OJK Circular No. 13/SEOJK.05/2016 on Insurance Product Reporting for Insurance Companies

To:

1. The Board of Directors of General Insurance Companies; and
2. The Board of Directors of Life Insurance Companies,
   At their respective locations.

COPY

CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 13/SEOJK.05/2016

CONCERNING

INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

In connection with the mandate of Article 44 of the Financial Services Authority Regulation Number 23/POJK.05/2015 concerning Insurance Products and Insurance Product Marketing (State Gazette of the Republic of Indonesia Year 2015 Number 287, Supplement to the State Gazette of the Republic of Indonesia Number 5770), it is necessary to further regulate the procedures, forms, and formats for insurance product reporting in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

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

1. Insurance Product is:
   a. a program that promises protection against 1 (one) type or more of insurable risks arising from an uncertain event by providing compensation to the policyholder, insured, or participant for losses, damages, costs incurred, loss of profit, or legal liability to third parties that may be suffered by the policyholder, insured, or participant, or providing a guarantee of fulfilling the obligations of the insured party to the other party if the insured party cannot fulfill its obligations; b. a program that promises protection against 1 (one) type or more of risks related to the death of an insured person, the survival and death of an insured person, or life insurance annuities;
   c. a program that promises protection against 1 (one) type or more of risks related to the physical health condition of a person or the deterioration of the health condition of an insured person; and/or
   d. a program that promises protection against 1 (one) type or more of risks by providing compensation or payment to the policyholder, insured, or participant or other entitled parties in the event of an accident.

2. Investment-Linked Insurance Product, hereinafter referred to as PAYDI, is an Insurance Product that provides at least protection against mortality risk and provides benefits referring to the investment results of a fund pool specifically formed for the Insurance Product, whether expressed in unit form or non-unit form.

3. Joint Insurance Product is an Insurance Product designed to be marketed and underwritten or risk-managed by 2 (two) or more insurance companies.

4. Standard Insurance Product is an Insurance Product that meets the criteria as regulated in the Financial Services Authority Regulation Number 23/POJK.05/2015 concerning Insurance Products and Insurance Product Marketing.

5. Micro Insurance Product is an Insurance Product designed to provide protection against financial risks faced by low-income communities.

6. Insurance Policy is an insurance agreement deed or other document equated with an insurance agreement deed, and other documents that are an inseparable part of the insurance agreement, which are made in writing and contain an agreement between the insurance company and the policyholder.

7. Premium is an amount of money determined by the insurance company and agreed upon by the policyholder to be paid based on the insurance agreement or an amount of money determined based on statutory regulations underlying mandatory insurance programs to obtain benefits.

8. Insurance Company means general insurance companies and life insurance companies.

9. General Insurance Company is a company conducting general insurance business as referred to in Law Number 40 of 2014 concerning Insurance.

10. Life Insurance Company is a company conducting life insurance business as referred to in Law Number 40 of 2014 concerning Insurance.

11. Board of Directors:
    a. for General Insurance Companies and Life Insurance Companies in the form of a limited liability company, is the Board of Directors as referred to in statutory regulations concerning limited liability companies; b. for General Insurance Companies and Life Insurance Companies in the form of a cooperative legal entity, is the management as referred to in statutory regulations concerning cooperatives; or
    c. for General Insurance Companies and Life Insurance Companies in the form of a joint venture legal entity, is the Board of Directors as referred to in the company's articles of association.

12. Company Actuary is an actuary appointed and is an employee of the Insurance Company.

13. Financial Services Authority, hereinafter abbreviated as OJK, is the Financial Services Authority as referred to in Law Number 21 of 2011 concerning the Financial Services Authority.

II. FORM AND FORMAT OF INSURANCE PRODUCT APPROVAL REPORTING

1. Insurance Products that must be reported to the OJK to obtain an approval letter are:
   a. New Insurance Products that have never been marketed, except Standard Insurance Products; and

b. New Insurance Products other than Standard Insurance Products that have been marketed and have undergone changes including:

1. risks covered, including exclusions or restrictions on covered risk causes;
2. premium formulation;
3. risk category changes;
4. assumptions related to the formation of premium formulation; and/or
5. cash value calculation methods.

2. Insurance Product reporting to obtain an approval letter as referred to in item 1 must be accompanied by the following documents:
   a. new insurance product approval reporting form; b. premium income and expense projections related to the marketing of new Insurance Products for a period of 3 (three) years;
   c. description of the new Insurance Product; and
   d. specimen Insurance Policy.

3. In addition to the document completeness as referred to in item 2, reporting of new Insurance Products that are Joint Insurance Products must also be accompanied by documents:
   a. written agreement, if the Joint Insurance Product is a new Insurance Product as referred to in item 1 letter a; or b. approval letter or latest registration letter of the Joint Insurance Product, if the Joint Insurance Product is a new Insurance Product as referred to in item 1 letter b.

4. The new insurance product approval reporting form as referred to in item 2 letter a must be prepared in the following form and format:
   a. for Life Insurance Companies reporting Insurance Products other than PAYDI and Joint Insurance Products as referred to in Appendix I; b. for General Insurance Companies reporting Insurance Products other than PAYDI, Joint Insurance Products, and credit and/or suretyship Insurance Products as referred to in Appendix II;
   c. for Insurance Companies reporting PAYDI as referred to in Appendix III;
   d. for Insurance Companies reporting Joint Insurance Products as referred to in Appendix IV; or e. for General Insurance Companies reporting credit and/or suretyship Insurance Products as referred to in Appendix V, which are an inseparable part of this OJK Circular Letter.

5. Insurance Companies must submit more than 1 (one) new insurance product approval reporting form as referred to in item 4 in the event:
   a. reporting of PAYDI which is a Joint Insurance Product using the form as referred to in item 4 letter c and letter d; b. reporting of credit and/or suretyship Insurance Products which are Joint Insurance Products using the form as referred to in item 4 letter d and letter e; or
   c. reporting of Insurance Products other than letters a and b requires a combination of forms as referred to in item 4 according to the characteristics of the reported Insurance Product.

6. The Insurance Product description as referred to in item 2 letter c must be prepared in the form and format as referred to in Appendix VI, which is an inseparable part of this OJK Circular Letter.

III. FORM AND FORMAT OF INSURANCE PRODUCT REGISTRATION REPORTING

1. Insurance Products that must be reported to the OJK to obtain a registration letter are:
   a. New Insurance Products that are Standard Insurance Products; and

b. Insurance Products that have been marketed and have undergone changes other than changes as referred to in Roman II item 1 letter b with the provisions:

1. the Insurance Product in question is marketed to individual insured persons; or
2. the Insurance Product in question is marketed to insured persons other than individuals, which has previously had its marketing stopped.

2. Reporting of new Insurance Products that are Standard Insurance Products as referred to in item 1 letter a must be accompanied by the following documents:
   a. new insurance product registration reporting form; b. description of the new Insurance Product; and
   c. written agreement, specifically for Joint Insurance Products.

3. The new insurance product registration reporting form as referred to in item 2 letter a must be prepared in the following form and format:
   a. for Insurance Companies reporting Standard Insurance Products other than Joint Insurance Products, and credit and/or suretyship Insurance Products as referred to in Appendix VII; b. for Insurance Companies reporting Standard Insurance Products that are Joint Insurance Products as referred to in Appendix VIII; or
   c. General Insurance Companies reporting Standard Insurance Products that are suretyship Insurance Products as referred to in Appendix IX,
   which are an inseparable part of this OJK Circular Letter.

4. Insurance Companies must submit more than 1 (one) new insurance product registration reporting form as referred to in item 3 in the event:
   a. reporting of Standard Insurance Products that are suretyship Insurance Products and Joint Insurance Products using the form as referred to in item 3 letter b and letter c; b. reporting of Standard Insurance Products other than letter a requires a combination of forms as referred to in item 3 according to the characteristics of the reported Insurance Product.

5. Registration reporting of Insurance Products that have been marketed and have undergone changes as referred to in item 1 letter b must be accompanied by the following documents:
   a. insurance product change registration reporting form; b. approval letter or latest registration letter of the Insurance Product or Joint Insurance Product before the change;
   c. description of the Insurance Product;
   d. matrix comparing the Insurance Product before and after the change; and e. specimen Insurance Policy after the change, specifically for Insurance Products other than Standard Insurance Products.

6. The insurance product change registration reporting form as referred to in item 5 letter a must be prepared in the following form and format:
   a. for Insurance Companies reporting changes to Insurance Products other than Joint Insurance Products as referred to in Appendix X; or b. for Insurance Companies reporting changes to Joint Insurance Products as referred to in Appendix XI, which are an inseparable part of this OJK Circular Letter.

7. The Insurance Product description as referred to in item 2 letter b and item 5 letter c must be prepared in the form and format as referred to in Appendix VI, which is an inseparable part of this OJK Circular Letter.

IV. PROCEDURES FOR SUBMITTING INSURANCE PRODUCT REPORTS

1. Insurance Companies are required to report Insurance Products to the OJK in the form and format as referred to in the appendices of this OJK Circular Letter.

2. Insurance Product reports as referred to in item 1 are submitted to the OJK online through the OJK data communication network system.

3. In the event that the OJK data communication network system as referred to in item 2 is not available or there are technical disruptions during the submission of Insurance Product reports, the Insurance Product reports as referred to in item 1 are submitted to the OJK offline.

4. Offline Insurance Product reports as referred to in item 3 must be submitted in electronic data format via compact disc (CD) or other electronic data storage media, and specifically Part A.I and/or B.I of the Insurance Product description as referred to in Appendix VI, which is an inseparable part of this OJK Circular Letter, must be prepared in spreadsheet format.

5. If technical disruptions as referred to in item 3 are experienced by the OJK, the OJK announces via the OJK website on the same day the technical disruption occurs.

6. Submission of Insurance Product reports as referred to in item 2 and item 3 must be accompanied by a cover letter signed by:
   a. The Board of Directors of the Insurance Company; or b. The Board of Directors of the Insurance Company appointed as the chairman in the marketing of Joint Insurance Products.

7. Submission of offline Insurance Product reports as referred to in item 3 is addressed to:
   Financial Services Authority u.p. Director of Institutions and Non-Bank Financial Products Menara Merdeka Building Mailing Room 12th Floor Jl. Budi Kemuliaan I No.2 Central Jakarta

8. Submission of offline Insurance Product reports as referred to in item 3 can be done in one of the following ways:
   a. handed in directly to the OJK office; b. sent via registered post office; or
   c. sent via a courier service company,
   according to the address as referred to in item 7.

9. An Insurance Company is deemed to have submitted an Insurance Product report with the following provisions:
   a. for online submission via the OJK data communication network system, evidenced by a receipt from the OJK; or b. for offline submission, evidenced by:

1. a receipt letter from the OJK, if the report is handed in directly to the OJK office as referred to in item 8 letter a; or
2. a shipping receipt from the post office or courier service company, if the report is sent via post office or courier service company as referred to in item 8 letter b and letter c.

10. In the event of a change in the OJK office address for report submission as referred to in item 7, the OJK will convey notification regarding the address change via letter or announcement.

V. CLOSING

The provisions in this OJK Circular Letter shall take effect on the date of determination.

Determined in Jakarta on 22 April 2016

EXECUTIVE HEAD OF INSURANCE, PENSION FUND, FINANCING INSTITUTION, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed FIRDAUS DJAELANI

Copy in accordance with the original Director of Law 1 Legal Department signed Yuliana

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 13 /SEOJK.05/2016 CONCERNING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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INSURANCE PRODUCT APPROVAL REPORTING FORM OTHER THAN PAYDI AND JOINT INSURANCE PRODUCTS FOR LIFE INSURANCE COMPANIES

I. ASSESSMENT FORM FOR NEW INSURANCE PRODUCT APPROVAL REPORTING

GENERAL INFORMATION
Insurance Company Name
Contact Person Name and Phone/Email Technical PIC:
Board of Directors in charge of Insurance Product Development:
Report Number and Date
Insurance Product Name
Classification/Business Line
Marketing Target
Insurance Product
Individual Insured
Non-Individual Insured (Companies, etc.)
Individual and Non-Individual Insured (Companies, etc.) Brief Description of Insurance Product

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NO. DESCRIPTION YES NO NOTES

1. Insurance Product Status
   (Article 28 POJK No.23/POJK.05/2015) a. Never marketed; or b. Changes to a marketed Insurance Product where the changes include:

• risks covered including exclusions or
  restrictions on covered risk causes;
• premium formulation;
• risk category changes;
• assumptions related to the formation of
  premium formulation; and/or
• cash value calculation methods.
  Provide a brief explanation of changes made by the Insurance Company

2. Insurance Product Name
   (Article 10 POJK No.23/POJK.05/2015) The name of the Insurance Product to be marketed meets the provisions:
   a. using the word insurance or synonymous words; b. does not cause interpretation that the product is not an Insurance Product; and
   c. using the phrase "micro insurance" or synonymous phrases (specifically for
   Micro Insurance Products).
   State the name of the Insurance Product to be reported The Insurance Product Name must be used consistently throughout all documents of the Insurance Product report

3. New Insurance Products reported must be listed in the Insurance Company's business plan
   (Article 28 POJK
   No.23/POJK.05/2015)
   State the title and date of the Insurance Company's business plan

4. Fulfillment of Financial Health and Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015) a. Insurance Company meets the financial health level provisions State the RBC achievement ratio for the last quarter

3/14 b. Insurance Company is not subject to administrative sanctions If the Insurance Company is subject to sanctions, state:

• type of violation
• sanction letter number
• type of sanction

II DOCUMENT COMPLETENESS ANALYSIS (Article 32 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Board of Directors of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach cover letter

2. Premium income and expense projections related to the marketing of new Insurance Products for a period of 3 (three) years
   Attach profit testing or asset share completed with qualitative explanation of assumptions used (specifically for premium growth, claim ratio, and profitability), and its relation to historical data

3. Description of new Insurance Product
   Attach description of new Insurance Product as referred to in Appendix VI

4. Specimen Insurance Policy
   Attach:

• Insurance Policy Provisions
• Insurance Policy Summary accompanied by dummy coverage data
• Insurance Policy Certificate/membership proof accompanied by dummy coverage data (specifically for group Insurance Products)
• example participant list accompanied by dummy coverage data (specifically for group Insurance Products)

5. Statement Letter of the Company Actuary
   (Article 26 POJK
   No. 23/POJK.05/2015)
   According to the Company Actuary statement letter as referred to in Roman II This Form

6. Statement Letter of the Board of Directors stating that:
   a. Insurance Company meets financial health level provisions; b. Insurance Company is not subject to administrative sanctions; and
   c. The reported Insurance Product is included in the Insurance Company's business plan approved by shareholders.
   (Article 28 and Article 30 POJK
   No. 23/POJK.05/2015)
   Attach Board of Directors statement letter as referred to in Roman III This Form

7. Description of marketing methods and examples of marketing kits (brochures, scratch card copies, telemarketing scripts, etc.)
   (Article 11 and Article 20 POJK
   No.1/POJK.07/2013)
   Attach example marketing kit

8. Summary of Insurance Product Information
   (Part VI SEOJK
   No.12/SEOJK.07/2014)
   Attach example summary of Insurance Product Information. (summary of Insurance Product Information is not an agreement document and is different from offer documents such as brochures and leaflets and different from Insurance Product description)

9. Example Life Insurance Application Form (SPAJ)
   (Article 16 POJK
   No.1/POJK.07/2013)
   Attach example SPAJ

10. Risk profile, interest rates, mortality or morbidity tables, estimated investment results from Premium, acquisition costs, administrative costs, and other general costs for calculating Premium
    (Article 26 POJK
    No.23/POJK.05/2015)
    Attach mortality table or morbidity table used and data source

11. Matrix comparing Insurance Product before and after changes (specifically for Insurance Products previously marketed)
    (Article 28 POJK
    No.23/POJK.05/2015)
    Attach matrix

III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Insurance
   a. Provides protection from at least 1 (one) type of insurable risk (Article 2 POJK No.23/POJK.05/2015) b. Consistent with the scope of business of the Life Insurance Company and consistent with general insurance principles (Article 9 POJK No.23/POJK.05/2015) State the life insurance business line according to the classification as referred to in Appendix VI

