OJK Circular Letter No. 4/SEOJK.05/2013 on Monthly Reports of Insurance and Reinsurance Companies Conducting All Business on Sharia Principles and Sharia Units

Yth.

Property Insurance Companies;
Life Insurance Companies; and
Reinsurance Companies,
which conduct all or part of their business based on Sharia Principles at Location

COPY
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 4/SEOJK.05/2013 CONCERNING MONTHLY REPORTS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES THAT CONDUCT ALL THEIR BUSINESS WITH SHARIA PRINCIPLES AND SHARIA UNITS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES

In connection with Financial Services Authority Regulation Number 3/POJK.05/2013 dated 12 September 2013 concerning Monthly Reports of Non-Bank Financial Service Institutions (State Gazette of the Republic of Indonesia Year 2013 Number 150, Supplement to the State Gazette of the Republic of Indonesia Number 5443), it is necessary to regulate implementation provisions regarding monthly reports of Insurance Companies and Reinsurance Companies that conduct all their business with Sharia principles and Sharia Units of Insurance Companies and Reinsurance Companies in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

Financial Services Authority, hereinafter abbreviated as OJK, is an independent institution free from the interference of other parties, which has the functions, duties, and authorities for regulation, supervision, examination, and investigation, as referred to in Law Number 21 of 2011 concerning the Financial Services Authority.
Monthly Report is a financial report prepared by non-bank financial service institutions for the benefit of OJK, covering the period from the 1st to the end of the current month and submitted according to the format and procedures determined by OJK.

II. FORM AND STRUCTURE OF MONTHLY REPORTS
The form, structure, and guidelines for preparing Monthly Reports for Insurance Companies and Reinsurance Companies that conduct all their business with Sharia principles and Sharia Units of Insurance Companies and Reinsurance Companies are as follows:
a. for Property Insurance Companies and Reinsurance Companies that conduct all their business with Sharia principles and Sharia Units of Property Insurance Companies and Reinsurance Companies as contained in Appendix I; and b. for Life Insurance Companies that conduct all their business with Sharia principles and Sharia Units of Life Insurance Companies as contained in Appendix II, which constitute an inseparable part of this OJK Circular Letter.

III. TIME FOR SUBMISSION OF MONTHLY REPORTS

Insurance Companies and Reinsurance Companies that conduct all or part of their business based on Sharia principles are required to submit Monthly Reports to OJK no later than the 10th of the following month.
In the event that the date of the 10th as referred to in paragraph 1 falls on a holiday, the Monthly Report must be submitted on the next working day.

IV. PROCEDURES FOR SUBMISSION

Submission of Monthly Reports is done online through the OJK data communication network system.
In the event that the OJK data communication network system is not yet available, Monthly Reports are submitted online via the company's official email (email) by attaching a softcopy of the Monthly Report in spreadsheet format to LBAR.Syariah@ojk.go.id.
In the event that Monthly Reports are submitted offline, submission is done via a letter signed by at least one member of the Board of Directors and addressed to:
Financial Services Authority u.p. Director of Sharia Non-Bank Financial Institution Supervision Sumitro Djojohadikusumo Building, 13th Floor Jl. Lapangan Banteng Timur Number 2-4 Jakarta 10710
Submission of Monthly Reports offline as referred to in paragraph 3 can be done in the following ways:
a. handed directly to the OJK office; b. sent via registered post office; or
c. sent via courier/courier service company.
Insurance Companies and Reinsurance Companies that conduct all or part of their business based on Sharia principles are deemed to have submitted Monthly Reports with the following provisions:
a. for submission online via email, evidenced by an email receipt from OJK, b. for submission offline, evidenced by:

a receipt letter from OJK, if the report is handed directly to the OJK office; or
a shipping receipt from the post office or courier/courier service company, if the report is sent via post office or courier/courier service company.

In the event of changes to the OJK email address as referred to in paragraph 2 and/or changes to the OJK office address as referred to in paragraph 3, OJK will communicate the address changes via letter or announcement.

V. SANCTION PROVISIONS

OJK imposes administrative sanctions in the form of a first written warning as regulated in Article 6 paragraph (3) of OJK Regulation Number 3/POJK.05/2013 concerning Monthly Reports of Non-Bank Financial Service Institutions, with a deadline for fulfilling the obligation to submit Monthly Reports of up to 30 (thirty) days from the establishment of the administrative sanction in the form of a first written warning.
If within the time limit as referred to in paragraph 1 the obligation to submit Monthly Reports is not fulfilled, OJK imposes administrative sanctions in the form of a second written warning as regulated in Article 6 paragraph (4) of OJK Regulation Number 3/POJK.05/2013 concerning Monthly Reports of Non-Bank Financial Service Institutions, with a deadline for fulfilling the obligation to submit Monthly Reports of up to 30 (thirty) days from the establishment of the administrative sanction in the form of a second written warning.
If within the time limit as referred to in paragraph 2 the obligation to submit Monthly Reports is not fulfilled, OJK imposes administrative sanctions in the form of a third written warning as regulated in Article 6 paragraph (4) of OJK Regulation Number 3/POJK.05/2013 concerning Monthly Reports of Non-Bank Financial Service Institutions, with a deadline for fulfilling the obligation to submit Monthly Reports of up to 30 (thirty) days from the establishment of the administrative sanction in the form of a third written warning.

VI. TRANSITIONAL PROVISIONS

Insurance Companies and Reinsurance Companies that conduct all or part of their business based on Sharia principles are required to submit Monthly Reports to OJK for the reporting period of September 2013 through the reporting period of August 2014 no later than the end of the following month.
In the event that the date of the end of the following month as referred to in paragraph 1 falls on a holiday, the Monthly Report must be submitted on the next working day.

VII. CLOSING
This OJK Circular Letter takes effect on the date of determination.
To ensure everyone knows, ordering the publication of this OJK Circular Letter by placing it in the State Gazette of the Republic of Indonesia. Determined in Jakarta on 25 November 2013 EXECUTIVE HEAD OF NON-BANK FINANCIAL INSTITUTION SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed, FIRDAUS DJAELANI

Copy consistent with the original
Head of Legal Assistance Division
Legal Directorate
Signed,
Mufli Asmawidjaja
STATE GAZETTE OF THE REPUBLIC OF INDONESIA NUMBER 7 DATED 24 JANUARY YEAR 2014

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 4/SEOJK.05/2013 CONCERNING MONTHLY REPORTS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES THAT CONDUCT ALL THEIR BUSINESS WITH SHARIA PRINCIPLES AND SHARIA UNITS OF INSURANCE COMPANIES AND REINSURANCE COMPANIES

To: Financial Services Authority u.p. Director of Sharia Non-Bank Financial Institutions Sumitro Djojohadikusumo Building, 14th Floor Jl. Lapangan Banteng Timur 1 - 4 Jakarta - 10710

MONTHLY REPORT
SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS Month… Year… PT XYZ

DESCRIPTION BALANCE SAK BALANCE SAP
ASSETS
Investment
Bank Deposits
Sharia Stocks
Sharia Sukuk or Bonds
Sharia Government Securities
Sharia Securities Issued by Bank Indonesia Sharia Securities Issued by Countries Other Than the Republic of Indonesia Sharia Securities Issued by Multinational Institutions Sharia Mutual Funds Sharia Asset-Backed Securities Financing Through Cooperation with Other Parties. Pure Gold Other Investments Total Investment =SUM(C11:C22) =SUM(D11:D22) Non-Investment Cash and Banks Contribution Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Other Assets Total Non-Investment =SUM(C25:C30) =SUM(D25:D29) Total Assets =+C23+C31 =+D23+D31 LIABILITIES AND OWN EQUITY Liabilities Debts Claims Payable Reinsurance Payables Ujrah Payables to Companies Underwriting Surplus Allocation Payables to Insureds Underwriting Surplus Allocation Payables to Companies Investment Profit Sharing Dana Tabarru' Payables Zakat Payables Other Payables Total Debts =SUM(C36:C43) =SUM(D36:D43) Technical Provisions Contribution Provisions Provisions for Contributions Not Yet Become Income/Rights Claim Provisions Total Technical Provisions =SUM(C46:C48) =SUM(D46:D48) Qardh Total Liabilities =C44+C49+C50 =D44+D49+D50 Participant Equity Accumulated Dana Tabarru' Funds Increase (Decrease) in Securities Valuation Differences Based on SAK and SAP Disallowed Assets Total Participant Equity =SUM(C53:C54) =SUM(D53:D56) Total Liabilities and Participant Equity =+C51+C57 =+D51+D57

PT.XYZ
A. DANA TABARRU'
SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS (in millions of Rupiah)
I. STATEMENT OF FINANCIAL POSITION
As of …

DESCRIPTION CURRENT MONTH ACCUMULATIVE
Underwriting Revenue
Contributions from Participants*)
Reinsurance Contributions
Decrease (Increase) in Provisions for Contributions Not Yet Become Income/Rights (KYBMP)) a. Beginning KYBMP b. Ending KYBMP Decrease (Increase) in Contribution Provisions*) a. Beginning Contribution Provisions b. Ending Contribution Provisions Total Net Contribution Revenue =+C15-C16+C18-C19+C21-C22 =+D15-D16+D18-D19+D21-D22 Claim Expenses a. Gross Claims b. Reinsurance Claims Received
c. Increase (Decrease) in Claim Provisions
c.1. Beginning Claim Provisions c.2. Ending Claim Provisions Total Claim Expenses =+C25-C26-C28+C29 =+D25-D26-D28+D29 Adjuster Costs (Specifically for Property Insurance) Underwriting Surplus (Deficit) (6-8-9) =+C23-C30-C31 =+D23-D30-D31 Note:
SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ A. DANA TABARRU'
II. UNDERWRITING SURPLUS CALCULATION
For Periods Ended
(in millions of Rupiah)
*) Participant contributions accumulated into dana tabarru' ) KYBMP : contributions that are not yet income/rights are for insurance products with a coverage period of less than 1 year Month… Year… *) Contribution provisions for insurance products with a coverage period of more than 1 year.

DESCRIPTION CURRENT MONTH ACCUMULATIVE
Beginning Balance :
Cash - Bank
Cash Flows from Operating Activities
Cash Inflows

Contributions from Participants
Reinsurance Claims Received
Receipt of Underwriting Surplus Distribution from Reinsurance
Total Cash Inflows =SUM(B17:B19) =SUM(C17:C19) Cash Outflows
Payment of Insurance Ujroh
Reinsurance Contributions Paid
Claims Paid
Others
Total Cash Outflows =SUM(B22:B25) =SUM(C22:B25) Total Cash Flows from Operating Activities =B20-B26 =C20-C26 Cash Flows from Investing Activities Cash Inflows
Receipt of Investment Returns from Dana Tabarru'
Withdrawal of Dana Tabarru' Investments
Sale of Land and Buildings
Others
Total Cash Inflows =SUM(B30:B33) =SUM(C30:B33) Cash Outflows
Investment Placement
Payment of Underwriting Surplus Distribution to Company
Payment of Underwriting Surplus Distribution to Participants
Payment of Investment Profit Sharing Dana Tabarru' to Company
Purchase of Fixed Assets
Others
Total Cash Outflows =SUM(B36:B41) =SUM(C36:B41) Total Cash Flows from Investing Activities =B34-B42 =C34-C42 Cash Flows from Financing Activities Cash Inflows
Qardh
Others
Total Cash Inflows =SUM(B46:B47) =SUM(C46:B47) Cash Outflows
Payment of Qardh
Others
Total Cash Outflows =SUM(B50:B51) =SUM(C50:B51) Total Cash Flows from Financing Activities =B48-B52 =C48-C52 Ending Cash Balance =B14+B27+B43+B53 =C14+C27+C43+C53

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ A. DANA TABARRU'
III. STATEMENT OF CASH FLOWS
Month… Year…

(in millions of Rupiah)
DESCRIPTION TOTAL
Solvency Ratio
Permitted Assets
Liabilities
Total Solvency Ratio =C14-C15
Risk of Losses That May Arise Due to Deviations in the Management of Assets and/or Liabilities
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Total Funds Required To Anticipate Risk of Losses That May Arise Due to Deviations in the Management of Assets and/or Liabilities =SUM(C18:C23) Solvency Achievement Ratio =+C16/C24 Month… Year…

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ A. DANA TABARRU'
IV. FINANCIAL HEALTH RATIOS OF DANA TABARRU'
ACHIEVEMENT OF DANA TABARRU' SOLVENCY LEVEL

Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year #DIV/0! #DIV/0! #DIV/0! 1 year < age ≤ 5 years #DIV/0! #DIV/0! #DIV/0! 5 years < age ≤ 10 years #DIV/0! #DIV/0! #DIV/0!

