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 your respective locations.

COPY
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 10 /SEOJK.05/2021 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

In relation to the mandate of regulations:

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); and
Article 7 paragraph (3), Article 14 paragraph (5), Article 15 paragraph (5), and Article 19 of the Financial Services Authority Regulation Number 24/POJK.05/2019 concerning Business Plans of Non-Bank Financial Service Institutions (State Gazette of the Republic of Indonesia Year 2019 Number 175, Supplement to the State Gazette of the Republic of Indonesia Number 6392),
it is necessary to regulate provisions regarding the scope, form, structure, and method of submission of periodic reports for Sharia insurance companies, Sharia reinsurance companies, and Sharia units in this Financial Services Authority Circular Letter as follows:

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

Company means a Sharia insurance company, a Sharia reinsurance company, a Sharia unit within an insurance company, and a Sharia unit within 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 during a specific 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 during a specific period.

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

Company Periodic Reports consist of:
a. Monthly Reports; b. Quarterly Reports;
c. Annual Reports; and
d. Other Reports.
Annual Reports as referred to in item 1 letter c for the Company consist of:
a. financial aspects; and b. management aspects.
Financial aspects as referred to in item 2 letter a are annual financial statements as referred to in Financial Services Authority Regulations concerning the Financial Health of Sharia Insurance Companies and Sharia Reinsurance Companies, namely annual financial statements based on accounting standards audited by public accountants and annual financial statements based on provisions of legislation in the field of insurance.
Annual financial statements based on accounting standards audited by public accountants as referred to in item 3 are annual financial statements that have obtained approval from the General Meeting of Shareholders (GMS) or its equivalent.
The form and structure of Company Periodic Reports as referred to in item 1 are as contained in the Appendix which is an inseparable part of this Financial Services Authority Circular Letter, with the following provisions:
a. The form and structure of Monthly Reports as referred to in item 1 letter a, Quarterly Reports as referred to in item 1 letter b, and Annual Reports for financial aspects as referred to in item 2 letter a are as contained in Appendix I which is an inseparable part of this Financial Services Authority Circular Letter, with the following provisions:
1) for general Sharia insurance companies and Sharia Units within general insurance companies, as contained in Format IA;
2) for Sharia Reinsurance Companies and Sharia Units within reinsurance companies, as contained in Format IB; and
3) for life Sharia insurance companies and Sharia Units within life insurance companies, as contained in Format IC;
b. The form and structure of Annual Reports for management aspects as referred to in item 2 letter b for the Company is as contained in Format ID of Appendix I which is an inseparable part of this Financial Services Authority Circular Letter;
c. The form and structure of Other Reports as referred to in item 1 letter d for the Company is as contained in Appendix II which is an inseparable part of this Financial Services Authority Circular Letter, with the following provisions:
1) for business plans as contained in Format IIA;
2) for business plan realization reports, including business plan realization reports, as contained in Format IIB;
3) for business plan supervision reports, including business plan supervision reports, as contained in Format IIC;
4) for automatic reinsurance/retrocession program reports as contained in Format IID;
5) for consumer complaint reports and follow-up on service and resolution of consumer complaints as contained in Format IIE;
6) for self-assessment reports on the implementation of integrated governance for financial conglomerates as contained in Format IIF;
7) for integrated governance reports for financial conglomerates as contained in Format IIG;
8) for integrated risk profile reports as contained in Format IIH;
9) for integrated capital adequacy reports as contained in Format III;
10) for data update activity plans and customer data update realization reports as contained in Format IIJ;
11) for reports on the appointment of public accountants and/or public accounting firms for audits of annual historical financial information as contained in Format IIK;
12) audit committee evaluation results regarding the implementation of audit services for annual historical financial information by public accountants and/or public accounting firms as contained in Format III L;
13) self-assessment results of the Company's health level as contained in Format III M;
14) action plans which are follow-ups to the self-assessment results of the Company's health level as contained in Format III N;
15) reports on the implementation of action plans as contained in Format III O; and
16) summaries of quarterly and annual financial reports as contained in Format III Q; and
d. The form and structure of Other Reports consisting of business plan reports, business plan realization reports, and business plan supervision reports for Sharia Units within general insurance companies, reinsurance companies, and life insurance companies are submitted in accordance with the Financial Services Authority Circular Letter concerning the form and structure of periodic reports for insurance companies and reinsurance companies.

III. METHOD OF SUBMISSION OF PERIODIC REPORTS

Submission of Periodic Reports is conducted online through the Financial Services Authority's data communication network system.
In the event that the Financial Services Authority's data communication network system as referred to in item 1 is not yet available or experiences technical disturbances, the Company must submit Periodic Reports online via electronic mail to the Financial Services Authority.
In the event that the Company must submit reports online via electronic mail to the Financial Services Authority as referred to in item 2, the Financial Services Authority provides written notification 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.
For the purpose of online submission via electronic mail as referred to in item 2, the Company must provide written notification to the Financial Services Authority of the Company's electronic mail address used for the submission of Periodic Reports to the Financial Services Authority.
In the event that the Financial Services Authority's data communication network system as referred to in items 1 and 2 experiences technical disturbances or the Company experiences disturbances preventing online submission of Periodic Reports, reports are submitted offline accompanied by written notification and supporting documents in the form of reports using compact disk (CD) media or other electronic data storage media, and sent to the Financial Services Authority via a letter signed by the Board of Directors or its equivalent, addressed to:
Financial Services Authority
Attention: Director of Sharia Non-Banking Financial Institutions Wisma Mulia 2 Building, 15th Floor Jalan Jenderal Gatot Subroto Kav. 40 Jakarta 12710.
Offline submission of Periodic Reports as referred to in item 5 is carried out by one of the following methods:
a. handed directly to the Financial Services Authority office; or b. sent via 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, proven by a receipt from the Financial Services Authority's data communication network system; or
2) electronic mail to the Financial Services Authority, proven by proof of electronic mail transmission, in cases where transmission via the data communication network cannot be performed; or
b. for offline submission, proven by a receipt from the Financial Services Authority.
The Financial Services Authority may request original printed documents of Periodic Reports already submitted by the Company through the Financial Services Authority's data communication network system.

IV. CLOSING

Provisions in this Financial Services Authority Circular Letter shall take effect 2 (two) months after the date of determination.
Upon the commencement of this Financial Services Authority Circular Letter:
a. Financial Services Authority Circular Letter Number 2/SEOJK.05/2018 concerning the Form and Structure of Periodic Reports for Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units; b. Appendix II and Appendix IV in Financial Services Authority Circular Letter Number 17/SEOJK.05/2017 concerning Reports on the Implementation of Reinsurance/Retrocession Placement; and
c. Roman Numeral III Item 4 letter a and Appendix II in Financial Services Authority Circular Letter Number 10/SEOJK.05/2016 concerning Guidelines for the Implementation of Risk Management and Self-Assessment Results Reporting for Non-Bank Financial Service Institutions,
are repealed and declared invalid.

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

Determined in Jakarta on March 1, 2021 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed RISWINANDI

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 10 /SEOJK.05/2021 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES AND SHARIA UNITS

FORMAT IA
To
The Director of Sharia Non-Banking Financial Institutions Financial Services Authority Wisma Mulia 2 Jakarta - 12710

ANNUAL REPORT
GENERAL SHARIA INSURANCE BUSINESS
January Month Year 1900

No. Sheet Name Form Name
1 GENERAL DATA
2 COVER
3 VALIDATION
4 THPPUSY Company Profile
5 THPPSAUS Shareholder Details
6 THPPUAUS Principal Details
7 THRPPAUS-1 Education and Training Details 8 Product Profile 9 Branch/Regional Office Profile 10 THLPKSY Balance Sheet Report 11 THLKKUS Financial Performance Report 12 THLAKSY Cash Flow Calculation Report 13 THLPDS Fund Change Report 14 THSAP Asset and Liability Sap Calculation Analysis 15 THRPTSAUS Solvency Level Achievement 16 THRIKSTSU Ratios Other Than Solvency Level 17 THRKUS Minimum Risk-Based Capital and Minimum Risk-Based Tabarru' Funds 18 THRKRKAUS Credit Risk 19 THRKRAUS Credit Risk - Default or Inability Risk of Debtors or Other Parties 20 THRKLAUS Credit Risk - Insurer/Retrocessionaire Failure/Inability 21 THRPSYA Liquidity Risk 22 THRPAS Market Risk 23 THRPSB Market Risk - Market Price Changes 24 THRPSC Market Risk - Foreign Exchange Rate Changes 25 THRSAS Market Risk - Investment Yield Rate Changes 26 THRSAS1 Insurance Risk 27 THRSAS2 Insurance Risk - Contribution Reserves 28 THRSAS3 Insurance Risk - Reserves for Contributions Not Yet Revenue 29 THRSAS4 Insurance Risk - Claim Reserves 30 THRSOS Insurance Risk - Disaster Risk Reserves 31 THRA110 Operational Risk 32 THRA120 Investment and Property Details 33 THRA130 Receivables Details 34 THRA210 Other Assets Details 35 THRA220 Liabilities Details 36 THRA221 Ujroh Reserves, Contribution Reserves, Reserves for Contributions Not Yet Revenue 37 THRA222 Claim Reserves 38 THRA310 Disaster Risk Reserves (Catastrophic Risk) 39 Asset and Liability Recapitulation Details by Currency and Maturity 40 Contribution Details 41 Claim Details 42 Policy Details 43 Reserve Details 44 THRC110 Natural Disaster Insurance Risk Report 45 THRD110 Guarantee Fund Development Summary and Guarantee Fund Adequacy Calculation 46 THRD120 Micro Insurance Marketing Performance by Insurance Product Type 47 THRF110 Micro Insurance Marketing Channel Performance 48 Outward Reinsurance Details 49 Marketing Channel Selection and Accountability Implementation 50 Monthly Product Performance Evaluation 51 Annual Product Performance Evaluation

General Data
Report Version 4/30/2020 11:34:50 AM Reporting Date Company Code / Party Company Name / Party Reporting Period Reporting Month January Fiscal Year Type of Reporting Period Annual Report Board of Directors Name / Person in Charge Board of Directors Position / Person in Charge Company Address / Party

Company Profile
As of 31-Jan-1900
Description
Company Name
Full Address
Number of Employees
Telephone
E-mail
Taxpayer Identification Number (NPWP) Single Investor Identification (SID) Number of Branches/Representative Offices Divisions Number of Participants External Auditor Controller Person in Charge of Financial Reports Report Compiler Officer Name Fax E-mail Extension Telephone DATI I (Province) DATI II (Regency/City) Fax Business License Number Business License Date Position Telephone Fax Email Extension Board of Directors Person in Charge Person in Charge Name

Shareholder Name
Parent Shareholder
Shareholder
Controller
Group Level
Degree of Ownership
Type of Shareholder (Counterparty Code) Location Code (Country) Supervisory Authority Name Insurance Subsidiaries Rating Legal Entity Rating Agency Equity Period Equity Nominal Shares (Rp) Ownership Percentage (%) Row Number Shareholder Details As of 31-Jan-1900

THPPUAUS
Row Number Name Position Start Date Principal Details As of 31-Jan-1900

(in millions of rupiah)
Participant Type for Training
(Employee/Director/Commissioner/
DPS)
Row Number Description
Realization
Education and Training Details
As of 31-Jan-1900

Marketing Media
Currency Code
Approval/Recording Number
Product at OJK
Loss Ratio (%)
Morbidita
(Health Insurance)
Commission Expense (Rp)
General & Administrative Costs (Rp) Underwriting Result (Rp) Loss Ratio (%) Morbidita (Health Insurance) Commission Expense (Rp) General & Administrative Costs (Rp) Underwriting Result (Rp) PRODUCT PROFILE DETAILS Calculation Method Estimate* Description Product Investment (Yes/ No) Company Product Code (Unique for all fields in this product profile) Product Name Product Status Marketing Channel Code License Date Business Line Code Estimate Profit/Loss* Assumption* Realization* Reinsurance Support Impact of deviation on established contributions Mitigation actions taken to address deviations and impact of deviations (if any)

BRANCH/REPRESENTATIVE OFFICE PROFILE Branch Name Branch License Number Branch License Date Branch/Representative Office Type Branch Leader Name Location Address (DT II) Latitude Longitude Phone No. Email

-
-

Balance Sheet Report
As of 31-Jan-1900
(in millions of rupiah)
Investments
Time Deposits -
Certificate of Deposits -
Adjustments
Combined SAK
ASSETS SAP Tabarru' Funds SAK SAP Investment Funds SAK Fund SAK Sharia State Securities - Sharia Securities Issued by Bank Indonesia - Sharia Securities Issued by Countries Other Than [Indonesia] - Sharia Stocks - Sukuk or Sharia Bonds - Sharia MTN - Sharia Real Estate Investment Funds - REPO - Financing Through Cooperation with Other Parties. - Sharia Securities Issued by Institutions - Sharia Mutual Funds - Sharia Asset-Backed Securities - Pure Gold - Regional Sukuk - Infrastructure Investment Funds in the form of collective investment contracts - Sharia Financing with Mortgage Rights - Direct Participation - Investment Properties - Receivables - Reinsurance Assets - Deferred acquisition costs - Other investments - Non-investments Cash and Banks - Liabilities Claim payables or investment benefits - - - Non-Investment Properties - Other Assets - LIABILITIES AND EQUITY

-
Expenses Payable - - - - - - -

Technical Reserves
Ujroh Reserves - -
Other Liabilities - -
Reserves for contributions not yet revenue - - Claim reserves - - PAYDI reserves providing investment principal guarantees - - - Contribution reserves - - Fund Equity Paid-in Capital - - - Disaster risk reserves - - - Qardh - - - - - Profit Equilization Reserve - Retained Earnings Balance - - - Share Agio/Disagio - - - Accumulated Funds - - - - - Prohibited Wealth - - - -

Difference between SAK Balance and SAP Balance - - Other Equity Components - - - -

Financial Performance Report
For the Period Ending 31-Jan-1900
(in millions of rupiah)
Mudharabah Agreement
Participant Investment Funds
Combined Adjustments
Description
Company Funds Tabarru' Funds Wakalah Bil Ujrah Agreement INCOME INVESTMENT INCOME AND INVESTMENT MANAGEMENT UJROH Investment Results - Investment Results Distributed to Company Funds - - - - - Total Investment Income and Investment Management Ujroh UNDERWRITING INCOME Gross Contributions/Ujroh Received/Investment Allocation a. Direct Contribution Allocation: Tabarru'/Ujroh/Investment - - Total Investment Results Total Investment Management Ujroh - - Net Contributions Decrease (Increase) in Contribution Reserves and PAYDI Reserves a. Decrease (Increase) in Contribution Reserves - - b. Indirect Contribution Allocation: Tabarru'/Ujroh - Total Gross Contributions/Ujroh Received/Allocated for Investment - Reinsurance/Retrocession Contributions - Total Net Contribution Income UNDERWRITING INCOME EXPENSES UNDERWRITING EXPENSES Claim Expenses b. Decrease (Increase) in PAYDI Reserves - -
c. Decrease (Increase) in Disaster Risk Reserves - -
d. Withdrawal of Participant Investment Funds that have matured - e. Withdrawal/Redemption of Participant Investment Funds (not yet matured) - Total Net Claim Expenses a. Gross Claims - b. Claim recovery -
c. Increase (Decrease) in Claim Reserves - -
- b. Underwriting surplus for Participants - - - - Adjuster Expenses - TOTAL UNDERWRITING EXPENSES - TOTAL UNDERWRITING SURPLUS (DEFICIT) - BUSINESS EXPENSES:
a. Marketing Expenses - - b. Acquisition Expenses - - a. Underwriting surplus for Company Funds - -

Other General and Administrative Expenses - -
Increase (Decrease) in Ujroh Reserves - -
c. General and Administrative Expenses:
Employee and Management Expenses - -
Education and Training Expenses - -

Other Expenses - - -
TOTAL BUSINESS EXPENSES
SHARIA INSURANCE BUSINESS PROFIT (LOSS) Other Income - - Increase (Decrease) in Asset Value TOTAL PERFORMANCE OF ALL FUNDS PROFIT AFTER TAX OTHER COMPREHENSIVE INCOME - PROFIT (LOSS) BEFORE TAX Income Tax - -

Cash Flow Statement

For the Period Ending 31-Jan-1900
(in millions of rupiah)

Description	Mudharabah Agreement	Participant Investment Funds	Combined
Company Funds	Tabarru' Fund	Wakalah Bil Ujrah Agreement
INITIAL BALANCE	-	-	-
INCREASE (DECREASE) IN CASH BALANCE
ENDING CASH BALANCE
CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
Participant Contributions
Receipts from Underwriting Surplus Distribution Reinsurance	-
Other Receipts	-	-
Receipts from Allocation of Tabarru' Fund Surplus	-	-	-
Claims Received from Reinsurance	-
Co-insurance Claims
Withdrawal of Maturity Participant Investment Funds	-	-
Withdrawal/Redemption of Non-Maturity Participant Investment Funds	-	-
	-	-
b. Cash Outflows
Claims Paid	-	-	-
Marketing Expenses	-
Payment of Reinsurance Ujroh	-
Payment of Insurance Ujroh
Payment of UW Surplus Distribution to Company	-
Payment of UW Surplus Distribution to Participants/Policyholders	-
Acquisition Costs	-
Zakat Payments	-
Tax Payments	-
Others	-
	-
Reinsurance Contributions Paid	-	-
Lease Payments	-
Investment Income Received	-	-	-
	-	-
CASH FLOWS FROM INVESTMENT ACTIVITIES
a. Cash Inflows
Sale of Fixed Assets	-
Receipts from Investment Profit Sharing of Tabarru' Fund	-
Receipts from Investment Profit Sharing of Participant Investment Funds	-
Investment Liquidation	-
b. Cash Outflows
Investment Placements	-	-	-
Others	-	-	-
	-
Payment of ujroh/fee to Company	-	-	-
Purchase of Fixed Assets	-
	-
Investment Results Distributed to Company Fund	-	-	-
CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
Capital Injection/Working Capital	-
Subordinated Loans
Others	-	-
	-
b. Cash Outflows
Payment of Subordinated Loans
Qardh Receipts	-
Others	-
	-	-
Dividend Payments
Qardh Payments	-
Others	-	-

STATEMENT OF CHANGES IN FUNDS

For the Period Ending 31-Jan-1900

Description	Company Funds	Tabarru' Fund	Participant Investment Funds
I. Initial Fund Balance	-	-	-
II. Additions
Paid-in Capital	-
Comprehensive Income for Current Period	-
Increase in Accumulated Tabarru'/Participant Investment Funds	-	-
Other Additions	-	-	-
III. Deductions
Comprehensive Loss for Current Period	-
Decrease in Accumulated Tabarru'/Investment Funds	-	-
IV. Ending Fund Balance
Dividend Payments	-
Other Deductions	-	-	-

ANALYSIS

ASSET AND LIABILITY CALCULATION

As of 31-Jan-1900
(in millions of rupiah)

Description	Ledger Balance (SAK)	Assessment Based on SAP	Difference Based on SAK and SAP Assessment	AYD After Per-Type Asset Limit	AYD After Affiliation Limit	AYD After Foreign Limit (SAP Balance)
I. Investments
COMPANY FUNDS
Deposits	-	-	-	-	-	-
Sharia Stocks	-	-	-	-	-	-
Deposit Certificates	-	-	-	-	-	-
Sharia MTN	-	-	-	-	-	-
Sukuk or Sharia Bonds	-	-	-	-	-	-
Sharia Securities Bank Indonesia	-	-	-	-	-	-
Sharia Securities State RI	-	-	-	-	-	-
Sharia Securities Multinational Institutions	-	-	-	-	-	-
Sharia Securities States Other Than RI	-	-	-	-	-	-
Sharia Asset-Backed Securities	-	-	-	-	-	-
Sharia Mutual Funds	-	-	-	-	-	-
REPO	-	-	-	-	-	-
Sharia Real Estate Investment Funds	-	-	-	-	-	-
Sharia Financing with Mortgage Rights	-	-	-	-	-	-
Financing Through Cooperation with Other Parties (Executing)	-	-	-	-	-	-
Investment Property	-	-	-	-	-	-
Direct Participation	-	-	-	-	-	-

Regional Sukuk	-	-	-	-	-	-
Pure Gold	-	-	-	-	-	-
Other Investments
Total Investments
II. Non-Investments
Cash and Banks	-
Infrastructure Investment Funds in the form of collective investment contracts	-	-	-
Co-insurance Ujroh Receivables	-	-	-	-
	-	-
Direct Closing Ujroh Receivables	-	-	-	-
Investment Receivables	-	-	-	-
Investment Return Receivables	-	-	-	-
Other Assets
Total Non-Investments
TOTAL WEALTH (I+II)
Non-Investment Property	-	-	-	-	-	-
	-
Deferred Acquisition Costs	-	-	-	-	-	-
Reinsurance Assets	-	-	-	-	-	-
I. Liabilities
II. Provisions for Ujroh
III. Provisions for Guaranteeing Principal Investment PAYDI
TOTAL LIABILITIES (I+II+III)
I. Investments
Deposits
Deposit Certificates
Sharia Stocks
Sukuk or Sharia Bonds
TABARRU' FUND
Sharia MTN
Sharia Securities State RI
Sharia Securities Bank Indonesia
Sharia Securities States Other Than RI
Sharia Securities Multinational Institutions
Sharia Mutual Funds
Sharia Asset-Backed Securities
Sharia Real Estate Investment Funds
REPO
Financing Through Cooperation with Other Parties (Executing)
Pure Gold
Regional Sukuk
Infrastructure Investment Funds in the form of collective investment contracts
Other Investments
Total Investments
II. Non-Investments
Cash and Banks
PAYDI Assets
Guaranteed PAYDI Assets
	-	-	-	-	-	-
	-	-	-	-	-	-
	-	-	-	-	-	-
Direct Closing Contribution Receivables
Claim Provisions
Catastrophic Risks Provisions
Total Liabilities
I. Investments
Deposits
Co-insurance Contribution Receivables
Reinsurance Contribution Receivables
Co-insurance Claim Receivables
Reinsurance Claim Recovery Receivables
Investment Return Receivables
Investment Receivables
Reinsurance Assets
Other Assets
Total Non-Investments
PARTICIPANT INVESTMENT FUNDS
Liabilities
Sharia Asset-Backed Securities
Sharia Real Estate Investment Funds
REPO
Financing Through Cooperation with Other Parties (Executing)
Pure Gold
Regional Sukuk
Infrastructure Investment Funds in the form of collective investment contracts
Other Investments
Total Investments
Deposit Certificates
Sharia Stocks
Sukuk or Sharia Bonds
Sharia MTN
Sharia Securities State RI
Sharia Securities Bank Indonesia
Sharia Securities States Other Than RI
Sharia Securities Multinational Institutions
Sharia Mutual Funds
TOTAL ASSETS (I+II)
Liabilities
Contribution Provisions
Provision for Contributions Not Yet Revenue (PKYBMP)
Accumulation of Participant Investment Funds
PAYDI Provisions Providing Principal Investment Guarantees
TOTAL LIABILITIES
II. Non-Investments
Cash and Banks
Investment Return Receivables
Investment Receivables
Other Assets
Total Non-Investments
TOTAL WEALTH (I + II)

FINANCIAL RATIOS

SOLVENCY LEVEL ACHIEVEMENT

As of 31-Jan-1900
(in millions of rupiah)

Description	Tabarru' Fund	Company Fund
Solvency Level
A. Permitted Assets (AYD)
B. Liabilities, excluding Qardh from Company Fund
DTMBR/MMBR
A. Credit Risk
B. Liquidity Risk
C. Market Risk
D. Insurance Risk
E. Operational Risk
F. MMBR for Guaranteed PAYDI
1. Guaranteed PAYDI Risk
a. Credit Risk
b. Liquidity Risk
c. Market Risk
2. Guaranteed PAYDI Assets
3. Guaranteed PAYDI Liabilities
Solvency Level Ratio before considering Assets Available for Qardh (in %)	0.00%	0.00%
Solvency Level Ratio with DTMBR/MMBR Required by Regulation (percentage per POJK 72)	0.00%	0.00%
Assets Available For Qardh Considered as Addition to Tabarru' Fund AYD
A. Deficiency (Surplus) of solvency level from internal target
B. Insufficiency of investments, cash and banks
Tabarru' Fund and Tanahud Fund Solvency Level Ratio
Internal Target Solvency Level Ratio (annual) (percentage per POJK 72)

FINANCIAL RATIOS

OTHER THAN SOLVENCY LEVEL

As of 31-Jan-1900
(in millions of rupiah)

Description	Tabarru' Fund	Company Fund	Participant Investment Funds
Liquidity Ratio
A. Current Wealth	-	-	-
B. Current Obligations	-	-	-
C. Ratio (a:b)
Investment-to-Liability Balance Ratio
A. Investments, cash and banks	-
B. Technical Provisions Own Retention	-
C. Own Retention Claim Liabilities	-
D. Ratio [a:(b+c)]
Net Investment Income Ratio
A. Net Investment Income	-
Assets Considered For Qardh in Company Fund
D. Ratio [a:(b+c)] after addition	-
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 Change (a-b)
D. Ratio (c:b)
Sharia Unit Asset Ratio
A. Tabarru' Fund Assets	-
D. Ratio (a+b) : (a+b+c)	-	-	-
B. Participant Investment Fund Assets	-	-	-

B. Total Assets	-
C. Company Insurance (Conventional) Fund Assets	-
Employee and Management Costs
Education and Training Costs
Education and Training Ratio
Total Qardh Required (a-b)
Calculation of Required Qardh for Tabarru' Fund
A. Total Liabilities other than Qardh

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK

As of 31-Jan-1900
(in millions of rupiah)

Description	Tabarru' Fund	Company Fund
Credit Risk (a)
Credit Risk (b)	-
Total Credit Risk
PAYDI Deviation Total (Guaranteed)

Description	Factor	Deviation
Deposit Certificates	1.20%
Special Category (up to 2 billion per bank)	2.10%
Other Categories, according to Bank Rating:
a. Cluster Rating 1	3.00%
b. Cluster Rating 2	4.50%
c. Cluster Rating 3	9.00%
d. Cluster Rating 4	-
e. Cluster Rating 5	-

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK - DEFAULT OR INABILITY OF DEBTOR OR OTHER PARTY

As of 31-Jan-1900
(in millions of rupiah)

Description	Tabarru' Fund Factor	Company Fund Factor	PAYDI Deviation Total (Guaranteed)
Other Categories, according to Bank Rating:
a. Cluster Rating 1	-	-	-
Investments
Time Deposits
Special Category (up to 2 billion per bank)	-	-	-
d. Cluster Rating 4	-	-	-
e. Cluster Rating 5	-	-	-
b. Cluster Rating 2	-	-	-
c. Cluster Rating 3	-	-	-
Sharia Corporate Sukuk / Bonds
a. Cluster Rating 1	-	-	-
Sharia MTN
a. Cluster Rating 1	-	-	-
d. Cluster Rating 4	-	-	-
e. Cluster Rating 5	-	-	-
b. Cluster Rating 2	-	-	-
c. Cluster Rating 3	-	-	-
Securities Issued by States other than RI
a. Cluster Rating 1	-	-	-
State Sharia Securities	-	-	-
Securities Issued by Bank Indonesia	-	-	-
d. Cluster Rating 4	-	-	-
e. Cluster Rating 5	-	-	-
b. Cluster Rating 2	-	-	-
c. Cluster Rating 3	-	-	-
Financing Through Cooperation with Other Parties*
a. Very Healthy	-	-	-
Securities Issued by Multinational Institutions	-	-	-
REPO	-	-	-
d. Unhealthy	-	-	-
Financing Secured with Mortgage Rights
b. Healthy	-	-	-
c. Less Healthy	-	-	-
b. 65% < LTV < 75%	-	-	-
Other Commercial Properties
Residential Properties
a. LTV < 65%	-	-	-
Unused Properties	-	-	-
Regional Sukuk
a. LTV < 65%	-	-	-
b. 65% < LTV < 75%	-	-	-
c. Cluster Rating 3	-	-	-
a. Cluster Rating 1	-	-	-
b. Cluster Rating 2	-	-	-

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK - DEFAULT OR INABILITY OF DEBTOR OR OTHER PARTY

As of 31-Jan-1900
(in millions of rupiah)

Description	Tabarru' Fund Factor	Company Fund Factor	PAYDI Deviation Total (Guaranteed)	AYD Total
6.00%	-	-	-
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%	-	-	-
	-	-	-	-
d. Cluster Rating 4	-	-	-
Cash and Banks	-	-	-
Direct Closing Contribution Receivables	-	-	-
e. Cluster Rating 5	-	-	-
Non-Investments
b. assets sourced from long-term contract agreements for capital-oriented reinsurance support programs	-	-	-
Co-insurance Claim Receivables
Reinsurance Assets
a. assets sourced from estimated recovery value of claims on reinsurance portions (discharged in Credit Risk b)	-	-	-
a. Cluster Rating 1	-	-	-
b. Cluster Rating 2	-	-	-
Domestic	-	-	-
Foreign:
e. Cluster Rating 5	-	-	-
Reinsurance Contribution Receivables
c. Cluster Rating 3	-	-	-
d. Cluster Rating 4	-	-	-
Cluster Rating 1	-	-	-
Cluster Rating 2	-	-	-
Domestic	-	-	-
Foreign
Cluster Rating 5	-	-	-
Reinsurance Claim Receivables
Cluster Rating 3	-	-	-
Cluster Rating 4	-	-	-
a. Cluster Rating 1	-	-	-
b. Cluster Rating 2	-	-	-
Domestic	-	-	-
Foreign:
e. Cluster Rating 5	-	-	-
Investment Receivables
c. Cluster Rating 3	-	-	-
d. Cluster Rating 4	-	-	-
Investment Return Receivables	-	-	-
Total
a. Investments not yet paid at maturity date	-	-	-
b. Investments defaulted at maturity/liquidation date	-	-	-

AUTOMATIC REINSURANCE (Treaty)

Type	Percentage
Proportional	0.00%
- Quota Share	0.00%
- Surplus	0.00%
- Non Proportional	0.00%
- Cath X/L	0.00%
- Work X/L	0.00%

FACULTATIVE REINSURANCE

Type	Percentage
Proportional	0.00%
- Quota Share	0.00%
- Surplus	0.00%
- Non Proportional	0.00%
	0.00%
	0.00%
	0.00%
	0.00%
	0.00%
	0.00%
	0.00%
	0.00%

Reinsurer Code

RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK - REINSURER DEFAULT/INABILITY

As of 31-Jan-1900
(in millions of rupiah)

Row No.	Technical Provisions Expense	Reinsurer Deposit and/or Contributions Held	Company Type	Reinsurance Type	Exposure Number	Net Reinsurance Exposure ((G)-(H))	Factor Number	Deviation Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

MATURITY ANALYSIS

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	More than 10 years	Total

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

LIQUIDITY RISK

As of 31-Jan-1900
(in millions of rupiah)

Description	Company Fund						PAYDI (Guaranteed)						Tabarru' Fund
	Up to 1 yr	>1 to 3 yrs	>3 to 5 yrs	>5 to 10 yrs	>10 yrs	Total	Up to 1 yr	>1 to 3 yrs	>3 to 5 yrs	>5 to 10 yrs	>10 yrs	Total	Up to 1 yr	>1 to 3 yrs	>3 to 5 yrs	>5 to 10 yrs	>10 yrs	Total
Assets
Investments
Time Deposits	-	-	-	-	-	-
Deposit Certificates	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Sharia Corporate Sukuk / Bonds	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Sharia Stocks	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
State Sharia Securities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Sharia MTN	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Securities Issued by States Other Than RI	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Securities Issued by Bank Indonesia	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Sharia Mutual Funds	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Securities Issued by Multinational Institutions	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Real Estate Investment Funds	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Sharia Asset-Backed Securities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Financing Through Cooperation with Other Parties (Executing)	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
REPO	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Sharia Financing with Mortgage Rights	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Pure Gold	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Investment Property	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Direct Participation	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Regional Sukuk	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Infrastructure Investment Funds in Collective Investment Contracts	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Other Investments	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Non-Investments
Cash and Banks	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Direct Closing Contribution/Ujroh Receivables	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Reinsurance Contribution/Ujroh Receivables	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Reinsurance Assets	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Reinsurance Claim Recovery Receivables	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Co-insurance Claim Receivables	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Investment Receivables	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Non-Investment Property	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Investment Return Receivables	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Other Fixed Assets	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Deferred Acquisition Costs	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Other Assets	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Co-insurance Liabilities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Liabilities and Equity
Liabilities
Liabilities
Claim or Investment Benefit Liabilities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Reinsurance Liabilities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Ujroh Liabilities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Tax Liabilities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Other Liabilities	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Accrued Expenses	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
PAYDI Provisions Providing Principal Investment Guarantees	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Technical Provisions
Ujroh Provisions	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Contribution Provisions Not Yet Revenue	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Contribution Provisions	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Catastrophic Risks Provisions	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Claim Provisions	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
LIABILITY AND ASSET DIFFERENCE
DEVIATION (4% X (Max (Li - AYDi), 0))
Accumulation of Participant Investment Funds	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

MARKET RISK

As of 31-Jan-1900
(in millions of rupiah)

Description	Company Fund	Tabarru' Fund	PAYDI (Guaranteed)	Deviation Total
Total Market Risk (A)
Market Risk (B)
Market Risk (C)	-
Total Market Risk

Description	Factor	Deviation
15%	-	-
20%	-	-
30%	-	-
20%	-	-
30%	-	-
	-	-
0%	-	-
6%	-	-
16%	-	-
	-	-
	-	-
1.60%	-	-
2.80%	-	-
4%	-	-
6%	-	-
12%	-	-
10%	-	-
	-	-
10%	-	-
20%	-	-
	-	-
7%	-	-
15%	-	-
40%	-	-
3%	-	-
10.00%	-	-
	-	-
4%	-	-
	-	-

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

MARKET RISK - MARKET PRICE CHANGES

As of 31-Jan-1900
(in millions of rupiah)

Description	Company Fund Factor	Tabarru' Fund Factor	PAYDI Deviation Total (Guaranteed)	AYD Total
Shares traded on Indonesian exchange
Investments
Sharia Stocks
Including IDX30 or JII	-	-	-
Other Shares	-	-	-
Sharia Mutual Funds
Shares traded on foreign exchanges
Main index constituent shares of main exchanges in Asia Pacific and European countries members of World Federation of Exchanges	-	-	-
Fully consisting of equity securities	-	-	-
Mixed*)
Fully consisting of government debt securities	-	-	-
Fully consisting of private debt and/or money market securities (SBPU)	-	-	-

Tabarru' Fund	-	-	-	-
Company Fund	-	-	-	-
Sharia 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 Returns 2% - 4%	-	-	-
Investment Returns less than 2%	-	-	-
Investment Property
Investment Returns 4% or more	-	-	-
TOTAL
NON-INVESTMENTS
Non-Investment Property	-	-	-
Pure Gold	-	-	-
Infrastructure Investment Funds	-	-	-

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO RISK MARKET RISK - FOREIGN CURRENCY EXCHANGE RATE CHANGES As of Jan 31, 1900 (in millions of rupiah)

Permitted Assets
Deposits - - -
GBP Other IDR
PAYDI (guaranteed)
Total USD JPY AUD EUR SGD GBP Other IDR Total Tabarru' Fund USD JPY AUD EUR SGD SGD GBP Other IDR Total DESCRIPTION USD

JPY AUD EUR
Corporate Fund
Sharia Stocks - - - -

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

Sharia MTN - - - -

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

Sharia Securities Issued by Bank Indonesia

- - - - Government Sharia Securities - - - -

Sharia Securities Issued by Multinational Institutions

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

Sharia Asset-Backed Securities - - - -

- - - - Sharia Mutual Funds - - - -

REPO - - - -

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

Sharia Financing with Collateral Rights

- - - - Financing Through Cooperation
        with Other Parties.

