru' Funds, Tanahud Funds, and Corporate Funds Internal Target Solvency Ratio Level (annual) (percentage per POJK 72)
C. Market Risk
D. Insurance Risk
E. Operational Risk
F. MMBR for Guaranteed PAYDI

Guaranteed PAYDI Risk
a. Credit Risk b. Liquidity Risk
c. Market Risk
Guaranteed PAYDI Assets
Guaranteed PAYDI Liabilities
Solvency Ratio Level before Considering Assets Available for Qardh (in %) B. Liquidity Risk ACHIEVEMENT OF SOLVENCY LEVEL FINANCIAL REPORTS (in millions of rupiah) Tabarru' Fund and Tanahud Fund Description Corporate Fund Solvency Level A. Permitted Assets (AYD) B. Liabilities other than Qardh from Corporate Fund Minimum Risk-Based Tabarru' and Tanahud Funds (DTMBR) A. Credit Risk -117-

Tabarru' Fund and
Tanahud Fund
Corporate Fund
Participant Investment Fund Combined

0.00% 0.00% 0.00% 0.00%

0.00% - - -

0.00% 0.00% 0.00% 0.00%

- - 0.00%

Qardh Total Required (a-b)
Calculation of Required Qardh for Tanahud Fund A. Total Liabilities other than Qardh B. Total Assets Qardh Total Required (a-b) B. Total Assets A. Current year/quarter/month funds B. Previous year/quarter/month funds
C. Fund changes (a-b)
D. Ratio (c:b)
Sharia Business Unit Asset Ratio A. Tabarru' and Tanahud Fund Assets B. Participant Investment Fund Assets
C. Corporate Insurance (Conventional) Fund Assets
D. Ratio (a+b) : (a+b+c)
Calculation of Required Qardh for Tabarru' Fund A. Total Liabilities other than Qardh Fund Change Ratio B. Technical Provisions
C. Retention Claim Payables
D. Ratio [a:(b+c)]
Net Investment Income Ratio A. Net Investment Income B. Average Investments
C. Ratio (a:b)
Claim Expense Ratio
A. Net Claim Expenses
B. Net Contributions
C. Ratio (a:b)
A. Investments, cash and banks FINANCIAL RATIOS OTHER THAN SOLVENCY LEVEL FINANCIAL REPORTS (in millions of rupiah) Indicator Description Liquidity Ratio A. Liquid Wealth B. Current Liabilities
C. Ratio (a:b)
Investment-to-Liability Balance Ratio -118-

RKJS
Tabarru' and Tanahud Funds Corporate Fund PAYDI (guaranteed)

Credit Risk (a)
Credit Risk (b)
Total Credit Risk
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS CREDIT RISK (in millions of rupiah) Description Amount Deviation

1
1
9
-

RKRKAJS
Tabarru' and
Tanahud Funds
Corporate Fund PAYDI (guaranteed) Factor Tabarru' and Tanahud Funds Corporate Fund PAYDI (guaranteed)

- - 0.0% - - -

- - 1.2% - - -
- - 2.1% - - -
- - 3.0% - - -
- - 4.5% - - -
- - 9.0% - - -

- - 1.6% - - -
- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -
- - 12.0% - - -

- - 1.6% - - -
- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -
- - 12.0% - - -
- - 0.0% - - -
- - 0.0% - - -

- - 1.6% - - -
- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -
- - 12.0% - - -
- - 0.0% - - -
- - 1.0% - - -

- - 1.6% - - -
- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -

- - 2.8% - - -
- - 4.0% - - -

- - 5.6% - - -
- - 8.0% - - -
- - 12.0% - - -

- - 0.0% - - -
- - 8.0% - - -

- - 0.0% - - -
- - 30.0% - - -

- - 2.8% - - -

- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -
- - 12.0% - - -
- - 15.0% - - -

- - 2.8% - - -

- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -
- - 12.0% - - -
- - 15.0% - - -

- - 2.0% - - -
- - 25.0% - - -
- - 2.0% - - -

Investment Receivables a. Investments not yet received b. Defaulted investments on Investment Income Receivables Total e. Cluster rating 5 b. Cluster rating 2
c. Cluster rating 3
d. Cluster rating 4 e. Cluster rating 5 Reinsurance Claims Receivables Domestic Foreign:
a. Cluster rating 1 b. Cluster rating 2
c. Cluster rating 3
d. Cluster rating 4 a. Cluster rating 1 b. 65% < LTV < 75% Unused Properties Non-Investments Cash and Banks Direct Closing Contribution Receivables Reinsurance Assets a. assets sourced from value b. assets sourced from agreements Coinsurance Claims Receivables Domestic Foreign:
a. LTV < 65%
REPO
Financing Through Cooperation With a. Very Healthy b. Healthy
c. Less Healthy
d. Unhealthy
Loans Secured with Mortgage Residential Property Residuals a. LTV < 65% b. 65% < LTV < 75% Other Commercial Properties Securities Issued By
c. Cluster rating 3
d. Cluster rating 4 e. Cluster rating 5 State Sharia Securities Securities Issued By Securities Issued By a. Cluster rating 1 b. Cluster rating 2
c. Cluster rating 3
d. Cluster rating 4 e. Cluster rating 5 b. Cluster rating 2
c. Cluster rating 3
d. Cluster rating 4 e. Cluster rating 5 Sharia Corporate Sukuk / Bonds a. Cluster rating 1 b. Cluster rating 2
c. Cluster rating 3
d. Cluster rating 4 e. Cluster rating 5 Sharia MTN a. Cluster rating 1 b. Cluster rating 2 MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS CREDIT RISK - DEFAULT OR INABILITY OF DEBTOR OR OTHER PARTIES (in millions of rupiah) Description AYD Amount Deviation Amount Investments Term Deposits and Certificates Special Category (up to 2 billion per bank) Other Categories, per Bank Rating:
a. Cluster rating 1
-120-

RKRAJ

- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% -
- - - 0.00% - 10
      4
      5
      6
      7
      8
      9
      Net Reinsurance Exposure ((2)-(3)) Factor Amount Deviation 1 2 3 MINIMUM RISK-BASED TABARRU' FUNDS CREDIT RISK - REINSURER DEFAULT/INABILITY (in millions of rupiah) No Type Reinsurer Name Technical Provisions Reinsurer Expenses Deposits and/or Contributions Held at Company
1
2
1
-

RKLAJS
Up to
1 year
More than 1 year up to 3 years More than 3 years up to 5 years More than 5 years up to 10 years More than 10 years Total Up to 1 year More than 1 year up to 3 years More than 3 years up to 5 years More than 5 years up to 10 years More than 10 years Total (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)

Claim Provisions
Provisions for Catastrophic Risks Accumulation of Participant Investment Funds LIABILITY AND ASSET DIFFERENCE DEVIATION (4% X (Max (Li - AYDi), 0)) Provisions for contributions not yet recognized as revenue Payables for Claims and Benefits Coinsurance Payables Reinsurance Payables Ujrah Payables Tax Payables Expenses Still to be Paid Other Payables Technical Provisions Ujrah Provisions Investment Principal Guarantee Provisions Contribution Provisions Payables Reinsurance Assets Coinsurance Claims Receivables Reinsurance Recovery Claims Receivables Investment Receivables Investment Income Receivables Non-Investment Property Deferred Acquisition Costs Other Fixed Assets Other Assets Liabilities and Equity Liabilities Direct Closing Contribution/Ujrah Receivables Sharia Asset-Backed Securities Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Sharia Financing With Mortgage Rights Direct Participation Investment Properties Pure Gold Other Investments Non-Investments Cash and Banks Sharia Mutual Funds Assets Investments Term Deposits Certificates of Deposits Sharia Stocks Sharia Corporate Sukuk / Bonds Sharia MTN Securities Issued By RI State Securities Issued By Countries Other Than RI Securities Issued By Bank Indonesia Securities Issued By Multinational Institutions MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS LIQUIDITY RISK (in millions of rupiah) Description Corporate Fund Tabarru' and Tanahud Funds PAYDI (guaranteed) (1)

1
2
2
-

RPSYA-J
Corporate Fund
Tabarru' and Tanahud Funds
PAYDI (guaranteed) Total

Market Risk (A)
Market Risk (B)
Market Risk (C)
Total Market Risk
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS MARKET RISK (in millions of rupiah) Description Amount Deviation

1
2
3
-

Corporate Fund
Tabarru' and
Tanahud Funds
PAYDI
(guaranteed)
Factor Corporate Fund
Tabarru' and
Tanahud Funds
PAYDI (guaranteed)

- - 15.0% - - -
- - 20.0% - - -
- - 30.0% - - -
- - 20.0% - - -
- - 30.0% - - -

- - 0.0% - - -
- - 6.0% - - -
- - 16.0% - - -

- - 0.0% - - -
- - 0.0% - - -
- - 0.0% - - -

- - 1.6% - - -
- - 2.8% - - -
- - 4.0% - - -
- - 6.0% - - -
- - 12.0% - - -
- - 10.0% - - -

- - 10.0% - - -
- - 20.0% - - -
- - 0.0% - - -

- - 7.0% - - -
- - 15.0% - - -
- - 40.0% - - -
- - 3.0% - - -

- - 4.0% - - -

Pure Gold
NON-INVESTMENTS
Non-Investment Properties
TOTAL
Not Under OJK Supervision
Direct Participation in
Special Purpose Companies (SPV) Investment Properties Investment Returns 4% or more Investment Returns 2% - 4% Investment Returns less than 2% Under OJK Supervision Corporate Fund Tabarru' and Tanahud Funds PAYDI (guaranteed) Sharia Asset-Backed Securities a. Cluster rating 1 b. Cluster rating 2
c. Cluster rating 3
d. Cluster rating 4 e. Cluster rating 5 Real Estate Investment Funds Direct Participation Mixed*) Investments Sharia Stocks Including IDX30 or JII Stocks traded on Indonesian exchange Stocks traded on foreign exchanges Stocks constituting the main index of Asia Pacific and European main exchanges members of World Federation of Exchanges Other Stocks Sharia Mutual Funds Completely consisting of state sharia securities (SBSN) Completely consisting of private debt securities and/or money market securities (SBPU) Completely consisting of equity sharia securities or sharia indices Description Amount AYD Amount Deviation MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS MARKET RISK - MARKET PRICE CHANGES (in millions of rupiah)

1
2
4
-

USD JPY AUD EUR SGD GBP Others IDR Total USD JPY AUD EUR SGD GBP Others IDR Total USD JPY AUD EUR SGD Others IDR Total (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27)

Provisions for contributions not yet recognized as revenue Liabilities Claim Payables Coinsurance Payables Reinsurance Payables Ujrah Payables Tax Payables Expenses Still to be Paid Other payables Ujrah Provisions Investment Principal Guarantee Provisions Contribution Provisions Amount Deviation Claim Provisions Provisions for Catastrophic Risks Total Liabilities Exchange Rate Total Permitted Assets In Rupiah Total Liabilities In Rupiah Difference Between Permitted Assets and Liabilities Factor Total Permitted Assets Pure Gold Cash and Banks Direct Closing Contribution Receivables Reinsurance Contribution Receivables Reinsurance Assets Coinsurance Claims Receivables Reinsurance Claims Receivables Investment Receivables Investment Income Receivables Non-Investment Property Deferred Acquisition Costs Sharia Financing With Mortgage Rights Securities Issued By RI State Securities Issued By Countries Other Than RI Securities Issued By Bank Indonesia Securities Issued By Multinational Institutions Sharia Mutual Funds Sharia Asset-Backed Securities Real Estate Investment Funds REPO Direct Participation Investment Properties Financing Through Cooperation With Other Parties (Executing) Sharia MTN (in millions of rupiah) DESCRIPTION Corporate Fund Tabarru' and Tanahud Funds PAYDI (guaranteed) (1) Permitted Assets Term Deposits Certificates of Deposits Sharia Stocks Sharia Sukuk or Bonds MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS MARKET RISK - FOREIGN CURRENCY EXCHANGE RATE CHANGES -125-

15% 15%

-
fPHI
PHI
PKrf
PKo
Max((PKrf-PKo),0)
PUrf
PUo
Max((PUrf-PUo),0)
Description Corporate Fund Tabarru' and Tanahud Funds MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUNDS MARKET RISK - INVESTMENT YIELD LEVEL CHANGE RISK (in millions of rupiah)
1
2
6
-

-
-
-
-
-
I. Total max ((PK* - PK), 0)
II. Total ((PAKYBMPi - ARi)fpki
III. Total ((PKli - ARi)fpkli)
IV. Total ((PRBi - ARi)fpbi)
Total Deviation
Description Amount Deviation MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' INSURANCE RISK (in millions of rupiah)

1
2
7
-

Personal Accident
Others
I. Total max ((PK* - PK), 0)
Long-Term Death
Endowment and/or Combinations Whole Life Annuity Single Premium Death Health Insurance Branch PK PK* Amount Deviation MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' INSURANCE RISK - CONTRIBUTION PROVISIONS (in millions of rupiah)

1
2
8
-
- 10% -
- 10% -
- 10% -
- 10% -
- 10% -
- 25% -
- 25% -
- 10% -

Personal Accident
Others
II. Total ((PAKYBMPi - ARi)fpki
Long-Term Death
Endowment and/or Combinations Whole Life Annuity Single Premium Death Health M n MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' INSURANCE RISK - PROVISIONS FOR CONTRIBUTIONS NOT YET RECOGNIZED AS REVENUE (in millions of rupiah) Insurance Branch PAKYMBPi ARi fpki Amount Deviation PAKYBMPi

1
2
9
-
- 10% -
- 10% -
- 10% -
- 10% -
- 10% -
- 20% -
- 20% -
- 10% -

Personal Accident
Others
III. Total ((PKli - ARi)fpkli)
Long-Term Death
Endowment and/or Combinations Whole Life Annuity Single Premium Death Health MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' INSURANCE RISK - CLAIM PROVISIONS (in millions of rupiah) Insurance Branch Amount Deviation PKli ARi fpkli Amount Deviation PKli

1
3
0
-
- 10% -
- 10% -
- 10% -
- 10% -
- 10% -
- 25% -
- 25% -
- 10% -

Personal Accident
Others
IV. Total ((PRBi - ARi)fpbi)
Long-Term Death
Endowment and/or Combinations Whole Life Annuity Single Premium Death Health M n MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' INSURANCE RISK - PROVISIONS FOR CATASTROPHIC RISKS (in millions of rupiah) Insurance Branch PRBi (Gross) ARi fcbi Amount Deviation PRBi

1
3
1
-

j. Sub Total RODT = (1‰*i) f. Sub Total Operational Risk of Company (c+e)
II. PAYDI Operational Risk (ROPAYDI)
g. PAYDI Fund Assets h. Sub Total PAYDI Operational Risk (ROPAYDI = (1‰*g))
III. Tabarru' Fund Operational Risk (RODT)
i. Tabarru' Fund and Tanahud Investments
e. Operational Risk =(50%d) MINIMUM CAPITAL BASED ON RISK AND MINIMUM TABARRU' FUND BASED ON RISK OPERATIONAL RISK (in millions of rupiah) Description of Tabarru' Fund and Tanahud Fund Fund Company
I. Operational Risk of Company
a. General and Administrative Expenses b. Education and Training Expenses
c. Operational Risk = (1%(a-b))
d. Deferred Acquisition Costs Balance - 1 3 2 -

(in millions of rupiah)
Identity
Investment Instrument
Investment Guarantee Fund
In The Context Of
Infrastructure Financing
Issuer Name
/ Counterparty
Group Name / Issuer
Category
Supervisor Type
Investment
DD/MM/YY
Start Date
DD/MM/YY
Maturity Date
Rating Name
Rating Agency
Business Category
Economic Sector
Location
(2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

Special Relationship
Ownership Purpose
Ownership Share
(% )
Currency Type Return Rate
Return Rate
(% )
Collectibility Book Balance SAP Valuation Balance Investment Yield Period Running Cash Received Investment Yield Receivables Investment Yield Receivables Previous Period Cash Received Running Period Total Investment Yield Investment Yield Ready For Distribution (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32)

- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
- 0,00% - - 0,00% - - - - - - - - -
  No
  (1)
  1
  2
  3
  4
  5
  6
  7
  8
  9
  10
  DETAILS A-110. Investment and Property Details No Maturity Period (1) 7 8 9 10 1 2 3 4 5 6 - 1 3 3 -

RA120-J
(2) (3) (4) (5) (6) (7) (8) (9) (10)

7
8
9
10
1
2
3
4
5
6
DD/MM/YY Start Currency Rating Debtor (1) Book Balance (Million Rp) SAP Valuation Balance (Million Rp) AYD (Million Rp) (in millions of rupiah) No Debtor Name Business Category Claim Type Fund Type DETAILS A-120. Receivables Details - 1 3 4 -

6
7
8
9
10
Description
1
2
3
4
5
DETAILS A-130. Other Assets Details (in millions of rupiah) No Asset Name Basis Valuation Fund Type Balance Million (Rp) - 1 3 5 -

- - - - 10
        4
        5
        6
        7
        8
        9
        C u r r e n c y
        B o o k
        B a l a n c e
        V a l u a t i o n
        B a l a n c e
        S
        A
        P
        1
        2
        3
        DE
        TAI
        LS
        A-210. De bt s
        De ta i ls
        F in a n c i a l
        St a t em en ts
        (i n m i ll io ns o f r u p ia h) N o N a m e Ty pe o f D eb t Ty pe o f Fu nd DD / MM / Y Y Pe ri od St ar t Date -136-

RA220-J
Provision
Risk Provision
Provision for
PAYDI Risks
Accumulated
Fund Provision
Risk Provision
Provision for
PAYDI Risks
Accumulated
Fund Provision
Risk Provision
Provision for
PAYDI Risks
Accumulated
Fund Provision
TOTAL Contribution Provision Policies Due To Mature < 1 year
Period......
Previous
(2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)

- - - - Total Contribution Provision
        4. Health
        6. Others
        Sub Total A
        B. Annuities
        Sub Total B
        5. Personal Accident
        (in millions of rupiah)
        Insurance Branch Contribution Provision Paid-up Policies Contribution Provision Regular Policies (Installments) Contribution Provision Single Premium Policies DETAILS A-220. Contribution Provisions Financial Statements (1) A. Life Insurance
        1. Term Life
        2. Endowment and/or
        Combinations
        3. Whole Life
        -
        1
        3
        7
        -

Total PARYBD
Max
(PAKYBMP,PARYBD)
Health
II Provisions For
Unearned Risks
Term Life
Personal Accident
Health
Total PAKYBMP
Personal Accident
A-230 Provisions For Contributions Not Yet Earned Income Financial Statements (in millions of rupiah) Insurance Branch Provision Contributions Policies Single Premium Policies Provision Contributions Policies Paid-up Provision Contributions (Regular Policies (Installments)) Total Provision Contributions Policies Due To Mature Total PAKYBMP Period Previous
I. Term Life
(Enter all life insurance products) Term Life Endowment / Endowment Combination - 1 3 8 -

Total Retention
Self
Total Retention
Self
Total Retention
Self
Total
Claim Provision
Reserve Claims
< 1 year
Quarter ... /
Year ...
(Period

- - - - Total
        A-240. Claim Provisions
        (in millions of rupiah)
        Insurance Branch
        Provision
        Claims In Process
        Provision
        IBNR Claims
        Provision
        Periodic Claim Payments
        Quarter ... / Year ...
        Death
        Term Life
        (Enter all Death Term
        Personal Accident
        Health
        Annuities
        -
        1
        3
        9
        -

Traditional PAYDI Total Provisions For Catastrophic Risks For policies Due To Mature < 1 year Period Previous

6. Others
Sub Total A
B. Annuities
Sub Total B
Total Provisions For Risks
5. Personal Accident
DETAILS A-250.
CATASTROPHIC RISK PROVISIONS (in millions of rupiah) Insurance Branch Provisions For Catastrophic Risks A. Life Insurance
1. Term Life
2. Endowment
and/or Combinations
3. Whole Life
4. Health -1
4
0
-

Rupiah Foreign Currency Total Rupiah Foreign Currency Total Rupiah Foreign Currency Total

- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
        0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00%

- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
        0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00%

- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
- - - - 0,00% 0,00% 0,00%
        0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% 0,00% >= 10 years Total Current Asset (Liability) Ratio Total Current Asset (Liability) Ratio Company Investment Funds <= 1 year 1 year < Age < 5 years 5 years = Age < 10 years >= 10 years Tabaru and Tanahud Funds <= 1 year 1 year < Age < 5 years 5 years = Age < 10 years >= 10 years Total Current Asset (Liability) Ratio Company Funds <= 1 year 1 year < Age < 5 years 5 years = Age < 10 years Asset Age1) Liability1) Asset Ratio Against DETAILS A-310 Details Recapitulation of Assets and Liabilities By Currency and Maturity Age - 1 4 1 -

RB110-J
Line
Of Business
Location
Currency
Distribution Channel
Number Number Of Policies
Inforce
Number
Of Participants
Number Of Policies
With Claims
Number Of Participants
With Claims
Allocation For
Ujrah
Allocation For
Tabarru
Allocation
For DIP
(2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)

Allocation
For
Ujrah
Allocation
For
Tabarr u
Contrib
Reins urance/retr osesi
Gross Claims Claims
Recovery
Fund Withdrawal
Participants Due To Maturity Partial Withdrawal (Withdrawa l) Full Withdrawal (Surrender) Adjuster Expenses Commission Expenses (14) (15) (16) (17) (18) (19) (20) (21) (22) (23)

9
10
(1)
5
6
7
8
1
2
3
4
5
6
7
8
Contributions And Claims By Line Of Business DETAILS B-110 No Contributions Fund Withdrawals N 1 2 o Marketing Contributions Gross - Direct (1) 9 10 3 4 - 1 4 2 -

-
-
-
-
-
-
-
-
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......
9. Guarantee Funds
Owned
10. Excess (Deficiency) Of Funds
3. Provision for tabarru' contributions
4. Total Provisions (2+3)
5. Provision for PAYDI
6. Minimum Guarantee Fund Limit I
7. Minimum Guarantee Fund Limit II
8. Minimum Guarantee Fund Limit
2. Provision for tabarru' contributions
I. Summary Of Fund Development
1. Opening Balance Of Guarantee Funds
2. New Guarantee Fund Placements:
a. Guarantee Funds In The Form Of b. Guarantee Funds In The Form Of
3. Guarantee Fund Withdrawals:
a. Guarantee Funds In The Form Of b. Guarantee Funds In The Form Of
4. Closing Balance Of Guarantee Funds (1 + 2
II. Calculation Of Fund Sufficiency
1. Minimum Equity Required
Description
Total
C-110. GUARANTEE FUNDS REPORT Summary Of Guarantee Fund Development And Calculation -143-

Contributions
New Underwriting
Continuing Contributions
Pure Contributions
Ujroh For New Underwriting
Ujroh For Continuing Acquisition Costs Others Policy Maintenance Costs Other Costs Total Costs Total Contributions (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

- - - - Total
        Single Premium Contributions Regular Contributions Health Single Premium Contributions Regular Contributions Sub Total (2) Single Premium Contributions Regular Contributions Sub Total (1 + 2) Single Premium Contributions Regular Contributions Personal Accident Single Premium Contributions Regular Contributions Whole Life Combinations Single Premium Contributions Regular Contributions General Annuities Single Premium Contributions Regular Contributions Pension Fund Annuities Single Premium Contributions Regular Contributions Whole Life Single Premium Contributions Regular Contributions Death Term Other Than Single Premium Contributions Regular Contributions Endowment Single Premium Contributions Regular Contributions Endowment Combinations Single Premium Contributions Regular Contributions Term Life Regular Contributions Personal Accident Single Premium Contributions Regular Contributions Health Single Premium Contributions Regular Contributions Sub Total (1) Single Premium Contributions Regular Contributions

Group Underwriting
Single Premium Contributions Regular Contributions Whole Life Single Premium Contributions Regular Contributions Whole Life Combinations Single Premium Contributions Regular Contributions General Annuities Single Premium Contributions Regular Contributions 100 Pension Funds (in millions of rupiah) Single Premium Contributions
Individual Underwriting
Term Life
Single Premium Contributions Regular Contributions Death Term Other Than Single Premium Contributions Regular Contributions Endowment Single Premium Contributions Regular Contributions Endowment Combinations (1) Payment Method & Insurance Branch Assumed Costs DETAILS D-110 Composition Of Contributions And Loading For Traditional Insurance Products -144-

Type
Of Underwriting
Product Name
Investment
Currency
Payment Method Contributions New Underwriting Continuing Contributions Top-Up Contributions Risk Contributions Investment Contributions (2) (3) (4) (5) (6) (7) (8) (9) (10)

Ujroh
For New Underwriting
Ujroh For Continuing Acquisition Costs Others Policy Maintenance Costs Other Costs Investment Management Costs Total Costs Total Contributions (11) (12) (13) (14) (15) (16) (17) (18)

9
1
(
0
1)
1
2
3
4
5
6
7
8
No
7
8
9
10
Assumed Costs
(1)
DETAILS D-120
COMPOSITION OF CONTRIBUTIONS AND LOADING FOR INSURANCE PRODUCTS WITH INVESTMENT No 1 2 3 4 5 6 - 1 4 5 -

RD 130-J
Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25)

11. Changes To Other Insurance Branches
12. Total II (6+7+8+9+10+11)
13. Underwriting At End Of Year (5-12)
5. Total I (1+2+3+4)
6. Death
7. Contract Expired
8. Contract Termination For Products Generated In The Current Year (xxxx)
9. Contract Termination For Products Generated Before Last Year (xxxx-1)
10. Contract Termination For Products Generated Before Last Year (xxxx-1)
Investment Products Total
1. Underwriting Still Active At Start Of Year
2. New Underwriting
3. Reinstatement
Personal Accident Health
4. Changes From Other Insurance Branches
Whole Life Whole Life General Annuities Pension Fund Annuities Term Life Death Endowment Endowment (1) (In Millions of Rupiah) DETAILS D-130. Evolution Of Individual Underwriting Portfolio - 1 4 6 -

Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP Number Of Policies Number Of JUP (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25)

11. Changes To Other Insurance Branches
12. Total II (6+7+8+9+10+11)
13. Underwriting At End Of Year
(5-12)
5. Total I (1+2+3+4)
6. Death
7. Contract Expired
8. Contract Termination For Products Generated In The Current Year (xxxx)
9. Contract Termination For Products Generated Before Last Year (xxxx-1)
10. Contract Termination For Products Generated Before Last Year (xxxx1)
Investment Products Total
1. Underwriting Still Active At Start Of Year
2. New Underwriting
3. Reinstatement
Personal Accident Health
4. Changes From Other Insurance Branches
Whole Life Whole Life General Annuities Pension Fund Annuities Term Life Death Endowment Endowment (1) DETAILS D-140. Evolution Of Group Underwriting Portfolio (In Millions of Rupiah) - 1 4 7 -