10 years #DIV/0! #DIV/0! #DIV/0!
Total #DIV/0!
Rupiah 2) Foreign Currency 2) Total 2)
Notes:

In millions of Rupiah
In percentage
Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with an age of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with an age of more than 1 year Current Liabilities to Non-Current Liabilities Ratio
V. ASSET AND LIABILITY RECAPITULATION BASED ON CURRENCY AND MATURITY DATE
As of…
Asset Age 1) Liability 1) Asset to Liability Ratio 2)

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ A. DANA TABARRU' Description Current Asset to Current Non-Current Asset Ratio

(in millions of Rupiah)
DESCRIPTION BALANCE SAK
ASSETS
Investment
Deposits
Sharia Stocks
Sharia Sukuk or Bonds
Sharia Government Securities
Sharia Securities Issued by Bank Indonesia Sharia Securities Issued by Countries Other Than the Republic of Indonesia Sharia Securities Issued by Multinational Institutions Sharia Mutual Funds Sharia Asset-Backed Securities Financing Through Cooperation With Other Parties Shariah. Pure Gold Direct Participation Buildings with Strata Rights or Land with Buildings For Investment Other Investments Total Investment =SUM(C11:C24) Non-Investment Cash and Banks Investment Receivables Investment Income Receivables Ujrah Receivables from Participants Tabarru' Fund Surplus Allocation Receivables Tabarru' Fund Investment Management Profit Sharing Receivables Qardh Receivables Buildings with Strata Rights or Land with Buildings For Own Use Computer Hardware Other Fixed Assets Other Assets Total Non-Investment =SUM(C27:C37) TOTAL ASSETS =+C25+C38 LIABILITIES AND EQUITY Liabilities Commission Payables Reinsurance Ujrah Payables Tax Payables Expenses Still to Be Paid Zakat Payables Other Payables Total Liabilities =SUM(C42:C47) Subordinated Loans Equity Paid-in Capital Share Premium Reserves Increase (Decrease) in Securities Valuation Differences of Fixed Assets Retained Earnings Total Equity =SUM(C51:C56) TOTAL LIABILITIES AND EQUITY =+C48+C49+C57

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ B. DANA PERUSAHAAN
I. STATEMENT OF FINANCIAL POSITION
As of …

(in millions of Rupiah)
DESCRIPTION CURRENT MONTH ACCUMULATIVE
REVENUE
Ujrah Received a. Ujrah for Risk Management b. Ujrah for Management of Dana Tabarru' Investments
c. Ujrah for Management of Participant Investment Funds
Total Ujrah Received =SUM(C13:C15) =SUM(D13:C15) Commission Receipts Profit Sharing from Dana Tabarru' Investment Management Profit Sharing from Participant Investment Fund Management Allocation of Underwriting Surplus of Dana Tabarru' Company Investment Returns Total Revenue =SUM(C16:C21) =SUM(D16:C21) Operating Expenses Acquisition Costs a. Commission Expense - First Year b. Commission Expense - Subsequent Years
c. Commission Expense - Overriding
d. Other Expenses
Total Acquisition Costs =SUM(C25:C28) =SUM(D25:C28) Reinsurance Ujrah Marketing Expenses General and Administrative Expenses Other Expenses Total Operating Expenses =SUM(C29:C33) =SUM(D29:C33) DPLK/Other Management Service Fees Other Income Profit (Loss) Before Zakat =+C22-C34+C35+C36=+D22-D34+D35+D36 Zakat Profit (Loss) Before Tax =+C37-C38 =+D37-D38 Income Tax Profit After Tax =+C39-C40 =+D39-D40 Other Comprehensive Income Comprehensive Income =C41+C43 =D41+D43 Month…Year…

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ
II. INCOME STATEMENT
B. DANA PERUSAHAAN
For Periods Ended

(in millions of Rupiah)
DESCRIPTION CURRENT MONTH ACCUMULATIVE
Cash - Bank
1 Ujroh received
2 Receipt of Underwriting Surplus Allocation Dana Tabarru' 3 Receipt of Profit Sharing Investment Dana Tabaru' 4 Receipt of Profit Sharing Investment Participant Investment Funds 5 Others =SUM(D18:D22) =SUM(E18:E22) 1 Commission 2 Marketing Expenses 3 Payment of Reinsurance Ujroh 4 Rent Payments 5 Zakat Payments 6 Tax Payments 7 Others =SUM(D25:D31) =SUM(E25:E31) =D23-D32 =E23-E32 1 Receipt of Company Investment Returns 2 Withdrawal of Company Investments 3 Sale of Fixed Assets 4 Others =SUM(D36:D39) =SUM(E36:E39) 1 Investment Placement 2 Purchase of Fixed Assets 3 Others =SUM(D42:D44) =SUM(E42:E44) =D40-D45 =E40-E45 1 Subordinated Loans 2 Capital Deposits/Working Capital 3 Receipt of Qardh 4 Others =SUM(D49:D52) =SUM(E49:E52) 1 Payment of Subordinated Loans 2 Dividend Payments 3 Qardh 4 Others =SUM(D55:D58) =SUM(E55:E58) =D53-D59 =E53-E59 Ending Cash Balance (A+B+C+D) =D15+D33+D46+D60=E15+E33+E46+E60 Total Cash Flows from Financing Activities Total Cash Inflows Total Cash Flows from Investing Activities Total Cash Outflows Total Cash Inflows Cash Inflows Cash Outflows Total Cash Outflows Total Cash Outflows Total Cash Flows from Operating Activities Cash Inflows Cash Outflows Cash Flows from Financing Activities Cash Flows from Investing Activities

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ Beginning Balance :
Cash Flows from Operating Activities
Cash Inflows
Cash Outflows
Total Cash Inflows
Month…. Year….
For Periods Ended
B. DANA PERUSAHAAN
III. STATEMENT OF CASH FLOWS

A. ASSETS AVAILABLE FOR QARDH
(in millions of Rupiah)
DESCRIPTION TOTAL
Risk of Losses That May Arise Due to Deviations in the Management of Assets and/or Liabilities
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Total =SUM(C12:C17)
Amount Used as the Basis for Calculation
Assets That Must Be Provided for Qard =45%*C18 Funds That Must Be Provided To Anticipate Risk of Losses That May Arise From Failure of Production Processes, Inability of Human Resources and/or Systems to Perform Well, Or the Occurrence of Other Adverse Events. Total Funds That Must Be Prepared To Maintain the Required Level of Solvency of Dana Tabarru' (Dana Tabarru' Solvency Shortfall) Total Funds That Must Be Prepared To Maintain Balance Between Investments Plus Cash and Banks With Technical Provisions Plus Claim Liabilities Retention Amount of Assets That Must Be Provided for Qardh =+C19+C20+MAX(C21;C22) Company Assets Counted as Assets Available for Qardh Excess (Shortage) of Assets Available for Qardh =+C24-C23 B. SOLVENCY OF COMPANY FUNDS (in millions of Rupiah) DESCRIPTION TOTAL Assets Liabilities Total Solvency of Company Funds =+C30-C31 Total Assets That Must Be Provided for Qardh =+C23 Required Own Capital or Working Capital Minimum Solvency of Company Funds =+MAX(C33:C34) Achievement / Balance of Company Funds Solvency =+C32-C35 Month… Year…

SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS PT.XYZ B. DANA PERUSAHAAN
IV. FINANCIAL HEALTH OF COMPANY FUNDS

(in millions of Rupiah)
Total
Description Total Adjustment After Adjustment
Dana Tabarru' Company Funds (If Any) Adjustment Investment Portfolio Deposits ='DT-LPK'!C11 ='DP-LPK'!C11 =C15+D15 =E15 Sharia Stocks ='DT-LPK'!C12 ='DP-LPK'!C12 =C16+D16 =E16 Sharia Sukuk or Bonds ='DT-LPK'!C13 ='DP-LPK'!C13 =C17+D17 =E17 Sharia Government Securities ='DT-LPK'!C14 ='DP-LPK'!C14 =C18+D18 =E18 Sharia Securities Issued by Bank Indonesia ='DT-LPK'!C15 ='DP-LPK'!C15 =C19+D19 =E19 Sharia Securities Issued by Countries Other Than the Republic of Indonesia ='DT-LPK'!C16 ='DP-LPK'!C16 =C20+D20 =E20 Sharia Securities Issued by Multinational Institutions ='DT-LPK'!C17 ='DP-LPK'!C17 =C21+D21 =E21 Sharia Mutual Funds ='DT-LPK'!C18 ='DP-LPK'!C18 =C22+D22 =E22 Sharia Asset-Backed Securities ='DT-LPK'!C19 ='DP-LPK'!C19 =C23+D23 =E23 Financing Through Cooperation With Other Parties Shariah. ='DT-LPK'!C20 ='DP-LPK'!C20 =C24+D24 =E24 Pure Gold ='DT-LPK'!C21 ='DP-LPK'!C21 =C25+D25 =E25 Direct Participation ='DP-LPK'!C22 =D26 =E26 Buildings With Strata Rights or Land With Buildings For Investment ='DP-LPK'!C23 =D27 =E27 Other Investments ='DT-LPK'!C22 ='DP-LPK'!C24 =C28+D28 =E28 Total Investment =SUM(C15:C28) =SUM(D15:D28) =SUM(E15:E28) =SUM(F15:F28) =SUM(G15:G28) Non-Investment Assets ='DT-LPK'!C31 ='DP-LPK'!C38 =C30+D30 0 =E30-F30 Debts ='DT-LPK'!C44 ='DP-LPK'!C48 =C31+D31 0 =E31-F31 Gross Contributions ='DT-SU'!C15 ='DP-LR'!C16 =C32+D32 0 =E32-F32 Gross Claims and Benefits ='DT-SU'!C25 =C33 =C33+E33 Investment Returns 0 ='DP-LR'!C21 =C34+D34 =E34 Explanation:
Adjustments are required for the following matters:
PT. XYZ
SHARIA PROPERTY INSURANCE / REINSURANCE BUSINESS
3. Adjustments to Debts are required if the total company/sharia unit debt does not equal the sum of dana tabarru' debts on Tabarru' Fund Balance Sheet Form Number 30 plus company fund debts on Company Fund Balance Sheet Form Number 35 plus participant investment fund debts on Participant Investment Fund Balance Sheet Form Number 17. This is caused by transactions between funds that affect the debt balance.
2. Adjustments to Non-Investment Assets are required if the total non-investment assets managed by the company/sharia unit do not equal the sum of dana tabarru' non-investment assets on Tabarru' Fund Balance Sheet Form Number 20 plus company fund non-investment assets on Company Fund Balance Sheet Form Number 27 plus non-investment assets on Participant Investment Fund Balance Sheet Form Number 17. This is caused by

Adjustments to gross contributions are required if the total gross contributions including investment product contributions do not equal the sum of participant contributions on Tabarru' Fund Underwriting Surplus Calculation Form Number 2 plus ujrah received by the company on Company Fund Income Statement Form Number 3 plus the portion of contributions allocated for investment on Participant Investment Fund Change Form Number 2a. This happens, for example, if there are ujrah received by the company that are not charged to the gross contributions received but rather
C. SUMMARY OF DANA TABARRU' AND COMPANY FUNDS REPORTS
Month ...