2. Insurance Policy
   a. Benefits agreed upon in the Insurance Policy are consistent with the Insurance Product description State the article in the Insurance Policy governing it

b. Provisions in the Insurance Policy must at least contain the following:

1. General Provisions
   (Article 11 POJK
   No.23/POJK.05/2015) a) Effective date of coverage State the article in the Insurance Policy governing it

4/14 b) Description of agreed benefits State the article in the Insurance Policy governing it c) Premium payment method State the article in the Insurance Policy governing it d) Grace period for premium payment State the article in the Insurance Policy governing it e) Exchange rate used for Insurance Policies with foreign currency if premium and benefit payments are linked to the rupiah currency (excluding Micro Insurance Products) State the article in the Insurance Policy governing it The exchange rate used for Insurance Policies with foreign currency must be an equivalent rate issued by Bank Indonesia at the time of payment (Article 16 POJK No.23/POJK.05/2015) f) Time recognized as the time of premium payment receipt State the article in the Insurance Policy governing it g) Insurance Company's policy set if premium payment is made after the agreed grace period State the article in the Insurance Policy governing it h) Period during which the Insurance Company cannot review the validity of the insurance contract (incontestable period) on long-term Insurance Products State the article in the Insurance Policy governing it i) Cash value table, for Insurance Products containing cash value (excluding Micro Insurance Products) State the article in the Insurance Policy governing it and attach the cash value table j) Calculation of Policy Dividends or similar, for Insurance Products promising Policy Dividends State the article in the Insurance Policy governing it

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6/14

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Insurance or similar
(except Micro Insurance Products) k) Termination clauses of coverage, whether from the Insurance Company or from the policyholder, insured, or participant, including the conditions and causes thereof Specify the article in the Insurance Policy that governs it l) Conditions and procedures for filing claims, including relevant supporting evidence required in the claim filing Specify the article in the Insurance Policy that governs it m) Procedures for settlement and payment of claims Specify the article in the Insurance Policy that governs it n) Dispute resolution clauses which among others contain mechanisms for resolution within the court and outside the court and the selection of the venue for dispute resolution (except Micro Insurance Products) Specify the article in the Insurance Policy that governs it Dispute resolution outside the court is conducted through the Alternative Dispute Resolution Institution (LAPS) which is included in the list of LAPS established by OJK o) Language used as a reference in case of disputes or differences of opinion, for Policies printed in 2 (two) languages or more Specify the article in the Insurance Policy that governs it
2) Dispute Resolution Provisions
(Article 17 and Article 18 POJK
No.23/POJK.05/2015) a) There are no provisions in the Insurance Policy that can be interpreted as the policyholder, insured, or participant being unable to

8/14 legal action so that the policyholder, insured, or participant must accept the rejection of claim payment b) There are no provisions in the Insurance Policy that can be interpreted as a restriction on legal action for the parties in case of disputes regarding the provisions of the Insurance Policy c) Provisions in the Insurance Policy regarding dispute resolution over insurance agreements conducted outside the court provide alternative options for dispute resolution namely through alternative dispute resolution institutions as regulated in legislation regarding alternative dispute resolution institutions in the financial services sector (except Micro Insurance Products) Specify the article in the Insurance Policy that governs it Dispute resolution outside the court is conducted through the Alternative Dispute Resolution Institution (LAPS) which is included in the list of LAPS established by OJK d) Provisions in the Insurance Policy regarding dispute resolution over insurance agreements conducted through the court do not limit the selection of courts only to the district court at the domicile of the Insurance Company
c. Insurance Policies issued
and marketed in the jurisdiction of Indonesia are made in the Indonesian language. In case of need, Insurance Policies can be issued in foreign languages or regional languages alongside

9/14 the Indonesian language
(Article 20 POJK
No.23/POJK.05/2015) d. The specimen of the Insurance Policy has included the section of Premiums received by the Insurance Company and the section of Premiums passed on to the insurance brokerage company as remuneration for intermediary services (if using insurance brokerage intermediary services) (Explanation of Article 29 Law No 40 Year 2014) Specify the section in the Insurance Policy that governs it e. There is a statement that "This Agreement has been adjusted to regulations including OJK regulations" (Part III Circular Letter No.13/SEOJK.07/2014)
3. Marketing Kit
a. There is information regarding cost details, benefits, and risks (Romans III Circular Letter No.12/ SEOJK.07/2014) b. There is the name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013)
c. There is a statement that
"The Insurance Company is registered and supervised by OJK" (Article 20 POJK No.1/POJK.07/2013)
4. Summary of Insurance Product Information
The summary of Insurance Product Information must at least contain:
a. name and type of Insurance
Product; b. name of the Insurance Company;
c. summary data;

10/14 d. benefits; e. risks; f. requirements and procedures; g. costs; h. simulation;
i. service procedures and
complaint resolution procedures; and j. additional information. (Article 8 POJK No.1/POJK.07/2013 and Part VI Circular Letter No.12/SEOJK.07/2014)
5. Example of Life Insurance Application Letter (SPAJ)
Attach an example SPAJ that contains matters including information regarding the suitability between the customer profile with the offered Insurance Product
6. Premium Calculation
a. Premiums that are appropriate to the promised benefits, which are set at a level that is sufficient, not excessive, and not applied discriminatorily (Article 3 POJK No.23/POJK.05/2015) Specify the section in the Insurance Product description that contains the premium calculation formula b. The setting of Risk Premiums has considered all coverage as described in the Insurance Product description or specimen of the Insurance Policy Specify the section in the Insurance Product description that contains the premium calculation formula
c. The premium calculation formula
in the Insurance Product description has been in accordance with the insurance benefits to be provided Specify the section in the Insurance Product description that contains the premium calculation formula d. The setting of Premiums considers at least:
(Article 26 POJK
No.23/POJK.05/2015)

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• Pure Premiums calculated based
  on risk profiles, interest rates, mortality tables, or morbidity tables Explain the suitability between Pure Premiums and risk profile data as referred to in
  Appendix VI
• Interest rates Specify the assumption
  of interest rates used
• Acquisition costs Specify the proportion
  of acquisition cost components in Gross Premiums
• Administrative costs Specify the proportion
  of administrative cost components in Gross Premiums
• Other general costs Specify the proportion
  of other general cost components in Gross Premiums
• Estimated investment returns Attach investment return data and investment strategies
  that support the estimated investment returns e. The premium calculation methodology for the newly reported Insurance Products has been in accordance with the principles of insurance that are generally applicable and commonly used (best practice and common practice) f. Assumptions used in Premium calculations use reasonable and realistic figures

7. Cash Value
   (Article 12 KMK No.422/KMK.06/2003) Does not apply to Micro Insurance Products The amount of cash value is in accordance with applicable regulations

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8. Profit Testing or Asset Share
a. There is fairness in the assumptions used b. Surplus from the reported Insurance Products is sufficient for the Insurance Company IV CONCLUSION All requirements for reporting approval of new Insurance Products have been met We, the undersigned, hereby declare that the assessment form above has been in accordance with the actual conditions and has been completed with sufficient documents.

…(filled with city name, date, month, and year) Board of Directors in charge of Insurance Product Development (Filled with job title) Company Actuary (filled with Company Name) signature signature (Name) (Name and registration number)

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We, the undersigned, hereby declare that the Premium and technical reserve calculations for the Insurance Product …… [filled with the name of the reported Insurance Product] have been in accordance with applicable legislation and are based on reasonable assumptions and common insurance practices. This statement is made truthfully. If it is later found that this statement is not true, then we are willing to be responsible and may be subject to sanctions in accordance with applicable legislation. …(filled with city name, date, month, and year) Company Actuary… (filled with name of the Insurance Company) signature

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We, the undersigned, hereby declare that:

1. The Insurance Company meets the financial health ratio requirements;
2. The Insurance Company is not currently subject to administrative sanctions; and
3. The Insurance Product ..... [filled with the name of the reported Insurance Product]
   is included in the Insurance Company's business plan which has been approved by the shareholders. This statement is made truthfully. If it is later found that this statement is not true, then we are willing to be responsible and may be subject to sanctions in accordance with applicable legislation. …(filled with city name, date, month, and year) Board of Directors in charge of Insurance Product Development (job title) signature (Name) Determined in Jakarta on April 22, 2016 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, sign FIRDAUS DJAELANI Copy in accordance with the original Legal Director 1 Legal Department sign Yuliana

APPENDIX II
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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FORM FOR REPORTING APPROVAL OF INSURANCE PRODUCTS OTHER THAN PAYDI, JOINT INSURANCE PRODUCTS, AND CREDIT INSURANCE PRODUCTS AND/OR SURETYSHIP FOR GENERAL INSURANCE COMPANIES
I. ASSESSMENT FORM FOR REPORTING APPROVAL OF NEW
INSURANCE PRODUCTS
GENERAL INFORMATION
Insurance Company Name
Contact Person Name and Phone/email Technical PIC:
Board of Directors in charge of Product Development Insurance :
Number and Date of Reporting Letter Insurance Product Name Classification/Business Line Marketing Target Insurance Product Individual Insured Non-Individual Insured (Companies, etc.) Individual and Non-Individual Insured (Companies, etc.) Brief Description of Insurance Product

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1. Status of Insurance Product
   (Article 28 POJK No.23/POJK.05/2015) a. Has not been marketed; or b. Changes to an already marketed Insurance Product where the changes include:

• risks covered
  including exclusions or restrictions on covered risks;
• Premium formulation;
• changes in risk categories;
• assumptions related to the formation of
  Premium formulation; and/or
• cash value calculation methods.
  Provide a brief explanation of the changes made by the Insurance Company

2. Name of Insurance Product
   (Article 10 POJK No.23/POJK.05/2015) The name of the Insurance Product to be marketed meets the requirements:
   a. using the word insurance or other synonymous words; b. does not cause interpretation that the product is not an Insurance Product; and
   c. using the phrase "micro insurance" or other synonymous phrases (specifically for
   Micro Insurance Products)
   Specify the name of the Insurance Product to be reported The name of the Insurance Product must be used consistently throughout all documents of the Insurance Product Report
3. Newly reported Insurance Products must be listed in the
   Company's business plan
   (Article 28 POJK
   No.23/POJK.05/2015)
   Specify the title and date of the Company's business plan
4. Fulfillment of Financial Health and
   Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015) a. The Insurance Company meets the financial health ratio requirements Specify the ratio of the last quarter's RBC achievement

3/14 b. The Insurance Company is not currently subject to administrative sanctions If the Insurance Company is subject to sanctions, specify:

• type of violation
• sanction letter number
• type of sanction
  II DOCUMENT COMPLETENESS ANALYSIS (Article 32 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Board of Directors
   of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach the cover letter
2. Premium income projections and
   expenditures linked to the marketing of new Insurance Products for a period of 3 (three) years Attach the underwriting projections
3. Description of new Insurance Products Attach the description
   of new Insurance Products as referred to in
   Appendix VI
4. Specimen of Insurance Policy Attach:

• Policy Provisions
• Policy Summary
  accompanied by dummy coverage data
• Policy Certificate/proof of
  membership accompanied by dummy coverage data (specifically for Group Insurance Products)
• example participant list
  accompanied by dummy coverage data (specifically for Group Insurance Products)

5. Statement Letter of the Company
   Actuary
   (Article 26 POJK
   No.23/POJK.05/2015)
   In accordance with the
   Company Actuary's statement letter as referred to in Romans II this Form

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6. Statement Letter of the Board of Directors stating that:
a. The Insurance Company meets the financial health ratio requirements; b. The Insurance Company is not currently subject to administrative sanctions; and
c. The reported Insurance Product is included in the
Insurance Company's business plan which has been approved by the shareholders. (Article 28 and Article 30 POJK No.23/POJK.05/2015) Attach the Board of Directors' statement letter as referred to in Romans III this Form
7. Description of marketing methods and
examples of marketing kits (brochures, scratch card copies, telemarketing scripts, and others) (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach examples of marketing kits
8. Summary of Insurance Product Information
Attach examples of summary of Insurance Product Information (summary of Insurance Product Information is not a contract document and is different from documents such as brochures and leaflets and different from the description of Insurance Products)
9. Example of Application for Insurance Request Letter (SPPA)
(Article 16 POJK
No.1/POJK.07/2013)
Attach an example of SPPA
10. Loss profile (risk and loss
profile) of the relevant insurance type for at least 5 (five) years, acquisition costs, administrative costs, and other general costs for calculating Premiums (Article 26 POJK No.23/POJK.05/2015) Attach the risk and loss profile table containing information regarding sum insured, Premium income, claim values paid per year, for a period of at least 5 (five) years
11. Product comparison matrix before and after
changes (specifically for
Insurance Products that have been marketed previously) (Article 28 POJK No.23/POJK.05/2015) Attach the matrix

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III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Coverage
   a. Provides protection from at least 1 (one) type of risk that can be insured (Article 2 POJK No.23/POJK.05/2015) b. Consistent with the scope of business of the General Insurance Company and consistent with the principles of insurance that are generally applicable (Article 9 POJK No.23/POJK.05/2015) Specify the general insurance business line according to the classification as referred to in
   Appendix VI
2. Insurance Policy
   a. Benefits agreed upon in the Insurance Policy have been in accordance with the description of the Insurance Product Specify the article in the Insurance Policy that governs it b. Provisions in the Insurance Policy must at least contain the following matters:

1. General Provisions
   (Article 11 POJK
   No.23/POJK.05/2015) a) Date of coverage commencement Specify the article in the Insurance Policy that governs it b) Description of agreed benefits Specify the article in the Insurance Policy that governs it c) Method of Premium payment Specify the article in the Insurance Policy that governs it d) Grace period for Premium payment Specify the article in the Insurance Policy that governs it

e) Exchange rate used for Insurance Policies with foreign currency if Premium payment and benefits are linked to the Indonesian Rupiah currency (except Micro Insurance Products) Specify the article in the Insurance Policy that governs it The exchange rate used for Insurance Policies with foreign currency must be an equivalent rate issued by Bank Indonesia at the time of payment (Article 16 POJK No.23/POJK.05/2015) f) Time recognized as the time of receipt of Premium payment Specify the article in the Insurance Policy that governs it g) Insurance Company's policy set if Premium payment is made after the agreed grace period Specify the article in the Insurance Policy that governs it h) Period during which the Insurance Company cannot review the validity of the insurance contract (incontestable period) for long-term Insurance Products Specify the article in the Insurance Policy that governs it i) Termination clauses of coverage, whether from the Insurance Company or from the policyholder, insured, or participant, including the conditions and causes thereof Specify the article in the Insurance Policy that governs it j) Conditions and procedures for filing claims, including relevant supporting evidence required in the claim filing Specify the article in the Insurance Policy that governs it k) Procedures for settlement and payment of claims Specify the article in the Insurance Policy that governs it

7/14 l) Dispute resolution clauses which among others contain mechanisms for resolution within the court and outside the court and the selection of the venue for dispute resolution (except Micro Insurance Products) Specify the article in the Insurance Policy that governs it Dispute resolution outside the court is conducted through the Alternative Dispute Resolution Institution (LAPS) which is included in the list of LAPS established by OJK m) Language used as a reference in case of disputes or differences of opinion, for Policies printed in 2 (two) languages or more Specify the article in the Insurance Policy that governs it
2) Dispute Resolution Provisions
(Article 17 and Article 18 POJK
No.23/POJK.05/2015) a) There are no provisions in the Insurance Policy that can be interpreted as the policyholder, insured, or participant being unable to legal action so that the policyholder, insured, or participant must accept the rejection of claim payment b) There are no provisions in the Insurance Policy that can be interpreted as a restriction on legal action for the parties in case of disputes regarding the provisions of the Insurance Policy c) Provisions in the Insurance Policy regarding dispute resolution over insurance agreements conducted outside the court provide alternative options for dispute resolution namely Specify the article in the Insurance Policy that governs it Dispute resolution outside the court is conducted through the Alternative