Type Of Underwriting Currency Line Of Business Description Product Name S.P P.U P.R S.P P.U P.R Year Running Year Previous (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) Year Running Year Previous Contrib ution Pure Gross Contributions Average Contract Period Average Age Participants Average Age Policies Mortality
Table
Discount
Rate
Calculation
Method
(14) (15) (16) (17) (18) (19) (20) (21) (22) (23) 9 1 (1 0 ) 5 6 7 8 9 1 1 2 3 4 5 6 7 8 0 Total Sum Insured 1 2 3 4 (In Millions of Rupiah) No Provision Contributions Year Provision Contributions Year Number Of Participants (1) DETAILS E-110 Provision For Underwriting Contributions No - 1 4 8 -

RE120- J
(in millions of rupiah)
Underwriting Period Policy Type Line Of Business Number Of Policies Number Of Participants Number Of Sum Insured Net Contributions Reinsurance Contributions (2) (3) (4) (5) (6) (7) (8) (9)

US $ & Other Foreign Currency Rupiah Total KYBMP US & Foreign Currency Other Claims In Process Rupiah Claims In Process Total Claims In Process US & Other Foreign Currency IBNR Rupiah IBNR Total IBNR (10) (11) (12) (13) (14) (15) (16) (17) (18)

9
10
(1)
1
2
3
4
5
6
7
8
No Total Contributions
7
8
9
10
Contributions Not Yet Earned Income Claim Provisions (1) Details E-120. Contribution Provisions For Accident, Health, Term Life Products No 1 2 3 4 5 6 - 1 4 9 -

RE130- J
Period
Of Underwriting
Type
Of Policy
Type
Of Product
Number
Of Policies
Number
Of Participants
Number Of Sum
Insured
Term P.A Health Accumulated Fund

7
8
9
10
1
2
3
4
5
6
Details E-130. Contribution Provisions For Investment Products (in millions of rupiah) No Provision Contributions - 1 5 0 -

RF110-J
Contributions
Paid Ujroh
Received Claim
Recovery
Contributions
Paid Ujroh
Received Claim
Recovery
Contributions
Paid Ujroh Received Claim Recovery (2) (3) (4) (5) (6) (7) (8) (9) (10)

- - - - TOTAL
        Whole Life Combinations
        General Annuities
        Pension Fund Annuities
        Personal Accident
        Health
        Investment Products
        Whole Life
        Whole Life Combinations
        General Annuities
        Pension Fund Annuities
        Personal Accident
        Health
        Investment Products
        Group Underwriting:
        Term Life
        Death Term
        Endowment
        Endowment Combinations
        Whole Life
        Line Of Business Domestic ASEAN NON-ASEAN (1) DETAILS F-110. Reinsurance Outflow Sharia Insurance Underwriting Individual Underwriting:
        Term Life
        Death Term
        Endowment
        Endowment Combinations
        -
        1
        5
        1
        -

Product Name Policy Type Line Of Business Number Of Active Participants At Start Of Period Report Number Of New Participants In Reporting Period Number Of Memberships Extended In Reporting Period Number Of Memberships Terminated Due To Maturity Number Of Memberships Cancelled Number Of Memberships Terminated Due To Claims Number Of Active Participants At End Of Period Report Gross Premium / Contributions (Rp) Gross Claims (Rp) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)

Number Of Active Participants At Start Of Period Report Number Of New Participants In Reporting Period Number Of Memberships Extended In Reporting Period Number Of Memberships Terminated Due To Maturity Number Of Memberships Cancelled Number Of Memberships Terminated Due To Claims Number Of Active Participants At End Of Period Report Gross Premium / Contributions (Rp) Gross Claims (Rp) (14) (15) (16) (17) (18) (19) (20) (21) (22)

9
10
DETAILS G-110
Micro Insurance Marketing Performance Per Product Type Of Insurance (1) 1 2 3 4 5 6 7 8 No In Accordance With OJK SE NO. 9/SEOJK.05/2017 7 8 9 10 Not In Accordance With OJK SE NO. 9/SEOJK.05/2017 (1) No 1 2 3 4 5 6 - 1 5 2 -

RG120J
Channel
Type
Marketing Region
Legal Entity Category Number Of Legal Entities Number Of Individual Marketers Product Name Being Marketed Number Of Participants/Insured Gross Premium/Contributions (Rp) (2) (3) (4) (5) (6) (7) (8) (9)

7
8
9
10
1
2
3
4
5
6
(in millions of rupiah)
No Marketer Legal Entity
(1)
DETAILS G-120. Micro Insurance Marketing Channel Performance - 1 5 3 -

-154-
FORMAT I D
FORMAT AND STRUCTURE OF ANNUAL REPORT ON MANAGEMENT ASPECTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

I. Report on the Implementation of Good Corporate Governance for Sharia Insurance Companies and Sharia Reinsurance Companies

Transparency in the Implementation of Good Corporate Governance
a. Conduct of GMS
Conduct of annual GMS and extraordinary GMS, as well as decisions made at each GMS. No. Time of Conduct Agenda Participants Decision Deed Number Notary Notes 1. 2. Etc.

b. Board of Directors
1) Number, name, position, criteria, date of appointment by GMS, term of office, nationality, and domicile of Board of Directors members.
No Name Position Criteria Date of Appointment by GMS Term of Office Nationality Domicile Last Formal Education and Professional Degree Competency and Fit Test 1. 2. Etc.

2) In the event that there are changes in the composition of Board of Directors members during the reporting year, the previous composition must be listed in a table as follows:
No. Name Position Date of Appointment by GMS Date of Dismissal by GMS

3) Concurrent positions held by Board of Directors members.
No. Name Position in Company Position in Other Company Name of Other Company Business Field 1. 1. 2. Etc.
2. 1.

-155-
No. Name Position in Company Position in Other Company Name of Other Company Business Field 2. Etc. Etc.

4) Frequency of Board of Directors meetings held within 1 (one) year.
No Name Position Total 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 the type and number of shares.
No Name Position Share Ownership by Board of Directors Members Reaching 5% (Five Percent) or More of Paid-Up Capital A B C D Notes:
Indonesia/Foreign Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership 1. 2. Etc. Notes:
A. The company itself;
B. other insurance companies;
C. financial service companies other than insurance companies; and
D. other companies located both domestically and internationally, including shares obtained through the stock exchange.

6) Financial relationships and family relationships of Board of Directors members with other Board of Directors members, Board of Commissioners members, Sharia Supervisory Board members, and/or shareholders of the company where the respective Board of Directors member serves.
No. Name Financial Relationship With Other Directors Board of Commissioners Sharia Supervisory Board Shareholders Yes No Note* Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc.

-156-
No. Name Family Relationship With Other Directors Board of Commissioners Sharia Supervisory Board Shareholders Yes No Note* Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc. Notes:
*) Form of financial relationship: debt-receivables, business cooperation, etc. ) Form of family relationship: spouse/children/parents/siblings/in-laws, etc.

c. Board of Commissioners
1) Number, name, position, criteria, date of appointment by GMS, term of office, nationality, and domicile of Board of Commissioners members.
No Name Position Criteria Date of Appointment by GMS Term of Office Nationality Domicile Last Formal Education and Professional Degree Competency and Fit Test 1. 2. Etc.

2) In the event that there are changes in the composition of Board of Commissioners members during the reporting year, the previous composition must be listed in a table as follows:
No. Name Position Date of Appointment by GMS Date of Dismissal by GMS

3) Concurrent positions held by Board of Commissioners members.
No. Name Position in Company Position in Other Company Name of Other Company Business Field 1. 1. 2. Etc.
2. 1.
2.
Etc.
Etc.

-157-
4) Frequency of Board of Commissioners meetings held within 1 (one) year.
No Name Position Total Board 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 Total Commissioner Meetings (... times meeting) % Attendance Physical Attendance Teleconference/Video/Conference/Other Electronic Media Facilities 1. 2. Etc.

6) Disclosure of share ownership by Board of Commissioners members reaching 5% (five percent) or more of paid-up capital, including the type and number of shares.
No Name Position Share Ownership by Board of Directors Members Reaching 5% (Five Percent) or More of Paid-Up Capital A B C D Notes:
Indonesia/Foreign Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership Total Nominal Shares % Ownership 1. 2. Etc. Notes:
A. The company itself; B. other insurance companies;
C. financial service companies other than insurance companies; and
D. other companies located both domestically and internationally, including shares obtained through the stock exchange.

7) Financial relationships and family relationships of Board of Commissioners members with other Board of Commissioners members, Board of Directors members, Sharia Supervisory Board members, and/or shareholders of the company where the respective Board of Commissioners member serves.

-158-
Name Financial Relationship With Other Board of Commissioners Board of Directors Sharia Supervisory Board Shareholders Yes No Note* Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc. No. Name Family Relationship With Other Board of Commissioners Board of Directors Sharia Supervisory Board Shareholders Yes No Note* Yes No Note* Yes No Note* Yes No Note* 1. 2. Etc. Notes:
*) Form of financial relationship: debt-receivables, business cooperation, etc. ) Form of family relationship: spouse/children/parents/siblings/in-laws, etc.

d. Sharia Supervisory Board
1) Number, name, position, criteria, date of appointment by GMS, term of office, nationality, and domicile of Sharia Supervisory Board members.
No Name Position Criteria Date of Appointment by GMS Term of Office Nationality Domicile Last Formal Education and Professional Degree Competency and Fit Test 1. 2. Etc.

2) In the event that there are changes in the composition of Sharia Supervisory Board members during the reporting year, the previous composition must be listed in a table as follows:

-159-
No. Name Position Date of Appointment by GMS Date of Dismissal by GMS

3) Concurrent positions held by Sharia Supervisory Board members.
No. Name Position in Company Position in Other Company Name of Other Company Business Field 1. 1. 2. Etc.
2. 1.
2.
Etc.
Etc.

4) Frequency of Sharia Supervisory Board meetings held within 1 (one) year.
No Name Position Total Board Meetings (... times meeting) % Attendance Physical Attendance Teleconference/Video/Conference/Other Electronic Media Facilities 1. 2. Etc.

e. Report on Supervision Results of the Board of Commissioners and Independent Commissioners
1) Board of Commissioners activity report (including supervision results over the realization of the business plan)
Summary of Supervision Results Recommendations
2) Independent Commissioner activity report
Summary of Supervision Results Recommendations

-160- f. Committees
1) Committees under the Board of Directors
No. Committee Name Member Names Position* Tenure Appointment Decree Total Meetings in One Year

Investment Committee 1.
2.
Etc.
Product Development Committee 1.
2.
Etc.
Etc.

2) Committees under the Board of Commissioners
No. Committee Name Member Names Position* Tenure Appointment Decree Total Meetings in One Year

Audit Committee 1.
2.
Etc.
Risk Monitoring Committee 1.
2.
Etc.
Etc.

g. Implementation of external auditor functions. No. Description Year n-2 Year n-1 Year n

Public Accounting Firm Name
Public Accountant Name
Audit Period
GMS Number

h. Implementation of remuneration policies and other facilities for Board of Directors, Board of Commissioners, and Sharia Supervisory Board members. Total number of Board of Directors, Board of Commissioners, Sharia Supervisory Board, and employees receiving remuneration packages in 1 (one) year, grouped according to income level as follows:
Total Remuneration per Person in 1 Year *) Total Board of Directors Board of Commissioners Sharia Supervisory Board Employees Above IDR 2 billion Above IDR 1 billion up to IDR 2 billion Above IDR 500 million up to IDR 1 billion

-161-
IDR 500 million and below
Note:*) requested in cash

i. Outsourcing of Investment Management
No. Type of Investment Name of Outsourcing Company Investment Value Agreement Number % of Total Investment Portfolio 1. 2. Etc.

j. Company functions 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. Disclosure of other important matters. No. Description Checklist *) If Yes, Explain. Yes No

Resignation or dismissal of external auditor
Material transactions with related parties
Material claims filed by and/or against the Insurance Company
Conflicts of interest currently ongoing and/or likely to occur
Other material information regarding the Insurance Company
Company has a compliance function
Company has an internal auditor
Company has a risk management function
Company has an investment management function/unit
Company has a special work unit and/or appoints a PJK 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 a controlling relationship with the Company, either directly or indirectly, through ownership, management, and/or financial relationships.

-162-
2. Self-Assessment on the Implementation of Good Corporate Governance
Completion of the Good Corporate Governance Implementation questionnaire is done by the company concerned. Completion of this questionnaire is done by providing answers to questions/statements in the said questionnaire. How to Fill Out:
Generally, answers to the Questions/Statements consist of 5 criteria as follows (except for answers requiring different criteria):
A= The company concerned DOES NOT HAVE written policies regarding the Question/Statement in question. B= The company concerned HAS written policies regarding the Question/Statement in question, but the policy has NOT been implemented. C= The company concerned HAS written policies regarding the Question/Statement in question, but the policy has NOT been implemented CONSISTENTLY. D= The company concerned HAS written policies regarding the Question/Statement in question, the policy IS IMPLEMENTED CONSISTENTLY but has NOT BEEN UPDATED periodically. E= The company concerned HAS written policies regarding the Question/Statement in question and the policy IS IMPLEMENTED CONSISTENTLY and UPDATED periodically. Interpretation of Results An assessment is needed to interpret the numbers obtained in answering the questions of this Questionnaire, most of whose answers consist of 5 (five) scales ranging from the lowest assessment (A/ No), to the highest assessment (E/ Yes). Specifically for "A/No" answers in assessment criteria required by legislation (mandatory), a minus number is given. For groups of Questions/Statements skipped due to "None" and which are not "not applicable", in the interpretation of results, they must still be considered by giving the same score as the "A/No" answer.

I. BUSINESS ETHICS AND CODE OF CONDUCT

The Company has a Vision, Mission, and Company Values A B C D E
The Company has a Business Ethics Policy which among others includes:
2.1. General policies directing towards applicable laws and codes of ethics A B C D E
2.2. Policies for company organs A B C D E
2.3. Policies for employees A B C D E
2.4. Policies for policyholders A B C D E
2.5. Policies for business partners A B C D E
2.6. Policies for fellow insurance and reinsurance companies A B C D E

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3. The Company has a Code of Conduct which is an elaboration of Company Values and Business Ethics.
A B C D E
4. The Code of Conduct covers guidelines on:
4.1. Conflict of Interest A B C D E
4.2. Giving gifts and donations A B C D E
4.3. Compliance with regulations A B C D E
4.4. Information confidentiality A B C D E
4.5. Reporting violations and protection for whistleblowers A B C D E
5. In carrying out their duties, Board of Commissioners, Board of Directors, and company employees:
5.1. Make a statement of "no conflict of interest" against every decision taken by the authorized party making the decision.
No Yes
5.2. Make a statement every year regarding the implementation of the company's established code of conduct.
No Yes
5.3. Make a statement every year not to receive and/or give anything that can influence decision-making.
No Yes
6. The Company records its assets, liabilities, and own equity correctly using generally accepted accounting principles or special accounting principles applicable to companies.
No Yes
7. Has a complaint system regarding violations of the code of conduct, company regulations, legal provisions, and matters related to Policyholders, which ensures protection for the Whistleblower.
A B C D E

II. COMPANY ORGANS
A. General Meeting of Shareholders (GMS)

Every Shareholder is entitled to obtain accurate information regarding procedures to be fulfilled concerning the organization of GMS.
A B C D E
Company policy on complete explanation and accurate information regarding GMS procedures in accordance with applicable legal provisions.
A B C D E
Every Shareholder is entitled to obtain a complete explanation regarding procedures to be fulfilled concerning the organization of GMS.
No Yes
The complete explanation and information include the following matters:
4.1. GMS Call No Yes
4.2. Information regarding each agenda item in the GMS agenda. No Yes
4.3. Availability of information at the company headquarters. No Yes
4.4. Commitment to hold GMS transparently. No Yes
4.5. Notification to every shareholder regarding GMS results. No Yes
In taking GMS decisions:
5.1. Board of Commissioners and Board of Directors members appointed have passed the Fit and Proper Test for the company.
No Yes
5.2. Considering the opinion of the Nomination and Remuneration Committee or the function handling Nomination and Remuneration in the appointment of Board of Commissioners and Board of Directors.
A B C D E

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5.3. Considering the quality of reports related to GCG in making decisions to accept or reject the report.
A B C D E
5.4. Determining the external auditor. No Yes
5.5. Decisions taken consider the fair interests of stakeholders.
A B C D E
5.6. Considering the company's financial condition in granting bonuses, tantiems, and dividends.
A B C D E

B. Board of Commissioners and Board of Directors

The Board of Commissioners, Board of Directors, and Sharia Supervisory Board together, according to their respective functions, have carried out the following:
1.1. Internal control. A B C D E
1.2. Risk management. A B C D E
1.3. Fair return for Shareholders. A B C D E
1.4. Policies related to stakeholder interests. A B C D E
1.5. Leadership succession and management continuity at all levels of the organization.
A B C D E
1.6. Implementation of GCG. A B C D E
The Board of Commissioners, Board of Directors, and Sharia Supervisory Board jointly agree on the following matters:
2.1. Company business objectives. A B C D E
2.2. Company long-term plan. A B C D E
2.3. Annual work plan and budget. A B C D E
2.4. Policies in fulfilling legal provisions and the company's articles of association.
A B C D E
2.5. Policies in avoiding all forms of conflict of interest.
A B C D E
2.6. Company valuation policies and methods. A B C D E
2.7. Unit valuation policies and methods within the company. A B C D E
2.8. Executive-level organizational structure. A B C D E

C. Board of Commissioners

Composition, Appointment, and Dismissal of Board of Commissioners
1.1. The number of Board of Commissioners members has been adjusted to the complexity of the company while still considering the effectiveness of decision-making.
No Yes
1.2. The composition of the Board of Commissioners includes commissioners who do not come from affiliated parties, known as Independent Commissioners.
No Yes
1.3. Appointment of Independent Commissioners in accordance with applicable regulations.
No Yes
1.4. The Board of Commissioners consists of members who collectively possess competencies such as *):
a. Insurance field. No Yes b. Finance field. No Yes
c. Management field. No Yes
1.5. Has Proxy Commissioners, besides Independent Commissioners. No Yes
1.6. Board of Commissioners members are appointed and dismissed by GMS according to a transparent process based on reasonable grounds and given the opportunity to defend themselves.
No Yes

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1.7. Does not hold concurrent positions as Board of Directors members or Board of Commissioners members in Sharia Insurance Companies, Sharia Reinsurance Companies, and Insurance or Reinsurance Companies conducting part of their business based on Sharia Principles.
No Yes
1.8. Does not hold concurrent positions in more than 4 (four) other Financial Service Institutions.
No Yes
1.9. The Board of Commissioners does not hold concurrent positions as Board of Commissioners members, Board of Directors members, or DPS members in Insurance Companies having the same business field.
No Yes
2. Competence and Integrity of the Board of Commissioners
2.1. Meets Fit and Proper Test requirements. No Yes
2.2. Complies with and understands the Company's Articles of Association. A B C D E
2.3. Complies with and implements GCG. A B C D E
2.4. Does not utilize the company for personal, family, business group, or other parties' interests that can harm the company.
No Yes
3. Competence and Integrity of DPS
3.1. Obtains recommendation from the National Sharia Council? No Yes
3.2. DPS has received approval from OJK. No Yes
3.3. Complies with and understands the Company's Articles of Association. No Yes
3.4. Complies with and implements GCG. No Yes
3.5. Does not utilize the company for personal, family, business group, or other parties' interests that can harm the company.
No Yes
3.6. 50% or more of DPS members are Indonesian citizens. No Yes
4. Supervision Functions of the Board of Commissioners
4.1. The Board of Commissioners supervises the management of the company by the Board of Directors.
A B C D E
4.2. The Board of Commissioners does not participate in operational decision-making.
A B C D E
4.3. The Board of Commissioners can impose sanctions on the Board of Directors in the form of temporary dismissal, provided that it must be followed up by holding a GMS.
A B C D E
4.4. The Board of Commissioners obtains complete and timely information about the company.
A B C D E
4.5. The Board of Commissioners has Rules of Procedure and Working Guidelines (charter).
A B C D E
4.6. In carrying out its duties, the Board of Commissioners forms an Audit Committee and other committees.
A B C D E
4.7. The Board of Commissioners reports its supervisory responsibilities and receives acquittal and discharge from GMS.
A B C D E
4.8. The Board of Commissioners holds meetings regularly. No Yes
4.9. Minutes of every Board of Commissioners meeting are recorded. No Yes
4.10. Meeting minutes record dissenting opinions with decisions taken in the meeting.
A B C D E
4.11. Every Board of Commissioners member, whether attending the meeting or not,
No Yes

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5. Supervision Functions of the Sharia Board
5.1. Information provided by the Board of Directors to DPS is delivered completely and timely.
No Yes
5.2. DPS conducts supervision and provides advice and suggestions regarding business activities in accordance with Sharia Principles.
No Yes
5.3. DPS holds meetings regularly. No Yes
5.4. Minutes of every DPS meeting are recorded. No Yes
5.5. Meeting minutes record dissenting opinions with decisions taken in the meeting.
No Yes
5.6. Every DPS member, whether attending the meeting or not, is entitled to receive DPS meeting minutes.
No Yes
6. Board of Commissioners Committees (answered if any)
6.1. Audit Committee.
No Continue to
Exists 6.1.8.
The Audit Committee serves as a facilitator for the Board of Commissioners to ensure the following matters:
6.1.1. The company's internal control structure is implemented properly.
A B C D E
6.1.2. Internal audit is conducted in accordance with applicable auditing standards.
A B C D E
6.1.3. Follow-up on internal audit findings is implemented by management.
A B C D E
6.1.4. External audit has been conducted in accordance with applicable auditing standards.
No Yes
6.1.5. Follow-up on external audit findings is implemented by management.
A B C D E
6.1.6. Improvement in the quality of openness and financial reporting. A B C D E
6.1.7. Audit Committee members consist of:
a. An Independent Commissioner as Chairman. No Yes b. Board of Commissioners members. No Yes
c. Independent external parties possessing expertise, experience, and other necessary qualities.
No Yes
6.1.8. For Companies that do not have an Audit Committee, there are commissioner members who specifically serve to ensure the following matters:
a. The company's internal control structure has been implemented properly. A B C D E b. Internal audit is conducted in accordance with applicable auditing standards. A B C D E
c. Follow-up on internal audit findings is implemented by management.
A B C D E d. External audit has been conducted in accordance with applicable auditing standards. No Yes e. Follow-up on external audit findings is implemented by management. A B C D E f. Improvement in the quality of openness and financial reporting. A B C D E

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6.2. Risk Policy Committee Not Available Continue to 6.2.4.

The Risk Policy Committee serves as a facilitator for the Board of Commissioners on the following matters:

6.2.1. Assessing the quality of A B C D E risk management policies.
6.2.2. Assessing the effectiveness of risk management implemented by the Company, including assessing the risk tolerance taken by the Board of Directors.
A B C D E

6.2.3. Members of the Risk Policy Committee consist of:
a. Members of the Board of Commissioners. Not / Yes b. Independent external parties who have expertise, experience, and other qualities in managing risk management. Not / Yes

6.2.4. For Companies that do not have a Risk Policy Committee, there are Commissioner members who specifically serve on the following matters:
a. Assessing the quality of risk management policies. A B C D E b. Assessing the effectiveness of risk management implemented by the Company, including assessing the risk tolerance taken by the Board of Directors. A B C D E

6.3. Nomination and Remuneration Committee Not Available Continue to 6.3.11.

The Nomination and Remuneration Committee serves as a facilitator for the Board of Commissioners on the following matters:

6.3.1. Assisting the Board of Commissioners in proposing to the General Meeting of Shareholders (GMS) regarding the system and procedures for nominating the Board of Commissioners.
A B C D E
6.3.2. Assisting the Board of Commissioners in proposing to the GMS regarding the system and procedures for nominating the Board of Directors.
A B C D E
6.3.3. Assisting the Board of Commissioners in proposing to the GMS regarding the system and procedures for nominating senior officials of the Company.
A B C D E
6.3.4. Assisting the Board of Commissioners and/or shareholders in selecting commissioners so as to meet competence and propriety requirements.
A B C D E
6.3.5. Assisting the Board of Commissioners and/or shareholders in selecting directors so as to meet competence and propriety requirements.
A B C D E
6.3.6. Assisting the Board of Commissioners in proposing to the GMS regarding the performance evaluation system for Commissioners.
A B C D E
6.3.7. Assisting the Board of Commissioners in proposing to the GMS regarding the performance evaluation system for the Board of Directors.
A B C D E
6.3.8. Assisting the Board of Commissioners in proposing to the GMS regarding the remuneration system for the Board of Commissioners.
A B C D E
6.3.9. Assisting the Board of Commissioners in proposing to the GMS regarding the remuneration system for the Board of Directors.
A B C D E

6.3.10. Members of the Nomination and Remuneration Committee consist of:
a. Members of the Board of Commissioners. Not / Yes -168- b. Independent external parties who have the necessary expertise, experience, and qualities. Not / Yes

6.3.11. For Companies that do not have a Nomination and Remuneration Committee, there are Commissioner members who specifically serve on the following matters:
a. Assisting the Board of Commissioners in proposing to the GMS regarding the system and procedures for nominating the Board of Commissioners. A B C D E b. Assisting the Board of Commissioners in proposing to the GMS regarding the system and procedures for nominating the Board of Directors. A B C D E
c. Assisting the Board of Commissioners in proposing to the GMS regarding the system and procedures for nominating senior officials of the Company.
A B C D E d. Assisting the Board of Commissioners and/or shareholders in selecting commissioners so as to meet competence and propriety requirements. A B C D E e. Assisting the Board of Commissioners and/or shareholders in selecting directors so as to meet competence and propriety requirements. A B C D E f. Assisting the Board of Commissioners in proposing to the GMS regarding the performance evaluation system for Commissioners. A B C D E g. Assisting the Board of Commissioners in proposing to the GMS regarding the performance evaluation system for the Board of Directors. A B C D E h. Assisting the Board of Commissioners in proposing to the GMS regarding the remuneration system for the Board of Commissioners. A B C D E
i. Assisting the Board of Commissioners in proposing to the GMS regarding the remuneration system for the Board of Directors.
A B C D E

6.4. Corporate Governance Policy Committee Not Available Continue to 6.4.4.

The Corporate Governance Policy Committee (whether independent or combined within the Nomination and Remuneration Committee) serves to assist the Board of Commissioners in the following matters:

6.4.1. Assisting the Board of Commissioners in comprehensively reviewing Good Corporate Governance (GCG) policies drafted by the Board of Directors.
A B C D E
6.4.2. Assessing the suitability of GCG implementation in the Company against the GCG policies drafted by the Board of Directors, including those related to Business Ethics and CSR.
A B C D E
6.4.3. Members of the Corporate Governance Policy Committee consist of:
a. Members of the Board of Commissioners. Not / Yes b. Independent external parties who have expertise, experience, and qualities in the field of corporate governance. Not / Yes