Rupiah Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year 1 year < age ≤ 5 years 5 years < age ≤ 10 years

10 years
Total
Rupiah 2) Foreign Currency 2) Total 2)
Notes:

In millions of rupiah
In percentage
Already converted into rupiah currency
Current assets/liabilities are assets/liabilities with an age of less than 1 year up to 1 year.
Non-current assets/liabilities are assets/liabilities with an age of more than 1 year.
Determined in Jakarta
On the date of 25 November 2014
A copy in accordance with the original
Head of Legal Assistance Division Ttd.
Legal Directorate FIRDAUS DJAELANI
Ttd.
Mufli Asmawidjaja
Description
Ratio of Current Assets to Non-Current Assets
Ratio of Current Liabilities to Non-Current Liabilities EXECUTIVE HEAD OF IKNB SUPERVISOR FINANCIAL SERVICES AUTHORITY NON-LIFE INSURANCE / SHARIA REINSURANCE BUSINESS PT.XYZ A. COMPANY FUNDS
V. ASSET AND LIABILITY RECAPITULATION BASED ON CURRENCY AND MATURITY AGE
Asset Age 1) Liability 1) Asset to Liability Ratio 2) For...

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 4/SEOJK.05/2013 CONCERNING MONTHLY REPORTS OF NON-LIFE INSURANCE COMPANIES AND REINSURANCE COMPANIES THAT OPERATE THEIR ENTIRE BUSINESS WITH SHARIA PRINCIPLES AND MONTHLY REPORTS OF SHARIA UNITS OF NON-LIFE INSURANCE AND REINSURANCE COMPANIES

MONTHLY REPORTS OF NON-LIFE INSURANCE COMPANIES AND REINSURANCE COMPANIES THAT OPERATE THEIR ENTIRE BUSINESS WITH SHARIA PRINCIPLES AND MONTHLY REPORTS OF SHARIA UNITS OF NON-LIFE INSURANCE AND REINSURANCE COMPANIES A. GENERAL

In accordance with Article 40 paragraph (1) letters b and c of Financial Services Authority Regulation Number 3/POJK.05/2013 concerning Monthly Reports of the Non-Bank Financial Industry, non-life insurance companies and reinsurance companies that conduct all or part of their business on Sharia principles are required to submit monthly reports.
The reports referred to in item 1 above are made specifically for the supervision of the Sharia insurance industry. Therefore, the form, content, and arrangement of the aforementioned reports are made in accordance with applicable statutory regulations and the Financial Accounting Standards (SAK) applicable in Indonesia.
B. REPORT ARRANGEMENT
The Monthly Report of Non-Life Insurance Companies and Reinsurance Companies that conduct their entire business on Sharia principles and the Monthly Report of Sharia Units of Non-Life Insurance and Reinsurance Companies consist of:
Report Cover
Board of Directors Statement
Tabarru’ Fund Report
a. Statement of Financial Position b. Underwriting Surplus
c. Statement of Cash Flows
d. Tabarru’ Fund Financial Health e. Asset and Liability Matching Analysis Report
Company Fund Report
a. Statement of Financial Position b. Comprehensive Income Statement
c. Statement of Cash Flows
d. Company Fund Financial Health e. Asset and Liability Matching Analysis Report
Summary of Tabarru’ Fund and Company Fund Reports
C. GUIDELINES FOR PREPARING MONTHLY REPORTS
General Guidelines
a. Monthly reports of non-life insurance companies and reinsurance companies that conduct their entire business on Sharia principles and monthly reports of Sharia units of non-life insurance and reinsurance companies are prepared with the arrangement and form of forms as referred to in Section B and Section D. b. The company name must be clearly written on each report title according to the available forms.
c. Account values are presented in millions of rupiah with 2 (two) decimal places.
d. Negative account values are presented in parentheses (xxx). e. If there are rows or columns that must be filled but the value is zero (0) or non-existent, the said row or column is filled with 0 (zero).
Report Cover
The monthly report cover page contains the following information:
a. Month and year of the reporting period. b. Full name and address of the company.
Board of Directors Statement Page
Every submitted monthly report must be signed by at least one member of the Board of Directors. The content of the statement is in accordance with the Board of Directors statement form. The company is required to fill in the company name, the date the statement is signed, and the name and position of the Board of Directors member who signed the statement. A soft copy of the monthly report must be accompanied by a scan of the signed Board of Directors statement form.
Tabarru’ Fund Report
a. Statement of Financial Position

The Statement of Financial Position presents the SAK Balance and SAP Balance of asset, liability, and participant equity accounts at the end of the reporting month. The SAK Balance is the account position measured/valued with reference to the applicable Financial Accounting Standards (SAK). The SAP Balance is the account position measured/valued with reference to statutory accounting principles (SAP), namely based on applicable statutory regulations for Sharia insurance or Sharia reinsurance business.
Accounts in the Statement of Financial Position are classified according to the purpose of their inclusion, so that accounts presented in monthly financial reports may differ from accounts presented in financial reporting based on SAK. The purpose of including these accounts is as a comparison for the measurement/valuation results of these accounts based on SAP.
Assets presented in the SAP Balance column in the Statement of Financial Position are permitted assets calculated based on applicable statutory regulations regarding types, conditions, valuation methods, and limits of Tabarru’ Fund assets.
The total assets and liabilities in the SAP Balance column are subsequently used in calculating the solvency achievement of the Tabarru’ Fund on the Tabarru’ Fund Financial Health form.
Explanation of presented accounts:
a) Accounts included in the investment asset category. Accounts included in the investment asset category are classified by investment type. Investment types not included in permitted investment types are categorized as other investments. b) Accounts included in the non-investment category. Accounts included in the non-investment asset category consist of:
(1) Cash and bank.
(2) Contribution receivables, namely receivables from participants/ceding companies for Sharia insurance/reinsurance contributions allocated to Tabarru’ premiums, excluding ujrah. (3) Reinsurance receivables, namely receivables from reinsurers/retrocedors for claim recovery. (4) Investment receivables, namely receivables from the sale of investment assets. (5) Investment return receivables, namely receivables from investment returns from other parties, such as banks and sukuk issuers on the returns provided. (6) Other assets, namely non-investment assets not permitted based on applicable statutory regulations in the management of Tabarru’ Fund assets, such as land and buildings or computer equipment used for company operations. c) Accounts included in the liability category. Accounts included in the liability category consist of:
(1) Claim payables, namely payables to Sharia insurance participants/ceding companies for approved claims/claim recovery. (2) Reinsurance payables, namely payables for Tabarru’ contributions to reinsurers/retrocedors. (3) Ujrah payables to the company, namely ujrah payables to the company for the wakalah bil ujrah contract in the management of risk and/or management of Tabarru’ Fund investments. The company needs to record ujrah payables if:
(a) the company has not recorded contributions separately in the Tabarru’ Fund and Company Fund since the contribution was first recognized. In this case, the company recognizes all contributions to the Tabarru’ Fund first, then allocates/charges ujrah to the Tabarru’ Fund; and/or (b) ujrah for the management of Tabarru’ Fund investments is not paid from contributions but paid from the managed Tabarru’ Fund. If the company has recorded contributions separately in the Tabarru’ Fund and Company Fund since the first receipt of contributions was recognized and the company does not charge ujrah for the management of Tabarru’ Fund investments from the managed Tabarru’ Fund, this account is nil (zero). (4) Payables for Allocation of Surplus to Policyholders, namely payables to participants for the portion of underwriting surplus that has become the right of the said participants. (5) Payables for Allocation of Underwriting Surplus to the Company, namely payables to the company as manager for the portion of underwriting surplus that has become the right of the company. (6) Payables for Tabarru’ Fund Investment Profit Sharing to the Company, namely payables to the company for Tabarru’ Fund investment profit sharing if the management of Tabarru’ Fund investments uses the mudharabah or mudharabah musytarakah contract. (7) Zakat Payables. (8) Other Payables. (9) Contribution Provisions, namely contribution provisions for long-term policies calculated based on applicable statutory regulations. (10) Provision for Contributions Not Yet Earned/Entitled, namely contribution provisions for short-term policies calculated based on applicable statutory regulations. (11) Claim Provisions, namely provisions for claims still in process and claims incurred but not reported (IBNR) calculated based on applicable statutory regulations. (12) Qardh, namely loans given by the company to the Tabarru’ Fund. d) Accounts included in the participant equity category. Accounts included in the participant equity category consist of:
(1) Accumulated Tabarru’ Fund, namely Tabarru’ Fund assets minus Tabarru’ Fund liabilities at the end of the reporting period. (2) Difference in SAK and SAP Valuation, namely the difference in the valuation results of assets and liabilities based on SAK versus based on SAP. This may arise if there are differences in methods used in valuing assets and liabilities based on SAK and based on SAP. (3) Non-permitted assets, namely:
(a) assets that do not meet regulations regarding permitted asset types, such as land and buildings, and (b) assets that meet the permitted asset types and have been valued based on applicable statutory regulations (valued based on SAP) but cannot be recognized as permitted assets because they exceed the limits regulated in applicable statutory regulations. For example, assets in the form of deposits at general Sharia banks have been valued according to nominal value but exceed the investment limit in one bank, so the portion exceeding the one-bank limit is included as non-permitted assets. b. Underwriting Surplus
The underwriting surplus report presents the calculation of underwriting surplus based on the accrual basis of all Sharia insurance business lines during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the reporting month (year to date).
Explanation of presented accounts.
a) Participant contributions are contributions from participants accumulated into the Tabarru’ Fund (Tabarru’ premiums, excluding ujrah). b) Reinsurance contributions are the portion of Tabarru’ premiums used to pay Tabarru’ premiums to reinsurers. c) Beginning KYBMP provision is contributions that are not yet income at the beginning of the month and beginning of the current year. d) Ending provision for the current period is contributions that are not yet income at the end of the current month. e) Beginning contribution provision is the contribution provision at the beginning of the month and beginning of the current year. f) Ending provision for the current period is the contribution provision at the end of the current month. g) Gross claims are claims approved during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the current month (year to date). h) Reinsurance claims received are claim recoveries from reinsurers approved during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the current month (year to date). i) Beginning claim provision is the claim provision at the beginning of the month and beginning of the current year. j) Ending claim provision for the current period is the claim provision at the end of the current month. k) Adjuster costs are adjuster costs during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the current month (year to date).
c. Statement of Cash Flows
The statement of cash flows is presented using the direct method. Cash flows are grouped into three categories: operating activities, investing activities, and financing activities. The beginning cash balance is the cash balance at the beginning of the current month and beginning of the current year. The ending cash balance is the cash balance at the end of the current month, namely as presented in the statement of financial position. d. Tabarru’ Fund Financial Health Report
This form presents the calculation of Tabarru’ Fund solvency based on applicable statutory regulations.
The assets and liabilities presented in this report are assets and liabilities calculated based on applicable statutory regulations. The said assets and liabilities are the same as the balances presented in the SAP Balance column of the Tabarru’ Fund Statement of Financial Position.
Schedule A to Schedule F are filled based on the company's calculation results with reference to applicable statutory regulations regarding the calculation of funds required to anticipate losses resulting from failures in the management of Tabarru’ Fund assets/liabilities.
e. Asset and Liability Matching Analysis Report
The Asset and Liability Matching Analysis Report presents assets and liabilities in rupiah and foreign currency based on age, namely:
(a) ≤ 1 year
(b) 1 year < age ≤ 5 years
(c) 5 years < age ≤ 10 years
(d) > 10 years
The determination of asset age is based on asset maturity or the company's planned timeframe to hold the said assets.
The determination of liability age is based on debt maturity or the company's estimate regarding the maturity of the said liabilities.