Investment Properties - - - - - - - - Direct Participation - - - -

Regional Sukuk - - - - - - - -
Pure Gold - - - -

-
Contract-Based Infrastructure Investment Funds

Cash and Banks - - - -

- - - - Other Investments - - - -

Reinsurance Contribution Receivables - - - -

- - - - Direct Writing Contribution Receivables

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

- - - - Reinsurance Assets -

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

Investment Income Receivables - - - -

- - - - Investment Receivables - - - -

Deferred Acquisition Costs - - - - - - - - Non-Investment Properties - - - - Total Permitted Assets Liabilities

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO MARKET RISK - FOREIGN CURRENCY EXCHANGE RATE CHANGES As of Jan 31, 1900 (in millions of rupiah) GBP Other IDR PAYDI (guaranteed) Total USD JPY AUD EUR SGD GBP Other IDR Total Tabarru' Fund USD JPY AUD EUR SGD SGD GBP Other IDR Total DESCRIPTION USD JPY AUD EUR Corporate Fund

-
Co-insurance Payables - - - - - - - -

- - - Claims Payables - -

Ujroh Payables - - - - - - - - - - - Reinsurance Payables - - - -

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

-
Accrued Expenses - - - - - - - - - - - - -

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

Contribution Provisions - - - -

Principal Investment Guarantee Provisions

Ujroh Provisions - - - -

Claims Provisions - - - -

- - - - Provisions for Contributions That Have Not Yet Become Revenue

Total Liabilities
Exchange Rate - - -

- - - - Disaster Risk Provisions - - - -
        Total Deviation
        -
        Total Permitted Assets in Rupiah
        Total Liabilities in Rupiah
        Difference Between Permitted Assets and Liabilities Factor

-
-
15,00% 15,00%

-
MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO MARKET RISK - INVESTMENT YIELD RATE CHANGE RISK As of Jan 31, 1900 (in millions of rupiah) Description Tabarru' Fund PKrf - PKo - Max((PKrf-PKo),0) PUrf - PUo - Max((PUrf-PUo),0) fPTB PTPI

-
-
-
-
-
MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU INSURANCE RISK As of Jan 31, 1900 (in millions of rupiah)
IV. Total ((PRBi - ARi)fpbi)
Total Deviation
Description Total Deviation
I. Total max ((PK* - PK), 0)
II. Total ((PAKYBMPi - ARi)fpki
III. Total ((PKli - ARi)fpkli)

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

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM INSURANCE RISK - CONTRIBUTION PROVISIONS As of Jan 31, 1900 (in millions of rupiah) PK PK* Total Deviation Property (Property) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - -
Ship Hull (Marine Hull) - -
Aircraft Hull (Aviation Hull) - -
Satellite - -
Onshore Energy (Oil and Gas) - -
Offshore Energy (Oil and Gas) - -
Engineering (Engineering) - -
Liability (Liability) - -
Credit (Credit) - -
Miscellaneous - -
Health - -
Total max ((PK* - PK), 0)
Personal Accident - -
Life*) - -
25% -
25% -
30% -
30% -
30% -
25% -
35% -
35% -
25% -
35% -
30% -
25% -
25% -
25% -
10% -

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO INSURANCE RISK - PROVISION FOR CONTRIBUTIONS THAT HAVE NOT YET BECOME REVENUE As of Jan 31, 1900 (in millions of rupiah) PAKYBMP AR fpk Total Deviation PAKYBMP Property (Property) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - -
Ship Hull (Marine Hull) - -
Aircraft Hull (Aviation Hull) - -
Satellite - -
Onshore Energy (Oil and Gas) - -
Offshore Energy (Oil and Gas) - -
Engineering (Engineering) - -
Liability (Liability) - -
Credit (Credit) - -
Miscellaneous - -
Life*) - -
Total ((PAKYBMPi - ARi)fpbi + (PKi - Health - - Personal Accident - - 20% - 20% - 25% - 25% - 25% - 20% - 30% - 30% - 20% - 30% - 20% - 20% - 20% - 10% -

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO INSURANCE RISK - CLAIMS PROVISIONS As of Jan 31, 1900 (in millions of rupiah) Claims Provision AR fpk Total Deviation Claims Provision((2) - (3)) x (4) Property (Property) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

-
Transportation (Marine Cargo) - -
Ship Hull (Marine Hull) - -
Aircraft Hull (Aviation Hull) - -
Satellite - -
Onshore Energy (Oil and Gas) - -
Offshore Energy (Oil and Gas) - -
Engineering (Engineering) - -
Liability (Liability) - -
Miscellaneous - -
Health - -
Total
Personal Accident - -
Life*) - -
25% -
25% -
30% -
30% -
30% -
25% -
35% -
35% -
25% -
35% -
25% -
25% -
25% -
10% -

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO INSURANCE RISK - DISASTER RISK PROVISIONS As of Jan 31, 1900 (in millions of rupiah) Disaster Risk Provision AR fpk Total Deviation Disaster Risk Provision ((2) - (3)) x Property (Property) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

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

-
-

MODAL MINIMUM BERBASIS RISIKO DAN DANA TABARRU MINIMUM BERBASIS RISIKO OPERATIONAL RISK As of Jan 31, 1900 (in millions of rupiah) Description Tabarru' Fund Corporate Fund Corporate Operational Risk a. General and Administrative Expenses - b. Education and Training Expenses -
c. Operational Risk = (1%*(a-b))
d. Balance of Deferred Acquisition Costs - e. Operational Risk =(50%*d) f. Sub Total Corporate Operational Risk (c+e) PAYDI Operational Risk (ROPAYDI) g. PAYDI Fund Assets - Total Deviation (f+h+j) h. Sub Total PAYDI Operational Risk (ROPAYDI = (1‰*g)) Tabarru' Fund Operational Risk (RODT)
i. Tabarru' Fund Investments -
j. Sub Total RODT = (1‰*i)
Account Number
(SID /
Bank Account)
Investment Type Code
Instrument Name
Investment Instrument Code
Issuer / Counterparty Name
Company Group Code /
Issuer
Group Name
Fund Type Code
Fund Code
Guarantee Code
Investment Code
In The Context Of
Infrastructure Financing
Supervisor Code
DD/MM/YYYY Start
DD/MM/YYYY Maturity
Debtor Rating Code
Rating Agency Name Code
Business Category Code /
Debtor Category
Economic Sector Code

(in millions of rupiah)
Row Number
Time Frame
DETAILS A-110. Investment and Property Details As of Jan 31, 1900 (in millions of rupiah) Row Number DETAILS A-110. Investment and Property Details As of Jan 31, 1900 Location Code Status Code Affiliation Code Ownership Purpose Code Ownership Share (%) Currency Code Type Code Return Rate Return Rate (%) Collectibility Code Acquisition Value Book Balance Valuation Balance SAP AYD Investment Income Period Received Cash Receivables Investment Income Receivables Investment Income Period Previously Received Cash Period Running Total Investment Income Investment Income Ready For Distribution

- - 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% - - - - - - - -
    (in millions of rupiah)
    As of Jan 31, 1900
    DETAILS A-120. Receivables Details
    As of Jan 31, 1900
    (in millions of rupiah)
    AYD (Million Rp)
    1 - - - - - - - -
    DD/MM/YYYY Start
    Currency Code
    Debtor Rating Code
    Book Balance
    (Million Rp)
    Valuation Balance
    SAP (Million
    Rp)
    Row Number
    Debtor Name
    Business Category Code /
    Debtor Category
    Receivable Type Code
    Fund Type Code
    -
    3 - - - - - - - -
    2 - - - - - - -
    -
    5 - - - - - - - -
    4 - - - - - - -
    -
    7 - - - - - - - -
    6 - - - - - - -
    -
    9 - - - - - - - -
    8 - - - - - - -
    -
    11 - - - - - - - -
    10 - - - - - - -
    -
    13 - - - - - - - -
    12 - - - - - - -
    -
    15 - - - - - - - -
    14 - - - - - - -
    -
    17 - - - - - - - -
    16 - - - - - - -
    -
    19 - - - - - - - -
    18 - - - - - - -
    -
    21 - - - - - - - -
    20 - - - - - - -
    -
    23 - - - - - - - -
    22 - - - - - - -
    -
    25 - - - - - - - -
    24 - - - - - - -
    -
    27 - - - - - - - -
    26 - - - - - - -
    -
    29 - - - - - - - -
    28 - - - - - - -
    -
    31 - - - - - - - -
    30 - - - - - - -
    -
    33 - - - - - - - -
    32 - - - - - - -
    -
    35 - - - - - - - -
    34 - - - - - - -
    -
    37 - - - - - - - -
    36 - - - - - - -
    -
    39 - - - - - - - -
    38 - - - - - - -
    -
    41 - - - - - - - -
    40 - - - - - - -
    -
    43 - - - - - - - -
    42 - - - - - - -
    -
    45 - - - - - - - -
    44 - - - - - - -
    -
    47 - - - - - - - -
    46 - - - - - - -
    -
    49 - - - - - - - -
    48 - - - - - - -
    50 - - - - - - - -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    -
    DETAILS A-130. Other Assets Details As of Jan 31, 1900 (in millions of rupiah) Description 1 - - - Row Number Asset Name Basis of Valuation Fund Type Code Market Value / Appraisal Balance Million (Rp) 3 - - - 2 - - - 5 - - - 4 - - - 7 - - - 6 - - - 9 - - - 8 - - - 11 - - - 10 - - - 13 - - - 12 - - - 15 - - - 14 - - - 17 - - - 16 - - - 19 - - - 18 - - - 21 - - - 20 - - - 23 - - - 22 - - - 25 - - - 24 - - - 27 - - - 26 - - - 29 - - - 28 - - - 31 - - - 30 - - - 33 - - - 32 - - - 35 - - - 34 - - - 37 - - - 36 - - - 39 - - - 38 - - - 41 - - - 40 - - - 43 - - - 42 - - - 45 - - - 44 - - - 47 - - - 46 - - - 49 - - - 48 - - - 50 - - - DETAILS A-210. Payables Details As of Jan 31, 1900 (in millions of rupiah) Currency Code Country Code Book Balance (Million Rp) Valuation Balance SAP (Million Rp) Row Number Name Code Payable Type Code Fund Type Code DD/MM/YYYY Start Period 1 - - - - - -

3 - - - - - -
2 - -

5 - - - - - -
4 - -

7 - - - - - -
6 - -

9 - - - - - -
8 - -

11 - - - - - -
10 - -

13 - - - - - -
12 - -

15 - - - - - -
14 - -

17 - - - - - -
16 - -

19 - - - - - -
18 - -

21 - - - - - -
20 - -

23 - - - - - -
22 - -

25 - - - - - -
24 - -

27 - - - - - -
26 - -

29 - - - - - -
28 - -

31 - - - - - -
30 - -

33 - - - - - -
32 - -

35 - - - - - -
34 - -

37 - - - - - -
36 - -

39 - - - - - -
38 - -

41 - - - - - -
40 - -

43 - - - - - -
42 - -

45 - - - - - -
44 - -

47 - - - - - -
46 - -

49 - - - - - -
48 - -
50 - - - - - -

DETAILS A-220. UJROH PROVISIONS, CONTRIBUTION PROVISIONS, AND PROVISIONS FOR CONTRIBUTIONS THAT HAVE NOT YET BECOME REVENUE As of Jan 31, 1900 (in millions of rupiah) Disaster Risk Provision for PAYDI Combined Total
I. Ujroh/Contribution Provisions
Property (Property) - -
Disaster Risk Provision Disaster Risk Provision for PAYDI Total Tabarru' Fund Disaster Risk Provision Insurance Branch Ujroh Provision Ujroh Provision for PAYDI Total Corporate Fund Ship Hull (Marine Hull) - - Aircraft Hull (Aviation Hull) - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

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

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

DETAILS A-221.
CLAIMS PROVISIONS
As of Jan 31, 1900
Insurance Branch
Claims Provision In Process IBNR Claims Provision Installment Payment Provision Tabarru' Fund Total Claims Provision Property (Property) - - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

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

-
DETAILS A-222
Disaster Risk Provisions
As of Jan 31, 1900
Insurance Branch
Self-Retention
Tabarru' Fund
Reinsurance
Property (Property) - -
Motor Vehicles (Own Damage,
Third Party Liability, and Personal Accident)

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

- - - - 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% Total DETAILS A-310 Summary of Assets and Liabilities Details By Currency and Maturity As of Jan 31, 1900 Asset Maturity (SAK) Liabilities (SAK) Asset to Tabaru Fund Ratio <= 1 year 1 year < maturity < 5 years 5 years = maturity < 10 years >= 10 years 5 years = maturity < 10 years Current Asset (Liability) to Non-Current Asset (Liability) Ratio Corporate Fund <= 1 year 1 year < maturity < 5 years 5 years = maturity < 10 years >= 10 years Total Current Asset (Liability) to Non-Current Asset (Liability) Ratio Corporate Investment Fund <= 1 year 1 year < maturity < 5 years 5 years = maturity < 10 years >= 10 years Total Current Asset (Liability) to Non-Current Asset (Liability) Ratio >= 10 years Total Current Asset (Liability) to Non-Current Asset (Liability) Ratio ALL <= 1 year 1 year < maturity < 5 years Product Code Policy Type Payment Method Location Economic Sector Code Policyholder Code Counterparty Policyholder Type: - Ujrah - Tabarru - Tanahud - DIP - Wakalah Bil Agreement - DIP - Mudharabah Agreement Commission Expense New Continuation Top Up Gross Contribution CONTRIBUTION DETAILS Product Code Policy Type Payment Method Location Economic Sector Code Policyholder Code Counterparty Policyholder Gross Claims Claims Recovery Withdrawal Investment Funds Participants Due Withdrawal Investment Funds Participants Not Due (Wakalah Bil Ujrah Agreement) Withdrawal Funds Participant Investment Not Due Term (Akad Mudharabah) Expense Adjuster Total Number of Policies Claims Number of Participants Claims Tabarru' Fund Tanahud Fund Tabarru' Fund Tanahud Fund Wakalah Bil Ujrah Agreement Mudharabah Agreement Partial Withdrawal Full Withdrawal Partial Withdrawal Full Withdrawal Tabarru' Fund Tanahud Fund CLAIMS DETAILS Product Code Policy Code Traditional /PAYDI Policy Type Code Payment Method Code Location Code Economic Sector Code Policyholder Code Counterparty Policyholder Status (Active/Inactive) Inforce/Not Inforce Code Number of Policies Number of Participants Amount of Benefits Sharia Insurance (Millions Rp) POLICY DETAILS Continuing Participants New Participants Restoration of Membership Change From Other Insurance Lines Participant Deceased Membership Expired Contract Termination of Products Produced In The Current Year Change To Other Insurance Lines Contribution Provision (Rp) Provision for contributions that have not yet become revenue (Rp) Ujroh Provision (Rp) Claims/Benefits Provision In Process (Rp) Total Number of Policies Product Code Technical Provisions* PROVISIONS DETAILS No. in millions of rupiah Province *) Occupation Code ) Number of Risks Contribution Type of Coverage Coverage Amount Total Report on Natural Disaster Insurance Risks YYYY (Company Name) *) Follows Province in Earthquake Insurance Zone in SEOJK regarding Premium or Contribution Tariff Setting On Business Line Insurance Property and Motor Vehicle Insurance ) Follows Occupation Code in SEOJK regarding Premium or
        Contribution Tariff Setting On Business Line Insurance Property and Motor Vehicle Insurance - - - - - - - - - - - C-110. GUARANTEE FUND REPORT Summary of Guarantee Fund Development and Calculation of Guarantee Fund Adequacy As of Jan 31, 1900 Description Total

Summary of Guarantee Fund Development
Opening Balance of Guarantee Fund - New Guarantee Fund Placements:
a. Guarantee Fund in the Form of Deposits - b. Guarantee Fund in the Form of SUN/Other Securities Issued by the State (SBN) - Total New Guarantee Fund Placements (3 + 4) Guarantee Fund Withdrawals:
a. Guarantee Fund in the Form of Deposits - b. Guarantee Fund in the Form of SUN/Other Securities Issued by the State (SBN) - Total Guarantee Fund Withdrawals (7 + 8) Closing Balance of Guarantee Fund (1 + 5 – 9)
Annual Calculation of Guarantee Fund Adequacy
Required Minimum Equity -
Net Contribution Total*) -
Reinsurance Contribution Total*) -
Total Provisions 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 (Value between 5 and 6 whichever is greater) Guarantee Fund Owned Excess (Deficiency) of Guarantee Fund (8 - 7) Number of Participants Active at End of Reporting Period Report Premium / Gross Contribution (Rp) Gross Claims (Rp) Not Compliant with SE OJK NO. 9/SEOJK.05/2017 Participants Who Claim Compliant with SE OJK NO. 9/SEOJK.05/2017 Number of Participants Active at Start of Reporting Period Report Number of New Participants In Reporting Period Number of Memberships Renewed in Reporting Period Number of Memberships That Ended Because Expired - - - - - - - Gross Claims (Rp) Participants Who Claim Number of Participants Active at Start of Reporting Period Number of New Participants In Reporting Period Number of Memberships Renewed in Reporting Period Number of Memberships That Ended Because Expired Number of Memberships That Were Cancelled Number of Memberships That Ended Because of Claims Row Number Name Product Policy Type (Group/Individual) Business Line DETAILS D-110 Micro Insurance Marketing Performance By Product Type As of Jan 31, 1900 - - - - -

1 - - - - - - - - - - -
Number of Memberships
That Ended
Because of Claims
Number of
Participants
Active at
End of
Reporting Period
Gross Contribution (Rp)
-
-
-
-
-
- - 3 - - -
    -
    -
2 - - - - - - - - - - -
-
-
-
-
-
-
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......

DETAILS OF D-120. Performance of Microinsurance Marketing Channels As of Jan-31-1900 (in millions of rupiah) Total Legal Entity Marketing Legal Entity Total Individual Marketers Name of Product Marketed Total Participants Gross Contribution (Rp) Row Number Type of Marketing Channel Marketing Region Category Legal Entity

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

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

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

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

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

Domestic
Code
Business Line
Code
Policy Type
Contribution to
Reinsurer
Ujroh to
Reinsurer
Claim
Recovery
Underwriting Surplus from
Reinsurer
Contribution Paid
Ujroh Received
Claim
Recovery
Underwriting Surplus from
Reinsurer
Contribution Paid
Ujroh Received
Claim
Recovery
Underwriting Surplus from
Reinsurer
Row Number
Domestic ASEAN NON-ASEAN
DETAILS OF F-110. Outward Reinsurance Sharia Insurance Business As of Jan-31-1900

No.
Implementation Period *) :
Category
Marketing Channel 1)
Number of Parties
Selected 2)
Number of
New Parties 3)
Number of Parties
Attending Training 4)
Number of Parties
Passing Training 5)
Number of Parties
Attending
Marketer Certification Exam 6)
Number of Parties
Passing Marketer Certification 7)
Number of Marketing Materials and Product Information Summaries Evaluated (RIPLAY) 8) Number of Marketing Materials and Product Information Summaries Corrected 9) Number of Markers Subject to Evaluation 10) Number of Markers Terminated 11) Filling Instructions:
*) Fill in the implementation time of selection: Quarter 1 (January 1-March 31), Quarter 2 (April 1-June 30), Quarter 3 (July 1-September 30), or Quarter 4 (October 1-December 31)
1) Fill in the marketing channel being evaluated: direct marketing, Insurance agent, bank, BUSB, or Marketer personnel
2) Fill in the number of people selected according to the implementation period
3) Fill in the number of people newly recruited by the Company from the selection process according to the implementation period
4) Fill in the number of people attending training according to the implementation period
5) Fill in the number of people attending training and passing that training according to the implementation period
6) Fill in the number of people attending the agency certification exam from the Professional Certification Body in the insurance field according to the implementation period
7) Fill in the number of people passing the agency certification exam from the Professional Certification Body in the insurance field according to the implementation period
8) Fill in the number of marketing materials and RIPLAY evaluated for compliance with what is established or approved by the Company according to the implementation period
9) Fill in the number of marketing materials and RIPLAY corrected and adjusted according to Company approval according to the implementation period
10)
11) Fill in the number of people terminated by the Company due to non-compliance with cooperation agreements and applicable regulations according to the implementation period
Implementation of Selection and Accountability of Marketing Channels (Quarterly) Fill in the number of people evaluated by the Company, e.g., suitability of marketer parties in conveying information, compliance with agreements, etc. according to the implementation period

No. i ii iii iv v vi vii viii
Sub-fund Name Currency Exchange Rate NAV NAB/Unit Annual Investment Result Investment Result Benchmark SHARPE Ratio i Sub-fund Name PAYDI ii Currency used by PAYDI Sub-fund iii Exchange rate used at the time of reporting, using BI mid-rate (in rupiah) iv Net Asset Value (in PAYDI Sub-fund currency) v Net Asset Value / total units, only filled by PAYDI in unit form (in PAYDI Sub-fund currency) vi PAYDI Sub-fund investment result for the last one year (in %) vii Reference investment result established by the company at the creation of PAYDI Sub-fund, for the last one year (in %) viii (Annual Investment Result - Risk Free Rate) / Standard Deviation of PAYDI sub-fund investment results; Risk free rate uses the interest rate of general banks guaranteed by LPS. `

Details of PAYDI Sub-fund Investments
i ii iii iv v vi vii viii ix x xi xii xiii xiv Description Account Sub-fund Name Asset Status Investment Type Domestic/Foreign Currency Exchange Code (Counterparty) Name (Counterparty) Is Counterparty Affiliated with Company? (Yes/No) Serial Number Category Economic Sector Name Investment Manager (IM) detail row ke1 detail row ke2 detail row ke3 and furthermore Total i xv xvi xvii xviii xix xx xxi xxii xxiii xxiv xxv xxvi xxvii Description Account Cluster Rating Type Collateral Maturity (Days) Market Value of Collateral Balance at Placement Total (Grams) Balance % NAV Sub-fund Current Balance (Less than One Year) Target Investment Return Rate Investment Return Rate Description detail row ke1 detail row ke2 detail row ke3 and furthermore Total i Filled with the name of the investment portfolio in the PAYDI sub-fund ii PAYDI Sub-fund Name iii vi Filled with the currency of the investment asset. vii Filled with Bank Indonesia mid-rate of the investment asset currency on the report date. x Filled "Yes" or "No". Definition of affiliation relationship as referred to in POJK 71/2016 and POJK 72/2016. xxii Filled with the percentage of each underlying asset from the NAV of the PAYDI Sub-fund xxv Filled with the target annual investment return for each underlying asset, in percentage. xxvi Filled with asset status based on its allocation, namely "PAYDI Sub-fund Non-Guaranteed Assets", "PAYDI Sub-fund Guaranteed Assets", "PAYDI Sub-fund Back-Up Guaranteed Assets". The back-up asset refers to company assets provided in anticipation of adding PAYDI Sub-funds under guarantee. Filled with the annual investment result for each underlying asset, in percentage.
Availability of Assets for Guaranteed PAYDI
i ii iii iv v vi vii viii ix x
Type of Guarantee
Provided Currency Exchange
Assumption / Target
Investment Return Rate Total Participants Assets Liabilities on Guaranteed Sub-fund Average Monthly Addition of Guaranteed PAYDI Sub-funds Estimate Back-Up Asset Requirement for Guaranteed PAYDI Sub-fund 1 Month Ahead Total i Filled with PAYDI Sub-fund Name ii Filled with type of guarantee provided, e.g., investment return guarantee, principal investment guarantee. iii Filled with PAYDI Sub-fund currency iv Filled with PAYDI Sub-fund currency exchange rate v Filled with assumption of investment return rate to fulfill the guarantee provided. vi Filled with number of participants having PAYDI Sub-fund vii Filled with total assets of guaranteed PAYDI Sub-fund. viii Filled with total liabilities on guaranteed PAYDI, for the investment benefit portion (cash value) after considering the guarantee provided. ix Filled with average monthly addition of Guaranteed PAYDI Sub-funds. x Filled with estimate of Back-Up Asset requirement for Guaranteed PAYDI Sub-fund in the upcoming 1 month. Sub-fund Name Characteristics of Guarantee Provided Fund Development

Total
Contribution
(Rp) Total
Policies Total
Claims (Rp) Total
Policies Provision
Contribution
PAPYBMP Provision
Ujroh Provision
Claims In
Process
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 PRODUCT EVALUATION DETAILS Descr iption Product Name Product Code Product Status Distribution Channel Product License Date Business Line Estimate Profit/ Loss* Calculation Method Estimation* Contribution Claims Technical Provision*

No
17 Description
Filled with description of estimation calculation method used when selecting "Others" in column 6, and description of other relevant columns Filled with amount of technical provision for Company Funds (gross) for that product as of the report date as reported in the position statement in the monthly financial report Technical Provision – PAPYBMP Filled with PAPYBMP amount (gross) for that product as of the report date as reported in the position statement in the monthly financial report Ujroh Provision Technical Provision – Claims In Process Provision Filled with Claims In Process Provision amount (gross) for that product as of the report date as reported in the Claims Provision Detail Claims - Number of Claims (Rp) Filled with gross claim amount from the beginning of the year until the report date as reported in the Contribution and claims detail per business line in the monthly financial report Claims - Number of Policies Filled according to the number of policies making a claim Technical Provision – Contribution Provision Filled with Contribution Provision amount (gross) for that product as of the report date as reported in the position statement in the monthly financial report Calculation Method Estimation Filled with choice of estimation calculation method namely Profit Testing, Embedded Value, Value of New Business, and Contribution - Number of Contributions (Rp) Filled with Contribution revenue originating from Gross Contribution (before deducting commission) for that product from the beginning of the year until the report date as reported in the Contribution and claims detail per business line in the monthly financial report Contribution - Number of Policies Filled with number of policies making Contribution payment (for group Contribution, still calculated based on policy) Estimate Profit/Loss Filled with choice of estimation result being “Profit” or “Loss” based on estimation calculation method Marine Hull Aviation Hull Satellite Onshore Energy (Oil and Gas) Offshore Energy (Oil and Gas) Engineering Liability Credit Miscellaneous Health Personal Accident Product License Date Filled with OJK approval date for that product 6 Business Line Filled with one of the codes for general insurance business lines as follows:
Property
Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident) Transportation (Marine Cargo) Product Status Filled with choice being new product, product still sold, and product no longer sold 4 Distribution Channel Filled with product marketing channel code namely:
Direct
Agency
Bancassurance
Non-Bank Business Entity - Laku Pandai Agent Non-Bank Business Entity - Other than Laku Pandai Agent Marketer Personnel (Micro) - Laku Pandai Agent Marketer Personnel (Micro) - Other than Laku Pandai Agent Column Filling Instructions Product Name Filled with name of product receiving license from OJK Product Code Filled with product code created by the company, this product code must not change

Total
Contribution (Rp) Total
Policies Total
Claims (Rp) Total
Policies Provision
Contribution
PAPYBMP Ujroh Provision
Provision
Claims In
Process
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Loss Ratio (%) Morbidita (Health Insurance) Commission Expense (Rp) General & Admin Cost (Rp) Underwriting Result (Rp) Loss Ratio (%) Morbidita (Health Insurance) Commission Expense (Rp) General Costs & Administration (Rp) Underwrit ing Result (Rp) 17 18 19 20 21 22 23 24 25 26 27 28 29 30 PRODUCT EVALUATION DETAILS Assumption* Realization* Reinsurance Support Estimate Profit/Loss * Calculation Method Estimation* Contribution Claims Technical Provision* Product Name Product Code Product Status Distribution Channel License Date Product Business Line Impact deviation against Contribution that has been set Mitigation that was done to overcome deviation and impact deviation (if any) Description

No
1201 Direct
1202 Agency
1203 Bancassurance
1204 Non-Bank Business Entity - Laku Pandai Agent 1205 Non-Bank Business Entity - Other than Laku Pandai Agent 1206 Marketer Personnel (Micro) - Laku Pandai Agent 1207 Marketer Personnel (Micro) - Other than Laku Pandai Agent 1101 Property 1102 Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident) 1103 Transportation (Marine Cargo) 1104 Marine Hull 1105 Aviation Hull 1106 Satellite 1107 Onshore Energy (Oil and Gas) 1108 Offshore Energy (Oil and Gas) 1109 Engineering 1110 Liability 1111 Credit 1112 Miscellaneous 1113 Health 1114 Personal Accident 12 Claims - Number of Policies Filled according to the number of policies making a claim Contribution - Number of Contributions (Rp) Filled with Contribution revenue originating from Gross Contribution (before deducting commission) for that product from the beginning of the year until the report date as reported in the Contribution and claims detail per business line on monthly financial report Contribution - Number of Policies Filled with number of policies making Contribution payment (for group Contribution, still calculated based on policy) Claims - Number of Claims (Rp) Filled with gross claim amount from the beginning of the year until the report date as reported in the detail Contribution and claims per business line in the monthly financial report 6 Business Line Filled with one of the codes for general insurance business lines as follows:
Estimate Profit/Loss
Filled with choice of estimation result being “Profit” or “Loss” based on estimation calculation method as regulated in Article 56 POJK Number 23/POJK.05/2015 concerning Insurance Products and Marketing 4 Distribution Channel Filled with product marketing channel code namely:
Product License Date Filled with OJK approval date for that product Product Code Filled with product code created by the company, this product code must not change Calculation Method Estimation Filled with choice of estimation calculation method namely Profit Testing, Embedded Value, Value of New Business, and Others as regulated in Article 56 POJK Number 23/POJK.05/2015 concerning Insurance Products and Marketing Product Status Filled with choice being new product, product still sold, and product no longer sold Column Filling Instructions Product Name Filled with name of product receiving license from OJK

30 Description Filled with description of estimation calculation method used when selecting "Others" in column 6 Reinsurance Support Filled based on reinsurance support for that product Impact of deviation against Contribution that has been set Filled with brief description regarding impact of deviation (difference between assumption and realization) against Contribution that has been set Mitigation done to overcome deviation and impact of deviation (if any) Filled with brief description regarding mitigation done by the company to overcome deviation and impact of deviation Realization - Commission Expense (Rp) Filled with realization of commission amount paid for that product Realization - General Costs & Filled based on realization of general costs & administration amount for that product Realization - Underwriting Result (Rp) Filled based on realization of underwriting result for that product Assumption - Underwriting Result (Rp) Filled based on assumption of underwriting result for that product when reporting new product Realization - Loss Ratio (%) Filled based on loss ratio level for that product Realization - Morbidita Filled based on realization of morbidity table for that product Assumption - Morbidita Filled based on assumption of morbidity table used when reporting new product Assumption - Commission Expense (Rp) Filled with assumption of commission amount paid for that product when reporting new product Assumption - General Costs & Administration (Rp) Filled based on assumption of general costs & administration amount for that product when reporting new product Ujroh Provision Filled with amount of technical provision for Company Funds (gross) for that product as of the report date as reported in the position statement in the annual financial report Technical Provision – Claims Provision Filled with Claims In Process Provision amount (gross) for that product as of the report date as reported Assumption - Loss Ratio (%) Filled based on loss ratio level used when reporting new product Technical Provision – Contribution Provision Filled with Contribution Provision amount (gross) for that product as of the report date as reported in the position statement in the annual financial report Technical Provision – PAPYBMP Filled with PAPYBMP amount (gross) for that product as of the report date as reported in the annual financial report

IB FORMAT
To
Honorable Directorate IKNB Syariah
Financial Services Authority
Wisma Mulia 2
Jakarta - 12710
ANNUAL REPORT
SHARIA REINSURANCE BUSINESS
January Year 1900

No. Sheet Name Form Name
1 General Data
2 Cover
3 Validation
4 THPPUSY Company Profile
5 THPPSRESU Shareholder Detail
6 THPPURES Key Party Detail
7 THRPPRES-1 Education and Training Detail 8 Product Profile 9 Profil Kacab Kanwil 10 THLPKRE-SY Position Statement Report 11 THLKKRE Financial Performance Report 12 THLAK-R CASH FLOW CALCULATION 13 THLPDR STATEMENT OF CHANGES IN FUNDS 14 THSAP ASSET AND LIABILITY SAP CALCULATION ANALYSIS 15 THRPTSRES SOLVENCY ACHIEVEMENT 16 THRIKSTSRU RATIOS OTHER THAN SOLVENCY LEVEL 17 THRKUS-RE RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS CREDIT RISK 18 THRKRKRES CREDIT RISK - DEFAULT OR INSOLVENCY RISK OF DEBTOR OR OTHER PARTY 19 THRKRKRES1 CREDIT RISK - DEFAULT/INSOLVENCY OF GUARANTOR 20 THRKLRES LIQUIDITY RISK 21 THRPSYA-R MARKET RISK 22 THRPARES MARKET RISK - MARKET PRICE CHANGE 23 THRPSB-R MARKET RISK - FOREIGN EXCHANGE RATE VALUE CHANGE 24 THRPSC-R MARKET RISK - INVESTMENT RETURN RATE CHANGE RISK 25 THRSAS-R INSURANCE RISK 26 THRSAS1-R INSURANCE RISK - CONTRIBUTION PROVISION 27 THRSAS2-R INSURANCE RISK - PROVISION FOR CONTRIBUTIONS NOT YET REVENUE 28 THRSAS3-R INSURANCE RISK - CLAIM PROVISION 29 THRSAS4-R INSURANCE RISK - DISASTER RISK PROVISION 30 THRSOS-R OPERATIONAL RISK 31 THRA110-R Investment and Property Detail 32 THRA120-R Receivable Detail 33 THRA130-R Other Assets Detail 34 THRA210-RU Payable Detail 35 THRA220-R Ujroh Provision, Contribution Provision, Provision for Contributions Not Yet Revenue 36 THRA221-R Claims Provision 37 THRA222-R PROVISION FOR DISASTER RISK (CATASTROPHIC RISK) 38 THRA310-R Recapitulation Detail of Assets and Liabilities Based on Currency and Maturity 39 CONTRIBUTION DETAIL 40 CLAIM DETAIL 41 POLICY DETAIL 42 PROVISION DETAIL 43 THRC110-RE Summary of Guarantee Fund Development and Guarantee Fund Adequacy Calculation 44 THRD110-R Microinsurance Marketing Performance Per Product Type 45 THRD-120 Performance of Microinsurance Marketing Channels 46 THRF110 Outward Reinsurance Detail

General Data
Report Version 4/30/2020 12:51:55 PM Reporting Date Company Code / Party Company Name / Party Reporting Period Reporting Month January Fiscal Year Reporting Period Type Annual Report Directorate Name / Person in Charge Directorate Position / Person in Charge Company Address / Party

Company Profile
As of Jan-31-1900
Description
Company Name
Full Address
Total Participants
External Auditor
Controller
Total Branches/Representatives
Total Employees
Telephone
Fax
Email
Extension
PIC Financial Report
Report Compiler
Officer Name
Division
Telephone
Fax
E-mail
Extension
Directorate Responsible Person
Responsible Person Name
Position
DATI I (Province)
DATI II (Regency/City)
Business License No.
Business License Date
`
Fax
Telephone
E-mail
NPWP

Shareholder
Name
Parent
Shareholder
Shareholder
Controller
Group
Degree
Level
Ownership
Type of Shareholder (Code
Counterparty)
Location
Code
(Country)
Name
Supervisory Authority
Insurance Subsidiary
Rating
Legal Entity
Rating Agency
Equity
Period
Equity
Nominal
Shares
(Rp)
Ownership Percentage
(%)
Row Number
Shareholder Detail
As of Jan-31-1900

Row Number Name Position Start Date Key Party Detail As of Jan-31-1900

Participant Type Training Cost Education and Training (Employees/Directorate/Commissioners/DPS) Realization Education and Training Detail As of Jan-31-1900 (in millions of rupiah) Row Number Description