6.4.4. For Companies that do not have a Corporate Governance Policy Committee, there are Commissioner members who specifically serve on the following matters:
a. Comprehensively reviewing GCG policies drafted by the Board of Directors. A B C D E b. Assessing the suitability of GCG implementation in the Company against the GCG policies drafted by the Board of Directors, including those related to Business Ethics and CSR. A B C D E -169-

7. Independent Commissioners The Company has Independent Commissioners with the following criteria:

7.1. Does not have an affiliation *) relationship with Controlling Shareholders of the Company. Not / Yes
7.2. Does not have an affiliation *) relationship with Directors of the Company. Not / Yes
7.3. Does not have an affiliation *) relationship with other Commissioners. Not / Yes
7.4. Has never held an Executive position at the same Insurance Company and Sharia Insurance Company within the last 6 (six) months. Not / Yes
7.5. Does not hold an executive position in a company that has a business relationship with the Company. Not / Yes
7.6. Has never held an Executive position at another affiliated Company within the last 6 (six) months. Not / Yes
7.7. Is not a partner or principal at a consulting firm providing professional services to the Company and other affiliated companies. Not / Yes
7.8. Is not a significant supplier or holds an executive and commissioner position at a supplier company. Not / Yes
7.9. Is not a significant customer or holds an executive and commissioner position at a significant customer company of the Company. Not / Yes
7.10. Is not a significant supplier of affiliated companies or holds an executive and commissioner position at a supplier company of the affiliated Company. Not / Yes
7.11. Is not a significant customer of affiliated companies or holds an executive and commissioner position at a customer company of the affiliated Company. Not / Yes
7.12. Is free from all interests and business activities or other relationships with the Company that can be interpreted as hindering or reducing the ability of the Independent Commissioner to act and think independently for the benefit of the Company. Not / Yes
7.13. Understands the Limited Liability Company Law. A B C D E
7.14. Understands the Insurance Law and its implementing regulations. A B C D E
7.15. Does not concurrently work as a Commissioner, Director, and Sharia Supervisory Board at Insurance Companies and Sharia Insurance Companies that have the same business field. A B C D E

D. Board of Directors

1. Composition, Appointment, and Dismissal of Board of Directors Members

1.1. The Board of Directors consists of members who collectively possess competence *) such as:
1.1.a Insurance Field. Not / Yes 1.1.b Finance Field. Not / Yes 1.1.c Management Field. Not / Yes
1.2. The domicile of Board of Directors members is arranged to enable effective decision-making. Not / Yes
1.3. Board of Directors members are appointed and dismissed by the GMS through a transparent mechanism. Not / Yes

2. Requirements for Board of Directors Members

2.1. Board of Directors members meet the provisions of the Articles of Association. Not / Yes
2.2. Board of Directors members meet competence and propriety requirements according to the regulations of the supervising authority. Not / Yes
2.3. Board of Directors members meet requirements according to Company regulations. A B C D E
2.4. Board of Directors members must understand and implement GCG. A B C D E
2.5. Board of Directors members are prohibited from utilizing the Company for personal, family, business group, or other interests that harm the Company's interests. Not / Yes
2.6. The President Director does not concurrently hold a position as a Commissioner in more than 1 (one) Insurance Company with a different business field. Not / Yes
2.7. Other than the President Director, they do not concurrently hold a position as a Commissioner in more than 1 (one) Insurance Company with a different business field that is not a Subsidiary Company. Not / Yes
2.8. The Board of Directors does not concurrently hold positions in companies that are not Insurance Companies. Not / Yes

3. Functions of the Board of Directors

3.1. Management
3.1.1. The Board of Directors formulates the Company's Vision, Mission, Values, and long-term and short-term programs. A B C D E
3.1.2. The Board of Directors manages owned resources effectively and efficiently, including ensuring the availability of human resources meeting specific qualifications to perform their functions. A B C D E
3.1.3. The Board of Directors considers the legitimate interests of stakeholders. A B C D E
3.1.4. The Board of Directors forms Committees to support the execution of their duties. A B C D E
3.1.5. The Board of Directors has and complies with rules of procedure and working guidelines (charters). A B C D E

3.2. Risk Management
3.2.1. The Board of Directors formulates and implements a Risk Management System covering all aspects of Company activities. A B C D E
3.2.2. The Company has a Risk Policy Committee and a Risk Management Work Unit. Not / Yes

3.3. Internal Control
3.3.1. The Company has an internal supervision function. Not / Yes
3.3.2. Responsible to the President Director or the Director overseeing the internal supervision task. Not / Yes
3.3.3. Reports are submitted to the Board of Commissioners/Audit Committee. Not / Yes
3.3.4. The Head of the Internal Audit Work Unit is appointed by the Board of Directors based on clear criteria. Not / Yes
3.3.5. The appointment of the Head of the Internal Audit Work Unit receives approval from the Board of Commissioners. Not / Yes
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3.3.6. The Internal Audit Work Unit is tasked with ensuring the internal control system functions effectively and efficiently. A B C D E
3.3.7. Conducts evaluations on the implementation of Company programs. A B C D E
3.3.8. Ensures the Internal Control System functions effectively and efficiently. A B C D E
3.3.9. Provides suggestions to improve the effectiveness of risk control processes. A B C D E
3.3.10. Conducts compliance evaluations regarding legislation, GCG implementation, and Company regulations. A B C D E
3.3.11. Facilitates the smooth execution of audits by External Auditors. A B C D E

3.4. Communication
3.4.1. The Company has a Company Secretary who executes communication between the Company and stakeholders. Not Available / Continue to 3.4.2 / Yes / Yes
3.4.2. In cases where Company complexity does not yet require the appointment of a Company Secretary, the communication function is held by one of the Board of Directors members. Not / Yes
3.4.3. The Company Secretary must be able to:
a. Ensure the Company has met information disclosure provisions according to legislation. A B C D E b. Provide services to stakeholders regarding any relevant information needed. A B C D E
3.4.4. The Company Secretary's Task Execution Report is submitted to the Board of Directors and Board of Commissioners. Not / Yes
3.4.5. The Company Secretary executes functions to ensure compliance with legislation in case the Company does not have its own compliance committee. Not / Yes

3.5. Actuarial
3.5.1. The Company has Actuaries who meet the following principles:
a. Appointed Actuaries have qualifications and standards as determined, proven by recognition from the Actuarial Professional Body. Not / Yes b. Company Actuaries meet qualifications according to applicable legislation. Not / Yes
c. Appointed Actuaries, in performing their duties, refer to practice standards and professional ethical codes in effect. Not / Yes
3.5.2. The Company must appoint an actuarial consulting company to evaluate Company obligations. Not / Yes

3.6. Investment
3.6.1. Investments are conducted with prudent principles, yielding optimal results, easily liquidated, and safe for the Company. A B C D
3.6.2. The Company has an Investment Committee to assist the Board of Directors. Not / Yes
3.6.3. The Investment Committee executes tasks objectively based on directives from the Board of Directors. A B C D E
3.6.4. The Investment Committee assists the Board of Directors in evaluating and establishing planned investment strategies. A B C D E
3.6.5. The Investment Committee assists the Board of Directors in maintaining sufficient liquidity to meet obligations. A B C D E
3.6.6. The Company has an Investment Management function. Not / Yes

3.7. Marketing
3.7.1. The Company has a Promotion Program (media plan) essentially disclosing clear and relevant information, not misleading, and complying with applicable ethical codes and legislation. Not / Yes
3.7.2. The Company issues brochures containing complete and clear explanations of products sold to the general public. Not / Yes
3.7.3. The Company has agents and an agency system. Not / Yes
3.7.4. The Company has standard agency contracts. Not / Yes
3.7.5. The Company ensures that all agents must have agency certification and training as required. A B C D E
3.7.6. The Company has and applies an Agency Code of Ethics in marketing its products. Not / Yes
3.7.7. The Company has cooperation with insurance brokers. Not / Yes
3.7.8. The Company has utilized electronic media to carry out marketing activities. Not / Yes

3.8. Information Technology (IT)
3.8.1. The Company has an integrated computerized administration system. A B C D E
3.8.2. The Company has a computerized system for calculating the magnitude of accumulated risks and technical reserves. A B C D E
3.8.3. The Company has a special unit to handle IT standing alone under the supervision of a Director. Not / Yes
3.8.4. The Company has Standard Operating Procedures for the IT department. A B C D E
3.8.5. The Company conducts periodic IT audits. Not / Yes
3.8.6. The Company has clear arrangements for responsibilities over the use of Information Technology. A B C D E

3.9. Social Responsibility
3.9.1. The Company has a sustainable social responsibility program. A B C D E
3.9.2. The report on social responsibility implementation is submitted by the Board of Directors in the Annual Report. Not / Yes

4. Accountability of the Board of Directors
4.1. The Board of Directors prepares accountability reports on Company management in the form of an Annual Report. Not / Yes
4.2. Criteria for the Annual Report include:
4.2.1. Contains at least:
a. Financial Report. Not / Yes b. Company Activity Report. Not / Yes
c. GCG Implementation Report. Not / Yes
4.2.2. Receives approval from the GMS. Not / Yes
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4.2.3. Specifically, the financial report must receive ratification from the GMS. Not / Yes
4.2.4. Must be available before the GMS is held according to applicable regulations so that Shareholders can conduct assessments. Not / Yes

4.3. Board of Directors Meetings
4.3.1. The Board of Directors holds meetings periodically. Not / Yes
4.3.2. The Board of Directors establishes meeting rules of procedure. Not / Yes
4.3.3. Minutes are made for every Board of Directors meeting. Not / Yes
4.3.4. Meeting minutes record dissenting opinions with decisions taken in the meeting (if any). A B C D E
4.3.5. Every member of the Board of Directors, whether attending the meeting or not, has the right to receive the Board of Directors Meeting Minutes. Not / Yes

III. SHAREHOLDERS

1. Shareholder Requirements
1.1. Controlling Shareholders must at all times meet competence and propriety requirements. Not / Yes
1.2. Competence and propriety assessments are conducted at all times if the Controlling Shareholder is suspected of no longer meeting competence and propriety requirement provisions based on analysis results, examination results, and/or complaints. Not / Yes
1.3. PSP [Controlling Shareholder] does not become a PSP in 1 (one) other Company that is an Insurance Company or Reinsurance Company with the same business field. Not / Yes

2. Rights and Responsibilities of Shareholders
2.1. The Company guarantees Shareholder rights, so Shareholders can use them according to correct procedures. Not / Yes
2.2. Do the rights guaranteed by the Company include but are not limited to the following:
a. Right to attend the GMS. Not / Yes b. Right to vote in a GMS. Not / Yes
c. Right to obtain material information promptly. Not / Yes
d. Right to obtain material information regularly. Not / Yes e. Right to receive a portion of profits allocated for Shareholders, proportional to the number of shares owned. Not / Yes

3. Obligations of Shareholders
3.1. Shareholders comply with the Articles of Association and legislation provisions. A B C D E
3.2. Shareholders do not conduct Company supervision activities performed by the Board of Commissioners. A B C D E
3.3. Shareholders do not conduct Company management activities performed by the Board of Directors. A B C D E
3.4. Shareholders are obligated not to utilize the Company for personal interests with a spirit and method contrary to legislation and healthy practices in the insurance industry. A B C D E
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3.5. Shareholders are obligated not to utilize the Company for family interests with a spirit and method contrary to legislation and healthy practices. A B C D E
3.6. Shareholders are obligated not to utilize the Company for Company interests. A B C D E
3.7. Shareholders are obligated not to utilize the Company for their business group interests with a spirit and method contrary to legislation and healthy practices. A B C D E
3.8. Shareholders conduct performance evaluations of the Board of Commissioners through the GMS mechanism. Not / Yes
3.9. Shareholders conduct performance evaluations of the Board of Directors through the GMS mechanism. Not / Yes

4. Company Responsibility towards Shareholder Rights and Obligations
4.1. The Company protects shareholder rights according to the Articles of Association and other legislation. A B C D E
4.2. The Company maintains a shareholder register according to the Company's Articles of Association and legislation provisions. A B C D E
4.3. The Company provides information about the Company promptly, correctly, and regularly to shareholders, except for confidential matters. A B C D E
4.4. The Company does not favor certain shareholders by providing information not disclosed to other shareholders. A B C D E
4.5. The Company provides complete explanations and accurate information regarding the organization of the GMS. A B C D E

IV. STAKEHOLDERS

A. Policyholders

The Company must fulfill and execute:
1.1. Obligations as agreed with policyholders. Not / Yes
1.2. Protection of policyholder interests. Not / Yes
1.3. Confidentiality protection for policyholders. Not / Yes
1.4. Evaluation of policyholder needs. A B C D E
1.5. Disclosure of material and relevant information for policyholders. A B C D E
1.6. Service to policyholders based on the principle of utmost good faith with high integrity and competence. A B C D E
1.7. Appointment of adjusters together with policyholders when necessary. Not / Yes
The Company ensures that policyholders:
2.1. Submit information to the Company honestly regarding insured data and risk objects. Not / Yes
2.2. Pay premiums on time. Not / Yes
2.3. Report claims to the Company according to procedures. Not / Yes
2.4. Give opportunities to conduct surveys and cooperate with adjusters. Not / Yes

B. Employees

Employees must fulfill and execute:
1.1. Employee acceptance based on work ability and criteria related to the nature of the job adhering to principles. A B C D E
1.2. The following matters objectively without discrimination based on ethnicity, religion, gender, and physical condition of a person:
1.2.1. Remuneration setting patterns. A B C D E
1.2.2. Participation in training. A B C D E
1.2.3. Career level setting. A B C D E
1.2.4. Job requirement setting. A B C D E
1.3. Have written regulations governing recruitment patterns and employee rights and obligations. A B C D E
1.4. Provide a conducive work environment, including occupational health and safety. A B C D E
1.5. Provide communication facilities for conveying information to employees. A B C D E
1.6. Give opportunities to employees to form Labor Unions while still observing legislation. A B C D E
The Company must fulfill and execute:
2.1. Obligations as clearly regulated in Company regulations and/or Collective Labor Agreements. A B C D E
2.2. Prohibition on using the Company's name, facilities, or goodwill with external parties for personal interests. A B C D E
2.3. Right to convey opinions and suggestions regarding the work environment and employee welfare. A B C D E
2.4. Reporting violations of Business Ethics and Code of Conduct as well as related legislation with the right to protection as a whistleblower. A B C D E

C. Other Insurance and Reinsurance Companies

Insurance companies and reinsurance companies conduct healthy business competition. A B C D E
In case of business relationships, parties must fulfill each other's rights and obligations including but not limited to:
2.1. There is a written agreement between both parties. A B C D E
2.2. Disclosure and submission of relevant and accurate information and data. A B C D E
2.3. Execution of commitments to fulfill each party's obligations according to agreements and legislation. A B C D E
The Company has automatic coverage from reinsurance companies. A B C D E
The Company has its own retention for each risk closure based on size on its own capital (equity) and the associated risk profile. A B C D E
Each automatic (treaty) reinsurance closure is based on an agreement agreed upon by the Company and... A B C D E

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Related Reinsurance Company

D. Supporting Companies

Relationship with Insurance Brokers and Reinsurance Brokers
In relations with insurance brokers and reinsurance brokers, the company refers to the following matters:

1.1. The company carries out acceptance according to prudent principles and settles claims according to agreements.
A B C D E

1.2. The company ensures that the broker:
1.2.1. Has a business license from the authority and competence proven by recognition from the broker professional body.
Not Yes

1.2.2. Provides all relevant information to the company correctly, honestly, and completely.
Not Yes

1.2.3. Carries out rights and obligations according to agreements, contracts, and statutory regulations.
Not Yes

Relationship with Insurance Loss Adjusters
In relations with insurance loss adjusters (adjusters), the company refers to the following rights:

2.1. The company must disclose information about policy conditions and provide complete and accurate data regarding the occurrence of a claim.
A B C D E

2.2. The company ensures that the loss adjuster:
2.2.1. Knows and understands the policy requirements agreed upon between the company and the policyholder.
Not Yes

2.2.2. Uses policy requirements and conditions as the basis to determine whether the loss incurred is covered.
Not Yes

2.2.3. Draws conclusions from examinations and research competently and independently representing the interests of the company and the policyholder.
Not Yes

2.2.4. Discloses all important information regarding the occurrence of losses and their causes, according to known facts fairly without favoring either party.
Not Yes

2.2.5. Carries out rights and obligations according to agreements, contracts, and statutory regulations.
Not Yes

Relationship with Actuarial Consultants
In relations with actuarial consultants, the company refers to the following matters:

3.1. The company discloses data and information accurately as needed by the actuarial consultant in carrying out their duties and fulfills obligations according to agreements.
A B C D E

3.2. The company ensures the appointed actuarial consultant:
3.2.1. Has integrity and a good reputation and is recognized by the competent authority.
Not Yes

3.2.2. Is independent from the company and free from shareholder interests.
Not Yes

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3.2.3. Prepares reports and recommendations to the Board of Directors based on applicable practice standards and professional ethical codes.
Not Yes

3.2.4. Carries out rights and obligations according to agreements.
Not Yes

Relationship with Insurance Agents
In relations with insurance agents, the company refers to the following matters:

4.1. The company fulfills obligations according to the agency agreement.
A B C D E

4.2. Includes the ethical code established by the relevant insurance association in the agency agreement, along with sanctions imposed for each violation.
Not Yes

4.3. Ensures that the appointed agent:
4.3.1. Is competent in representing the company in selling products and providing insurance services, proven by certificates from the competent authority.
Not Yes

4.3.2. Receives continuous education and training from the company to maintain and enhance their competence.
Not Yes

4.3.3. Signs, implements, and complies with the agency agreement with the Company.
Not Yes

4.3.4. Remits policyholder premium payments to the Company according to the agreement.
Not Yes

4.3.5. Carries out rights and obligations according to the agreement.
Not Yes

4.4. The company provides supervision tools, including but not limited to:
4.4.1. Requiring all Agents to sign a statement that they have read and understood the applicable ethical code.
A B C D E

4.4.2. Forming a sales compliance department related to product sales, directly under the supervision of one of the Directors.
A B C D E

4.4.3. Requiring the sales compliance department to submit periodic reports to the Board of Directors.
A B C D E

4.4.4. The Board of Directors is required to report to the relevant association every ethical code violation that occurs.
A B C D E

Business Partners
Business Partners are suppliers, distributors, creditors, debtors, and other parties conducting business transactions with the company. In relations with business partners, the company refers to the following matters:

5.1. Having regulations that can guarantee the implementation of the rights and obligations of business partners according to agreements and statutory regulations.
A B C D E

5.2. Ensuring that the company and business partners:
5.2.1. Obtain relevant information from each other according to the business relationship conducted, so that each party can make decisions based on fair and reasonable considerations.
Not Yes

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5.2.2. Keep each other's information confidential and protect each other's interests, unless otherwise required by statutory regulations.
Not Yes

5.2.3. Conduct work relationships according to ethical values and statutory regulations.
Not Yes

Society
In relations with society, the company refers to the following matters:

6.1. Having regulations that can guarantee harmony in the relationship between the Company and society, including partnership programs and environmental development.
A B C D E

6.2. The company is responsible for negative impacts caused by the company's activities on society.
A B C D E

V. HEALTHY BUSINESS PRACTICES

A. Underwriting

The company has an underwriting policy detailed in the Underwriting Guidelines.
A B C D E
The Underwriting Guidelines contain technical acceptance policies, authority limits for each underwriter, pricing, and insurance coverage capacity.
A B C D E
In conducting prudent underwriting, the company:
3.1. Applies basic insurance principles.
A B C D E

3.2. Considers factors supporting the implementation process, such as: risk surveys, premium rate determination, and coverage value determination.
A B C D E

3.3. Complies with statutory regulations.
A B C D E

Coverage provided by the company must be clear and easy to understand to prevent disputes in the future and provide benefits as needed by the policyholder.
A B C D E

B. Claims

The company informs the policyholder about the procedure for settling insurance claims.
A B C D E
Ensuring the company receives information about the procedures and requirements for submitting reinsurance claims by:
A B C D E
The reinsurance company and the insurance company involved in the reinsurance arrangement made by the company.
A B C D E
The company uses the services of an independent loss adjuster if necessary.
Not Yes
Claim handling policy is detailed in the company's Claim Settlement Guidelines.
A B C D E
1. The company strives for prompt claim settlement and timely payment according to statutory regulations.
  A B C D E

C. Reinsurance and Retrocession

The company conducts reinsurance (reinsurance/retrocession) for risks exceeding or outside the company's capacity according to statutory regulations.
A B C D E

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Implementation of reinsurance/retrocession is based on written agreements between the Company and the reinsurer, whether facultative or treaty.
A B C D E

D. Compliance

The company has a compliance function.
Not Yes
The company runs the compliance function against statutory regulations, internal policies, and agreements agreed upon with other parties.
A B C D E
The company runs the compliance function against business ethics and codes of conduct.
A B C D E
The Board of Directors is tasked with performing the compliance function.
A B C D E
The Board of Commissioners monitors the implementation of the compliance function through a Risk Monitoring Committee or Compliance Committee specifically formed.
A B C D E
Information regarding non-compliance in the form of deviations and/or fraud that occur is collected through the Violation Reporting System mechanism number 4 there is no compliance committee, only a risk monitoring committee.
A B C D E
The company has a Chief Compliance Officer.”
A B C D E
The Director overseeing the compliance technique function does not concurrently hold the insurance technique, finance, or marketing functions.
A B C D E

E. Risk Management

The company has a risk management function.
Not Yes
The company has a risk management policy detailing main principles and setting responsibilities among all aspects of activities covering:
2.1. An efficient system to identify, assess, measure, control, reduce, and monitor risks.
A B C D E

2.2. Strategies, policies, and procedures appropriate to ensure fulfillment of internal policies and statutory regulations.
A B C D E

2.3. Adequate internal control systems to ensure that Risk Management and Compliance can be implemented well.
A B C D E

2.4. Risk Management personnel with high integrity, competence, experience, and meeting established qualifications.
A B C D E

The company develops a basic framework for Asset and Liability Management (ALM) strategy implemented at the Board-level committee. Important tasks of this committee include discussing new products to be marketed by the company.
A B C D E
The company conducts Stress Tests related to risks in fulfilling solvency requirements, including measuring the company's ability to face various possibilities, such as changes in economic conditions, which can impact the financial condition of the Company.
A B C D E
The company develops Contingency Plans specifically to handle risks believed to occur, such as:
A B C D E

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natural disasters, terrorist attacks, failure of information technology systems, vacancy of the Board of Directors or key management positions. The preparation of Contingency Plans is done through a continuous approach and communicated to employees through training.

F. Internal Audit
The company has a working unit that performs the internal auditor function. To carry out its function well, internal auditors must:

Prepare and implement audit plans to test and evaluate the adequacy and effectiveness of the systems owned by the Company.
A B C D E
Audit all activity areas containing material enough risk within an adequate timeframe.
A B C D E
Issue reports of findings and recommendations based on audit results to Management.
A B C D E
Report significant audit results and findings to the Board of Directors and Board of Commissioners.
A B C D E
Report the adequacy of the risk management function, compliance function, and other control functions to management.
A B C D E
The audit plan is discussed with the audit committee and submitted to the Board of Directors for approval.
A B C D E

G. External Auditor

External Auditors (public accounting firms) conduct independent examinations of the truthfulness of reports presented by the Board of Directors.
Not Yes
The appointed public accounting firm (KAP) is registered with the Supervisory Authority.
Not Yes
The appointment of KAP is proposed by the Board of Directors to the Board of Commissioners and subsequently requests approval from the General Meeting of Shareholders (RUPS).
Not Yes
External Auditors are free from Commissioner influence.
Not Yes
External Auditors are free from Board of Directors influence.
Not Yes
External Auditors are free from influence of other interested parties in the Company.
Not Yes
External Auditors have access to all accounting records.
Not Yes
External Auditors have access to all supporting data required.
Not Yes
External Auditors do not provide other services besides audit services.
Not Yes
The appointment of KAP is proposed by the audit committee to the Board of Commissioners and subsequently requests approval from RUPS.
Not Yes

H. Violation Reporting System (Whistleblowing System)

The company has a Violation Reporting System mechanism that records every violation endangering the company's interests.
A B C D E
The person in charge of the violation reporting system submits violation reports to the Company.
A B C D E
The Violation Reporting System mechanism can protect the Reporter.
A B C D E
The person in charge of the Violation Reporting System immediately follows up on every report submitted by the Reporter.
A B C D E

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I. Company Actuary
Not directly to VI
Yes

The company has a company actuary who acts independently.
Actuaries are required to provide professional advice to the Board of Directors regarding:
2.1. Opinions on technical determinations related to the evaluation framework prepared by the company.
A B C D E

2.2. Identification and estimation of major risks and appropriate risk management.
A B C D E

2.3. Assessing risk management.
A B C D E

2.4. Testing financial conditions.
A B C D E

2.5. Investment strategy and asset-liability management.
A B C D E

2.6. Assessing capital adequacy from regulatory and economic perspectives.
A B C D E

2.7. Premium adequacy and cash value.
A B C D E

2.8. Managing participating funds, including analysis of main effects resulting from strategies and policies.
A B C D E

2.9. Product design, reducing risks, and other risk management liabilities.
A B C D E

Actuaries have access to the Board of Directors and relevant Board meetings as well as operational units.
A B C D E
Actuaries are given authority to communicate with staff in divisions whose work results relate to the appointed actuarial function.
A B C D E
Actuaries provide recommendations on premium rates with the assurance that the premium rate determination has been consistent with the internal structure.
A B C D E
Actuaries provide recommendations on dividend amounts for policyholders to be distributed to participating policyholders, considering fairness and justice among various groups of policyholders.
A B C D E
Actuaries can provide opinions on investment methods that the company should undertake.
A B C D E
The company does not assign other tasks to the actuary that could cause conflicts of interest.
Not Yes

VI. STATEMENT OF GCG GUIDELINE IMPLEMENTATION

The Statement on GCG Implementation is stated in the Company's Annual Report which can be accessed by stakeholders.
No
Yes
The annual report must contain information about the structure and working mechanisms of the company organs including:
2.1. Names of Board of Commissioners members.
Not Yes

2.2. Number of meetings held by the Board of Commissioners and attendance lists.
Not Yes

2.3. Mechanism and criteria for self-assessment of each Commissioner's performance.
Not Yes

2.4. Explanation of supporting committees of the Board of Commissioners:
2.4.1. Name.
Not Yes

2.4.2. Function Description.
Not Yes

2.4.3. Working Mechanism.
Not Yes

2.4.4. Number of Meetings.
Not Yes

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2.4.5 Attendance List.
Not Yes

2.4.6. Mechanism and Criteria for Committee Performance Assessment.
Not Yes

2.5. Names of Board of Directors members with their respective positions and functions.
Not Yes

2.6. Brief explanation of the Board of Directors' working mechanism.
Not Yes

2.7. Number of meetings held by the Board of Directors and Attendance List.
Not Yes

2.8. Statement regarding the effectiveness of the implementation of the internal control system, including risk control systems and internal supervision and audit systems.
Not Yes

2.9. Other information related to GCG implementation, including:
2.9.1. Company Vision, Mission, and Values.
Not Yes

2.9.2. Controlling Shareholders.
Not Yes

2.9.3. Policy and Amount of Remuneration for Board of Commissioners and Directors.
Not Yes

2.9.4. Transactions with parties having conflicts of interest.
Not Yes

2.9.5. Results of GCG implementation assessment reported in the Annual General Meeting of Shareholders (RUPS).
Not Yes

2.9.6. Extraordinary events experienced by the company and affecting Company performance.
Not Yes

Action Plan

No.	Corrective Action	Target Completion	Obstacles to Completion	Notes
1.
2
etc.