Company Fund Report
a. Statement of Financial Position

The Statement of Financial Position presents the SAK Balance of asset, liability, and participant equity accounts at the end of the reporting month. The SAK Balance is the account position measured/valued with reference to the applicable Financial Accounting Standards (SAK). Accounts are reclassified according to the purpose of their inclusion, so that accounts presented in monthly financial reports may differ from accounts presented in financial reporting based on SAK.
Explanation of presented accounts:
a) Accounts included in the investment category. Accounts included in the investment category are classified by investment type. b) Accounts included in the non-investment category. Non-investment accounts consist of:
(1) Cash and bank.
(2) Investment receivables, namely receivables from the sale of investment assets.
(3) Investment return receivables, namely receivables from investment returns from other parties, such as sukuk issuers on the returns provided. (4) Ujrah receivables from participants, namely receivables from participants for the portion of Sharia insurance contributions allocated to ujrah. (5) Receivables for allocation of Tabarru’ Fund underwriting surplus, namely receivables from the Tabarru’ Fund for the portion of underwriting surplus allocated to the company. (6) Receivables for Tabarru’ Fund investment profit sharing, namely receivables from the Tabarru’ Fund for Tabarru’ Fund investment profit sharing if the management of Tabarru’ Fund investments uses the mudharabah or mudharabah musytarakah contract. (7) Qardh receivables, namely receivables from the Tabarru’ Fund for qardh given by the company. (8) Buildings with strata rights or land with buildings for own use. (9) Computer hardware. (10) Other fixed assets. (11) Other assets. c) Accounts included in the liability category. Liability accounts consist of:
(1) Commission payables, namely payables to insurance agents, insurance brokers, and/or other parties.
(2) Reinsurance ujrah payables, namely ujrah payables to reinsurers/retrocedors for the wakalah bil ujrah contract in the management of risk and/or management of Tabarru’ Fund investments. (3) Tax payables. (4) Accrued expenses. (5) Zakat payables. (6) Other payables. d) Subordinated loans. e) Accounts included in the company equity category. Accounts included in the company equity category consist of:
(1) Paid-up capital, namely capital paid by shareholders in full-fledge Sharia insurance or working capital for Sharia units. (2) Share premium. (3) Reserves. (4) Increase (decrease) in securities. (5) Difference in fixed asset valuation. (6) Retained earnings. b. Comprehensive Income Statement
The income statement presents the calculation of the company's profit/loss during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the reporting month (year to date).
Explanation of presented accounts.
a) Ujrah received by the company is grouped into:

Ujrah received for risk management, namely ujrah received by the company for the wakalah bil ujrah contract in risk management.
Ujrah received for Tabarru’ Fund investment management, namely ujrah received by the company if the management of Tabarru’ Fund investments uses the wakalah bil ujrah contract.
Ujrah received for participant fund investment management.
b) Commission receipts, namely commissions received by the company from other parties. c) Tabarru’ Fund investment profit sharing, namely profit sharing received by the company if the management of Tabarru’ Fund investments uses the mudharabah or mudharabah musytarakah contract. d) Allocation of Tabarru’ Fund underwriting surplus, namely the portion of underwriting surplus received by the company in accordance with regulations stipulated in the policy. e) Company investment management results, namely investment returns from Company Fund investment assets. f) Acquisition costs, namely sales commissions and other costs incurred in the context of accepting new insurance participants. g) Reinsurance ujrah, namely ujrah to reinsurers/retrocedors for the wakalah bil ujrah contract in risk management and management of Tabarru’ Fund investments. h) Marketing expenses. i) Administrative and general expenses. j) Other business expenses. k) DPLK service fees/other management services. l) Other Non-Business Income. m) Zakat. n) Income tax expenses. o) Profit (loss) after tax. p) Other comprehensive income, namely other comprehensive income based on SAK. q) Comprehensive Income.
c. Statement of Cash Flows
The statement of cash flows is presented using the direct method. Cash flows are grouped into three categories: operating activities, investing activities, and financing activities. The beginning cash balance is the cash balance at the beginning of the current month and beginning of the current year. The ending cash balance is the cash balance at the end of the current month, namely as presented in the statement of financial position. d. Company Fund Financial Health Report

This form presents information regarding assets available for qardh and Company Fund solvency at the end of the current month.
Assets available for qardh are Company Fund assets provided by the company to give qardh to the Tabarru’ Fund and are calculated based on applicable statutory regulations regarding types, conditions, valuation methods, and limits of assets available for qardh.
The amount of assets that must be provided for qardh is the sum of the following components:
a) A certain percentage of the amount of funds required to anticipate losses that may arise as a result of deviations in the management of Tabarru’ Fund assets and/or liabilities, in accordance with applicable statutory regulations regarding assets available for qardh. The said percentage is 45% for monthly reports up to the November 2014 period and 70% for monthly reports starting from the December 2014 period. b) Funds that must be provided to anticipate losses that may arise from failures in the production process, inability of human resources and/or systems to perform well, or other adverse events. c) The larger amount between the amount of funds that must be prepared to maintain the required solvency level of the Tabarru’ Fund or the amount of funds that must be prepared to maintain the balance between investments plus cash and bank with technical provisions plus retained claim liabilities, with the provisions:
(1) The amount of funds that must be prepared to maintain the required solvency level of the Tabarru’ Fund is equal to the shortfall of Tabarru’ Fund solvency minus a certain percentage of the amount of funds required to anticipate losses that may arise as a result of deviations in the management of Tabarru’ Fund assets and/or liabilities, in accordance with applicable regulations. The said percentage is 15% for monthly reports up to the November 2014 period and 30% for monthly reports starting from the December 2014 period. (2) The amount of funds that must be prepared to maintain the balance between investments plus cash and bank with technical provisions plus retained claim liabilities is equal to the shortfall resulting from the sum of permitted Tabarru’ Fund assets in the form of investments plus cash and bank minus the sum of technical provisions plus retained claim liabilities.
Company Fund solvency is calculated as Company Fund assets minus Company Fund liabilities at the end of the current month. The said asset and liability balances are the same as the balances presented in the Company Fund Statement of Financial Position.
Company Fund solvency must be at least the larger amount between:
a) The amount of assets that must be provided for qardh; or b) Capital...

b) Own capital or working capital required based on applicable legislation, namely:
(1) Own capital of a Sharia insurance company: IDR 50 Billion (2) Working capital of the Sharia business unit of an insurance company: IDR 25 Billion (3) Own capital of a Sharia reinsurance company: IDR 100 Billion (4) Working capital of the Sharia business unit of a reinsurance company: IDR 50 Billion e. Asset and Liability Matching Analysis Report

The Asset and Liability Matching Analysis Report presents assets and liabilities in Rupiah and foreign currency based on maturity, namely:
a) ≤ 1 year b) 1 year < maturity ≤ 5 years c) 5 years < maturity ≤ 10 years d) > 10 years
The determination of asset maturity is based on the asset's due date or the company's planned timeframe for holding the said asset.
The determination of liability maturity is based on the debt's due date or the company's estimate regarding the due date of the said liability.

Summary Report of Tabarru' Fund and Company Fund
a. This report presents combined data from several accounts contained in the tabarru' fund and the company fund. Information is presented in five columns, namely the tabarru' fund, the company fund, total, adjustments, and total after adjustments. b. The tabarru' fund and company fund columns are filled based on data from each respective fund. The total column is filled with the sum of the values in the tabarru' fund and company fund columns. The adjustment column is filled with necessary adjustment values to obtain consolidated data from the tabarru' fund and the company fund. The total after adjustments column is filled with the total value minus the adjustments.
c. Explanation of the presented accounts:

Accounts included in the investment asset category.
a) Investment assets consist of accounts according to the type of investment. The investment value presented in the tabarru' fund column... and the company fund column is equal to the value of each type of investment presented in the Statement of Financial Position of the Tabarru' Fund (SAK) and the Statement of Financial Position of the Company Fund. b) The value presented in the Total column is the sum of each type of investment found in the tabarru' fund and company fund columns.
Non-investment wealth.
a) The non-investment wealth value presented in the tabarru' fund and company fund columns is equal to the non-investment wealth value presented in the Statement of Financial Position of the Tabarru' Fund (SAK), the Statement of Financial Position of the Company Fund, and the Statement of Financial Position of the Company Fund. b) The value presented in the Total column is the sum of non-investment wealth found in the tabarru' fund and company fund columns. c) The Adjustment column is filled if the total non-investment assets managed by the company/Sharia unit do not match the sum of non-investment assets in the tabarru' fund and company fund columns. This is caused by transactions between funds that affect the non-investment asset balance.
Liabilities
a) The liability value presented in the tabarru' fund and company fund columns is equal to the liability value presented in the Statement of Financial Position of the Tabarru' Fund (SAK), the Statement of Financial Position of the Company Fund, and the Statement of Financial Position of the Company Fund. b) The value presented in the Total column is the sum of liabilities found in the tabarru' fund and company fund columns. c) The Adjustment column is filled if the total liabilities of the company/Sharia unit do not match the sum of liabilities in the tabarru' fund and company fund columns. This is caused by transactions between funds that affect the liability balance.
Gross Contribution
a) The value presented in the tabarru' fund and company fund columns is respectively the participant contribution in the Underwriting Surplus Calculation Report and the ujrah received by the company in the Company Fund Income Statement. b) The value presented in the Total column is the sum of the values in the tabarru' fund and company fund columns. c) The Adjustment column is filled if the total gross contribution of the company/Sharia unit does not match the sum of values in the tabarru' fund and company fund columns. This is caused by transactions between funds that affect the calculation of total gross contribution, for example, if there is ujrah received by the company that is not charged to the gross contribution received but is charged to the accumulation of the tabarru' fund.
Gross Claims and Benefits
The value presented in the tabarru' fund column is equal to the gross claims in the Underwriting Surplus Calculation Report.
Investment Results
a) The value presented in the tabarru' fund column is equal to the tabarru' fund investment results after being reduced by investment costs if using the wakalah bil ujrah contract and/or investment profit sharing to the manager if using the mudharabah or musharakah mudharabah contract. b) The value presented in the company fund column is equal to the company fund investment results after being reduced by investment costs if using the wakalah bil ujrah contract and/or investment profit sharing to the manager if using the mudharabah or musharakah mudharabah contract. D. FORM OF MONTHLY REPORT FORMS The monthly reports of property insurance companies and reinsurance companies conducting all their business under Sharia principles, and the monthly reports of the Sharia units of property insurance companies and reinsurance companies, are prepared using the form as referred to in this section.