Marketing
Media
Currency
Code
Approval
Number /
Product Recording at OJK
Loss
Ratio
(%)
Morbidita
(Health Insurance)
Commission
Expense
(Rp)
General Costs
&
Administration
(Rp)
Underwriting
Result
(Rp)
Loss
Ratio
(%)
Morbidita
(Health Insurance)
Commission
Expense
(Rp)
General Costs &
Administration
(Rp)
Underwriting
Result
(Rp)
PRODUCT PROFILE DETAILS
Estimate
Profit
/Loss*
Calculation
Method
Estimation*
Description
Investment
Product
(Yes/No)
Assumption* Realization*
Reinsurance
Support
Impact deviation against
Contribution that has been set
Mitigation that was done to overcome deviation and impact deviation (if any) Code Business Line Product Code from Company (Unique for all fields in this product profile) Product Name Product Status Channel Code Marketing License Date Product

BRANCH / REPRESENTATIVE PROFILE
Branch Name Office License No. Office License Date Type of Branch/Representative Office Leader Name Location Address (DT II) Latitude Longitude Phone No. Email

-
-

Position Statement Report
As of Jan-31-1900
(in millions of rupiah)
Adjustment
Combined
SAK
ASSETS
SAP
Tabarru' Funds
SAK SAP
Participant
Investment Funds
DESCRIPTION
SAK SAP
Company
Funds
SAK
Certificate Deposits - - -
Shariah Stocks - - -
Investments
Deposits - - -
Shariah Government Securities - - - Shariah Securities Issued by Bank Indonesia - - - Sukuk or Shariah Bonds - - - Shariah MTN - - - Shariah Mutual Funds - - - Shariah Asset-Backed Securities - - - Shariah Securities Issued by Countries Other Than [Indonesia] - - - Shariah Securities Issued by Multilateral Institutions - - - Financing Through Cooperation with Other Parties. - - - Shariah Financing With Mortgage Rights - Shariah Real Estate Investment Funds - - - REPO - - - Regional Sukuk - - - Infrastructure Investment Fund in the form of investment contracts - - - Direct Participation - Investment Properties - Pure Gold - - - Receivables - - - Reinsurance Assets - Other Investments - - Not an investment Cash and Banks - - - LIABILITIES AND EQUITY Liabilities Payables for claims or investment benefits - - Deferred acquisition costs - Non-Investment Properties - Other Assets - -

Expenses Still Payable - - - - - - -

Technical Provisions
Ujroh provision - - -
Other payables - - - -
Provision for contributions not yet revenue - - Claims provision - - Provision for PAYDI providing principal investment guarantee - - - Contribution provision - - Fund Equity Paid-in Capital - - - Provision for disaster risk - - Qardh - - - - - Profit Equilization Reserve - - - Retained Earnings Balance - - Agio/Disagio Shares - - - Accumulated Funds - - - - - Forbidden Wealth - - - -

Difference between SAK Balance and SAP Balance - - - - Other Equity Components - - - -

Financial Performance Report
For the Period Ending 31-Jan-1900
(in millions of rupiah)
INCOME
INVESTMENT INCOME AND INVESTMENT MANAGEMENT UJROH Investment Results Mudharabah Contract Participant Investment Fund Combined Adjustment Description Company Fund Tabarru' Fund Wakalah Bil Ujrah Contract Total Investment Results Total Investment Management Ujroh Investment Results Distributed to Company Fund Total Income from Investment Results and Investment Management Ujroh UNDERWRITING INCOME Gross Contribution/Ujroh Received/Investment Allocation a. Direct Contribution Allocation: Tabarru'/Ujroh/Investment Reinsurance/Retrocession Contribution Net Contribution b. Indirect Contribution Allocation: Tabarru'/Ujroh Total Gross Contribution/Ujroh Received/Allocated for Investment b. Decrease (Increase) in Provision for Unearned Contributions and Provision for Accrued Benefits (PKYBMP)
c. Decrease (Increase) in Provision for Catastrophic Risks
Decrease (Increase) in Provision for Contributions and PKYBMP a. Decrease (Increase) in Provision for Contributions UNDERWRITING EXPENSES Claim Expenses a. Gross Claims b. Recovery Claims Total Net Contribution Income UNDERWRITING INCOME EXPENSES e. Withdrawal/Redemption of Participant Investment Funds (not yet due) Total Net Claim Expenses
c. Increase (Decrease) in Claim Provisions
d. Withdrawal of Participant Investment Funds that have matured TOTAL UNDERWRITING SURPLUS (DEFICIT) a. Underwriting surplus for Company fund Adjuster Expenses TOTAL UNDERWRITING EXPENSES BUSINESS EXPENSES:
a. Marketing Expenses b. Underwriting surplus for Participants

Education and Training Expenses
Other General and Administrative Expenses
b. Acquisition Expenses
c. General and Administrative Expenses:
Employee and Management Expenses
INSURANCE BUSINESS PROFIT (LOSS)
Other Income
Increase (Decrease) in Ujroh Provisions TOTAL BUSINESS EXPENSES TOTAL PERFORMANCE OF ALL FUNDS OTHER COMPREHENSIVE INCOME Income Tax PROFIT AFTER TAX PROFIT (LOSS) BEFORE TAX Other Expenses Increase (Decrease) in Asset Values

-
Description
Company Fund Tabarru' Fund Wakalah Bil Ujrah Contract Cash Flow Statement For the Period Ending 31-Jan-1900 (in millions of rupiah) Mudharabah Contract Participant Investment Fund Combined - Ujroh received - INCREASE (DECREASE) IN CASH BALANCE ENDING CASH BALANCE CASH FLOWS FROM OPERATING ACTIVITIES a. Cash Inflows Contributions from Participants Beginning Balance - - - - Receipt of Tabarru' Fund Surplus Allocation - Reinsurance Claims Received - Receipt of Reinsurance Underwriting Surplus Distribution - Coinsurance Claims

-
b. Cash Outflows
Claims Paid - - -
Others - - - -
Payment of UW Surplus Distribution to Company - Payment of UW Surplus Distribution to Participants/Policyholders - Acquisition Expenses - Withdrawal of Participant Investment Funds that have matured - - Withdrawal/Redemption of Participant Investment Funds not yet due - - - Reinsurance Contributions Paid - - Rent Payments - Marketing Expenses - Reinsurance Ujroh Payments - Insurance Ujroh Payments

CASH FLOWS FROM INVESTING ACTIVITIES a. Cash Inflows Zakat Payments - Tax Payments - Others - Tabarru' Fund Investment Profit Sharing Receipts - Participant Investment Fund Investment Profit Sharing Receipts - Investment Liquidation - Investment Results Receipts - - Others - - - -

Sale of Fixed Assets -
-
Investment Results Distributed to Company Fund - - - b. Cash Outflows Investment Placements - - - Others - - - - Payments of ujroh/fees to Company - - - Purchase of Fixed Assets - Qardh Receipts - Others - CASH FLOWS FROM FINANCING ACTIVITIES a. Cash Inflows Capital Deposits/Working Capital - Subordinated Loans -

-
Dividend Payments
Qardh Payments -
Others - -

b. Cash Outflows
Subordinated Loan Payments

Wakalah Bil Ujrah Contract Mudharabah Contract

STATEMENT OF CHANGES IN FUNDS
For the Period Ending 31-Jan-1900
(in millions of rupiah)
DESCRIPTION Company Fund Tabarru' Fund Combined
I. Beginning Fund Balance - -
Participant Investment Fund
II. Additions
Paid-in Capital -
Comprehensive income for the current period - Increase in accumulated Tabarru' funds / participant investment funds - Other additions - -
III. Deductions
Comprehensive loss for the current period - Decrease in accumulated Tabarru' funds / participant investment funds -
IV. Ending Fund Balance
-
Dividend Payments -
Other deductions - -
ANALYSIS
ASSET AND LIABILITY CALCULATION
As of 31-Jan-1900
(in millions of rupiah)
Certificate of Deposit
AYD
After
Perimeter Limit
Asset Type
AYD
After
Affiliation Limit
AYD
After
Foreign Limit
(Balance
SAP)
I. Investments
Deposit
Description Book Balance
(SAK)
Valuation
Based on
SAP
Difference Based on
Valuation
Based on
SAK and SAP
AYD After
Perimeter Limit
Company
Sharia Bonds or Sukuk
Sharia Stocks
Indonesian State Sharia Securities
Sharia MTN
State Sharia Securities Other than RI Bank Indonesia Sharia Securities Sharia Mutual Funds Multinational Institution Sharia Securities Sharia Real Estate Investment Funds Sharia Asset-Backed Securities Financing Through Cooperation with Other Parties (Executing) REPO Direct Participation Sharia Financing with Mortgage Rights Pure Gold Investment Property Infrastructure Investment Funds in the form of contracts Regional Sukuk Indirect Closing Ujroh Receivables Other Investments Total Investments
II. Non-Investments
Cash and Banks
Investment Receivables
Investment Result Receivables
Other Assets
Total Non-Investments
TOTAL WEALTH (I+II)
Non-Investment Property
Deferred Acquisition Costs
Reinsurance Assets
I. Liabilities
II. Ujroh Provisions
III. Provisions for Guaranteeing Principal Investment PAYDI
TOTAL LIABILITIES (I+II+III)
I. Investments
Deposit
Certificate of Deposit
Sharia Stocks
Sharia Bonds or Sukuk
TABARRU' FUNDS
Sharia MTN
Indonesian State Sharia Securities
Bank Indonesia Sharia Securities
State Sharia Securities Other than RI Multinational Institution Sharia Securities Sharia Mutual Funds Sharia Asset-Backed Securities Sharia Real Estate Investment Funds REPO Financing Through Cooperation with Other Parties (Executing) Pure Gold Regional Sukuk Collective Investment Contract Infrastructure Investment Funds Other Investments Total Investments COMPANY FUNDS PAYDI Assets Guaranteed

ANALYSIS
ASSET AND LIABILITY CALCULATION
As of 31-Jan-1900
(in millions of rupiah)
AYD
After
Perimeter Limit
Asset Type
AYD
After
Affiliation Limit
AYD
After
Foreign Limit
(Saldo
SAP)
Description Book Balance
(SAK)
Valuation
Based on
SAP
Difference Based on
Valuation
Based on
SAK and SAP
AYD After
Perimeter Limit
Company
PAYDI Assets
Guaranteed
Total Non-Investments
TOTAL WEALTH (I+II)
Liabilities
PARTICIPANT INVESTMENT FUNDS
II. Non-Investments
Cash and Banks
Indirect Closing Contribution Receivables TOTAL LIABILITIES REPO Financing Through Cooperation with Other Parties (Executing) Pure Gold Regional Sukuk Collective Investment Contract Infrastructure Investment Funds Other Investments Total Investments
II. Non-Investments
Cash and Banks
Provisions for PAYDI providing principal investment guarantees Sharia Bonds or Sukuk Sharia MTN Indonesian State Sharia Securities Bank Indonesia Sharia Securities State Sharia Securities Other than RI Multinational Institution Sharia Securities Sharia Mutual Funds Sharia Asset-Backed Securities Sharia Real Estate Investment Funds Investment Result Receivables Investment Receivables Other Assets Total Non-Investments TOTAL WEALTH ( I + II ) Liabilities Accumulation of Participant Investment Funds Contribution Provisions Provision for Contributions Not Yet Revenue (PKYBMP) Claim Provisions Provision for Catastrophic Risks TOTAL LIABILITIES
I. Investments
Deposit
Certificate of Deposit
Sharia Stocks
Reinsurance/Retrocession Contribution Receivables Reinsurance/Retrocession Claim Recovery Receivables Investment Result Receivables Investment Receivables Reinsurance Assets Other Assets

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

0,00% 0,00%
FINANCIAL RATIOS
ACHIEVEMENT OF SOLVENCY LEVEL
As of 31-Jan-1900
(in millions of rupiah)
Description Tabarru' Fund
Company Fund
Solvency Level
A. Permitted Assets (AYD)
B. Liabilities other than Qardh from Company Fund DTMBR/MMBR A. Credit Risk B. Liquidity Risk
C. Market Risk
D. Insurance Risk
E. Operational Risk
F. MMBR on 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 Available for Qardh (in %) 0,00% 0,00% Solvency Level Ratio with DTMBR/MMBR Required by Regulations (percentage according to POJK 72) 0,00% 0,00% Assets Available For Qardh Considered as Addition to Tabarru' Fund AYD A. Deficiency (Surplus) of solvency level from internal target B. Insufficient investments, cash and banks Solvency Level Ratio for Tabarru' Fund and Tanahud Fund Internal Target Solvency Level Ratio (annual) (percentage according to POJK 72)

-
-
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 RATIOS
OTHER THAN SOLVENCY LEVEL
As of 31-Jan-1900
(in millions of rupiah)
Description
Tabarru' Fund Company Fund
Combined Indicator
Liquidity Ratio
A. Current Wealth - -
B. Current Liabilities - -
C. Ratio (a:b)
Ratio of investment balance to liabilities A. Investments, cash and banks - B. Technical provisions for own retention -
C. Own retention claim liabilities -
D. Ratio [a:(b+c)]
Net investment income ratio
A. Net investment income -
Assets Considered For Qardh in Company Fund D. Ratio [a:(b+c)] after addition - 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 (Conventional) - -
D. Ratio (a+b) : (a+b+c)
Calculation of Required Qardh for Tabarru' Fund Employee and Management Costs Education and Training Costs Education and Training Ratio A. Total Liabilities other than Qardh - B. Total Assets - Total Required Qardh (a-b)

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

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

- - 0,00% - - -
- - 0,00% - - -
- - 0,00% - - -
- - 1,20% - - -
- - 2,10% - - -
- - 3,00% - - -
- - 4,50% - - -
- - 9,00% - - -
- - 0,00% - - -
- - 1,60% - - -
- - 2,80% - - -
- - 4,00% - - -
- - 6,00% - - -
- - 12,00% - - -
- - 0,00% - - -
- - 1,60% - - -
- - 2,80% - - -
- - 4,00% - - -
- - 6,00% - - -
- - 12,00% - - -
- - 0,00% - - -
- - 0,00% - - -
- - 0,00% - - -
- - 1,60% - - -
- - 2,80% - - -
- - 4,00% - - -
- - 6,00% - - -
- - 12,00% - - -
- - 0,00% - - -
- - 1,00% - - -
- - 0,00% - - -
- - 1,60% - - -
- - 2,80% - - -
- - 4,00% - - -
- - 6,00% - - -
- - 0,00% - - -
- - 0,00% - - -
- - 2,80% - - -
    4,00% - - -

5,60% - - -
8,00% - - -
12,00% - - -
MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND CREDIT RISK - DEFAULT OR INABILITY OF DEBTOR OR OTHER PARTY As of 31-Jan-1900 (in millions of rupiah) Investments Time Deposits - - - Factor Tabarru' Fund Company Fund Total Deviation PAYDI (guaranteed) Description Tabarru' Fund Company Fund PAYDI (guaranteed) Total AYD a. Cluster Rank 1 - - - b. Cluster Rank 2 - - - Special Category (up to 2 billion per bank)

Other Categories, according to Bank Rating:
e. Cluster Rank 5 - - -
Sharia Corporate Sukuk / Bonds
c. Cluster Rank 3 - - -
d. Cluster Rank 4 - - -
Certificate of Deposit
Special Category (up to 2 billion per bank) Other Categories, according to Bank Rating:
a. Cluster Rank 1 b. Cluster Rank 2
c. Cluster Rank 3
d. Cluster Rank 4 e. Cluster Rank 5
c. Cluster Rank 3
d. Cluster Rank 4 a. Cluster Rank 1 b. Cluster Rank 2 e. Cluster Rank 5 Sharia MTN
c. Cluster Rank 3
d. Cluster Rank 4 a. Cluster Rank 1 b. Cluster Rank 2 e. Cluster Rank 5 Securities Issued by Multinational Institutions
c. Cluster Rank 3
d. Cluster Rank 4 a. Cluster Rank 1 b. Cluster Rank 2 Securities Issued by Bank Indonesia Securities Issued by Countries other than RI e. Cluster Rank 5 State Sharia Securities Loans Secured with Mortgage Rights Residential Property a. LTV < 65% c.Unhealthy d.Not Healthy a.Very Healthy b.Healthy REPO Financing Through Cooperation with Other Parties* Other Commercial Properties a. LTV < 65% - - - b. 65% < LTV < 75% - - - b. 65% < LTV < 75% - - - Unused Properties - - - Factor Tabarru' Fund Company Fund Total Deviation PAYDI (guaranteed) Description Tabarru' Fund Company Fund PAYDI (guaranteed) Total AYD

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

Regional Sukuk a. Cluster Rank 1 - - - d. Cluster Rank 4 - - - e. Cluster Rank 5 - - - b. Cluster Rank 2 - - -
c. Cluster Rank 3 - - -
Indirect Closing Contribution Receivables

Reinsurance Assets
Non-Investments
Cash and Banks - - -
Coinsurance Claim Receivables
Domestic - - - a. assets sourced from estimated claim recovery value over reinsurance coverage portion (charged in Credit Risk b)

b. assets sourced from long-term contract agreements for capital-oriented reinsurance support programs ( - - - b. Cluster Rank 2 - - -
c. Cluster Rank 3 - - -
Foreign:
a. Cluster Rank 1 - - -
Reinsurance Contribution Receivables Domestic - - - d. Cluster Rank 4 - - - e. Cluster Rank 5 - - - Cluster Rank 2 - - - Cluster Rank 3 - - - Foreign Cluster Rank 1 - - - Reinsurance Claim Receivables Domestic - - - Cluster Rank 4 - - - Cluster Rank 5 - - - b. Cluster Rank 2 - - -
c. Cluster Rank 3 - - -
Foreign:
a. Cluster Rank 1 - - -
Investment Receivables a. Investments not yet paid on the maturity date

d. Cluster Rank 4 - - - e. Cluster Rank 5 - - - Total b. Investments that failed to pay on the maturity date/at the time of liquidation

Investment Result Receivables - - -

Automatic Reinsurance
(Treaty)
0,00% -
-Proportional - 0,00% -
- Quota Share - 0,00% -
- Surplus - 0,00% -
- Non Proportional - 0,00% -
- Cath X/L - 0,00% -
- Work X/L - 0,00% -
  -
  Facultative Reinsurance
0,00% -
-Proportional - 0,00% -
- Quota Share - 0,00% -
- Surplus - 0,00% -
- Non Proportional - 0,00% -
- 0,00% -
  MINIMUM RISK-BASED TABARRU' FUND
  CREDIT RISK - REINSURER DEFAULT/DISABILITY As of 31-Jan-1900 (in millions of rupiah) 2 - - Net Reinsurance Exposure ((2)-(3)) Factor Total Deviation 1 - - Row Number Technical Provisions Reinsurer Expense and/or Contribution withheld by Company Code Type Reinsurer Name Reinsurance Type 5 - - 4 - - 3 - - 8 - - 7 - - 6 - - 11 - - 10 - - 9 - - 13 - - 12 - -

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 As of 31-Jan-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 years Tabarru' Fund PAYDI (guaranteed) More than Total 10 years Tabarru' Fund Up to 1 year Assets Investments Time Deposits - - - - - - 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

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

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

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

Securities Issued by Countries Other Than RI

Securities Issued by Bank Indonesia -

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

Sharia Real Estate Investment Funds

Sharia Asset-Backed Securities -

Financing Through
Cooperation with Other Parties
(Executing)

REPO -
Sharia Financing with
Mortgage Rights

Pure Gold - - - - - -
-
Investment Property - - - - -
Direct Participation - - - -
-
Regional Sukuk - - - - - - - - - - - - - -

-
Infrastructure Investment Funds in the form of collective investment contracts

Other Investments - - - - - - - - - - - - - - - Non-Investments Cash and Banks - - - - - - - - - - - - - - - Contribution/Ujroh Receivables Indirect Closing

Contribution/Ujroh Receivables
Reinsurance

Reinsurance Assets - - - - - - - -
-
Claim Recovery Receivables - - - - - - - - Coinsurance Claim Receivables - - - - - - - Investment Receivables - - - - - - - - - - - - - -

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

Other Assets - - - - - - - - - - - - Coinsurance Liabilities - - - - - - - Liabilities and Equity Liabilities Liabilities Claim Liabilities or investment benefits

-
Reinsurance Liabilities - - - - - - - - - - - - - -

-
Ujroh Liabilities - - - - - - - - - - - - - - -

Expenses Still Payable

Tax Liabilities -
-
Technical Provisions
Ujroh Provisions - - - - -
-
Other Liabilities - - - - - - - - - - - - - -

-
Provisions for contributions that are not yet revenue

-
Contribution Provisions - - -
Provisions for PAYDI that provide principal investment guarantee

-
Provisions for catastrophic risks

Claim Provisions - - - -
-
DIFFERENCE BETWEEN LIABILITIES AND ASSETS DEVIATION (4% X (Max (Li - AYDi), 0)) Accumulation of Participant Investment Funds - - - - - - - - - -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND MARKET RISK As of 31-Jan-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

15% - - -
20% - - -

20% - - -
30% - - -

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

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

10% - - -
20% - - -

7% - - -
15% - - -
40% - - -
3% - - -
10,00% - - -

4% - - -

MINIMUM RISK-BASED CAPITAL AND MINIMUM RISK-BASED TABARRU' FUND MARKET RISK - MARKET PRICE CHANGES As of 31-Jan-1900 (in millions of rupiah) Factor Company Fund Tabarru' Fund Total Deviation PAYDI (guaranteed) Description Company Fund Tabarru' Fund PAYDI (guaranteed) Total AYD - Shares traded on Indonesian exchange - - - Investments Sharia Stocks Including IDX30 or JII - - Other Shares - - - Sharia Mutual Funds Shares traded on foreign exchanges - - - Shares constituting the main index of the main stock exchange of Asia Pacific and European countries members of World Federation of Exchanges

Fully consisting of equity securities - - - Mixed*) Fully consisting of government debt securities - - - Fully consisting of private debt securities and/or money market securities (SBPU)

-
Tabarru' Fund - - - -
Company Fund - - - -
Sharia Asset-Backed Securities a. Cluster Rank 1 - - - PAYDI (guaranteed) - - - d. Cluster Rank 4 - - - e. Cluster Rank 5 - - - b. Cluster Rank 2 - - -
c. Cluster Rank 3 - - -
Under OJK Supervision - - -
Not Under OJK Supervision - - -
Real Estate Investment Funds - - -
Direct Participation
Investment Results 2% - 4% - - -
Investment Results less than 2% - - - Investment Property Investment Results 4% or more - - - TOTAL NON-INVESTMENTS Non-Investment Property - - - Pure Gold - - - Collective Investment Contract Infrastructure Investment Funds - - -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUND MARKET RISK - FOREIGN CURRENCY EXCHANGE RATE FLUCTUATION RISK As of Jan 31, 1900 (in millions of Rupiah) EUR SGD IDR Other Total EUR DESCRIPTION USD JPY GBP AUD Company Fund Permitted Assets Deposits - - - SGD IDR Other PAYDI (Guaranteed) SGD IDR Other Total USD JPY GBP AUD EUR Total Tabarru Fund USD JPY GBP AUD

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

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

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

Sharia Securities Issued by Countries Other Than the Republic of Indonesia

Sharia Securities Issued by Bank Indonesia - - - - -

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

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

REPO - - - - - - - -

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

Financing Through Cooperation with Other Parties.

Infrastructure Investment Fund in the form of collective investment contracts

Regional Sukuk - - - - - - - - - - - - -

Cash and Banks - - - -
Other Investments - - - - - - - - -

Reinsurance Contribution Receivables - - - - Direct Closing Contribution Receivables

Reinsurance Assets - - - -

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

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

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

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

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

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

Accrued Expenses - - - - - - - - - - - -

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

-
-
Ujroh Provisions - - - -

Contribution Provisions
Provisions for Contributions That
Have Not Yet Become Revenue
Claim Provisions
Provisions for Catastrophe Risks
Total Liabilities
Principal Investment Guarantee Provisions

Total Permitted Assets
In Rupiah
Total Liabilities In Rupiah
Difference Between Permitted Assets And Liabilities Factor Total Deviation Exchange Rate - - - - - - - - - - - - -

15% 15%

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

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

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUND INSURANCE RISK - CONTRIBUTION PROVISIONS 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) - -
Hull (Marine Hull) - -
Aviation Hull (Aviation Hull) - -
Satellite - -
Onshore Energy (Oil and Gas) - -
Offshore Energy (Oil and Gas) - -
Engineering - -
Liability - -
Credit - -
Miscellaneous - -
Health - -
I. Total max ((PK* - PK), 0)
Personal Accident - -
Life*) - -

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

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUND INSURANCE RISK - PROVISIONS FOR CONTRIBUTIONS THAT HAVE NOT YET BECOME REVENUE 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) - -
Hull (Marine Hull) - -
Aviation Hull (Aviation Hull) - -
Satellite - -
Onshore Energy (Oil and Gas) - -
Offshore Energy (Oil and Gas) - -
Engineering - -
Liability - -
Credit - -
Miscellaneous - -
Life*) - -
Total ((PAKYBMPi - ARi)fpbi + (PKi - Health - - Personal Accident - -

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

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

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

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

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUND INSURANCE RISK - PROVISIONS FOR CATASTROPHE RISKS As of Jan 31, 1900 (in millions of Rupiah) Catastrophe Risk Provisions AR fpk Total Deviation Catastrophe Risk Provisions ((2) - (3)) x (4) Property - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

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

-
-
-
-
-
-
-
-

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM 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. Subtotal Company Operational Risk (c+e) PAYDI Operational Risk (ROPAYDI) g. PAYDI Fund Assets - Total Deviation (f+h+j) h. Subtotal PAYDI Operational Risk (ROPAYDI = Tabarru Fund' Operational Risk (RODT)
i. Tabarru Fund' Investments -
j. Subtotal RODT = (1‰*i)

Account Number
(SID
/ Bank
Account)
Investment Type Code
Instrument Name
Investment Instrument Code
Issuer Name /
Counterparty
Group Code
Company / Issuer
Group Name
Fund Type Code
Fund Code
Collateral
Investment Code
In The Context Of
Infrastructure Financing
Supervisor Code
DD/MM/YYYY
Start Date
DD/MM/YYYY
Maturity Date
Debtor Rating Code
Rating Agency Name Code
Category Code
Business /
Debtor Category
Sector Code
Economic Location Code

(in millions of Rupiah)
Row Number
Time Horizon
DETAILS A-110. Investment and Property Details As of Jan 31, 1900

(in millions of Rupiah)
Row Number
DETAILS A-110. Investment and Property Details As of Jan 31, 1900 Status Code Relatedness Code Ownership Purpose Code Ownership Share (%) Currency Code Type Code Return Rate Return Rate (%) Collectibility Code Acquisition Value Book Balance Valuation Balance SAP Investment Income Due Period Received Cash Receivables Investment Income Receivables Investment Income Previous Period Cash Received Current Period Total Investment Income Investment Income Ready For Distribution

- 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% - - - - - - - -
  (in millions of Rupiah)

DETAILS A-120. Receivables Details
As of Jan 31, 1900
(in millions of Rupiah)
AYD
(Million
Rp)
1 - - - - - - - -
DD/MM/YYYY
Start Date
Currency Code
Debtor Rating Code
Book Balance
(Million Rp)
Valuation Balance
SAP (Million
Rp)
Row Number
Debtor Name
Category Code
Business /
Debtor Category
Receivable Type Code
Fund Type Code
-
3 - - - - - - - -
2 - - - - - - -
-
5 - - - - - - - -
4 - - - - - - -
-
7 - - - - - - - -
6 - - - - - - -
-
9 - - - - - - - -
8 - - - - - - -
10 - - - - - - - -

-
-
-
-
-
-
-
-
-
-
DETAILS A-130. Other Assets Details As of Jan 31, 1900 (in millions of Rupiah) Description 1 - - Row Number Asset Name Underlying Valuation Code Fund Type Market Value / Appraisal Million (Rp) 3 - - - 2 - - - 5 - - - 4 - - - 7 - - - 6 - - - 9 - - - 8 - - - 10 - - -

DETAILS A-210. Payables Details
As of Jan 31, 1900
(in millions of Rupiah)
Currency Code
Country Code
Book Balance
(Million Rp)
Valuation Balance
SAP (Million
Rp)
Row Number Name Code Payable Type
Fund Type Code
DD/MM/YYYY
Start Period
1 - - - - - -

3 - - - - - -
2 - -

5 - - - - - -
4 - -

7 - - - - - -
6 - -

9 - - - - - -
8 - -
10 - - - - - -

DETAILS A-220. UJROH PROVISIONS, CONTRIBUTION PROVISIONS, AND PROVISIONS FOR CONTRIBUTIONS THAT HAVE NOT YET BECOME REVENUE As of Jan 31, 1900 (in millions of Rupiah) Catastrophe Risk Provisions For PAYDI Combined Total
I. Ujroh/Contribution Provisions
Property - -
Catastrophe Risk Provision Catastrophe Risk Provision For PAYDI Total Tabarru Fund Risk Provision Insurance Branch Ujroh Provision Ujroh Provision For PAYDI Total Company Fund Hull (Marine Hull) - - Aviation 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) - -
-
Health - -
Credit - -
Liability - -
Personal Accident - - -
Life*) - -
II. PKYBMP
Property - -
Suretyship - -
Miscellaneous - -
Hull (Marine Hull) - -
Aviation 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 - -
Suretyship - -

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

DETAILS A-221.
CLAIM PROVISIONS
Monthly
Insurance Branch
Provision For Claims In Process IBNR Claim Provisions Provision For Periodic Payment Claims Tabarru Fund Total Claim Provisions Property - - - Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident)

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

DETAILS A-222
Catastrophe Risk Provisions
As of Jan 31, 1900
Insurance Branch
Self-Retention
Tabarru Fund
Reinsurance
Property - -
Motor Vehicles (Own Damage,
Third Party Liability, and Personal Accident)

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

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%

- - - - 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% Total DETAILS A-310 Asset and Liability Recapitulation Details By Currency And Maturity Age As of Jan 31, 1900 Asset Age (SAK) Liabilities (SAK) Asset Ratio Against Tabaru Fund <= 1 year 1 year < age < 5 years 5 years = age < 10 years >= 10 years 5 years = age < 10 years Current Asset (Liability) Ratio Against Assets Company Fund <= 1 year 1 year < age < 5 years 5 years = age < 10 years >= 10 years Total Current Asset (Liability) Ratio Against Assets Company Investment Fund <= 1 year 1 year < age < 5 years 5 years = age < 10 years >= 10 years Total Current Asset (Liability) Ratio Against Assets >= 10 years Total Current Asset (Liability) Ratio Against Assets ALL <= 1 year 1 year < age < 5 years Product Code Policy Type Payment Method Location Economic Sector Code Policyholder Code Counterparty Policyholder Type: - Ujrah - Tabarru - Tanahud - DIP - Wakalah Bil Agreement - DIP - Mudharabah Agreement Commission Expense New Renewal Top Up Gross Contribution CONTRIBUTION DETAILS

Product Code
Policy Type
Payment Method
Location
Economic Sector Code
Policyholder
Code
Counterparty
Policyholder Code
Gross Claims
Claims Recovery
Withdrawal Of
Investment Funds
Participants Who
Mature
Withdrawal Of
Funds
Investment
Participants
Not Yet Mature
(Akad
Wakalah Bil
Ujrah)
Withdrawal Of
Investment Funds
Participants Not Yet
Mature
(Akad
Mudharabah)
Expense
Adjuster
Total
Policies
Claims
Total
Participants
Claims
Tabarru
Fund
Tanahud
Fund
Tabarru
Fund
Tanahud
Fund
Wakalah Bil
Agreement
Mudharabah
Agreement
Partial Withdrawal
Full Withdrawal
Partial Withdrawal
Full Withdrawal
Tabarru
Fund
TanAHUD
Fund
CLAIMS DETAILS

Product Code
Policy Code
Traditional
/PAYDI
Policy Type Code
Payment Method Code
Location Code
Economic Sector Code
Policyholder
Code
Counterparty
Policyholder Code
Status
(Active/N on Active)
Inforce/Not Inforce Code
Total
Policies
Total
Participants
Total
Benefits
Sharia Insurance
(Millions
Rp)
POLICY DETAILS
Renewing Participants
New Participants
Restoration Of Membership
Change From Other Insurance Lines
Participant Deceased
Membership Contract Expired
Termination Of Products Produced In The Current Year Change To Other Insurance Lines

Contribution Provisions (Rp)
Provisions for contributions that have not yet become revenue (Rp) Ujroh Provisions (Rp) Claims/Benefits Provisions In Process (Rp) Total Policies Product Code Technical Provisions* PROVISIONS DETAILS

-
-
-
-
-
-
-
-
-
-
-
-
C-110. GUARANTEE FUND REPORT
Summary Of Guarantee Fund Development And Calculation Of Guarantee Fund Adequacy As of Jan 31, 1900 Description Total

Summary Of Guarantee Fund Development
Opening Balance Of Guarantee Fund - New Guarantee Fund Placements:
a. Guarantee Fund In The Form Of Deposits - b. Guarantee Fund In The Form Of SUN/Other Government Securities (SBN) - Total New Guarantee Fund Placements (3 + 4) Disbursement Of Guarantee Funds:
a. Guarantee Fund In The Form Of Deposits - b. Guarantee Fund In The Form Of SUN/Other Government Securities (SBN) - Total Disbursement Of Guarantee Funds (7 + 8) Closing Balance Of Guarantee Fund (1 + 5 – 9)
Annual Calculation Of Guarantee Fund Adequacy
Required Minimum Equity -
Net Contribution Total*) -
Reinsurance Contribution Total*) -
Total Provisions 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)) Minimum Guarantee Fund Limit Used (The Greater Of 5 And 6) Guarantee Funds Owned Excess (Deficiency) Of Guarantee Funds (8 - 7)

DETAILS D-110
Micro Insurance Marketing Performance Per Insurance Product Type As of Jan 31, 1900 In Accordance With SEOJK No. 9/SEOJK.05/2017 Total Membership Ended Due To Claims Total Active Participants At The End Of The Reporting Period Gross Contribution (Rp) Gross Claims (Rp) Total Participants Claims Total Active Participants At The Beginning Of The Reporting Period Total New Participants In The Reporting Period Total Membership That Was Renewed In The Reporting Period Total Membership That Ended Due To Maturity Total Membership That Was Cancelled

- - - - 1 - - -
        Row Number Name
        Product
        Policy Type
        (Group/
        Individual)
        Line Of Business
- 2 - - - - - - - - - -

3 - - - - - - - - - - - -
5 - - - - - - - - - -

- - - - 4
        6 - - - - - - - - - - - -
        -
- - - - 7 - - -
- 8 - - - - - - - - - -

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

- - - - 10

DETAILS D-110
Micro Insurance Marketing Performance Per Insurance Product Type As of Jan 31, 1900 1 - - Row Number Name Product Policy Type (Group/ Individual) Line Of Business 2 - -

-
3 - -
5 - -
6 - -
7 - -
8 - -
-
-
9 - -
DETAILS D-110
Micro Insurance Marketing Performance Per Insurance Product Type As of Jan 31, 1900 Total Participants Active At The Beginning Of The Reporting Period Total New Participants In The Reporting Period Total Membership That Was Renewed In The Reporting Period Total Membership That Ended Due To Maturity Not In Accordance With SEOJK No. 9/SEOJK.05/2017 Total Participants Claims - Not In Accordance With Grand Design Micro Insurance Total Membership That Ended Due To Claims Total Active Participants At The End Of The Reporting Period Gross Contribution (Rp) Gross Claims (Rp)

DETAILS D-120. Micro Insurance Distribution Channel Performance As of Jan 31, 1900 (in millions of Rupiah) Total Legal Entities Marketers Legal Entity Total Individual Marketers Name Of Product Being Marketed Total Participants Gross Contribution (Rp) Row Number Distribution Channel Type Marketing Region Legal Entity Category