8/14 through alternative dispute resolution institutions as regulated in legislation regarding alternative dispute resolution institutions in the financial services sector (except Micro Insurance Products) Resolution Institution (LAPS) which is included in the list of LAPS established by OJK d) Provisions in the Insurance Policy regarding dispute resolution over insurance agreements conducted through the court do not limit the selection of courts only to the district court at the domicile of the Company
c. Insurance Policies issued
and marketed in the jurisdiction of Indonesia are made in the Indonesian language. In case of need, Insurance Policies can be issued in foreign languages or regional languages alongside the Indonesian language (Article 20 POJK No.23/POJK.05/2015) d. The specimen of the Insurance Policy has included the section of Premiums received by the Insurance Company and the section of Premiums passed on to the insurance brokerage company as remuneration for intermediary services (if using insurance brokerage intermediary services) (Explanation of Article 29 Law No 40 Year 2014) Specify the section in the Insurance Policy that governs it e. There is a statement that "This Agreement has been adjusted to regulations including OJK regulations" (Part III Circular Letter No.13/SEOJK.07/2014)

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3. Marketing Kit
a. There is information regarding cost details, benefits, and risks (Romans III Circular Letter No.12/ SEOJK.07/2014) b. There is the name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013
c. There is a statement that
"The Insurance Company has been registered and supervised by the Financial Services Authority" (Article 20 POJK No.1/POJK.07/2013)
4. Summary of Insurance Product Information
The summary of Insurance Product Information must at least contain:
a. name and type of Insurance
Product; b. name of the Company;
c. summary data;
d. benefits; e. risks; f. requirements and procedures; g. costs; h. simulation;
i. service procedures and
complaint resolution procedures; and j. additional information. (Article 8 POJK No.1/POJK.07/2013 and Part VI Circular Letter No.12/SEOJK.07/2014)
5. Example of Application for Insurance Request Letter (SPPA)
Attach an example of SPPA that contains matters including information regarding the suitability between the customer profile with the offered Insurance Product
6. Premium Calculation
a. Premiums that are appropriate to the promised benefits, which are set at a level that is sufficient, not excessive, Specify the section in the Insurance Product description that contains the premium calculation formula

10/14 and not set discriminatorily (Article 3 POJK No.23/POJK.05/2015) Premiums b. The setting of Risk Premiums has considered all coverage as described in the Insurance Product description or specimen of the Insurance Policy Specify the section in the Insurance Product description that contains the premium calculation formula
c. There is a clear formulation in
the calculation of Risk Premiums including therein the relevance between risk profile data and Risk Premium rates Specify the section in the Insurance Product description that contains the premium calculation formula d. The setting of Premiums considers at least:
(Article 26 POJK
No.23/POJK.05/2015)

• Pure Premiums calculated
  based on the loss profile (risk and loss profile) of the relevant insurance type for at least 5 (five) years Explain the suitability between Pure Premiums and risk profile data as referred to in
  Appendix VI
• Acquisition costs Specify the proportion
  of acquisition cost components in Gross Premiums
• Administrative costs Specify the proportion
  of administrative cost components in Gross Premiums
• Other general costs Specify the proportion
  of other general cost components in Gross Premiums e. There is a clear formulation in the calculation of cost components in the calculation of Premiums including the existence of relevance between cost data and the cost rates set by the Insurance Company for the reported Insurance Product Specify the section in the Insurance Product description that contains the premium calculation formula

11/14 f. The premium calculation methodology for the newly reported Insurance Products has been in accordance with the principles of insurance that are generally applicable and commonly used (best practice and common practice) g. Assumptions used in Premium calculations use reasonable and realistic figures
7. Underwriting Projections
a. Underwriting projections refer to the company's underwriting surplus report containing a list and explanation of assumptions used at least:

• Premium growth
• claim ratio
• profitability
  b. There is fairness in Premium income assumptions
  c. There is fairness in claim expense assumptions
  d. There is fairness in technical reserve assumptions e. There is fairness in cost assumptions f. Underwriting surplus is sufficiently adequate g. Elements in the underwriting projections are complete IV CONCLUSION All requirements for reporting approval of new Insurance Products have been met

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We, the undersigned, hereby declare that the assessment form above has been in accordance with the actual conditions and has been completed with sufficient documents. …(filled with city name, date, month, and year) Board of Directors in charge of Insurance Product Development (Filled with job title) Company Actuary (filled with Company Name) signature signature (Name) (Name and registration number)

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We, the undersigned, hereby declare that the premium and technical reserve calculations for Insurance Product …… [filled with the name of the reported Insurance Product] have complied with applicable laws and regulations and are based on reasonable assumptions and common insurance practices. This statement is made truthfully. If it is later found that this statement is untrue, we are willing to be held responsible and may be subject to sanctions in accordance with applicable laws and regulations. ...(filled with city name, date, month, and year) Company Actuary (filled with Insurance Company name) signature

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We, the undersigned, hereby declare that:

1. The Insurance Company meets the financial health level requirements;
2. The Insurance Company is not currently subject to administrative sanctions; and
3. The Insurance Product ..... [filled with the name of the reported Insurance Product] is included in the Insurance Company's business plan approved by the shareholders.
   This statement is made truthfully. If it is later found that this statement is untrue, we are willing to be held responsible and may be subject to sanctions in accordance with applicable laws and regulations. ...(filled with city name, date, month, and year) Board of Directors in charge of Insurance Product development (job title) signature (Name) Determined in Jakarta on April 22, 2016 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signature FIRDAUS DJAELANI Copy consistent with the original Legal Director 1 Legal Department signature Yuliana

APPENDIX III
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 13/SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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REPORTING FORM
PAYDI APPROVAL FOR INSURANCE COMPANIES
I. ASSESSMENT FORM FOR NEW PAYDI APPROVAL REPORTING
GENERAL INFORMATION
Insurance Company Name
Contact Person Name and Phone/Email Technical PIC:
Board of Directors in charge of Insurance Product Development:
Report Number and Date
Insurance Product Name
Classification/Business Line
Marketing Target
Insurance Product
Individual Insured
Non-Individual Insured (Companies, etc.)
Individual and Non-Individual Insured (Companies, etc.) Brief Description Insurance Product

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NO. DESCRIPTION YES NO NOTES

1. Insurance Product Status
   (Article 28 POJK No.23/POJK.05/2015) a. Never marketed before; or b. Changes to an already marketed Insurance Product where the changes include:
    risks covered, including exclusions or restrictions on covered risks;  premium formulation;  risk category changes;  assumptions related to premium formulation; and/or  cash value calculation methods. Provide a brief explanation of the changes made by the Insurance Company
2. Insurance Product Name
   (Article 10 POJK No.23/POJK.05/2015) a. The Insurance Product name to be marketed meets the requirements:
    using the word insurance or a synonymous word; and  not causing interpretation that the product is not an Insurance Product. State the name of the Insurance Product to be reported The Insurance Product Name must be used consistently throughout all Insurance Product reporting documents b. Does not use an Insurance Product name that could cause interpretation different from its investment strategy
3. New Insurance Products to
   be reported must be listed in the Insurance Company's business plan (Article 28 POJK No.23/POJK.05/2015) State the title and date of the Insurance Company's business plan
4. Fulfillment of Financial Health and Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015)

3/20 a. The Insurance Company meets the financial health level requirements State the ratio of RBC achievement in the last quarter b. The Insurance Company is not currently subject to administrative sanctions If the Insurance Company is subject to sanctions, state:

• type of violation
• sanction letter number
• type of sanction
  II DOCUMENT COMPLETENESS ANALYSIS (Article 32 POJK No.23/POJK.2015)

1. Cover letter signed by the Board of Directors
   of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach the cover letter
2. Premium income projections and
   expenses related to the marketing of new Insurance Products for a period of 3 (three) years Attach:
    For
   Profit testing or asset share
   Life Insurance Products accompanied by qualitative explanation of the assumptions used (particularly for premium growth, claim ratio, and profitability), and their relation to historical data; or  For General Insurance Products underwriting projections accompanied by qualitative explanation of the assumptions used (particularly for premium growth, claim ratio, and profitability), and their relation to historical data
3. Description of new Insurance Product Attach the description
   of the new
   Insurance Product as referred to in Appendix VI

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4. Insurance Policy Specimen Attach:

• Policy Terms
• Insurance Policy Summary
  accompanied by dummy coverage data
• Insurance Policy Certificate/proof of
  insurance coverage accompanied by dummy coverage data (specifically for Group Insurance Products)
• example participant list
  accompanied by dummy coverage data (specifically for Group Insurance Products)

5. Actuary Statement Letter of the Company
   (Article 26 POJK
   No.23/POJK.05/2015)
   In accordance with the
   Actuary Statement Letter of the Company as referred to in Roman numeral II of this Form
6. Board of Directors Statement Letter stating that:
   a. The Insurance Company meets the financial health level requirements; b. The Insurance Company is not currently subject to administrative sanctions; and
   c. The reported Insurance Product is included in the
   Insurance Company's business plan approved by the shareholders. (Article 28 and Article 30 POJK No. 23/POJK.05/2015) Attach the Board of Directors statement letter as referred to in Roman numeral III of this Form
7. Description of marketing methods and
   example marketing kit (brochures and others) (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach example marketing kit
8. Fund development report
   (Number 8 Appendix KEP104/BL/2006) Attach example fund development report
9. Proposal or Illustration of Insurance
   Product or Illustration of Insurance Product accompanied by dummy coverage data and investment performance projections Attach proposal

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10. Summary of Insurance Product Information
(Part VI SEOJK No.12/SEOJK.07/2014) Attach example summary of Insurance Product Information (summary of Insurance Product Information is not a contract document and is different from documents such as brochures and leaflets and is different from description of Insurance Product)
11. Example insurance application letter
(Article 16 POJK
No.1/POJK.07/2013)
Attach example insurance application letter
12. Risk profile, interest rate, mortality or morbidity tables,
estimated investment returns from Premium, acquisition costs, administrative costs, and other general costs for calculating Premium (Article 26 POJK No.23/POJK.05/2015) Attach the table used and data source
13. Proof of having expert personnel with
assistant manager qualifications with at least 3 (three) years of experience in their field (Article 5 KMK 422/KMK.06/2003) Attach:
 Investment assistant manager certificate;  list of investment assistant manager resumes; and  appointment letter of investment assistant manager
14. Proof of having adequate information systems for
marketing PAYDI
(Article 5 KMK
422/KMK.06/2003)
Attach proof of having adequate information systems for marketing PAYDI (example: manual information system related to PAYDI) for Insurance Companies that

6/20 market PAYDI for the first time
15. Proof that agents or sales personnel marketing
unit link products have:
a. Held specific agency certification for unit link products from the relevant association Attach photocopy of unit link agency certificate b. Undergone training regarding unit link products Attach photocopy of training materials and attendance list
16. Reporting form for joint Insurance Product approval
in the event PAYDI is marketed together with other Insurance Companies Attach form as referred to in Appendix IV
17. Matrix comparing Insurance Products before and after
changes (specifically for Insurance Products previously marketed) (Article 28 POJK No.23/POJK.05/2015) Attach matrix III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Coverage
   a. Providing protection from at least 1 (one) type of insurable risk (Article 2 POJK No.23/POJK.05/2015) b. Consistent with the scope of business of the Insurance Company and consistent with general insurance principles (Article 9 POJK No.23/POJK.05/2015) State the insurance business line according to the classification as referred to in
   Appendix VI
   c. Coverage benefits from the proposed PAYDI must at least offer death coverage benefits
   (Article 4 POJK
   No.23/POJK.05/2015)

d. The sum insured for death coverage benefits as referred to above must be at least equal to the applicable requirements State the sum insured e. The insurance coverage period must at least comply with applicable requirements State the insurance coverage period f. Has a specific investment strategy State the investment strategy
2. Insurance Policy
a. Benefits agreed upon in the Insurance Policy are consistent with the description of the Insurance Product State the article in the Insurance Policy governing it b. Provisions within the Insurance Policy must at least contain the following:

1. General Provisions
   (Article 11 POJK
   No.23/POJK.05/2015) a) Commencement of coverage State the article in the Insurance Policy governing it b) Description of agreed benefits State the article in the Insurance Policy governing it c) Premium payment method State the article in the Insurance Policy governing it d) Grace period for premium payment State the article in the Insurance Policy governing it e) Exchange rate used for Insurance Policies with foreign currency if premium payment and benefits are linked to the rupiah currency State the article in the Insurance Policy governing it The exchange rate used for Insurance Policies with foreign currency must be an equivalent rate issued by Bank Indonesia at the time of

8/20 payment
(Article 16 POJK
No.23/POJK.05/2015) f) Time recognized as the time of receipt of premium payment State the article in the Insurance Policy governing it g) Insurance Company policy established if premium payment exceeds the agreed grace period State the article in the Insurance Policy governing it h) Period during which the Insurance Company cannot review the validity of the insurance contract (incontestable period) on long-term Insurance Products State the article in the Insurance Policy governing it i) Cooling off period State the article in the Insurance Policy governing it Cooling off period is the period during which the policyholder is allowed to return the Insurance Policy to the Insurance Company and receive a refund of premiums paid after deducting administrative costs j) Investment strategy State the article in the Insurance Policy governing it In the event the company establishes more than one investment sub-fund, include this clause with the name of the sub-fund and the investment strategy of each sub-fund established

9/20 k) Policyholder's right to choose one or more investment sub-funds State the article in the Insurance Policy governing it l) Fund switching State the article in the Insurance Policy governing it m) Policyholder's right not to pay premiums in a certain period (Premium holiday) State the article in the Insurance Policy governing it n) Details of all costs charged to the policyholder State the article in the Insurance Policy governing it The cost details include acquisition costs, management costs, and mortality costs o) Insurance Company's obligation to submit fund development reports at least once a year State the article in the Insurance Policy governing it p) Termination clauses, both from the Insurance Company and from the policyholder, insured, or participant, including conditions and causes State the article in the Insurance Policy governing it q) Conditions and procedures for filing claims, including relevant supporting documents required for claim filing State the article in the Insurance Policy governing it r) Procedures for claim settlement and payment State the article in the Insurance Policy governing it s) Dispute resolution clauses which include among others State the article in the Insurance Policy governing it

10/20 mechanisms for resolution within the court and outside the court and the choice of venue for dispute resolution Dispute resolution outside the court is conducted through an Alternative Dispute Resolution Institution (LAPS) listed in the LAPS list established by OJK t) Language used as reference in the event of disputes or disagreements, for Insurance Policies printed in 2 (two) or more languages State the article in the Insurance Policy governing it u) Mechanism for conveying information in the event of cost changes (Article 12 POJK No.1/POJK.07/2013) State the article in the Insurance Policy governing it v) Formation of units or investments sourced from Premium State the article in the Insurance Policy governing it Include this clause with the method and time for formation of units or participant investments from Premium w) Method and frequency of calculating unit value or participant investment fund value for each participant sub-fund managed by the company on the reported Insurance Product State the article in the Insurance Policy governing it
2) Dispute Resolution Provisions
(Article 17 and Article 18 POJK
No.23/POJK.05/2015) a) There are no provisions in the Insurance Policy that can be interpreted as preventing the policyholder, insured, or participant from taking legal action, so that the policyholder, insured, or participant must accept the rejection of claim payment b) There are no provisions in the Insurance Policy that can be interpreted as restricting legal action by the parties in the event of disputes regarding Insurance Policy provisions c) Provisions in the Insurance Policy regarding dispute resolution for insurance agreements conducted outside the court provide alternative dispute resolution options through alternative dispute resolution institutions as regulated in laws and regulations regarding alternative dispute resolution institutions in the financial services sector State the article in the Insurance Policy governing it Dispute resolution outside the court is conducted through an Alternative Dispute Resolution Institution (LAPS) listed in the LAPS list established by OJK d) Provisions in the Insurance Policy regarding dispute resolution for insurance agreements conducted through the court do not limit the choice of court only to the district court at the location of the Insurance Company

c. Insurance Policies issued and marketed within the Indonesian legal jurisdiction must be in the Indonesian language.