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 4/SEOJK.05/2013 REGARDING MONTHLY REPORTS OF INSURANCE AND REINSURANCE COMPANIES CONDUCTING ALL THEIR BUSINESS UNDER SHARIA PRINCIPLES AND THE SHARIA UNITS OF INSURANCE AND REINSURANCE COMPANIES

To: Financial Services Authority
Attn: Director of Sharia IKNB
Sumitro Djojohadikusumo Building, 14th Floor
East Banteng Field Street 1 - 4
Jakarta - 10710

MONTHLY REPORT
SHARIA LIFE INSURANCE BUSINESS
Month… Year…
PT XYZ

BALANCE DESCRIPTION SAK BALANCE SAP
WEALTH
Investment
Bank Deposits
Shariah Stocks
Shariah Sukuk or Bonds
Shariah Government Securities
Shariah Securities Issued by Banks
Shariah Securities Issued by States
Other than the Republic of Indonesia
Shariah Securities Issued by Multinational Institutions Shariah Mutual Funds Shariah Asset-Backed Securities Financing Through Cooperation with Other Parties Pure Gold Other Investments Total Investment =SUM(C14:C25) =SUM(D14:D25) Non-investment Cash and Bank Contribution Receivables Reinsurance Receivables Investment Receivables Investment Result Receivables Other Assets Total Non-Investment =SUM(C28:C33) =SUM(D28:D32) Total Wealth =+C26+C34 =+D26+D34 LIABILITIES AND OWN CAPITAL Liabilities Debts Claims Payable Reinsurance Payable Ujrah Payable to Company Underwriting Surplus Allocation Payable to Insured Underwriting Surplus Allocation Payable to Company Investment Profit Sharing Payable from Tabarru' Fund Zakat Payable Other Payables Total Debts =SUM(C39:C46) =SUM(D39:D46) Technical Provisions Contribution Provisions Provisions for Contributions Not Yet Earned Claim Provisions Total Technical Provisions =SUM(C49:C51) =SUM(D49:D51) Qardh Total Liabilities =C47+C52+C53 =D47+D52+D53 Participant Equity Accumulated Tabarru' Fund Increase (Decrease) in Securities Difference in Valuation Based on SAK and SAP Non-Permitted Wealth Total Participant Equity =SUM(C56:C57) =SUM(D56:D59) Total Liabilities and Participant Equity =+C54+C60 =+D54+D60 PT.XYZ A. TABARRU' FUND SHARIA LIFE INSURANCE BUSINESS (in millions of rupiah)
I. STATEMENT OF FINANCIAL POSITION
As of .... Month .... Year

DESCRIPTION
CURRENT MONTH ACCUMULATED
Underwriting Revenue
Participant Contributions*)
Reinsurance Contributions
Decrease (Increase) in Provision for Contributions Not Yet Earned/Right (KYBMP)) a. Beginning KYBMP b. Ending KYBMP Decrease (Increase) in Contribution Provisions*) a. Beginning Contribution Provisions b. Ending Contribution Provisions Net Contribution Revenue =+C15-C16+C18-C19+C21-C22 =+D15-D16+D18-D19+D21-D22 Claim Expenses a. Gross Claims b. Reinsurance Claims Received
c. Increase (Decrease) in Claim Provisions
c.1. Beginning Claim Provisions c.2. Ending Claim Provisions Total Claim Expenses =+C25-C26-C28+C29 =+D25-D26-D28+D29 Underwriting Surplus (Deficit) (6-8-9) =+C23-C30 =+D23-D30 Note:
SHARIA LIFE INSURANCE BUSINESS
PT.XYZ
A. TABARRU' FUND
II. UNDERWRITING SURPLUS CALCULATION
For the Period Ended
(in millions of rupiah)
*) Participant contributions accumulated to the tabarru' fund ) KYBMP : contributions that are not yet income/rights are for insurance products with a coverage period of less than 1 year Date .... Month .... Year *) Contribution provisions for insurance products with a coverage period of more than 1 year.

Description
CURRENT MONTH ACCUMULATED
Beginning Balance:
Cash - Bank
Cash Flow from Operating Activities
Cash Inflows

Participant Contributions
Reinsurance Claims Received
Receipt of Reinsurance Underwriting Surplus Distribution
Total Cash Inflows =SUM(C19:C21) =SUM(D19:D21) Cash Outflows
Payment of Insurance Ujroh
Reinsurance Contributions Paid
Claims Paid
Others
Total Cash Outflows =SUM(C24:C27) =SUM(D24:D27) Total Cash from Operating Activities =C22-C28 =D22-D28 Cash Flow from Investment Activities Cash Inflows
Receipt of Tabarru' Fund Investment Results
Withdrawal of Tabarru' Fund Investments
Sale of Land and Buildings
Others
Total Cash Inflows =SUM(C32:C35) =SUM(D32:C35) Cash Outflows
Investment Placement
Payment of Underwriting Surplus Distribution to Company
Payment of Underwriting Surplus Distribution to Participants/Policyholders
Payment of Tabarru' Fund Investment Profit Sharing to Company/Operator
Purchase of Fixed Assets
Others
Total Cash Outflows =SUM(C38:C43) =SUM(D38:D43) Total Cash from Investment Activities =C36-C44 =D36-D44 Cash Flow from Financing Activities Cash Inflows
Qardh
Others
Total Cash Inflows =SUM(C48:C49) =SUM(D48:D49) Cash Outflows
Payment of Qardh
Others
Total Cash Outflows =SUM(C52:C53) =SUM(D52:D53) Total Cash from Financing Activities =C50-C54 =D50-D54 Ending Cash Balance =C16+C29+C45+C55 =D16+D29+D45+D55 SHARIA LIFE INSURANCE BUSINESS PT.XYZ A. TABARRU' FUND
III. CASH FLOW STATEMENT
Date .... Month .... Year
For the Period Ended

(in millions of rupiah)
DESCRIPTION TOTAL
Solvency Ratio
Permitted Wealth
Liabilities
Total Solvency Ratio =C14-C15
Risk of Losses That May Arise Due to Deviations in the Management of Wealth and/or Liabilities
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Total Funds Required to Anticipate Risk of Losses That May Arise Due to Deviations in the Management of Wealth and/or Liabilities =SUM(C18:C23) Solvency Achievement Ratio =+C16/C24 As of .... Month .... Year SHARIA LIFE INSURANCE BUSINESS PT.XYZ A. TABARRU' FUND
IV. TABARRU' FUND FINANCIAL HEALTH RATIOS
TABARRU' FUND SOLVENCY ACHIEVEMENT

Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year 1 year < maturity ≤ 5 years 5 years < maturity ≤ 10 years

10 years
Total
Rupiah 2) Foreign Currency 2) Total 2)
Note:

In millions of rupiah
In percentage
Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with a maturity of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with a maturity of more than 1 year Ratio of Current Liabilities to Non-Current Liabilities PT.XYZ A. TABARRU' FUND Asset Maturity 1) Liabilities 1) Asset to Liability Ratio 2) SHARIA LIFE INSURANCE BUSINESS
V. ASSET AND LIABILITY MATCHING ANALYSIS REPORT
As of .... Month .... Year
Description
Ratio of Current Assets to Non-Current Assets

(in millions of rupiah)
BALANCE DESCRIPTION SAK BALANCE SAP
WEALTH
Investment
Deposits
Shariah Stocks
Shariah Sukuk or Bonds
Shariah Government Securities
Shariah Securities Issued by Bank Indonesia
Shariah Securities Issued by Entities Other Than the Republic of Indonesia Shariah Securities Issued by Multinational Institutions Shariah Mutual Funds Shariah Asset-Backed Securities Financing Through Cooperation With Pure Gold Other Investments Total Investment =SUM(C14:C27) Non-Investment Cash and Bank Investment Receivables Investment Result Receivables Ujrah Receivables from Participants Tabarru' Fund Surplus Allocation Receivables Tabarru' Fund Investment Management Profit Sharing Receivables Qardh Receivables Buildings with Strata Rights or Land with Buildings for Personal Use Computer Hardware Other Fixed Assets Other Assets Total Non-Investment =SUM(C30:C40) TOTAL WEALTH =+C28+C41 LIABILITIES AND EQUITY Liabilities Commission Payables Reinsurance Ujrah Payables Tax Payables Accrued Expenses Zakat Payables Other Payables Total Liabilities =SUM(C45:C50) Subordinated Loans Equity Paid-up Capital Share Premium Reserves Increase (Decrease) in Securities Difference in Valuation of Fixed Assets Retained Earnings Total Equity =SUM(C54:C59) TOTAL LIABILITIES AND EQUITY =+C51+C52+C60 SHARIA LIFE INSURANCE BUSINESS PT.XYZ B. COMPANY FUND
I. STATEMENT OF FINANCIAL POSITION
As of .... Month .... Year

(in millions of rupiah)
DESCRIPTION CURRENT MONTH ACCUMULATED
REVENUE
Ujrah Received a. Ujrah for Risk Management b. Ujrah for Tabarru' Fund Investment Management
c. Ujrah for Participant Fund Investment Management
Total Ujrah Received =SUM(C16:C18) =SUM(D16:D18) Commission Receipts Tabarru' Fund Investment Management Profit Sharing Participant Investment Fund Investment Management Profit Sharing Tabarru' Fund Underwriting Surplus Allocation Company Investment Management Results Total Revenue =SUM(C19:C24) =SUM(D19:D24)\nOperating Expenses Acquisition Costs a. First-Year Commission Expenses b. Subsequent-Year Commission Expenses
c. Overriding Commission Expenses
d. Other Acquisition Expenses
Total Acquisition Costs =SUM(C28:C31) =SUM(D28:D31) Reinsurance Ujrah Marketing Expenses General and Administrative Expenses Other Operating Expenses Total Operating Expenses =SUM(C32:C36) =SUM(D32:D36) DPLC/Other Management Service Fees Other Non-Operating Revenue Profit (Loss) Before Zakat =+C25-C37+C38+C39=+D25-D37+D38+D39 Zakat Profit (Loss) Before Tax =+C40-C41 =+D40-D41 Income Tax Profit After Tax =+C42-C43 =+D42-D43 Other Comprehensive Income Comprehensive Profit =C44+C46 =D44+D46 Date .... Month .... Year SHARIA LIFE INSURANCE BUSINESS PT.XYZ
II. COMPREHENSIVE INCOME / LOSS CALCULATION
B. COMPANY FUND
For the Period Ended