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Anti-Fraud Strategy Implementation

(Company Name)......
REPORT ON FRAUD CONTROL AND ANTI-FRAUD STRATEGY IMPLEMENTATION SEMESTER I/II*) - YEAR ……

a. Fraud Incident Inventory and Follow-up

Type of Fraud a)	Date of Fraud Occurrence	Division/Department Where Fraud Occurred	Involved Party b)	Position	Loss in Rupiah c)	Company Action d)	Weakness/Cause of Fraud e)	Follow-up/Improvement f)	Chronology of Fraud Incident g)

b. Progress of Anti-Fraud Strategy Implementation g)

1) Prevention:
………………
………………
………………

2) Detection:
………………
………………
………………

3) Investigation, Reporting, and Sanctions:
………………
………………
………………

4) Monitoring, Evaluation, and Follow-up:
………………
………………
………………

Prepared by, Acknowledged,

(Signature) (Signature)
(Name) (Name)
(Chief Executive Officer)

*) delete one

EXPLANATION FOR REPORT COMPLETION:
a) Types of Fraud include, among others, fraud, deception, asset embezzlement, information leakage, corporate criminal acts, or others. b) Parties involved include all parties indicated to be involved/participating in Fraud. If more than 1 (one) party is involved, the role of each party is explained. c) Losses are filled with losses that have occurred or estimated losses. d) Company Action is the Company's response to the Fraud incident, whether actions towards perpetrators, victims, or other actions. Actions towards Fraud perpetrators include administrative personnel sanctions and/or compensation obligations. Actions towards victims include compensation and/or efforts to restore reputation. Other actions include reports to competent authorities and/or legal efforts undertaken. e) Weaknesses/causes of Fraud are identifications of weaknesses in the Company that caused Fraud, which can be policy, system, and procedure weaknesses, or human resources, or other causes not originating from the Company. f) Follow-up/improvement are efforts already or to be undertaken by the Company regarding weaknesses causing Fraud. g) Briefly explain the process of prevention, detection, investigation, reporting, sanctions, and monitoring, evaluation, and follow-up steps in implementing the anti-Fraud strategy during the reporting period.

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REPORT ON SUPERVISION RESULTS OF THE SHARIA SUPERVISORY BOARD

Statement of the Sharia Supervisory Board

Bismillaahirrahmaanirrahiim

We have conducted supervision over the implementation of basic principles of organizing insurance/reinsurance business with Sharia principles organized by PT. ………………/Sharia Unit of PT. ……………… (“the company”) during the period from date ………………… to date …………………, as mandated by Article 16 of Minister of Finance Regulation Number 18/PMK.010/2010 concerning the Implementation of Basic Principles of Organizing Insurance and Reinsurance Business with Sharia Principles. In order to conduct such supervision, we carried out assessments of the operations of the aforementioned company covering aspects of asset and liability management, aspects of marketed products, and aspects of marketing practices conducted by the aforementioned company, and other operational activities.

From the results of supervision, it was known that the Company had conducted operational practices violating Islamic Sharia principles. Thus, based on the assessment results of the aspects in paragraph 1 above, in our opinion, the implementation of these matters by the Company is not in accordance with Islamic Sharia principles.

Summary of the company's operational practices inconsistent with Islamic Sharia principles, the period of occurrence, and their causal factors are as follows:

1.……………
2.……………
3.etc

......(City Name),...... (Date-Month-Year) Sharia Supervisory Board :

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No	Name	Signature	Remarks
1
2
etc.

*) Choose one appropriate statement

We have conducted supervision over the implementation of basic principles of organizing insurance/reinsurance business with Sharia principles conducted by PT/Sharia Unit of PT. ……………… (“the Company”) during the period from date ………………… to date …………………, as mandated by Article 16 of Minister of Finance Regulation Number 18/PMK.010/2010 concerning the Implementation of Basic Principles of Organizing Insurance and Reinsurance Business with Sharia Principles. In order to conduct such supervision, we carried out assessments of the operations of the aforementioned Company covering aspects of asset and liability management, aspects of marketed products, aspects of marketing practices conducted by the aforementioned Company, and other operational activities.

The Company did not provide us with access to obtain documents and information we needed to perform assessments of the aspects in paragraph 1 above, therefore we do not provide an opinion regarding the implementation of basic principles of organizing insurance/reinsurance business with Sharia principles in the Company's operations.

…….(City Name),……………….(Date-Month-Year) Sharia Supervisory Board:

No	Name	Signature	Remarks
*) Choose one appropriate statement

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Completion of questionnaire on Sharia Supervisory Board supervision results. Completion is done by providing answer choices to questions/statements in the aforementioned questionnaire.

A. Asset and Liability Management

Main Material 1:
System and procedures for asset and liability management. Conformity Status:
Not Yes

Main Material 2:
Clear and firm separation of recording assets and liabilities between Tabarru’ Funds, Company Funds, and Participant Investment Funds, including administration of proof of ownership of assets and liabilities conducted according to agreements in the policy. Conformity Status:
Not Yes

Main Material 4:
Formation of Tabarru’ Funds is made separately:

per business line or combined business lines and
Conformity Status:
Not Yes

Main Material 5:
Formation of Participant Investment Funds for each type of investment portfolio according to its contract (akad). Conformity Status:
Not Yes

Main Material 6:
Recording and administration of participant accounts individually as part of the assets and liabilities of Participant Investment Funds. Conformity Status:
Not Yes

Main Material 7:
Giving and returning Qardh to/from Tabarru’ Funds. Conformity Status:
Not Yes

Main Material 3:
Restriction on the use of Tabarru’ Funds as regulated in Article 4 paragraph (2) of PMK No. 18/PMK.010/2010. Conformity Status:
Not Yes

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Core Material 8:
The management of Tabarru' Funds, Company Funds, and Participant Investment Funds is conducted with reference to Sharia principles, for example, such assets are only placed in investment instruments that do not contradict Sharia principles. Compliance Status:
No Yes

Core Material 9:
Calculation and distribution of underwriting surplus according to the policy. In the event that participants entrust the payment of the participant's share of underwriting surplus as sadaqah, the payment of said sadaqah is carried out in accordance with Sharia principles. Compliance Status:
No Yes

Core Material 10:
In the event that participants entrust the payment of zakat on participant investment funds, the calculation, collection, and payment of said zakat are carried out in accordance with Sharia principles. Compliance Status:
No Yes

B. Products Marketed

Core Material 1:
Systems and procedures for the design, issuance, implementation, and monitoring of products marketed. Compliance Status:
No Yes

Core Material 2:
Preparation and implementation of policy contents and insurance application forms (SPPA)/membership application forms which include:
a. Use of tabarru' contracts and tijarah contracts. b. Minimum substance that must be contained in each contract.
c. Fair and reasonable methods for allocating and distributing underwriting surplus for all participants.
d. Provision of qard by the Company and repayment of qard to the Company. Compliance Status:
No Yes

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Core Material 3:
Determination and charging of ujrah/remuneration amounts in risk management using the wakalah bil ujrah contract stated in policies and insurance application forms (SPPA)/membership application forms are carried out fairly and meet the basic principles as referred to in Article 54 POJK Number 69/POJK.05/2016. Compliance Status:
No Yes

Core Material 4:
Determination and charging of ujrah/remuneration amounts in investment management using the wakalah bil ujrah contract and/or nisbah/profit-sharing amounts in mudharabah contracts and joint mudharabah contracts stated in policies and insurance application forms (SPPA)/membership application forms are carried out fairly and meet the basic principles as referred to in Article 54 POJK Number 69/POJK.05/2016. Compliance Status:
No Yes

Core Material 5:
Collection or charging of costs to Participants in accordance with what is stated in the policy. Compliance Status:
No Yes

Core Material 6:
Implementation of underwriting procedures for each product is carried out fairly, reasonably, and without discriminatory application. Compliance Status:
No Yes

Core Material 7:
In the event that the management of Tabarru' Funds uses the wakalah bil ujrah contract, the Company has no right to obtain a share of the investment results. Compliance Status:
No Yes

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C. Marketing Practices Conducted by the Company

Core Material 1:
The Company, in this case, marketing personnel or insurance agents, have obtained training regarding marketed products and have provided correct, accurate, and complete explanations to prospective participants, including: a. Agreed-upon contracts. b. The position, rights, and obligations of each party. Compliance Status:
No Yes

Core Material 2:
Every policy issuance must be accompanied by an insurance application form (SPPA)/membership application form that is filled out correctly and completely, signed by the participant and the Company as a form of approval (ijab qabul) for the contracts within the policy. Compliance Status:
No Yes

Core Material 3:
Agreements between the Company and business partners, including insurance agents, insurance/reinsurance brokers, loss assessors, reinsurers, and other parties, are carried out in accordance with Sharia principles. Compliance Status:
No Yes

Core Material 4:
Marketing practices for products and participant services do not contradict Sharia principles, for example, not giving bribes/kickbacks in the context of product marketing and participant services. Compliance Status:
No Yes

Core Material 5:
Payment of marketing commissions is carried out fairly, reasonably, and proportionally, including but not limited to business acquisition/policy closing activities. Compliance Status:
No Yes

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II. Report on the Implementation of Risk Management by Sharia Insurance/Sharia Reinsurance Companies

1. Overview of General Risk Management Implementation a. Active Supervision by the Board of Directors and Board of Commissioners (Filled with an explanation of the role of the Board of Directors and Board of Commissioners in Risk Management and the Risk Management organizational structure) b. Adequacy of Policies, Procedures, and Risk Limit Setting (Filled with an explanation of risk appetite, risk tolerance, and risk limit setting)
c. Adequacy of the Process for Risk Identification, Measurement, Monitoring, and Control
(Filled with an explanation of the Risk Identification, Measurement, Monitoring, and Control Process) d. Risk Management Information System (Filled with an explanation of how the company's information system supports the implementation of Risk Management) e. Comprehensive Internal Control System (Filled with an explanation of how internal control, including the compliance function, is conducted by the company)

2. Risk Management Implementation for Each Type of Risk a. Strategic Risk

Scope of Risk Management Implementation	Description
Active Supervision by the Board of Directors and Board of Commissioners	(Filled with an explanation of active supervision by the Board of Directors and Board of Commissioners over Strategic Risk)
Adequacy of Policies, Procedures, and Risk Limit Setting	(Filled with an explanation of risk appetite, risk tolerance, and limit setting for Strategic Risk)
Adequacy of the Process for Risk Identification, Measurement, Monitoring, and Control	(Filled with an explanation of the process for identification, measurement, monitoring, and control of Strategic Risk)

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Scope of Risk Management Implementation	Description
Risk Management Information System	(Filled with an explanation of how the company's information system supports the implementation of Risk Management for Strategic Risk)
Comprehensive Internal Control System	(Filled with an explanation of how internal control, including the compliance function, is conducted by the company for Strategic Risk)

b. Operational Risk

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

c. Asset and Liability Risk

Scope of Risk Management Implementation	Description
Active Supervision by the Board of Directors and Board of Commissioners	(Filled with an explanation of active supervision by the Board of Directors and Board of Commissioners over Asset and Liability Risk)
Adequacy of Policies, Procedures, and Risk Limit Setting	(Filled with an explanation of risk appetite, risk tolerance, and limit setting for Asset and Liability Risk)
Adequacy of the Process for Risk Identification, Measurement, Monitoring, and Control	(Filled with an explanation of the process for identification, measurement, monitoring, and control of Asset and Liability Risk)
Risk Management Information System	(Filled with an explanation of how the company's information system supports the implementation of Risk Management for Asset and Liability Risk)

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Scope of Risk Management Implementation	Description
Comprehensive Internal Control System	(Filled with an explanation of how internal control, including the compliance function, is conducted by the company for Asset and Liability Risk)

d. Governance Risk

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

e. Management Risk

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

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f. Capital Support Risk (Funding)

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

g. Insurance Risk

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

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III. Business Plan Realization Report

1. Financial Realization Report for General Sharia Insurance Companies/Sharia Reinsurance Companies (in millions of rupiah)

DESCRIPTION	Business Plan	Realization	Deviation Rupiah	Deviation %
ASSETS
Investments
Securities held
Deposits and Certificates of Deposit
Sharia Stocks
Sukuk or Sharia Bonds
Sharia MTN
State Sharia Securities
Sharia Securities issued by Bank Indonesia
Sharia Securities Issued by entities other than the Republic of Indonesia
Sharia Securities Issued by Multinational Institutions
Sharia Mutual Funds
Sharia Asset-Backed Securities
Sharia Real Estate Investment Funds
REPO
Financing Through Cooperation with Other Parties
Direct Participation (details)
Investment Property (details)
Pure Gold
Other Investments
Total Investments
Non-Investments
Cash and Banks

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DESCRIPTION	Business Plan	Realization	Deviation Rupiah	Deviation %
Receivables (details)
Reinsurance Assets
Deferred Acquisition Costs
Non-Investment Property (details)
Other Assets
Total Non-Investments
TOTAL ASSETS
LIABILITIES AND EQUITY
Liabilities
Payables
Claim Payables
Other Payables (details)
Accrued Expenses
Technical Provisions
Ujroh Provisions
Investment Principal Guarantee Provisions
Contribution Provisions
Provisions for Contributions Not Yet Revenue
Claim Provisions
Disaster Risk Provisions
Qardh / Subordinated Qardh
Fund Equity
Paid-in Capital
Share Premium
Provisions
Accumulated Funds
Increase (Decrease) in Securities
Difference Between SAK Balance and SAP Balance
Profit Balance
Disallowed Wealth

-197-

2. Financial Realization Report for Life Sharia Insurance Companies (in millions of rupiah)

DESCRIPTION	Business Plan	Realization	Deviation
ASSETS
Investments
Securities held
Deposits and Certificates of Deposit
Sharia Stocks
Sukuk or Sharia Bonds
Sharia MTN
State Sharia Securities
Sharia Securities issued by Bank Indonesia
Sharia Securities Issued by entities other than the Republic of Indonesia
Sharia Securities Issued by Multinational Institutions
Sharia Mutual Funds
Sharia Asset-Backed Securities
Sharia Real Estate Investment Funds
REPO
Financing Through Cooperation with Other Parties
Direct Participation (details)
Investment Property (details)
Pure Gold
Other Investments
Total Investments
Non-Investments
Cash and Banks
Receivables (details)
Reinsurance Assets
Deferred Acquisition Costs
Non-Investment Property (details)
Other Assets
Total Non-Investments

-198-

DESCRIPTION	Business Plan	Realization	Deviation
TOTAL ASSETS
LIABILITIES AND EQUITY
Liabilities
Payables
Claim Payables
Other Payables (details)
Accrued Expenses
Technical Provisions
Ujroh Provisions
Investment Principal Guarantee Provisions
Contribution Provisions
Provisions for Contributions Not Yet Revenue
Claim Provisions
Disaster Risk Provisions
Qardh / Subordinated Qardh
Fund Equity
Paid-in Capital
Share Premium
Provisions
Accumulated Funds
Increase (Decrease) in Securities
Difference Between SAK Balance and SAP Balance
Profit Balance
Disallowed Wealth
ASSETS
Investments
Securities held
Deposits and Certificates of Deposit

3. Comprehensive Income/Loss Realization for General Sharia Insurance/Sharia Reinsurance Companies (in millions of rupiah)

DESCRIPTION	Plan	Realization	Deviation
UNDERWRITING REVENUE
Gross Premiums
a. Direct Written Premiums
b. Indirect Written Premiums

-199-

DESCRIPTION	Plan	Realization	Deviation
c. Commissions Paid
Total Gross Premiums
Reinsurance Premiums
a. Reinsurance Premiums Ceded
b. Reinsurance Commission Received
Total Reinsurance Premiums
Net Premiums
Decrease (Increase) in Premium Reserves and CAPYBMP
a. Decrease (Increase) in Premium Reserves
b. Decrease (Increase) in CAPYBMP
Decrease (Increase) in Premium Reserves and CAPYBMP
Total Net Premium Revenue
Other Net Underwriting Revenue
UNDERWRITING REVENUE
UNDERWRITING EXPENSES
Claim Expenses
a. Gross Claims
b. Reinsurance Claims
c. Increase (Decrease) in Claim Reserves
Total Net Claim Expenses
Other Net Underwriting Expenses
TOTAL UNDERWRITING EXPENSES
UNDERWRITING RESULT
Investment Results
Operating Expenses:
a. Marketing Expenses
b. General and Administrative Expenses:
- Employee and Executive Expenses
Education and Training Expenses
- Other General and Administrative Expenses
Total Operating Expenses
INSURANCE OPERATING PROFIT (LOSS)
Other Results (Expenses)
PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL COMPREHENSIVE PROFIT (LOSS)

-200-

4. Comprehensive Income/Loss Realization for Life Sharia Insurance Companies (in millions of rupiah)

DESCRIPTION	Plan	Realization	Deviation
REVENUE
Gross Contribution Revenue
a. Allocation of Direct Contributions for Tabarru, Ujroh, and Investment
b. Allocation of Indirect Contributions for Tabarru, Ujroh, and Investment
Reinsurance Contributions
a. Reinsurance Contributions Ceded
b. Reinsurance Contributions Received
Decrease (Increase) in Contributions Not Yet Revenue
Contribution Revenue
Total Net Contribution Revenue
Investment Results
Other Revenue
TOTAL REVENUE
EXPENSES
Claims and Benefits
Claims and Benefits Paid
Reinsurance Claims
Increase (Decrease) in Ujroh Provisions
Increase (Decrease) in Investment Principal Guarantee Provisions
Increase (Decrease) in Contribution Provisions
Increase (Decrease) in Contribution Provisions Not Yet Revenue
Increase (Decrease) in Claim Provisions
Increase (Decrease) in Disaster Risk Provisions (details pending)
Total Claims and Benefit Expenses
Acquisition Costs
a. First Year Commission Expenses
b. Renewal Year Commission Expenses

-201-

DESCRIPTION	Plan	Realization	Deviation
REVENUE
c. Overriding Commission Expenses
d. Other Commission Expenses
Total Acquisition Costs
Marketing
General and Administrative
Other Results (Expenses)
TOTAL EXPENSES
PROFIT (LOSS) BEFORE ZAKAT
TAXES
PROFIT (LOSS) AFTER TAX

5. Cash Flow Realization for General Sharia Insurance Companies (in millions of rupiah)

DESCRIPTION	Plan	Realization	Deviation
BEGINNING BALANCE
ENDING CASH BALANCE
CASH FLOWS FROM OPERATING ACTIVITIES
Cash Inflows
Participant Contributions
Ujroh Received
Reinsurance Claims Received
Receipt of Underwriting Surplus Distribution from Reinsurance
Others
Cash Outflows
Claims Paid
Ujroh
Marketing Expenses
Payment of Reinsurance Ujroh
Payment of Insurance Ujroh
Reinsurance Contributions Paid
Rent Payments
Zakat Payments
Tax Payments
Others

-202-

DESCRIPTION	Plan	Realization	Deviation
CASH FLOWS FROM INVESTMENT ACTIVITIES
Cash Inflows
Receipt of Investment Results
Receipt of Allocation of Tabarru' Fund Surplus
Receipt of Investment Profit Sharing for Tabarru' Funds
Investment Liquidation
Sale of Land and Buildings
Cash Receipts from Participants
Sale of Fixed Assets
Others
Cash Outflows
Investment Placement
Payments to Participants
Payment of UW Surplus Distribution to Company
Payment of UW Surplus Distribution to Participants/Policyholders
Payment of Investment Profit Sharing
DT to Company/Operator
Payment of ujroh/fee to Company
Purchase of Fixed Assets
Others
CASH FLOWS FROM FINANCING ACTIVITIES
Cash Inflows
Capital Injection/Working Capital
Subordinated Loans
Receipt of Qardh
Qardh
Others
Cash Outflows
Payment of Subordinated Loans
Dividend Payments
Payment of Qardh
Qardh
Others

-203-

6. Cash Flow Realization for Life Sharia Insurance Companies (in millions of rupiah)

DESCRIPTION	Plan	Realization	Deviation
BEGINNING BALANCE
ENDING CASH BALANCE
CASH FLOWS FROM OPERATING ACTIVITIES
Cash Inflows
Participant Contributions
Ujroh Received
Reinsurance Claims Received
Receipt of Underwriting Surplus Distribution from Reinsurance
Others
Cash Outflows
Claims Paid
Commissions
Marketing Expenses
Payment of Reinsurance Ujroh
Payment of Insurance Ujroh
Reinsurance Contributions Paid
Rent Payments
Zakat Payments
Tax Payments
Others
CASH FLOWS FROM INVESTMENT ACTIVITIES
Cash Inflows
Receipt of Investment Results
Receipt of Allocation of Tabarru' Fund Surplus
Receipt of Investment Profit Sharing for Tabarru' Funds
Investment Liquidation
Sale of Land and Buildings
Cash Receipts from Participants
Sale of Fixed Assets
Others
Cash Outflows
Investment Placement

-204-

DESCRIPTION	Plan	Realization	Deviation
Payments to Participants
Payment of UW Surplus Distribution to Company
Payment of UW Surplus Distribution to Participants/Policyholders
Payment of Investment Profit Sharing
DT to Company/Operator
Payment of ujroh/fee to Company
Purchase of Fixed Assets
Others
CASH FLOWS FROM FINANCING ACTIVITIES
Cash Inflows
Capital Injection/Working Capital
Subordinated Loans
Receipt of Qardh
Qardh
Others
Cash Outflows
Payment of Subordinated Loans
Dividend Payments
Payment of Qardh
Qardh
Others

7. Realization of Ratios and Other Specific Items for General Sharia Insurance/Sharia Reinsurance Companies (in millions of rupiah) (ratios in percentage)

DESCRIPTION	Actual	Projection	Deviation
SOLVENCY LEVEL OF ALLOWED ASSETS
Liabilities (excluding Subordinated Loans)
Total Solvency Level (a)
Minimum Risk-Based Capital (MRBC)

-205-

DESCRIPTION	Actual	Projection	Deviation
Total MRBC (b)
Excess (Deficiency) of Solvency Level Limit
Solvency Achievement Ratio (a:b)
FINANCIAL HEALTH RATIOS OTHER THAN MRBC
Liquidity Ratio
a. Current Assets
b. Current Liabilities
c. Ratio (a : b)
Investment Adequacy Ratio
a. Investments + Cash & Bank (See SAP Balance Sheet)
b. Own Retention Technical Reserves
c. Own Retention Claim Payables + Other Payables to Insured
d. Ratio (a : (b + c))
Investment Return vs Net Premium Revenue Ratio
a. Investment Results
b. Net Premium Revenue
c. Ratio (a : b)
Claim Expense, Operating Expense, and Commission Ratio
a. Net Claim Expenses
b. Operating Expenses
c. Net Commissions
d. Net Premium Revenue
e. Ratio a : d (Ratio I)
f. Ratio b : d (Ratio II)
g. Ratio c : d (Ratio III)
h. Ratio I + Ratio II + Ratio III
v. Return on Investment (ROI)
a. Profit (Loss) After Tax
b. Average Investments
c. Ratio a:b
vi. Return on Equity (ROE)
a. Profit (Loss) After Tax
b. Equity
c. Ratio a:b

-206-

8. Realization of Ratios and Other Specific Items for Life Sharia Insurance Companies

DESCRIPTION	Plan	Realization	Deviation
SOLVENCY LEVEL OF ALLOWED ASSETS
Allowed Assets
Liabilities (except Qardh from Company Funds)
Tabarru' Funds and Tanahud Funds Minimum Risk-Based Capital (DTMBR)
Solvency Level Ratio before Available Assets for Qardh
Internal target solvency level ratio (annual) with DTMBR
Solvency level ratio with minimum regulatory required DTMBR
Excess (deficiency) of solvency level from internal target
Insufficiency of investments, cash, and bank
Available Assets for Qardh Counted as Additions to DT Fund AYD
Solvency Level Ratio for Tabarru' Funds and Tanahud Funds
B. FINANCIAL HEALTH RATIOS OTHER THAN MRBC
i. Liquidity Ratio
a. Current Assets
b. Current Liabilities
c. Ratio (a : b)
ii. Investment Adequacy Ratio
a. Investments + Cash & Bank (See SAP Balance Sheet)
b. Own Retention Technical Reserves
c. Own Retention Claim Payables + Other Payables to Insured
d. Ratio (a : (b + c))
iii. Investment Return vs Net Premium Revenue Ratio

-207-

DESCRIPTION	Plan	Realization	Deviation
a. Investment Results
b. Net Premium Revenue
c. Ratio (a : b)
iv. Claim Expense, Operating Expense, and Commission Ratio
a. Net Claim Expenses
b. Operating Expenses
c. Net Commissions
d. Net Premium Revenue
e. Ratio a : d (Ratio I)
f. Ratio b : d (Ratio II)
g. Ratio c : d (Ratio III)
h. Ratio I + Ratio II + Ratio III
v. Return on Investment (ROI)
a. Profit (Loss) After Tax
b. Average Investments
c. Ratio a:b
vi. Return on Equity (ROE)
a. Profit (Loss) After Tax
b. Equity
c. Ratio a:b

9. Non-Financial Realization

No	Description	Target	Realization	Notes
1	Capitalization
2	Investment Results
3	Reinsurance
4	New Products
5	Human Resources
6	Education and Training
7	Office Network
8	Foreign Workers
9	APU & PPT Training Implementation
10	Others

10. Realization of Product Development and Marketing of Insurance Products for Insurance Companies or Realization of Reinsurance Program Development for Reinsurance Companies for the Next 1 (One) Year.