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

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

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

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

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

Domestic
Within
Country
Line Of Business Code
Policy Type Code
Contributions To
Reinsurer
Ujroh To
Reinsurer
Claim
Recovery
Underwriting Surplus From
Reinsurer
Contributions Paid
Ujroh
Received
Claim
Recovery
Underwriting Surplus
From Reinsurer
Contributions Paid
Ujroh
Received
Claim
Recovery
Underwriting Surplus
From Reinsurer
DETAILS F-110. Outward Reinsurance
Sharia Insurance Business
As of Jan 31, 1900
Row Number
Domestic ASEAN NON-ASEAN

IC FORMAT
To
Dear Sharia IKNB Directorate
Financial Services Authority
Wisma Mulia 2
Jakarta - 12710
ANNUAL REPORT
SHARIA LIFE INSURANCE BUSINESS
January 1900 Year

No.	Sheet Name	Form Name
1	GENERAL DATA
2	COVER
3	VALIDATION
4	THPPAJS	Company Profile
5	THPSAJS	Shareholder Details
6	THPPUAJS	Principal Party Details
7	THRPPAJS-1	Education and Training Ratio - I
8	Product Profile
9	Branch/Representation Profile of Regional Office
10	THLPKS-J	Financial Position Report
11	THLKK-J	Financial Performance Report
12	THLAK-J	Cash Flow Calculation
13	THLPDS-J	Fund Change Report
14	THSAP	Asset and Liability SAP Calculation Analysis
15	THRPTSAJSC	Solvency Level Achievement
16	THRSTSAJSC	Ratios Other Than Solvency Level
17	THRKJS	Risk-Based Minimum Capital and Risk-Based Minimum Tabarru' Fund
18	THRKRKAJS	Credit Risk
19	THRKRAJ	Credit Risk - Debtor or Other Party Failure or Inability
20	THRKLAJS	Credit Risk - Reinsurer Failure/Inability
21	THRPSYA-J	Liquidity Risk
22	THRPSA-J	Market Risk
23	THRPSB-J	Market Risk - Market Price Changes
24	THRPSC-J	Market Risk - Foreign Exchange Rate Changes
25	THRSAS-J	Market Risk - Investment Yield Rate Changes
26	THRSAS1-J	Insurance Risk
27	THRSAS2-J	Insurance Risk - Contribution Provisions
28	THRSAS3-J	Insurance Risk - Provisions for Contributions Not Yet Revenue
29	THRSAS4-J	Insurance Risk - Claim Provisions
30	THRSOS-J	Insurance Risk - Disaster Risk Provisions
31	THRA110-J	Operational Risk
32	THRA120-J	Investment and Property Details
33	THRA130-J	Receivables Details
34	THRA210-J	Other Assets Details
35	THRA310-J	Liabilities Details
36	Recapitulation Details of Assets and Liabilities by Currency and Maturity
37	Contribution Details
38	Claim Details
39	Policy Details
40	THRA 220-J	Provision Details
41	THRA230-J	Contribution Provisions
42	THRA240-J	Provisions for Contributions Not Yet Revenue
43	THRA 250-J	Claim Provisions
44	THRC110-J	Disaster Risk (Catastrophic Risk) Provisions
45	THRE110-J	Summary of Guarantee Fund Development and Guarantee Fund Adequacy Calculation
46	THRE110-J (1) E-110 Details: Technical Provisions, Reinsurance Assets, and Accumulated Participant Investment Funds
47	THRF110-J	For Non-Renewable Long-Term Policies
48	THRG 110J	For Renewable Long-Term Policies and Short-Term Policies
49	THRG120J	Outward Reinsurance
50	Micro Insurance Marketing Performance by Insurance Product Type
51	Micro Insurance Marketing Channel Performance
52	Monthly Product Performance Evaluation
53	Annual Product Performance Evaluation

General Data
Report Version 4/30/2020 12:43:58 PM Reporting Date Company / Party Code Company / Party Name Reporting Period Reporting Month January Fiscal Year Reporting Period Type Annual Report Directorate / Responsible Person Name Directorate / Responsible Person Position Company / Party Address

Description
Company Profile
As of Jan 31, 1900
Number of Branches/Representations
Company Name
Full Address
DATI I (Province)
DATI II (Regency/City)
Telephone
Fax
E-mail
NPWP
Business License Number
Business License Date
Single Investor Identification (SID) Email Number of Employees Number of Participants External Auditor Controller Financial Reporting PIC Report Compiler Officer Name Division Telephone Extension Fax E-mail Directorate Responsible Person Responsible Person Name Position Telephone Extension Fax

Name
Shareholder
Parent
Shareholder
Shareholder
Controller
Group Level
Degree
Ownership
Type
Shareholder
(Code
Location Code
(Country)
Name
Supervisory Authority
Subsidiary
Reinsurance
Rating
Legal Entity
Rating Agency
Equity Period
Equity
Nominal
Stock
(Rp)
Ownership Percentage
(%)
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

-
Row Number
SHAREHOLDER DETAILS
Ownership Percentage
(in millions of rupiah)

Row Number Name Position Start Date Principal Party Details As of Jan 31, 1900

Participant Type Training
(Employee/Directorate/Commissioner/ DPS) Education and Training Details - I As of Jan 31, 1900 (in millions of rupiah) Row Number Description Realization

Mortality
Partial
Withdrawal
(%)
Acquisition Cost
(Rp)
General &
Administration Costs
(Rp)
New Contributions (Rp)
Investment Return
(%)
Mortality Morbidity Lapse (%)
Partial
Withdrawal
(%)
Acquisition Cost
(Rp)
General & Administration Costs
(Rp)
Investment Return (%)
License Date
Product
Estimate
Profit/Loss*
Calculation Method
Estimate*
PRODUCT PROFILE DETAILS
Marketing Media
Code
Currency Code
Approval Number /
OJK Product Registration
Description
Product
Investment
(Yes/No)
Business Line Code
Product Code from
Company
(Unique for all fields in this product profile) Product Name Product Status Channel Code Marketing Assumptions* Realization* Impact of deviation on established Contributions Mitigation actions taken to address deviation and deviation impact (if any)

Branch Name Branch License Number Branch License Date Branch Type/Branch/Representation Branch Leader Name Location Address (DT II) Latitude Longitude Phone No. Email BRANCH / REPRESENTATION PROFILE

Profit Equilization Reserve
Retained Earnings Balance
Agio/Disagio Stock
Accumulated Funds
Assets Not Permitted
Difference Between SAK Balance and SAP Balance Other Equity Components Fund Equity Paid-in Capital Qardh Claim Provisions Provisions for disaster risks Contribution provisions Provisions for contributions not yet revenue Ujroh provisions PAYDI provisions that guarantee principal investment Technical Provisions Other Liabilities Costs Still Payable LIABILITIES AND EQUITY Liabilities Claims and benefits paid Deferred acquisition costs Non-Investment Property Other Assets Receivables Reinsurance Assets Other Investments Not investments Cash and Bank Pure Gold Regional Sukuk Infrastructure Investment Funds in the form of Collective Investment Contracts Sharia Financing with Collateral Rights Direct Participation Investment Property Sharia Real Estate Investment Funds REPO Financing Through Cooperation with Other Parties Sharia Securities Issued by Multinational Institutions Sharia Mutual Funds Sharia Asset-Backed Securities Fund SAK DT State Sharia Securities Sharia Securities Issued by Bank Indonesia Sharia Securities Issued by Countries Other Than the Republic of Indonesia Sharia Stocks Sharia Sukuk or Bonds Sharia MTN Financial Position Report As of Jan 31, 1900 (in millions of rupiah) Investments Deposits Certificate of Deposits Adjustments Combined SAK SHARIA ASSETS SAK DTH SAP Tabarru' Fund and SAK SAP DESCRIPTION Investment Fund SAK SAP

TOTAL PERFORMANCE OF ALL FUNDS
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
PROFIT (LOSS) BEFORE TAX
Income Tax
Other Expenses
Increase (Decrease) in Asset Value
Other Income
Increase (Decrease) in Provisions
PAYDI providing guarantee on investment principal TOTAL OPERATING EXPENSES INSURANCE UNDERWRITING PROFIT (LOSS)

General and Administrative Expenses
Others
Increase (decrease) in Provisions
Ujroh
c. General and Administrative Expenses:
Employee and Management Expenses
Education and Training Expenses
OPERATING EXPENSES:
a. Marketing Expenses b. Acquisition Expenses b. Underwriting surplus for Participants TOTAL SURPLUS (DEFICIT) a. Underwriting surplus for fund Company Adjuster Expenses TOTAL UNDERWRITING EXPENSES d. Withdrawal of Participant Investment Funds that have matured e. Withdrawal/Redemption of Participant Investment Funds (not yet matured) Net Claim Expense Total b. Claim recovery
c. Increase (Decrease) in Provisions
UNDERWRITING INCOME
EXPENSES
UNDERWRITING EXPENSES
Claim Expenses a. Gross Claims
c. Decrease (Increase) in Provisions
for Disaster Risks
Net Contribution Income Total b. Decrease (Increase) in PAKYBMP Net Contributions Decrease (Increase) in Provisions for Contributions and PAKYBMP a. Decrease (increase) in Provisions for Contributions Total Investment Return and Ujroh Income from Investment Management UNDERWRITING INCOME Tabarru'/Contributions Tanahud/Ujroh/Investment Allocation Reinsurance/Retrosession Contributions Total Investment Returns Total Ujroh from Investment Management INCOME INVESTMENT AND UJROH INCOME Investment Returns Investment Returns Distributed to Company Funds Financial Performance Report For the Period Ending Jan 31, 1900 (in millions of rupiah) Wakalah Bil Ujrah Contract Mudharabah Contract Participant Investment Funds Combined Adjustments Description Company Fund Tabarru' Fund Tanahud Fund

Cash Flow Out
Loan Payments
Subordination
Others
Others
Dividend Payments
Qardh Payments
Capital Injection/Working Capital
Subordinated Loans
Qardh Receipts
CASH FLOW FROM FINANCING ACTIVITIES Cash Flow In Fixed Asset Purchases Others Payment of ujroh/fee to Company Investment Returns Distributed to Company Funds Cash Flow Out Investment Placements Others Fixed Asset Sales Investment Profit Sharing Receipts Tabaru' Fund Investment Profit Sharing Receipts Participant Investment Funds Investment Liquidation CASH FLOW FROM INVESTMENT ACTIVITIES Cash Flow In Investment Return Receipts Others Rent Payments Zakat Payments Tax Payments Insurance Ujroh Payments Reinsurance Contributions Paid Acquisition Expenses Marketing Expenses Reinsurance Ujroh Payments Underwriting Surplus Distribution Payment to Company Underwriting Surplus Distribution Payment to Participants/Policyholders Withdrawal of Participant Investment Funds that have matured Withdrawal/Redemption of Participant Investment Funds not yet matured Cash Flow Out Claims Paid Other - Others Receipt of Underwriting Reinsurance Surplus Distribution Ujroh received Allocation Surplus Receipts Tabarru' Fund Reinsurance Claims Received Co-insurance Claims Participant Contributions INCREASE (DECREASE) IN CASH BALANCE ENDING CASH BALANCE CASH FLOW FROM OPERATING ACTIVITIES Cash Flow In BEGINNING BALANCE CASH FLOW CALCULATION For the Period Ending Jan 31, 1900 (in millions of rupiah) Wakalah Bil Ujrah Contract Mudharabah Contract Participant Investment Funds Combined Description Company Fund Tabarru' Fund Tanahud Fund

Wakalah Bil Ujrah Contract Mudharabah Contract
IV. Ending Fund Balance
Dividend Payments
Other Reductions
III. Reductions
Comprehensive loss for the current period Decrease in accumulated tabarru' funds / Participant Investment Funds Increase in accumulated tabarru' funds / Participant Investment Funds Other Additions
II. Additions
Paid-in Capital
Comprehensive profit for the current period Combined
I. Beginning Fund Balance
Description Company Fund Tabarru' Fund Tanahud Fund Participant Investment Funds FUND CHANGE REPORT For the Period Ending Jan 31, 1900 (in millions of rupiah)

ANALYSIS
SAP ASSET AND LIABILITY CALCULATION As of Jan 31, 1900 (in millions of rupiah) Description Book Balance (Ledger) (SAK) Valuation Based On SAP Difference Based On Valuation Based On SAK and SAP AYD After Limit Per Company Sharia Stocks Sharia Sukuk or Bonds Sharia MTN State Sharia Securities RI Sharia Securities Bank Indonesia Sharia Securities Countries Other Than RI AYD After Limit Per Asset Type AYD After Limit Affiliate AYD After Limit Outside Country (Balance SAP)
I. Investments
Deposits
Sharia Financing with Collateral Rights Direct Participation Investment Property Pure Gold Regional Sukuk Infrastructure Investment Funds in collective investment contracts Sharia Securities Multinational Institutions Sharia Mutual Funds Sharia Asset-Backed Securities Sharia Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Investment Return Receivables Investment Receivables Reinsurance Assets Deferred Acquisition Costs Non-Investment Property Other Assets Other Investments Total Investments
II. Non-Investments
Cash and Bank
Direct Closing Ujroh Receivables
Co-insurance Ujroh Receivables
Total Non-Investments
TOTAL WEALTH (I+II)
I. Liabilities
II. Ujroh Provisions
III. Provisions for Guarantees on Investment Principal
TOTAL OBLIGATIONS (I+II+III)
PAYDI Assets
Guaranteed
COMPANY FUNDS

ANALYSIS
SAP ASSET AND LIABILITY CALCULATION As of Jan 31, 1900 (in millions of rupiah)
I. Investments
Deposits
Certificate of Deposits
Sharia Stocks
Sharia Sukuk or Bonds
Sharia MTN
Sharia Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Pure Gold Regional Sukuk Infrastructure Investment Funds in collective investment contracts State Sharia Securities RI Sharia Securities Bank Indonesia Sharia Securities Countries Other Than RI Sharia Securities Multinational Institutions Sharia Mutual Funds Sharia Asset-Backed Securities Reinsurance Claim Recovery Receivables Investment Return Receivables Investment Receivables Reinsurance Assets Other Assets Total Non-Investments Other Investments Total Investments
II. Non-Investments
Cash and Bank
Direct Closing Contribution Receivables Co-insurance Contribution Receivables Reinsurance Contribution Receivables Co-insurance Claim Receivables Total Liabilities TOTAL WEALTH (I+II) Liabilities Contribution Provisions Contribution Provisions Not Yet Revenue Claim Provisions Provisions for Disaster Risks (Catastrophic Risks) TABARRU' FUNDS AND TANAHUD FUNDS

ANALYSIS
SAP ASSET AND LIABILITY CALCULATION As of Jan 31, 1900 (in millions of rupiah)
I. Investments
Deposits
Certificate of Deposits
Sharia Stocks
Sharia Sukuk or Bonds
Sharia Asset-Backed Securities
Sharia Real Estate Investment Funds REPO Financing Through Cooperation With Other Parties (Executing) Financing with Collateral Rights Direct Participation Sharia MTN State Sharia Securities RI Sharia Securities Bank Indonesia Sharia Securities Countries Other Than RI Sharia Securities Multinational Institutions Sharia Mutual Funds PARTICIPANT INVESTMENT FUNDS Liabilities Accumulated Participant Investment Funds PAYDI provisions that guarantee principal investment TOTAL LIABILITIES Reinsurance Assets Deferred Acquisition Costs Non-Investment Property Other Assets Total Non-Investments TOTAL WEALTH (I+II)
II. Non-Investments
Cash and Bank
Investment Return Receivables
Investment Receivables
Investment Property
Pure Gold
Regional Sukuk
Infrastructure Investment Funds in collective investment contracts Other Investments Total Investments

-
Assets Available for Qardh That
Are Counted as Increases to Tabarru' and Tanahud Funds A. Deficiency (Surplus) of solvency level from internal target B. Insufficiency of investments, cash and bank Ratio of Solvency Level for Tabarru' Funds and Tanahud Funds, and Company Funds Internal Target Solvency Level Ratio (annual) (percentage according to POJK 72) Solvency Level Ratio with DTMBR/MMBR Required by Regulations (percentage according to POJK 72) b. Liquidity Risk
c. Market Risk
2. Guaranteed PAYDI Assets
3. Guaranteed PAYDI Liabilities
Solvency Level Ratio before considering Assets Available for Qardh (in %) D. Insurance Risk E. Operational Risk F. MMBR on Guaranteed PAYDI

Guaranteed PAYDI Risk
a. Credit Risk
B. Liabilities other than Qardh from Company Funds Tabarru' Funds and Tanahud Funds Solvency Level A. Permitted Assets (AYD) SOLVENCY LEVEL ACHIEVEMENT FINANCIAL REPORTS As of Jan 31, 1900 (in millions of rupiah)

Total Qardh Required (a-b)
Total Qardh Required (a-b)
Calculation of Qardh Required for Tanahud Funds A. Total Obligations other than Qardh B. Total Assets Calculation of Qardh Required for Tabarru' Funds A. Total Obligations other than Qardh B. Total Assets B. Participant Investment Fund Assets
C. Company Insurance Fund Assets (Conventional)
D. Ratio (a+b) : (a+b+c)
C. Fund Changes (a-b)
D. Ratio (c:b)
Sharia Unit Asset Ratio
A. Tabarru' and Tanahud 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 expenses
B. Net contributions
B. Average investments
C. Own retention claim liabilities
D. Ratio [a:(b+c)]
Net Investment Income Ratio
A. Net investment income
Assets Counted for Qardh in Company Funds D. Ratio [a:(b+c)] after addition
C. Ratio (a:b)
Investment-Liability Balance Ratio
A. Investments, cash and bank
B. Own retention technical provisions

B. Current Liabilities - - - -
Employee and Management Expenses
Education and Training Expenses
Education and Training Ratio
FINANCIAL RATIOS OTHER THAN SOLVENCY LEVEL FINANCIAL REPORTS As of Jan 31, 1900 (in millions of rupiah) Description Tabarru' and Tanahud Funds Company Funds Participant Investment Funds Indicator Combined Liquidity Ratio A. Current Wealth

Credit Risk (a)
Credit Risk (b)
Total Credit Risk
Description
Tabarru' and Tanahud Funds Company Funds PAYDI (guaranteed) Total Deviation PAYDI (guaranteed) RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUND CREDIT RISK As of Jan 31, 1900 (in millions of rupiah)

Tabarru' and Tanahud Funds Company Funds PAYDI (guaranteed) Factor Tabarru' and Tanahud Funds Company Funds PAYDI (guaranteed)

- - 0,0% - - -

- - 1,2% - - -
- - 2,1% - - -
- - 3,0% - - -
- - 4,5% - - -
- - 9,0% - - -

- - 0,01 - - -
- - 0,02 - - -
- - 0,03 - - -
- - 0,05 - - -
- - 0,09 - - -

- - 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% - - -

- - 1,6% - - -
- - 2,8% - - -
- - 4,0% - - -
- - 6,0% - - -
- - 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% - - -

b. Cluster Rating 2
RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUND CREDIT RISK - DEBTOR OR OTHER PARTY FAILURE OR INABILITY As of Jan 31, 1900 (in millions of rupiah) Description Total AYD Total Deviation Investments Time Deposits Special Category (up to 2 billion per bank) Other Categories, according to Bank Rating:
a. Cluster Rating 1
Sharia Corporate Sukuk / Bonds
c. Cluster Rating 3
d. Cluster Rating 4 e. Cluster Rating 5 Certificate of Deposits Special Category (up to 2 billion per bank) Other Categories, according to Bank Rating:
a. Cluster Rating 1 b. Cluster Rating 2
c. Cluster Rating 3
d. Cluster Rating 4 e. Cluster Rating 5 State Sharia Securities 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
c. Cluster Rating 3
d. Cluster Rating 4 e. Cluster Rating 5 b.Healthy Securities Issued by Bank Indonesia Securities Issued by Countries other than RI a. Cluster Rating 1 b. Cluster Rating 2
c. Cluster Rating 3
d. Cluster Rating 4 e. Cluster Rating 5 Securities issued by Multinational Institutions REPO Financing Through Cooperation with Other Parties* a.Very Healthy a. Cluster Rating 1 c.Unhealthy d.Unhealthy Loans Secured with Collateral Rights Residential Property a. LTV < 65% b. 65% < LTV < 75% Other Commercial Property a. LTV < 65% b. 65% < LTV < 75% Unused Property Regional Sukuk Domestic b. Cluster Rating 2
c. Cluster Rating 3
d. Cluster Rating 4 e. Cluster Rating 5 Non-Investments Cash and Bank Direct Closing Contribution Receivables Reinsurance Assets a. assets sourced from estimated recovery value of claims over b. assets sourced from long-term contract agreements Co-insurance Claim Receivables
c. Cluster Rating 3
Foreign:
a. Cluster Rating 1 b. Cluster Rating 2
c. Cluster Rating 3
d. Cluster Rating 4 e. Cluster Rating 5 Reinsurance Claim Receivables Domestic Foreign:
a. Cluster Rating 1 b. Cluster Rating 2 Total d. Cluster Rating 4 e. Cluster Rating 5 Investment Receivables a. Investments not yet received payment on the date b. Investments that failed to pay on maturity date/at time Investment Return Receivables

Automatic Reinsurance
(Treaty)

0,00% -
-Proportional - 0,00% -
Quota Share - 0,00% -
Surplus - 0,00% -
Non Proportional - 0,00% -
Cath X/L - 0,00% -
Work X/L - 0,00% -
Facultative Reinsurance - 0,00% -
-Proportional - 0,00% -
Quota Share - 0,00% -
Surplus - 0,00% -
Non Proportional - 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% -
......
51 - - - - 0,00% -
50 - - -
49 - - -
48 - - -
47 - - -
46 - - -
45 - - -
44 - - -
43 - - -
42 - - -
41 - - -
40 - - -
39 - - -
38 - - -
37 - - -
36 - - -
35 - - -
34 - - -
33 - - -
32 - - -
31 - - -
30 - - -
29 - - -
28 - - -
27 - - -
26 - - -
25 - - -
24 - - -
23 - - -
22 - - -
21 - - -
20 - - -
19 - - -
18 - - -
17 - - -
16 - - -
15 - - -
14 - - -
13 - - -
12 - - -
11 - - -
10 - - -
9 - - -
8 - - -
7 - - -
6 - - -
5 - - -
4 - - -
3 - - -
MINIMUM TABARRU' FUND BASED ON RISK CREDIT RISK - REINSURER FAILURE/INABILITY As of Jan 31, 1900 (in millions of rupiah) 2 - - - Net Reinsurance Exposure ((G)-(H)) Factor Total Deviation 1 - - - Row Number Code Type of Reinsured Name of Reinsured Technical Provisions Expenses Reinsured Deposits and/or Contributions held at the Company Type of Reinsurance

SELISIH LIABILITAS DAN ASET
DEVIASI (4% X (Max (Li - AYDi), 0)) Accumulated Investment Funds - - - - - - - - - - Participants - - - -

Provision for disaster risk - - - - -
Claims provision - - - -
Provision for contributions that are not yet revenue - - - - -
Contribution provision - - -
Principal investment guarantee provision - - - -

Technical Provisions

Ujroh provision - - - - -

Other Liabilities - - - - - - - - - - - - - - - Expenses Incurred but Not Yet Paid - - - - - - - -

Tax Payables - - - - - - - - - - - - - - - Ujroh Payables -

Reinsurance Payables - - - - - - - - - - - - - - - Co-insurance Payables - - - - - - - - - -

Liabilities
Payables
Claims and Benefits Payables - -

Other Fixed Assets
Other Assets
Liabilities and Equity

Deferred Acquisition Costs

Non-Investment Property - - - - - - - -

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

Recovery Claims Receivables - - - - - - - - - - - - - - -
Co-insurance Claims Receivables - - - - - - - -

Reinsurance Assets - - - - - - - - - - - - - - -

Contribution/Ujroh Receivables - - - - - - - - - -

Non-Investment
Cash and Banks - - -

Other Investments - - - -

Infrastructure Investment Funds - - - - - - - - - - - Regional Sukuk - - - - - -

Pure Gold - - - - - - - - - - - - - - - Investment Property - -

Direct Participation - - - - - - - - - - - - - - - Sharia Financing with Mortgage Rights

Financing Through Cooperation with Other Parties (Executing)

REPO -

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

Sharia Mutual Funds - - - - - - - - - - - - - - -

Securities Issued by Institutions

Securities Issued by Banks - - - - - - - - - - - - - - -

Securities Issued by Countries Other Than

Securities Issued by the Republic of Indonesia - - - - - - - - - - - - - - -

Sharia Medium-Term Notes (MTN) -

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

More than 3 years up to 5 years More than 5 years up to 10 years More than 10 years

Deposit Certificates - - - - - - - -

Investment Assets
Time Deposits - - - - - -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS LIQUIDITY RISK As of Jan 31, 1900 (in millions of Rupiah)

Description	Total Company Funds	Total Tabarru' and Tanahud Funds	More than 10 years	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	PAYDI (Guaranteed)
Description	Total	Tabarru' and Tanahud Funds	> 10 years	<= 1 year	> 1 year <= 3 years	> 3 years <= 5 years	> 5 years <= 10 years	PAYDI (Guaranteed)
Deviation Total	Total

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS MARKET RISK As of Jan 31, 1900 (in millions of Rupiah)

Description	Company Funds	Tabarru' Funds and PAYDI Funds (Guaranteed)	Deviation Total	Total
Market Risk (A)
Market Risk (B)
Market Risk (C)
Total Market Risk

Description	Company Funds	Tabarru' Funds and PAYDI Funds (Guaranteed)	Deviation Total	Total
15.0%
20.0%
30.0%
20.0%
30.0%
0.0%
6.0%
16.0%
0%
1.6%
2.8%
4.0%
6.0%
12.0%
10.0%
10.0%
20.0%
7.0%
15.0%
40.0%
3.0%
10.0%
4.0%
TOTAL

NON-INVESTMENT
Non-Investment Property - - -
Pure Gold - - -
Infrastructure Investment Funds in the form of collective investment contracts - - - Investment Returns 2% - 4% - - - Investment Returns less than 2% - - -

Investment Property
Investment Returns 4% or more - - - Direct participation in Special Purpose Vehicles (SPV) - - - 0.0%

Under OJK Supervision - - -
Not Under OJK Supervision - - -

Real Estate Investment Funds - - -

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) - - - 0.0%
Tabarru' Funds - - - 0.0%
Company Funds - - - 0.0%

Entirely consisting of Sharia equity securities or indices - - - Mixed)*

Entirely consisting of Sharia Government Securities (SBSN) - - - Entirely consisting of private debt securities and/or money market securities (SBPU) - - -

Other Stocks - - -

Sharia Mutual Funds
Stocks traded on foreign exchanges - - - Stocks constituting the main index of Asia Pacific and European stock exchanges that are members of the World

Stocks traded on the Indonesian exchange - - -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS MARKET RISK - MARKET PRICE CHANGES As of Jan 31, 1900 (in millions of Rupiah)

Description	Company Funds	Tabarru' Funds and Tanahud Funds	PAYDI (Guaranteed)	Deviation Total
Factor
Factor
Allowed Assets Amount in Rupiah
Liabilities Amount in Rupiah
Difference Between Allowed Assets and Liabilities
Factor
Deviation Total

Description	Company Funds	Tabarru' Funds and Tanahud Funds	PAYDI (Guaranteed)	Allowed AYD Total
Liabilities Amount
Exchange Rate

Provision for disaster risk - - - - - - - - - - - - -

Claims provision - - - - - - - - - - -

Provision for contributions that are not yet revenue - - - - - - - - - - - - - - - - - - -

Contribution provision - - - - - - - - - - - - -

Principal investment guarantee provision - - - - - - - - - - -

Ujroh provision - - - - - - - - - - - - - - - - - - -

Other payables - - - - - - - - - - - - -

Expenses Incurred but Not Yet Paid - - - - - - - - - - -

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

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

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

Co-insurance Payables - - - - - - - - - - - - - -

Allowed Assets Total

Liabilities
Claims Payables - -

Deferred Acquisition Costs - - - - - - - - - - - - -

Non-Investment Property - - - - - - - - - - -

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

Investment Receivables - - - - - - - - - - - - -

Reinsurance Claims Receivables - - - - - - - - - - -

Co-insurance Claims Receivables - - - - - - - - - - - - - - - - - - -

Reinsurance Assets - - - - - - - - - - - - -

Reinsurance Contribution Receivables - - - - - - - - - - -

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

Cash and Banks - - - - - - - - - - - - -

Infrastructure Investment Funds in the form of collective investment contracts - - - - - - - - - - -

Regional Sukuk - - - - - - - - - - - - - - - - - - -

Pure Gold - - - - - - - - - - - - -

Sharia Financing with Mortgage Rights - - - - - - - - - - -

Financing Through Cooperation with Other Parties (Executing) - - - - - - - - - - - - - - - - - - -

Investment Property - - - - - - - - - - - - -

Direct Participation - - - - - - - - - - - - - - -

REPO - - - - - - - - - - - - - - - - - - -

Real Estate Investment Funds - - - - - - - - - - - - -

Sharia Asset-Backed Securities - - - - - - - - - - -

Sharia Mutual Funds - - - - - - - - - - - - - - - - - - -

Securities Issued by Multinational Institutions - - - - - - - - - - - - -

Securities Issued by Bank Indonesia - - - - - - - - - - -

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

Securities Issued by the Republic of Indonesia - - - - - - - - - - - - -

Sharia Medium-Term Notes (MTN) - - - - - - - - - - - - - - - - - - - - -

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

Sharia Stocks - - - - - - - - - - - - -

Deposit Certificates - - - - - - - -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS MARKET RISK - FOREIGN EXCHANGE RATE CHANGE RISK As of Jan 31, 1900 (in millions of Rupiah)

Description	Company Funds	Tabarru' Funds	PAYDI (Guaranteed)	Total
Allowed Assets Amount	USD JPY AUD EUR SGD GBP Other IDR Total	USD JPY AUD EUR SGD GBP Other IDR Total	USD JPY AUD EUR SGD GBP Other IDR Total
Time Deposits - - - - - - - - - -

Description	Company Funds	Tabarru' Funds	PAYDI (Guaranteed)	Total
SGD GBP Other IDR Total
Other IDR
PAYDI (Guaranteed)
Total
Allowed Assets Amount	USD JPY AUD EUR SGD	Tabarru' Funds: USD JPY AUD EUR	Company Funds: USD JPY AUD EUR	SGD GBP Other IDR Total

SGD GBP Other IDR Total

15% 15%

PUo -
Max((PUrf-PUo),0) fPHI
PHI
PKo -
Max((PKrf-PKo),0)
PUrf -

Description	Company Funds	Tabarru' Funds
PKrf -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS MARKET RISK - INVESTMENT YIELD LEVEL CHANGE RISK As of Jan 31, 1900 (in millions of Rupiah)

IV. Total ((PRBi - ARi)fpbi)
Total Deviation

Description	Deviation Total
I. Total max ((PK* - PK), 0)
II. Total ((PAKYBMPi - ARi)fpki)
III. Total ((PKli - ARi)fpkli)

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS INSURANCE RISK As of Jan 31, 1900 (in millions of Rupiah)

Other - -

I. Total max ((PK* - PK), 0)
Health - -
Personal Accident - -
Annuity - -
Term Life - -
Endowment and/or Combinations - -
Whole Life - -
Insurance Branch PK PK* Deviation Total Mortality Term Life - -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS INSURANCE RISK - CONTRIBUTION PROVISION As of Jan 31, 1900 (in millions of Rupiah)

10% -
10% -
10% -
10% -
10% -
25% -
25% -
10% -
II. Total ((PAKYBMPi - ARi)fpki) - - - -
Personal Accident - -
Other - -
Term Life - -
Health - -
Whole Life - -
Annuity - -
Mortality Term Life - -
Endowment and/or Combinations - -
Insurance Branch PAKYMBPi ARi fpki Deviation Total PAKYBMPi

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS INSURANCE RISK - PROVISION FOR CONTRIBUTIONS NOT YET REVENUE As of Jan 31, 1900 (in millions of Rupiah)

10% -
10% -
10% -
10% -
10% -
20% -
20% -
10% -
III. Total ((PKli - ARi)fpkli) - - - -
Personal Accident - -
Other - -
Term Life - -
Health - -
Whole Life - -
Annuity - -
Mortality Term Life - -
Endowment and/or Combinations - -
Insurance Branch Deviation Total PKli ARi fpkli Deviation Total PKli

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS INSURANCE RISK - CLAIMS PROVISION As of Jan 31, 1900 (in millions of Rupiah)

10% -
10% -
10% -
10% -
10% -
25% -
25% -
10% -
IV. Total ((PRBi - ARi)fpbi) - - - -
Personal Accident - -
Other - -
Term Life - -
Health - -
Whole Life - -
Annuity - -
Mortality Term Life - -
Endowment and/or Combinations - -
Insurance Branch PRBi (Gross) ARi fcbi Deviation Total PRBi

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS INSURANCE RISK - PROVISION FOR DISASTER RISK As of Jan 31, 1900 (in millions of Rupiah)

Total Deviation - -

h. Subtotal Operational Risk PAYDI
(ROPAYDI = (1‰*g))

III. Operational Risk Tabarru' Funds
(RODT)
i. Tabarru' Funds Investment -
j. Subtotal RODT = (1‰*i)

e. Operational Risk =(50%*d) f. Subtotal Operational Risk Company (c+e)

II. Operational Risk PAYDI (ROPAYDI)
g. PAYDI Funds Assets - b. Education and Training Expenses -
c. Operational Risk = (1%*(a-b))
d. Balance of Deferred Acquisition Costs

Description	Tabarru' and Tanahud Funds	Company Funds
I. Operational Risk Company
a. General and Administrative Expenses -

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU FUNDS OPERATIONAL RISK As of Jan 31, 1900 (in millions of Rupiah)

| Account Number (SID / Bank Account) | Investment Type Code | Instrument Name | Investment Instrument Code | Issuer/Counterparty Name | Issuer Group Code | Fund Type Code | Fund Code | Collateral | Infrastructure Financing Investment Code | Supervisor Code | Start Date DD/MM/YYYY | Maturity Date DD/MM/YYYY | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | ---
| --- |
| Debtor Rating Code | Rating Agency Name | Category Code | Economic Sector Code | Location Code | Related Party Status Code | Ownership Purpose Code | Ownership Share (%) | Currency Code | Return Type Code | Return Rate (%) | Collectibility Code | Acquisition Value | Book Balance | SAP Valuation Balance | AYD Investment Result | Current Period Received Cash | Investment Receivables | Previous Period Investment Receivables Received Cash | Current Period Total Investment Result | Distributable Investment Result | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| - - - - - - - 0,00% - - 0,00% - - - - - - - - | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | ...... |

(in millions of Rupiah)

Line Number	Maturity Period	Line Number
DETAILS A-110. Investment and Property Details
As of Jan 31, 1900

Book Balance (Million Rp)	SAP Valuation Balance (Million Rp)	AYD (Million Rp)
DETAILS A-120. Receivables Details
As of Jan 31, 1900
(in millions of Rupiah)
Line Number	Debtor Name	Business Category/Debtor Category Code
:---	:---	:---

Description

DETAILS A-130. Other Assets Details As of Jan 31, 1900 (in millions of Rupiah)

Line Number	Asset Name	Basis for Valuation	Fund Type Code	Market Value/Appraisal Balance Million (Rp)

Currency Code	Book Balance (Million Rp)	SAP Valuation Balance (Million Rp)
DETAILS A-210. Liabilities Details
Financial Statements
As of Jan 31, 1900
(in millions of Rupiah)
Line Number	Name	Payable Type Code
:---	:---	:---

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%

Total

DETAILS A-310
Asset and Liability Recapitulation Details by Currency and Maturity Age As of Jan 31, 1900