(in millions of rupiah)
DESCRIPTION CURRENT MONTH ACCUMULATED
Cash - Bank
1 Ujrah Received
2 Receipt of Tabarru' Fund Underwriting Surplus Allocation 3 Receipt of Tabarru' Fund Investment Profit Sharing 4 Receipt of Participant Investment Fund Profit Sharing 5 Others =SUM(D22:D26) =SUM(E22:E26) 1 Commission 2 Marketing Expenses 3 Payment of Reinsurance Ujrah 4 Payment of Rent 5 Payment of Zakat 6 Payment of Tax 7 Others =SUM(D29:D35) =SUM(E29:E35) =D27-D36 =E27-E36 1 Receipt of Company Investment Results 2 Withdrawal of Company Investments 3 Sale of Fixed Assets 4 Others =SUM(D40:D43) =SUM(E40:D43) 1 Investment Placement 2 Purchase of Fixed Assets 3 Others =SUM(D46:D48) =SUM(E46:D48) =D44-D49 =E44-E49 1 Subordinated Loans 2 Capital/Working Capital Deposits 3 Receipt of Qardh 4 Others =SUM(D53:D56) =SUM(E53:D56) 1 Payment of Subordinated Loans 2 Payment of Dividends 3 Qardh 4 Others =SUM(D59:D62) =SUM(E59:D62) =D57-D63 =E57-E63 Ending Cash Balance (A+B+C+D) =D19+D37+D50+D64 =E19+E37+E50+E64 SHARIA LIFE INSURANCE BUSINESS Beginning Balance:
Cash Flow from Operating Activities
Cash Inflows
Cash Outflows
Total Cash Inflows
PT.XYZ
Date .... Month .... Year
For the Period Ended
B. COMPANY FUND
III. CASH FLOW STATEMENT
Total Cash Outflows
Total Cash from Operating Activities
Cash Inflows
Cash Outflows
Cash Flow from Financing Activities
Cash Flow from Investment Activities
Total Cash from Financing Activities
Total Cash Inflows
Total Cash from Investment Activities
Total Cash Outflows
Total Cash Inflows
Cash Inflows
Cash Outflows
Total Cash Outflows

A. WEALTH AVAILABLE FOR QARDH
(in millions of rupiah)
DESCRIPTION TOTAL
Risk of Losses That May Arise From
Deviations in the Management of Wealth and/or Liabilities
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Total =SUM(C15:C20)
Amount Used as the Basis for Calculating
Wealth to be Provided for Qard =45%*C21
Funds to be Provided to Anticipate Risk of Losses That May Arise From Failure of the Production Process, Inability of Human Resources and/or Systems to Perform Well, or Other Adverse Events. Total Funds to be Prepared to Maintain the Required Solvency Level of the Tabarru' Fund (Tabarru' Fund Solvency Deficiency) Total Funds to be Prepared to Maintain Balance Between Investments Plus Cash and Bank With Technical Provisions Plus Claim Liabilities Retention Amount of Wealth to be Provided for Qardh =+C22+C23+MAX(C24;C25) Company Wealth Counted as Wealth Available for Qardh Excess (Deficiency) of Wealth Available for Qardh =+C27-C26 B. COMPANY FUND SOLVENCY (in millions of rupiah) DESCRIPTION TOTAL Wealth Liabilities Total Company Fund Solvency =+C33-C34 Total Wealth to be Provided for Qardh =+C26 Required Own Capital or Working Capital Minimum Company Fund Solvency =+MAX(C36:C37) Achievement / Balance of Company Fund Solvency =+C35-C38 As of .... Month .... Year SHARIA LIFE INSURANCE BUSINESS PT.XYZ B. COMPANY FUND
IV. COMPANY FUND FINANCIAL HEALTH

Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year 1 year < maturity ≤ 5 years 5 years < maturity ≤ 10 years

10 years
Total
Rupiah 2) Foreign Currency 2) Total 2)
Note:

In millions of rupiah
In percentage
Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with a maturity of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with a maturity of more than 1 year SHARIA LIFE INSURANCE BUSINESS PT.XYZ B. COMPANY FUND
V. ASSET AND LIABILITY MATCHING ANALYSIS REPORT
As of .... Month .... Year
Ratio of Current Liabilities to Non-Current Liabilities Asset Maturity 1) Liabilities 1) Asset to Liability Ratio 2) Description Ratio of Current Assets to Non-Current Assets

BALANCE DESCRIPTION SAK BALANCE SAP
WEALTH
Investment
Deposits
Shariah Stocks
Shariah Sukuk or Bonds
Shariah Government Securities
Shariah Securities Issued by Bank Indonesia
Shariah Securities Issued By
Entities Other Than the Republic of Indonesia
Shariah Securities Issued By
Multinational Institutions
Shariah Mutual Funds
Shariah Asset-Backed Securities
Financing Through Cooperation With
Pure Gold
Other Investments
Total Investment =SUM(C15:C26)=SUM(D15:D26)
Non-Investment
Cash and Bank
Investment Receivables
Investment Result Receivables
Total Non-Investment =SUM(C29:C31)=SUM(D20:D31) TOTAL WEALTH =C32+C27 =D32+D27 LIABILITIES Fund Management Ujrah/Fee Payables Profit Sharing Payables Investment Fund Withdrawal Payables Accumulation of Participant Investment Funds TOTAL LIABILITIES =SUM(C35:C38)=SUM(D35:D38) COMBINED ALL CONTRACTS As of .... Month .... Year (in millions of rupiah) SHARIA LIFE INSURANCE BUSINESS PT.XYZ
C. PARTICIPANT INVESTMENT FUNDS
I. STATEMENT OF FINANCIAL POSITION

DESCRIPTION CURRENT MONTH ACCUMULATED
Participant Investment Funds at the Beginning of the Period Additions to Participant Investment Funds a. Additions to Participant Investment Funds from Contribution Allocation b. Additions to Participant Investment Funds from Investment Results Total Additions to Participant Investment Funds =SUM(C19:C20) =SUM(D19:D20) Investment Management Costs (Ujrah) Withdrawals of Participant Investment Funds a. Withdrawals of Matured Participant Investment Funds b. Withdrawals/Redemptions of Unmatured Participant Investment Funds Total Withdrawals of Participant Investment Funds =+C26+C27 =+D26+D27 Total Participant Investment Funds at the End of the Period =C16+C21-C23-C28 =D16+D21-D23-D28 Date .... Month .... Year For the Period Ended SHARIA LIFE INSURANCE BUSINESS PT.XYZ
C. PARTICIPANT INVESTMENT FUNDS
II. CHANGES IN PARTICIPANT INVESTMENT FUNDS MANAGED BY THE COMPANY
COMBINED ALL CONTRACTS

Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year 1 year < maturity ≤ 5 years 5 years < maturity ≤ 10 years

10 years
Total
Rupiah 2) Foreign Currency 2) Total 2)
Note:

In millions of rupiah
In percentage
Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with a maturity of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with a maturity of more than 1 year SHARIA LIFE INSURANCE BUSINESS PT.XYZ
C. PARTICIPANT INVESTMENT FUNDS
IV. ASSET AND LIABILITY MATCHING ANALYSIS REPORT
As of .... Month .... Year
Ratio of Current Liabilities to Non-Current Liabilities Asset Maturity 1) Liabilities 1) Asset to Liability Ratio 2) Description Ratio of Current Assets to Non-Current Assets

(in millions of rupiah)
Total
Description Tabarru' Fund Participant Investment Fund Total Adjustments (If Any) Total After Adjustments Investment Portfolio Deposits Shariah Stocks Shariah Sukuk or Bonds Shariah Government Securities Shariah Securities Issued by Bank Indonesia Shariah Securities Issued by Entities Other Than the Republic of Indonesia Shariah Securities Issued by Multinational Institutions Shariah Mutual Funds Shariah Asset-Backed Securities Financing Through Cooperation With Other Parties Shariah Pure Gold Direct Participation Buildings With Strata Rights or Land With Buildings For Investment Other Investments Total Investments Non-Investment Wealth Liabilities Gross Contributions Gross Claims and Benefits Investment Results PT. XYZ SHARIA LIFE INSURANCE BUSINESS D. SUMMARY REPORT OF TABARRU' FUND, COMPANY FUND, AND PARTICIPANT INVESTMENT FUNDS
Month .... Year....

Explanation:
Adjustments are required for the following matters:
Signed,
FIRDAUS DJAELANI
Copy matches the original
Head of Legal Assistance Division
Legal Directorate
Mufli Asmawidjaja
Established in Jakarta on November 25, 2013
EXECUTIVE HEAD OF INSURANCE AND FINANCIAL INSTITUTIONS SUPERVISOR FINANCIAL SERVICES AUTHORITY Signed,
3. Adjustments to Liabilities are necessary if the total liabilities of the company/Sharia unit do not equal the sum of Tabarru' fund liabilities from the Tabarru' Fund Financial Position Report Form No. 30 plus company fund liabilities from the Company Fund Financial Position Report Form No. 35 plus participant investment fund liabilities from the Participant Investment Fund Financial Position Report Form No. 17. This is caused by transactions between funds that affect the non-investment asset balance.
2. Adjustments to Non-Investment Assets are necessary if the total non-investment assets managed by the company/Sharia unit do not equal the sum of Tabarru' fund non-investment assets from the Tabarru' Fund Financial Position Report Form No. 20 plus company fund non-investment assets from the Company Fund Financial Position Report Form No. 27 plus participant investment fund non-investment assets from the Participant Investment Fund Financial Position Report Form No. 17. This is caused by transactions between funds that affect the non-investment asset balance.

Adjustments to Gross Contributions are necessary if the total gross contributions including investment product contributions do not equal the sum of participant contributions from the Tabarru' Fund Underwriting Surplus Calculation Form No. 2 plus ujrah received by the company from the Company Fund Profit and Loss Report Form No. 3 plus the portion of contributions allocated to investment from the Participant Investment Fund Change Report Form No. 2a. This occurs, for example, if there is ujrah received by the company that is not charged to the gross contributions received but is charged to the accumulation of Tabarru' funds or the accumulation of participant investment funds.

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 4/SEOJK.05/2013 REGARDING MONTHLY REPORTS OF LIFE INSURANCE COMPANIES AND REINSURANCE COMPANIES CONDUCTING ALL BUSINESS ON SHARIA PRINCIPLES AND SHARIA UNITS OF LIFE INSURANCE COMPANIES AND REINSURANCE COMPANIES

MONTHLY REPORTS OF LIFE INSURANCE COMPANIES CONDUCTING ALL BUSINESS ON SHARIA PRINCIPLES AND MONTHLY REPORTS OF SHARIA UNITS OF LIFE INSURANCE COMPANIES A. GENERAL

In accordance with Article 40 paragraph (1) letter b and c of Financial Services Authority Regulation Number .../POJK.05/2013 regarding Monthly Reports of the Non-Bank Financial Industry, life insurance companies conducting all or part of their business on Sharia principles are required to submit monthly reports.
The reports referred to in item 1 above are made specifically for the supervision of the Sharia insurance industry. Therefore, the form, content, and arrangement of the said reports are made in accordance with applicable legislation and the Indonesian Financial Accounting Standards (SAK).
B. ARRANGEMENT OF REPORTS
The monthly reports of life insurance companies conducting all business on Sharia principles and the Monthly Reports of Sharia units of Life Insurance Companies consist of:
Report Cover
Board of Directors Statement
Tabarru' Fund Reports
a. Balance Sheet Report b. Underwriting Surplus Report
c. Cash Flow Report
d. Tabarru' Fund Financial Health Report e. Asset and Liability Matching Analysis Report
Company Fund Reports
a. Balance Sheet Report b. Comprehensive Income Statement
c. Cash Flow Report
d. Company Fund Financial Health Report e. Asset and Liability Matching Analysis Report
Participant Investment Fund Reports
a. Balance Sheet Report b. Participant Investment Fund Change Report
c. Asset and Liability Matching Analysis Report
Summary of Tabarru' Fund, Company Fund, and Participant Investment Fund Reports
C. GUIDELINES...