-208-
No
Product Name
New
Business Line/Branch
Insurance
Marketing Channel
Realization of issuance/ implementatio n 1 2 Etc.
11. Report on the Realization of Activities in the Context of Enhancing Financial Literacy
Period: January to December ... (filled with year) … (filled with the name of the financial service business actor) No. Component Plan Description 1 Activity Name … (filled with the name of the activity describing the activity) 2 Activity Objective … (filled with the objective of the activity to be achieved by the FSBA) 3 Implementation Form Financial Education Infrastructure Development -learning Website development Financial Education

-209-
(check one option)
Category
(check one option)
4 Implementation Method and Measurement Method and Tools Implementation Method Direct directly with tools:
… (mention)
Others: …
(mention)
Measurement
Method
Financial
Education
Comparing results before and after activity implementation (pre and post test)  Opinion polls for specific segments regarding:
 benefits,
 ease of understanding material,  suitability with target,  others: … (mention)  Surveys to determine the level of financial literacy individuals/groups specific  Others: … (mention) (can be filled with more than one) Tools for Measurement Electronic media online … (mention)

-210-
Infrastructure
Development
Human Resources (HR)
Comparing results before and after activity implementation (pre and post test) (mention) Non-HR on completion of infrastructure development suitability of infrastructure function development for specific targets (mention) (can be filled with more than one) Implementation Method Indirect, through media … (mention) (mention) Measurement Method Financial Education Comparing results before and after activity implementation (pre and post test) Tools for Measurement electronic online … (mention)

-211- opinion polls for specific segments regarding:
material understood, with target, (mention) determine financial literacy level individuals/groups specific (mention) (can be filled with more than one) Infrastructure Development Human Resources (HR) Comparing results before and after activity implementation (pre and post test) (mention) Non-HR on completion of infrastructure development

-212- suitability of infrastructure function development for specific targets (mention) (can be filled with more than one) Category (check one option) 5 Material a. Financial Management, including:
personal/company financial health (budgeting), including taxation, identification of income and regular/irregular expenses monthly/yearly in the future b. Types of financial service industries and characteristics of products and/or financial services Types of financial service industries:
al

-213-
(mention)
(can be filled with more than one) Characteristics of products and/or financial services, including:
settlement of disputes
c. Taxation
financial services
Category
(check one option)
6 Target mention)

-214-
Pensioners
Social Welfare (PMKS): … (mention) il, and outermost (mention) (mention) (check one option) Category same community; does not apply to General Public Target) (check one option) 7 Number of Participants … people (filled with number of participants) 8 Implementation Schedule : Start … end … (filled with planned date and/or month of implementation) 9 Implementation Area Province Bengkulu

-215- ku
(filled if implemented domestically and can be filled with more than one) Regency/City … (filled if applicable) Other Areas … (filled if applicable) Category (check one option) 10 Frequency of Implementation … times

-216-
11 Cost Source
(mention)
(check one option)
12 Cost Amount (in rupiah)
…
(filled with planned cost amount allocated for each activity) 13 Monitoring Parameters : Financial Education (mention) (can be filled with more than one) Infrastructure Development Human Resources (HR) (mention) Non-HR infrastructure implementation of work framework infrastructure development (mention) (can be filled with more than one) 14 Monitoring Form (referring to monitoring parameters completed with monitoring form) (mention) (can be filled with more than one) 15 Evaluation Parameters Financial Education

-217-
(mention)
(can be filled with more than one) Infrastructure Development Human Resources (HR) submitting teaching materials Non-HR (mention) infrastructure development (mention) (can be filled with more than one) 16 Evaluation Form activity report, implementation documentation, and/or results of participant and/or staff interviews of activity implementers

previous period to know trends and patterns
achievement through comparison between planning and realization of activities between activities in the context of enhancing Financial Literacy with the set targets … (mention) (can be filled with more than one) 17 Measurement Results (systematically will refer to the measurement method used completed with measurement results)

-218-
Financial Education activity implementation (pre and post test) (according to the topic of opinion poll conducted) (mention) individuals/specific groups (according to the group determined) (filled with other measurement results) Infrastructure Development Human Resources (HR) before and after activity implementation (pre and post test) Non-HR suitability of infrastructure function development results (filled with other measurement results) 18 Monitoring Results Monitoring Results (systematically will refer to the monitoring parameter completed with choice adjustment) is fishermen (description)

-219-
… (description)
19 Evaluation Results provide positive benefits for increasing ability to calculate KUR interest. However, still 20% of the public assess that the simulation is less beneficial and 10% among them assess that the brevity of the simulation affects their understanding. needs to be addressed in the future, for example by increasing the number of officers explaining regarding the simulation. (description of measurement results linked to results analysis of opportunities and challenges of activity implementation) Evaluation Results (systematically will refer to the evaluation parameter completed with choice adjustment) large demand for KUR (description) (description) (description) Behavior (mention) (can be filled with more than one) 20 Notes -each party in case FSBA collaborates with other FSBA:

… (party 1 name)
… (description of party 1 role),
… (party 2 name)
… (description of party 2 role), etc.
There are changes in roles in execution collaboration adjusting

-220-
1. … (party 1 name)
… (description of party 1 role),
2. … (party 2 name)
… (description of party 2 role), etc.
Other Information:
Additional information considered necessary to further explain the Financial Literacy activities conducted by the FSBA. ... (description) with resource availability
Table 2
Fulfillment of Financial Literacy Principles No Principle Fulfillment of Principle 1 Planned and Measurable Automatically filled if FSBA fills table 1 numbers 3 – 12 as well as 13 – 14 and/or 15 – 16 2 Achievement-Oriented Automatically filled if FSBA fills table 1 numbers 2, 6, 7, and 11 3 Sustainable Automatically filled if FSBA fills Category "Sustained" in one of table 1 numbers 3, 4, 5, 6, and 9 4 Collaboration Automatically filled if FSBA fills table 1 number 17 with description of cooperation with FSBA and/or other parties.
12. Report on the Realization of Activities in the Context of Enhancing Financial Inclusion
Period: January to December ... (filled with year) … (filled with the name of the financial service business actor) No. Component Plan Description 1 Scope of Activity Financial inclusion (check one option) 2 Name …

-221-
Activity (filled with the name of the activity describing the activity) 3 Implementation Form Access Expansion Addition of office network infrastructure that can support expansion of financial access public: … (mention) and/or financial services: … (mention) special needs: … (mention) kan) Provision of products and/or financial services financial: … (mention) (check one option) Category (check one option) 4 Target

-222-
Indonesia (CTKI)
Social Welfare (PMKS): … (mention) outermost Others: … (mention) (check one option) Category (check one option) 5 User Target ... users (filled with number of users) 6 Schedule Start … end … (filled with date and/or month of implementation) 7 Area Province

-223-
(filled if implemented domestically and can be filled with more than one) Regency/City … (filled if applicable) Other Areas … (filled if applicable) Category (check one option) 8 Parameter Increase in access to institutions, products and/or financial services can support expansion of financial access public

-224- and/or financial services Increase in availability of products and/or financial services financial services available according to public needs and capabilities at various distribution channels Increase in usage of products and/or financial services savings/credit/financing/securities/pension funds venture capital debtors Increase in quality of usage of products and financial services according to public needs and capabilities only using products and/or financial services that are similar, but also using products and/or financial services other measure and analyze products and/or financial services that can drive increase in frequency of utilization of products and/or financial services and in case needed able to utilize complaint/settlement of dispute services that are appropriate with the financial management needs to be achieved

-225-
(can be filled with more than one) 9 Monitoring Form Monitoring Form (referring to monitoring parameters completed with monitoring form) (mention) (can be filled with more than one) conducted in a (referring to monitoring form) (mention) (can be filled with more than one) 10 Evaluation Pay attention to administrative data such as activity reports and implementation documentation

previous period
achievement through comparison of planning and realization of activities between activities in the context of enhancing Financial Inclusion with the set targets (mention) (can be filled with more than one) 11 Monitoring Results and/or Evaluation Monitoring Results (systematically will refer to the parameter completed with monitoring results) Increase in access to institutions, products and/or financial services Before After office network … (filled with number) … (filled with number) cooperation with other parties … (filled with number) … (filled with number) Addition of infrastructure that can support expansion of financial access public … (filled with number) … (filled with number) Addition distribution channels products and/or financial services … (filled with number) … (filled with number) (mention) … (filled with number/ percentage) … (filled with number/ percentage) Increase in availability of products and/or financial services Before After types of products and/or financial services available according to needs and capabilities public at various channels … (filled with number) … (filled with number)

-227- distribution
(mention)
…
(filled with number/ percentage) … (filled with number/ percentage) Increase in usage of products and/or financial services Before After Addition of savings accounts/cr edit/ financing/ securities/pension funds … (filled with number) … (filled with number) Addition number of transactions … (filled with number) … (filled with number) Addition number of insurance policies … (filled with number) … (filled with number) Addition number of guarantee certificates … (filled with number) … (filled with number) Addition number of business partners and/or venture capital debtors … (filled with number) … (filled with number) Addition transactions … (filled with number) … (filled with number)

-228- pawn
(mention)
…
(filled with number)
…
(filled with number)
Increase in quality of usage of products and financial services according to public needs and capabilities Before After number Consumers who do not only use products and/or financial services that are similar, but also use products and/or financial services other … (filled with number) … (filled with number) Increase Consumer capability who can measure and analyze products and/or financial services that can drive increase in frequency of utilization products … (filled with condition) … (filled with condition)

-229- and/or financial services as well as in case needed able to utilize complaint services/ settlement of disputes that are appropriate with the needs financial management that want to be achieved (mention) … (filled with number/ condition) … (filled with number/ condition) Evaluation Results … (description of analysis of monitoring results linked to opportunities and challenges of activity implementation) 12 Notes -each party in case FSBA collaborates with other FSBA:
1. … (party 1 name)
… (description of party 1 role),
2. … (party 2 name)
… (description of party 2 role), etc.
1. … (party 1 name)
… (description of party 1 role),
2. … (party 2 name)
… (description of party 2 role), etc.

-230-
Other Information:
Additional information considered necessary to further explain the Financial Literacy activities conducted by the FSBA. ... (description)
Table 2
Fulfillment of Financial Inclusion Principles No Principle Fulfillment of Principle 1 Measurable Automatically filled if FSBA fills table 1 numbers 5, 8, as well as 9 and/or 10 2 Affordable Automatically filled if FSBA fills table 1 numbers 3 and 8 3 Targeted Automatically filled if FSBA fills table 1 numbers 3, 4, and 5 4 Sustainable Automatically filled if FSBA fills “Category” in table 1 number 3 completely, 4, and 7

-231-
IV. Evidence of certificate or other evidence showing that the Principal Party
has met the sustainability requirements. Evidence of certificate or other evidence showing that the Principal Party has met these sustainability requirements based on POJK 4/POJK.05/2013 Regulations Regarding Assessment of Competence and Fit and Proper Test for Principal Parties of Financial Service Institutions. In the context of reporting, submission of certificates can be uploaded via the SIJINGGA system. FORM SELF ASSESSMENT REPORT ON FULFILLMENT OF SUSTAINABILITY REQUIREMENTS PRINCIPAL PARTIES OF NON-BANK FINANCIAL SERVICE INSTITUTIONS Company Name :
Report Letter Number :
Report Letter Date :
Contact Person (Name,
Tel/email)
: NO DESCRIPTION
LEGAL BASIS
YES
NO
NOTES
1.
Sustainability requirement fulfillment report submitted by the Company Board of Directors to OJK no later than 1 (one) month after annual period ends.
Article 21
POJK
4/POJK.
05/2013
2. Evidence of sustainability requirement fulfillment Additional notes (if needed):
We declare that the entries above are in accordance with the actual documents. If there are differences, corrections will be made. Board of Directors (Company Name) signature (Clear Name) No Name Type of Principal Party *) No. and Date of FPT SK Type of Fulfillment *) Title of Activity Organizer of Activity *) Name of Organizer Date of Implementation Fulfillment Year Proof of Fulfillment *) *) choose one ..... o Director o Commissioner o Actuary ..... o attending seminar, workshop, or activity ..... o financial service regulator inside and ..... ..... ..... o certificate (number and

-232- rise
Company o Internal Auditor o Task Executor Management others of similar nature in the field of financial industry ..... o attending course, training, or education program similar in the field of financial industry ..... o writing papers, articles, or other written works published in the field of financial industry ..... o becoming speaker in seminar, workshop, or activity similar in the field of financial industry, becoming teacher or becoming instructor in course, training, or education program similar in the field of financial industry abroad ..... o association of financial service institutions inside and abroad ..... o university inside and abroad ..... o training institution obtaining license from competent authority date) o attendance proof o other, that is
.....
For the Interest of the Financial Services Authority Note:

Filling method: click twice on the box, then select "Checked"
This Self Assessment Form is prepared based on OJK Regulation No. 4 /POJK.05/2013 Regarding Assessment of Competence and Fit and Proper Test for Principal Parties in Insurance Companies, Pension Funds, Financing Companies, and Guarantee Companies

-233-
V. Report on Insurance Risk Profile Data
This Insurance Risk Profile Data Report is based on POJK 2/POJK.05/2015 Regulations Regarding Maintenance and Reporting of Insurance Risk Data and Application of Premium Rates and Contributions for Property Insurance and Motor Vehicle Insurance Business Lines and SEOJK 28/SEOJK.05/2015 Regarding Reporting of Insurance Risk Data. In the context of reporting, this report has been included in the OJK system with the application name SIPETIR.
VI. Report on Risk Level Assessment Results
This Risk Level Assessment Results Report is based on POJK 10/POJK.05/2014 Regulations Regarding Risk Level Assessment of Non-Bank Financial Service Institutions and SEOJK 3/SEOJK.05/2015 Regarding Risk Level Assessment of Insurance Companies and Reinsurance Companies. In the context of reporting, this report has been included in the OJK system with the application name SIRIBAS.
VII. Report on Follow-up Actions on Risk Level Assessments
This Follow-up Actions on Risk Level Assessments Report is based on POJK 10/POJK.05/2014 Regulations Regarding Risk Level Assessment of Non-Bank Financial Service Institutions POJK No.10/POJK.05/2014 and SEOJK 3/SEOJK.05/2015 Regarding Risk Level Assessment of Insurance Companies and Reinsurance Companies. In the context of reporting, this report has been included in the OJK system with the application name SIRIBAS.

-234-
IV. Reinsurance Placement Report
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX All Insurance Business Lines in millions of rupiah Sum Insured (SI) Premium No Description Total SI Self Retention Automatic Reinsurance Treaty Facultative Reinsurance Self Retention Automatic Reinsurance Treaty Facultative Reinsurance (1) (2) (3) A Self Retention B Reinsurer Support Domestic Foreign per Country 1. 2.
3. ....
C Total
Notes:

Self retention in the sum insured column is sum insured minus part of sum insured reinsured
Self retention in the premium column is gross premium minus reinsurance premium
The Foreign per country description column is filled with the name of the reinsurer referring to the reinsurer's location, not the country of origin of the reinsurer.
Example swiss re singapore filled with singapore, not swiss.

-235-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Insurance Business Line :
Property in millions of rupiah Sum Insured No Description Country Rating Number of Policies Total SI Self Retention Automatic Reinsurance Treaty Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with reinsurer rating from internationally recognized rating agencies. If the reinsurer rating is issued by more than one rating agency, the lowest rating is used.
Column (7) is filled with sum insured minus sum insured reinsured
Column (15) is filled with gross premium minus reinsurance premium
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer

-236-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Insurance Business Line :
Property in millions of rupiah Premium Self Retention Automatic Reinsurance Treaty Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Column (3) is filled with reinsurer rating from internationally recognized rating agencies. If the reinsurer rating is issued by more than one rating agency, the lowest rating is used.
Column (7) is filled with sum insured minus sum insured reinsured
Column (15) is filled with gross premium minus reinsurance premium
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer

-237-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Insurance Business Line :
Motor Vehicles in millions of rupiah Sum Insured No Description Country Rating Number of Policies Total SI Self Retention Automatic Reinsurance Treaty Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with reinsurer rating from internationally recognized rating agencies. If the reinsurer rating is issued by more than one rating agency, the lowest rating is used.
Column (7) is filled with sum insured minus sum insured reinsured
Column (15) is filled with gross premium minus premium
reinsurance
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer

-238-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Insurance Business Line :
Motor Vehicles in millions of rupiah Premium Self Retention Automatic Reinsurance Treaty Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Column (3) is filled with reinsurer rating from internationally recognized rating agencies. If the reinsurer rating is issued by more than one rating agency, the lowest rating is used.
Column (7) is filled with sum insured minus sum insured reinsured
Column (15) is filled with gross premium minus reinsurance premium
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer

-239-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Insurance Business Line :
Transportation in millions of rupiah Sum Insured No Description Country Rating Number of Policies Total SI Self Retention Automatic Reinsurance Treaty Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with reinsurer rating from internationally recognized rating agencies. If the reinsurer rating is issued by more than one rating agency, the lowest rating is used.
Column (7) is filled with sum insured minus sum insured reinsured
Column (15) is filled with gross premium minus premium
reinsurance
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer

-240-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Transportation in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-241-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Hull in millions of rupiah
Sum Insured
No Notes Rating Country
Total
Policies
Total SI
Self-Retention
Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-242-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Hull in millions of rupiah
Premiums
Self-Retention
Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT

-243-
20XX
Line of Business Insurance :
Aircraft Hull in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-244-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Aircraft Hull in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT

-245-
20XX
Line of Business Insurance :
Satellite in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-246-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Satellite in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-247-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Onshore Energy in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-248-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Onshore Energy in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-249-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Offshore Energy in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-250-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Offshore Energy in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-251-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Engineering in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-252-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Engineering in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-253-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Liability in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-254-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Liability in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-255-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Life in millions of rupiah
Sum Insured
No Notes Rating Country
Total
Policies
Total SI
Self-Retention
Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-256-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Life in millions of rupiah
Premiums
Self-Retention
Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-257-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Personal Accident in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-258-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Personal Accident in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-259-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Health in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-260-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Health in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-261-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Credit in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-262-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Credit in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-263-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Suretyship in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-264-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Suretyship in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

-265-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Miscellaneous in millions of rupiah Sum Insured No Notes Rating Country Total Policies Total SI Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A Self-Retention B Reinsurer Support Domestic 1. 2. 3.
4. ......
Foreign
1.
2.
3. ....
C Total
Notes:

Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. In the event that the reinsurer's rating is issued by more than one rating agency, the lowest rating shall be used.
Column (7) is filled with the sum insured minus the sum insured reinsured.
Column (15) is filled with gross premium minus reinsurance premium.
In column (2), after the rows "domestic" and "foreign", the name of the reinsurer is filled in.

-266-
REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX Line of Business Insurance :
Miscellaneous in millions of rupiah Premiums Self-Retention Automatic Treaty Reinsurance Facultative Reinsurance Prop Risk Non Prop Risk Prop Non Prop Quota Share Surpl us Cath X/L Work X/L Quota Share Surpl us (15) (16) (17) (18) (19) (20) (21) (22)

V. Actuarial Report
1. Actuarial Statement
1.1 Company Actuarial Information:

Company Name;
Actuary Name;
Home Address and Telephone Number;
Office Address and Telephone Number;
Date of Appointment;
Place and Date of Birth;
Professional Qualification;
Work Experience (consistent with the field of work duties).
1.2 Description of procedures carried out and compliance with sound practice standards.
1.3 The Company Actuary's responsibility for the annual actuarial report.
I, the undersigned, declare that:
1. All information provided has been made based on professional actuarial judgment and has applied adequate tests;
2. I am fully responsible for this annual actuarial report as a whole; and
3. This report is prepared in accordance with applicable statutory regulations and general actuarial principles.
Place, date of creation
Signed,
Name
No. Indonesia Actuaries Association (PAI) Register Public Actuary License No.:
2. Board of Directors' Statement
We, the undersigned, declare that:
1. The liability determination procedure complies with statutory regulations;
2. The information provided to the Company Actuary in

-268- the annual actuarial report of PT … year … is accurate and complete; and
3. We have understood the contents of this annual actuarial report and will implement the recommendations outlined in this report.
Place, date of creation Position*) Signed, Name *)The Board of Directors authorized according to the Company's internal mechanism
3. Executive Summary
Purpose of the report preparation, scope of the report, summary of changes since the last report, main conclusions (key findings) from the report including the Company's estimated ability to meet future obligations and recommendations given by the Company Actuary to the Board of Directors.
4. Introduction

background and purpose of the report;
scope of the report;
legal basis of the report; and
materiality, reliance, and limitations in the preparation of the report.
Follow-up on Previous Period Recommendations
Recommendations already implemented and recommendations not yet implemented, including any limitations encountered and completion target times.
Data Quality
Data completeness, data reliability, procedures carried out to ensure data completeness and reliability, including methods used and weaknesses in the data.

-269-
7. Company Business Overview
In this section, the actuary provides a description of general Company information consisting of the Company's structure and operations, including:
a. Lines of business or products marketed b. Target market
c. Distribution channels used
8. Financial Health and Capital Adequacy Level
This section must contain at least:
a. Analysis of financial health and capital adequacy b. Projection of financial health and capital adequacy
c. Assumptions used

d. Analysis of the Company's access to capital needs e. Analysis of the Company's risks related to the formation of non-investment assets
9. Premium Pricing and Profitability
This section must contain at least:
a. Premium pricing policy b. Review of pricing policy
c. Analysis of cost realization and profitability
d. Profitability analysis for new and old business e. Profit distribution

-271- f. Historical profitability analysis
10. Liabilities
a. Methods, assumptions, and calculation models used b. Actuary's opinion
11. Asset-Liability Matching
12. Reinsurance
13. Risk Management

-272-
14. Financial Projections
15. Other Areas Requiring Attention
Determined in Jakarta on January 24, 2018 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signature RISWINANDI This copy is consistent with the original Director of Law 1 Law Department signature Yuliana

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 2 /SEOJK.05/2018 ABOUT FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

1 -
FORMAT II A
STRUCTURE OF OTHER PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS This Corporate Plan Report is based on the provisions of Article 68 in POJK 73/POJK.05/2016, with a submission deadline every 5 years, namely October 31 of the previous year. CORPORATE PLAN REPORT SHARIA GENERAL INSURANCE COMPANY / SHARIA REINSURANCE COMPANY / SHARIA LIFE INSURANCE COMPANY / SHARIA UNIT 1
Year ...... 2
(fill in company name and address) 1Write one according to the company's business field. 2The period of the Corporate Plan reported, e.g., year 2015 – 2020 , 20xx Director (Company Stamp) N a m e C l e a r Position
2 -

Executive Summary
The executive summary is the entry point to the Corporate Plan. This paragraph is merely a summary emphasizing the content of the corporate plan submitted.
Evaluation of Previous Corporate Plan Implementation Period
(a) Comparison Between Corporate Plan and Realization of Business Plan Each Year (Ignore if your company is a new company) Detail the current corporate plan and its realization with the business plan each year. In this section, the company can view its performance during that period by comparing the corporate plan with the realization of the business plan. The example table below can be modified in more detail according to the company's needs. Indicator 20XX-1 20XX-2 20XX-3 20XX-4 20XX-5 Corporate Plan Realization % Corporate Plan Realization % Corporate Plan Realization % Corporate Plan Realization % Corporate Plan Realization % (1) (2) ( 2 / 1 ) (1) (2) ( 2 / 1 ) (1) (2) ( 2 / 1 ) (1) (2) ( 2 / 1 ) (1) (2) ( 2 / 1 ) Gross Contribution Profit (Loss) After Tax Achievement Ratio Solvency (%) ( Note:

If the submission of the corporate plan is for the year 2015-2019, then 20XX-1 is 2014, 20XX-2 is 2013, etc.