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If necessary, Insurance Policies may be issued in foreign languages or regional languages alongside the Indonesian language (Article 20 POJK No.23/POJK.05/2015) d. The Insurance Policy specimen must include the section of Premium received by the Insurance Company and the section of Premium forwarded to the insurance brokerage company as remuneration for intermediary services (if using insurance brokerage services) (Explanation of Article 29 Law No. 40 of 2014) State the section in the Insurance Policy governing it e. There is a statement that "This Agreement has been adjusted to the provisions of laws and regulations including the provisions of the Financial Services Authority regulations" (Part III SEOJK No.13/SEOJK.07/2014)
3. Marketing Brochures
(Number 5 Appendix KEP104/BL/2006) Attach marketing brochure In marketing PAYDI, Insurance Companies are required to use brochures containing at least the following:
a. General explanation of insurance benefits explaining that the amount of Insurance Policy benefits depends on investment performance and other factors affecting Insurance Policy benefits; b. Explanation of investment strategy;
c. Description of risks borne by the policyholder;

13/20 d. Details of all costs charged to the policyholder including acquisition costs, management costs, and mortality costs; e. Withdrawal costs; f. Description of the basis for calculating Insurance Policy benefits; g. Description of the basis and frequency of fund valuation; h. Description of guarantees for policyholders if any, such as guaranteed minimum death benefits, maximum mortality load and other costs, minimum interest rate, minimum cash value, and guaranteed maturity benefits;
i. Illustration of benefit growth, including death insurance benefits, based on realistic assumptions and presented in graph or diagram form;
Assumptions used in investment return projection illustrations must at least include best, moderate, and worst assumptions j. Description of investment performance of each sub-fund of the reported PAYDI for at least the last 5 (five) years or for the actual period experienced by Insurance Companies selling the Insurance Product for less than 5 (five) years; k. Statement confirming that:
 benefit values may increase or decrease;  benefit growth as referred to in letter i is only an illustration;

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 sub-fund investment performance is not guaranteed to be the same as performance during the period referred to in letter j; and  benefit values may be smaller than the invested fund value, depending on whether there is a guaranteed benefit portion.
l. Information regarding cost details, benefits, and risks
(Roman numeral III SEOJK No.12/SEOJK.07/2014) m. Name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013) n. Statement that "The Insurance Company is registered and supervised by the Financial Services Authority" (Article 20 POJK No.1/POJK.07/2013)
4. Summary of Insurance Product Information
Summary of Insurance Product Information must at least contain:
a. name and type of Insurance Product; b. name of Insurance Company;
c. summary data;
d. benefits; e. risks; f. requirements and procedures; g. costs; h. simulation;
i. service procedures and complaint resolution procedures; and
j. other additional information.
(Article 8 POJK
No.1/POJK.07/2013 & Part VI SEOJK No.12/SEOJK.07/2014)
5. Example Application Letter Attach example SPAJ

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Life Insurance Application (SPAJ) containing items including information regarding the suitability between the customer profile and the offered Insurance Product
6. Premium Calculation
a. Premiums are consistent with promised benefits, set at levels that are sufficient, not excessive, and not applied discriminatorily (Article 3 POJK No.23/POJK.05/2015) State the section in the Insurance Product description containing the premium calculation formula b. Risk premium setting has considered all coverage scopes as described in the Insurance Product description or Insurance Policy specimen State the section in the Insurance Product description containing the premium calculation formula
c. The premium calculation formula in the Insurance Product description is consistent with the insurance benefits to be provided
State the section in the Insurance Product description containing the premium calculation formula d. Premium setting considers at least:
(Article 26 POJK
No.23/POJK.05/2015)
 Pure premium calculated based on risk profile, interest rate, mortality table, or morbidity table Explain the consistency between pure premium and risk profile data as referred to in Appendix VI  Interest rate State the interest rate assumption used  Acquisition costs State the proportion of acquisition cost components in gross premium

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 Administrative costs State the proportion of administrative cost components in gross premium  Other general costs State the proportion of other general cost components in gross premium  Estimated investment returns Attach investment return data and investment strategy supporting the estimated investment returns e. The premium calculation methodology for the new Insurance Product reported is consistent with general insurance principles and commonly used (best practice and common practice) f. Assumptions used in premium calculation use reasonable and realistic figures
7. Fund Development Reporting
(Number 8 Appendix KEP-104/BL/2006) Fund development reporting must contain at least the following:
a. details of all costs charged to the policyholder including acquisition costs, management costs, mortality costs, and additional coverage costs; b. sum insured for death at the end of the current period;
c. net cash value at the end of the current period;
d. policy loan balance, if any, at the end of the current period;

• 17/20
  e. net investment returns for at least the last (five) years, if available, for each sub-fund; f. investment composition details for each sub-fund per reporting date; g. unit value and price of sub-funds per valuation date for the current and previous periods (specifically for PAYDI unit link); h. unit value and price of sub-funds purchased in the current period (specifically for PAYDI unit link); and
  i. unit value and price of sub-funds sold in the current period (specifically for PAYDI unit link).

8. Cash Value
   (Article 12 KMK No.422/KMK.06/2003) The cash value must be at least equal to the accumulated funds to the policyholder
9. For General Insurance Products, underwriting projections related to the marketing of Insurance Products
   a.
   Underwriting projections refer to the company's underwriting surplus report containing a list and explanation of assumptions used at least:
    premium growth
    claim ratio
    profitability b. Reasonableness of premium income assumptions
   c. Reasonableness of claim expense assumptions
   d. Reasonableness of technical reserve assumptions

e. Reasonableness of cost assumptions f. Underwriting surplus is sufficiently adequate g. Elements in underwriting projections are complete
10. For Life Insurance Products, profit testing or asset share
a. Reasonableness of assumptions used b. Surplus from the reported Insurance Product is sufficiently adequate for the Insurance Company IV CONCLUSION All requirements for new PAYDI approval reporting have been fulfilled We, the undersigned, hereby declare that the assessment form above is consistent with the actual situation and has been completed with sufficient documents. …(filled with city name, date, month, and year) Board of Directors in charge of Insurance Product development (Filled with job title) Company Actuary (filled with Insurance Company name) (Name) (Name and registration number)

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We, the undersigned, hereby declare that the calculation of Premiums and technical reserves for Insurance Products …… [filled with the name of the Joint Insurance Product reported] has been in accordance with the applicable statutory regulations and is based on reasonable assumptions and common insurance practices. This statement is made truthfully. If it is later found that this statement is not true, we are willing to take responsibility and may be subject to sanctions in accordance with the applicable statutory regulations. …(filled with city name, date, month, and year) Company Actuary (filled with Insurance Company name) signature

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We, the undersigned, hereby declare that:

1. The Insurance Company meets the financial health level requirements;
2. The Insurance Company is not currently subject to administrative sanctions; and
3. The Insurance Product ..... [filled with the name of the Insurance Product reported]
   is included in the Insurance Company's business plan which has been approved by the shareholders. This statement is made truthfully. If it is later found that this statement is not true, we are willing to take responsibility and may be subject to sanctions in accordance with the applicable statutory regulations. …(filled with city name, date, month, and year) Board of Directors responsible for the development of Insurance Products (job title) signature (Name) Determined in Jakarta on 22 April 2016 EXECUTIVE HEAD OF SUPERVISION OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, ttd FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department ttd Yuliana

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APPENDIX IV
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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REPORTING FORM
JOINT INSURANCE PRODUCT APPROVAL FOR INSURANCE COMPANIES
I. ASSESSMENT FORM FOR REPORTING NEW JOINT INSURANCE PRODUCTS
GENERAL INFORMATION
Insurance Company Name
Chairman :
Members :
Name and Phone/email
Contact Person
Technical PIC:
Board of Directors responsible for the development of Insurance Products :
Number and Date of Reporting Letter Insurance Product Name Classification/Business Line Marketing Target Insurance Product Individual Insured Non-Individual Insured (Companies, etc.) Individual and Non-Individual Insured (Companies, etc.) Brief Description of Insurance Product

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1. Status of Insurance Product
   (Article 28 POJK No.23/POJK.05/2015) a. Never marketed before; or b. Changes to an Insurance Product already marketed where the changes include:
    risks covered including exclusions or restrictions on the causes of risks covered;  Premium formulation;  changes in risk category;  assumptions related to the formation of Premium formulation; and/or  method for calculating cash value. Provide a brief explanation of the changes made by the Insurance Company
2. Name of Insurance Product
   (Article 10 POJK No.23/POJK.05/2015) The name of the Insurance Product to be marketed meets the requirements:
   a. using the word insurance or a word with similar meaning; b. does not cause interpretation that the product is not an Insurance Product; and
   c. using the phrase
   “micro insurance” or a phrase with similar meaning (specifically for Micro Insurance Products). State the name of the Insurance Product to be reported The Insurance Product Name must be used consistently throughout all documents for the reporting of Insurance Products
3. New Insurance Products to
   be reported must be included in the Insurance Company's business plan (Article 28 POJK No.23/POJK.05/2015) State the title and date of the Insurance Company's business plan

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4. Fulfillment of Financial Health
Requirements and Compliance
(Article 30 POJK No.23/POJK.05/2015) a. Insurance Companies that are part of marketing and bearing the marketing of Joint Insurance Products have met the financial health level requirements State the achievement ratio of the last quarter's RBC for each Insurance Company that is part of marketing and bearing the marketing of Joint Insurance Products b. Insurance Companies that are part of marketing and bearing the marketing of Joint Insurance Products are not currently subject to administrative sanctions If an Insurance Company is subject to sanctions, state:

• type of violation
• sanction letter number
• type of sanction

5. Reporting of Joint Insurance
   Products is conducted by the Board of Directors of the Insurance Company designated as Chairman in marketing and bearing the marketing of Joint Insurance Products II ANALYSIS OF DOCUMENT COMPLETENESS (Article 32 and Article 33 POJK No.23/POJK.05/2015)
6. Cover letter signed by the Board of Directors
   of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach the cover letter
7. Premium income projections and expenses
   associated with the marketing of new Insurance Products for a period of 3 (three) years Attach:
    For Life Insurance Products profit testing or asset share accompanied by qualitative explanation of assumptions used (specifically for Premium growth, claim ratio, and profitability), as well as their relation to historical data; or  For General Insurance Products underwriting projections accompanied by

4/19 qualitative explanation of assumptions used (specifically for Premium growth, claim ratio, and profitability), as well as their relation to historical data
3. Description of new Insurance Product
Attach the description of the new Insurance Product as referred to in Appendix VI
4. Specimen of Insurance Policy Attach:

• Insurance Policy Terms
• Insurance Policy Summary accompanied by
  dummy coverage data
• Policy Certificate/membership proof accompanied by
  dummy coverage data
  (specifically for Group Insurance Products)
• example of participant list accompanied by
  dummy coverage data
  (specifically for Group Insurance Products)

5. Actuary's statement letter from each
   Insurance Company that is part of the marketing of Joint Insurance Products (Article 26 POJK No.23/POJK.05/2015) In accordance with the Actuary's statement letter as referred to in Roman numeral II of this Form
6. Director's statement letter from each
   Insurance Company that is part of the marketing of Joint Insurance Products stating that:
   a. The Insurance Company meets the financial health level requirements; b. The Insurance Company is not currently subject to administrative sanctions; and
   c. The Insurance Product reported
   is included in the
   Insurance Company's business plan Attach the statement letter

5/19 which has been approved by the shareholders. (Article 28 and Article 30 POJK No.23/POJK.05/2015)
7. Description of marketing methods and
example marketing kit (brochure, scratch card copy, telemarketing script, and other items) (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach example marketing kit
8. Summary of Insurance Product Information
(Part VI SEOJK No.12/SEOJK.07/2014) Attach example summary of Insurance Product Information (summary of Insurance Product Information is not a contract document and is different from offer documents such as brochures and leaflets and different from the Description of Insurance Products)
9. Example insurance application letter
(Article 16 POJK
No.1/POJK.07/2013)
Attach example insurance application letter
10. Risk profile, interest rate,
mortality or morbidity tables, estimated investment returns from Premiums, acquisition costs, administrative costs, and other general costs for calculating Premiums (for Life Insurance Products) (Article 26 POJK No.23/POJK.05/2015) Attach the mortality table or morbidity table used and data source
11. Loss profile (risk and loss
profile) of the relevant insurance type for at least 5 (five) years used for calculating Pure Premiums (for General Insurance Products) (Article 26 POJK No.23/POJK.05/2015) Attach the risk profile table containing information regarding sum insured, Premium income, claim values paid per year, for a period of at least 5 (five) years
12. Comparison matrix of
Insurance Products before and after changes (specifically for Insurance Products that have been marketed previously) Attach the matrix

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(Article 28 POJK
No.23/POJK.2015)
13. Written agreement document
for the marketing of Joint
Insurance Products that has been initialed by the Board of Directors from each Insurance Company that is part of the marketing of Joint Insurance Products (Article 33 POJK No.23/POJK.05/2015) Attach the draft written agreement III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Coverage
   a. Providing protection from at least 1 (one) type of insurable risk (Article 2 POJK No.23/POJK.05/2015) b. In accordance with the scope of business of each party and in accordance with the principles of insurance that are commonly applied (Article 5 and Article 9 POJK No.23/POJK.05/2015) State the insurance business line in accordance with the classification as referred to in
   Appendix VI for each
   Insurance Company that is part of the marketing of Joint Insurance Products
2. Insurance Policy
   a. Benefits agreed upon in the
   Insurance Policy have been in accordance with the description of the Insurance Product State the article in the Insurance Policy that regulates it b. Provisions within the Insurance Policy must at least contain the following:

1. General Provisions
   (Article 11 POJK
   No.23/POJK.05/2015) a) Effective date of coverage State the article in the Insurance Policy that regulates it

7/19 b) Description of agreed benefits State the article in the Insurance Policy that regulates it c) Method of Premium payment State the article in the Insurance Policy that regulates it d) Grace period (grace period) for Premium payment State the article in the Insurance Policy that regulates it e) Exchange rate used for Insurance Policies with foreign currency if Premium payment and benefits are linked to the rupiah currency. (except for Micro Insurance Products) State the article in the Insurance Policy that regulates it The exchange rate used for Insurance Policies with foreign currency must be an equivalent rate issued by Bank Indonesia at the time of payment (Article 16 POJK No.23/POJK.05/2015) f) Time recognized as the time of receipt of Premium payment State the article in the Insurance Policy that regulates it g) Company Policy established if Premium payment is made after the agreed grace period State the article in the Insurance Policy that regulates it h) Period during which the Insurance Company cannot review the validity of the insurance contract (incontestable period) for long-term Insurance Products State the article in the Insurance Policy that regulates it i) Cash value table, for Insurance Products that contain cash value. (except for Micro Insurance Products) State the article in the Insurance Policy that regulates it and attach the cash value
table (if any)
j) Dividend calculation State the article in the Insurance

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Policy or similar, for
Insurance Products that promise dividends for Insurance Products or similar. (except for Micro Insurance Products) Policy that regulates it (if any) k) Termination clause of coverage, both from the Insurance Company or from the policyholder, insured, or participant, including conditions and causes State the article in the Insurance Policy that regulates it l) Conditions and procedures for filing claims, including relevant supporting evidence required in claim filing State the article in the Insurance Policy that regulates it m) Procedures for claim settlement and payment State the article in the Insurance Policy that regulates it n) Dispute resolution clause which among others contains mechanisms for settlement in court or out of court and selection of venue for dispute resolution (except for Micro Insurance Products) State the article in the Insurance Policy that regulates it Dispute resolution out of court is conducted through an Alternative Dispute Resolution Institution (LAPS) which is included in the list of LAPS established by OJK o) Language used as reference in case of disputes or differences of opinion, for Insurance Policies printed in 2 State the article in the Insurance Policy that regulates it

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(two) languages or more p) contains a section on risks to be covered by each Insurance Company that is part of the marketing of Joint Insurance Products (Article 15 paragraph POJK No.23/POJK.05/2015) State the article in the Insurance Policy that regulates it
2) Dispute Resolution Provisions
(Article 17 and Article 18 POJK
No.23/POJK.05/2015) a) There are no provisions in the Insurance Policy that can be interpreted as preventing the policyholder, insured, or participant from taking legal action so that the policyholder, insured, or participant must accept the rejection of claim payment b) There are no provisions in the Insurance Policy that can be interpreted as restricting legal action by the parties in case of disputes regarding the provisions of the Insurance Policy c) Provisions in the Insurance Policy regarding dispute resolution for insurance agreements conducted out of court, must provide State the article in the Insurance Policy that regulates it Dispute resolution out of court is conducted through an Alternative Dispute Resolution Institution (LAPS) which is included in the list of LAPS established by

10/19 alternative options for dispute resolution namely through alternative dispute resolution institutions as regulated in statutory regulations regarding alternative dispute resolution institutions in the financial services sector (except for Micro Insurance Products) OJK d) Provisions in the Insurance Policy regarding dispute resolution for insurance agreements conducted through court must not restrict the choice of court only to the district court at the location of the Insurance Company's domicile
c. The Insurance Policy must
be signed by:
(Article 15 POJK
No.23/POJK.05/2015
)
i. All Insurance
Companies that are part of the marketing of Joint Insurance Products; or
ii. The Insurance
Company that acts as the leader in the marketing of Joint Insurance Products