Asset Age (SAK)	Liabilities (SAK)	Ratio of Assets to Tabaru' and Tanahud Funds
<= 1 year
1 year < age < 5 years
5 years = age < 10 years
>= 10 years
5 years = age < 10 years
Ratio of Current Assets (Liabilities) to Non-Current Assets (Liabilities)
Company Funds
<= 1 year
1 year < age < 5 years
5 years = age < 10 years
>= 10 years
Total
Ratio of Current Assets (Liabilities) to Non-Current Assets (Liabilities)
Company Investment Funds
<= 1 year
1 year < age < 5 years
5 years = age < 10 years
>= 10 years
Total
Ratio of Current Assets (Liabilities) to Non-Current Assets (Liabilities)
>= 10 years
Total
Ratio of Current Assets (Liabilities) to Non-Current Assets (Liabilities)
ALL
<= 1 year
1 year < age < 5 years

Product Code	Policy Type	Payment Method	Location	Economic Sector Code	Policyholder
Counterparty Code	Policyholder Type: - Ujrah - Tabarru - Tanahud - DIP - Akad Wakalah Bil - DIP - Akad Mudharabah	Commission Expense New Renewal Top Up Gross Contribution
Tabarru' Funds	Tanahud Funds	Tabarru' Funds	Tanahud Funds	Wakalah Bil Ujrah Akad	Mudharabah Akad	Partial Withdrawal	Full Withdrawal	Partial Withdrawal	Full Withdrawal	Tabarru' Funds	Tanahud Funds

CONTRIBUTION DETAILS

Investment Fund Withdrawal	Investment Fund Withdrawal	Adjuster Expense
Total Policies	Claims	Participants
Claim Amount	Recovery Claims	Investment Fund Withdrawal
Product Code	Policy Type	Payment Method	Location	Economic Sector Code	Policyholder

Product Code	Policy Code	Traditional/PAYDI Code	Policy Type Code	Payment Method Code	Location Code	Economic Sector Code	Policyholder	Counterparty Code	Status (Active/Inactive)	Inforce/Not Inforce Code	Number of Policies	Number of Participants	Sharia Insurance Benefits Amount (Millions Rp)
Renewing Participants	New Participants	Reinstatement of Membership	Change from Other Insurance Lines	Participant Death	Contract Expiry	Products Generated in the Current Year	Change to Other Insurance Lines

POLICY DETAILS

Contribution Provision (Rp)	Provision for Contributions Not Yet Revenue (Rp)	Ujroh Provision (Rp)	Claims/Benefits in Process Provision (Rp)	Total
Number of Policies	Technical Provisions*

Product Code

PROVISION DETAILS

Subtotal B
Total Contribution Provisions

Subtotal A
B. Annuity - - -

6. Others - - - - - - - - - - -
5. Personal Accident - - - - - - - - -

4. Health - - - - - - - - - - -
3. Whole Life (Whole Life) - - - - - - - - -

Endowment (Endowment) and/or Combinations

A. Life Insurance

Term Life (Term Life) - - -

Provision for PAYDI Risk	Accumulated Fund Provision	Regular Policy Contribution Provision
Insurance Branch	Risk Provision	Contribution Provision
Single Contribution Policy Contribution Provision
Provision for PAYDI Risk	Accumulated Fund Provision	Single Contribution Policy Contribution Provision

DETAILS A-220. Contribution Provisions Financial Statements As of Jan 31, 1900 (in millions of Rupiah)

Total Contribution Provisions	Policies Maturing < 1 Year
Period...... Previous
Risk Provision	Provision for PAYDI Risk	Accumulated Fund Provision	Paid-up Policy Contribution Provision
Risk Provision

Total PAKYBMP
Total PARYBD
Maks (PAKYBMP,PARYBD)

Health - - - - -
Personal Accident - - - -

II. Provision for Unexpired Risk

Yearly Term Death - - - - -
Health - - - -
Personal Accident - - - -
Endowment / Endowment Combination - - - -

Provision
Contribution
Policies Due

Total PAKYBMP
Previous Period

I. Yearly Term Death (Include all life insurance products)

Yearly Term Death - - - - -

Branch	Provision	Contribution	Policies	Single Premium Provision	Contribution (Regular Policies/Installments)	Total
A-230. Provision for Contributions Not Yet Earned Income
As at 31-Jan-1900
(in millions of rupiah)

Total

Annuity - - - -
Health - - - - - - - -
Personal Accident - - - -
Long Term Death - - - - - - - -
Yearly Term Death (Include all - - - - -

Total Claim Provision
Claim Reserve < 1 year

Quarter … / Year …
Self-Retention Quarter … / Year … (Previous Period)

IBNR Claim Provision
Total Self-Retention

Branch	Payment Provision
Total Self-Retention
Claim Provision In Process
Total

A-240. Claim Provision
As at 31-Jan-1900
(in millions of rupiah)

Sub Total B
Total Provision for Catastrophic Risk Sub Total A

B. Annuity - - -
6. Others - - - -
5. Personal Accident - - - -
4. Health - - - -
3. Whole Life - - - -
2. Endowment and/or Combination

Provision for Catastrophic Risk for policies due < 1 year Previous Period

A. Life Insurance

Term Life

Branch	Traditional PAYDI	Total
Provision for Risk

RINCIAN A-250.
PROVISION FOR CATASTROPHIC RISK As at 31-Jan-1900 (in millions of rupiah)

10. Excess (Deficiency) of Guarantee Fund ((9-8)) -
6. Minimum Guarantee Fund I (20% x 1)
7. Minimum Guarantee Fund II (2% x 5) + (5% x 4)
8. Minimum Guarantee Fund Used (Greater value between 6 and 7)
9. Guarantee Fund Owned -
3. Provision for unearned tabarru’ contribution -
4. Total Provision (2+3)
5. Provision for PAYDI -
4. Ending Balance of Guarantee Fund (1 + 2 – 3)

II. Annual Calculation of Guarantee Fund Adequacy
1. Required minimum Equity -
2. Provision for tabarru' contribution and land -
3. Withdrawal of Guarantee Fund:
a. Guarantee Fund in Deposit Form - b. Guarantee Fund in SUN/Other Government Securities (SBN) Form -

2. Placement of New Guarantee Fund:
a. Guarantee Fund in Deposit Form - b. Guarantee Fund in SUN/Other Government Securities (SBN) Form -

Description	Amount
I. Summary of Guarantee Fund Development
1. Beginning Balance of Guarantee Fund -

C-110. GUARANTEE FUND REPORT
Summary of Guarantee Fund Development and Calculation of Guarantee Fund Adequacy As at 31-Jan-1900

Provision	Current Period	Previous Year	Current Period	Previous Year	Current Period	Previous Year	Current Period	Previous Year	Current Period	Previous Year	Current Period	Previous Year
Claim Provision In Process
Periodic Claim Payment Provision
IBNR Claim Provision
Catastrophic Risk Provision
Reinsurance Assets
Ujrah Provision
PAYDI Guaranteed Provision
Current Period
Previous Year
Net Contribution
Gross Contribution
Average Contract Term
Average Participant Age
Average Policy Age

Table	Number of Participants	Line Number
Contribution Provision Period		10
Contribution Provision Year		10
		9
		8
		7
		5
		6
		4
		3
Currency	Remaining Term
Sharia Insurance	(months)
		1
		2

Rincian E-110. Technical Provisions, Reinsurance Assets, and Accumulation of Participant Investment Funds For Non-Renewable Long-Term Policies As at 31-Jan-1900

Line Number	P.R	Contribution Provision Year	P.U	P.R	Contribution Provision Period	Name S.P	P.U	Product	Net Contribution	Reinsurance Contribution	Product Code	Policy Type	S.P
Product Code	Number of Participants	Number of UP	Catastrophic Risk Provision	Previous Year	Reinsurance Assets	Current Period	Reinsurance Assets	Previous Year	Ujrah Provision	Current Period	Ujrah Provision	Previous Year	PAYDI Guaranteed Provision	Current Period	PAYDI Guaranteed Provision	Previous Year	Current Period	Previous Year	Current Period	Previous Year	Net Contribution	Gross Contribution	Average Contract Term	Average Participant Age	Average Policy Age	Table Mortality or Morbidity	Discount Rate	Calculation Method

9
10

7
8
6
5
4
3
2

IBNR Claim Provision	Previous Year	Catastrophic Risk Provision	Current Period	Claim Provision In Process	Current Period	Claim Provision In Process	Previous Year	Periodic Claim Payment Provision	Current Period	Periodic Claim Payment Provision	Previous Year	IBNR Claim Provision	Current Period
Product Name	Net Contribution	Reinsurance Contribution	Contribution Provision Not Yet Earned Income	Current Period	Contribution Provision Not Yet Earned Income	Previous Year

For Renewable Long-Term Policies and Short-Term Policies As at 31-Jan-1900

Rincian E-110. Technical Provisions, Reinsurance Assets, and Accumulation of Participant Investment Funds

Line Number	Business Line	Policy Type	Currency	Remaining Term Sharia Insurance (months)
1
TOTAL
PAYDI
Health
Personal Accident
General Annuity
Sharia Pension Fund Annuity
Whole Life Combination
Whole Life
Endowment Combination
Endowment
Term Death

Group Coverage:

Yearly Term - - -
PAYDI - - - - - - - - - - - -
Health - - - - - - - - -
Personal Accident - - - - - - - - - - - -
Sharia Pension Fund Annuity - - - - - - - - -
General Annuity - - - - - - - - - - - -
Whole Life Combination - - - - - - - - -
Whole Life - - - - - - - - - - - -
Endowment Combination - - - - - - - - -
Endowment - - - - - - - - - - - -
Term Death - - - - - - - - - - -

Individual Sharia Insurance:

Yearly Term - - -

Surplus Underwriting from ASEAN Reinsurers	Paid Contribution	Received Ujroh
RINCIAN F-110. Outward Reinsurance
Sharia Insurance Business
As at 31-Jan-1900

Claim Recovery	NON-ASEAN	Surplus Underwriting from Reinsurers	Paid Contribution	Received Ujroh	Claim Recovery
Domestic
Business Line	Contribution to Reinsurer	Ujroh to Reinsurer	Claim Recovery

Active Participants at Start of Reporting Period	New Participants in Reporting Period	Participants Extended in Reporting Period	Participants Terminated Due to Maturity	Participants Cancelled	Participants Terminated Due to Claim	Active Participants at End of Reporting Period
Gross Contribution (Rp)
Gross Claims (Rp)

Line Number	Does Not Comply with OJK Circular No. 9/SEOJK.05/2017
10
9
8
6
5
7
4
3
Line Number	Product Name
---	---	---
2
Policy Type	Business Line
Participants Terminated Due to Claim	Active Participants at End of Reporting Period
Gross Contribution (Rp)	Gross Claims (Rp)
Complies with OJK Circular No. 9/SEOJK.05/2017
Active Participants at Start of Reporting Period	New Participants in Reporting Period
Participants Extended in Reporting Period	Participants Terminated Due to Maturity
Participants Cancelled

Micro Insurance Marketing Performance by Product Type As at 31-Jan-1900

RINCIAN G-110

50
49
48
47
46
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1

RINCIAN G-120. Micro Insurance Marketing Channel Performance As at 31-Jan-1900 (in millions of rupiah)

Number of Legal Entities	Marketer Legal Entities	Number of Individual Marketers	Marketed Product Name	Number of Participants	Gross Contribution (Rp)
Line Number	Channel Type	Marketing Region	Legal Entity Category

Implementation Period *)	Channel Category 1)	Number of Parties Selected 2)	Number of New Parties 3)	Number of Parties Attending Training 4)	Number of Parties Passing Training 5)	Number of Parties Taking Agent Certification Exam 6)	Number of Parties Passing Agent Certification 7)	Number of Marketing Materials and Product Information Summaries Evaluated 8)	Number of Marketing Materials and Product Information Summaries Revised and Adjusted per Company Approval 9)	Number of Marketers Evaluated by Company 10)	Number of Marketers Dismissed 11)

Filling Instructions:
*) Fill the number of people attending training according to the implementation period.
1) Fill the implementation time of Selection and Accountability of Marketing Channels (Quarterly): Quarter 1 (January 1-March 31), Quarter 2 (April 1-June 30), Quarter 3 (July 1-September 30), or Quarter 4 (October 1-December 31).
2) Fill with the marketing channel being evaluated: direct marketing, Insurance agent, bank, BUSB, or Marketer personnel.
3) Fill the number of people selected according to the implementation period.
4) Fill the number of people newly recruited by the Company from the selection process according to the implementation period.
5) Fill the number of people dismissed by the Company due to non-compliance with cooperation agreements and prevailing regulations according to the implementation period.
6) Fill the number of people attending training and passing said training according to the implementation period.
7) Fill the number of people taking the agent certification exam from the Professional Certification Body in the insurance field according to the implementation period.
8) Fill the number of people passing the agent certification exam from the Professional Certification Body in the insurance field according to the implementation period.
9) Fill the number of marketing materials and RIPLAY evaluated for compliance with what is set or approved by the Company according to the implementation period.
10) Fill the number of marketing materials and RIPLAY revised and adjusted per Company approval according to the implementation period.
11) Fill the number of people evaluated by the Company, e.g., suitability of marketer parties in conveying information, compliance with agreements, etc., according to the implementation period.

i	ii	iii	iv	v	vi	vii	viii
Subfund Name	Currency	Exchange Rate	NAB	NAB/Unit	Annual Investment Return	Benchmark Investment Return	SHARPE Ratio
i	ii	iii	iv	v	vi	vii	viii

2. Detail of PAYDI Subfund Investments

i	ii	iii	iv	v	vi	vii	viii	ix	x	xi	xii	xiii	xiv
Description	Account	Subfund Name	Asset Status	Investment Type	In/Out Country	Currency	Exchange Rate	Code (Counterparty)	Name (Counterparty)	Is Counterparty Affiliated?	Serial Number	Category	Economic Sector
Investment Manager
detail row ke1
detail row ke2
detail row ke3 and onwards
Total

xv	xvi	xvii	xviii	xix	xx	xxi	xxii	xxiii	xxiv	xxv	xxvi	xxvii
Description	Account	Cluster Rating	Collateral Type	Tenor (Days)	Market Value of Collateral	Balance at Placement	Amount (Gram)	Balance % NAB Subfund	Liquid Balance (Less than One Year)	Target Investment Return Rate	Actual Investment Return Rate	Description
detail row ke1
detail row ke2
detail row ke3 and onwards
Total

i	ii	iii	vi	vii	x	xxii	xxv	xxvi

1. PAYDI Subfund Performance

Item	Description
PAYDI Subfund Name
Currency used by PAYDI Subfund
Exchange rate used in reporting, using BI middle rate (in rupiah)
Net Asset Value (in PAYDI Subfund currency)
Net Asset Value / number of units, only filled by PAYDI in unit form (in PAYDI Subfund currency)
PAYDI Subfund investment return for the last one year (in %)
Reference investment return set by the company at the creation of the PAYDI Subfund, for the last one year (in %)
(Annual Investment Return - Risk Free Rate) / Standard Deviation of PAYDI Subfund investment return; Risk free rate uses the interest rate of LPS-guaranteed general banks.

Item	Description
Investment Portfolio Name in PAYDI Subfund
PAYDI Subfund Name
Asset status based on allocation, i.e.,

No
1201 Direct
1202 Agency
1203 Bancassurance
1204 Non-Bank Business Entity - Laku Pandai Agent 1205 Non-Bank Business Entity - Other than Laku Pandai Agent 1206 Marketing Personnel (Micro) - Laku Pandai Agent 1207 Marketing Personnel (Micro) - Other than Laku Pandai Agent 1101 Property 1102 Motor Vehicle (Own Damage, Third Party Liability, and Personal Accident) 1103 Marine Cargo 1104 Marine Hull 1105 Aviation Hull 1106 Satellite 1107 Onshore Energy (Oil and Gas) 1108 Offshore Energy (Oil and Gas) 1109 Engineering 1110 Liability 1111 Credit 1112 Miscellaneous 1113 Health 1114 Personal Accident 12 Claims - Number of Policies Filled in accordance with the number of policies that filed claims Contribution - Contribution Amount (Rp) Filled with contribution revenue originating from gross contribution (before commission deduction) for that product from the beginning of the year until the reporting date as reported in the detail of Contribution and claims per business line in monthly financial reports Contribution - Number of Policies Filled with the number of policies that made Contribution payments (for group contributions, it is still calculated based on policies) Claims - Claim Amount (Rp) Filled with the gross claim amount from the beginning of the year until the reporting date as reported in the detail of Contribution and claims per business line in monthly financial reports 6 Business Line Filled with one of the codes for general insurance business lines as follows:
Estimation Profit/Loss Filled with the choice of estimation results being “Profit” or “Loss” based on the estimation calculation method as regulated in Article 56 POJK Number 23/POJK.05/2015 concerning Insurance Products and Marketing 4 Distribution Channel Filled with the code for the product marketing channel, namely:
Product Approval Date Filled with the OJK approval date for that product Estimation Calculation Method Filled with the choice of estimation calculation methods, namely Profit Testing, Embedded Value, Value of New Business, and Others as regulated in Article 56 POJK Number 23/POJK.05/2015 concerning Insurance Products and Marketing Product Status Filled with choices being new products, products still sold, and products no longer sold Product Code Filled with the product code created by the company; this product code must not change Product Name Filled with the product name that has received approval from OJK Column Filling Instructions

30 Description Filled with the description of the estimation calculation method used if choosing the entry “Others” in column 6 Reinsurance Support Filled based on reinsurance support for that product Impact of deviation on established Contributions Filled with a brief description regarding the impact of deviation (difference between assumptions and realization) on established Contributions Assumption - Underwriting Result (Rp) Filled based on the underwriting result assumption for that product when reporting a new product Realization - Loss Ratio (%) Filled based on the loss ratio level for that product Realization - Morbidity Filled based on the morbidity table realization for that product Assumption - Morbidity Filled based on the morbidity table assumption used when reporting a new product Assumption - Commission Expense (Rp) Filled with the assumption of the commission amount paid for that product when reporting a new product Assumption - General & Administrative Expenses (Rp) Mitigation measures taken to overcome deviation and the impact of deviation (if any) Filled with a brief description regarding mitigation measures taken by the company to overcome deviation and the impact of deviation Realization - Commission Expense (Rp) Filled with the realization of the commission amount paid for that product Realization - General & Administrative Expenses (Rp) Filled based on the realization of the general & administrative expenses amount for that product Realization - Underwriting Result (Rp) Filled based on the realization of the underwriting result for that product Filled based on the assumption of the general & administrative expenses amount for that product when reporting a new product Ujroh Provision Filled with the amount of technical provision for Company Funds (gross) for that product as of the reporting date as reported in the position of financial statements in annual financial reports Technical Provision – Claim Provision Filled with the amount of In-Process Claim Provision (gross) for that product as of the reporting date as reported in the Assumption - Loss Ratio (%) Filled based on the loss ratio level used when reporting a new product Technical Provision – Contribution Provision Filled with the amount of Contribution Provision (gross) for that product as of the reporting date as reported in the position of financial statements in annual financial reports Technical Provision – PAPYBMP Filled with the amount of PAPYBMP (gross) for that product as of the reporting date as reported in the position of financial statements in annual financial reports

COMPANY PROFILE
SHARIA LIFE/GENERAL/REINSURANCE INSURANCE COMPANY 1 Company Name: "Company Name" 2 Full Address: "Company Address" 3 Phone and Fax No.:
4 E-mail:
5 NPWP (Tax ID):
6 License No. & Date:
7 a. Number of Branches/
Representatives b. Number of Insureds:
8 External Auditor:
9 Shareholders
Shareholder Name Controlling Shareholder Ownership Rupiah Percentage Total 10 Controlling Entity:
11 Board of Directors and Commissioners Board of Directors Name Position Commissioner Name Position 12 Reporting PIC Name Position Email Phone/Mobile No. 13 Personnel with Expert Qualifications Name Qualification and Granting Institution Field Registration No. Qualification Expertise 14 Number of Employees:
(including Directors/Managers at equivalent levels) 15 Number of Agents a. Legal Entities:
b. Individuals:
16 Number of Brokers:
"Place", "Date"
"Company Name"
"Director Name"
"Director Position"
FORMAT ID

A. Report on the Implementation of Good Corporate Governance for Sharia Insurance Companies, Sharia Reinsurance Companies, and Sharia Units

Transparency of Good Corporate Governance Implementation
a. Implementation of GMS (General Meeting of Shareholders) Annual GMS implementation and other GMS implementations as well as decisions resulting from each GMS No. Time Implementation Agenda Participants Decisions GMS Notary Deed No. Notes 1. 2. Etc. b. Board of Directors
1) Number, names, positions, criteria, appointment dates by GMS, term of office, citizenship, and domicile of Board of Directors members
No Name Position
Criteria
Appointment
Date by GMS
Term of
Office
Citizenship Domicile
Final 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 membership composition of the Board of Directors must be included with a table as follows:
No. Name Position
Appointment Date by GMS
Dismissal Date 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.
2.
Etc.
Etc.

4) Frequency of Board of Directors meetings held within 1 (one) year.
No Name Position
Number of Board of Directors Meetings (... times meetings) % 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, which includes the type and number of shares.
No Name Position
Board of Directors member share ownership reaching 5% (five percent) or more of paid-up capital A B C D Notes: Names of companies (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 domestically or 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 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. (Resume of Meeting Results)

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. or Form of family relationship: husband/wife/children/parents/siblings/in-laws, etc.
c. Board of Commissioners
1) Number, names, positions, criteria, appointment dates by GMS, term of office, citizenship, and domicile of Board of Commissioners members
No Name Position
Criteria
Appointment
Date by GMS
Term of
Office
Citizenship Domicile
Final 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 membership composition of the Board of Commissioners must be included with a table as follows:
No. Name Position
Appointment Date by GMS
Dismissal Date 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.

4) Frequency of Board of Commissioners meetings held within 1
(one) year.
No Name Position
Number of Board of Commissioners Meetings (... times meetings) % Attendance Physical Attendance Teleconference/Video/ Conference/Other Electronic Media Facilities 1. 2. Etc.
5) Board of Commissioners meetings with the Board of Directors
No Name Position
Number of Board of Commissioners Meetings (... times meetings) % 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, which
includes the type and number of shares.
No Name Position
Board of Directors member share ownership reaching 5% (five percent) or more of paid-up capital A B C D Notes:
Names of companies
(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 domestically or 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,
(Resume of Meeting Results)

Sharia Supervisory Board members, and/or shareholders of the Company where the Board of Commissioners member serves 8) No. Name Financial Relationship With Other Board of Commissioners 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 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. or Form of family relationship: husband/wife/children/parents/siblings etc. d. Sharia Supervisory Board
1) Number, names, positions, criteria, appointment dates by GMS, term of office, citizenship, and domicile of Sharia Supervisory Board members
No Name Position
Criteria
Appointm ent
Date by
GMS
Term of
Office
Citizen ship
Domicile
Educ ation
Final
Formal and professional degree
Compet ency 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 membership composition of the Sharia Supervisory Board must be included with a table
as follows:

No. Name Position
Appointment Date by GMS
Date
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
Number of Sharia Supervisory Board Meetings (... times meetings) % Attendance Physical Attendance Teleconference/Video/Conf erence/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
Summary of Supervision Results Recommendations  realization of Business Plan both quantitatively and qualitatively  factors affecting performance efforts to improve Company performance (Resume of Meeting Results)

2) Independent Commissioner activity report
Summary of Supervision Results Recommendations f. Committees
1) Committees under the Board of Directors
No.
Committee
Name
Member
Name
Position*)
Work
Period
Appointment
Decision Letter
Number of
Meetings in
One Year
1.
Investment
Committee
1.
2.
Etc
2.
Product
Development
Committee
1.
2.
Etc
Etc
2) Committees under the Board of Commissioners
No.
Committee
Name
Member
Name
Position*)
Work
Period
Appointment
Decision Letter
Number of
Meetings in
One Year
1.
Audit
Committee
1.
2.
Etc
2.
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 No.
h. Implementation of remuneration policies and other facilities for Board of Directors, Board of Commissioners, and Sharia Supervisory Board members Number of Board of Directors, Board of Commissioners, Sharia Supervisory Board, and employees receiving remuneration packages in 1 (one) year which are grouped according to income level as follows:

Individual Remuneration Total in 1 year ) Total Board of Directors Number of Board of Commissioners Number of Sharia Supervisory Board Employees Above Rp2 billion Above Rp1 billion up to Rp2 billion Above Rp500 million up to Rp1 billion Rp500 million and below Notes:) requested in cash
i. Outsourcing of Investment Management
No. Investment Type Name of Company Outsourcing Investment Value No. Agreement % 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 No. Description Checklist *) If Yes, Yes No Explain.
1. Resignation or dismissal of external auditors
2. Material transactions with related parties
3.
Material claims filed by and/or against the Insurance Company 4. Conflict of Interest currently ongoing and/or that may occur 5. Other material information regarding the Insurance Company
6. Company has a compliance function
7. Company has internal auditors
8. Company has a risk management function
9.
Company has an investment management function/unit of work 10. Company has a special work unit and/or appoints a Company official responsible for the implementation of AML and CFT programs *) choose one answer by placing a “√” mark

*) Related Parties are individuals or companies/entities that have a controlling relationship with the Company, either directly or indirectly, through ownership, management, and/or financial relationships
2. Self-Assessment on the Implementation of Good Corporate Governance
The completion of the Good Corporate Governance Implementation questionnaire by the Company is done by the Company itself. Completion of this questionnaire is done by providing answers to questions/statements in the questionnaire intended. Completion Method:
Generally, answers to the Questions/Statements mentioned consist of 5 criteria as follows (except for answers requiring different criteria) :
A= The Company does NOT HAVE written policies regarding the Question/Statement intended. B= The Company HAS written policies regarding the Question/Statement intended, but those policies have NOT been implemented. C= The Company HAS written policies regarding the Question/Statement intended, but those policies have NOT been implemented CONSISTENTLY. D= The Company HAS written policies regarding the Question/Statement intended, those policies ARE IMPLEMENTED CONSISTENTLY but have NOT BEEN UPDATED regularly. E= The Company HAS written policies regarding the Question/Statement intended and those policies ARE IMPLEMENTED CONSISTENTLY and UPDATED regularly. 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 starting from the lowest assessment (A/ No), to the highest assessment (E/ Yes). Specifically for the answer "A/No" on assessment criteria required by legislation (mandatory), a negative score is given. For groups of Questions/Statements skipped because "None exist" and those that are not "not applicable", in the interpretation of results they must still be considered by giving the same score as the answer "A/No".
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 policy directing towards regulations
legislation and applicable codes of ethics A B C D E
2.2. Policy for company organs A B C D E

2.3. Policy for employees A B C D E
2.4. Policy for policyholders A B C D E
2.5. Policy for business partners A B C D E
2.6. Policy for fellow insurance companies and reinsurance
companies
A B C D E
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 "having no conflict of interest" against
every decision taken by the competent authority 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 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, and regulatory provisions
and matters related to Policyholders that ensure protection for Whistleblowers. A B C D E
II. COMPANY ORGANS
A. General Meeting of Shareholders (GMS)
1. Every Shareholder has the right to obtain accurate information regarding procedures that must be fulfilled concerning
the organization of GMS
A B C D E
2. Company policy on complete explanation and accurate information regarding GMS procedures in accordance with applicable regulatory provisions
A B C D E
3. Every Shareholder has the right to obtain a complete explanation
regarding procedures that must be fulfilled concerning the organization of GMS No Yes
4. Complete explanations and information include the following matters:
4.1 GMS Call No Yes
4.2 Information regarding every 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 the results
of GMS
No Yes

5. In taking GMS decisions:
5.1 Board of Commissioners and Directors appointed have passed the Fit
and Proper Test for the company
No Yes
5.2 Consider the opinion of the Nomination and Remuneration Committee
or the function handling Nomination and Remuneration in the appointment of Board of Commissioners and Directors A B C D E
5.3 Consider the quality of reports related to
GCG in making decisions to accept or reject the report A B C D E
5.4 Appoint external auditors No Yes
5.5 Decisions taken consider the fair interests of
stakeholders
A B C D E
5.6 Consider the company's financial condition in granting
bonus, tantiem, and dividends
A B C D E
B. Board of Commissioners and Board of Directors
1. 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.GCG Implementation A B C D E
2. The Board of Commissioners, Board of Directors, and Sharia Supervisory Board jointly agree on the following:
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 regulatory provisions and company articles of association A B C D E 2.5.Policies in avoiding all forms of conflict of interest (conflict of interest). A B C D E 2.6.Assessment policies and methods for the company A B C D E 2.7.Assessment policies and methods for units within the company A B C D E 2.8.Organizational structure at the executive level A B C D E
C. Board of Commissioners
1. 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 effectiveness decision-making No Yes 1.2.In the composition of the Board of Commissioners, there are commissioners who are not 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 competence such as *):
a. insurance field No Yes

b. financial field No Yes
c. management field. No Yes
1.5. Having an Authorized Commissioner, in addition to Independent Commissioners No Yes
1.6. Members of the Board of Commissioners are appointed and dismissed by the General Meeting of Shareholders (GMS) according to a transparent process based on reasonable grounds and given the opportunity to defend themselves
No Yes
1.7. Not holding concurrent positions as members of the Board of Directors or members of the Board of Commissioners in Sharia Insurance Companies, Sharia Reinsurance Companies, and Insurance or Reinsurance Companies that conduct part of their business based on the same Sharia Principles
No Yes
1.8. Not holding 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 members of the Board of Commissioners, members of the Board of Directors, or members of the Sharia Supervisory Board in Insurance Companies having the same business field
No Yes
2. Competence and Integrity of the Board of Commissioners
2.1. Meeting Fit and Proper Test requirements No Yes
2.2. Complying with and understanding the Company's Articles of Association A B C D E
2.3. Complying with and implementing GCG A B C D E
2.4. Not utilizing the company for personal, family, business group, or other interests that can harm the company
No Yes
3. Competence and Integrity of DPS (Sharia Supervisory Board)
3.1. Obtaining recommendation from the National Sharia Council? No Yes
3.2. DPS has obtained approval from OJK No Yes
3.3. Complying with and understanding the Company's Articles of Association No Yes
3.4. Complying with and implementing GCG No Yes
3.5. Not utilizing the company for personal, family, business group, or other interests that can harm the company
No Yes
3.6. 50% or more of DPS members are Indonesian citizens No Yes
4. Supervisory Functions of the Board of Commissioners
4.1. The Board of Commissioners supervises the company's management 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 may impose sanctions on the Board of Directors in the form of temporary dismissal, with the condition 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 Work 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 obtains acquit et decharge from the GMS
A B C D E

4.8. The Board of Commissioners holds meetings periodically No Yes
4.9. Minutes of each Board of Commissioners meeting are recorded No Yes
4.10. Meeting minutes include dissenting opinions regarding decisions taken in the meeting
A B C D E
4.11. Each member of the Board of Commissioners, whether attending the meeting or not, is entitled to receive the minutes of the Board of Commissioners meetings
No Yes
5. Supervisory 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 periodically No Yes
5.4. Minutes of each DPS meeting are recorded No Yes
5.5. Meeting minutes include dissenting opinions regarding decisions taken in the meeting
No Yes
5.6. Each member of DPS, whether attending the meeting or not, is entitled to receive the minutes of DPS meetings
No Yes
6. Committees of the Board of Commissioners (answered if applicable)
6.1. Audit Committee
No
Yes continue to
6.1.8.
The Audit Committee serves as a facilitator for the Board of Commissioners to ensure the following:
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 implementation 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. Improving the quality of openness and financial reporting A B C D E
6.1.7. Members of the Audit Committee consist of:
a. one Independent Commissioner as Chairman or an Independent Party for Reinsurance Companies or Sharia Reinsurance Companies that do not have Independent Commissioners No Yes b. members of the Board of Commissioners No Yes
c. independent external parties possessing the necessary expertise, experience, and other qualities No Yes
6.2. Risk Monitoring Committee No
Yes continue to
6.2.4.
The Risk Monitoring Committee serves as a facilitator for the Board of Commissioners regarding the following:
6.2.1. Assessing the quality of risk management policies A B C D E

6.2.2. Assessing the effectiveness of risk management applied 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 Monitoring Committee consist of:
a. 1 (one) chairman who also serves as a member who is an Independent Commissioner; No Yes b. 1 (one) member possessing expertise in risk management and/or actuarial science; and No Yes
c. 1 (one) member possessing expertise in finance, economics, and/or insurance No Yes
6.3. Remuneration and Nomination Committee No
Yes continue to
6.3.11.
The Remuneration and Nomination Committee serves as a facilitator for the Board of Commissioners regarding the following:
6.3.1. Assisting the Board of Commissioners in proposing to the GMS regarding the nomination system and procedures for the Board of Commissioners
A B C D E
6.3.2. Assisting the Board of Commissioners in proposing to the GMS regarding the nomination system and procedures for the Board of Directors
A B C D E
6.3.3. Assisting the Board of Commissioners in proposing to the GMS regarding the nomination system and procedures for 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 board members 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. (one) chairman who also serves as a member who is a member of the Board of Commissioners No Yes b. 1 (one) member from Independent Commissioners or Independent Parties possessing expertise in human resources; and No Yes
c. 1 (one) member from Company Executive Officials overseeing the human resources field or 1 (one) employee representative.
6.3.11. For Companies that do not have a Nomination and Remuneration Committee, there are Commissioner members who specifically serve the following tasks:

a. Assisting the Board of Commissioners in proposing to the GMS regarding the nomination system and procedures for the Board of Commissioners A B C D E b. Assisting the Board of Commissioners in proposing to the GMS regarding the nomination system and procedures for the Board of Directors A B C D E
c. Assisting the Board of Commissioners in proposing to the GMS regarding the nomination system and procedures for 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 board members 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
No
Yes continue to
6.4.4.
The Corporate Governance Policy Committee (whether standalone or combined within the Nomination and Remuneration Committee) assists 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 alignment of GCG application in the company against 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 No Yes b. Independent external parties possessing expertise, experience, and quality in the field of corporate governance No Yes
6.4.4. For Companies that do not have a Corporate Governance Policy Committee, there are Commissioner members who specifically serve the following tasks:
a. Reviewing GCG policies comprehensively drafted by the Board of Directors A B C D E b. Assessing the alignment of GCG application in the company against GCG policies drafted by the Board of Directors, including those related to Business Ethics and CSR A B C D E

7. Independent Commissioners
The Company has Independent Commissioners with the following criteria:
7.1. Does not have affiliation relationships *) with controlling Shareholders of the company
No Yes
7.2. Does not have affiliation relationships *) with Company Directors No Yes
7.3. Does not have affiliation relationships *) with other Commissioners No Yes
7.4. Has never held executive positions in the same Insurance Company and Sharia Insurance Company within the last 6 (six) months
No Yes
7.5. Does not hold executive positions in companies having business relationships with the company
No Yes
7.6. Has never held executive positions in other affiliated companies within the last 6 (six) months
No Yes
7.7. Is not a partner or principal at a consulting firm providing professional services to the company and other affiliated companies
No Yes
7.8. Is not a significant supplier or holding executive and commissioner positions at supplier companies
No Yes
7.9. Is not a significant customer or holding executive and commissioner positions at significant customer companies of the Company
No Yes
7.10. Is not a significant supplier of affiliated companies or holding executive and commissioner positions at supplier companies of affiliated companies.
No Yes
7.11. Is not a significant customer of affiliated companies or holding executive and commissioner positions at customer companies of affiliated companies.
No Yes
7.12. Free from all interests and business activities or other relationships with the company that can be interpreted as hindering or reducing the ability of Independent Commissioners to act and think independently for the benefit of the Company.
No Yes
7.13. Understanding the Limited Liability Company Law A B C D E
7.14. Understanding the Insurance Law and its implementing regulations.
A B C D E
7.15. Not holding concurrent positions as Commissioners, Directors, and Sharia Supervisory Boards in Insurance Companies and Sharia Insurance Companies having the same business field.
A B C D E
D. Board of Directors
1. Composition of 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 No Yes
1.1.b Finance Field No Yes
1.1.c Management Field No Yes
1.2. Residence of Board of Directors members is arranged to enable effective decision-making
No Yes
1.3. Board of Directors members are appointed and dismissed by the GMS through a transparent mechanism
No Yes

