SEOJK on the Form and Structure of Financial Statements and the Form and Structure of Summary Financial Statement Announcements for General Insurance and Reinsurance Companies — OJK — ID

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page i

Yth. Otoritas Jasa Keuangan
Up. Direktorat Pengawasan Perasuransian Gedung Sumitro Djojohadikusumo, Lantai 14 Jl. Lapangan Banteng Timur 1 - 4 Jakarta - 10710

FINANCIAL STATEMENTS
GENERAL INSURANCE / REINSURANCE COMPANY Per .../ Quarter ... Year … PT XYZ (Company Address)

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page ii

Financial Statements
General Insurance / Reinsurance Company PT. XYZ Per …/ Quarter … Year …

1 Company Name :
2 Full Address :
3 Telephone and Fax. :
4 E-mail :
5 NPWP (Taxpayer Identification Number) :
6 No. & Date of Business License :
7 a. Number of Branches/
Representatives :
b. Number of Insured Parties:
8 External Auditor :
9 Shareholders :
Share Ownership
Rupiah Percentage
Total
10 Board of Directors and Board of Commissioners:
Name of Directors Position Name of Commissioners Position 11 Financial Reporting PIC :
Name of Division/Section No Phone, ext. Email ………………, …………………. PT. Asuransi ……………………………. Name of Directors Board of Directors Name of Shareholders

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iii

………………, ………………….
Board of Directors PT XYZ
Name
Position

Statement of the Board of Directors Regarding Responsibility for Financial Statements Per …/ Quarter … Year … PT XYZ

We, the undersigned, declare that:

We are responsible for the preparation and presentation of the financial statements of PT XYZ (the Company);
All information in the Company's financial statements has been presented completely and in accordance with the actual conditions;
The Company's financial statements do not contain incorrect material information or facts, and do not omit material information or facts.

This statement is made truthfully.

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iv

Page
Cover Page i
Company Profile ii
Statement iii
Table of Contents iv

I Main Financial Statements
1.1. Financial Statements
1.2. Statement of Financial Position 1
1.3. Statement of Comprehensive Income 2
1.4. Statement of Cash Flows 3
1.5. Statement of Changes in Equity 4
1.6. Solvency Level Report
a. Solvency Achievement Ratio 5 b. Minimum Risk-Based Capital (MMBR)
Schedule A Asset Management Failure Risk 6
Schedule B Imbalance Between Asset and Liability Cash Flow Projections 7
Schedule C Imbalance Between Asset and Liability Values in Each Currency Type 8
Schedule D Difference Between Incurred Claim Expenses and Estimated Claim Expenses 9
Schedule E Premium Insufficiency Due to Investment Result Differences 10
Schedule F Reinsurance Risk 11
Schedule G Operational Risk 12
1.7. Calculation of SAP Assets and Liabilities 13
Sub A Investments Not with One Party 14 Sub B Investments with Affiliated Parties of the Company 15 Sub C Investments with Non-Affiliated Parties 16 Sub D Investments Abroad 17 Sub E List of Affiliated Companies 18
1.8. Details
101 Time Deposits and Certificates of Deposits 19 102 Stocks 20 103 Corporate Bonds and Corporate Sukuk 21 104 Securities Issued by the Republic of Indonesia 22 105 Securities Issued by Countries Other Than the Republic of Indonesia 23 106 Securities Issued by Bank Indonesia 24 107 Securities Issued by Multinational Institutions 25 108 Mutual Funds 26 109 Collective Investment Contracts for Asset-Backed Securities 27 110 Real Estate Investment Funds 28 111 Direct Investments 29 112 Buildings with Strata Rights or Land with Buildings for Investment 30 113 Purchase of Receivables for Financing Companies and/or Banks 31 114 Pure Gold 32 115 Loans Secured by Mortgage Rights 33 116 Other Investments 34 201 Direct Written Premium Receivables 35 202 Coinsurance Claim Receivables 36 203 Reinsurance Receivables 37 204 Investment Receivables 38 205 Investment Income Receivables 39 206 Buildings with Strata Rights or Land with Buildings for Own Use 40 207 Other Fixed Assets 41 208 Other Assets 42 301 Claim Payables 43 302 Coinsurance Payables 44 303 Reinsurance Payables 45 304 Commission Payables 46 305 Accrued Expenses 47 306 Other Payables 48 401 Premium Reserves and Reserves for Premiums Not Yet Earned Income 49 402 Claim Reserves 50 501 Underwriting Results 51 502 Decrease (Increase) in Premium Reserves, CAPYBMP, and Claim Reserves 52 503 Investment Results 53 504 Other Results (Expenses) 54 505 Other Comprehensive Income 55 601 Current Assets and Current Liabilities 56