11/19 d. Insurance Policies issued and marketed within the jurisdiction of Indonesia must be made in the Indonesian language. In case of need, Insurance Policies may be issued in foreign languages or regional languages alongside the Indonesian language (Article 20 POJK No.23/POJK.05/2015) e. The Specimen of Insurance Policy must include the section of Premiums received by the Insurance Company and the section of Premiums forwarded to the insurance brokerage company as remuneration for brokerage services (if brokerage services are used) (Explanation of Article 29 Law No 40 of 2014) State the section in the Insurance Policy that regulates it f. There is a statement that “This Agreement has been adjusted with the provisions of statutory regulations including provisions of the regulations of the Financial Services Authority” (Part III SEOJK No.13/SEOJK.07/2014)
3. Marketing Kit
a. Contains information regarding cost details, benefits, and risks (Roman numeral III SEOJK No.12/ SEOJK.07/2014) b. Contains the name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013)

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c. Contains a statement
that “The Insurance
Company is registered and supervised by the Financial Services Authority” (Article 20 POJK No.1/POJK.07/2013) d. Information regarding the share of risks covered by each Insurance Company that is part of the marketing of Joint Insurance Products
4. Summary of Insurance Product Information
a. The summary of
Insurance Product Information must at least contain:

1. name and type
   of Insurance Product;
2. name of the
   Insurance Company;
3. summary data;
4. benefits;
5. risks;
6. requirements and procedures;
7. costs;
8. simulation;
9. service procedures and
   complaint resolution; and
10. other additional
    information.
    (Article 8 POJK
    No.1/POJK.07/2013 jo
    Part VI SEOJK
    No.12/SEOJK.07/2014) b. Information regarding the share of risks covered by each Insurance Company that is part of marketing and bearing the marketing of Joint Insurance Products

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5. Example Insurance Application Letter
Attach example insurance application letter containing items including information regarding the suitability between the customer profile and the offered Insurance Product
6. Premium Calculation
a. Premiums that are in accordance with the benefits promised, which are set at a level that is sufficient, not excessive, and not applied in a discriminatory manner (Article 3 POJK No.23/POJK.05/2015) State the section in the Insurance Product description that contains the Premium formulation b. The setting of risk Premiums has taken into account the entire coverage as described in the description of the Insurance Product or specimen of the Insurance Policy State the section in the description of the Insurance Product that contains the Premium formulation
c. For General Insurance risk Premiums,
there is a clear formulation in the calculation of risk Premiums including there is relevance between risk profile data and risk Premium rates State the section in the description of the Insurance Product that contains the Premium formulation d. For Life Insurance risk Premiums, the Premium formulation in the Insurance Product description has been in accordance with the insurance benefits to be provided State the section in the description of the Insurance Product that contains the Premium formulation

e. Calculation of cost components within for General Insurance risk Premiums, there is a clear formulation in the calculation of Premiums including there is relevance between cost data and cost rates set by the Insurance Company for the reported Insurance Product State the section in the description of the Insurance Product that contains the Premium formulation f. Premium calculation methodology for new products reported has been in accordance with the principles of insurance that are commonly applied and commonly used (best practice and common practice) g. Premium setting considers at least (Article 26 POJK No.23/POJK.05/2015)  For Life Insurance risks, Pure Premiums calculated based on risk profiles, interest rates, mortality tables, or morbidity tables Explain the suitability between Pure Premiums and risk profile data as referred to in Appendix VI  For General Insurance risks, Pure Premiums calculated based on loss profiles (risk and loss profile) of the relevant insurance type for at least 5 (five) years Explain the suitability between Pure Premiums and risk profile data as referred to in Appendix VI  Interest rates (for Life Insurance risks) State the interest rate assumption used

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 Estimated investment returns (for Life Insurance risks) Attach investment return data and investment strategy supporting the estimated investment returns  Acquisition Costs State the proportion of acquisition cost components in Gross Premiums  Administrative Costs State the proportion of administrative cost components in Gross Premiums  Other General Costs State the proportion of other general cost components in Gross Premiums
7. For General Insurance Products, underwriting projections associated
with the marketing of Insurance Products a. Underwriting projections refer to the company's underwriting surplus report containing a list and explanation of assumptions used at least:
 Premium growth
 Claim ratio
 Profitability b. There is reasonableness in Premium income assumptions
c. There is reasonableness in claim expense assumptions
d. There is reasonableness in technical reserve assumptions e. There is reasonableness in cost assumptions f. Underwriting surplus is sufficiently adequate g. Elements in underwriting projections are complete
8. For Life Insurance Products, profit testing or
asset share a. There is reasonableness in the assumptions used.

16/19 b. Surplus from the reported Insurance Product is sufficiently adequate for the Insurance Company.
9. Written Agreement Document
(Article 6 POJK No.23/POJK.05/2015) The written agreement must at least contain the following:
a. Membership structure, including the Insurance Company that acts as the leader (leader) who will coordinate the activities of marketing the Joint Insurance Product in question; b. Duties of the leader;
c. Risk sharing for each
Insurance Company that is part of the marketing of Joint Insurance Products in accordance with the scope of business of each Insurance Company; d. Procedures for Premium payment by the policyholder; e. Underwriting procedures, receipt procedures, and forwarding of Premiums, as well as procedures for claim settlement and payment; and f. Dispute resolution procedures between Insurance Companies that are part of the marketing of Joint Insurance Products. IV CONCLUSION All reporting requirements for approval of new Joint Insurance Products have been met

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We, the undersigned, hereby declare that the assessment form above has been in accordance with the actual situation and has been completed with sufficient documents. ...(filled with city name, date, month, and year) Board of Directors responsible for the development of Insurance Products Company Actuary (Filled with the name of the Insurance Company acting as Chairman) (Filled with the name of the Insurance Company) As Chairman signature signature (Name) (Name and registration number)

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We, the undersigned, hereby declare that the calculation of Premiums and technical reserves for Insurance Products …… [filled with the name of the Joint Insurance Product reported] has been in accordance with the applicable statutory regulations and is based on reasonable assumptions and common insurance practices. This statement is made truthfully. If it is later found that this statement is not true, we are willing to take responsibility and may be subject to sanctions in accordance with the applicable statutory regulations. ...(filled with city name, date, month, and year) Company Actuary PT. ... (filled with the name of the Insurance Company) Company Actuary PT. .. (filled with the name of the Insurance Company) signature signature (Name and registration number) (Name and registration number) Company Actuary PT. ... (filled with the name of the Insurance Company) Company Actuary PT. .. (filled with the name of the Insurance Company) signature signature (Name and registration number) (Name and registration number)

19/19
We, the undersigned, hereby declare that each Insurance Company under our authority has:

1. met the financial health level requirements;
2. is not currently subject to administrative sanctions, to market the Insurance
   Product ... [filled with the name of the Joint Insurance Product reported]; and
3. includes the Insurance Product ... [filled with the name of the Joint Insurance Product
   reported] in the Insurance Company's business plan which has been approved by the shareholders. This statement is made truthfully. If it is later found that this statement is not true, we are willing to take responsibility and may be subject to sanctions in accordance with the applicable statutory regulations. ...(filled with city name, date, month, and year) Board of Directors responsible for the development of Insurance Products As Chairman signature (Name) Board of Directors responsible for the development of Insurance Products [Filled with the name of the Insurance Company] As Member signature (Name) Board of Directors responsible for the development of Insurance Products [Filled with the name of the Insurance Company] As Member signature (Name) Determined in Jakarta on 22 April 2016 EXECUTIVE HEAD OF SUPERVISION OF INSURANCE, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, ttd FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department ttd Yuliana

APPENDIX V
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 ON INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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REPORTING FORM
APPROVAL OF CREDIT INSURANCE AND/OR SURETYSHIP PRODUCTS FOR GENERAL INSURANCE COMPANIES

I. REPORTING ASSESSMENT FORM FOR CREDIT INSURANCE AND/OR SURETYSHIP PRODUCT APPROVAL

GENERAL INFORMATION
Insurance Company Name:
Contact Person Name and Phone/e-mail:
Technical PIC:
Board of Directors in charge of Insurance Product Development:
Reporting Letter Number and Date:
Insurance Product Name:
Insurance Credit Line of Business Classification:
Suretyship
Marketing Target for Insurance Product:
Individual Insured
Non-Individual Insured (Companies, etc.)
Individual and Non-Individual Insured (Companies, etc.) Brief Description of Insurance Product:

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1. Insurance Product Status
   (Article 28 POJK No.23/POJK.05/2015) a. Has never been marketed; or b. Modification of an Insurance Product already marketed, where the modification includes:

• risks covered, including exclusions or restrictions on the causes of risks covered;
• formulation of Premium or remuneration;
• change of risk category;
• assumptions related to the formulation of Premium or remuneration; and/or
• calculation method for cash value.
  Provide a brief explanation of the changes made by the Insurance Company.

2. Insurance Product Name
   (Article 10 POJK No.23/POJK.05/2015) The name of the Insurance Product to be marketed must meet the requirements:
   a. using the word insurance or synonymous words; and b. not creating an interpretation that the product is not an Insurance Product. State the name of the Insurance Product to be reported. The Insurance Product Name must be used consistently in all Insurance Product reporting documents.

3. New Insurance Products reported must be included in the Insurance Company's business plan
   (Article 28 POJK No.23/POJK.05/2015) State the title and date of the Insurance Company's business plan.

4. Fulfillment of Financial Health and Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015) a. The Company meets the solvency ratio requirements State the achievement ratio of the last quarter's RBC.

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b. The Company meets the requirements for the ratio of investment balance and technical reserves as well as obligations for payment of retained claims State the ratio of the last quarter.
c. The Company meets the minimum liquidity ratio of 150% (one hundred fifty percent)
State the ratio of the last quarter. d. The Company has own funds of at least 250 billion Rupiah (applicable only to Insurance Companies that will market credit insurance and guarantees on the implementation of payment obligations from credit transactions) State the own funds of the last quarter. e. The Insurance Company is not currently subject to administrative sanctions If the Insurance Company is subject to sanctions, state:

• type of violation
• sanction letter number
• type of sanction
  f. The Insurance Company has experts with AAIK qualifications or foreign association expert titles that are assessed by OJK to be equivalent to AAMAI Attach:
• Photocopy of the Decree of Appointment as an Insurance Company expert
• Photocopy of the expert certificate in the name of the aforementioned expert
  g. The Company has experts with AAAIK qualifications or foreign association junior expert titles that are assessed by the Financial Services Authority to be equivalent to AAMAI, assigned to manage the credit insurance or suretyship line of business, with the following requirements:
• Experience as an underwriter for credit insurance and suretyship lines of business for at least 3 (three) years
• Has previously attended education and training for credit insurance and suretyship lines of business
  Attach:
• Photocopy of the Decree of Appointment as a manager of the credit insurance or suretyship line of business
• Photocopy of the expert certificate in the name of the aforementioned expert
• Photocopy of the training certificate in the name of the aforementioned expert
• Curriculum vitae list of the aforementioned expert

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h. The Company has employees assigned to manage the credit insurance or suretyship line of business who have attended specialized education and training in the field of credit insurance or suretyship, including at branches marketing Insurance Products in the credit insurance or suretyship line of business Attach:

• List of employees managing the credit insurance or suretyship line of business
• Photocopy of the training certificate in the name of the aforementioned employee
  i. Has underwriting manuals for each Insurance Product in the credit insurance or suretyship line of business marketed, which reflect that the risk selection process is carried out carefully and in accordance with general insurance practices
  Attach the underwriting manual approved by the Board of Directors. j. Has an information system that allows debtors or principals, creditors or obligees, and OJK to check the validity of the issuance of specific credit insurance or suretyship Attach a screenshot of the user interface of the information system.

II
ANALYSIS OF DOCUMENT COMPLETENESS (Article 32 and Article 34 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Board of Directors of the Insurance Company
   (Article 29 POJK No.23/POJK.05/2015) Attach the cover letter.

2. Projection of Premium or remuneration income and expenses associated with the marketing of new Insurance Products for a period of 3 (three) years
   Attach the underwriting projection completed with qualitative explanations of the assumptions used (specifically for the growth of Premium or remuneration, claim ratio, and profitability), as well as its relation to historical data.

3. Description of new Insurance Products
   Attach the description of new Insurance Products as referred to in Appendix VI.

4. Specimen of Insurance Policy or other documents containing credit insurance or suretyship agreements
   Attach:

• Insurance Policy Terms
• Policy Summary or guarantee certificate issued by the Insurance Company accompanied by dummy coverage data.

5. Actuarial Statement Letter of the Company
   (Article 26 POJK No.23/POJK.05/2015) As per the Actuarial Statement Letter of the Company as referred to in Roman numeral II of this Form.

6. Board of Directors Statement Letter stating that:
   a. The Company meets the financial health ratio requirements; b. The Company is not currently subject to administrative sanctions;
   c. The reported Insurance Product is included in the Insurance Company's business plan approved by the shareholders;
   d. The Company meets the requirements for the ratio of investment balance and technical reserves as well as obligations for payment of retained claims; e. The Company meets the minimum liquidity ratio of 150% (one hundred fifty percent); and f. The Company has own funds of at least 250 billion Rupiah (applicable only to Insurance Companies that will market credit insurance and guarantees on the implementation of payment obligations from credit transactions). (Article 28 and Article 30 POJK No.23/POJK.05/2015 and Article 4 PMK No.124/PMK.010/2008) Attach the statement letter of this Form.

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7. Description of marketing methods and examples of marketing kits (brochures, scratch card copies, etc.)
   (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach examples of marketing kits.

8. Summary of Insurance Product Information
   (Part VI SEOJK No.12/SEOJK.07/2014) Attach examples of Insurance Product Information summaries (Insurance Product Information summaries are not agreement documents and differ from offer documents such as brochures and leaflets, and differ from Insurance Product descriptions).

9. Example of Insurance Request Application Letter (SPPA)
   (Article 16 POJK No.1/POJK.07/2013) Attach example SPPA.

10. Loss profile (risk and loss profile) of the relevant insurance type for at least 5 (five) years to calculate Premium or remuneration
    (Article 26 POJK No.23/POJK.05/2015) Attach the risk and loss profile table containing information regarding coverage amounts, Premium or remuneration income, and claim values paid per year, for a period of at least 5 (five) years.

11. Comparison Matrix of Insurance Products before and after changes (specifically for Insurance Products previously marketed)
    (Article 28 POJK No.23/POJK.05/2015) Attach the matrix.

12. Reporting Form for Joint Insurance Product Approval in the event that credit insurance and/or suretyship is marketed together with other Insurance Companies
    Attach the form as referred to in Appendix IV.

III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Coverage Object
   a. Provides protection from at least 1 (one) type of insurable risk (Article 2 POJK No.23/POJK.05/2015) b. Consistent with the scope of business of General Insurance Companies and in accordance with general insurance principles (Article 9 POJK No.23/POJK.05/2015) State the general insurance line of business with classification as referred to in Appendix VI.
   c. The type of guarantee provided is credit guarantee or suretyship guarantee
   State the type of guarantee provided.

2. Specimen of Insurance Policy or other documents containing credit insurance or suretyship agreements
   a. The benefits agreed upon in the Insurance Policy/specimen/guarantee certificate are consistent with the Insurance Product description. b. Must state the tariff amount (Premium or remuneration). The Premium or remuneration tariff is stated in the certificate/Insurance Policy specimen.
   c. The provisions within the Insurance Policy/specimen/guarantee certificate must contain at least the following:

1. General Provisions (Article 11 POJK No.23/POJK.05/2015)

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a) Coverage effective date
State the article in the Insurance Policy governing it. b) Description of agreed benefits State the article in the Insurance Policy governing it. c) Payment method for Premium or remuneration State the article in the Insurance Policy governing it. d) Grace period for Premium or remuneration payment State the article in the Insurance Policy governing it. e) Exchange rate used for Insurance Policies in foreign currency if Premium or remuneration payment and benefits are linked to the Rupiah currency State the article in the Insurance Policy governing it. The exchange rate used for Insurance Policies in foreign currency must be an equivalent rate issued by Bank Indonesia at the time of payment. (Article 16 POJK No.23/POJK.05/2015) f) Time recognized as the time of receipt of Premium or remuneration payment State the article in the Insurance Policy governing it. g) Insurance Company policy established if Premium or remuneration payment is made after the agreed grace period State the article in the Insurance Policy governing it. h) Coverage termination clauses, from both the Insurance Company and the policyholder, insured, or participant, including conditions and causes State the article in the Insurance Policy governing it. i) Conditions and procedures for claim submission, State the article in the Insurance Policy governing it.