2. Requirements for Board of Directors Members
2.1 Board of Directors members meet articles of association provisions No Yes
2.2. Board of Directors members meet competence and propriety requirements according to regulator and supervisor regulations
No 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 detrimental to the company's interests
No Yes
2.6. The President Director does not hold concurrent positions as a Board of Commissioner in more than 1 (one) Insurance Company with different business fields
No Yes
2.7. Besides the President Director, does not hold concurrent positions as a Board of Commissioner in more than 1 (one) Insurance Company with different business fields that are not subsidiaries
No Yes
2.8. The Board of Directors does not hold concurrent positions in companies that are not Insurance Companies
No Yes
3. Functions of the Board of Directors
3.1. Management
3.1.1. The Board of Directors formulates the Company's Vision, Mission, and Values as well as 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 possession of human resources meeting certain 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 its duties
A B C D E
3.1.5. The Board of Directors has and complies with rules of procedure and work guidelines (charter)
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
No Yes
3.3. Internal Control
3.3.1. The Company has an internal supervision function No Yes
3.3.2. Responsible to the President Director or Director overseeing internal supervision tasks
No Yes
3.3.3. Submitting reports to the Board of Commissioners/Audit Committee
No Yes
3.3.4. Head of the Internal Auditor Work Unit is appointed by the Board of Directors, based on clear criteria
No Yes
3.3.5. Appointment of the Head of the Internal Auditor Work Unit obtains approval from the Board of Commissioners
No Yes

3.3.6. The Internal Auditor Work Unit is tasked to ensure the internal control system functions effectively and efficiently
A B C D E
3.3.7. Conducting evaluations of company program implementation A B C D E
3.3.8. Ensuring the Internal Control System functions effectively and efficiently
A B C D E
3.3.9. Providing suggestions to improve the effectiveness of risk control processes
A B C D E
3.3.10. Conducting compliance evaluations against laws and regulations, GCG implementation, and company regulations
A B C D E
3.3.11. Facilitating 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
No Yes continue to 3.4.2
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
No Yes
3.4.3. The Company Secretary must be able to:
a. Ensure the company has met information disclosure requirements according to laws and regulations A B C D E b. Provide services to stakeholders regarding any relevant information needed. A B C D E
3.4.4. Reports on the Company Secretary's task execution are submitted to the Board of Directors and Board of Commissioners
No Yes
3.4.5. The Company Secretary executes functions to guarantee compliance with laws and regulations in the event the company does not have its own compliance committee.
No Yes
3.5. Actuarial
3.5.1. The Company has Actuaries meeting the following principles
a. Appointed Actuaries have qualifications and standards as determined, proven by recognition from the Actuarial Professional Body. No Yes b. Company Actuaries meet qualifications according to applicable legislation. No Yes
c. Appointed Actuaries in performing their duties refer to practice standards and professional ethical codes that apply.
No
Yes
3.5.2. The Company must appoint an actuarial consulting company to evaluate company liabilities
No Yes
3.6. Investment
3.6.1. Investments are conducted with prudence 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 No Yes
3.6.3. The Investment Committee executes duties objectively based on Board of Directors directives
A B C D E
3.6.4. The Investment Committee assists the Board of Directors in evaluating and A B C D E
planning investment strategies
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 No 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 ethical codes and applicable laws and regulations
No Yes
3.7.2. The Company issues brochures containing complete and clear explanations of products sold to the general public
No Yes
3.7.3. The Company has agents and an agency system No Yes
3.7.4. The Company has standard agency contracts No 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 possesses and applies an Agency Code of Ethics in marketing its products
No Yes
3.7.7. The Company has cooperation with insurance brokers No Yes
3.7.8 The Company has utilized electronic media to carry out marketing activities
No 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 possesses 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
No 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 No Yes
3.8.6. The Company has clear responsibility arrangements regarding 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. Reports on social responsibility implementation are submitted by the Board of Directors in the Annual Report
No Yes
4. Accountability of the Board of Directors
4.1. The Board of Directors prepares accountability reports for company management in the form of an Annual Report
No Yes
4.2. Criteria for the Annual Report include:
4.2.1. Containing at least:
a. Financial Statements No Yes b. Company Activity Report No Yes
c. GCG Implementation Report No Yes
4.2.2. Obtaining GMS approval No Yes

4.2.3. Specifically, financial statements must obtain GMS ratification No Yes
4.2.4. Must be available before the GMS is held according to applicable regulations so that Shareholders can perform assessments.
No
Yes
4.3. Board of Directors Meetings
4.3.1. The Board of Directors holds meetings periodically No Yes
4.3.2. The Board of Directors establishes meeting rules No Yes
4.3.3. Minutes of each Board of Directors meeting are recorded No Yes
4.3.4. Meeting minutes include dissenting opinions regarding decisions taken in the meeting (if any)
A B C D E
4.3.5. Each Board of Directors member, whether attending the meeting or not, is entitled to receive the Minutes of Board of Directors Meetings
No Yes
III. SHAREHOLDERS

Shareholder Requirements
1.1. Controlling Shareholders must always meet competence and propriety requirements
No Yes
1.2. Competence and propriety assessment is conducted whenever Controlling Shareholders are suspected of no longer meeting competence and propriety requirement provisions based on analysis results, examination results, and/or complaints
No Yes
1.3 Controlling Shareholders do not become Controlling Shareholders in 1 (one) other Company that is an Insurance or Reinsurance Company having the same business field
No Yes
Rights and Responsibilities of Shareholders
2.1. The Company guarantees Shareholder rights, so that Shareholders can utilize them according to correct procedures
No Yes
2.2. Do the rights guaranteed by the Company include but are not limited to the following:
a. Right to attend GMS No Yes b. Right to vote in a GMS No Yes
c. Right to obtain material information promptly No Yes
d. Right to obtain material information regularly No Yes e. Right to receive a portion of profits designated for Shareholders, proportional to the number of shares owned No Yes
Obligations of Shareholders
3.1. Shareholders comply with Articles of Association and laws and regulations 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 required not to utilize the Company for personal interests in a manner and spirit contrary to laws and regulations and
A B C D E

healthy practices in the insurance industry
3.5. Shareholders are required not to utilize the Company for family interests in a spirit and manner contrary to legislation and healthy practices.
A B C D E
3.6. Shareholders are required not to utilize the Company for the Company's own interests in a spirit and manner contrary to legislation and healthy practices.
A B C D E
3.7. Shareholders are required not to utilize the Company for the interests of their business group in a spirit and manner contrary to legislation and healthy practices.
A B C D E
3.8. Shareholders evaluate the performance of the Board of Commissioners through the General Meeting of Shareholders (GMS) mechanism.
No Yes
3.9. Shareholders evaluate the performance of the Board of Directors through the GMS mechanism.
No Yes
4. Company Responsibility towards Shareholder Rights and Obligations
4.1. The Company protects shareholder rights in accordance with the Articles of Association and other applicable legislation.
A B C D E
4.2. The Company maintains a register of shareholders in accordance with the Company's Articles of Association and relevant legislation.
A B C D E
4.3. The Company provides information about the Company accurately, 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 undisclosed information 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
1. The Company must fulfill and implement:
1.1. Obligations as agreed with policyholders No Yes
1.2. Protection of policyholders' interests No Yes
1.3. Confidentiality protection for policyholders No Yes
1.4. Evaluation of policyholders' 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
No Yes
2. The Company ensures that policyholders
2.1. Provide information to the Company honestly regarding insured data and risk objects No Yes
2.2. Pay premiums on time No Yes
2.3. Report claims to the Company according to procedures No Yes
2.4. Give opportunities to conduct surveys and cooperate with adjusters
No Yes
B.Employees
1. Employees must fulfill and implement:
1.1. Employee recruitment 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 aspects objectively without discrimination based on ethnicity, religion, race, gender, and physical condition:
1.2.1. Remuneration setting patterns A B C D E
1.2.2. Inclusion in training A B C D E
1.2.3. Career level determination A B C D E
1.2.4. Job requirement determination A B C D E
1.3. Having written regulations governing recruitment patterns and employee rights and obligations
A B C D E
1.4. Providing a conducive working environment, including occupational health and safety
A B C D E
1.5. Providing communication facilities for conveying information to employees
A B C D E
1.6. Giving employees the opportunity to form Labor Unions while still observing legislation
A B C D E
2. The Company must fulfill and implement:
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 working 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 reporter
A B C D E
C. Other Insurance and Reinsurance Companies
1. Insurance companies and reinsurance companies engage in healthy business competition
A B C D E
2. In the event 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. Implementation of commitments to fulfill each party's obligations according to agreements and legislation
A B C D E
3. The Company has automatic coverage from reinsurance companies A B C D E
4. The Company has its own retention for every risk closure based on its own capital (equity) and the associated risk profile
A B C D E
5. Every automatic (treaty) reinsurance closure is based on an agreement agreed upon by the Company and the respective reinsurance company
A B C D E
D.Supporting Companies
1. 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 implements 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
No Yes
1.2.2. Provides all relevant information to the Company correctly, honestly, and completely
No Yes
1.2.3. Implements rights and obligations according to agreements, contracts, and legislation.
No Yes
2. Relationship with Loss Adjusters
In relations with loss adjusters, the Company refers to the following rights:
2.1. The Company must disclose information about policy conditions and provide complete and accurate data related to 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
No Yes
2.2.2. Uses policy terms and conditions as the basis for determining whether the loss occurred is covered
No Yes
2.2.3. Draws conclusions from examinations and research competently and independently representing the interests of the Company and the policyholder
No Yes
2.2.4. Discloses all important information regarding the occurrence of loss and its causes, according to known facts without favoring either party
No Yes
2.2.5. Implements rights and obligations according to agreements, contracts, and legislation
No Yes
3. Relationship with Actuarial Consultants
In relations with actuarial consultants, the Company refers to the following matters:
3.1. The Company discloses accurate data and information as needed by the actuarial consultant in performing 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 good integrity and reputation and is recognized by the competent authority
No Yes
3.2.2. Is independent from the Company and free from shareholder interests No Yes
3.2.3. Makes reports and recommendations to the Board of Directors based on prevailing practice standards and professional codes of ethics
No Yes
3.2.4. Implements rights and obligations according to agreements No Yes
4. Relationship with Insurance Agents
In relations with insurance agents, the Company refers to the following matters:
4.1. The Company fulfills obligations according to agency agreements
A B C D E
4.2. Including the code of ethics established by the relevant insurance association in the agency agreement, along with sanctions imposed for any violations.
No Yes
4.3. Ensuring that the appointed agent:
4.3.1. Is competent in representing the Company in selling products and providing insurance services, proven by certificates from competent authorities
No Yes
4.3.2. Receives continuous education and training from the Company to maintain and improve competence.
No Yes
4.3.3. Signs, implements, and complies with agency agreements with the Company
No Yes
4.3.4. Implements premium payments from policyholders to the Company according to agreements
No Yes
4.3.5. Implements rights and obligations according to agreements No 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 code of ethics
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 provide 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 violation of the code of ethics that occurs
A B C D E
5. 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 business partners' rights and obligations according to agreements and legislation
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
No Yes
5.2.2. Keep each other's information confidential and protect each other's interests, unless otherwise required by legislation
No Yes
5.2.3. Implement working relationships in accordance with ethical values and legislation.
No Yes
6. 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 nurturing
A B C D E
6.2. The Company is responsible for negative impacts caused by Company activities on society.
A B C D E
V.HEALTHY BUSINESS PRACTICES
A.Underwriting
1. The Company has an underwriting policy detailed in the Underwriting Guidelines
A B C D E
2. The Underwriting Guidelines contain technical acceptance policies, authority limits for each underwriter, pricing, and insurance coverage capacity
A B C D E
3. In conducting prudent underwriting, the Company:
3.1. Applies basic insurance principles A B C D E
3.2. Considers factors supporting implementation, such as: risk surveys, premium rate determination, and coverage value determination.
A B C D E
3.3. Complies with legislation A B C D E
4. Coverage provided by the Company must be clear and easy to understand to prevent disputes in the future and provide benefits as needed by policyholders
A B C D E
B.Claims
1. The Company informs policyholders about the procedure for settling insurance claims
A B C D E
2. Ensuring the Company receives information about the procedures and requirements for submitting reinsurance claims by the reinsurance company and the insurance company related to the reinsurance coverage conducted by the Company
A B C D E
3. The Company uses independent loss adjuster services when necessary
No Yes
4. Claim handling policies are detailed in the Company's Claim Settlement Guidelines
A B C D E
5. The Company strives for prompt claim settlement and timely payment according to legislation
A B C D E
C.Reinsurance and Retrocession
1. The Company conducts reinsurance/retrocession for risks exceeding or outside the Company's capacity
A B C D E according to legislation
2. Reinsurance/retrocession implementation is based on written agreements between the Company and the reinsurer, whether facultative or treaty
A B C D E
D.Compliance
1. The Company has a compliance function No Yes
2. The Company executes the compliance function against legislation provisions, internal policies, and agreements with other parties
A B C D E
3. The Company executes the compliance function regarding business ethics and codes of conduct
A B C D E
4. The Board of Directors is tasked with performing the compliance function A B C D E
5. The Board of Commissioners monitors the execution of the compliance function through a Risk Monitoring Committee or Compliance Committee specifically formed
A B C D E
6. Information regarding non-compliance, including deviations and/or fraud, is collected through the Reporting System mechanism
A B C D E
7. The Company has a Chief Compliance Officer A B C D E
8. Directors overseeing the compliance technique do not concurrently hold positions in insurance techniques, finance functions, or marketing functions
A B C D E
E.Risk Management
1. The Company has a risk management function No Yes
2. The Company has a risk management policy detailing main principles and responsibility setting among all aspects of activities, including:
2.1. An efficient system for identifying, assessing, measuring, controlling, reducing, and monitoring risks
A B C D E
2.2. Strategies, policies, and procedures to ensure fulfillment of internal policies and legislation
A B C D E
2.3. Adequate internal control systems to ensure that Risk Management and Compliance are executed 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
3. The Company develops a strategic framework for Asset and Liability Management (ALM) implemented at the Director-level committee. Important tasks of this Committee include discussing new products to be marketed by the Company
A B C D E
4. 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 Company's financial state.
A B C D E
5. The Company develops Contingency Plans specifically to handle risks believed to occur, such as
A B C D E natural disasters, terrorist attacks, information technology system failures, vacancies in 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 work unit implementing the internal auditor function. To perform its function well, internal auditors must:
1.Prepare and execute audit plans to test and evaluate the adequacy and effectiveness of the systems owned by the Company A B C D E 2.Audit all activity areas containing sufficiently material risks within an adequate timeframe A B C D E 3.Issue finding reports and recommendations based on audit results to Management A B C D E 4.Report audit results and significant findings to the Board of Directors and Board of Commissioners A B C D E 5.Report the adequacy of risk management, compliance, and other control functions to management. A B C D E 6.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
1. External Auditors (public accounting firms) conduct independent examinations of the truthfulness of reports presented by the Board of Directors
No Yes
2. The appointed public accounting firm (KAP) is registered with the Supervisory Authority
No Yes
3. The appointment of the KAP is proposed by the Board of Directors to the Board of Commissioners and subsequently requires GMS approval.
No Yes
4. External Auditors are free from Commissioner influence No Yes
5. External Auditors are free from Board of Directors influence No Yes
6. External Auditors are free from influence by other interested parties in the Company.
No Yes
7. External Auditors have access to all accounting records No Yes
8. External Auditors have access to all supporting data required
No Yes
9. External Auditors do not provide other services besides audit services. No Yes
10. The appointment of the KAP is proposed by the audit committee to the Board of Commissioners and subsequently requires GMS approval No Yes
H.Violation Reporting System (Whistleblowing System)
1. The Company has a Violation Reporting System mechanism that records every violation endangering the Company's interests
A B C D E
2. The person in charge of the violation reporting system submits violation reports to the Company
A B C D E
3. The Violation Reporting System mechanism can protect the Reporter A B C D E
4. The person in charge of the Violation Reporting System immediately follows up on every report submitted by the Reporter A B C D E
I.Company Actuary
Not directly to VI
Yes
1. The Company has a company actuary who acts independently
2. 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 obligations
A B C D E
3. Actuaries have access to the Board of Directors and relevant Board Meetings as well as operational units
A B C D E
4. Actuaries are given authority to communicate with staff in divisions whose work results relate to the designated actuarial function.
A B C D E
5. Actuaries provide recommendations on premium rates with the assurance that the rate determination has been consistent with internal structure.
A B C D E
6. 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
7. Actuaries can provide opinions on investment methods that the Company should undertake
A B C D E
8. The Company does not assign other tasks to actuaries that could cause conflicts of interest No Yes
VI.STATEMENT OF GCG GUIDELINE APPLICATION
1. The Statement on GCG Application is stated in the Company's Annual Report accessible to stakeholders.
No
Exists
Yes
2. The annual report must contain information about the structure and working mechanisms of the Company's organs, including:
2.1. Names of Board of Commissioners members No Yes
2.2. Number of meetings held by the Board of Commissioners and attendance lists No Yes
2.3. Mechanism and criteria for self-assessment of each Commissioner's performance
No Yes
2.4. Explanation of the Board of Commissioners' support committees
2.4.1. Name No Yes
2.4.2. Function Description No Yes
2.4.3. Working Mechanism No Yes
2.4.4. Number of Meetings No Yes
2.4.5 Attendance List No Yes
2.4.6. Mechanism and Criteria for Committee Performance Assessment No Yes
2.5. Names of Board of Directors members with their respective positions and functions
No Yes
2.6. Brief explanation of the Board of Directors' working mechanism No Yes
2.7. Number of meetings held by the Board of Directors and Attendance List No Yes
2.8. Statement regarding the effectiveness of internal control system implementation, including risk control systems and internal supervision and audit systems.
No Yes
2.9. Other information related to GCG application, including:
2.9.1. Company Vision, Mission, and Values No Yes
2.9.2. Controlling Shareholders No Yes
2.9.3. Policy and Amount of Remuneration for Board of Commissioners and Directors
No Yes
2.9.4. Transactions with parties having conflicts of interest No Yes
2.9.5. Results of GCG application assessment reported in the Annual GMS
No Yes
2.9.6. Extraordinary events experienced by the Company and affecting Company performance
No Yes
3. Action Plan
No. Corrective Action
Target
Completion
Obstacles
Completion
Remarks
1. etc
4. Anti-Fraud Strategy Application
(Company Name)......
FRAUD CONTROL REPORT AND ANTI-FRAUD STRATEGY IMPLEMENTATION YEAR …… a. Inventory of Fraud Events and Follow-up Type Fraud a) Date of Fraud Occurrence Division/
Section
of
Fraud Occurrence
Parties
Involved b)
Position Loss in Rupiah c)
Company
Actions d)
Weaknesses/
Causes of
Fraud e)
Follow-up/
Improvement f)
Chronology of
Fraud
Events

b. Progress in the Implementation of Anti-Fraud Strategies
1) Prevention:
………………
………………
………………
2) Detection:
………………
………………
………………
3) Investigation, Reporting, and Sanctions:
………………
………………
………………
4) Monitoring, Evaluation, and Follow-up:
………………
………………
………………

EXPLANATION FOR REPORT FILLING:
a) Types of Fraud include, among others, fraud, deception, embezzlement, information leakage, corporate criminal acts, or others. b) Parties involved include all parties indicated to be involved/participating in the Fraud. If more than one (1) party is involved, the role of each party must be explained. c) Losses are filled with losses that have occurred or estimated losses. d) Company actions are the Company's response to Fraud incidents, whether actions against perpetrators, injured parties, or other actions. Actions against Fraud perpetrators include administrative sanctions for employees and/or compensation obligations. Actions towards injured parties 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 within the Company that caused the Fraud, which can be policy, system, and procedure weaknesses, or human resource issues, as well as other causes not originating from the Company. f) Follow-up/improvements are efforts that have been or will be undertaken by the Company regarding weaknesses that caused the 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.

SHARIA SUPERVISORY BOARD SUPERVISION RESULTS REPORT
a. Compliant/Non-Compliant Statement Sharia Supervisory Board Statement Bismillaahirrahmaanirrahiim We have supervised the implementation of business activities (insurance/reinsurance*) of PT .... (“the Company”) regarding the application of Sharia principles during the period from date ……………… to date ………………, as mandated by Article 38 of Financial Services Authority Regulation Number 73/POJK.05/2016 on ...... In carrying out this supervision, we conducted an assessment of the Company's business activities covering aspects of asset and liability management, marketed Sharia insurance products, and marketing practices of Sharia insurance products. From the supervision results, it is known that (there is / there is no)* practice of organizing business activities that violate Sharia principles. Regarding such violations, the Company (has / has not)* corrected the violation practices of those activities. The practices violating Sharia principles are as follows:
No Business Activity Violating Sharia Principles Period Occurred Follow-up (cross out if no violations exist). Thus, the general practice of organizing business activities (compliant / non-compliant)* with Sharia principles. ......(City Name),...... (Date-Month-Year) Sharia Supervisory Board :
No Name Signature Remarks etc.
*) Choose one appropriate statement

b. Non-Opinion Statement
We have supervised the implementation of business activities (insurance/reinsurance*) of PT .... (“the Company”) regarding the application of Sharia principles during the period from date ……………… to date ………………, as mandated by Article 38 of the Financial Services Authority Regulation. In carrying out this supervision, we conducted an assessment of the Company's business activities covering aspects of asset and liability management, marketed Sharia insurance products, and marketing practices of Sharia insurance products. The Company did not provide us access to obtain documents and information we needed to conduct assessments on the aspects mentioned in paragraph 1 above, therefore we do not give an opinion on the application of Sharia principles regarding the Company's business organization. …………(City Name),….(Date-Month-Year) Sharia Supervisory Board:
No Name Signature Remarks etc.
*) Choose one appropriate statement

Filling Out the Sharia Supervisory Board Supervision Results Questionnaire Filling is done by providing answer choices to questions/statements in the said questionnaire. A. Asset and Liability Management Main Material 1:
System and procedures for managing assets and liabilities. Compliance Status:
No 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 its assets and liabilities carried out in accordance with agreements in the policy. Compliance Status:
No Yes
Main Material 4:
Formation of Tabarru’ Funds (created separately per business line or combined business lines) has complied with its contract (akad). Compliance Status:
No Yes
Main Material 5:
Formation of Participant Investment Funds for each type of investment portfolio in accordance with its contract (akad). Compliance Status:
No Yes
Main Material 6:
Recording and administration of participant accounts individually as part of the assets and liabilities of Participant Investment Funds. Compliance Status:
No Yes
Main Material 3:
Restriction on the use of Tabarru’ Funds as regulated in Article 4 paragraph (2) POJK No. 72/POJK.05/2016 Compliance Status:
No Yes

Main Material 7:
Giving and returning Qardh to/from Tabarru’ Funds.
Compliance Status:
No Yes
Main Material 8:
Management of Tabarru’ Funds, Company Funds, and Participant Investment Funds is conducted based on Sharia principles, for example, these assets are only placed in investment instruments that do not contradict Sharia principles. Compliance Status:
No Yes
Main Material 9:
Calculation and distribution of underwriting surplus in accordance with the policy and provisions of Article 6 of Financial Services Authority Regulation number 72/POJK.05/2016 on Financial Health of Insurance Companies and Reinsurance Companies with Sharia Principles. Compliance Status:
No Yes
Main Material 10:
Distribution of participant's share of underwriting surplus utilized for social funds in accordance with Sharia principles. Compliance Status:
No Yes
B. Marketed Products
Main Material 1:
System and procedures for designing, issuing, implementing, and monitoring marketed products. Compliance Status:
No Yes
Main Material 2:
Preparation and implementation of policy contents and insurance request forms (SPPA)/membership request forms which include:
a. Use of tabarru’ contracts and tijarah contracts. b. Minimum substance that must be contained in every contract.
c. Fair and equitable method of allocating and distributing underwriting surplus for all participants.
d. Giving qardh by the Company and repayment of qardh to the Company. Compliance Status:
No Yes

Main Material 3:
Determination and charging of ujrah/remuneration in risk management using wakalah bil ujrah contracts stated in policies and insurance request forms (SPPA)/membership request forms is conducted fairly and meets basic principles as referred to in Article 54 POJK number 69/POJK.05/2016. Compliance Status:
No Yes
Main Material 4:
Determination and charging of ujrah/remuneration in investment management using wakalah bil ujrah contracts and/or nisbah/profit-sharing ratios in mudharabah contracts and mudharabah musytarakah contracts stated in policies and insurance request forms (SPPA)/membership request forms is conducted fairly and meets basic principles as referred to in Article 54 POJK number 69/POJK.05/2016. Compliance Status:
No Yes
Main Material 5:
Collection or charging of costs to Participants in accordance with what is stated in the policy. Compliance Status:
No Yes
Main Material 6:
Underwriting procedures for each product are conducted fairly, equitably, and not applied discriminatively. Compliance Status:
No Yes
Main Material 7:
In the event that Tabarru’ Fund investment management uses wakalah bil ujrah contracts, the Company has no right to obtain a share of the investment results. Compliance Status:
No Yes

C. Marketing Practices Conducted by the Company
Main Material 1:
The Company, specifically marketing personnel or insurance agents, has received training on marketed products and has provided correct, accurate, and complete explanations to prospective participants, including:
a. Agreed contracts (akads). b. Position, rights, and obligations of each party. Compliance Status:
No Yes
Main Material 2:
Every policy issuance must be accompanied by an insurance request form (SPPA)/membership request form filled correctly and completely, signed by the participant and the Company as a form of agreement (ijab qabul) to the contracts within the policy. Compliance Status:
No Yes
Main Material 3:
Agreements between the Company and business partners, including insurance agents, insurance/reinsurance brokers, loss adjusters, reinsurers, and other parties, are conducted in accordance with Sharia principles. Compliance Status:
No Yes
Main Material 4:
Product marketing practices and participant services do not contradict Sharia principles, for example, not giving bribes/kickbacks in the course of product marketing and participant services. Compliance Status:
No Yes
Main Material 5:
Marketing commission is given fairly, equitably, and proportionally, including but not limited to business acquisition/policy closing activities. Compliance Status:
No Yes

B. Insurance Risk Profile Data Report This Insurance Risk Profile Data Report is based on POJK 2/POJK.05/2015 Regulations on 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 on Insurance Risk Data Reporting. For reporting purposes, this report has been included in the OJK system with the application name SIPETIR.

C. Reinsurance Placement Report
a. For General Insurance/Reinsurance Companies REINSURANCE/RETROCESSION IMPLEMENTATION REPORT 20XX A. All Insurance Business Lines in millions of rupiah No Description Sum Insured (SI) Premium Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance (1) (2) (3) (4) (5) (6) (7) (8) (9) A Self Retention B Reinsurer Support Domestic Foreign per Country 1. 2.
3. ....
Sub Total
C Total
Notes:

Areas marked with black blocks do not need to be filled.
Column (4) sum insured minus sum insured reinsured.
Column (7) filled with gross premium minus reinsurance premium.
Domestic reinsurer support description column filled with total domestic reinsurance support.
Foreign country per country description column filled with the name of the reinsurer country referring to the location of the reinsurer, not the country of origin of the reinsurer.

20XX
Insurance Business Line :
A-1. Property
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Premium
Self Retention
Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A-2. Motor Vehicles
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A-3. Transport
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A-4. Ship Hull
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A.5. Aircraft Hull
(in millions of rupiah)
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A.6. Satellites
(in millions of rupiah)
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A-7. Energy - Onshore
(in millions of rupiah)
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A-8. Energy - Offshore
(in millions of rupiah)
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Insurance Business Line :
A-9. Engineering
(in millions of rupiah)
No Desc Rating Country Number of Policies Sum Insured Total SI Self Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2) after the rows "domestic" and "foreign" filled with the name of the reinsurer.
Column (3) filled with reinsurer rating from internationally recognized rating agencies. In case the reinsurer rating is issued by more than one rating agency, the lowest rating used is the rating.
Column (5) presented in whole numbers.
Column (7) filled with sum insured minus sum insured reinsured.
Column (15) filled with gross premium minus reinsurance premium.

20XX
Business Line Insurance:
A-10. Liability
(in millions of rupiah)
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Premium
Self-Retention
Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional Quota Share Surplus Cath X/L Work X/L Quota Share Surplus (15) (16) (17) (18) (19) (20) (21) (22) Notes:

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

20XX
Business Line Insurance:
A-11. Death
(in millions of rupiah)
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

20XX
Business Line Insurance
A-12. Personal Accident
(in millions of rupiah)
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

20XX
Business Line Insurance:
A.13-Health
(in millions of rupiah)
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

20XX
Business Line Insurance:
A.14-Credit
(in millions of rupiah)
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

b. For Life Insurance Companies
YEAR 20XX
A. All Business Lines Insurance
No Description
Sum Insured (UP) Premium
Total UP
Self-Retention
Automatic Reinsurance
(Treaty)
Facultative Reinsurance
Self-Retention
Automatic Reinsurance
(Treaty)
Facultative Reinsurance
(1) (2) (3) (4) (5) (6) (7) (8) (9) A Self-Retention B Reinsurer Support Domestic Foreign per Country 1. 2.
3. ....
Sub Total
C Total
Notes:

Areas marked with black blocks do not need to be filled.
Column (4) sum insured minus sum insured that is reinsured.
Column (7) is filled with gross premium minus reinsurance premium.
Column description of domestic reinsurer support is filled with total domestic reinsurance support.
Column description of foreign per country is filled with the name of the country of the reinsurer referring to the location of the reinsurer, not the country of origin of the reinsurer.

YEAR 20XX
Business Line Insurance:
A.1. Term Life
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A.2-Term Life Other Than Term
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A.3- Endowment
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A.4- Endowment Combination
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A.5- Whole Life
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A.6- Whole Life Combination
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A.7-General Annuity
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A-8. Pension Fund Annuity
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance:
A-9.Non-Traditional
No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance :
A.10- Personal Accident (In millions of rupiah) No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

YEAR 20XX
Business Line Insurance :
A.11- Health. (In millions of rupiah) No Note Country Rating Number of Policies Sum Insured Total UP Self-Retention Automatic Reinsurance (Treaty) Facultative Reinsurance Proportional Non-Proportional Proportional Non-Proportional 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. ......
Sub Total
Foreign
1.
2.
3. ....
Sub Total
C Total

Areas marked with black blocks do not need to be filled.
In column (2), after the "domestic" and "foreign" rows, fill in the name of the reinsurer.
Column (3) is filled with the reinsurer's rating from an internationally recognized rating agency. If the reinsurer's rating is issued by more than one rating company, the lowest rating shall be used.
Column (5) is presented in full integers.
Column (7) is filled with sum insured minus sum insured that is reinsured.
Column (15) is filled with gross premium minus reinsurance premium.

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

Company Name;
Actuary Name;
Home Address and Phone Number;
Office Address and Phone Number;
Date of Appointment;
Place and Date of Birth;
Professional Qualification;
Work Experience (in accordance with the scope of their 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 submitted 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 based on applicable laws and regulations and generally accepted actuarial principles.
Place, date of creation
Signed,
Name
No. Indonesia Actuaries Association (PAI) Register Public Actuary License No.:
2. Board of Directors Declaration
We, the undersigned, declare that:
1. The procedure for determining liabilities has complied with applicable laws and regulations;
2. The information provided to the Company Actuary in

the annual actuarial report of PT … for year … is accurate and complete; and
3. Has understood the contents of this annual actuarial report and will implement the recommendations outlined in this report.
Place, date of creation Position*)
Signed,
Name
*)Directors authorized according to the Company's internal mechanisms

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
1. background and purpose of the report;
2. scope of the report;
3. legal basis of the report; and
4. materiality, reliance, and limitations in the preparation of the report.

5. Follow-up on Previous Period Recommendations
Recommendations that have been implemented and recommendations that have not been implemented, including any limitations encountered and target completion times.

6. Data Quality
Data completeness, data reliability, procedures carried out to ensure data completeness and reliability, including methods used and weaknesses in the data.

7. Overview of the Company's Business
In this section, the actuary provides an overview of general Company information consisting of structure and operations including:
a. Business lines or products marketed b. Target market
c. Distribution channels used

8. Financial Health Level and Capital Adequacy
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 coverage e. Profit distribution 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

This copy corresponds to the original Legal Director 1 Legal Department signed Mufli Asmawidjaja

Financial Projections
Other Areas Requiring Attention
Determined in Jakarta on March 1, 2021 CHIEF EXECUTIVE SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed RISWINANDI

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 10 /SEOJK.05/2021 CONCERNING THE FORM AND STRUCTURE OF PERIODIC REPORTS FOR SHARIA INSURANCE COMPANIES, SHARIA REINSURANCE COMPANIES, AND SHARIA UNITS

FORMAT II A
FORM AND STRUCTURE OF OTHER REPORTS FOR INSURANCE COMPANIES AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES Business Plan Report in accordance with Article 7 paragraph (3), Article 15 paragraph (5) and Article 19 of POJK Number 24/POJK.05/2019 concerning Business Plans of Non-Bank Financial Service Institutions with a submission deadline no later than November 30 of the previous year. BUSINESS PLAN REPORT
Year ......
(fill in company name and address)
Approved,
Board of Commissioners
(Company Stamp)
Full Name
Position
20xx
Director,
(Company Stamp)
Full Name
Position

BUSINESS PLAN REPORT FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES Format 1: Executive Summary Format 2: Evaluation of Previous Period Business Plan Implementation Format 3: Vision, Mission, and Business Strategy Format 4: Business Activity Plan Format 5: Business Development or Expansion Plan Format 6: Investment Plan Format 7: Capital Plan Format 8: Financing Plan Format 9: Office Network and/or Distribution Channel Development and/or Change Plan Format 10: Organization, Human Resources, and/or Information Technology Development Plan Format 11: Activities to Improve Financial Literacy and Inclusion for Consumers and/or Society Format 12: Projected Financial Statements and Assumptions Used Format 13: Projected Ratios and Certain Other Items Format 14: Other Information

Format 1: Executive Summary a. Short-Term Strategic Plans and Steps for Period 1 (one) year 1)
......
......
......
b. Medium-Term Strategic Plans and Steps for Period 3 (Three) Years 1
......
......
......
c. Medium-Term Strategic Plans and Steps for Period 5 (Five) Years 1
......
......
......
d. Key Financial Indicators
Filled in millions of rupiah
No. Financial Indicator
Performance
Sept X1
Projection
Performance
Dec X-1
Projection
June
Year X
December
Year X
A. Company Funds
1 Assets
2 Investments
3 Liabilities
4 Technical Provisions
5 Qardh
6 Equity
7 Ujroh on contributions
8 Marketing Expenses
9 Acquisition Expenses
10 General and Administrative Expenses 11 Marketing Expenses 12 Investment Results 13 Profit (Loss) Before Tax Profit (Loss) After Tax 15 Other Comprehensive Income B. Tabarru’ Funds 1 Assets 2 Investments 3 Liabilities 4 Technical Provisions 5 Qardh 6 Accumulated Funds Tabarru & Tanahud Contributions 8 Gross Claims Underwriting Surplus (deficit) 10 Investment Results
C. Tanahud Funds
1 Assets
2 Investments
3 Liabilities
4 Technical Provisions
5 Qardh
6 Accumulated Funds
Tabarru & Tanahud Contributions
8 Gross Claims
Underwriting Surplus (deficit)
10 Investment Results
D. Participant Investment Funds
1 Assets
2 Investments
3 Liabilities
4 Investment Results
Accumulated Participant Investment Funds Participant Investment Fund Allocation Contributions Withdrawal of Matured Participant Investment Funds Withdrawal/Redemption of Participant Investment Funds (not yet matured) Note:
X-1 year of report preparation.
X year of business plan position. e. Financial Ratios No. Financial Indicator Performance Sept X-1 Projection Performance Dec X-1 Projection Year X June X Dec X A. Company Funds 1 Solvency Achievement Ratio 2 Liquidity Ratio 3 Expense Ratio (Business Expenses/Company Fund Contributions or Ujroh) 4 Commission Expense Ratio 5 Return on Investment (ROI) 6 Return on Equity (ROE) B. Tabarru’ Funds and Tanahud Funds 1 Solvency Achievement Ratio 2 Investment Adequacy Ratio 3 Liquidity Ratio 4 Net Claim Expense Ratio 5 Return on Investment (ROI)
C. Participant Investment Funds
1 Liquidity Ratio
2 Return on Investment (ROI) f. Description of the Company's Financial Condition
......
......
......
*Description of the Company's financial condition reflected by financial indicators and ratios, including reasons for increases/decreases. g. Description of Short-Term Targets for Period 1 (One Year) 1)
a. ......
b. ......
c. ......
d. ......
e. ......
Note:
1) among others include improving Company efficiency, strengthening capital, applying governance, applying risk management, and increasing Company profit.