II. Additional Financial Statements
2.1. Guarantee Fund Report
Summary of Guarantee Fund Development 57 Calculation of Guarantee Fund Adequacy 57 Details of Final Guarantee Fund Position 58
2.2. Financial Health Ratios other than MMBR 59
2.3. Education and Training Cost Ratio 60
2.4. Asset and Liability Matching 61
2.5. Details of Premium Income and Claim Expenses by Distribution Channel 62

Table of Contents
Financial Statements
PT. XYZ
General Insurance and Reinsurance Company

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Detail Description
SAK Balance
SAP Balance
SAK Balance
SAP Balance
(1) (2) (3) (4) (5) (6)

ASSETS
Investments
Time Deposits and Certificates of Deposits 101 - - - - Stocks 102 - - - - Corporate Bonds and Corporate Sukuk 103 - - - - Securities Issued by the Republic of Indonesia 104 - - - - Securities Issued by Countries Other Than the Republic of Indonesia 105 - - - - Securities Issued by Bank Indonesia 106 - - - - Securities Issued by Multinational Institutions 107 - - - - Mutual Funds 108 - - - - Collective Investment Contracts for Asset-Backed Securities 109 - - - - Real Estate Investment Funds 110 - - - - Direct Investments 111 - - - - Buildings with Strata Rights or Land with Buildings for Investment 112 - - - - Purchase of Receivables for Financing Companies and/or Banks 113 - - - - Pure Gold 114 - - - - Loans Secured by Mortgage Rights 115 - - - - Other Investments 116 - - - - Total Investments - - - - Non-Investments Cash and Banks - - - - Direct Written Premium Receivables 201 - - - - Coinsurance Claim Receivables 202 - - - - Reinsurance Receivables 203 - - - - Investment Receivables 204 - - - - Investment Income Receivables 205 - - - - Buildings with Strata Rights or Land with Buildings for Own Use 206 - - - - Other Fixed Assets 207 - - Other Assets 208 - - Total Non-Investments - - - - TOTAL ASSETS - - - -

LIABILITIES AND EQUITY
Liabilities
Payables
Claim Payables 301 - - - -
Coinsurance Payables 302 - - - - Reinsurance Payables 303 - - - - Commission Payables 304 - - - - Tax Payables - - - - Accrued Expenses 305 - - - - Other Payables 306 - - - - Total Payables - - - - Technical Reserves Premium Reserves 401 - - - - Reserves for Premiums Not Yet Earned Income 401 - - - - Claim Reserves 402 - - - - Total Technical Reserves - - - - Total Liabilities - - - - Subordinated Loans - - - - Equity Paid-up Capital - - - - Share Premium - - - - Retained Earnings Balance - - - - Other Equity Components - - - - Difference in Valuation Based on SAK and SAP - - Assets Not Included in AYD - - Total Equity - - - - TOTAL LIABILITIES AND EQUITY - - - -

Quarter … Year … Quarter … Year … PT XYZ GENERAL INSURANCE COMPANY STATEMENT OF FINANCIAL POSITION Non-Consolidated As of …. and As of ….