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including relevant supporting documents required for claim submission. j) Claim settlement and payment procedures State the article in the Insurance Policy governing it. k) Dispute resolution clauses, which include dispute resolution mechanisms in and out of court, and the choice of dispute resolution venue (except for Micro Insurance Products) State the article in the Insurance Policy governing it. Dispute resolution out of court is conducted through an Alternative Dispute Resolution Institution (LAPS) included in the LAPS list established by OJK. l) Language used as reference in case of disputes or differences of opinion, for Insurance Policies printed in 2 (two) or more languages State the article in the Insurance Policy governing it.

2. Dispute Resolution Provisions (Article 17 and Article 18 POJK No.23/POJK.05/2015)
   a) There are no provisions in the Insurance Policy that can be interpreted as preventing the policyholder, insured, or participant from taking legal action, thereby forcing the policyholder, insured, or participant to accept claim rejection. b) There are no provisions in the Insurance Policy that can be interpreted as restricting legal action by the parties in case of disputes regarding Insurance Policy provisions. c) Provisions in the Insurance Policy regarding dispute resolution for insurance agreements conducted out of court provide alternative dispute resolution options through alternative dispute resolution institutions as regulated in laws and regulations regarding alternative dispute resolution institutions in the financial services sector (except for Micro Insurance Products) State the article in the policy governing it. Dispute resolution out of court is conducted through an Alternative Dispute Resolution Institution (LAPS) included in the LAPS list established by OJK. d) Provisions in the Insurance Policy regarding dispute resolution for insurance agreements conducted through courts do not restrict the choice of court only to the district court at the location of the Insurance Company.

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d. Insurance Policies issued and marketed within the Indonesian legal jurisdiction must be in the Indonesian language. If necessary, Insurance Policies may be issued in foreign or regional languages alongside the Indonesian language. (Article 20 POJK No.23/POJK.05/2015) e. The Insurance Policy specimen must state the portion of Premium or remuneration received by the Insurance Company and the portion of Premium or remuneration forwarded to the insurance brokerage company as remuneration for brokerage services (if using insurance brokerage services). (Explanation of Article 29 Law No. 40 of 2014) State the section in the Insurance Policy governing it. f. There is a statement that "This agreement has been adjusted to the provisions of laws and regulations, including Financial Services Authority regulations." (Part III SEOJK No.13/SEOJK.07/2014)

3. Marketing Kit
   a. Contains information regarding cost details, benefits, and risks (Roman numeral III SEOJK No.12/SEOJK.07/2014) b. Contains the name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013)
   c. Contains the statement that "The Insurance Company is registered and supervised by the Financial Services Authority" (Article 20 POJK No.1/POJK.07/2013)

4. Insurance Product Information Summary
   The Insurance Product Information Summary must contain at least:
   a. name and type of Insurance Product; b. Insurance Company name;
   c. summary data;
   d. benefits; e. risks; f. requirements and procedures; g. costs; h. simulations;
   i. service procedures and complaint resolution procedures; and
   j. additional information.
   (Article 8 POJK No.1/POJK.07/2013 and Part VI SEOJK No.12/SEOJK.07/2014)

5. Example of Insurance Request Application Letter (SPPA)
   Attach example SPPA containing matters including information regarding the suitability between the customer profile and the offered Insurance Product.

6. Premium Calculation
   a. The Insurance Company has determined the amount of Premium or remuneration tariffs. b. The determination of Premium or remuneration tariff elements must be supported by reasonable and sufficient data and/or assumptions.
   c. Acquisition cost elements in tariff determination are at most 20% (twenty percent) of the Premium or remuneration tariff.
   d. Premium or remuneration tariffs appropriate to the promised benefits, determined at sufficient levels, not excessive, and not determined discriminatorily. State the section in the Insurance Product description containing the formulation for calculating Premium or remuneration. e. There is a clear formulation in tariff calculation for risks, including relevance between risk profile data and risk tariffs. State the section in the Insurance Product description containing the formulation for calculating Premium or remuneration. f. Determination of Premium or remuneration considers at least (Article 26 POJK No.23/POJK.05/2015)

• Risk tariffs calculated based on the loss profile (risk and loss profile) of the relevant insurance type for at least 5 (five) years of the last period
  Explain the correspondence between pure Premium and risk profile data as referred to in Appendix VI.
• Acquisition costs State the proportion of acquisition cost components in gross Premium or remuneration.
• Administrative costs State the proportion of administrative cost components in gross Premium or remuneration.
• Profits State the proportion of profits in gross Premium or remuneration.

g. There is a clear formulation in the calculation of cost components in the calculation of Premium or remuneration or including relevance between cost data and cost tariffs set by the Insurance Company for the reported Insurance Product. State the section in the Insurance Product description containing the formulation for calculating Premium or remuneration. h. The methodology for calculating Premium or remuneration for the reported new Insurance Product has been consistent with general insurance principles and commonly used (best practice and common practice).

7. Guarantee Value Limits (Article 7 PMK 124/PMK.010/2008)
   a. Gross Guarantee Limits State in the underwriting manual. b. Retention Guarantee Limits State in the underwriting manual.

8. Underwriting Projection
   a. There is fairness in Premium income assumptions. b. There is fairness in claim expense assumptions.
   c. There is fairness in technical reserve assumptions.
   d. There is fairness in cost assumptions. e. Underwriting surplus is sufficiently adequate. f. Elements in the underwriting projection are complete.

IV CONCLUSION
All requirements for reporting approval of credit insurance and/or suretyship products have been met.

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We, the undersigned, hereby declare that the aforementioned assessment form is consistent with the actual situation and has been completed with sufficient documents. (to be filled with city name, date, month, and year) Board of Directors in charge of Insurance Product Development (to be filled with job title) Company Actuary (to be filled with Company name) signature signature (Name) (Name and registration number)

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We, the undersigned, hereby declare that the Premium or remuneration calculation and technical reserves for the Insurance Product …… [filled with the name of the reported Insurance Product] are consistent with the provisions of applicable laws and regulations and are based on reasonable assumptions and general insurance practices. This statement is made truthfully. If it is later found that this statement is incorrect, we are willing to be responsible and subject to sanctions according to applicable laws and regulations. … (to be filled with city name, date, month, and year) Company Actuary (to be filled with Company name) signature

11/17

We, the undersigned, hereby declare that:

1. The Insurance Company meets the financial health ratio requirements;
2. The Insurance Company is not currently subject to administrative sanctions;
3. The Insurance Product ..... [filled with the name of the reported Insurance Product] is included in the Insurance Company's business plan approved by the shareholders;
4. Meets the requirements for the ratio of investment balance and technical reserves as well as obligations for payment of retained claims;
5. Meets the minimum liquidity ratio of 150% (one hundred fifty percent); and
6. Has own funds of at least 250 billion Rupiah (for Credit Insurance Products).
   This statement is made truthfully. If it is later found that this statement is incorrect, we are willing to be responsible and subject to sanctions according to applicable laws and regulations. … (to be filled with city, date, month, and year) Board of Directors in charge of Insurance Product Development (job title) signature (Name)

Established in Jakarta on April 22, 2016 EXECUTIVE HEAD OF INSURANCE, PENSION FUND, LEMBAGA PEMBIAYAAN, AND OTHER FINANCIAL SERVICES INSTITUTIONS SUPERVISOR FINANCIAL SERVICES AUTHORITY, signature FIRDAUS DJAELANI Copy consistent with the original Legal Director 1 Legal Department signature Yuliana

APPENDIX VI
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 ON INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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INSURANCE PRODUCT DESCRIPTION

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A. GENERAL INSURANCE
Part A.I

1 Product Name State the name of the Insurance Product to be marketed.

2 Insurance Company Name State the Insurance Company name.

3 Chairman Name specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

Member 1 Name specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

Member 2 Name specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

Member 3 Name specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

Member 4 Name specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

Member 5 Name specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

etc. specific for Joint Insurance Products (PAB) and Insurance Products marketed via consortium.

4 Line of Business of Insurance Product a) Select the type of line of business according to the provided classification.

5 Type of Insurance Product a. Standard or non-standard b) Select the type of Insurance Product as standard or non-standard. b. Individual or group c) Select the type of Insurance Product as individual or group.

6 Benefits or Risks Guaranteed a. Insurance benefits or risks guaranteed Describe the insurance benefits and risks guaranteed in the policy. b. Excluded risks Describe the risks excluded in the policy.
c. Clarity regarding risk sharing (specific for PAB)
Describe risk sharing according to the scope of business (specific for PAB).

7 Characteristics of Insurance Product a. Underwriting provisions describe underwriting provisions. b. Coverage period describe the coverage period (1 month, 1 year, 10 years, etc.).
c. Premium payment scheme
describe the Premium payment scheme (e.g., annual, monthly, quarterly, lump sum,

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etc.)

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...)

d. Payment method
Premium describe the premium payment method (e.g., cash, transfer, autodebit, credit card, etc.)

e. Currency (Rupiah,
USD, others) d)
Select currency (Rupiah, USD, others) d)

8 Risk Profile and Loss Data a. Risk premium rate (based on risk profile data for the last 5 years) State the risk premium rate based on 5-year last data for similar Insurance Products b. Percentage (%) of loss ratio (loss ratio) State the percentage (%) loss ratio (loss ratio) based on 5-year last data for similar Insurance Products
c. Percentage (%) of
acquisition costs
State the percentage (%) acquisition costs based on 3-year last data for similar Insurance Products d. Percentage (%) of administrative and general costs State the percentage (%) administrative and general costs based on 3-year last data for similar Insurance Products

9 Gross Premium Composition
(total a+b+c+d+e = 100%) a. Pure premium (%) State the allocation of pure premium in percentage (%) and total premium composition must be 100% b. Acquisition costs (%) State the allocation of acquisition costs in percentage (%) and total premium composition must be 100%
c. Administrative costs (%) State the allocation of administrative costs in
percentage (%) and total premium composition must be 100% d. Profit margin (%) State the allocation of profit margin in percentage (%) and total premium composition must be 100% e. Others (%) State the allocation of other costs in percentage (%) if any and state

10 Reinsurance Treaty Support Description a. Reinsurance Company Identity Reinsurance treaty leader b. Type of reinsurance State the type of reinsurance used (e.g., surplus, quota share, excess of loss, etc.)
c. Amount of own retention
State the amount of own retention

11 Marketing Description a. Distribution channel e) Select distribution channel according to the provided classification b. Marketing media describe the marketing media used (e.g., telemarketing, scratch card, website, brochures, etc.)

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c. Marketing target f) select marketing target according to the
provided classification

12 Specifically for name changes or reporting other names a. Initial Insurance Product Name according to registration letter State the initial Insurance Product name according to the registration letter (specifically for name changes or reporting other names) b. Number of letter approval or registration State the number of approval or registration letter for the Insurance Product before change
c. Date of letter
approval or registration
State the date of approval or registration letter for the Insurance Product before change

Note:
If submitted in softcopy format, it must be arranged in spreadsheet format

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Part A.II

1. Premium or service fee calculation:
   (Article 26 POJK No.23/POJK.05/2015) a. Formula for calculating pure premium based on loss profile (risk and loss profile) of the relevant insurance type for at least 5 (five) years last b. Cost assumptions or loading (acquisition costs, administrative costs, and other general costs) and profit margin
   c. Basis for setting administrative and general costs using cost data
   for at least 3 (three) years last d. Gross premium range e. Sum insured range

2. Technical Reserve Calculation Formula
   a. Premium reserve formula

b. Claim reserve formula

Part A.III

Describe additional information regarding the Insurance Product being reported

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Note:
a)
Business Line
Property
Motor Vehicles
Transportation
Ship Hull
Aircraft Hull
Satellite
Offshore Energy
Onshore Energy
Engineering
Liability
Personal Accident
Health
Credit
Suretyship
Miscellaneous
Others

b)
Type of Insurance Product 1
Standard Product
Non-standard Product

c)
Type of Insurance Product 2
Individual (person)
Group (group)

d)
Currency
Rupiah
USD
Others

e)
Distribution Channel
Directly (direct marketing)
Insurance agent
Bancassurance
Non-bank business entity (state....)

f)
Marketing Target
Individual Participants
Non-Individual Participants (companies, etc.)
Individual and Non-Individual Participants (companies, etc.)

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B. LIFE INSURANCE

Part B.I

1 Product Name State the name of the Insurance Product to be marketed

2 Insurance Company Name State the name of the Insurance Company

3 Name of Chairman specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium Name Member 1 specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium Name Member 2 specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium Name Member 3 specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium Name Member 4 specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium Name Member 5 specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium etc. specifically for Joint Insurance Products (PAB) and Insurance Products marketed via consortium

4 Business Line of
Insurance Product a)
Select business line type according to the provided classification

5 Type of Insurance Product a. Standard or non-standard Select standard or non-standard Insurance Product type b. Individual or group b) Select individual or group Insurance Product type
c. Traditional or
non-traditional c)
Select traditional or non-traditional Insurance Product type d. Unitized or non-unitized (specifically for PAYDI) d) Select unitized or non-unitized Insurance Product type

6 Benefits or Risks Covered a. Insurance benefits or risks covered Describe insurance benefits and risks covered in the policy b. Risks excluded describe risks excluded in the policy
c. Clarity regarding risk
sharing (specifically for
PAB) describe risk sharing according to business scope (specifically for PAB)

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7 Insurance Product Characteristics a. Underwriting regulations describe underwriting regulations
i. type of underwriting e) select type of underwriting used
according to the provided classification
ii. minimum or
maximum sum insured describe minimum and maximum age that can be covered b. Coverage period describe coverage period (1 month, 1 year, 10 years, etc.)
c. Premium payment scheme
describe premium payment scheme (e.g., annual, monthly, quarterly, lump sum, etc.) d. Payment method Premium describe premium payment method (e.g., cash, transfer, autodebit, credit card, etc.) e. Currency (Rupiah, USD, others) f) Select currency (Rupiah, USD, others) f)

8 Gross Premium Composition
(total a+b+c+d+e = 100%) a. Pure premium (%) State the allocation of pure premium in percentage (%) and total premium composition must be 100% b. Acquisition costs (%) State the allocation of acquisition costs in percentage (%) and total premium composition must be 100%
c. Administrative costs (%) State the allocation of administrative costs
in percentage (%) and total premium composition must be 100% d. Profit margin (%) State the allocation of profit margin in percentage (%) and total premium composition must be 100% e. Others (%) State the allocation of other costs in percentage (%) if any and state

9 Interest Rate Assumptions a. Premium calculation describe the interest rate assumption in premium calculation b. Technical reserve calculation describe the interest rate assumption in technical reserve calculation

10 Type of Mortality or Morbidity Table a. Premium calculation State the type of mortality or morbidity table used as the basis for premium calculation b. Technical reserve calculation state the type of mortality or morbidity table used as the basis for technical reserve calculation

11 Reinsurance Treaty Support Description a. Reinsurance Company Identity Reinsurance treaty leader

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b. Type of reinsurance State the type of reinsurance used (e.g., surplus, quota share, excess of loss, etc.)
c. Amount of own retention State the amount of own retention

12 Marketing Description a. Distribution channel g) Select distribution channel according to the provided classification b. Marketing Media describe marketing media used (e.g., telemarketing, scratch card, website, brochures, etc.)
c. Marketing target h) select marketing target according to the provided
classification

13 Specifically for name changes or reporting other names a. Initial Insurance Product Name according to registration letter State the initial Insurance Product name according to registration letter (specifically for name changes or reporting other names) b. Number of letter approval or registration State the number of approval or registration letter for the Insurance Product before change
c. Date of letter
approval or registration
State the date of approval or registration letter for the Insurance Product before change

Note:
If submitted in softcopy format, it must be arranged in spreadsheet format

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Part B.II

1. Premium or Service Fee Calculation:
   (Article 26 POJK No.23/POJK.05/2015) a. Formula for calculating pure premium based on risk profile, interest rate, mortality table, or morbidity table b. Estimated investment return from Premium
   c. Cost assumptions or loading (acquisition costs, administrative costs, and
   other general costs) and profit margin d. Gross premium range e. Sum insured range f. Interest rate used to calculate Premium (including explanation regarding the basis for setting interest rate, which considers historical investment returns) g. Type of mortality or morbidity table used

2. Net Present Value Calculation Formula (for Insurance Products
   containing cash value)

3. Technical Reserve Calculation Formula
   a. Premium Reserve Formula b. Claim Reserve Formula

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Part B.III

Describe additional information regarding the Insurance Product being reported)

Note:
a)
Business Line
Personal Accident
Health
Term Insurance
Term Endowment
Whole Life
Whole Life Combination
General Annuity
Pension Fund Annuity
PAYDI
Others

b)
Type of Insurance Product 1
Standard
Non-standard

c)
Type of Insurance Product 2
Individual (person)
Group (group)

d)
Type of Insurance Product 3
Traditional Product
Non-traditional Product

e)
Type of Product 4
PAYDI - unitized (unit link)
PAYDI – non-unitized

f)
Type of Underwriting
Guaranteed acceptance
Non-guaranteed acceptance
Simplified underwriting

g)
Currency
Rupiah
USD
Others

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h)
Distribution Channel
Directly (direct marketing)
Insurance agent
Bancassurance
Non-bank business entity (state....)

i)
Marketing Target
Individual Participants
Non-Individual Participants (companies, etc.)
Individual and Non-Individual Participants (companies, etc.)