(b) Obstacles Faced and Problem-Solving Efforts Clearly state the obstacles faced in implementing the established corporate plan and what the solutions are for problem-solving.
3. Current Position of Sharia Insurance Company or Sharia Reinsurance Company
No. Business Line Market Share Rating (%) Notes 1. 2. 3. 4. Other
4. Assumptions Used in Preparing the Corporate Plan
No. Assumption
Projection
Year
1
Year
2
Year
3
Year
4
Year
5
1 Rupiah exchange rate
2 Inflation rate
3 Catastrophic losses (in rupiah) 4 Investment yield rate 5 New coverage amount (in contribution rupiah) 6 Policy lapse rate (policies lapsed / total policies at start of period) 7 Claim rate (gross claims / gross contributions) 8 Other relevant assumptions
5. Objectives, Targets, and Strategies for Achieving the Corporate Plan
(a) Financial Position/Balance Sheet Projection Each Year for Five Years Description Projection (Jan – Dec) 20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* (b) Comprehensive Profit/Loss Projection Each Year for Five Years Description Projection (Jan – Dec) 20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* (c) Cash Flow Projection Each Year for Five Years (1) Cash Flow Projection for General Sharia Insurance Company / Sharia Reinsurance Company Description Projection (Jan – Dec) 20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* BEGINNING BALANCE ENDING CASH BALANCE CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows Contributions from Participants Ujroh received

4 -
Description
Projection (Jan – Dec)
20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* Reinsurance Claims Received Distribution of Underwriting Surplus Reinsurance Others Cash Outflows Claims Paid Ujroh Marketing Expenses Payment of Ujroh Reinsurance Payment of Ujroh Insurance Reinsurance Contributions Paid Rent Payments Zakat Payments Tax Payments Others CASH FLOWS FROM INVESTMENT ACTIVITIES Cash Inflows Investment Yield Receipts Allocation of Tabarru' Fund Surplus Receipts Investment Profit-Sharing Receipts from Tabaru' Funds Investment Liquidation Sale of Land and Buildings Cash Receipts from Participants Sale of Other Fixed Assets Others Cash Outflows Investment Placements Payments to Participants Distribution of UW Surplus Payment to Company Distribution of UW Surplus Payment to Participants/Policyholders Investment DT Profit-Sharing Payment to Company/Operator Payment of ujroh/fee to Company Purchase of Fixed Assets Others
5 -
Description
Projection (Jan – Dec)
20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* CASH FLOWS FROM FINANCING ACTIVITIES Cash Inflows Capital Injection/Capital Working Capital Subordinated Loans Qardh Qardh Receipts Others Cash Outflows Subordinated Loan Repayments Dividend Payments Qardh Qardh Payments Others Cash Inflows Capital Injection/Capital Working Capital Subordinated Loans Qardh Qardh Receipts Others (2) Cash Flow Projection for Sharia Life Insurance Company Description Projection (Jan – Dec) 20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* BEGINNING BALANCE ENDING CASH BALANCE CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows Contributions from Participants Ujroh received Reinsurance Claims Received Distribution of Underwriting Surplus Reinsurance Others Cash Outflows Claims Paid Commission Marketing Expenses Payment of Ujroh Reinsurance
6 -
Description
Projection (Jan – Dec)
20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* Payment of Ujroh Insurance Reinsurance Contributions Paid Rent Payments Zakat Payments Tax Payments Others CASH FLOWS FROM INVESTMENT ACTIVITIES Cash Inflows Investment Yield Receipts Allocation of Tabarru' Fund Surplus Receipts Investment Profit-Sharing Receipts from Tabaru' Funds Investment Liquidation Sale of Land and Buildings Cash Receipts from Participants Sale of Other Fixed Assets Others Cash Outflows Investment Placements Payments to Participants Distribution of UW Surplus Payment to Company Distribution of UW Surplus Payment to Participants/Policyholders Investment DT Profit-Sharing Payment to Company/Operator Payment of ujroh/fee to Company Purchase of Fixed Assets Others CASH FLOWS FROM FINANCING ACTIVITIES Cash Inflows Capital Injection/Capital Working Capital Subordinated Loans Qardh Qardh Receipts Others Cash Outflows Subordinated Loan Repayments
7 -
Description
Projection (Jan – Dec)
20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* Dividend Payments Qardh Qardh Payments Others Notes:

If the submission of the corporate plan is for the year 2015-2019, then 20XX is 2015, 20XX+1 is 2016
etc.
(d) Projection of MMBR Financial Health Ratios and Non-MMBR Financial Health Ratios and Profitability Ratios DESCRIPTION Projection Jan - Dec 20XX* 20XX+1* 20XX+2* 20XX+3* 20XX+4* SOLVENCY LEVEL ALLOWED ASSETS Allowed Assets Liabilities (excluding Subordinated Loans) Total Solvency Level (a) Minimum Risk-Based Capital (MMBR) Total MMBR (b) Excess (Deficiency) Solvency Level Limit Solvency Achievement Ratio (a:b) FINANCIAL HEALTH RATIOS OTHER THAN MMBR Liquidity Ratio a. Current Assets b. Current Liabilities
c. Ratio (a : b)
Investment Adequacy Ratio a. Investments + Cash & Bank (See SAP Balance Sheet) b. Technical Reserves Own Retention
c. Own Retention Claim Liabilities + Other Liabilities to Insured
- d. Ratio (a : (b + c)) - Ratio of Investment Yield to Net Contribution Income a. Investment Yield b. Net Contribution Income
c. Ratio (a : b)
Ratio of Claim Expenses, Operating Expenses, and Commission a. Net Claim Expenses b. Operating Expenses -
c. Net Commission
d. Net Contribution Income e. e. Ratio a : d (ratio I)

8 -
(e) Projection of Other Specific Ratios and Items for Sharia General Insurance Companies (in millions of rupiah) (ratios in percentage) Description Actual Projection JanSept 20XX-1* Jan-Dec 20XX-1* Year 1 JanMar 20XX* JanJun 20XX* JanSep 20XX* JanDec 20XX* Jan-Dec 20XX+1 * Jan-Dec 20XX+2 * SOLVENCY LEVEL ALLOWED ASSETS Allowed Assets Liabilities (excluding Subordinated Loans) Total Solvency Level (a) Minimum Risk-Based Capital (MMBR) Total MMBR (b) Excess (Deficiency) Limit Solvency Level Solvency Achievement Ratio (a:b) FINANCIAL HEALTH RATIOS OTHER THAN MMBR Liquidity Ratio a. Current Assets b. Current Liabilities
c. Ratio (a : b)
Investment Adequacy Ratio a. Investments + Cash & Bank (See SAP Balance Sheet) b. Technical Reserves Own Retention
c. Own Retention Claim
Liabilities +
Other Liabilities to Insured d. Ratio (a : (b + c)) Ratio of Investment Yield to Net Contribution Income f. f. Ratio b : d (ratio II) g. g. Ratio c : d (ratio III) - h. h. Ratio I + Ratio II + Ratio III Return of Investment (ROI) a. Profit (Loss) After Tax b. Average Investments
c. Ratio a:b
vi. Return on Equity (ROE)
a. Profit (Loss) After Tax
- b. Equity
c. Ratio a:b
9 -
Description
Actual Projection
JanSept
20XX-1*
Jan-Dec
20XX-1*
Year 1
JanMar
20XX*
JanJun
20XX*
JanSep
20XX*
JanDec
20XX*
Jan-Dec
20XX+1
*
Jan-Dec
20XX+2
* a. Investment Yield b. Net Contribution Income
c. Ratio (a : b)
Ratio of Claim Expenses,
Operating Expenses, and
Commission
i. Net Claim
Expenses j. Operating Expenses k. Net Commission
l. Net Contribution
Income m. e. Ratio a : d
(ratio I) n. f. Ratio b : d (ratio II) o. g. Ratio c : d (ratio III) p. h. Ratio I + Ratio II + Ratio III Return of Investment (ROI) d. Profit (Loss) After Tax e. Average Investments f. Ratio a:b
vi. Return on Equity
(ROE) d. Profit (Loss)
After Tax e. Equity f. Ratio a:b Notes:
If the submission of the business plan is for the year 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is year 2015 etc. If there are accounts that must be filled from accumulation calculations, e.g., from profit and loss reports, they should be filled with accumulated values. (f) Projection of Other Specific Ratios and Items for Sharia Life Insurance Companies DESCRIPTION Actual Projection Year 1 Jan-Sept Jan-Dec JanMar 20XX JanJun 20XX* JanSep 20XX* JanDec 20XX* Jan-Dec 20XX+1* Jan-Dec 20XX+2* 20XX-1* 20XX-1* SOLVENCY LEVEL ALLOWED ASSETS Liabilities (excluding Subordinated Loans) Total Solvency Level (a) Minimum Risk-Based Capital (MMBR) Total MMBR (b) Excess (Deficiency) Limit Solvency Level Solvency Achievement Ratio
10 -
DESCRIPTION
Actual Projection
Year 1
Jan-Sept Jan-Dec
JanMar
20XX*
JanJun
20XX*
JanSep
20XX*
JanDec
20XX*
Jan-Dec
20XX+1*
Jan-Dec
20XX+2* 20XX-1* 20XX-1*
Solvency (a:b)
FINANCIAL HEALTH RATIOS OTHER THAN MMBR
i. Liquidity Ratio
a. Current Assets b. Current Liabilities
c. Ratio (a : b)
ii. Investment Adequacy
Ratio a. Investments + Cash & Bank (See SAP Balance Sheet) b. Technical Reserves Own Retention
c. Own Retention Claim
Liabilities +
Other Liabilities to Insured d. Ratio (a : (b + c))
iii. Ratio
of Investment Yield to Net Contribution Income a. Investment Yield b. Net Contribution Income
c. Ratio (a : b)
iv. Ratio of Claim
Expenses, Operating
Expenses, and Commission a. Net Claim Expenses b. Operating Expenses
c. Net Commission
d. Net Contribution Income e. Ratio a : d (ratio I) f. Ratio b : d (ratio II) g. Ratio c : d (ratio III) h. Ratio I + Ratio II

Ratio III
v. Return of
Investment (ROI) a. Profit (Loss) After Tax b. Average Investments
c. Ratio a:b
vi. Return on Equity
(ROE) a. Profit (Loss)
After Tax b. Equity
c. Ratio a:b
Notes:
*If the submission of the business plan is for the year 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is year 2015 etc. If there are accounts that must be filled from accumulation calculations, e.g., from profit and loss reports, they should be filled with accumulated values.

11 -
6. Objectives, Targets, Strategies, Policies, and Non-Financial Activity Programs
Example:
Strategic Issue 1:
HR Structure
Targets:
1. Increase productive age to 90.5%.
2. Increase expert personnel from 10% (40 people) to 25% (100 people).
3. Achieve an ideal HR composition structure.
Strategy:
HR Recomposition and Mapping Policy:
HR Recomposition is based on competencies required by the company No Program 20XX 20XX+1 20XX+2 20XX+3 20XX+4 1 Conduct manpower planning 2 Job enrichment 3 Systematic and continuous employee transfers or rotations based on competence and company needs 4 Conduct recruitment according to the competencies required by the company (a) Human Resources (b) Information Technology Strategic Issue:
......
Targets:
1. ......
2. ......
3. ......
Strategy:
......
Policy:
HR Recomposition is based on competencies required by the company No Program 20XX 20XX+1 20XX+2 20XX+3 20XX+4
1 ......
2 ......
3 ......
4 ......
Etc.
Strategic Issue:
......
Targets:
1. ......
2. ......
3. ......
12 -
Notes:

If the submission of the corporate plan is for the year 2015-2019, then 20XX is 2015, 20XX+1 is 2016
etc.
(c) Product Development
Strategic Issue:
......
Targets:
1. ......
2. ......
3. ......
Strategy:
......
Policy:
HR Recomposition is based on competencies required by the company No Program 20XX 20XX+1 20XX+2 20XX+3 20XX+4
1 ......
2 ......
3 ......
4 ......
Etc.
(d) Office Network Development Strategic Issue:
......
Targets:
1. ......
2. ......
3. ......
Strategy:
......
Policy:
HR Recomposition is based on competencies required by the company No Program 20XX 20XX+1 20XX+2 20XX+3 20XX+4
1 ......
2. ......
3 ......
Strategy:
......
Policy:
HR Recomposition is based on competencies required by the company No Program 20XX 20XX+1 20XX+2 20XX+3 20XX+4
1 ......
2 ......
3 ......
4 ......
Etc.

13 -
2 ......
3 ......
4 ......
Etc.
(e) Other Matters Related to Company Activities Additional information must include at least information that needs to be disclosed because it affects business activities not mentioned in the scope of the business plan. Example:
1. Merger, acquisition, and consolidation plans
2. Transfer of coverage portfolio
3. Plans to change insurance business fields
4. Plans to change business activities not based on sharia principles
based on sharia principles.
Strategic Issue:
......
Targets:
1. ......
2. ......
3. ......
Strategy:
......
Policy:
HR Recomposition is based on competencies required by the company No Program 20XX 20XX+1 20XX+2 20XX+3 20XX+4
1 ......
2 ......
3 ......
4 ......
Etc.
14 -
FORMAT II B
Business Plan Report in accordance with the provisions of Article 68 paragraph (4) of POJK Number 73/POJK.05/2016 concerning Good Corporate Governance for Companies, with a submission deadline no later than October 31 of the previous year. BUSINESS PLAN REPORT
Year ......
(fill in company name and address) , 20xx Director (Company Stamp) N a m e C l e a r Position STRUCTURE OF OTHER PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS
15 -
Company Business Plan

Executive Summary
a. Financial Indicators
No. Description
Projection
Millions of Rupiah % Growth 1 Assets 2 Investments 3 Liabilities 4 Technical Provisions 5 Equity 6 Gross Contributions 7 Gross Claims 8 Acquisition Expenses 9 Operating Expenses 10 Underwriting Results 11 Profit (Loss) Before Tax 12 Profit (Loss) After Tax 13 Comprehensive Profit (Loss) b. Financial Ratios No. Description % 1 Solvency Achievement Ratio 2 Investment Adequacy Ratio 3 Liquidity Ratio 4 Claim Expense Ratio 5 Operating Expense Ratio 6 Commission Ratio 7 Ratio of Claim Expenses, Operating Expenses, and Commission 8 Ratio of Investment Yield to Net Premium Income 9 Insurance Business Results Ratio 10 Return on Investment (ROI) 11 Return on Equity (ROE)
c. Non-Financial Executive Summary
The non-financial executive summary contains a summary of information regarding the Company's targets for 1 (one) to 3 (three) years ahead that the Company considers very necessary to include in the executive summary.
Management Policies and Strategies
Completed with targets to be achieved for 1 (one) to 3 (three) years ahead accompanied by policies and strategies to be implemented. No Target Policy Strategy 1. a. 1) 2) Etc. b. 1) 2) Etc.

16 -
No Target Policy Strategy
Etc.
2. a.
1)
2)
Etc. b.
1)
2)
Etc.

Current Company Performance
a. Premium Revenue
No.
Business Line
RKAP
Year n-1
RKAP
Year n
Actual per
30
September
Year n
%
Achievement
% Increase
(Decrease) against
RKAP Year n-1
1 2 3 4 5 6=5/4 7=(4-3)/3 b. Investment Results No. Investment Type Investment Results RKAP Year n-1 RKAP Year n Actual per 30 September Year n % Achievement % Increase (Decrease) against RKAP Year n-1 1 2 3 4 5 6=5/4 7=(4-3)/3
c. Profit
No. Profit
RKAP
Year n-1
RKAP
Year n
Actual per 30
Septemb er Year n
%
Achievement
% Increase
(Decrease) against
RKAP
Year n-1
1 2 3 4 5 6=5/4 7=(4-3)/3
Profit Before Tax
Profit After Tax
Comprehensive Profit (Loss) d. Underwriting Results No. Business Line RKAP Year n-1 RKAP Year n Actual per 30 Sept Year n % Achievement % Increase (Decrease) against RKAP Year n-1 1 2 3 4 5 6=5/4 7=(4-3)/3

17 -

Financial Statement Projections and Assumptions Used
a. Financial Position Projection for Sharia General Insurance Company / Sharia Reinsurance Company (in millions of rupiah) DESCRIPTION Actual per 30 Sept 20XX1* Projection per 31 Dec 20XX-1* Projection Year 1 Projection per 31 Mar 20XX* per 30 Jun 20XX* per 30 Sep 20XX* per 31 Dec 20XX* per 31 Dec 20XX +1* per 31 Dec 20XX +2* ASSETS Investments Securities held Deposits and Certificate of Deposits

Sharia Stocks - - - -
Sharia Sukuk or Bonds

Sharia MTN - - - -
Sharia Government Securities

Sharia Securities issued by Bank Indonesia

Sharia Securities Issued by other than the Republic of Indonesia

Sharia Securities Issued by Multinational Institutions

Sharia Mutual Funds - - - - Sharia Asset-Backed Securities

Sharia Real Estate Investment Funds

REPO - - - -
Financing Through Cooperation with Other Parties

Direct Participation (details)

Investment Properties (details)

Pure Gold - - - -
Other Investments
Total Investments - - - -
Non-Investments -
Cash and Banks - - - -
Receivables (details) - - - - Reinsurance assets - - - - Deferred acquisition costs

Non-Investment Property (details)

Other Assets - - - -
Total Non- investments - - - - TOTAL ASSETS - - - - LIABILITIES AND EQUITY - Liabilities -

18 -
DESCRIPTION
Actual per 30
Sept
20XX1*
Projection per 31
Dec
20XX-1*
Projection
Year 1
Projection per 31
Mar
20XX* per 30
Jun
20XX* per 30
Sep
20XX* per 31
Dec
20XX* per 31
Dec
20XX
+1* per 31
Dec
20XX
+2*
Liabilities -
Claim Liabilities - - - -
Other liabilities (details) - - - - Accrued Expenses

Technical Provisions - - - - Ujroh Provisions - - - - Investment Principal Guarantee Provisions

Contribution Provisions - - - - Provisions for contributions that have not yet become income

Claim Provisions -
Provisions for disaster risks

Qardh/ Qardh
Subordination

Equity Funds - - - -
Paid-in Capital - - - -
Share Premium - - - -
Provisions - - - -
Accumulated Funds - - - -
Increase (Decrease) in Securities

Difference between SAK Balance and SAP Balance

Retained Earnings - - - -
Assets Not Allowed

Notes:
If the submission of the business plan is for the year 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015 etc. If the descriptions below do not have numbers related to SAP, they should be entered manually in the ratio:
   
 b. Financial Position Projection for Life Insurance Companies (in millions of rupiah) DESCRIPTION Actual per 30 Sept 20XX1 Projection per 31 Dec 20XX-1* Projection Year 1 Projection per 31 Mar 20XX* per 30 Jun 20XX* per 30 Sep 20XX* per 31 Dec 20XX* per 31 Dec 20XX +1* per 31 Dec 20XX +2* ASSETS Investments Securities held

Deposits and Certificate of Deposits

Sharia Stocks - - - -
Sharia Sukuk or Bonds

Sharia MTN - - - -
Sharia Securities - - - -

19 -
DESCRIPTION
Actual per 30
Sept
20XX1*
Projection per 31
Dec
20XX-1*
Projection
Year 1
Projection per 31
Mar
20XX* per 30
Jun
20XX* per 30
Sep
20XX* per 31
Dec
20XX* per 31
Dec
20XX
+1* per 31
Dec
20XX
+2*
Government
Sharia Securities issued by Bank Indonesia

Sharia Securities Issued by other than the Republic of Indonesia

Sharia Securities Issued by Multinational Institutions

Sharia Mutual Funds - - - - Sharia Asset-Backed Securities

Sharia Real Estate Investment Funds

REPO - - - -
Financing Through Cooperation with Other Parties

Direct Participation (details)

Investment Properties (details)

Pure Gold - - - -
Other Investments -
Total Investments - - - -
Non-Investments - - - -
Cash and Banks - - - -
Receivables (details) - - - - Reinsurance assets - - - - Deferred acquisition costs

Non-Investment Property (details)

Other Assets - -
Total Non- investments - -
TOTAL ASSETS - - - -
LIABILITIES AND - - - -
EQUITY -
Liabilities -
Liabilities -
Claim Liabilities - - - -
Other liabilities (details) - - - - Accrued Expenses

Technical Provisions - - - - Ujroh Provisions - - - - Investment Principal Guarantee Provisions

Contribution Provisions - - - - Provisions for contributions that have not yet become income

Claim Provisions -
Provisions for disaster risks

20 -
DESCRIPTION
Actual as of Sept 30, 20XX1* Projection as of Dec 31, 20XX-1* Projection Year 1 Projection as of Mar 31, 20XX* Projection as of Jun 30, 20XX* Projection as of Sep 30, 20XX* Projection as of Dec 31, 20XX* Projection as of Dec 31, 20XX +1* Projection as of Dec 31, 20XX +2* Qardh/ Qardh Subordination - - - - Fund Equity - - - - Paid-in Capital - - - - Share Premium - - - - Provisions - - - - Accumulated Fund - - - - Increase (Decrease) in Securities - - - - Difference between SAK Balance and SAP Balance - - - - Balance of Profit - - - - Assets Not Permitted - - - - Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.
If the description below does not exist, it must be entered manually into the ratio     
c. Comprehensive Income/Loss Projection for General Sharia Insurance Companies/Sharia Reinsurance Companies
(in millions of rupiah)
DESCRIPTION
Actual Actual
Projection
Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX*
Jan-Dec
20XX +1*
Jan-31
Dec
20XX+ 2*
20XX1*
20XX1*
INCOME
UNDERWRITING
Gross Contributions
Allocation of Direct Contributions for Tabarru, Ujroh, and Investment Allocation of Indirect Contributions for Tabarru, Ujroh, and Investment Total Contribution Income
c. Ujroh Paid - -
Total Gross Contributions
Reinsurance Contributions a. Reinsurance Contributions Paid b. Reinsurance Ujroh Received

Total Reinsurance Contributions

-
Net Contributions
Decrease (Increase) in Provision for Contributions and PKYBMP
21 -
DESCRIPTION
Actual Actual
Projection
Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX*
Jan-Dec
20XX +1*
Jan-31
Dec
20XX+ 2*
20XX1*
20XX1* a. Decrease (Increase) in Provision for Contributions

b. Decrease (Increase) in PKYBMP

-
Decrease (Increase) in Provision for Contributions and PKYBMP Total Net Contribution Income

Other Net Underwriting Income UNDERWRITING INCOME UNDERWRITING EXPENSES Claim Expenses a. Gross Claims - - b. Reinsurance Claims
c. Increase (Decrease) in Claim Provisions

-
Total Net Claim Expenses

Other Net Underwriting Expenses TOTAL UNDERWRITING EXPENSES UNDERWRITING RESULT Investment Results Operating Expenses:
a. Marketing Expenses b. General and Administrative Expenses:

-
Employee and Management Expenses
Education and Training Expenses
INSURANCE OPERATING PROFIT (LOSS)

Other Income
Other Expenses
PROFIT (LOSS) BEFORE TAX

-
Income Tax - -
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL COMPREHENSIVE PROFIT (LOSS) Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.

22 -
d. Comprehensive Income/Loss Projection for Life Sharia Insurance Companies (in millions of rupiah) DESCRIPTION Actual Projection Year 1 Jan-Sept Jan-Dec Jan-Mar 20XX* Jan-Jun 20XX* Jan-Sep 20XX* Jan-Dec 20XX * Jan-Dec 20XX +1* Jan-Dec 20XX+ 2* 20XX1* 20XX1* INCOME Gross Contribution Income a. Allocation of Direct Contributions for Tabarru, Ujroh, and Investment b. Allocation of Indirect Contributions for Tabarru, Ujroh, and Investment Reinsurance Contributions a. Reinsurance Contributions Paid b. Reinsurance Contributions Received Decrease (Increase) in Contributions Not Yet Recognized as Income Contribution Income Total Net Contribution Income Investment Results Other Income TOTAL INCOME EXPENSES Claims and Benefits Claims and Benefits Paid Reinsurance Claims Increase (Decrease) in Ujroh Provisions Increase (Decrease) in Investment Principal Guarantee Provisions Increase (Decrease) in Contribution Provisions Increase (Decrease) in Provisions for Contributions Not Yet Recognized as Income Increase (Decrease) in Claim Provisions Increase (Decrease) in Disaster Risk Provisions (detail pending) Total Claims and Benefit Expenses Acquisition Costs
23 -
DESCRIPTION
Actual Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX *
Jan-Dec
20XX +1*
Jan-Dec
20XX+ 2*
20XX1*
20XX1*
INCOME a. First Year Commission Expenses b. Subsequent Year Commission Expenses
c. Overriding Commission Expenses
d. Other Commission Expenses Total Acquisition Costs Marketing General and Administrative Other (Income) Expenses TOTAL EXPENSES PROFIT (LOSS) BEFORE ZAKAT TAXES PROFIT (LOSS) AFTER TAX Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.
e. Cash Flow Projection for General Sharia Insurance Companies/Sharia Reinsurance Companies DESCRIPTION Actual Projection Year 1 Jan-Sept Jan-Dec Jan-Mar 20XX* Jan-Jun 20XX* Jan-Sep 20XX* Jan-Dec 20XX * Jan-Dec 20XX +1* Jan-Dec 20XX+ 2* 20XX1* 20XX1* BEGINNING BALANCE ENDING CASH BALANCE CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows Contributions from Participants Ujroh Received Reinsurance Claims Received Distribution of Underwriting Surplus Reinsurance Others - Cash Outflows Claims Paid Ujroh Marketing Expenses Payment of Reinsurance Ujroh Payment of Insurance Ujroh Reinsurance Contributions Paid - Rent Payments Zakat Payments Tax Payments Others

24 -
CASH FLOWS FROM
INVESTMENT ACTIVITIES
Cash Inflows -
Investment Returns Received Allocation of Tabarru' Fund Surplus Received Investment Profit Sharing from Tabarru' Funds Received Investment Liquidation Sale of Land and Buildings - Cash Receipts from Participants - Sale of Other Fixed Assets Others Cash Outflows Investment Placements Payments to Participants - Distribution of UW Surplus Payment to Company Distribution of UW Surplus Payment to Participants/Policyholders Investment Profit Sharing Payment DT to Company/Operator Payment of ujroh/fee to Company Purchase of Fixed Assets - Others - CASH FLOWS FROM FINANCING ACTIVITIES - Cash Inflows Capital/Capital Work Deposits Subordinated Loans Qardh Receipts Qardh Others Cash Outflows Subordinated Loan Repayments Dividend Payments Qardh Payments Qardh Others Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.