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Detail Description
Quarter …
Year …
Quarter …
Year …
(1) (2) (3) (4)

UNDERWRITING INCOME 501
Gross Premiums a. Direct Written Premiums b. Indirect Written Premiums
c. Commissions Paid
Total Gross Premiums - -
Reinsurance Premiums a. Reinsurance Premiums Paid b. Reinsurance Commissions Received Total Reinsurance Premiums - - Net Premiums - - Decrease (Increase) in Premium Reserves and CAPYBMP a. Decrease (Increase) in Premium Reserves 502 b. Decrease (Increase) in CAPYBMP 502 Decrease (Increase) in Premium Reserves and CAPYBMP - - Total Net Premium Income - - Other Net Underwriting Income UNDERWRITING INCOME - -

UNDERWRITING EXPENSES 501
Claim Expenses a. Gross Claims b. Reinsurance Claims
c. Increase (Decrease) in Claim Reserves 502
Total Net Claim Expenses - -
Other Net Underwriting Expenses TOTAL UNDERWRITING EXPENSES - - UNDERWRITING RESULTS 501 - - Investment Results 503 Operating Expenses:
a. Marketing Expenses b. General and Administrative Expenses:

Employee and Management Expenses
Education and Training Expenses
Other General and Administrative Expenses
Total Operating Expenses - -
INSURANCE OPERATING PROFIT (LOSS) - - Other Results (Expenses) 504 PROFIT (LOSS) BEFORE TAX - - Income Tax PROFIT (LOSS) AFTER TAX - - OTHER COMPREHENSIVE INCOME 505 TOTAL COMPREHENSIVE PROFIT (LOSS) - -

PT XYZ
GENERAL INSURANCE COMPANY
STATEMENT OF COMPREHENSIVE INCOME For the Period Ending On Date … and Date … Note:
The figures in this report are cumulative figures for the period from January 1 to the reporting date of the current period.

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Quarter …
Year …
Quarter …
Year …
(1) (2) (3)

BEGINNING BALANCE OF CASH AND BANKS - CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows a. Premiums b. Coinsurance Claims
c. Reinsurance Claims
d. Commissions e. Receivables f. Others Total Cash Inflows - - Cash Outflows a. Reinsurance Premiums b. Claims
c. Commissions
d. Expenses e. Others
Total Cash Outflows - -
TOTAL CASH FLOWS FROM OPERATING ACTIVITIES - - CASH FLOWS FROM INVESTING ACTIVITIES Cash Inflows a. Investment Income Received b. Investment Withdrawals
c. Sale of Fixed Assets
d. Others
Total Cash Inflows - -
Cash Outflows a. Investment Placements b. Purchase of Fixed Assets
c. Others
Total Cash Outflows - -
TOTAL CASH FLOWS FROM INVESTING ACTIVITIES - - CASH FLOWS FROM FINANCING ACTIVITIES Cash Inflows a. Subordinated Loans b. Capital Deposits
c. Others
Total Cash Inflows - -
Cash Outflows a. Dividend Payments b. Subordinated Loan Repayments
c. Others
Total Cash Outflows - -
TOTAL CASH FLOWS FROM FINANCING ACTIVITIES - - ENDING BALANCE OF CASH AND BANKS - -

PT XYZ
GENERAL INSURANCE COMPANY
STATEMENT OF CASH FLOWS
As of …. and As of ….

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Quarter …
Year …
Quarter …
Year …
(1) (2) (3)

SAK EQUITY
Beginning Balance -
Additions:
Paid-up Capital
Current Period Comprehensive Profit (Loss) - Other Additions:
a. b.
Total Additions - -
Deductions:
Dividend Payments
Other Deductions:
a. b.
Total Deductions - -
Ending SAK Balance - -
SAP EQUITY
Beginning Balance
SAK Equity Changes
Increase (Decrease) in SAK and SAP Valuation Difference (Increase) Decrease in Assets Not Included in AYD Ending SAP Balance - -

PT XYZ
GENERAL INSURANCE COMPANY
STATEMENT OF CHANGES IN EQUITY
As of …. and As of ….