Established in Jakarta on April 22, 2016 EXECUTIVE HEAD OF INSURANCE, PENSION FUND, LENDING INSTITUTION, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department signed Yuliana

ANNEX VII
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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INSURANCE PRODUCT REGISTRATION REPORTING FORM FOR STANDARD INSURANCE PRODUCTS OTHER THAN JOINT INSURANCE PRODUCTS AND CREDIT AND/OR SURETYSHIP INSURANCE PRODUCTS

I. ASSESSMENT FORM FOR REGISTRATION REPORTING OF STANDARD INSURANCE PRODUCTS OTHER THAN JOINT INSURANCE PRODUCTS
AND CREDIT AND/OR SURETYSHIP INSURANCE PRODUCTS

GENERAL INFORMATION
Insurance Company Name
Name and Phone/email
Contact Person
Technical PIC:
Directorate in charge of Insurance Product Development :
Number and Date of
Reporting Letter
Insurance Product Name
Classification/Business Line
Marketing Target
Insurance Product
Individual Insured
Non-Individual Insured (Company, etc.)
Individual and Non-Individual Insured (Company, etc.) Brief Description Insurance Product

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1. Standard Insurance Product Criteria
   (Article 7 and Article 23 POJK
   No.23/POJK.05/2015)
   Has an Insurance Policy identical to the standard insurance policy made by the insurance industry association that has been approved by OJK If not using the standard policy from the association, the Insurance Company must submit a request for Reporting Approval of New Insurance Product, as referred to in Annex I, II, III, IV, and/or V

2. Insurance Product Name
   (Article 10 POJK No.23/POJK.05/2015) The Insurance Product Name to be marketed meets the requirements:
   a. using the word insurance or words with similar meaning; b. does not cause interpretation that the product is not an Insurance Product; and
   c. using the phrase
   “micro insurance” or phrase with similar meaning (specifically for Micro Insurance Products). State the Insurance Product Name to be reported The Insurance Product Name must be used consistently in all documents insurance product reporting

3. New Insurance Product reported must be included in the
   Insurance Company's business plan (Article 28 POJK No.23/POJK.05/2015) State the title and date of the Insurance Company's business plan

4. Fulfillment of Financial Health and Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015) a. Insurance Company meets the financial health ratio requirements State the achievement ratio of RBC for the last quarter b. Insurance Company is not currently subject to administrative sanctions If the Insurance Company is subject to sanctions, state:

• type of violation
• sanction letter number
• type of sanction

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II DOCUMENT COMPLETENESS ANALYSIS (Article 38 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Directorate of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach cover letter

2. Insurance Product Description Attach Insurance Product description as
   referred to in Annex VI

3. Company Actuary Statement Letter
   (Article 26 POJK No.23/POJK.05/2015) Attach Company Actuary statement letter as referred to in Roman numeral II of this Form

4. Directorate Statement Letter stating that:
   a. Insurance Company meets the financial health ratio requirements; b. Insurance Company is not currently subject to administrative sanctions;
   c. The Insurance Product reported is included
   in the Insurance Company's business plan approved by shareholders; and d. Insurance policy matches that made by the insurance industry association. (Article 28 and
   Article 30 POJK
   No.23/POJK.05/2015)
   Attach statement letter this Form

5. Description of marketing method and
   example marketing kit
   (brochure, scratch card copy, telemarketing script, and others) (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach example marketing kit

6. Summary of Insurance Product Information
   (Part VI SEOJK No.12/SEOJK.07/2014) Attach example summary of Insurance Product Information (summary of Insurance Product Information is not a contract document and differs from document

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offerings such as brochures and leaflets and differs from Insurance Product description)

7. Example insurance application letter
   (Article 16 POJK
   No.1/POJK.07/2013)
   Attach example insurance application letter containing matters including information regarding the match between customer profile and Insurance Product offered

III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Coverage
   a. Provides protection from at least 1 (one) type of risk that can be insured (Article 2 POJK No.23/POJK.05/2015) b. Consistent with the business scope and consistent with insurance principles that are generally applicable (Article 9 POJK No.23/POJK.05/2015) State the insurance business line with classification as referred to in Annex VI

2. Marketing Kit
   a. Contains information regarding cost details, benefits, and risks (Roman numeral III SEOJK No.12/ SEOJK.07/2014) b. Name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013)
   c. Statement that
   “Insurance Company is registered and supervised by the Financial Services Authority” (Article 20 POJK No.1/POJK.07/2013)

3. Summary of Insurance Product Information
   Summary of Insurance Product Information must at least contain:
   a. name and type of Insurance Product; b. Insurance Company name;
   c. summary data;
   d. benefits; e. risks; f. requirements and procedures; g. costs; h. simulation;
   i. service procedures and
   complaint resolution procedures; and j. additional information. (Article 8 POJK No.1/POJK.07/2013 &
   Part VI SEOJK
   No.12/SEOJK.07/2014)

IV CONCLUSION
All Registration Reporting Requirements for Standard Insurance Products Other Than Joint Insurance Products and Credit and/or Suretyship Insurance Products have been met

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We, the undersigned below, hereby declare that the assessment form above is consistent with the actual situation and has been completed with sufficient documents. ...(filled with city name, date, month, and year) Directorate in charge of Insurance Product Development (Filled with job title) Company Actuary (filled with Insurance Company name) signature signature (Name) (Name and registration number)

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We, the undersigned below, hereby declare that the premium and technical reserve calculations for the Insurance Product …… [filled with the name of the reported Insurance Product] are consistent with the applicable legal regulations and are based on reasonable assumptions and generally applicable insurance practices. This statement is made truthfully. If it is later found that this statement is incorrect, we are willing to be responsible and may be subject to sanctions according to the applicable legal regulations. ...(filled with city name, date, month, and year) Company Actuary (filled with Insurance Company name) signature

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We, the undersigned below, hereby declare that:

1. Insurance Company meets the financial health ratio requirements
   and is not currently subject to administrative sanctions;
2. The Insurance Product ..... [filled with the name of the reported Insurance Product]
   is included in the Insurance Company's business plan approved by shareholders; and
3. The Insurance Policy of the Insurance Product ……. [filled with the name of the reported Standard Insurance Product]
   uses the standard insurance policy ……… [filled with the name of the referenced standard policy] made by the association ……. (filled with the relevant association) that has obtained approval from OJK. This statement is made truthfully. If it is later found that this statement is incorrect, we are willing to be responsible and may be subject to sanctions according to the applicable legal regulations. ...(filled with city name, date, month, and year) Directorate in charge of Insurance Product Development (job title) signature (Name)

Established in Jakarta on April 22, 2016 EXECUTIVE HEAD OF INSURANCE, PENSION FUND, LENDING INSTITUTION, AND OTHER FINANCIAL SERVICES INSTITUTIONS FINANCIAL SERVICES AUTHORITY, signed FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department signed Yuliana

ANNEX VIII
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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INSURANCE PRODUCT REGISTRATION REPORTING FORM FOR STANDARD INSURANCE PRODUCTS THAT ARE JOINT INSURANCE PRODUCTS

I. ASSESSMENT FORM FOR REGISTRATION REPORTING OF STANDARD INSURANCE PRODUCTS THAT ARE JOINT INSURANCE PRODUCTS

GENERAL INFORMATION
Insurance Company Name
Chairman :
Members :
Name and Phone/email
Contact Person
Technical PIC:
Directorate in charge of Insurance Product Development :
Number and Date of
Reporting Letter
Insurance Product Name
Classification/Business Line
Marketing Target
Insurance Product
Individual Insured
Non-Individual Insured (Company, etc.)
Individual and Non-Individual Insured (Company, etc.) Brief Description Insurance Product

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1. Standard Insurance Product Criteria
   (Article 7 and Article 23 POJK
   No.23/POJK.05/2015)
   Has an Insurance Policy identical to the standard insurance policy made by the insurance industry association that has been approved by OJK If not using the standard policy from the association, the Insurance Company must submit a request for Reporting Approval of New Joint Insurance Product, as referred to in Annex IV

2. Insurance Product Name
   (Article 10 POJK No.23/POJK.05/2015) The Insurance Product Name to be marketed meets the requirements:
   a. using the word insurance or words with similar meaning; b. does not cause interpretation that the product is not an Insurance Product; and
   c. using the phrase
   “micro insurance” or phrase with similar meaning (specifically for Micro Insurance Products). State the Insurance Product Name to be reported The Insurance Product Name must be used consistently in all documents insurance product reporting

3. New Insurance Product reported must be included in the
   Insurance Company's business plan (Article 28 POJK No.23/POJK.05/2015) State the title and date of the Insurance Company's business plan

4. Fulfillment of Financial Health and Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015) a. Insurance Company that is part of marketing and underwriting the Joint Insurance Product meets the financial health ratio requirements State the achievement ratio of RBC for the last quarter for each Insurance Company that is part of marketing and underwriting the Joint Insurance Product

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b. Insurance Company that is part of marketing and underwriting the Joint Insurance Product is not currently subject to administrative sanctions If the Insurance Company is subject to sanctions, state:

• type of violation
• sanction letter number
• type of sanction

5. Reporting of Joint Insurance Products is done by the Directorate of the Insurance Company designated as Chairman in
   marketing and underwriting the Joint Insurance Product

II DOCUMENT COMPLETENESS ANALYSIS (Article 32 and Article 33 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Directorate of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015
   Attach cover letter

2. Insurance Product Description Attach Insurance Product description as
   referred to in Annex VI

3. Company Actuary Statement Letter
   from each Insurance Company that is part of the marketing of the Joint Insurance Product (Article 26 POJK No.23/POJK.05/2015) As per the Company Actuary statement letter as referred to in Roman numeral II of this Form

4. Directorate Statement Letter from each Insurance Company
   that is part of the marketing of the Joint Insurance Product stating that:
   a. Each Insurance Company meets the financial health ratio requirements, each Insurance Company is not currently subject to administrative sanctions, and the Insurance Product reported is included Attach statement letter this Form

4/9 in the business plan
Insurance Company which has been approved by the shareholders; and b. The Insurance Policy used in the marketing of Joint Insurance Products that will be reported uses a standard policy made by the relevant association. (Article 28 and Article 30 POJK No.23/POJK.05/2015)
5. Description of marketing methods and
examples of marketing kits
(brochures, telemarketing scripts, and others) (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach example marketing kit
6. Summary of information
Insurance Product
(Part VI SEOJK
No.12/SEOJK.07/2014)
Attach example summary of Insurance Product information (summary of Insurance Product information is not a contract document and differs from offer documents such as brochures and leaflets and differs from description of Insurance Product)
7. Example of insurance application letter
(Article 16 POJK
No.1/POJK.07/2013)
Attach example insurance application letter
8. Written contract document
marketing of Joint Insurance
Products that has been signed by the Board of Directors of each Insurance Company that is part of the marketing of Joint Insurance Products (Article 33 POJK No.23/POJK.05/2015) Attach draft written contract

III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Insurance
   a. Providing protection from at least 1 (one) type

5/9 of risk that can be insured
(Article 2 POJK
No.23/POJK.05/2015) b. Consistent with the scope of business of each party and consistent with general insurance principles (Article 5 and Article 9 POJK No.23/POJK.05/2015) Mention the insurance business line consistent with the classification as referred to in
Appendix VI on each
Insurance Company that is part of the marketing of Joint Insurance Products
2. Marketing Kit
a. Contains information regarding cost details, benefits, and risks (Romawi III SEOJK No.12/SEOJK.07/2014) b. Contains the name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013)
c. Contains a statement
that "Insurance
Company has been registered and supervised by the Financial Services Authority" (Article 20 POJK No.1/POJK.07/2013) d. Information regarding the share of risk assumed by each Insurance Company that is part of the marketing of Joint Insurance Products
3. Summary of Insurance Product Information
a. The summary of information of Insurance Product must at least contain:

1. name and type
   of Insurance Product;
2. name of Insurance
   Company;

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3) summary data;
4) benefits;
5) risks;
6) requirements and procedures;
7) costs;
8) simulation;
9) service procedures and
complaint resolution; and
10) other additional
information.
(Article
8 POJK
No.1/POJK.07/2013 jo
Part VI SEOJK
No.12/SEOJK.07/2014
) b. Information regarding the share of risk assumed by each Insurance Company that is part of marketing and bearing the marketing of Joint Insurance Products
4. Written Contract Document
(Article
6 POJK No.23/POJK.05/2015
)
The written contract must at least contain the following:
a. Membership structure, including the Insurance Company that is the leader (leader) that will coordinate the marketing activities of the Joint Insurance Products in question ; b. Duties of the leader;
c. Risk allocation for each
Insurance Company that is part of the marketing of Joint Insurance Products consistent with the scope of business of each Insurance Company ;

7/9 d. Procedures for payment of Premiums by policyholders; e. Underwriting procedures, premium acceptance and pass-through procedures, and claim settlement and payment procedures; and Including the rights and obligations of each Insurance Company that is part of the marketing of Joint Insurance Products in the event of marketing of Joint Insurance Products, underwriting, policy issuance, premium payment, and claim settlement f. Dispute resolution procedures between Insurance Companies that are part of the marketing of Joint Insurance Products.