25 -
f. Cash Flow Projection for Life Sharia Insurance Companies DESCRIPTION Actual Projection Year 1 Jan-Sept Jan-Dec Jan-Mar 20XX* Jan-Jun 20XX* Jan-Sep 20XX* Jan-Dec 20XX * Jan-Dec 20XX +1* Jan-Dec 20XX+ 2* 20XX1* 20XX1* BEGINNING BALANCE ENDING CASH BALANCE CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows Contributions from Participants Ujroh Received Reinsurance Claims Received Distribution of Underwriting Surplus Reinsurance Others Cash Outflows Claims Paid Commissions Marketing Expenses Payment of Reinsurance Ujroh Payment of Insurance Ujroh - Reinsurance Contributions Paid - Rent Payments Zakat Payments Tax Payments Others CASH FLOWS FROM INVESTMENT ACTIVITIES Cash Inflows Investment Returns Received - Allocation of Tabarru' Fund Surplus Received Investment Profit Sharing from Tabarru' Funds Received Investment Liquidation Sale of Land and Buildings Cash Receipts from Participants - Sale of Fixed Assets - Others Cash Outflows Investment Placements Payments to Participants Distribution of UW Surplus Payment to Company - Distribution of UW Surplus Payment to Participants/Policyholders Investment Profit Sharing Payment
26 -
DESCRIPTION
Actual Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX *
Jan-Dec
20XX +1*
Jan-Dec
20XX+ 2*
20XX1*
20XX1*
Investment DT to Company/Operator Payment of ujroh/fee to Company Purchase of Fixed Assets Others - - CASH FLOWS FROM FINANCING ACTIVITIES - Cash Inflows Capital/Capital Work Deposits Subordinated Loans Qardh Receipts Qardh Others Cash Outflows Subordinated Loan Repayments Dividend Payments Qardh Payments Qardh Others Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.
g. Ratio and Other Specific Items Projection for General Sharia Insurance Companies/Sharia Reinsurance Companies (in millions of rupiah) (ratios in percentage) DESCRIPTION Actual Projection Year 1 Jan-Sept Jan-Dec Jan-Mar 20XX* Jan-Jun 20XX* Jan-Sep 20XX* Jan-Dec 20XX * Jan-Dec 20XX +1* Jan-Dec 20XX+ 2* 20XX1* 20XX1* SOLVENCY LEVEL PERMITTED ASSETS Permitted Assets Liabilities (excluding Qardh from Company Funds) Tabarru' Fund and Tanahud Minimum Risk-Based Fund (DTMBR) Solvency Level Ratio before Assets Available for Qardh Internal Solvency Target Ratio (annual) with DTMBR

27 -
DESCRIPTION
Actual Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX *
Jan-Dec
20XX +1*
Jan-Dec
20XX+ 2*
20XX1*
20XX1*
Solvency Level Ratio with
Minimum DTMBR required by regulations Excess (shortage) of solvency level from internal target Insufficiency of investments, cash and bank Assets Available For Qardh which are Considered as Additions to PAA Tabarru' Fund Tabarru' Fund and Tanahud Solvency Level Ratio B. FINANCIAL HEALTH RATIOS EXCLUDING MMBR
i. Liquidity Ratio
a. Current Assets b. Current Liabilities
c. Ratio (a : b)
ii. Investment Sufficiency Ratio
a. Investments + Cash & Bank (See SAP Balance Sheet) b. Technical Reserves Own Retention
c. Own Retention Claim Payables + Other Payables to Insured
d. Ratio (a : (b + c))
iii. Ratio of Investment Results to Net Premium Income
a. Investment Results b. Net Premium Income
c. Ratio (a : b)
iv. Ratio of Claim Expenses, Operating Expenses, and Commissions
a. Net Claim Expenses b. Operating Expenses
c. Net Commissions
d. Net Premium Income e. Ratio a : d (ratio I) f. Ratio b : d (ratio II) g. Ratio c : d (ratio III) h. Ratio I + Ratio II + Ratio III
v. Return on Investment
28 -
DESCRIPTION
Actual Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX *
Jan-Dec
20XX +1*
Jan-Dec
20XX+ 2*
20XX1*
20XX1*
(ROI) a. Profit (Loss) After Tax b. Average Investments
c. Ratio a:b
vi. Return on Equity
(ROE) a. Profit (Loss) After Tax b. Equity
c. Ratio a:b
Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.
If there are accounts that must be filled from accumulation calculations, e.g., from the income statement, they must be filled with the accumulated value. h. Ratio and Other Specific Items Projection for Life Sharia Insurance Companies DESCRIPTION Actual Projection Year 1 Jan-Sept Jan-Dec Jan-Mar 20XX* Jan-Jun 20XX* Jan-Sep 20XX* Jan-Dec 20XX * Jan-Dec 20XX +1* Jan-Dec 20XX+ 2* 20XX1* 20XX1* SOLVENCY LEVEL PERMITTED ASSETS Permitted Assets Liabilities (excluding Qardh from Company Funds) Tabarru' Fund and Tanahud Minimum Risk-Based Fund (DTMBR) Solvency Level Ratio before Assets Available for Qardh Internal Solvency Target Ratio (annual) with DTMBR Solvency Level Ratio with Minimum DTMBR required by regulations Excess (shortage) of solvency level from internal target Insufficiency of investments, cash and bank Assets Available For Qardh which are Considered as Additions to

29 -
DESCRIPTION
Actual Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20XX*
Jan-Jun
20XX*
Jan-Sep
20XX*
Jan-Dec
20XX *
Jan-Dec
20XX +1*
Jan-Dec
20XX+ 2*
20XX1*
20XX1*
PAA Tabarru' Fund
Tabarru' Fund and Tanahud
Solvency Level Ratio
B. FINANCIAL HEALTH RATIOS
EXCLUDING MMBR
i. Liquidity Ratio
a. Current Assets b. Current Liabilities
c. Ratio (a : b)
ii. Investment Sufficiency Ratio
a. Investments + Cash & Bank (See SAP Balance Sheet) b. Technical Reserves Own Retention
c. Own Retention Claim Payables + Other Payables to Insured
d. Ratio (a : (b + c))
iii. Ratio of Investment Results to Net Premium Income
a. Investment Results b. Net Premium Income
c. Ratio (a : b)
iv. Ratio of Claim Expenses, Operating Expenses, and Commissions
a. Net Claim Expenses b. Operating Expenses
c. Net Commissions
d. Net Premium Income e. Ratio a : d (ratio I) f. Ratio b : d (ratio II) g. Ratio c : d (ratio III) h. Ratio I + Ratio II + Ratio III
v. Return on Investment
(ROI) a. Profit (Loss) After Tax b. Average Investments
c. Ratio a:b
vi. Return on Equity
(ROE) a. Profit (Loss) After Tax b. Equity
c. Ratio a:b
30 -
Note:

If the business plan submission is for the years 2015 - 2017, then 20XX-1 is the year 2014 (current year), 20XX is the year 2015, etc.
If there are accounts that must be filled from accumulation calculations, e.g., from the income statement, they must be filled with the accumulated value.
i. Assumptions Used

Insurance Company Plan
a. 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 other capital addition plans. Companies may use the table format below if they do not have a standard format. The example table below applies to general Sharia insurance companies/life Sharia insurance companies/sharia reinsurance companies, and can be modified according to needs. DESCRIPTION Actual Projection Year 1 As of Sept 30 As of Dec 31 As of Mar 31 20XX As of Jun 30 20XX As of Sep 30, 20XX* As of Dec 31 20XX As of Dec 31 20XX +1 As of Dec 31 20XX +2 20XX-1 20XX-1 CAPITAL POSITION Shareholders (filled with nominal)
------
------
No. DESCRIPTION
Actual
Projection
Projection
Projection
Year 1
Jan-Sept
Jan-Dec
Jan-Mar
20X
X 2
Jan-Jun
20X
X 2
Jan-Sep
20X
X 2
Jan-Dec
20X
X 2
Jan-Dec
20XX +1 3
Jan-Dec
20XX +2 3
20XX1 1
20X
X-1 Rupiah exchange rate
2 Inflation rate
3 Catastrophic losses (in rupiah) 4 Investment return rate 5 Amount of new coverage (in premium rupiah) 6 Policy lapse rate (policies lapsed/number of policies at start of period) 7 Claim rate (gross claims/gross premiums) 8 etc. (other relevant assumptions)

31 -

------
------
Total Paid-in Capital
IPO (Initial Public Offering) - Go Public Issuance of new shares Others (such as subordinated loans) Note:

If the business plan submission is for the years 2015 - 2017, then 20XX1 is the year 2014 (current year), 20XX is the year 2015, etc.
b. Investment Composition Plan
1) Investment Composition
No.
Type of investment
Actual Projection
Year 1
As of Sept 30
As of Dec 31
As of Mar 31
20xx
As of Jun 30
20xx
As of Sep 30, 20xx*
As of Dec 31
20xx
As of Dec 31
20xx+1
As of Dec 31
20xx-1 20xx-1 20xx+2
1
2
Etc.
2) Investment Results
No.
Type of investment
Actual Projection
Year 1
As of Sept 30
As of Dec 31
As of Mar 31
20xx
As of Jun 30
20xx
As of Sep 30, 20xx*
As of Dec 31
20xx
As of Dec 31
20xx+1
As of Dec 31
20xx-1 20xx-1 20xx+2
1
2
Etc. a) Product Development and Marketing Plan for Sharia Insurance Companies or Reinsurance Coverage Program Development Plan for Reinsurance Companies for the Next 1 (One) Year. No New Product Name Line of Business/Branch Insurance Marketing Channel Plan for issuance/implementation 1 2 Etc. b) Organizational and Human Resources Development Plan
1) HR Quantity Requirement Plan
No
Level
Position
HR Quantity as of Sept 30
20XX-1
Recruitment To Be Implemented Quarter IV 20XX-1 Quarter I 20XX Quarter II 20XX Quarter III 20XX Quarter IV 20XX Addition Reduction Addition Reduction Addition Reduction Addition Reduction Addition Reduction 1 2 Etc

32 -
Total

Human Resources Education and Training Implementation Plan for Directors, Board of Commissioners, and Employees
No Material/Topic Participants Training Time 1 2 Etc c) Office Network Development and/or Change Plan The office network development and/or change plan must at least include plans for opening and merging offices outside the head office. No Type of Office Implementation Time 1 Location 2 Description 3 A. Opening 1 Offices having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims 2 Offices not having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims B. Status Change 1 Offices having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims 2 Offices not having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims
C. Merging
1 Offices having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims a. Between offices having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims

33 -
No Type of Office Implementation Time 1 Location 2 Description 3 b. Between offices not having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims etc. D. Address Relocation 1 2 Etc E. Office Closure 1 2 Etc Note:
1Filled with the month of the planned implementation time. 2For locations within the DKI Jakarta region, at least mention the name of the DKI Jakarta province. For locations outside the DKI Jakarta region, at least mention the name of the Regency/Municipality. 3 - Detailed descriptions can be attached in a separate sheet
Specifically for offices having the authority to accept or reject insurance closures, sign policies, determine to pay or reject claims, inform the experts who will fill those positions.
d) Report on Activity Plans to Enhance Financial Literacy for Consumers and/or the Community ACTIVITY PLAN REPORT TO ENHANCE FINANCIAL LITERACY PERIOD: January to December ... (filled with year) … (filled with name of financial service business actor) No. Plan Component 1 Activity Name … (filled with activity name describing activities in the event) 2 Activity Objective … (filled with activity objective to be achieved by the FSBA) 3 Implementation Form Financial Education Infrastructure Development trainers
34 -
-learning
Finance
(check one option)
Category million
(check one option)
4 Implementation Method and Measurement Methods Implementation Method Directly directly with facilities:
… (mention)
Others: …
(mention)
Measurement Method
Financial Education before and after activity implementation (pre and post test) Polling for specific segments regarding:
benefits, ease of understanding material, suitability with targets, others: … (mention) Survey to determine individual/group financial literacy levels Others: … (mention) (can be filled with more than one) Infrastructure Development HR before and after activity implementation (pre and post test) Non-HRM completion of infrastructure development infrastructure function development for specific targets (mention) (can be filled with more than one) Facilities Measurement Electronic media (mention)
35 -
one)
Implementation Method
Indirectly, through media
…
(mention)
(mention)
Measurement Method
Financial Education before and after activity implementation (pre and post test) specific segment regarding:
understood, targets,
(mention) determine financial literacy levels individual/group specific (mention) (can be filled with more than one) Infrastructure Development HR before and after activity implementation (pre and post test) Non-HRM completion of infrastructure development infrastructure function development for specific targets (mention) (can be filled with more than one) Facilities Measurement electronic (mention) Category (check one option) 5 Material a. Financial Management, including:
36 -
including taxation, identification of regular/non-regular monthly/yearly income and expenses next b. Types of financial service industries and characteristics of products and/or financial service offerings Type of financial service industry:
(mention)
(can be filled with more than one) Characteristics of products and/or financial service offerings, including:
settlement disputes
c. Taxation
Category
(check one option)
6 Target uh
37 -
mention)
Social (PMKS): … (mention)
(mention)
(mention)
(check one option)
Category
New same; does not apply to General Community Targets) (check one option) 7 Number of Participants … people (filled with number of participants) 8 Implementation Schedule : Start … end … (filled with planned date and/or month of implementation) 9 Implementation Area Province
38 -
(filled if implemented domestically and can be filled with more than one) Regency/City … (filled if applicable) Other Areas … (filled if applicable) Category (check one option) 10 Frequency of Implementation … times 11 Cost Source (mention) (check one option) 12 Cost Amount (in rupiah) … (filled with planned cost amount allocated for each activity) 13 Monitoring Parameters : Financial Education Material suitability (mention) (can be filled with more than one) Infrastructure Development HR lah participants
39 -
(mention)
Non-HRM infrastructure development (mention) (can be filled with more than one) 14 Monitoring Form (referring to monitoring parameters completed with monitoring form) (mention) (can be filled with more than one) 15 Evaluation Parameters Financial Education (mention) (can be filled with more than one) Infrastructure Development HR Non-HRM target infrastructure development (mention) (can be filled with more than one) 16 Evaluation Form documentation of implementation, and/or participant/staff interview results -period previous to know trends and patterns comparison between planning and realization of activities suitability between activities to enhance Financial Literacy with determined targets … (mention) (can be filled with more than one) 17 Notes -each party in case the FSBA collaborates with another FSBA:

… (party 1 name)
… (description of party 1 role),

40 -
2. … (party 2 name)
… (description of party 2 role), etc.
1. … (party 1 name)
… (description of party 1 role),
2. … (party 2 name)
… (description of party 2 role), etc.
Other information:
Additional information considered necessary to further explain the Financial Literacy activities conducted by the FSBA. ... (description)
Table 2
Fulfillment of Financial Literacy Principles No Principle Principle Fulfillment 1 Planned and Measurable Automatically filled if FSBA fills Table 1 numbers 3 – 12 as well as 13 – 14 and/or 15 – 16 2 Achievement-Oriented Automatically filled if FSBA fills Table 1 numbers 2, 6, 7, and 11 3 Sustainable Automatically filled if FSBA fills Category “Continuous” in one of Table 1 numbers 3, 4, 5, 6, and 9 4 Collaboration Automatically filled if FSBA fills Table 1 number 17 with description of cooperation with FSBA and/or other parties. e) Report on Activity Plans to Enhance Financial Inclusion for Consumers and/or the Community ACTIVITY PLAN REPORT TO ENHANCE FINANCIAL INCLUSION PERIOD: January to December ... (filled with year) … (filled with name of financial service business actor) No. Plan Component Description 1 Scope Financial activities (check one option) 2 Activity Name … (filled with activity name describing activities in the event) 3 Implementation Form Access Expansion Adding office networks
41 -
supporting the expansion of financial access for the public: … (state) and/or financial services: … (state) for persons with special needs: … (state) Provision of products and/or financial services:
(put a mark on one choice)
Category
(put a mark on one choice)
4 Objectives
MSMEs
Social Welfare (PMKS): … (state) outermost regions (put a mark on one choice) Category (put a mark on one choice)
42 -
5 Target
Users
... users
(filled with the number of users) 6 Schedule Started … Completed … (filled with the date and/or month of implementation) 7 Region Province (filled if implemented domestically and can be filled with more than one) Regency/City … (filled if applicable) Other Regions … (filled if applicable) Category (put a mark on one choice) 8 Parameters Increasing access to institutions, products
43 -
and/or financial services supporting the expansion of financial access for the public and/or financial services Increased availability of products and/or financial services financial services available according to the needs and abilities of the public in various distribution channels Increased usage of products and/or financial services savings/credit/financing/shares/pension funds guarantee certificates debtor venture capital Increased quality of usage of products and financial services according to the needs and abilities of the public not only using similar products and/or financial services, but also using other products and/or financial services measuring and analyzing products and/or financial services that can drive increased frequency of utilization of products and/or financial services and when needed, able to utilize complaint/complaint resolution services that are appropriate according to the financial management goals to be achieved (can be filled with more than one) 9 Monitoring Form Monitoring Form (referring to monitoring parameters completed with monitoring forms)
44 -
(state)
(can be filled with more than one) carried out (referring to monitoring forms) (state) (can be filled with more than one) 10 Evaluation Pay attention to administrative data such as activity reports and documentation of implementation - previous period achievement through comparison of planning and realization of activities between activities aimed at increasing Financial Inclusion with the targets set (state) (can be filled with more than one) 12 Notes -each party regarding PUJK collaborating with other PUJKs:
1. … (name of party 1)
… (description of party 1's role),
2. … (name of party 2)
… (description of party 2's role), etc.
1. … (name of party 1)
… (description of party 1's role),
2. … (name of party 2)
… (description of party 2's role), etc.
Other Information:
Additional information considered necessary to further explain the Financial Literacy activities conducted by PUJK. ... (description)
Table 2
Fulfillment of Financial Inclusion Principles No Principle Fulfillment of Principle 1 Measurable Automatically filled if PUJK fills Table 1 numbers 5, 8, and 9 and/or 10 2 Affordable Automatically filled if PUJK fills Table 1 numbers 3 and 8
45 -
3 Targeted Automatically filled if PUJK fills Table 1 numbers 3, 4, and 5 4 Sustainable Automatically filled if PUJK fills “Category” in Table 1 number 3 completely, 4, and 7 a) IT System Development Plan Detail the plan for the use of information technology used by the company to support business activities. No Type/Name Application Ownership (In-house/vendor) Vendor Name Application Function b) Foreign Manpower Transfer Program Plan No Name of TKA Subject/Topic Number of Participants Training Time c) Other Information Other information must at least include information that needs to be conveyed because it affects the company's business activities, which is not mentioned in the scope of the Business Plan. Example:

merger, acquisition, and consolidation plans;
portfolio transfer plans;
plans to change the insurance business field;
plans to change business activities from non-Sharia principles to Sharia principles.

46 -
FORMAT II C
This Automatic Reinsurance Program Report is based on Article 31 in POJK 14/POJK.05/2015 and SEOJK 31/2015, with a submission deadline of January 15 or 15 (fifteen) days since the date the automatic reinsurance/support/retrospective agreement becomes effective. AUTOMATIC REINSURANCE PROGRAM REPORT (filled with name and address of the company) , 20xx Director (Company Stamp) Full Name Position FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS
47 -
(1) All Lines of Life Insurance and Annuity Business. Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
B. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
a. …… b. ……
c. …… etc.
(2) Line of Insurance Business: Term Insurance Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
C. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
a. ……
48 -
b. ……
(3) Line of Insurance Business: Non-Term Death Insurance Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
D. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
a. …… b. ……
c. …… etc.
(4) Line of Insurance Business: Endowment Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
E. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
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a. …… b. ……
c. …… etc.
(5) Line of Insurance Business: Combined Endowment Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
F. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
a. …… b. ……
c. …… etc.
(6) Line of Insurance Business: Combined Whole Life Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
G. Foreign
1. ASEAN
a. ……
50 -
b. ……

NON ASEAN
a. …… b. ……
c. …… etc.
(7) Line of Insurance Business: General Annuity Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
H. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
a. …… b. ……
c. …… etc.
(8) Line of Insurance Business: Pension Fund Annuity Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
I. Foreign
1. ASEAN

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a. …… b. ……
c. …… etc.

NON ASEAN
a. …… b. ……
c. …… etc.
(9) Line of Insurance Business: Non-Traditional Company Name No. Description Reinsurance Form Yearly Renewable Term (YRT) Modified Co-insurance Co-insurance (1) (2) (3) (4) (5) I II Self Retention Reinsurer Support A. Domestic
1. ……
2. …… etc.
J. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
2. NON ASEAN
a. …… b. ……
c. …… etc.
(10) Line of Insurance Business: Health Company Name No. Description S.I (b) S.II …… (1) (2) (3) (4) (5) (6) I I Self Retention (d) Reinsurer Support A. Domestic
1. …… (Rp / %)
2. …… etc.
(e)

52 -
I
B. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
(Rp / %) (e)
2. NON ASEAN
a. …… b. ……
c. …… etc.
(Rp / %) (e)
(11) Line of Insurance Business: Personal Accident Company Name No. Description S.I (b) S.II …… (1) (2) (3) (4) (5) (6) I Self Retention (d) Reinsurer Support A. Domestic
1. …… (Rp / %)
2. …… etc.
(e)
B. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
(Rp / %) (e)
2. NON ASEAN
a. …… b. ……
c. …… etc.
(Rp / %) (e)
(12) Line of Insurance Business: Personal Accident. Company Name No. Description S.I (b) S.II …… (1) (2) (3) (4) (5) (6) I I Self Retention (d) Reinsurer Support A. Domestic
1. …… (Rp / %)
2. …… etc.
(e)
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I
B. Foreign
1. ASEAN
a. …… b. ……
c. …… etc.
(Rp / %) (e)
2. NON ASEAN
a. …… b. ……
c. …… etc.
(Rp / %) (e)
Notes
(a). Q.S. = Quota Share Treaty Reinsurance. (b). S = Surplus Treaty Reinsurance. (c). Filled according to needs. (d). Self Retention = includes X/L reinsurance support if any. (e). Strike out what is not needed. (13) Line of Insurance Business: Personal Accident. Company Name No. Description X/L 1 (a) X/L 2 …… (b) (1) (2) (3) (4) (5) I II Retention (c) Reinsurer Support A. Domestic
1. …… (Rp / %)
(d)
2. …… etc.
B. Foreign
1. ASEAN
a. …… (Rp / %)
(d) b. ……
c. …… etc.
2. NON ASEAN
a. …… (Rp / %)
(d) b. ……
c. …… etc.
Notes :
(a). X/L = Excess of Loss Treaty Reinsurance. (b). Filled according to needs. (c). R.S. = Does not include X/L reinsurance support. (d). Strike out what is not needed. (14) Line of Insurance Business: Health. Company Name No. Description X/L 1 (a) X/L 2 …… (1) (2) (3) (4) (5)
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No. Description X/L 1 (a) X/L 2 …… (1) (2) (3) (4) (5) I II Retention (c) Reinsurer Support A. Domestic
1. …… (Rp / %)
(d)
2. …… etc.
B. Foreign
1. ASEAN
a. …… (Rp / %)
(d) b. ……
c. …… etc.
2. NON ASEAN
a. …… (Rp / %)
(d) b. ……
c. …… etc.
Notes :
(a). X/L = Excess of Loss Treaty Reinsurance. (b). Filled according to needs. (c). R.S. = Does not include X/L reinsurance support. (d). Strike out what is not needed.
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FORMAT II D
CONSUMER COMPLAINT REPORT AND FOLLOW-UP ON SERVICES AND CONSUMER COMPLAINT RESOLUTION This Consumer Complaint Report and Follow-up on Services and Consumer Complaint Resolution is based on Article 34 of POJK 1/POJK.07/2013 and SE OJK 2/SE.OJK.07/2014, with a submission deadline on the 10th (ten) of every January, April, July, and October. This report has been included in the OJK system under the application name SIPEDULI.
Part I : Product Type and/or Service and Issues Complained About
No.
Product Type and/or
Service
Category
Issue
Quantity
Resolution Status
Completed
Not
Completed
In Progress
(a) (b) (c) (d) (e)
1
2
3
Part II: Complaints Resolved During the Reporting Period
No. Description
Quantity
≤ 20 Days
20 Days < X ≤
40 Days

40 Days
1
Complaints Received in
Previous Reporting Period
1. Has been resolved
2. Still in process of resolution
SUB TOTAL
2
Complaints Received in
Reporting Period
1. Has been resolved
2. Still in process of resolution
SUB TOTAL
TOTAL
Part III: Causes of Complaints
No. Description Quantity
1 Consumer's understanding of product characteristics 2 Insufficient product information 3 Device/system interference/damage and information technology systems 4 Consumer's understanding of product characteristics 5 Change/termination of contract/agreement 6 Consumer negligence 7 Financial Business Actor negligence 8 Criminal acts by Financial Business Actors 9 Others (state)…… TOTAL FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

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Part IV: Negative Publications
No. Description Quantity
1
Consumer Complaints in Print/Electronic Mass Media 2 Print/Electronic media articles 3 Print/Electronic media coverage 4 Publications/writings in public places 5 Social Media, Electronic Mail 6 Others (state)…… TOTAL
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FORMAT II E
Self Assessment Report on the Implementation of Integrated Governance for Financial Conglomerates is based on Article 46 in POJK 18/POJK.03/2014 with a submission deadline on May 30 every year. SELF ASSESSMENT REPORT ON THE IMPLEMENTATION OF INTEGRATED GOVERNANCE FOR FINANCIAL CONGLOMERATES Year …… (filled with name and address of the company) , 20xx Director (Company Stamp) Full Name Position FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS
58 -
Main Entity :………………
Report Position :………………
Self Assessment Results
Implementation of Integrated Governance Rank Definition of Rank ……………… (filled with Rank 1, 2, 3, 4 or 5) ……………… (filled with Rank Definition according to the rank value) Analysis ……………… (Contains an explanation regarding conclusions on the comprehensive and structured assessment of the implementation of Integrated Governance, covering structure, process, and results of Integrated Governance. In this explanation, identification of issues in the form of strengths and weaknesses of Integrated Governance implementation, their root causes, and improvement measures taken and to be taken is explained)
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FORMAT II F
Integrated Governance Report for Financial Conglomerates is based on
Article 45 in POJK 18/POJK.03/2014 with a submission deadline
each on August 15 and February 15.
ANNUAL REPORT ON THE IMPLEMENTATION OF INTEGRATED GOVERNANCE Year …… (filled with name and address of the company) , 20xx Director (Company Stamp) Full Name Position FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS FOR FINANCIAL CONGLOMERATES
60 -
Objective :
1. To obtain an overview of the implementation of Integrated Governance in
Financial Conglomerates; and
2. To identify strengths and weaknesses in the implementation of Integrated
Governance so that the Main Entity can formulate an action plan for improvement according to its problems. No. Indicator Analysis
1. Board of Directors of the Main Entity
a. Structure of Integrated Governance
1) The Board of Directors of the Main Entity has
met integrity, competence, and financial reputation requirements and has obtained approval from the Financial Services Authority.
2) The Board of Directors of the Main Entity has
knowledge regarding the Main Entity, including understanding of main business activities and main risks of LJK in the Financial Conglomerate. b. Process of Integrated Governance
1) The Board of Directors of the Main Entity submits
the Integrated Governance Guidelines to the Board of Directors of LJK in the Financial Conglomerate.
2) The Board of Directors of the Main Entity directs,
monitors, and evaluates the implementation of the Integrated Governance Guidelines.
3) The Board of Directors of the Main Entity
follows up directives or advice from the Board of Commissioners of the Main Entity in order to refine the Integrated Governance Guidelines.
4) The Board of Directors of the Main Entity
follows up findings from the Integrated Internal Audit Work Unit and the Integrated Compliance Work Unit.
c. Results of Integrated Governance
1) The Integrated Governance Guidelines have been
refined according to directives from the Board of Commissioners.
2) The Board of Directors of the Main Entity has ensured
that audit findings and recommendations from:
(a) Integrated Internal Audit Work Unit; (b) external auditors; (c) OJK supervision results; (d) supervision results from other authorities such as Bank Indonesia; and/or (e) supervision results from supervisory authorities against the Head Office of LJK in case LJK is a branch office of an entity located outside the country, have been followed up by
61 -
No. Indicator Analysis
LJK in the Financial Conglomerate

Board of Commissioners of the Main Entity
a. Structure of Integrated Governance
1) The Board of Commissioners of the Main Entity has
met integrity, competence, and financial reputation requirements and has obtained approval from the Financial Services Authority.
2) The Board of Commissioners of the Main Entity
has knowledge regarding the Main Entity, including understanding of main business activities and main risks of LJK in the Financial Conglomerate b. Process of Integrated Governance
1) The Board of Commissioners of the Main Entity
holds Board of Commissioners meetings regularly at least 1 (one) time every semester.
2) The Board of Commissioners of the Main Entity
supervises the implementation of duties and responsibilities of the Board of Directors of the Main Entity.
3) The Board of Commissioners of the Main Entity
supervises the application of Integrated Governance.
4) The Board of Commissioners of the Main Entity
evaluates the Integrated Governance Guidelines.
c. Results of Integrated Governance
1) Results of the Board of Commissioners meeting of the Main
Entity have been recorded in minutes and documented well, including clear disclosure of dissenting opinions and reasons arising during the Board of Commissioners meeting of the Main Entity.
2) Recommendations from the supervision results of the Board of
Commissioners of the Main Entity on:
(a) implementation of duties and responsibilities of the Board of Directors of the Main Entity; (b) application of Integrated Governance; (c) results of evaluation of the Integrated Governance Guidelines by the Board of Commissioners of the Main Entity have been submitted to the Board of Directors of the Main Entity.
3) The Board of Commissioners of the Main Entity has
formed the Integrated Governance Committee
Integrated Governance Committee
a. Structure of Integrated Governance
1) The Integrated Governance Committee consists of at least:
(a) an Independent Commissioner who serves as Chairman on one of the committees at the Main Entity, serving as Chairman ex-officio member;

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No. Indicator Analysis
(b) an Independent Commissioner representing and appointed from LJK in the Financial Conglomerate, as a member; (c) an independent party, as a member; (d) a member of the Sharia Supervisory Board from LJK in the Financial Conglomerate, as a member (in case the Financial Conglomerate has LJK conducting business activities based on Sharia principles).