Format 2: Evaluation of Previous Period Business Plan Implementation a. Comparison Between Business Plan and Realization of Business Plan Each Year (Ignore if your company is a new company). (Detail the current business plan and how it compares to the business plan each year). In this section, the Company can view its performance during that period by comparing the business plan with the realized business plan. The example table below can be modified in more detail according to the Company's needs.)

No. Indicator
June 20XX-1
Business Plan
Realization %
(1) (2) (2-1)/1
A. Company Funds
Ujroh on contributions Received
Business Expenses
Profit (Loss) After tax
Solvency Achievement Ratio
Liquidity Ratio
Expense Ratio
Commission Expense Ratio
Return on Investment (ROI)
Return on Equity (ROE) etc. (add other indicators as deemed necessary) B. Tabarru’ Funds Tabarru & Tanahud Contributions Gross Claims Underwriting Surplus Solvency Achievement Ratio Investment Adequacy Ratio Liquidity Ratio Net Claim Expense Ratio Return on Investment (ROI) Return on Equity (ROE) etc. (add other indicators as deemed necessary)
C. Tanahud Funds
Tabarru & Tanahud Contributions
Gross Claims
Underwriting Surplus
Solvency Achievement Ratio
Investment Adequacy Ratio
Liquidity Ratio
Net Claim Expense Ratio
Return on Investment (ROI)
Return on Equity (ROE) etc. (add other indicators as deemed necessary) D. Participant Investment Funds Participant Investment Fund Contributions Total Withdrawal/Redemption of Participant Investment Funds Liquidity Ratio Return on Investment (ROI) Return on Equity (ROE)

No. Indicator
June 20XX-1
Business Plan
Realization %
(1) (2) (2-1)/1 etc. (add other indicators as deemed necessary) b. Obstacles Encountered
......
......
......
*Clearly state the obstacles encountered in implementing the established business plan.
c. Problem-Solving Efforts
......
......
......
*Clearly state the solutions for problem-solving.

Format 3: Vision, Mission, and Business Strategy a. Company Vision *
......
......
......
*Vision is a picture of the company's condition in the future and represents the company's aspirations. Vision is a statement answering the question of the Company's direction forward. b. Company Mission
......
......
......
*Mission is an elaboration of the vision detailing existing environmental and market conditions and the company's anticipation for the future.
c. Company Business Strategy

analysis of the Company's position in facing business competition
......
......
......
Company policy direction
......
......
......
management policies (policy statements)
......
......
......
business development strategy
......
......
......

Format 4: Business Activity Plan *
*Plan regarding business activities previously carried out by the Company referring to legislation concerning the conduct of business of each Company and business licenses and approval of business activities by the Company to OJK. Can be added with reasons and considerations in preparing the said plan and strategies to realize the said plan. a. Product Development Plan and Insurance Product Marketing Plan for Insurance Companies or Reinsurance Coverage Program Development Plan for Reinsurance Companies for the Next 1 (One) Year. No. Proposal New Product Name Insurance Business Line/Branch Marketing Channel Publication Plan/Execution Time Etc. b. Reasons and Considerations
......
......
......
c. Strategy
......
......
......

Format 5: Business Development or Expansion Plan No. Type of Business Activity General Description of Business Activity Time of Execution of Business Activity Purpose of Business Activity Correlation of New Business Activity with Company Business Strategy Risks over Execution of Business Activity Risk Mitigation over Execution of Business Activity Note:

Business Development or Expansion Plan includes plans to carry out other insurance business based on Financial Services Authority approval and plans to carry out business activities that must be reported to OJK.
In accordance with Article 4 of POJK 69/2016 concerning Conduct of Business, it can be filled regarding expansion of the scope of insurance business, for example, general insurance in PAYDI activities, fee-based activities, and other assignments from the government.

Format 6: Investment Plan a. Investment Composition In millions of rupiah No. Type of Investment Actual Per 30 Sept 20xx-1 Projection Per 31 Dec 20xx-1 Projection Year 1 Per 30 Jun 20xx Per 31 Dec 20xx A. Company Funds 1. (adapted to investment ownership) 2. Etc B. Tabarru’ Funds 1. (adapted to investment ownership) 2. Etc
C. Tanahud
Funds
1.
(adapted to investment ownership)
2.
Etc
D.
Participant
Investment
Funds
1.
(adapted to investment ownership)
2.
Etc
Investment strategy information that can be added includes:

Target total return on investment for each instrument year on year (%)
Investment placement sector (Sharia banking, property, etc.)
Capitalization (big capitalization, medium capitalization, small capitalization)
Investment strategy (conservative, aggressive, or mix)
b. Investment Results
No.
Type of Investment
Actual
Per 30 Sept
20xx-1
Projection
Per 31 Dec
20xx-1
Projection
Year 1
Per 30 Jun
20xx
Per 31 Dec
20xx
A. Company Funds
1.
(adapted to investment ownership)
2.
Etc
B. Tabarru’
Funds
1.
(adapted to investment ownership)
2.
Etc
C. Tanahud
Funds
1.
(adapted to investment ownership)
2.
Etc
D.
Participant
Investment
Funds
1.
(adapted to investment ownership)
2.
Etc

Format 7: Capital Plan
(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 insurance companies/life insurance companies/reinsurance companies and general insurance companies/life insurance companies/reinsurance companies based on Sharia principles, and can be modified according to needs.) a. Capital Projection DESCRIPTION (Company Funds) Actual Per 30 Sept 20XX-1 Projection Per 31 Dec 20XX-1 Projection Per 30 Jun 20XX Per 31 Dec 20XX CAPITAL POSITION Shareholders (filled with nominal)

------
------
------ (etc)
IPO (Initial Public Offering)-Go Public Issuance of new shares Others (such as subordinated loans) Total Paid-in Capital Note:
X-1 year of report preparation.
X year of business plan position.

b. Capital Change Plan
1) Description Regarding Capital Change Plan
......
......
......
*filled with capital change plans accompanied by planned nominal amounts and planned timing for the implementation of such capital changes
2) Reasons and Considerations
......
......
......
*filled with reasons/considerations in preparing the capital change plan
3) Strategy
......
......
......
*filled with strategies to realize the capital change plan

Format 8: Financing Plan a) Description Regarding Financing Plan
......
......
......
*filled with plans based on financing sources to be obtained by the Company in the next 1 year. The mentioned financing sources can come from qardh or issuance of securities through public offerings. b) Reasons and Considerations
......
......
......
*filled with reasons/considerations in preparing the financing plan c) Strategy
......
......
......
*filled with strategies to realize the financing plan

Format 9: Office Network and/or Distribution Channel Development and/or Change Plan Office network development and/or change plans must at least include plans for opening and merging offices outside the head office. No. Type of Office Time of Execution Estimated Investment/Cost Location Note A. Opening 1 Offices having authority to accept or reject Sharia insurance closures, sign policies, determine to pay or reject claims 2 Offices not having authority to accept or reject Sharia insurance closures, sign policies, determine to pay or reject claims B. Address Change Etc
C. Closure
Etc
Note:

Filled with the month of the planned execution time.
For locations in 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.
Detailed notes can be attached in a separate sheet.
Specifically for offices having authority to accept or reject Sharia insurance closures, sign policies, determine to pay or reject claims, inform the experts who will fill those positions.

Format 10: Organizational, Human Resources, and/or Information Technology Development Plan

a. Organizational Development Plan

1) Description of the Organizational Development Plan

......
......
......

filled with an explanation regarding the organizational development plan, including plans for establishing work units/divisions, plans for changing work units/divisions, and plans for establishing committees, adjusted according to the size and complexity of the Company's business.

2) Reasons and Considerations

......
......
......

filled with reasons/considerations in formulating the organizational development plan.

3) Strategy

......
......
......

filled with strategies to realize the organizational development plan.

b. Human Resource Development Plan

1) Description of the Human Resource Fulfillment Plan

No	Level	Position	Number of HR per 30 Sept 20XX-1	Dec 20xx1 (+)* (-)*	June 20XX (+)* (-)*	Dec 20XX (+)* (-)*
*	*	*	*	*	*	*

filled with additions and reductions in the number of employees.

2) Reasons and Considerations

......
......
......

filled with reasons/considerations in formulating the human resource fulfillment plan.

3) Strategy

......
......
......

filled with strategies to realize the human resource fulfillment plan.

c. Plan for Implementing Education and Training for Directors, Board of Commissioners, and Employees

1) Table of Human Resource Development Plan

No	Material	Training Method	Estimated Training Time	Training Duration	Location / Speaker / Training Institution	Total Participants	Training Cost	etc.
*	*	*	*	*	*	*	*	*

2) Reasons and Considerations

......
......
......

filled with reasons/considerations in formulating the human resource development plan.

3) Strategy

......
......
......

filled with strategies to realize the human resource development plan.

d. Plan for Utilization of Foreign Workers

1) Table of Foreign Worker Utilization Plan

No	Name of Foreign Worker (if any) / Number of Foreign Workers	Position	Job Title	Field of Work	Assignment Duration	Name of Companion	Knowledge Transfer Program Plan	Reason
1)	1.	2.	3.	...

Notes:
1) Filled regarding the reason for utilizing foreign workers and the reason why Indonesian workers are not/not yet used.

2) Reasons and Considerations

......
......
......

filled with reasons/considerations in formulating the foreign worker utilization plan.

3) Strategy

......
......
......

filled with strategies to realize the foreign worker utilization plan.

e. Plan for Utilization of Outsourced Labor

1) Table of Outsourced Labor Utilization Plan

No	Field of Task	Reason for Utilization of Outsourced Labor	Number of Outsourced Workers	Name of Outsourcing Provider Company (if any)	Contract Period with Outsourcing Company
1.	2.	3.	...

2) Reasons and Considerations

......
......
......

filled with reasons/considerations in formulating the outsourced labor utilization plan.

3) Strategy

......
......
......

filled with strategies to realize the outsourced labor utilization plan.

f. Information Technology Development Plan

1) Description of Fundamental Information Technology Development and Procurement Plans, Including Information on Development and Maintenance Costs

......
......
......

No	Type/Name of Application	Ownership (In-house/vendor)	Vendor Name	Function of Application
*	*	*	*	*

2) Reasons and Considerations

......
......
......

filled with reasons/considerations in formulating fundamental information technology development and procurement plans.

3) Strategy

......
......
......

filled with strategies to realize fundamental information technology development and procurement plans.

Format 11: Report on Activities to Improve Financial Literacy and Inclusion for Consumers and/or the Public

a. Report on Activities to Improve Financial Literacy for Consumers and/or the Public

REPORT ON ACTIVITIES TO IMPROVE FINANCIAL LITERACY PERIOD: January to December ... (filled with year) … (filled with name of financial service business actor)

No.	Component of Plan	Details
1	Activity Name	… (filled with activity name describing the activity)
2	Activity Objective	… (filled with the objective to be achieved by the FSBA)
3	Implementation Form	Financial Education; • Socialization; • Workshop; • Consultation; • Assistance; • Simulation; • Training of Community; • Outreach program; • Others: … (specify); ; Infrastructure Development; • Training of trainers; • Training of facilitators; • E-learning development; • Website development; • Mobile application development; • Compilation/development of Financial Education modules/materials; • Others: … (specify); ; (Check one option); ; Category; • New; • Continuing; ; (Check one option)
4	Implementation Method and Measurement Methods and Tools	Implementation Method; • Direct:; - Face-to-face; - Broadcast via tools: … (specify); - Others: … (specify); ; Measurement Method; Financial Education; • Comparing results before and after activity execution (pre and post test); • Polling specific segments regarding: benefits, ease of understanding material, suitability with targets, others: … (specify); • Survey to determine individual/group financial literacy levels; • Others: … (specify); ; (Can fill more than one); ; Infrastructure Development; Human Resources; • Comparing results before and after activity execution (pre and post test); • Others: … (specify); ; Non-Human Resources; Tools; • Written; • Electronic media; • Online system; • Others: … (specify); ; Observation; • Observation of infrastructure development completion; • Testing suitability of infrastructure function for specific targets; • Others: … (specify); ; (Can fill more than one); ; Indirect Implementation, via Electronic Media: … (specify); Print; Others: … (specify); ; Measurement Method; Financial Education; • Comparing results before and after activity execution (pre and post test); • Polling specific segments regarding: benefits, ease of understanding material, suitability with targets, others: … (specify); • Survey to determine individual/group financial literacy levels; • Others: … (specify); ; (Can fill more than one); ; Infrastructure Development; Human Resources; • Comparing results before and after activity execution (pre and post test); ; Non-Human Resources; Tools; • Written; • Electronic media; • Online system; • Others: … (specify); ; Observation; • Observation of infrastructure development completion; • Testing suitability of infrastructure function for specific targets; • Others: … (specify); ; (Can fill more than one); ; Category; • New; • Continuing; ; (Check one option)
5	Material	a. Financial Management, including:; • Identification of personal/company financial health; • Objectives of financial management; • Stages in financial management; • Recording of owned assets; • Recording of income and expenses (budgeting), including taxation, identification of monthly/annual regular/non-regular income and expenses; • Planning programs for future financial goals; • Others: … (specify); ; b. Types of financial service industries and characteristics of financial service products and/or services; Types of financial service industries:; • Banking; • Capital Market; • Insurance; • Pension Funds; • Financing Institutions; • Guarantee Institutions; • Pawnshops; • Other financial service institutions: … (specify); ; (Can fill more than one); ; Characteristics of financial service products and/or services, including:; • Benefits; • Costs; • Risks; • Consumer rights; • Consumer obligations; • How to access or obtain; • Transaction mechanism information; • Mechanism for handling complaints and dispute resolution; • Others … (specify); ; c. Taxation; • Taxation related to financial service products and/or services; ; Category; • New; • Continuing; ; (Check one option)
6	Target	• Informal workers; • Farmers; • Fishermen; • Teachers; • Lecturers; • Extension workers; • Professionals: … (specify); • Employees; • Merchants; • MSME actors; • Women; • Students; • University students; • Youth; • Retirees; • Indonesian Migrant Workers (IMW); • Prospective Indonesian Migrant Workers (PIMW); • Families of Indonesian Migrant Workers (FIMW); • Persons with disabilities; • Social Welfare Problem Suffering Community Groups (PMKS): … (specify); • Communities in lagging, remote, and outermost regions; • Communities: … (specify); • General public; • Others: … (specify); ; (Check one option); ; Category; • New; • Continuing (for individual/community group participants who are the same; does not apply to General Public Target); ; (Check one option)
7	Number of Participants	… people (filled with number of participants)
8	Implementation Schedule	: Started … finished … (filled with planned date and/or month of execution)
9	Implementation Area	Province; • Aceh; • Bali; • Banten; • Bengkulu; • Gorontalo; • DKI Jakarta; • Jambi; • West Java; • Central Java; • East Java; • West Kalimantan; • South Kalimantan; • Central Kalimantan; • East Kalimantan; • North Kalimantan; • Bangka Belitung Islands; • Riau Islands; • Lampung; • Maluku; • North Maluku; • West Nusa Tenggara; • East Nusa Tenggara; • Papua; • West Papua; • Riau; • West Sulawesi; • South Sulawesi; • Central Sulawesi; • Southeast Sulawesi; • North Sulawesi; • West Sumatra; • South Sumatra; • North Sumatra; • DI Yogyakarta; • All Indonesia (filled if executed within the country and can be filled with more than one); ; Regency/City; … (filled if applicable); ; Other Areas; … (filled if applicable); ; Category; • New; • Continuing; ; (Check one option)
10	Frequency of Execution	… times
11	Cost Source	• Financial education budget; • CSR budget; • Other budgets: … (specify); ; (Check one option)
12	Cost Amount (in rupiah)	… (filled with planned cost amount allocated for each activity)
13	Monitoring Parameters	Financial Education; • Suitability of activity form; • Suitability of material; • Suitability of participant targets; • Suitability of participant numbers; • Others: … (specify); ; (Can fill more than one); ; Infrastructure Development; Human Resources; • Suitability of activity form; • Suitability of material; • Suitability of participant targets; • Suitability of participant numbers; • Others: … (specify); ; Non-Human Resources; • Suitability of infrastructure development stages; • Suitability of execution of infrastructure development terms of reference; • Others: … (specify); ; (Can fill more than one)
14	Monitoring Form	(Referring to monitoring parameters, completed with monitoring form); • Direct visit; • Others: … (specify); ; (Can fill more than one)
15	Evaluation Parameters	Financial Education; • Knowledge; • Skills; • Confidence; • Attitude; • Behavior; • Others: … (specify); ; (Can fill more than one); ; Infrastructure Development; Human Resources; • Ability of trainers/facilitators to deliver teaching materials; • Others: … (specify); ; Non-Human Resources; • Availability of infrastructure in the form of: … (specify); • Suitability of infrastructure function with infrastructure development objectives; • Others: … (specify); ; (Can fill more than one)
16	Evaluation Form	• Paying attention to administrative data such as activity reports, execution documentation, and/or participant and/or staff interview results; • Paying attention to data and reports from previous periods to know trends and patterns; • Conducting analysis of success or achievement through comparison between planning and realization of activities; • Analyzing information regarding suitability of activities to improve Financial Literacy with determined targets; • Others: … (specify); ; (Can fill more than one)
17	Description	Role of each party when FSBA collaborates with other FSBA:; 1. … (name of party 1); … (description of party 1's role),; 2. … (name of party 2); … (description of party 2's role), etc.; ; Collaborating with other parties:; 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:; This is additional information considered necessary to further explain the Financial Literacy activities conducted by the Company. ... (description)

Table 2
Compliance with Financial Literacy Principles

No	Principle	Principle Compliance
1	Planned and Measurable	Automatically filled if FSBA fills Table 1 items 3–12 and 13–14 and/or 15–2
2	Achievement-Oriented	Automatically filled if FSBA fills Table 1 items 2, 6, 7, and 11
3	Sustainable	Automatically filled if FSBA fills "Continuing" Category in at least one of Table 1 items 3, 4, 5, 6, and 9
4	Collaboration	Automatically filled if FSBA fills Table 1 item 17 with description of cooperation with FSBA and/or other parties.

b. Report on Activities to Improve Financial Inclusion for Consumers and/or the Public

REPORT ON ACTIVITIES TO IMPROVE FINANCIAL INCLUSION PERIOD: January to December ... (filled with year) … (filled with name of financial service business actor)

No.	Component of Plan	Description
1	Scope of Activity	Access Expansion; • Provision of financial service products and/or services; ; (Check one option)
2	Activity Name	… (filled with activity name describing the activity)
3	Implementation Form	Access Expansion; • Addition of office network; • Addition of cooperation with other parties; • Addition of infrastructure supporting expansion of public financial access: … (specify); • Addition of distribution channels for financial service products and/or services: … (specify); • Facilities for persons with special needs: … (specify); • Others: … (specify); ; Provision of financial service products and/or services; • Creation of schemes: … (specify); • Development of financial service products and/or services: … (specify); • Others: … (specify); ; (Check one option); ; Category; • New; • Continuing; ; (Check one option)
4	Target	• Informal workers; • Farmers; • Fishermen; • Educational institutions; • Professionals; • Employees; • Merchants; • MSME actors; • Women; • Students; • University students; • Youth; • Retirees; • Indonesian Migrant Workers (IMW); • Prospective Indonesian Migrant Workers (PIMW); • Families of Indonesian Migrant Workers (FIMW); • Persons with disabilities; • Social Welfare Problem Suffering Community Groups (PMKS): … (specify); • Communities in lagging, remote, and outermost regions; • Communities: … (specify); • General public; • Others: … (specify); ; (Check one option); ; Category; • New; • Continuing; ; (Check one option)
5	User Target	... users (filled with number of users)
6	Schedule	Started … finished … (filled with date and/or month of execution)
7	Area	Province; • Aceh; • Bali; • Banten; • Bengkulu; • Gorontalo; • DKI Jakarta; • Jambi; • West Java; • Central Java; • East Java; • West Kalimantan; • South Kalimantan; • Central Kalimantan; • East Kalimantan; • North Kalimantan; • Bangka Belitung Islands; • Riau Islands; • Lampung; • Maluku; • North Maluku; • West Nusa Tenggara; • East Nusa Tenggara; • Papua; • West Papua; • Riau; • West Sulawesi; • South Sulawesi; • Central Sulawesi; • Southeast Sulawesi; • North Sulawesi; • West Sumatra; • South Sumatra; • North Sumatra; • DI Yogyakarta; • All Indonesia (filled if executed within the country and can be filled with more than one); ; Regency/City; … (filled if applicable); ; Other Areas; … (filled if applicable); ; Category; • New; • Continuing; ; (Check one option)
8	Parameters	Increase in access to institutions, products and/or financial service providers; • Addition of office network; • Addition of cooperation with other parties; • Addition of infrastructure supporting expansion of public financial access; • Addition of distribution channels for financial service products and/or services; • Others: … (specify); ; Increase in availability of financial service products and/or services; • Addition of types of financial service products and/or services available according to community needs and capabilities across various distribution channels; • Others: … (specify); ; Increase in usage of financial service products and/or services; • Addition of number of savings accounts/credits/financing/securities/pension funds; • Addition of number of transactions; • Addition of number of insurance policies; • Addition of number of guarantee certificates; • Addition of number of venture capital business partners/debtors; • Addition of number of pawn transactions; • Others: … (specify); ; Increase in quality of usage of financial service products and services according to community needs and capabilities; • Increase in number of Consumers who not only use similar financial service products and/or services, but also use other financial service products and/or services; • Increase in Consumer ability to measure and analyze financial service products and/or services that can drive increased frequency of product and/or service utilization and, when needed, ability to utilize complaint/dispute resolution services appropriate to desired financial management goals; • Others: … (specify); ; (Can fill more than one)
9	Monitoring Form	Monitoring Form; (Referring to monitoring parameters, completed with monitoring form); ; Field; Via Reports; Others: … (specify); ; (Can fill more than one); ; Conducted via; (Referring to monitoring form); ; • Monthly; • Quarterly; • Annually; • Other periods: … (specify); ; (Can fill more than one)
10	Evaluation	• Paying attention to administrative data such as activity reports and execution documentation; • Paying attention to data and reports from previous periods; • Conducting analysis of success or achievement through comparison of planning and realization of activities; • Analyzing information regarding suitability of activities to improve Financial Inclusion with determined targets; • Others: … (specify); ; (Can fill more than one)
12	Description	Role of each party when FSBA collaborates with other FSBA:; 1. … (name of party 1); … (description of party 1's role),; 2. … (name of party 2); … (description of party 2's role), etc.; ; Collaborating with other parties:; 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:; This is additional information considered necessary to further explain the Financial Literacy activities conducted by the Company. ... (description)

Table 2
Compliance with Financial Inclusion Principles

No	Principle	Principle Compliance
1	Measurable	Automatically filled if FSBA fills Table 1 items 5, 8, and 9 and/or 10
2	Affordable	Automatically filled if FSBA fills Table 1 items 3 and 8
3	Targeted	Automatically filled if FSBA fills Table 1 items 3, 4, and 5
4	Sustainable	Automatically filled if FSBA fills "Category" in Table 1 item 3 completely, 4, and 7

Format 12: Financial Statement Projections and Assumptions Used

a. Financial Position Projection

1) For Company Funds

(in millions of rupiah)

DESCRIPTION	Actual Performance as of 30 Sept 20XX-1	Projection as of 31 Dec 20XX-1	Projection as of 30 Jun 20XX	Projection as of 31 Dec 20XX
I. ASSETS
1. Investments
1. Deposits
2. Certificate of Deposits
3. Shariah Stocks
4. Sukuk or Shariah Bonds
5. Shariah MTN
6. State Shariah Securities
7. Shariah Securities Issued by Bank Indonesia
8. Shariah Securities Issued by Countries Other than the Republic of Indonesia
9. Shariah Securities Issued by Multinational Institutions
10. Shariah Mutual Funds
11. Shariah Asset-Backed Securities
12. Shariah Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Other Parties
15. Shariah Financing with Mortgage Rights
16. Direct Participation
17. Investment Property
18. Pure Gold
19. Regional Sukuk
20. Infrastructure Investment Funds in the form of Collective Investment Contracts
21. Other Investments
2. Non-Investments
1. Cash and Banks
2. Receivables
3. Reinsurance Assets
4. Deferred Acquisition Costs
5. Non-Investment Property
6. Other Assets
3. LIABILITIES AND EQUITY
A. Liabilities
1. Accrued Expenses
2. Other Liabilities
3. Technical Provisions
a. Ujroh Provisions
b. PAYDI Provisions Providing Investment Principal Guarantees
B. Qardh
C. Fund Equity
1. Paid-in Capital
2. Share Agio/Disagio
3. Profit Balance
4. Other Equity Components.

2) For Tabarru’ Fund
(in millions of rupiah)

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
I. ASSETS
A. Investments
1. Deposits
2. Deposit Certificates
3. Sharia Stocks
4. Sukuk or Sharia Bonds
5. Sharia MTN
6. Sharia State Securities
7. Sharia Securities Issued by Bank Indonesia
8. Sharia Securities Issued by Countries Other than the Republic of Indonesia
9. Sharia Securities Issued by Multinational Institutions
10. Sharia Mutual Funds
11. Sharia Asset-Backed Securities
12. Sharia Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Third Parties
15. Pure Gold
16. Regional Sukuk
17. Infrastructure Investment Funds in the Form of Collective Investment Contracts
18. Other Investments
B. Non-Investments
1. Cash and Banks
2. Receivables
3. Reinsurance Assets
4. Other Assets
II. LIABILITIES AND EQUITY
A. Liabilities
1. Payable Claims and Benefits
2. Accrued Expenses
3. Other Payables
4. Technical Provisions
a. Contribution Provision
b. Provision on Contributions Not Yet Revenue
c. Claims Provision
d. Disaster Risk Provision
B. Qardh
C. Fund Equity
1. Accumulated Funds
2. Other Equity Components.

3) For Participant Investment Fund
(in millions of rupiah)

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
I. ASSETS
A. Investments
1. Deposits
2. Deposit Certificates
3. Sharia Stocks
4. Sukuk or Sharia Bonds
5. Sharia MTN
6. Sharia State Securities
7. Sharia Securities Issued by Bank Indonesia
8. Sharia Securities Issued by Countries Other than the Republic of Indonesia
9. Sharia Securities Issued by Multinational Institutions
10. Sharia Mutual Funds
11. Sharia Asset-Backed Securities
12. Sharia Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Third Parties
15. Pure Gold
16. Regional Sukuk
17. Infrastructure Investment Funds in the Form of Collective Investment Contracts
18. Other Investments
B. Non-Investments
1. Cash and Banks
2. Receivables
3. Other Assets
II. LIABILITIES AND EQUITY
A. Liabilities
1. Payable Claims and Benefits
2. Accrued Expenses
3. Other Payables
B. Fund Equity
1. Accumulated Funds
2. Profit Equalization Reserve (PER)
3. Other Equity Components.

b. Projection of Comprehensive Income Statement
1) For Company Fund
(in millions of rupiah)

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
I. REVENUE
1. INVESTMENT REVENUE AND UJROH FOR INVESTMENT MANAGEMENT
1. Investment Results
2. Investment Results Distributed to Company Fund
3. Total Investment Results
4. Total Ujroh for Investment Management
5. Total Investment Results and Ujroh for Investment Management Revenue
2. UNDERWRITING REVENUE
1. Participant Contributions (Ujroh)
2. Reinsurance/Retrosession Contributions
3. Net Underwriting Revenue Contributions
Underwriting Surplus for Company Fund
2. OPERATING EXPENSES:
1. Marketing Expenses
2. Acquisition Expenses
3. General and Administrative Expenses:
- Employee and Manager Expenses
- Education and Training Expenses
- Other General and Administrative Expenses
4. Increase (Decrease) in Ujroh Provision
5. Increase (Decrease) in PAYDI Provision
TOTAL OPERATING EXPENSES
INSURANCE OPERATING PROFIT (LOSS)
Other Revenue
Other Expenses
PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL PERFORMANCE OF ALL FUNDS

2) For Tabarru’ Fund
(in millions of rupiah)

DESCRIPTION	Actual as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
I. REVENUE
1. INVESTMENT REVENUE
1. Investment Results
2. Investment Results Distributed to Company Fund
3. Total Investment Results
2. UNDERWRITING REVENUE
1. Participant Contributions (Tabarru')
2. Reinsurance/Retrosession Contributions
3. Net Contributions
4. Decrease (Increase) in Contribution and PAKYBMP Provisions
a. Decrease (Increase) in Contribution Provision
b. Decrease (Increase) in PAKYBMP
c. Decrease (Increase) in Disaster Risk Provision
5. Total Net Contribution Revenue
TOTAL UNDERWRITING REVENUE
2. EXPENSES
1. UNDERWRITING EXPENSES
2. Claims Expenses
a. Gross Claims
b. Claims Recovery
c. Increase (Decrease) in Claims Provision
Net Claims Expenses Total
3. Adjuster Expenses
TOTAL UNDERWRITING EXPENSES
3. TOTAL UNDERWRITING SURPLUS (DEFICIT)
a. Underwriting Surplus for Company Fund
b. Underwriting Surplus for Participants
INSURANCE OPERATING PROFIT (LOSS)
Other Revenue
Other Expenses
PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL PERFORMANCE OF ALL FUNDS

3) For Tanahud Fund

DESCRIPTION	Actual as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
I. REVENUE
1. INVESTMENT REVENUE
1. Investment Results
2. Investment Results Distributed to Company Fund
3. Total Investment Results
2. UNDERWRITING REVENUE
1. Participant Contributions (Tabarru')
2. Reinsurance/Retrosession Contributions
3. Net Contributions
4. Decrease (Increase) in Contribution and PAKYBMP Provisions
a. Decrease (Increase) in Contribution Provision
b. Decrease (Increase) in PAKYBMP
c. Decrease (Increase) in Disaster Risk Provision
5. Total Net Contribution Revenue
TOTAL UNDERWRITING REVENUE
2. EXPENSES
1. UNDERWRITING EXPENSES
1. Claims Expenses
a. Gross Claims
b. Claims Recovery
c. Increase (Decrease) in Claims Provision
Net Claims Expenses Total
2. Adjuster Expenses
TOTAL UNDERWRITING EXPENSES
3. TOTAL UNDERWRITING SURPLUS (DEFICIT)
a. Underwriting Surplus for Company Fund
b. Underwriting Surplus for Participants
INSURANCE OPERATING PROFIT (LOSS)
Other Revenue
Other Expenses
PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL PERFORMANCE OF ALL FUNDS

4) For Participant Investment Fund
(in millions of rupiah)

DESCRIPTION	Actual as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
I. REVENUE
1. INVESTMENT REVENUE AND ALLOCATION CONTRIBUTION REVENUE
1. Investment Results
2. Investment Results Distributed to Company Fund
3. Total Investment Results
4. Total Investment Results and Ujroh for Investment Management Revenue
2. UNDERWRITING REVENUE
1. Participant Contributions (Investment Allocation)
2. EXPENSES
1. UNDERWRITING EXPENSES
1. Claims Expenses
a. Withdrawal of Matured Participant Investment Funds
b. Withdrawal/Redemption of Participant Investment Funds (Not Matured)
Total Claims Expenses
Underwriting Surplus for Participants
INSURANCE OPERATING PROFIT (LOSS)
Other Expenses
PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL PERFORMANCE OF ALL FUNDS

c. Cash Flow Projection
1) For Company Fund
(in millions of rupiah)

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Received Ujroh
2. Participant Contributions
3. Receipts of Tabarru' Fund Surplus Allocation
4. Others
b. Cash Outflows
1. Acquisition Expenses
2. Marketing Expenses
3. Payment of Reinsurance Ujroh
4. Paid Reinsurance Contributions
5. Rent Payments
6. Zakat Payments
7. Tax Payments
8. Others
5. CASH FLOWS FROM INVESTMENT ACTIVITIES
a. Cash Inflows
1. Receipts of Investment Results
2. Receipts of Investment Profit Sharing from Tabaru' Fund
3. Receipts of Investment Profit Sharing from Participant Investment Fund
4. Investment Liquidation
5. Sale of Fixed Assets
6. Others
b. Cash Outflows
1. Investment Placement
2. Purchase of Fixed Assets
3. Others
6. CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
1. Capital/Working Capital Deposits
2. Subordinated Loans
3. Others
b. Cash Outflows
1. Repayment of Subordinated Loans
2. Dividend Payments
3. Others

2) For Tabarru’ Fund
(in millions of rupiah)

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Participant Contributions
2. Received Reinsurance Claims
3. Receipts of Reinsurance Underwriting Surplus Distribution
4. Others
b. Cash Outflows
1. Claims Paid
2. Payment of UW Surplus Distribution to Company
3. Payment of UW Surplus Distribution to Participants/Policyholders
4. Payment of Insurance Ujroh
5. Paid Reinsurance Contributions
6. Others
5. CASH FLOWS FROM INVESTMENT ACTIVITIES
a. Cash Inflows
1. Receipts of Investment Results
2. Investment Liquidation
3. Others
b. Cash Outflows
1. Investment Placement
2. Investment Results Distributed to Company Fund
3. Payment of ujroh/fee to Company
4. Others
6. CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
1. Qardh Receipts
2. Others
b. Cash Outflows
1. Qardh Payments
2. Others

3) For Tanahud Fund

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Participant Contributions
2. Received Reinsurance Claims
3. Receipts of Reinsurance Underwriting Surplus Distribution
4. Others
b. Cash Outflows
1. Claims Paid
2. Payment of UW Surplus Distribution to Company
3. Payment of UW Surplus Distribution to Participants/Policyholders
4. Payment of Insurance Ujroh
5. Paid Reinsurance Contributions
6. Others
5. CASH FLOWS FROM INVESTMENT ACTIVITIES
a. Cash Inflows
1. Receipts of Investment Results
2. Investment Liquidation
3. Others
b. Cash Outflows
1. Investment Placement
2. Investment Results Distributed to Company Fund
3. Payment of ujroh/fee to Company
4. Others
6. CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
1. Qardh Receipts
2. Others
b. Cash Outflows
1. Qardh Payments
2. Others

4) For Company Investment Fund
(in millions of rupiah)

DESCRIPTION	Actual Performance as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Participant Contributions
2. Others
b. Cash Outflows
1. Claims Paid
2. Withdrawal of Matured Participant Investment Funds
3. Withdrawal/Redemption of Participant Investment Funds Not Matured
4. Others
5. CASH FLOWS FROM INVESTMENT ACTIVITIES
a. Cash Inflows
1. Receipts of Investment Results
2. Investment Liquidation
3. Others
b. Cash Outflows
1. Investment Placement
2. Investment Results Distributed to Company Fund
3. Payment of ujroh/fee to Company
4. Others
CASH FLOWS FROM FINANCING ACTIVITIES
Cash Inflows
1. Others
Cash Outflows
1. Others

d. Assumptions Used

No.	DESCRIPTION	Actual as of Sept 30, 20XX-1	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
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)

Format 13: Projection of Ratios and Other Specific Items a. Projection of Ratios and Other Specific Items
1) For Company Fund
(in millions of rupiah)
(ratios in percentage)

DESCRIPTION	Actual as of Sept 30, 20XX	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
A. Solvency Ratios
1. Solvency Level
a. Permitted Assets (AYD)
b. Liabilities
2. Minimum Capital Based on Risk
3. Solvency Level Ratio before Considering Assets Available for Qardh (in %)
4. Internal Target Solvency Level Ratio (annual) (percentage according to POJK 72)
5. Solvency Level Ratio with Regulatory Required Minimum Capital Based on Risk (percentage according to POJK 72)
6. Assets Available for Qardh Considered as Additions to AYD for Tabarru' and Tanahud Funds
a. Deficiency (Surplus) of solvency level from internal target
b. Insufficiency of investments, cash and banks
7. Solvency Level Ratio for Company Fund
B. Ratios Other Than Solvency Level Ratios
1. Liquidity Ratio
a. Current Assets
b. Current Liabilities
c. Ratio (a:b)
2. Net Investment Income Ratio
a. Net Investment Income
b. Average Investments
c. Ratio (a:b)
3. Fund Change Ratio
a. Company Fund Current Period
b. Company Fund Previous Period
c. Company Fund Change (a-b)
d. Ratio (c:b)
4. Sharia Unit Asset Ratio
a. Tabarru' and Tanahud Fund Assets
b. Participant Investment Fund Assets
c. Company Insurance Fund (Conventional) Assets
d. Ratio (a+b) : (a+b+c)

2) For Tabarru’ Fund

DESCRIPTION	Actual as of Sept 30, 20XX	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
A. Solvency Ratios
1. Solvency Level
a. Permitted Assets (AYD)
b. Liabilities other than Qardh from Company Fund
2. Minimum Basis-Based Risk for Tabaru' and Tanahud Funds
3. Solvency Level Ratio before Considering Assets Available for Qardh (in %)
4. Internal Target Solvency Level Ratio (annual) (percentage according to POJK 72)
5. Solvency Level Ratio with Regulatory Required Minimum Capital Based on Risk (percentage according to POJK 72)
6. Assets Available for Qardh Considered as Additions to AYD for Tabarru' and Tanahud Funds
a. Deficiency (Surplus) of solvency level from internal target
b. Insufficiency of investments, cash and banks
7. Solvency Level Ratio for Tabarru’ and Tanahud Funds
B. Ratios Other Than Solvency Level Ratios
1. Liquidity Ratio
a. Current Assets
b. Current Liabilities
c. Ratio (a:b)
2. Investment-to-Liability Balance Ratio
a. Investments, cash and banks
b. Technical Provisions
c. Retained Own Claims Payables
d. Ratio [a:(b+c)]
3. Net Investment Income Ratio
a. Net Investment Income
b. Average Investments
c. Ratio (a:b)
4. Claims Expense Ratio
a. Net Claims Expenses
b. Net Contributions
c. Ratio (a:b)
5. Fund Change Ratio
a. Tabarru' and Tanahud Funds Current Period
b. Tabarru' and Tanahud Funds Previous Period
c. Fund Change (a-b)
d. Ratio (c:b)
6. Calculation of Qardh Required for Tabarru Fund
a. Amount of Liabilities other than Qardh
b. Amount of Assets
c. Amount of Required Qardh (a-b)
7. Calculation of Qardh Required for Tanahud Fund
a. Amount of Liabilities other than Qardh
b. Amount of Assets
c. Amount of Required Qardh (a-b)

3) Participant Investment Fund
(in millions of rupiah)
(ratios in percentage)

DESCRIPTION	Actual as of Sept 30, 20XX	Projection as of Dec 31, 20XX-1	Projection as of Jun 30, 20XX	Projection as of Dec 31, 20XX
1. Liquidity Ratio
a. Current Assets
b. Current Liabilities
c. Ratio (a:b)
2. Net Investment Income Ratio
a. Net Investment Income
b. Average Investments
c. Ratio (a:b)
3. Fund Change Ratio
a. Participant Investment Fund Current Period
b. Participant Investment Fund Previous Period
c. Fund Change (a-b)
d. Ratio (c:b)

Format 14: Other Information
Other information includes information that needs to be disclosed because it affects the company's business activities, which is not mentioned in the scope of the Business Plan. Examples:

Merger, acquisition, and consolidation plans;
Plans for transferring insurance coverage portfolios;
Plans for changing the field of insurance business;
Plans for changing business activities from non-Sharia principles to Sharia principles; and
Sustainable Finance Action Plan based on POJK regarding the Implementation of Sustainable Finance for Financial Service Institutions, Issuers, and Public Companies.
Update of Sharia Unit Spin-Off Plan, including stating the year the spin-off will be conducted and the process of drafting the spin-off work plan.