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Quarter …
Year …
Quarter …
Year …
(1) (2) (3)

Solvency Level
Permitted Assets -
Liabilities (excluding Subordinated Loans) - Total Solvency Level - - Minimum Risk-Based Capital (MMBR)
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Schedule G
Total MMBR - -
Excess (Deficiency) of Solvency Level Limit - - Solvency Achievement Ratio (in %) 1) #DIV/0! #DIV/0!
1) Total Solvency Level divided by Total MMBR
In the event the Company experiences a solvency deficiency, the amount of funds needed to achieve a 100.00% RBC ratio 120.00% Period 2) Target 3) Realization Year ... % % Q ... % % Q ... % % Q ... % % Q ... % %
2) Current year period
3) Minimum target solvency level 120%
Reasons for failing to achieve the quarterly/current year solvency ratio target:

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Solvency Achievement Ratio
As of …. and As of ….

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Total AYD
Factor
Total
Deviation
(1) (2) (3) (4)

INVESTMENTS
Time Deposits and Certificates of Deposits Special Category (up to 2 billion per bank) 0.0% - Other Categories, according to Bank Rating: - a. Cluster Rating 1 1.2% - b. Cluster Rating 2 2.1% -
c. Cluster Rating 3 3.0% -
d. Cluster Rating 4 4.5% - e. Cluster Rating 5 9.0% - Stocks - Including LQ 45 on the Jakarta Stock Exchange, or equivalent 16.0% - Stocks traded on Indonesian exchanges 20.0% - Stocks traded on foreign exchanges: - Stocks constituting the main index of the main stock exchange of Asia-Pacific countries and European members of the World Federation of Exchanges 20.0% - Others 30.0% - Corporate Bonds and Corporate Sukuk - a. Cluster Rating 1 1.6% - b. Cluster Rating 2 2.8% -
c. Cluster Rating 3 4.0% -
d. Cluster Rating 4 6.0% -
Securities Issued by the Republic of Indonesia 0.0% - Securities Issued by Countries Other Than the Republic of Indonesia - a. Cluster Rating 1 1.6% - b. Cluster Rating 2 2.8% -
c. Cluster Rating 3 4.0% -
d. Cluster Rating 4 6.0% -
Securities Issued by Bank Indonesia 0.0% - Securities Issued by Multinational Institutions 0.0% - Mutual Funds - Entirely consisting of Government bonds 0.0% - Entirely consisting of private bonds and/or money market securities (SBPU) 6.0% - Entirely consisting of equity securities 16.0% - Mixed 1) rt - Collective Investment Contracts for Asset-Backed Securities - a. Cluster Rating 1 1.6% - b. Cluster Rating 2 2.8% -
c. Cluster Rating 3 4.0% -
d. Cluster Rating 4 6.0% -
Real Estate Investment Funds - a. Cluster Rating 1 1.6% - b. Cluster Rating 2 2.8% -
c. Cluster Rating 3 4.0% -
d. Cluster Rating 4 6.0% -
Direct Investments -
Under OJK Supervision 10.0% -
Not Under OJK Supervision 20.0% - Buildings with Strata Rights, or Land with Buildings - Investment Results 4% or more 7.0% - Investment Results 2% - 4% 15.0% - Investment Results less than 2% 40.0% - Purchase of Receivables - Leasing 3.0% - Credit Cards 20.0% - Consumer Financing 8.0% - Pure Gold 3.0% - Loans Secured by Mortgage Rights - Residential Property - a. LTV<60% 2.8% - b. 60%<LTV<80% 4.0% - Other Commercial Property - a. LTV<60% 5.6% - b. 60%<LTV<80% 8.0% - Unused Property 12.0% -

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule A - Asset Management Failure Risk

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Total AYD
Factor
Total
Deviation
(1) (2) (3) (4)