The number and composition of Independent Commissioners who are members
of the Integrated Governance Committee have been appropriate for the needs of the Financial Conglomerate as well as efficiency and effectiveness of the execution of the duties of the Integrated Governance Committee while considering representation of each financial service sector b. Process of Integrated Governance
1) The Integrated Governance Committee
evaluates the implementation of Integrated Governance at least through assessment of internal control adequacy and execution of compliance functions in an integrated manner.
2) The Integrated Governance Committee
holds Integrated Governance Committee meetings at least 1 (one) time every semester.
c. Results of Integrated Governance
1) The Integrated Governance Committee has
evaluated the implementation of Integrated Governance, at least through assessment of internal control adequacy and execution of compliance functions in an integrated manner.
2) The Integrated Governance Committee has
provided recommendations to the Board of Commissioners of the Main Entity for refinement of the Integrated Governance Guidelines.
3) Results of the Integrated Governance Committee meeting have been recorded in
minutes and documented well, including clear disclosure of dissenting opinions and reasons arising during the meeting of the Integrated Governance Committee.

Integrated Compliance Work Unit
a. Structure of Integrated Governance
1) The Integrated Compliance Work Unit is
independent from operational work units.
2) The Board of Directors of the Main Entity meets
human resource needs of quality as members of the Integrated Compliance Work Unit. b. Process of Integrated Governance Integrated Compliance Work Unit

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No. Indicator Analysis monitors and evaluates compliance functions at LJK in the Financial Conglomerate.
c. Results of Integrated Governance
The Integrated Compliance Work Unit has submitted a report on the execution of its duties and responsibilities to the Director overseeing the Compliance function of the Main Entity or the Director appointed to perform supervision against LJK in the Financial Conglomerate

Integrated Internal Audit Work Unit
a. Structure of Integrated Governance
1) The Integrated Internal Audit Work Unit is
independent from operational work units.
2) The Board of Directors of the Main Entity has met
human resource needs of quality as members of the Integrated Internal Audit Work Unit. b. Process of Integrated Governance The Integrated Internal Audit Work Unit has monitored the implementation of internal audits at LJK in the Financial Conglomerate.
c. Results of Integrated Governance
1) The Integrated Internal Audit Work Unit
has submitted a report on the execution of its duties and responsibilities to:
(a) the Director appointed to perform supervision against LJK in the Financial Conglomerate; (b) the Board of Commissioners of the Main Entity; and (c) the Director overseeing the Compliance function of the Main Entity.
2) The Integrated Internal Audit Work Unit acts objectively in performing
monitoring of audit implementation.
3) Audit result recommendations are appropriate to the problems and can
be used as a reference for improvement
Application of Integrated Risk Management
a. Structure of Integrated Governance
1) The Main Entity has an adequate organizational structure to
support the application of integrated risk management as regulated in Financial Services Authority regulations regarding the application of integrated risk management for financial conglomerates.
2) The Main Entity has policies, procedures, and risk limit determinations that
are adequate as regulated in Financial Services Authority regulations regarding the application of integrated risk management for financial conglomerates b. Process of Integrated Governance The Main Entity applies risk management

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No. Indikator Analisis integrated risk according to the provisions of the Financial Services Authority regarding the application of integrated risk management for financial conglomerates.
c. Integrated Governance Results
1) The Main Entity applies integrated risk management effectively in accordance with
the characteristics and complexity of the Financial Conglomerate's business.
2) The Board of Directors and Board of Commissioners of the Main Entity are able to perform their duties and responsibilities related to integrated risk management in accordance with the provisions of the Financial Services Authority regarding the application of integrated risk management

Integrated Governance Guidelines
a. Integrated Governance Structure
1) Integrated Governance Guidelines must at least include:
(a) Integrated Governance Framework for the Main Entity; (b) Integrated Governance Framework for SHIs (Sharia Financial Institutions).
2) The Integrated Governance Framework for the Main Entity must at least contain:
(a) requirements for the Board of Directors of the Main Entity and the Board of Commissioners of the Main Entity; (b) duties and responsibilities of the Board of Directors of the Main Entity and the Board of Commissioners of the Main Entity; (c) duties and responsibilities of the Integrated Governance Committee; (d) duties and responsibilities of the Integrated Compliance Unit; (e) duties and responsibilities of the Integrated Internal Audit Unit; and (f) implementation of integrated risk management.
3) The Integrated Governance Framework for SHIs in a Financial Conglomerate must at least contain:
(a) requirements for candidates for the Board of Directors and candidates for the Board of Commissioners; (b) requirements for candidates for members of the Sharia Supervisory Board *); (c) structure of the Board of Directors and Board of Commissioners; (d) structure of the Sharia Supervisory Board *); (e) independence of actions of the Board of Commissioners; (f) implementation of management functions for SHIs by the Board of Directors; (g) implementation of supervision functions by the Board of Commissioners; (h) implementation of supervision functions by the Sharia Supervisory Board *); (i) implementation of compliance functions,

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No. Indikator Analisis internal audit functions, and implementation of external audits; (j) implementation of risk management functions; (k) remuneration policies; and (l) management of conflicts of interest. *) in the event that the Financial Conglomerate has an SHI that conducts business activities based on Sharia principles. b. Integrated Governance Process The implementation of the Integrated Governance process by the Main Entity and SHIs must at least refer to the Integrated Governance Guidelines.
c. Integrated Governance Results
The Integrated Governance Results have reflected that the Main Entity and SHIs in the Financial Conglomerate have applied good governance principles in accordance with the Integrated Governance Guidelines. Conclusion :
Based on the analysis of indicators across all assessment factors for the implementation of Integrated Governance, it is concluded that:
A. Integrated Governance Structure
1. Values reflecting the strengths of the Integrated Governance structure aspect of the Financial Conglomerate are.....
2. Values reflecting the weaknesses of the Integrated Governance structure aspect of the Financial Conglomerate are.....
B. Integrated Governance Process
1. Values reflecting the strengths of the Integrated Governance process aspect of the Financial Conglomerate are.....
2. Values reflecting the weaknesses of the Integrated Governance process aspect of the Financial Conglomerate are.....
C. Integrated Governance Results
1. Values reflecting the strengths of the Integrated Governance results aspect of the Financial Conglomerate are.....
2. Values reflecting the weaknesses of the Integrated Governance results aspect of the Financial Conglomerate are.....
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FORMAT II G
This Integrated Risk Profile Report is governed by Article 28 of POJK 17/POJK.03/2014, with submission deadlines on August 15 and February 15. INTEGRATED RISK PROFILE REPORT
Year ......
(fill in company name and address) , 20xx Director (Company Stamp) N a m e C l e a r Position FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS
67 -
ASSESSMENT OF INTEGRATED RISK PROFILE Financial Conglomerate Group :……………… Report Position Date :……………… Risk Profile Rating Inherent Risk Integrated KPMR Rating Integrated Risk Level Rating Credit Risk Market Risk Liquidity Risk Operational Risk Legal Risk Strategic Risk Compliance Risk Reputation Risk Intra-Group Transaction Risk Insurance Risk (if any) Risk Profile Rating Analysis (This analysis column is filled with conclusions regarding the overall Risk Profile of the Financial Conglomerate, including assessments of Inherent Risk and Integrated KPMR, with analysis focus on significant matters supporting Risk exposure in the Financial Conglomerate).
68 -
RISK ANALYSIS ASSESSMENT ………..*)
Financial Conglomerate Group : ......
Report Position Date : ......
Analysis
Risk Level Rating:
......
(Filled with the final conclusion regarding the Risk Level Rating of the Financial Conglomerate after considering the Inherent Risk rating and the Integrated KPMR rating, thereby describing each respective Risk Level of the Financial Conglomerate). Inherent Risk Rating:
......
(Filled with descriptions of the assessment of the Inherent Risk rating based on analysis of assessment factors using relevant parameters and indicators, thereby describing each respective level of Inherent Risk of the Financial Conglomerate). Integrated KPMR Rating:
......
(Filled with descriptions of analysis regarding integrated KPMR consisting of four scopes as referred to in Appendix I). *) This working paper is used to support the analysis of each type of Risk in the Financial Conglomerate, including Credit Risk, Market Risk, Liquidity Risk, Operational Risk, Legal Risk, Strategic Risk, Compliance Risk, Reputation Risk, Intra-Group Transaction Risk, and Insurance Risk. Specifically for intra-group transactions, a report on intra-group transactions must be attached containing at least:
a. Recapitulation of transactions with related parties in accordance with applicable financial accounting standards; and b. Important agreements with related parties including information containing at least: (1) price; (2) determination of interest rate amounts; (3) determination of fee amounts; (4) collateral; (5) payment terms; and (6) significant requirements.
69 -
FORMAT II H
This Integrated Capital Adequacy Report is governed by Article 17 of POJK 26/POJK.03/2015, with submission deadlines on August 15 and February 15. INTEGRATED CAPITAL ADEQUACY REPORT
Year ......
(fill in company name and address) , 20xx Director (Company Stamp) N a m e C l e a r Position FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS
70 -
Integrated Capital Adequacy Name of Financial Conglomerate :
Position :
Main Entity :
No. Name
SHI
Type of SHI
Actual Capital
(Million Rp)
Total Deduction Factors from Actual Capital (Million Rp) Minimum Capital (Million Rp) Ratio Integrated CAAP 1 2 3 … Total Rp. Rp. Rp. Rp. Notes:

Name of SHI is filled with the name of the member SHI of the Financial Conglomerate.
Type of SHI is filled with bank, insurance/reinsurance company, financing company, or securities company.
Actual Capital is filled with:
a. (Core Capital + Supplementary Capital) actual after deducting capital deduction factors for SHIs that are banks; b. Adjusted capital actual for SHIs that are financing companies;
c. (Permitted Assets or Wealth – Liabilities) actual for SHIs that are insurance/reinsurance companies;
d. Adjusted Net Working Capital (ANWC) actual for SHIs that are securities companies.
Total Deduction Factors from Actual Capital is the sum of:
a. SHI's equity participation in other SHIs within the Financial Conglomerate; and/or b. SHI's fund placement in other SHIs within the Financial Conglomerate recognized as capital instruments (regulatory capital) by the aforementioned other SHIs,
c. provided they have not been accounted for in the capital calculation or have not been accounted for as deduction factors, in each respective financial sector.
Minimum Capital is the minimum capital that must be met by each SHI in accordance with regulations in each respective financial sector. Minimum Capital is filled with:
a. minimum capital according to risk profile for SHIs that are banks; b. minimum adjusted capital for SHIs that are financing companies;
c. minimum value of the difference between permitted assets/wealth and liabilities for SHIs that are insurance/reinsurance companies;
d. minimum value of Adjusted Net Working Capital (ANWC) for SHIs that are securities companies.
Integrated CAAP Ratio is calculated from (Total Actual Capital – Total Deduction Factors from Actual Capital) / Total Minimum Capital).

71 -
Details of Total Deduction Factors from Actual Capital in the form of Equity Participation of SHIs in Other SHIs within the Financial Conglomerate Name of Financial Conglomerate :
Position :
Main Entity :
No. Name of SHI Making
Equity Participation
(Investor)
Name of SHI
Target of
Equity Participation
(Investee)
Time of Equity Participation 1) Share of Equity Participation 2) Value of Equity Participation 3) (Million Rp) Total Equity Participation Notes:
1) Date, month, and year when equity participation becomes effective.
2) Percentage of equity participation (ownership) in the investee company per report position.
3) Value of equity participation per report position.
Details of Total Deduction Factors from Actual Capital in the form of Fund Placement of SHIs to Other SHIs within the Financial Conglomerate Recognized as Capital Instruments (Regulatory Capital) by Other SHIs Name of Financial Conglomerate :
Position :
Main Entity :
No. Name of SHI Making
Fund Placement
Name of SHI
Target of
Fund Placement
Time of Fund Placement 1)
Value of Fund Placement 2)
(Million Rp)
Total Fund Placement
Notes:
1) Date, month, and year when fund placement becomes effective.
2) Value of fund placement per report position.
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FORMAT II I
Data Update Activity Plan Report and Customer Data Update Realization Report in the framework of Implementing the Anti-Money Laundering and Counter-Terrorism Financing Program in the Financial Services Sector This is in accordance with Article 62 paragraph (1) letter c and letter d of POJK 12/POJK.01/2017 and SEOJK Number 37/SEOJK.05/2017 regarding Guidelines for Implementing the Anti-Money Laundering and Counter-Terrorism Financing Program in the Non-Bank Financial Industry Sector, with a submission deadline no later than the end of December. DATA UPDATE ACTIVITY PLAN REPORT AND DATA UPDATE REALIZATION REPORT IN THE FRAMEWORK OF IMPLEMENTING THE ANTI-MONEY LAUNDERING AND COUNTER-TERRORISM FINANCING PROGRAM IN THE FINANCIAL SERVICES SECTOR
Year ......
(fill in company name and address) , 20xx Director (Company Stamp) N a m e C l e a r Position FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

Description Nominal (Millions Rp) Combined Description ASSETS Tabarru' Funds and Tanahud Funds Corporate Funds Investment Funds Participants Cash and cash equivalents X Solvency Level - - Liquidity Ratio - - - - Contribution receivables X A. Permitted Assets (AYD) - - A. Current Assets - - - - Reinsurance receivables X B. Liabilities other than Qardh from Corporate Funds - - B. Current Liabilities - - - - Murabahah receivables X Minimum Tabarru' and Tanahud Funds Based on Risk (DTMBR) - - C. Ratio (a:b) 0.00% 0.00% 0.00% 0.00% Istishna’ receivables X A. Credit Risk - - Investment ratio with liabilities - - - - Mudharabah Financing X B. Liquidity Risk - - A. Investments, cash and banks - - - - Musyarakah Financing X C. Market Risk - - B. Technical Provisions - - - - Investments in securities X D. Insurance Risk - - C. Own retention claim liabilities - - - - Investments in associates and joint ventures X E. Operational Risk - - D. Ratio [a:(b+c)] - - - - Salam receivables X 1. Guaranteed PAYDI Risks - A. Net investment income - - - - Ijarah Assets X a. Credit Risk - B. Average investment - - - - Investment Properties X b. Liquidity Risk - C. Ratio (a:b) 0.00% 0.00% 0.00% 0.00% Fixed Assets X c. Market Risk - Claim expense ratio - - - - Intangible Assets X 2. Guaranteed PAYDI Assets - A. Net claim expenses - - - - TOTAL ASSETS XXX 3. Guaranteed PAYDI Liabilities - B. Net contributions - - - - Solvency Level before considering Assets Available for Qardh (in %) 0.00% 0.00% C. Ratio (a:b) 0.00% - - - LIABILITIES Target Internal Solvency Level 0.00% 0.00% Fund change ratio - - - - Claim payables X Solvency Level with DTMBR/MMBR Required by Regulations 0.00% 0.00% A. Funds current year/quarter/month - - - - Reinsurance payables X Assets Available For Qardh Considered as Additive to AYD Tabarru' and Tanahud Funds - - B. Funds previous year/quarter/month - - - - Participant share of underwriting surplus X A. Shortfall (surplus) of solvency level from internal target - - C. Fund changes (a-b) - - - - Advance Ujrah received X B. Insufficiency of investments, cash and banks - - D. Ratio (c:b) 0.00% 0.00% 0.00% 0.00% Provision for claims in process X Solvency Ratio of Tabarru' Funds and Tanahud Funds, and Corporate Funds 0.00% 0.00% Sharia Unit Asset Ratio - - - - Provision for incurred but not reported claims X A. Tabarru' and Tanahud Funds Assets - - - - Provision for unearned contributions X B. Participant Investment Fund Assets - - - - Provision for future policy benefits X C. Corporate Insurance Fund Assets - - - - PARTICIPANT FUNDS D. Ratio (a+b) : (a+b+c) - - - 0.00% Investment Funds X Description Nominal (Millions Calculation of Required Qardh Tabarru' Funds - - - - Tabarru' Funds X INSURANCE INCOME A. Total Liabilities other than Qardh - - - - EQUITY Contribution Income x B. Total Assets - - - - Paid-in Capital x Manager's share of contributions x Total Required Qardh (a-b) - - - - Additional Paid-in Capital x Reinsurer's share of contributions x
Calculation of Required Qardh for Dana - - - - Other Comprehensive Income Balance x A. Total Liabilities other than Qardh - - - - Retained Earnings X INSURANCE EXPENSES B. Total Assets - - - - TOTAL LIABILITIES, PARTICIPANT FUNDS, AND EQUITY Claim expenses x Total Required Qardh (a-b) - - - - Reinsurer's share of claims x Change in provision for claims in process x Change in provision for incurred but not reported claims x Primary Reinsurer
Change in unearned premium reserves x 1. ......
Change in future policy benefit reserves x SURPLUS (DEFICIT) UNDERWRITING x Company Owners
Underwriting Income Allocation x Individual participant allocated underwriting surplus x 1. ......
Investment Income x Underwriting surplus allocated to management entities x 2. ......
Underwriting Surplus Allocated to Tabarru' Funds x OPERATING EXPENSES Underwriting Surplus Allocated to Tabarru' Funds x Operating Expenses x INSURANCE INCOME AND EXPENSES Board of Commissioners
Net Operating Profit (Loss) x Profit sharing income x 1. ......
Non-operating Income x Gain on disposal of investments x 2. ......
Non-operating Expenses x Change in fair value of investments x 3. ......
Profit (Loss) Before Tax x Investment expenses x Income Tax Expense x TABARRU' FUND SURPLUS (DEFICIT) x Sharia Supervisory Board
Profit (Loss) x INITIAL BALANCE OF TABARRU' FUNDS x 1. ......
OTHER COMPREHENSIVE INCOME FINAL BALANCE OF TABARRU' FUNDS x 2. ......
Will not be reclassified to profit or loss Surplus from revaluation of fixed & intangible assets x Board of Directors
Fair value measurement of defined benefit liabilities x 1. ......
Income Tax x 2. ......
Will be reclassified to profit or loss 3. ......
Foreign currency translation differences Fair value differences of sukuk FVTOCI & AFS financial assets Income Tax COMPREHENSIVE INCOME (in millions of rupiah) FINANCIAL RATIOS OTHER THAN SOLVENCY LEVEL Underwriting Surplus Deficit Report for Tabarru' Funds
Financial Statements PT ......
Year ......
President Director
Chief Financial Officer
Chairman
...%
...%
...%
...%
(in millions of rupiah)
Note
Tabarru' Funds and Tanahud
Funds
Corporate
Funds
Indicators
Balance Sheet, Statement of Profit or Loss and Other Comprehensive Income, and Underwriting Surplus Deficit Report for Tabarru' Funds are prepared in accordance with generally accepted financial accounting standards and have been audited by Operational Director Sharia Insurance Balance Sheet Statement of Profit or Loss and Other Comprehensive Income (Audited) (Audited) (Audited) Independent Commissioner Independent Commissioner Member ACHIEVEMENT OF SOLVENCY LEVEL Independent Commissioner Principal Commissioner smd (Full Name) Solvency Level Report and Financial Ratios Other Than Solvency Level are Prepared Based on Legislation. Jakarta .....20xx Board of Directors
PT ......
FORMAT II J -73-
FORMS AND STRUCTURES OF OTHER REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

Wakalah Bil Ujrah Contract
Mudarabah Contract
ASSETS - - - - - - - - - INCOME - - - 1,00 - Investments - - - - - - - - - INVESTMENT INCOME AND INVESTMENT MANAGEMENT UJROH - - - - - - Deposits - Investment Results - - - - - - - Certificate of Deposits - Investment Results Distributed to Company Funds - - - - - - - Sharia Stocks - - Total Investment Results - - - - - - - Sharia Sukuk or Bonds - Total Investment Management Ujroh - - Sharia MTN - Total Investment Results and Investment Management Ujroh Income - - - - - - - Sharia Government Securities - UNDERWRITING INCOME - - - - - - - Sharia Securities Issued by Bank Indonesia - Tabarru'/Takaful Contribution/Management Ujroh/Investment Allocation - - - - - - - Sharia Securities Issued by Countries Other than NKRI - Reinsurance/Retrosession Contribution - - - - Sharia Securities Issued by Multinational Institutions - Net Contribution - - - - - - - Sharia Mutual Funds - Decrease (Increase) Provision for Contributions and PAKYBMP (Net After Reinsurance Assets)

Sharia Asset-Backed Securities - a. Decrease (Increase) Provision for Contributions - - - Sharia Real Estate Investment Trusts - b. Decrease (Increase) PAKYBMP - - - - REPO - c. Decrease (Increase) Provision for Disaster Risk - - - - Financing Through Cooperation with Other Parties - Total Net Contribution Income - - - - Sharia Financing with Mortgage Rights - UNDERWRITING INCOME - - - - - Direct Participation - EXPENSES - - - - - - - Investment Properties - UNDERWRITING EXPENSES - - - - - - - Pure Gold - Claim Expenses - - - - - - - Other Investments - a. Gross Claims - - - - Non-investments - - - - - - - - - b. Claim recovery - - - - Cash and Banks - c. Increase (Decrease) Provision for Claims - - - - Receivables - d. Withdrawal of Participant Investment Funds that have matured - - - - Reinsurance Assets - e. Withdrawal/Redemption of Participant Investment Funds (not yet matured) - - - - Deferred acquisition costs - Total Net Claim Expenses - - - - - - Non-Investment Properties - Adjuster Expenses - - - - Other Assets - TOTAL UNDERWRITING EXPENSES - - - - FUND LIABILITIES AND EQUITY - - - - - - - - - TOTAL UNDERWRITING SURPLUS (DEFICIT) - - - - Liabilities - - - - - - - - - a. Underwriting surplus for Company funds - - - - - Claims and benefits payable - b. Underwriting surplus for Participants - - - - - - Expenses still to be paid - OPERATING EXPENSES: - - - - - - - Other payables - a. Marketing Expenses - - Technical Provisions - - - - - - - b. Acquisition Expenses - - Ujroh Provisions - - - - c. General and Administrative Expenses: - - - Provision for PAYDI providing principal investment guarantee - - - - - Employee and Executive Expenses - - - Contribution Provisions - Education and Training Expenses - - - Provision for contributions that are not yet income - Other General and Administrative Expenses - - - Claims Provisions - Increase (decrease) Ujroh Provision - - - Disaster risk provision - Increase (decrease) PAYDI Provision Providing Principal Investment Guarantee - - - Qardh - TOTAL OPERATING EXPENSES - - - - Fund Equity - - - - - - - - - INSURANCE OPERATING PROFIT (LOSS) - - - Paid-up Capital - Other Income - - - - - Share Premium/Discount - Other Expenses - - - - - Accumulated Funds - PROFIT (LOSS) BEFORE TAX - - - Profit Equalization Reserve - Income Tax - - - - - - - Retained Earnings - PROFIT AFTER TAX - Other Equity Components - OTHER COMPREHENSIVE INCOME Difference between SAK Balance and SAP Balance - TOTAL ENTIRE FUND PERFORMANCE - - - - - - - Disallowed Assets - Combined No. Solvency Level - - 1. ...... Liquidity Ratio - - - - A. Permitted Assets (AYD) 2. ...... A. Current Wealth - B. Liabilities other than Qardh from Company Funds B. Current Liabilities - Tabarru' and Tanahud Funds Minimum Based on Risk (DTMBR) - - C. Ratio (a:b) 0,00% 0,00% 0,00% 0,00% A. Credit Risk No. Ratio of investment to liabilities balance - - - - B. Liquidity Risk 1. ...... A. Investments, cash and banks - - -
C. Market Risk 2. ...... B. Technical provisions - - -
D. Insurance Risk C. Retention claim liabilities - - - E. Operational Risk D. Ratio [a:(b+c)] - - - -

Guaranteed PAYDI Risk No. A. Net investment income -
a. Credit Risk 1. ...... B. Average investments - b. Liquidity Risk 2. ...... C. Ratio (a:b) 0,00% 0,00% 0,00% 0,00%
c. Market Risk Claim expense ratio - - - -
Guaranteed PAYDI Assets A. Net claim expenses - - -
Guaranteed PAYDI Liabilities No. B. Net contributions - - -
Solvency Level before considering Assets Available for Qardh (in %) 0,00% 0,00% 1. ...... C. Ratio (a:b) 0,00% - - - Internal Solvency Target Level 2. ...... Fund change ratio - - - - Solvency Level with DTMBR/MMBR Required by Regulations A. Current year/quarter/month funds - Assets Available For Qardh Considered as Add-on to AYD Tabarru' and Tanahud Funds

- B. Previous year/quarter/month funds -
  A. Deficiency (surplus) of solvency level from internal target - - No. C. Fund changes (a-b) - - - - B. Insufficiency of investments, cash and banks - 1. ...... D. Ratio (c:b) 0,00% 0,00% 0,00% 0,00% Ratio of Solvency Level for Tabarru' Funds and Tanahud Funds, and Company Funds 0,00% 0,00% 2. ...... Ratio of Sharia Unit Assets - - - - A. Tabarru' and Tanahud Fund Assets - - - - B. Participant Investment Fund Assets - - - -
  C. Company Insurance Fund Assets (Conventional) - - - -
  Jakarta .....20xx D. Ratio (a+b) : (a+b+c) - - - 0,00% Board of Directors Calculation of Required Qardh for Tabarru' Funds - - - - PT ...... A. Total Liabilities other than Qardh - - - B. Total Assets - - - signature Total Required Qardh (a-b) - - - - Calculation of Required Qardh for Tanahud Funds - - - - (Full Name) A. Total Liabilities other than Qardh - - - B. Total Assets - - - Total Required Qardh (a-b) - - - - The Statement of Financial Position, Statement of Financial Performance, Solvency Level Report, and Non-Solvency Financial Ratio Report are unaudited reports prepared based on legislation.
  ......
  ......
  ......
  Position Name
  ......
  ......

-
-
-
0,00% 0,00%
0,00% 0,00%
Name
Name
%
%
-
-
FINANCIAL RATIOS OTHER THAN SOLVENCY LEVEL (in millions of rupiah) -

-
-
-
-
Description
Tabarru' Funds and Company Funds Participant Investment Funds - Indicator

-
-
-

-
-
-
Company Owner
Commissioners Board
Commissioners Board
Position Name
Position Name
-
SOLVENCY LEVEL ACHIEVEMENT
(in millions of rupiah)
Description Tabarru' Funds and Tanahud Funds Company Funds Adjustment Primary Reinsurer Sharia Supervisory Board (in millions of rupiah)

-
-

-
-
-
-

Description
(in millions of rupiah)
Combined
SAK SAK DTH SAP
Tabarru' and Tanahud Funds
SAK SAP
Participant Investment Funds DESCRIPTION SAK SAP Company Funds SAK DT Statement of Financial Position

-
-

Financial Report Summary
PT ......

Company Funds Tabarru' Funds Tanahud Funds Adjustment Combined Participant Investment Funds Statement of Financial Performance
Quarter ... Year ....
-74-

Established in Jakarta on January 24, 2018 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signature RISWINANDI -75- This copy is consistent with the original Director of Law 1 Legal Department signature Yuliana

Lineage: Superseded

Timeline

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