A. Direct Participation Plans
2. Details of Direct Participation Plans
Name of Subsidiary Company | Actual Performance September 20XX-1 | Projection December 20XX-1 | Projection June 20XX | Projection December 20XX
3. Reasons and Considerations
......
......
...

filled with reasons/considerations in compiling direct participation plans

Strategy
......
......
...

filled with strategy to realize direct participation plans

B. Mergers, Consolidations, and/or Separations Plans

Merger Plan
a. Description regarding the merger plan:
Company merging into:
1) …….
2) …….
3) …….
Company receiving the merger: ……. b. Reasons and Considerations
......
......
......

filled with reasons/considerations for merger
c. Strategy
......
......
......
filled with merger strategy

Consolidation Plan
a. Description regarding the consolidation plan Company consolidating into:
1) …….
2) …….
3) …….
Company after consolidation: ……. b. Reasons and Considerations
......
......
......

filled with reasons/considerations for consolidation
c. Strategy
......
......
......
filled with consolidation strategy

Separation Plan
a. Description regarding the separation plan Company separating into:
1) …….
2) …….
3) …….
Company after separation: ……. b. Reasons and Considerations
......
......
......

filled with reasons/considerations for separation
c. Strategy
......
......
......
filled with separation strategy

C. Plans to Cease Business Activities So That It Is No Longer a Company

Explanation
......
......

filled with explanation regarding the plan to cease business activities so that it no longer becomes a Company, including reasons for ceasing business activities so that it is no longer a Company

Reasons and Considerations
......
......

filled with reasons/considerations for ceasing business activities so that it is no longer a Company

Strategy
......
......

filled with strategy for ceasing business activities so that it is no longer a Company

D. Plans to Convert an Insurance Company into a Sharia Insurance Company

Description regarding the conversion plan:
Resulting Company from conversion: …….
Reasons and Considerations
......
......
......

filled with reasons/considerations for conversion

Strategy
....

filled with strategy for conversion into a Sharia Insurance Company

E. Plans for Formation, Closure, or Separation of UUS

UUS Formation Plan
a. Description regarding the formation plan:
Resulting UUS from formation: ……. b. Reasons and Considerations
......
......

filled with reasons/considerations for forming UUS
c. Strategy
......
......
......*
filled with strategy for forming UUS

UUS Closure Plan
a. Information regarding the closure plan:
UUS to be closed: ….. b. Reasons and Considerations
......
......
......* filled with reasons/considerations for closing the UUS
c. Strategy
......
......
......* filled with the strategy for closing the UUS
UUS Separation Plan
a. Information regarding the UUS separation plan:
UUS separating itself: ….. b. Reasons and Considerations
......
......
......* filled with reasons/considerations for separating the UUS
c. Strategy
......
......
......* filled with the strategy for separating the UUS

FORMAT IIB
FORM AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES Business Plan Realization Report in accordance with Article 14 paragraph (5) of Financial Services Authority Regulation Number 24/POJK.05/2019 concerning Business Plans of Non-Bank Financial Service Institutions, with a submission deadline no later than one month after the relevant semester ends.

BUSINESS PLAN REALIZATION REPORT
Year ......
(filled with company name and address) Approved, Board of Commissioners (Company Stamp) Full Name Position , 20xx Director, (Company Stamp) Full Name Position

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

realization of business activity plans as referred to in item 4;
realization of business activity development or expansion plans as referred to in item 5;
realization of investment composition plans as referred to in item 6;
realization of capitalization plans as referred to in item 7;
realization of financing plans as referred to in item 8;
realization of office network and/or distribution channel development and/or changes plans as referred to in item 9;
realization of organization, human resources, and/or information technology development plans as referred to in item 10;
Report on Activities in the Framework of Improving Financial Literacy and Inclusion for Consumers and/or the Public as referred to in format 11;
realization of financial statement projections and Assumptions Used as referred to in format 12

B. Explanation Regarding Deviations from Business Plan Realization
1. Financial Realization for Financial Position Reports
a) For Company Funds
(in millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah %
I. ASSETS
A. Investments
1. Deposits
2. Deposit Certificates
3. Sharia Stocks
4. Sukuk or Sharia Bonds
5. Sharia MTN
6. Sharia Government Securities
7. Sharia Securities Issued by Bank Indonesia
8. Sharia Securities Issued by Countries Other Than the Republic of Indonesia
9. Sharia Securities Issued by Multilateral Institutions
10. Sharia Mutual Funds
11. Sharia Asset-Backed Securities
12. Sharia Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Other Parties
15. Sharia Financing with Collateral Rights
16. Direct Participation
17. Investment Properties
18. Pure Gold
19. Regional Sukuk
20. Infrastructure Investment Funds in the Form of Collective Investment Contracts
21. Other Investments
B. Non-Investments
1. Cash and Banks
2. Claims for Direct Closing Ujrah
3. Claims for Indirect Closing Ujrah
4. Investment Income Claims
5. Investment Claims
6. Reinsurance Assets
7. Deferred Acquisition Costs
8. Non-Investment Properties
9. Other Assets
II. LIABILITIES AND EQUITY
A. Liabilities
1. Accrued Expenses
2. Other Payables
3. Technical Provisions
a. Ujrah provisions b. PAYDI provisions guaranteeing investment principal B. Qardh
C. Fund Equity
1. Paid-up Capital
2. Share Agio/Disagio
3. Profit Balance
4. Other Equity Components.

b) For Tabarru’ Funds
(in millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah %
I. ASSETS
A. Investments
1. Deposits
2. Deposit Certificates
3. Sharia Stocks
4. Sukuk or Sharia Bonds
5. Sharia MTN
6. Sharia Government Securities
7. Sharia Securities Issued by Bank Indonesia
8. Sharia Securities Issued by Countries Other Than the Republic of Indonesia
9. Sharia Securities Issued by Multilateral Institutions
10. Sharia Mutual Funds
11. Sharia Asset-Backed Securities
12. Sharia Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Other Parties
15. Pure Gold
16. Regional Sukuk
17. Infrastructure Investment Funds in the Form of Collective Investment Contracts
18. Other Investments
B. Non-Investments
1. Cash and Banks
2. Claims for Direct Closing Contributions
3. Claims for Indirect Closing Contributions
4. Reinsurance Claims
5. Co-insurance Contribution Claims
6. Reinsurance Claim Recovery Claims
7. Investment Income Claims
8. Investment Claims
9. Reinsurance Assets
10. Other Assets
II. LIABILITIES AND EQUITY
A. Liabilities
1. Payable claims and benefits liabilities
2. Accrued Expenses
3. Other Payables
4. Technical Provisions
a. Contribution provisions b. Provisions for contributions that are not yet revenue
c. Claim provisions
d. Disaster risk provisions
B. Qardh
C. Fund Equity
1. Accumulated Funds
2. Other Equity Components.

c) For Tanahud Funds
DESCRIPTION Business Plan Realization Deviation Rupiah %
I. ASSETS
A. Investments
1. Deposits
2. Deposit Certificates
3. Sharia Stocks
4. Sukuk or Sharia Bonds
5. Sharia MTN
6. Sharia Government Securities
7. Sharia Securities Issued by Bank Indonesia
8. Sharia Securities Issued by Countries Other Than the Republic of Indonesia
9. Sharia Securities Issued by Multilateral Institutions
10. Sharia Mutual Funds
11. Sharia Asset-Backed Securities
12. Sharia Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Other Parties
15. Pure Gold
16. Regional Sukuk
17. Infrastructure Investment Funds in the Form of Collective Investment Contracts
18. Other Investments
B. Non-Investments
1. Cash and Banks
2. Claims for Direct Closing Contributions
3. Claims for Indirect Closing Contributions
4. Reinsurance Claims
5. Co-insurance Contribution Claims
6. Reinsurance Claim Recovery Claims
7. Investment Income Claims
8. Investment Claims
9. Reinsurance Assets
10. Other Assets
II. LIABILITIES AND EQUITY
A. Liabilities
1. Payable claims and benefits liabilities
2. Accrued Expenses
3. Other Payables
4. Technical Provisions
a. Contribution provisions b. Provisions for contributions that are not yet revenue
c. Claim provisions
d. Disaster risk provisions
B. Qardh
C. Fund Equity
1. Accumulated Funds
2. Other Equity Components.

d) For Participant Investment Funds (in millions of rupiah) DESCRIPTION Business Plan Realization Deviation Rupiah %
I. ASSETS
A. Investments
1. Deposits
2. Deposit Certificates
3. Sharia Stocks
4. Sukuk or Sharia Bonds
5. Sharia MTN
6. Sharia Government Securities
7. Sharia Securities Issued by Bank Indonesia
8. Sharia Securities Issued by Countries Other Than the Republic of Indonesia
9. Sharia Securities Issued by Multilateral Institutions
10. Sharia Mutual Funds
11. Sharia Asset-Backed Securities
12. Sharia Real Estate Investment Funds
13. REPO
14. Financing Through Cooperation with Other Parties
15. Pure Gold
16. Regional Sukuk
17. Infrastructure Investment Funds in the Form of Collective Investment Contracts
18. Other Investments
B. Non-Investments
1. Cash and Banks
2. Investment Income Claims
3. Investment Claims
4. Other Assets
II. LIABILITIES AND EQUITY

2. Financial Realization for Comprehensive Income/Loss
a) For Company Funds
(in millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah per Dec 31, 20XX
I. INCOME
1. INVESTMENT INCOME AND INVESTMENT MANAGEMENT UJROH
1. Investment Results
2. Investment Results Distributed to Company Funds
3. Total Investment Results
4. Total Investment Management Ujroh
5. Total Investment Results and Investment Management Ujroh Income
2. UNDERWRITING INCOME
1. Participant Contributions (Ujroh)
2. Reinsurance/Retrosession Contributions
3. Net Underwriting Income
Underwriting surplus for Company Funds A. Liabilities
1. Payable claims and benefits liabilities
2. Accrued Expenses
3. Other Payables
B. Fund Equity
1. Accumulated Funds
2. Profit Equalization Reserve (PER)
3. Other Equity Components.

DESCRIPTION Business Plan Realization Deviation Rupiah per Dec 31, 20XX
2. OPERATING EXPENSES:

Marketing Expenses
Acquisition Expenses
General and Administrative Expenses:

Employee and Manager Expenses
Education and Training Expenses
Other General and Administrative Expenses

Increase (decrease) in Ujroh Provisions
Increase (decrease) in PAYDI Provisions
TOTAL OPERATING EXPENSES
INSURANCE OPERATING PROFIT (LOSS)
Other Income
Other Expenses
PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL PERFORMANCE OF ALL FUNDS

b) For Tabarru’ Funds
(in millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah per Dec 31, 20XX
I. INCOME
1. INVESTMENT INCOME
1. Investment Results
2. Investment Results Distributed to Company Funds
3. Total Investment Results
2. UNDERWRITING INCOME
1. Participant Contributions (Tabarru')
2. Reinsurance/Retrosession Contributions
3. Net Contributions
4. Decrease (Increase) in Contribution Provisions and PAKYBMP
a. Decrease (increase) in Contribution Provisions b. Decrease (increase) in PAKYBMP
c. Decrease (Increase) in Disaster Risk Provisions
5. Total Net Contribution Income
TOTAL UNDERWRITING INCOME
2. EXPENSES
1. UNDERWRITING EXPENSES
2. Claim Expenses
a. Gross Claims b. Recovery claims
c. Increase (Decrease) in Claim Provisions
Net Claim Expenses Total
3. Adjuster Expenses
TOTAL UNDERWRITING EXPENSES
3. TOTAL UNDERWRITING SURPLUS (DEFICIT)
a. Underwriting surplus for Company Funds b. Underwriting surplus for Participants INSURANCE OPERATING PROFIT (LOSS) Other Income Other Expenses PROFIT (LOSS) BEFORE TAX Income Tax PROFIT AFTER TAX OTHER COMPREHENSIVE INCOME TOTAL PERFORMANCE OF ALL FUNDS

c) For Tanahud Funds
(in millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah per Dec 31, 20XX
I. INCOME
1. INVESTMENT INCOME
1. Investment Results
2. Investment Results Distributed to Company Funds
3. Total Investment Results
2. UNDERWRITING INCOME
1. Participant Contributions (Tabarru')
2. Reinsurance/Retrosession Contributions
3. Net Contributions
4. Decrease (Increase) in Contribution Provisions and PAKYBMP
a. Decrease (increase) in Contribution Provisions b. Decrease (increase) in PAKYBMP
c. Decrease (Increase) in Disaster Risk Provisions
5. Total Net Contribution Income
TOTAL UNDERWRITING INCOME
2. EXPENSES
1. UNDERWRITING EXPENSES
1. Claim Expenses
a. Gross Claims b. Recovery claims
c. Increase (Decrease) in Claim Provisions
Net Claim Expenses Total
2. Adjuster Expenses
TOTAL UNDERWRITING EXPENSES
3. TOTAL UNDERWRITING SURPLUS (DEFICIT)
a. Underwriting surplus for Company Funds b. Underwriting surplus for Participants INSURANCE OPERATING PROFIT (LOSS) Other Income Other Expenses PROFIT (LOSS) BEFORE TAX Income Tax PROFIT AFTER TAX OTHER COMPREHENSIVE INCOME TOTAL PERFORMANCE OF ALL FUNDS

d) For Participant Investment Funds (in millions of rupiah) DESCRIPTION Business Plan Realization Deviation Rupiah per Dec 20XX
I. INCOME
1. INVESTMENT INCOME AND ALLOCATION CONTRIBUTION INCOME
1. Investment Results
2. Investment Results Distributed to Company Funds
3. Total Investment Results
4. Total Investment Results and Investment Management Ujroh Income
2. UNDERWRITING INCOME
1. Participant Contributions (Investment Allocation)
2. EXPENSES
1. UNDERWRITING EXPENSES
1. Claim Expenses
a. Withdrawal of Participant Investment Funds that have matured b. Withdrawal/Redemption of Participant Investment Funds (not yet matured) Total Claim Expenses Underwriting Surplus for Participants INSURANCE OPERATING PROFIT (LOSS) Other Expenses PROFIT (LOSS) BEFORE TAX Income Tax PROFIT AFTER TAX OTHER COMPREHENSIVE INCOME TOTAL PERFORMANCE OF ALL FUNDS

3. CASH FLOW REPORT
a) For Company Funds
(In millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah %
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Received Ujroh
2. Participant Contributions
3. Receipts of Tabarru’ Fund Surplus Allocations
4. Others
b. Cash Outflows
1. Acquisition Expenses
2. Marketing Expenses
3. Reinsurance Ujroh Payments
4. Paid Reinsurance Contributions
5. Rent Payments
6. Zakat Payments
7. Tax Payments
8. Others
5. CASH FLOWS FROM INVESTING ACTIVITIES
a. Cash Inflows
1. Receipt of Investment Results
2. Receipt of Investment Profit Sharing for Tabarru’ Funds
3. Receipt of Investment Profit Sharing for Participant Investment Funds
4. Investment Liquidation
5. Sale of Fixed Assets
6. Others
b. Cash Outflows
1. Investment Placements
2. Purchase of Fixed Assets
3. Others
6. CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
1. Capital/Capital Work Deposits
2. Subordinated Loans
3. Others
b. Cash Outflows
1. Subordinated Loan Repayments
2. Dividend Payments
3. Others

b) For Tabarru’ Funds
(In millions of rupiah)
Description Business Plan Realization Deviation Rupiah %
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Participant Contributions
2. Received Reinsurance Claims
3. Receipts of Reinsurance Underwriting Surplus Distribution
4. Others
b. Cash Outflows
1. Claims Paid
2. Payment of UW Surplus Distribution to Company
3. Payment of UW Surplus Distribution to Participants/Policyholders
4. Insurance Ujroh Payments
5. Paid Reinsurance Contributions
6. Others
5. CASH FLOWS FROM INVESTING ACTIVITIES
a. Cash Inflows
1. Receipt of Investment Results
2. Investment Liquidation
3. Others
b. Cash Outflows
1. Investment Placements
2. Investment Results Distributed to Company Funds
3. Payment of ujroh/fees to Company
4. Others
6. CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
1. Qardh Receipts
2. Others
b. Cash Outflows
1. Qardh Payments
2. Others

c) For Tanahud Funds
(in millions of rupiah)
Description Business Plan Realization Deviation Rupiah %
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Participant Contributions
2. Received Reinsurance Claims
3. Receipts of Reinsurance Underwriting Surplus Distribution
4. Others
b. Cash Outflows
1. Claims Paid
2. Payment of UW Surplus Distribution to Company
3. Payment of UW Surplus Distribution to Participants/Policyholders
4. Insurance Ujroh Payments
5. Paid Reinsurance Contributions
6. Others
5. CASH FLOWS FROM INVESTING ACTIVITIES
a. Cash Inflows
1. Receipt of Investment Results
2. Investment Liquidation
3. Others
b. Cash Outflows
1. Investment Placements
2. Investment Results Distributed to Company Funds
3. Payment of ujroh/fees to Company
4. Others
6. CASH FLOWS FROM FINANCING ACTIVITIES
a. Cash Inflows
1. Qardh Receipts
2. Others
b. Cash Outflows
1. Qardh Payments
2. Others

d) For Company Investment Funds
(in millions of rupiah)
DESCRIPTION Business Plan Realization Deviation Rupiah Per Dec 31, 20XX
1. BEGINNING BALANCE
2. INCREASE (DECREASE) IN CASH BALANCE
3. ENDING CASH BALANCE
4. CASH FLOWS FROM OPERATING ACTIVITIES
a. Cash Inflows
1. Participant Contributions
2. Others
b. Cash Outflows
1. Claims Paid
2. Withdrawal of Matured Participant Investment Funds
3. Withdrawal/Redemption of Unmatured Participant Investment Funds
4. Others
5. CASH FLOWS FROM INVESTING ACTIVITIES
a. Cash Inflows
1. Receipt of Investment Results
2. Investment Liquidation
3. Others
b. Cash Outflows
1. Investment Placements
2. Investment Results Distributed to Company Funds
3. Payment of ujroh/fees to Company
4. Others
CASH FLOWS FROM FINANCING ACTIVITIES Cash Inflows
1. Others
Cash Outflows
1. Others

Rupiah Deviation = Realization – Plan
Deviation (%) = (Realization/Plan)x100%

C. Follow-up on Business Plan Achievement
......
......
......

D. Financial Ratios and Specific Items
1. Realization of Ratios and Other Specific Items
a) For Company Funds
(in millions of rupiah)
(ratios in percentage)
Business Plan Realization Deviation Rupiah %
I. Solvency Ratio
A. Solvency Level
1. Allowed Assets (AYD)
2. Liabilities
B. Risk-Based Minimum Capital
C. Solvency Level Ratio before considering Available Assets for Qardh (in %)
D. Internal Target Solvency Level Ratio (annual) (percentage according to POJK 72) E. Solvency Level Ratio with Regulatory Required MMBR (percentage according to POJK 72) F. Available Assets for Qardh considered as Additions to AYD for Tabarru’ and Tanahud Funds
1. Shortfall (surplus) of solvency level from internal target
2. Insufficiency of investments, cash and banks
G. Company Fund Solvency Level Ratio
II. Ratios Other Than Solvency Level Ratio
A. Liquidity Ratio
1. Current assets
2. Current liabilities
3. Ratio (a:b)
B. Net Investment Income Ratio
1. Net investment income
2. Average investments
3. Ratio (a:b)
C. Fund Change Ratio
1. Company Funds Current Period
2. Company Funds Previous Period
3. Change in Company Funds (a-b)
4. Ratio (c:b)
D. Sharia Unit Asset Ratio
1. Tabarru’ and Tanahud Fund Assets
2. Participant Investment Fund Assets
3. Company Insurance Assets (Conventional)
4. Ratio (a+b) : (a+b+c)

b) For Tabarru’ Funds
(in millions of rupiah)
(ratios in percentage)
Business Plan Realization Deviation Rupiah %
I. Solvency Ratio
A. Solvency Level
1. Allowed Assets (AYD)
2. Liabilities other than Qardh from Company Funds
B. Risk-Based Minimum Tabarru’ Funds
C. Solvency Level Ratio before considering Available Assets for Qardh (in %)
D. Internal Target Solvency Level Ratio (annual) (percentage according to POJK 72) E. Solvency Level Ratio with Regulatory Required MMBR (percentage according to POJK 72) F. Available Assets for Qardh considered as Additions to AYD for Tabarru’ and Tanahud Funds
1. Shortfall (surplus) of solvency level from internal target
2. Insufficiency of investments, cash and banks
G. Company Fund Solvency Level Ratio
II. Ratios Other Than Solvency Level Ratio
A. Liquidity Ratio
1. Current assets
2. Current liabilities
3. Ratio (a:b)
B. Investment-Liability Balance Ratio
1. Investments, cash and banks
2. Technical provisions
3. Retained claim payables
4. Ratio [a:(b+c)]
C. Net Investment Income Ratio
1. Net investment income
2. Average investments
3. Ratio (a:b)
D. Claim Expense Ratio
1. Net claim expenses
2. Net contributions
3. Ratio (a:b)
E. Fund Change Ratio
1. Tabarru’ and Tanahud Funds Current Period
2. Tabarru’ and Tanahud Funds Previous Period
3. Change in funds (a-b)
4. Ratio (c:b)
F. Calculation of Qardh Required by Tabarru’ Funds
1. Total Liabilities other than Qardh
2. Total Assets
3. Required Qardh Amount (a-b)
G. Calculation of Qardh Required by Tanahud Funds
1. Total Liabilities other than Qardh
2. Total Assets
3. Required Qardh Amount (a-b)

c) Participant Investment Funds
(in millions of rupiah)
(ratios in percentage)
Business Plan Realization Deviation Rupiah %
I. Liquidity Ratio
1. Current assets
2. Current liabilities
3. Ratio (a:b)
II. Net Investment Income Ratio
1. Net investment income
2. Average investments
3. Ratio (a:b)
III. Fund Change Ratio
1. Participant Investment Funds Current Period
2. Participant Investment Funds Previous Period
3. Change in funds (a-b)
4. Ratio (c:b)

E. Other Information
......
......
......

Filled with explanations regarding the achievement of other information in the Business Plan as well as the comparison of plans and realizations.
Example:
a. realization of merger, acquisition, and consolidation plans; b. realization of portfolio transfer plans;
c. realization of insurance business field change plans;
d. realization of business activity changes from non-sharia principles to sharia principles. e. latest realization of Sharia unit spin-off plans and explanations regarding the realization/process of preparing the spin-off work plan.

FORMAT II C
FORM AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES Business Plan Supervision Report in accordance with Article 15 paragraph (5) of Financial Services Authority Regulation Number 24/POJK.05/2019 concerning Business Plans of Non-Bank Financial Service Institutions, with a submission deadline no later than November 30 of the previous year.

BUSINESS PLAN SUPERVISION REPORT
Year ......
(filled with company name and address) , 20xx Board of Commissioners (Company Stamp) Full Name Position

(filled with the Board of Commissioners' assessment of the implementation of the Business Plan, consisting of quantitative and qualitative assessments of the Business Plan realization, including good corporate governance aspects, risk profile, profitability, and capitalization, as well as efforts to improve the Company's performance, if according to the assessment there is a decline in the Company's performance.)

FORMAT II D
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES AUTOMATIC REINSURANCE/RETROCESSION PROGRAM REPORT

The form and structure of the Automatic Reinsurance/Retrocession Program Report as referred to in the Financial Services Authority Regulation regarding Self-Retention and Domestic Reinsurance Support refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding Limits on Self-Retention, Amount of Reinsurance Support, and Reinsurance or Retrocession Programs.

FORMAT III E
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES CONSUMER COMPLAINT REPORT AND FOLLOW-UP ON SERVICE AND CONSUMER COMPLAINT RESOLUTION

The form and structure of the Consumer Complaint Report and Follow-up on Service and Consumer Complaint Resolution as referred to in the Financial Services Authority Regulation regarding Consumer Protection in the Financial Services Sector refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding Service and Resolution of Consumer Complaints by Financial Service Business Actors.

FORMAT II F
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES SELF-ASSESSMENT REPORT ON THE IMPLEMENTATION OF INTEGRATED GOVERNANCE FOR FINANCIAL CONGLOMERATES

The form and structure of the Self-Assessment Report on the Implementation of Integrated Governance for Financial Conglomerates as referred to in the Financial Services Authority Regulation regarding the Application of Integrated Governance for Financial Conglomerates refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding the Application of Integrated Governance. For Financial Conglomerates

FORMAT II G
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES INTEGRATED GOVERNANCE REPORT FOR FINANCIAL CONGLOMERATES

The form and structure of the Integrated Governance Report for Financial Conglomerates as referred to in the Financial Services Authority Regulation regarding the Application of Integrated Governance for Financial Conglomerates refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding the Application of Integrated Governance for Financial Conglomerates.

FORMAT II H
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES INTEGRATED RISK PROFILE REPORT

The form and structure of the Integrated Risk Profile Report as referred to in the Financial Services Authority Regulation regarding the Application of Integrated Risk Management for Financial Conglomerates refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding the Application of Integrated Risk Management for Financial Conglomerates.

FORMAT II I
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES INTEGRATED CAPITAL ADEQUACY REPORT

The form and structure of the Integrated Capital Adequacy Report as referred to in the Financial Services Authority Regulation regarding Integrated Minimum Capital Requirements for Financial Conglomerates.

FORMAT II J
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES REPORT ON DATA UPDATING ACTIVITY PLANS AND REPORT ON REALIZATION OF CUSTOMER DATA UPDATING

The Data Updating Activity Plan Report and Customer Data Updating Realization Report as referred to in the Financial Services Authority Regulation regarding the Implementation of Anti-Money Laundering and Counter-Financing of Terrorism Programs in the Financial Services Sector.

FORMAT II K
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES REPORT ON APPOINTMENT OF PUBLIC ACCOUNTANTS AND/OR PUBLIC ACCOUNTING FIRMS IN THE FRAMEWORK OF AUDIT ON ANNUAL HISTORICAL FINANCIAL INFORMATION

The form and structure of the report on the appointment of public accountants and/or public accounting firms in the framework of audit on annual historical financial information as referred to in the Financial Services Authority Regulation regarding the Use of Public Accountant Services and Public Accounting Firms in Financial Services Activities refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding Procedures for Using Public Accountant Services and Public Accounting Firms in Financial Services Activities.

FORMAT II L
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES REPORT ON AUDIT COMMITTEE EVALUATION RESULTS REGARDING THE IMPLEMENTATION OF AUDIT SERVICES ON ANNUAL HISTORICAL FINANCIAL INFORMATION BY PUBLIC ACCOUNTANTS AND/OR PUBLIC ACCOUNTING FIRMS

The form and structure of the report on the audit committee's evaluation results regarding the implementation of audit services on annual historical financial information by public accountants and/or public accounting firms as referred to in the Financial Services Authority Regulation regarding the Use of Public Accountant Services and Public Accounting Firms in Financial Services Activities refers to the form and structure as stated in the Appendix of the Financial Services Authority Circular regarding Procedures for Using Public Accountant Services and Public Accounting Firms in Financial Services Activities.

FORMAT II M
FORMS AND STRUCTURE OF RISK ASSESSMENT RESULTS REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES COMPANY HEALTH ASSESSMENT RESULTS

The form and structure of this Company Health Assessment Results is based on POJK provisions regarding Health Level Assessment of Non-Bank Financial Service Institutions. In terms of reporting, this report has been included in the OJK system under the application name SIRIBAS.

FORMAT III N
FORMS AND STRUCTURE OF RISK ASSESSMENT RESULTS REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES ACTION PLAN THAT CONSTITUTES FOLLOW-UP FROM SELF-ASSESSMENT RESULTS OF COMPANY HEALTH LEVEL

The form and structure of the action plan that constitutes follow-up from the self-assessment results of the Company's health level is based on POJK provisions regarding Health Level Assessment of Non-Bank Financial Service Institutions. In terms of reporting, this report has been included in the OJK system under the application name SIRIBAS.

FORMAT III O
FORMS AND STRUCTURE OF RISK ASSESSMENT RESULTS REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES IMPLEMENTATION OF ACTION PLAN

The form and structure of the implementation of the action plan is based on POJK provisions regarding Health Level Assessment of Non-Bank Financial Service Institutions. In terms of reporting, this report has been included in the OJK system under the application name SIRIBAS.

FORMAT II P
FORMS AND STRUCTURE OF OTHER REPORTS FOR INSURANCE AND REINSURANCE COMPANIES WITH SHARIA PRINCIPLES SUMMARY OF QUARTERLY AND ANNUAL FINANCIAL REPORTS

The form and structure of the summary of quarterly and annual financial reports as referred to in the Financial Services Authority Regulation regarding the Financial Health of Insurance and Reinsurance Companies.

A. Annual Report

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

B. Quarterly Report

Established in Jakarta on March 1, 2021

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

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Cash Flow Statement

STATEMENT OF CHANGES IN FUNDS

ANALYSIS

ASSET AND LIABILITY CALCULATION

FINANCIAL RATIOS

SOLVENCY LEVEL ACHIEVEMENT

FINANCIAL RATIOS

OTHER THAN SOLVENCY LEVEL

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK - DEFAULT OR INABILITY OF DEBTOR OR OTHER PARTY

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK - DEFAULT OR INABILITY OF DEBTOR OR OTHER PARTY

AUTOMATIC REINSURANCE (Treaty)

FACULTATIVE REINSURANCE

RISK-BASED MINIMUM TABARRU' FUNDS

CREDIT RISK - REINSURER DEFAULT/INABILITY

MATURITY ANALYSIS

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

LIQUIDITY RISK

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

MARKET RISK

RISK-BASED MINIMUM CAPITAL AND RISK-BASED MINIMUM TABARRU' FUNDS

MARKET RISK - MARKET PRICE CHANGES

Format 10: Organizational, Human Resources, and/or Information Technology Development Plan

a. Organizational Development Plan

1) Description of the Organizational Development Plan

2) Reasons and Considerations

3) Strategy

b. Human Resource Development Plan

1) Description of the Human Resource Fulfillment Plan

2) Reasons and Considerations

3) Strategy

c. Plan for Implementing Education and Training for Directors, Board of Commissioners, and Employees

1) Table of Human Resource Development Plan

2) Reasons and Considerations

3) Strategy

d. Plan for Utilization of Foreign Workers

1) Table of Foreign Worker Utilization Plan

2) Reasons and Considerations

3) Strategy

e. Plan for Utilization of Outsourced Labor

1) Table of Outsourced Labor Utilization Plan

2) Reasons and Considerations

3) Strategy

f. Information Technology Development Plan

1) Description of Fundamental Information Technology Development and Procurement Plans, Including Information on Development and Maintenance Costs

2) Reasons and Considerations

3) Strategy

Format 11: Report on Activities to Improve Financial Literacy and Inclusion for Consumers and/or the Public

a. Report on Activities to Improve Financial Literacy for Consumers and/or the Public

b. Report on Activities to Improve Financial Inclusion for Consumers and/or the Public

Format 12: Financial Statement Projections and Assumptions Used

a. Financial Position Projection

1) For Company Funds

Lineage: No known changes

Timeline

What changed in the obligations

Similar documents from other regulators

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