IV CONCLUSION
All requirements for Standard Insurance Products that are New Joint Insurance Products have been met We, the undersigned below, hereby declare that the assessment form above has been in accordance with the actual conditions and has been completed with sufficient documents. ...(filled with city name, date, month, and year) Board of Directors who oversee Insurance Product Development (Filled with Insurance Company name). As Chairman Company Actuary (Filled with name of Insurance Company that is the Chairman) signature signature (Name) (Name and registration number)

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We, the undersigned below, hereby declare that the Premium calculation and technical reserves for Insurance Product ..... [filled with the name of the reported Insurance Product] have been in accordance with the provisions of applicable legislation and are based on reasonable assumptions and general insurance practices. This statement is made truthfully. If it is later found that this statement is not true, then we are willing to be responsible and may be subject to sanctions in accordance with the provisions of applicable legislation. ...(filled with city name, date, month, and year) Company Actuary PT. ... (filled with Insurance Company name) Company Actuary PT. .. (filled with Insurance Company name) signature signature (Name and registration number) (Name and registration number) Company Actuary PT. ... (filled with Insurance Company name) Company Actuary PT. .. (filled with Insurance Company name) signature signature (Name and registration number) (Name and registration number)

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We, the undersigned below, hereby declare that:

1. each Insurance Company under our authority
   has met the financial health standards and is not currently subject to administrative sanctions to market the Insurance Product ... [filled with the name of the reported Joint Insurance Product];
2. Insurance Product ..... [filled with the name of the reported Insurance Product]
   is included in the business plan of the Insurance Company that has been approved by the shareholders; and
3. The Insurance Policy of Insurance Product ……. [filled with the name of
   Joint Insurance Product reported] uses a standard insurance policy ……… [filled with the name of the referenced standard policy] made by association ……. [filled with the relevant association] which has obtained approval from the OJK. This statement is made truthfully. If it is later found that this statement is not true, then we are willing to be responsible and may be subject to sanctions in accordance with the provisions of applicable legislation. ...(filled with city name, date, month, and year) Board of Directors who oversee Insurance Product Development (Filled with Insurance Company name) As Chairman signature (Name) Board of Directors who oversee Insurance Product Development (Filled with Insurance Company name) As Member signature (Name) Board of Directors who oversee Insurance Product Development (Filled with Insurance Company name) As Member signature (Name) Established in Jakarta on 22 April 2016 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, sign FIRDAUS DJAELANI Copy consistent with the original Legal Director 1 Legal Department sign Yuliana

APPENDIX IX
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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STANDARD INSURANCE PRODUCT REGISTRATION REPORTING FORM THAT IS A SURETYSHIP PRODUCT
I. SURETYSHIP PRODUCT REGISTRATION REPORTING ASSESSMENT FORM
(THAT USES STANDARD POLICIES)
GENERAL INFORMATION
Insurance Company Name
Contact Person Name and Phone/email Technical PIC:
Board of Directors overseeing Product Development Insurance :
Report Letter Number and Date
Insurance Product Name
Target Marketing
Insurance Product
Individual Insured
Non-Individual Insured (Companies, etc.)
Individual and Non-Individual Insured (Companies, etc.) Brief Description Insurance Product

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1. Criteria for Standard Insurance Products
   Article 7 POJK No.23/POJK.05/2015)
   Has an Insurance Policy that is the same as the standard insurance policy made by the insurance industry association that has been approved by the OJK If not using standard policy from the association, the Insurance Company must submit a request for Product Approval Reporting, as referred to in
   Appendix V
2. Name of Insurance Product
   (Article 10 POJK No.23/POJK.05/2015) The name of the Insurance Product marketed meets the requirements:
   a. using the word insurance or other words that are synonymous; and b. does not cause interpretation that the product is not an Insurance Product. Mention the name of the Insurance Product to be reported The name of the Insurance Product must be used consistently in all product reporting documents
3. New Insurance Products that
   are reported must be listed in the business plan of the Insurance Company (Article 28 POJK No.23/POJK.05/2015) Mention the title and date of the Insurance Company's business plan
4. Fulfillment of Financial Health and Compliance Requirements
   (Article 30 POJK No.23/POJK.05/2015) a. Insurance Company meets the solvency ratio requirements Mention the achievement ratio of the last quarter's RBC b. Insurance Company meets the ratio of investment and technical reserves balance and claim payment obligations retention Mention the ratio of the last quarter
   c. Insurance Company
   meets the liquidity ratio of at least 150% (one hundred fifty percent) Mention the ratio of the last quarter d. Insurance Company is not currently subject to administrative sanctions If the Insurance Company is subject to sanctions, mention:

• type of violation
• sanction letter number
• type of sanction
  e. Insurance Company has expert personnel with AAIK qualifications or expert degree from foreign association that based on assessment by the Financial Services Authority is equivalent to AAMAI Attach:
• Copy of Appointment Decree
  as expert personnel of Insurance Company
• Copy of expert certificate
  in the name of the expert personnel in question f. Insurance Company has expert personnel with AAAIK qualifications or junior expert degree from similar foreign association that based on OJK assessment is equivalent to AAMAI who is tasked to manage the suretyship business line with requirements:
• Experience as
  underwriter of suretyship business line for at least 3 (three) years
• Has attended education and
  training of suretyship business line Attach:
• Copy of Appointment Decree
  as manager of suretyship business line
• Copy of certificate in the name of
  the expert personnel in question expertise
• Copy of Training Certificate
  in the name of the expert personnel in question
• Curriculum vitae list of
  the expert personnel in question g. Insurance Company has employees assigned to manage the suretyship business line who have attended special education and training in the field of suretyship, including at branches that market Insurance Products in the suretyship business line Attach:
• List of employees who
  manage the suretyship business line
• Copy of training certificate
  in the name of the employee in question h. Has underwriting manual for each Insurance Product in the suretyship business line marketed, which reflects that the implementation of the process risk selection is done carefully and consistent with general insurance practices Attach approved underwriting manual by the Board of Directors

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i. Has an information system
that allows principal, obligee, and OJK to check the authenticity of the issuance of a specific suretyship Attach screenshot of user interface of the information system

II DOCUMENT COMPLETENESS ANALYSIS (Article 38 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Board of Directors
   of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach cover letter
2. Description of Insurance Product Attach description of Insurance Product as
   referred to in Appendix VI
3. Company Actuary Statement Letter
   (Article 26 POJK
   No.23/POJK.05/2015)
   Consistent with the Company Actuary statement letter as referred to in Romawi II This Form
4. Board of Directors statement letter stating that:
   a. Insurance Company meets the financial health standards b. Insurance Company is not currently subject to administrative sanctions
   c. Insurance Product that
   is reported is included in the business plan of the Insurance Company which has been approved by the shareholders d. Insurance Company meets the ratio of investment and technical reserves balance and claim payment obligations retention Attach statement letter This Form

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5. Description of marketing methods and
examples of marketing kits (brochures and others) (Article 11 and Article 20 POJK No.1/POJK.07/2013) Attach example marketing kit
6. Summary of Insurance Product
Information
(Part VI SEOJK
No.12/SEOJK.07/2014)
Attach example summary of
Insurance Product information
(summary of Insurance Product information is not a contract document and differs from offer documents such as brochures and leaflets and differs from description of Insurance Product)
7. Example of Insurance Application Request Letter (SPPA)
(Article 16 POJK
No.1/POJK.07/2013)
Attach example SPPA

III COMPLIANCE AND SUBSTANTIVE ANALYSIS

1. Subject Matter of Insurance
   Consistent with the scope of business of the General Insurance Company and consistent with the general insurance principles (Article 9 POJK No.23/POJK.05/2015) Mention the general insurance business line consistent with the classification as referred to in
   Appendix VI
2. Marketing Kit
   a. Contains information regarding cost details, benefits, and risks (Romawi III SEOJK No.12/ SEOJK.07/2014)

5/9 b. Contains the name and/or logo of the Insurance Company (Article 20 POJK No.1/POJK.07/2013
c. Contains a statement that
"Insurance Company has been registered and supervised by the Financial Services Authority" (Article 20 POJK No.1/POJK.07/2013)
3. Summary of Insurance Product Information
Summary of Insurance Product
Information must at least contain:
a. name and type of Insurance
Product; b. name of Insurance
Company;
c. summary data;
d. benefits; e. risks; f. requirements and procedures; g. costs; h. simulation;
i. service procedures and
complaint resolution; and j. other additional information. (Article 8 POJK No.1/POJK.07/2013 and
Part VI SEOJK
No.12/SEOJK.07/2014)
4. Guarantee Value Limit
(Article 7 PMK 124/PMK.010/2008) a. Gross Guarantee Limit Mention in the underwriting manual b. Retention Guarantee Limit Mention in the underwriting manual

IV CONCLUSION
All requirements for Standard Insurance Product Registration Reporting that is a suretyship Product have been met

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We, the undersigned below, hereby declare that the assessment form above has been in accordance with the actual conditions and has been completed with sufficient documents. [city name],……………. Board of Directors who oversee Insurance Product Development (Filled with job title) Company Actuary (filled with Insurance Company name) signature signature (Name) (Name and registration number)

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We, the undersigned below, hereby declare that the Premium calculation and technical reserves for Insurance Product …… [filled with the name of the reported Insurance Product] have been in accordance with the provisions of applicable legislation and are based on reasonable assumptions and general insurance practices. This statement is made truthfully. If it is later found that this statement is not true, then we are willing to be responsible and may be subject to sanctions in accordance with the provisions of applicable legislation. ...(filled with city name, date, month, and year Company Actuary (filled with Insurance Company name) signature

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We, the undersigned below, hereby declare that the Insurance Company:

1. meets the financial health standards;
2. is not currently subject to administrative sanctions;
3. Insurance Product ..... [filled with the name of the reported Insurance Product]
   is included in the business plan of the Insurance Company that has been approved by the shareholders;
4. meets the ratio of investment and technical reserves balance
   and claim payment obligations retention;
5. meets the liquidity ratio of at least 150% (one hundred
   fifty percent); and
6. The Insurance Policy of Insurance Product ……. (filled with the name of
   Standard Insurance Product reported) uses a standard insurance policy ……… (filled with the name of the referenced standard policy) made by Indonesian General Insurance Association (AAUI). This statement is made truthfully. If it is later found that this statement is not true, then we are willing to be responsible and may be subject to sanctions in accordance with the provisions of applicable legislation. ...(filled with city name, date, month, and year) Board of Directors who oversee Insurance Product Development (job title) signature (Name) Established in Jakarta on 22 April 2016 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, sign FIRDAUS DJAELANI Copy consistent with the original Legal Director 1 Legal Department sign Yuliana

APPENDIX X
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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CHANGE OF INSURANCE PRODUCT REPORTING FORM OTHER THAN JOINT INSURANCE PRODUCTS FOR INSURANCE COMPANIES
I. CHANGE OF INSURANCE PRODUCT REPORTING ASSESSMENT FORM
(OTHER THAN JOINT INSURANCE PRODUCTS) GENERAL INFORMATION Insurance Company Name Contact Person Name and Phone/email Technical PIC:
Board of Directors overseeing Product Development Insurance :
Report Letter Number and Date
Insurance Product Name
Classification/Business Line
Target Marketing
Insurance Product
Individual Insured
Non-Individual Insured (Companies, etc.)
Individual and Non-Individual Insured (Companies, etc.) Brief Description Insurance Product Description of Change Insurance Product

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NO. DESCRIPTION YES NO NOTES
I
PRELIMINARY ANALYSIS
(Article 37 POJK No.23/POJK.05/2015)

1. Insurance Product Status
   Has the Insurance Product obtained a letter of approval/ Insurance Product registration Mention the number and date of the letter of approval/registration
2. Emphasis on changes
   Insurance Product a. Changes to Insurance Products that have been marketed to individual insured persons b. Changes to Insurance Products that have been marketed to non-individual insured persons, which have previously been discontinued from marketing
   c. The reported Insurance Product changes do not include
   changes to:

• risks covered
  including exclusions or restrictions on the causes of risks covered;
• Premium formulation;
• changes in risk category;
• assumptions related to
  Premium formulation; and/or
• method of calculating cash
  value.
• Mention the scope
  of changes to Insurance
  Product
• If the answer is
  no, then the Insurance
  Product is included in new products and the Insurance Company must submit a request for approval of Insurance Product II DOCUMENT COMPLETENESS ANALYSIS (Article 38 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Board of Directors
   of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach cover letter
2. Letter of approval or
   registration of the Insurance
   Product before the change
   Attach copy of the letter of approval or registration of the last Insurance Product
3. Description of Insurance Product
   after the change
   Attach description of Insurance Product as referred to in
   Appendix VI
4. Comparison Matrix of Insurance
   Product before and after the change Attach comparison matrix of Insurance Product before and after the change

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5. Specimen of Insurance Policy
after the change, specifically for Insurance Products other than Standard Insurance Products Attach:

• Insurance Policy
  Provisions
• Summary of Insurance Policy
  accompanied by dummy coverage data
• Insurance Policy
  Certificate/proof of membership (if any) accompanied by dummy coverage data
• example of participant
  list accompanied by dummy coverage data (specifically for Group Insurance Products)

6. Other documents that also
   undergo changes:

• Marketing kit
• Summary of Insurance Product
  Information
• Fund development report (specifically for PAYDI)
• Others (relevant to the changes of Insurance
  Products reported)
  Attach documents that undergo changes

III CONCLUSION
All requirements for Change of Insurance Product Registration Reporting (other than Joint Insurance Products) have been met

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We, the undersigned below, hereby declare that the assessment form above has been in accordance with the actual conditions and has been completed with sufficient documents. …… (filled with city name, date, month, and year) Board of Directors who oversee Insurance Product Development (Filled with job title) Company Actuary (filled with Insurance Company name) signature signature (Name) (Name and registration number) Established in Jakarta on 22 April 2016 EXECUTIVE HEAD OF SUPERVISOR OF INSURANCE, PENSION FUNDS, LENDING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, sign FIRDAUS DJAELANI Copy consistent with the original Legal Director 1 Legal Department sign Yuliana

APPENDIX XI
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER NUMBER 13 /SEOJK.05/2016 REGARDING INSURANCE PRODUCT REPORTING FOR INSURANCE COMPANIES

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CHANGE OF JOINT INSURANCE PRODUCT REPORTING FORM FOR INSURANCE COMPANIES
I. CHANGE OF JOINT INSURANCE PRODUCT REPORTING ASSESSMENT FORM
GENERAL INFORMATION
Insurance Company Name
Chairman :
Member :
Contact Person Name and Phone/email Technical PIC:
Board of Directors overseeing Product Development Insurance :
Report Letter Number and Date
Insurance Product Name
Classification/Business Line
Target Marketing
Insurance Product
Individual Insured
Non-Individual Insured (Companies, etc.)
Individual and Non-Individual Insured (Companies, etc.) Brief Description Insurance Product Description of Change Insurance Product

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NO DESCRIPTION YES NO NOTES
I
PRELIMINARY ANALYSIS
(Article 37 POJK No.23/POJK.05/2015)

1. Insurance Product Status
   Has the Insurance Product obtained a letter of approval/registration of Insurance Products Mention the number and date of the letter of approval/registration
2. Emphasis on changes
   Insurance Product a. Changes to Insurance Products that have been marketed to individual insured persons b. Changes to Insurance Products that have been marketed to non-individual insured persons, which have previously been discontinued from marketing
   c. The reported Insurance Product changes do not include
   changes to:

• risks covered
  including exclusions or restrictions on the causes of risks covered;
• Premium formulation;
• changes in risk category;
• assumptions related to
  Premium formulation; and/or
• method of calculating cash
  value.
• Mention the scope
  of changes to Insurance
  Product
• If no, then
  the Insurance
  Company must submit a request for approval of Insurance Product II DOCUMENT COMPLETENESS ANALYSIS (Article 38 POJK No.23/POJK.05/2015)

1. Cover letter signed by the Board of Directors
   of the Insurance Company
   (Article 29 POJK
   No.23/POJK.05/2015)
   Attach cover letter

2. Letter of approval or
   registration of Joint Insurance Products before the change (Article 40 POJK No.23/POJK.05/2015) Attach copy of the letter of approval or registration of the last Insurance Products

3. Description of Insurance Product
   after the change
   Attach description of Insurance Product as referred to in
   Appendix VI

4. Comparison Matrix of
   Insurance Products before and after changes Attach the comparison matrix of Insurance Products before and after changes

5. Specimen of Insurance Policy after
   changes, specifically for
   Insurance Products other than Standard Insurance Products Attach:

• Policy Terms
• Policy Summary
  accompanied by dummy coverage data
• Policy Certificate/proof of
  membership (if any) accompanied by dummy coverage data
• example participant list
  accompanied by dummy coverage data (specifically for Group Insurance Products)

6. Written marketing agreement documents
   for Joint Insurance Products that have been initialed by the Board of Directors of each Insurance Company involved in marketing and bearing the cost of marketing Joint Insurance Products (Article 33 of POJK No.23/POJK.05/2015) Attach draft written agreement (after changes)

7. Other documents that also
   undergo changes:

• Marketing kit
• Summary of Insurance Product information
• Fund development report (specifically for PAYDI)
• Others (relevant to the reported Insurance Product changes)
  Attach documents that underwent changes

III CONCLUSION
All requirements for Reporting
Recording Changes to Joint Insurance Products have been met

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We, the undersigned, hereby declare that the aforementioned assessment form is consistent with the actual situation and has been completed with sufficient documents. ...(filled with city name, date, month, and year) Board of Directors responsible for Insurance Product Development (Filled with Insurance Company Name) As Chief Actuary of the Company (Filled with Insurance Company Name acting as Chair) signature signature (Name) (Name and registration number) Established in Jakarta on April 22, 2016 EXECUTIVE HEAD OF INSURANCE SUPERVISOR, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY, ttd FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department ttd Yuliana