C. GUIDELINES FOR PREPARING MONTHLY REPORTS

General Guidelines
a. Monthly reports of life insurance companies conducting all business on Sharia principles and monthly reports of Sharia units of life insurance companies are prepared with the arrangement and form of forms as referred to in Part B and Part D. b. The company name must be clearly written on each report title according to the available forms.
c. Account values are presented in millions of rupiah with 2 (two) decimal places after the comma.
d. Negative account values are presented in parentheses (xxx). e. If there are rows or columns that must be filled but the value is zero (nil) or does not exist, the said row or column is filled with 0 (zero).
Report Cover
The cover page of the monthly report contains the following information:
a. Month and year of the reporting period. b. Full name and address of the company.
Board of Directors Statement Page
Every submitted monthly report must be signed by at least one member of the Board of Directors. The content of the statement corresponds to what is contained in the board of directors statement form. The company is required to fill in the company name, the date the statement was signed, and the name and position of the director who signed the statement. A soft copy of the monthly report must be accompanied by a scan of the signed board of directors statement form.
Tabarru' Fund Reports
a. Balance Sheet Report

The Balance Sheet Report presents SAK Balances and SAP Balances of asset, liability, and participant equity accounts at the end of the reporting month. SAK Balance is the account position measured/valued based on the applicable Financial Accounting Standards (SAK). Meanwhile, SAP Balance is the account position measured/valued based on statutory accounting principles (SAP), namely based on applicable legislation for Sharia insurance or reinsurance businesses.
Accounts in the Balance Sheet Report are classified according to the purpose of their inclusion so that accounts presented in monthly financial reports may differ from accounts presented in financial reporting based on SAK... SAK. The purpose of including these accounts is as a comparison for the measurement/valuation results of the said accounts based on SAP.
Assets presented in the SAP Balance column in the Balance Sheet Report are permitted assets calculated based on applicable legislation regarding types, conditions, valuation methods, and limits of Tabarru' fund assets.
The total assets and liabilities in the SAP Balance column are subsequently used in calculating the solvency achievement of the Tabarru' Fund on the Tabarru' Fund Financial Health Form.
Explanation of accounts presented:
a) Accounts included in the investment asset category. Accounts included in the investment asset category are classified based on investment type. Investments not included in permitted investment types are categorized as other investments. b) Accounts included in the non-investment category. Accounts included in the non-investment asset category consist of:
(1) Cash and banks.
(2) Contribution receivables, namely receivables from participants for Sharia insurance contributions allocated to Tabarru' premiums, excluding ujrah. (3) Reinsurance receivables, namely receivables from reinsurers for claim recovery. (4) Investment receivables, namely receivables from the sale of investment assets. (5) Investment return receivables, namely receivables from investment returns from third parties, such as banks and sukuk issuers for the returns provided. (6) Other assets, namely non-investment assets not permitted based on applicable legislation in managing Tabarru' fund assets, such as land... land and buildings or computer equipment used for company operations. c) Accounts included in the liability category. Accounts included in the liability category consist of:
(1) Claim payables, namely payables to Sharia insurance participants for approved claims.
(2) Reinsurance payables, namely Tabarru' contribution payables to reinsurers.
(3) Ujrah payables to the company, namely ujrah payables to the company for wakalah bil ujrah contracts in risk management and/or Tabarru' fund investment management. The company records ujrah payables when:
(a) the company has not recorded contributions separately in Tabarru' funds and company funds since the said contributions were first recognized. In this case, the company recognizes all contributions in Tabarru' funds first and then allocates/charges ujrah to Tabarru' funds; and/or (b) ujrah for Tabarru' fund investment management is not paid from contributions but is paid from the managed Tabarru' funds. If the company has recorded contributions separately in Tabarru' funds and company funds since the first recognition of contribution receipts and the company does not charge ujrah for Tabarru' fund investment management from the managed Tabarru' funds, this account is nil (zero). (4) Underwriting surplus allocation payables to participants, namely payables to participants for the portion of underwriting surplus that has become the participant's right. (5) Underwriting surplus allocation payables to the company, namely payables to the company as manager for the portion of underwriting surplus that has become the company's right. (6) Tabarru' fund investment profit-sharing payables to the company, namely payables to the company for Tabarru' fund investment profit-sharing... Tabarru' if Tabarru' fund investment management uses mudharabah or mudharabah musytarakah contracts. (7) Zakat payables. (8) Other payables. (9) Contribution reserves, namely contribution reserves for long-term policies calculated based on applicable legislation. (10) Unearned/unacquired contribution reserves, namely contribution reserves for short-term policies calculated based on applicable legislation. (11) Claim reserves, namely reserves for claims still in process and incurred but not reported (IBNR) claims calculated based on applicable legislation. (12) Qardh, namely loans given by the company to Tabarru' funds. d) Accounts included in the participant equity category. Accounts included in the participant equity category consist of:
(1) Accumulated Tabarru' funds, namely Tabarru' fund assets minus Tabarru' fund liabilities at the end of the reporting period. (2) Difference between SAK and SAP Valuation, namely the difference in valuation results of assets and liabilities based on SAK versus based on SAP. This can arise if there are differences in methods used in valuing assets and liabilities based on SAK and based on SAP. (3) Non-permitted assets, namely:
(a) assets that do not meet regulations regarding permitted asset types, such as land and buildings, and (b) assets... (b) assets that meet permitted asset types and have been valued based on applicable legislation (valued based on SAP) but cannot be recognized as permitted assets because they exceed limits regulated in applicable legislation. For example, assets in the form of deposits at general Sharia banks have been valued at nominal value but exceed investment limits at one bank, so the portion exceeding the limit at one bank is included in non-permitted assets. b. Underwriting Surplus
The underwriting surplus report presents the calculation of underwriting surplus based on accrual basis from all Sharia insurance business lines during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the reporting month (year to date).
Explanation of accounts presented.
a) Participant contributions are contributions from participants accumulated into Tabarru' funds (Tabarru' premiums, excluding ujrah). b) Reinsurance contributions are the portion of Tabarru' premiums used to pay Tabarru' premiums to reinsurers. c) Beginning KYBMP reserve is contributions that are not yet income at the beginning of the month and beginning of the current year. d) Ending KYBMP reserve for the current period is contributions that are not yet income at the end of the current month. e) Beginning contribution reserve is contribution reserves at the beginning of the month and beginning of the current year. f) Ending contribution reserve for the current period is contribution reserves at the end of the current month. g) Gross claims are approved claims during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the current month (year to date). h) Reinsurance claims received are claim recoveries from reinsurers approved during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the current month (year to date). i) Beginning claim reserve is claim reserves at the beginning of the month and beginning of the current year. j) Ending claim reserve for the current period is claim reserves at the end of the current month. k) Adjuster costs are adjuster costs during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the current month (year to date).
c. Cash Flow Report
The cash flow report is presented using the direct method. Cash flows are grouped into three categories: operating activities, investing activities, and financing activities. Beginning cash balance is the cash balance at the beginning of the current month and beginning of the current year. Meanwhile, ending cash balance is the cash balance at the end of the current month, which corresponds to what is presented in the balance sheet report. d. Tabarru' Fund Financial Health Report
The Tabarru' Fund Financial Health Report presents the calculation of Tabarru' fund solvency based on applicable legislation.
Assets and liabilities presented in this report are assets and liabilities calculated based on applicable legislation. The said assets and liabilities are the same as balances presented in the SAP Balance column of the Tabarru' Fund Balance Sheet Report.
Schedule A to Schedule F are filled based on the company's calculation results guided by applicable legislation regarding the calculation of funds needed to anticipate losses resulting from failures in managing Tabarru' fund assets/liabilities.
e. Asset and Liability Matching Analysis Report
The Asset and Liability Matching Analysis Report presents assets and liabilities in Rupiah and foreign currency based on maturity, namely:
a) ≤ 1 year b) 1 year < maturity ≤ 5 years c) 5 years < maturity ≤ 10 years d) > 10 years
Asset maturity determination is based on asset maturity or the company's planned time frame to own the said assets.
Liability maturity determination is based on debt maturity or the company's estimate regarding the maturity of the said liabilities.

Company Fund Reports
a. Balance Sheet Report

The Balance Sheet Report presents SAK Balances of asset, liability, and participant equity accounts at the end of the reporting month. SAK Balance is the account position measured/valued based on the applicable Financial Accounting Standards (SAK). Accounts are reclassified according to the purpose of their inclusion so that accounts presented in monthly financial reports may differ from accounts presented in financial reporting based on SAK.
Explanation of accounts presented:
a) Accounts included in the investment category. Accounts included in the investment category are classified based on investment type. b) Accounts included in the non-investment category. Non-investment accounts consist of:
(1) Cash and banks.
(2) Investment receivables, namely receivables from the sale of investment assets.
(3) Investment return receivables, namely receivables from investment returns from third parties, such as sukuk issuers for returns provided. (4) Ujrah receivables from participants, namely receivables from participants for the portion of Sharia insurance contributions allocated to ujrah. (5) Tabarru' fund underwriting surplus allocation receivables, namely receivables from Tabarru' funds for the portion of underwriting surplus allocated to the company. (6) Tabarru' fund investment profit-sharing receivables, namely receivables from Tabarru' funds for Tabarru' fund investment profit-sharing if Tabarru' fund investment management uses mudharabah or mudharabah musytarakah contracts. (7) Qardh receivables, namely receivables from Tabarru' funds for qardh given by the company. (8) Buildings with strata rights or land with buildings for own use. (9) Computer hardware. (10) Other fixed assets. (11) Other assets. c) Accounts included in the liability category. Liability accounts consist of:
(1) Commission payables, namely payables to insurance agents, brokers, and/or third parties.
(2) Reinsurance ujrah payables, namely ujrah payables to reinsurers for wakalah bil ujrah contracts in risk management and/or Tabarru' fund investment management. (3) Tax payables. (4) Accrued expenses. (5) Zakat payables. (6) Other payables. d) Subordinated loans. e) Accounts included in the company equity category. Accounts included in the company equity category consist of:
(1) Paid-up capital, namely capital paid up by shareholders in companies conducting all business on Sharia principles or working capital in Sharia units. (2) Share premium. (3) Reserves. (4) Fixed asset valuation differences. (5) Retained earnings. b. Comprehensive Income Statement
The income statement presents the calculation of company profit/loss during the current month (month to date) and accumulated during the period from the beginning of the year to the end of the reporting month (year to date).
Explanation of accounts presented.
a) Ujrah received by the company is grouped into:
(1) Ujrah received for risk management, namely ujrah received by the company for wakalah bil ujrah contracts in risk management. (2) Ujrah received for Tabarru' fund investment management, namely ujrah received by the company if Tabarru' fund investment management uses wakalah bil ujrah contracts. (3) Ujrah received for participant fund investment management. b) Commission receipts, namely commissions received by the company from third parties. c) Tabarru' fund investment profit-sharing, namely profit-sharing received by the company if Tabarru' fund investment management uses mudharabah or mudharabah musytarakah contracts. d) Tabarru' fund underwriting surplus allocation, namely the portion of underwriting surplus received by the company in accordance with regulations stipulated in the policy. e. Investment management results, namely investment returns from company fund investment assets. f) Acquisition costs, namely sales commissions and other costs incurred in connection with accepting new insurance participants. g) Reinsurance ujrah, namely ujrah to reinsurers for wakalah bil ujrah contracts in risk management and/or Tabarru' fund investment management. h) Marketing expenses. i) Administrative and general expenses. j) Other expenses. k) DPLK service fees/other management services. l) Other income. m) Zakat. n) Income tax. o) Profit (loss) after tax. p) Other comprehensive income, namely other comprehensive income based on SAK. q) Comprehensive Income.
c. Cash Flow Report
The cash flow report is presented using the direct method. Cash flows are grouped into three categories: operating activities, investing activities, and financing activities. Beginning cash balance is the cash balance at the beginning of the current month and beginning of the current year. Meanwhile, ending cash balance is the cash balance at the end of the current month, which corresponds to what is presented in the balance sheet report. d. Company Fund Financial Health Report
This form presents information regarding assets available for qardh and company fund solvency at the end of the current month.
Assets available for qardh are company fund assets provided by the company to give qardh to Tabarru' funds and are calculated based on applicable legislation regarding types, conditions, valuation methods, and limits of assets available for qardh.
The amount of assets that must be provided for qardh is the sum of the following components:
a) A certain percentage of the amount of funds needed to anticipate losses that may arise as a result of deviations in managing Tabarru' fund assets and/or liabilities, in accordance with applicable legislation regarding assets available for qardh. The said percentage is 45% for monthly reports until the November 2014 period and 70% for monthly reports starting from the December 2014 period. b) Funds that must be provided to anticipate losses that may arise from production process failures, inability of human resources and/or systems to perform well, or other adverse events. c) The larger amount between the funds that must be prepared to maintain the required Tabarru' fund solvency level or the funds that must be prepared to maintain the balance between investments plus cash and banks with technical provisions plus retained claim liabilities, with the condition:
(1) The amount of funds that must be prepared to maintain the required Tabarru' fund solvency level is equal to the solvency shortfall of Tabarru' funds minus a certain percentage of the amount of funds needed to anticipate losses that may arise as a result of deviations in managing Tabarru' fund assets and/or liabilities, in accordance with applicable regulations. The said percentage is 15% for monthly reports until the November 2014 period and 30% for monthly reports starting from the December 2014 period. (2) The amount of funds that must be prepared to maintain the balance between investments plus cash and banks with technical...

technical reserve plus the obligation of own retention claims is equal to the difference resulting from the sum of the assets of Tabarru’ funds in permitted investments plus cash and bank accounts minus the sum of technical reserves plus the obligation of own retention claims.
4) Company fund solvency is calculated as the company's fund assets minus the company's fund liabilities at the end of the current month. The balances of assets and liabilities mentioned are the same as the balances presented in the Company Fund Financial Position Report.
5) Minimum company fund solvency is equal to the greater of:
a) The amount of assets that must be provided for qardh; or b) Equity or working capital required based on applicable legal regulations, namely:
(1) Equity of Sharia insurance companies: Rp50 Billion (2) Working capital of Sharia business units of insurance companies: Rp25 Billion (3) Equity of Sharia reinsurance companies: Rp100 Billion (4) Working capital of Sharia business units of reinsurance companies: Rp50 Billion e. Asset and Liability Matching Analysis Report

The Asset and Liability Matching Analysis Report presents assets and liabilities in Rupiah and foreign currency based on age, namely:
a) ≤ 1 year b) 1 year < age ≤ 5 years c) 5 years < age ≤ 10 years d) > 10 years
The determination of asset age is based on the maturity of the asset or the company's planned duration to hold the asset.
The determination of liability age is based on the maturity of the debt or the company's estimate regarding the maturity of the liability.

Report on Participant Investment Funds
a. Financial Position Report

The Financial Position Report presents the balances of asset, liability, and participant equity accounts at the end of the reporting month, valued according to applicable legal regulations and financial accounting standards (SAK).
Explanation of the accounts presented:
a) Accounts included in the investment category.
Accounts included in the investment category are classified based on the type of investment. b) Accounts included in the non-investment category. Non-investment accounts consist of:
(1) Cash and bank.
(2) Investment receivables, namely receivables from the sale of investment assets.
(3) Investment income receivables, namely receivables from investment returns from other parties, such as banks and sukuk issuers on the returns provided. c) Accounts included in the liability category. Liability accounts consist of:
(1) Ujroh/fee management debts, namely debts to the company under the wakalah bil ujrah contract for managing participant investment funds. (2) Profit-sharing debts, namely debts for investment profit-sharing to the company if the management of participant investment funds uses the mudharabah or mudharabah musytarakah contract. (3) Investment fund withdrawal debts, namely debts to participants for the withdrawal of part or all of participant investment funds. (4) Accumulation of participant investment funds, namely the total assets of participant investment funds minus the total liabilities of participant investment funds. b. Changes in Participant Investment Funds
This report presents the changes in participant investment fund balances during the current month (month to date) and during the period from the beginning of the year to the end of the current month (year to date).
Explanation of the accounts presented:
a) Participant investment funds at the beginning of the period, namely the balance of participant investment funds at the beginning of the current month and at the beginning of the current year. b) Addition of participant investment funds from contributions, namely the amount of participant contributions allocated for investment during the current month (month to date) and during the period from the beginning of the year to the end of the current month (year to date). c) Addition of participant investment funds from investment returns, namely investment returns accumulated into participant investment funds during the current month (month to date) and during the period from the beginning of the year to the end of the current month (year to date). d) Investment management costs (ujroh), namely ujroh under the wakalah bil ujrah contract for managing participant investment funds during the current month and during the period from the beginning of the year to the end of the current month. e) Withdrawal of matured participant investment funds, namely the withdrawal of participant investment funds when the policy matures, during the current month (month to date) and during the period from the beginning of the year to the end of the current month (year to date). f) Withdrawal/redemption of immature participant investment funds, namely the withdrawal of part and/or all of participant investment funds before the policy matures, during the current month (month to date) and during the period from the beginning of the year to the end of the current month (year to date). g) Total participant investment funds at the end of the period, namely the balance of participant investment funds at the end of the current month.
c. Asset and Liability Matching Analysis Report
The Asset and Liability Matching Analysis Report presents assets and liabilities in Rupiah and foreign currency based on age, namely:
a) ≤ 1 year b) 1 year < age ≤ 5 years c) 5 years < age ≤ 10 years d) > 10 years
The determination of asset age is based on the maturity of the asset or the company's planned duration to hold the asset.
The determination of liability age is based on the maturity of the debt or the company's estimate regarding the maturity of the liability.

Summary of Tabarru’ Funds, Corporate Funds, and Participant Investment Funds Reports
a. This report presents combined data from several accounts contained in Tabarru’ funds, corporate funds, and participant investment funds. Information is presented in six columns, namely Tabarru’ funds, corporate funds, participant investment funds, total, adjustments, and total after adjustments. b. The columns for Tabarru’ funds, corporate funds, and participant investment funds are filled based on data from each respective fund. The total column is filled with the sum of the values found in the Tabarru’ funds, corporate funds, and participant investment funds columns. The adjustment column is filled with the necessary adjustment values to obtain consolidated data from Tabarru’ funds, corporate funds, and participant investment funds. The total after adjustments column is filled with the total value minus the adjustments.
c. Explanation of the accounts presented:

Accounts included in the investment asset category.
a) Investment assets consist of accounts corresponding to the type of investment. The investment values presented in the Tabarru’ funds, corporate funds, and participant investment funds columns are equal to the values of each type of investment presented in the Tabarru’ Funds Financial Position Report (SAK), Corporate Funds Financial Position Report, and Participant Investment Funds Financial Position Report. b) The values presented in the Total column are the sum of each type of investment found in the Tabarru’ funds, corporate funds, and participant investment funds columns.
Non-investment assets.
a) The values of non-investment assets presented in the Tabarru’ funds, corporate funds, and participant investment funds columns are equal to the values of non-investment assets presented in the Tabarru’ Funds Financial Position Report (SAK), Corporate Funds Financial Position Report, and Participant Investment Funds Financial Position Report. b) The values presented in the Total column are the sum of non-investment assets found in the Tabarru’ funds, corporate funds, and participant investment funds columns. c) The Adjustment column is filled if the total non-investment assets managed by the company/Sharia unit are not equal to the sum of non-investment assets in the Tabarru’ funds, corporate funds, and participant investment funds columns. This is caused by transactions between funds that affect the balance of non-investment assets.
Liabilities
a) The values of liabilities presented in the Tabarru’ funds, corporate funds, and participant investment funds columns are equal to the values of liabilities presented in the Tabarru’ Funds Financial Position Report (SAK), Corporate Funds Financial Position Report, and Participant Investment Funds Financial Position Report. b) The values presented in the Total column are the sum of liabilities found in the Tabarru’ funds, corporate funds, and participant investment funds columns. c) The Adjustment column is filled if the total liabilities of the company/Sharia unit are not equal to the sum of liabilities in the Tabarru’ funds, corporate funds, and participant investment funds columns. This is caused by transactions between funds that affect the balance of liabilities.
Gross Contributions
a) The values presented in the Tabarru’ funds, corporate funds, and participant investment funds columns are each equal to participant contributions on the Underwriting Surplus Calculation Report, ujroh received by the company on the Corporate Funds Income Statement, and Addition of Participant Investment Funds from Contribution Allocation on the Changes in Participant Investment Funds Report. b) The values presented in the Total column are the sum of the values found in the Tabarru’ funds, corporate funds, and participant investment funds columns. c) The Adjustment column is filled if the total gross contributions of the company/Sharia unit are not equal to the sum of the values found in the Tabarru’ funds, corporate funds, and participant investment funds columns. This is caused by transactions between funds that affect the calculation of total gross contributions, for example, if there is ujroh received by the company that is not charged to gross contributions received but is charged to the accumulation of Tabarru’ funds or the accumulation of participant investment funds.
Gross Claims and Benefits
a) The values presented in the Tabarru’ funds and participant investment funds columns are each equal to gross claims on the Underwriting Surplus Calculation Report and the amount of participant investment fund withdrawals on the Changes in Participant Investment Funds Report. b) The values presented in the Total column are the sum of the values found in the Tabarru’ funds and participant investment funds columns.
Investment Returns
a) The values presented in the Tabarru’ funds column are equal to the returns of Tabarru’ funds after deducting investment costs if using the wakalah bil ujrah contract and/or profit-sharing returns to the manager if using the mudharabah or mudharabah musytarakah contract. b) The values presented in the corporate funds column are equal to the returns of corporate funds after deducting investment costs if using the wakalah bil ujrah contract and/or profit-sharing returns to the manager if using the mudharabah or mudharabah musytarakah contract. c) The values presented in the participant investment funds column are equal to the returns of participant investment funds after deducting investment costs if using the wakalah bil ujrah contract and/or profit-sharing returns to the manager if using the mudharabah or mudharabah musytarakah contract. D. FORM OF MONTHLY REPORT FORMS The monthly reports of life insurance companies conducting all business on Sharia principles and the monthly reports of Sharia units of life insurance companies are prepared using the form formats as referred to in this section.

Report Cover
Board of Directors' Statement
Tabarru’ Funds Report
3.a. Financial Position Report

3.b. Underwriting Surplus Report

3.c. Cash Flow Report

3.d. Tabarru’ Funds Financial Health Report

3.e. Asset and Liability Matching Analysis Report

Corporate Funds Report
4.a. Financial Position Report

4.b. Comprehensive Income Statement

4.c. Cash Flow Report

4.d. Corporate Funds Financial Health Report

4.e. Asset and Liability Matching Analysis Report

Participant Investment Funds Report
5.a. Financial Position Report

5.b. Changes in Participant Investment Funds Report

5.c. Asset and Liability Matching Analysis Report

Summary of Tabarru’ Funds, Corporate Funds, and Participant Investment Funds Reports

OJK Circular Letter No. 4/SEOJK.05/2013 on Monthly Reports of Insurance and Reinsurance Companies Conducting All Business on Sharia Principles and Sharia Units

Lineage: In force