NON-INVESTMENTS -
Cash and Banks 0.0% -
Direct Written Premium Receivables 8.0% - Coinsurance Claim Receivables - Under OJK Supervision 2.8% - Not Under OJK Supervision: - a. Cluster Rating 1 2.8% - b. Cluster Rating 2 4.0% -
c. Cluster Rating 3 6.0% -
d. Cluster Rating 4 12.0% - e. Cluster Rating 5 15.0% - Reinsurance Receivables - Under OJK Supervision 2.8% - Not Under OJK Supervision: - a. Cluster Rating 1 2.8% - b. Cluster Rating 2 4.0% -
c. Cluster Rating 3 6.0% -
d. Cluster Rating 4 12.0% - e. Cluster Rating 5 15.0% - Reinsurance Assets 0.0% - Investment Receivables 2.0% - Investment Income Receivables 2.0% - Buildings with Strata Rights, or Land with Buildings 4.0% - Total - -

Note:
1) For mixed mutual funds, the factor is filled with the weighted average based on the composition of underlying assets as regulated in applicable provisions. If the company does not fill in the factor, the maximum factor (10%) will be applied.
rt = weighted average risk according to calculation LTV = loan to value, LTV is calculated based on loan balances and property market value The total funds calculated in Schedule A are as follows:
1) Year 2013 = 50%
2) Year 2014 = 75%
3) Year 2015 = 100%

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Up to
1 year
More than 1 year up to
3 years
More than 3 years up to
5 years
More than 5 years up to
10 years
More than 10 years
Total
(1) (2) (3) (4) (5) (6) (7)

ASSETS
Investments
Time Deposits and Certificates of Deposits Stocks Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia Securities Issued by Countries Other Than the Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Institutions Mutual Funds Collective Investment Contracts for Asset-Backed Securities Real Estate Investment Funds Direct Investments Buildings with Strata Rights or Land with Buildings for Investment Purchase of Receivables Pure Gold Loans Secured by Mortgage Rights Total Investments - - - - - - Non-Investments Cash and Banks Direct Written Premium Receivables Coinsurance Claim Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Buildings with Strata Rights or Land with Buildings for Own Use Total Non-Investments - - - - - - TOTAL ASSETS - - - - - -

LIABILITIES AND EQUITY
Liabilities
Payables
Claim Payables
Coinsurance Payables
Reinsurance Payables
Commission Payables
Tax Payables
Accrued Expenses
Other Payables
Total Payables - - - - - -
Technical Reserves
Premium Reserves
Reserves for Premiums Not Yet Earned Income Claim Reserves Total Technical Reserves - - - - - - Total Liabilities - - - - - - LIABILITY AND ASSET DIFFERENCE - - - - - - DEVIATION (4% X (Max (Li - AYDi), 0)) - - - - - -

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule B - Risk of Imbalance Between Asset and Liability Cash Flow Projections

Note:
AYDi = book value of AYD maturing in period i Li = book value of liabilities maturing in period i The total funds calculated in Schedule B are as follows:
1) Year 2013 = 50%
2) Year 2014 = 75%
3) Year 2015 = 100%

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
USD
SGD
JPY
GBP
DKK
FRF
HKD
EUR
IDR
Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

Permitted Assets
Time Deposits and Certificates of Deposits Stocks Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia Securities Issued by Countries Other Than the Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Institutions Mutual Funds Collective Investment Contracts for Asset-Backed Securities Real Estate Investment Funds Direct Investments Buildings with Strata Rights or Land with Buildings for Investment Purchase of Receivables Pure Gold Loans Secured by Mortgage Rights Cash and Banks Direct Written Premium Receivables Coinsurance Claim Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Buildings with Strata Rights or Land with Buildings for Own Use Total Permitted Assets - - - - - - - - -

Liabilities
Claim Payables
Coinsurance Payables
Reinsurance Payables
Commission Payables
Tax Payables
Accrued Expenses
Other Payables
Premium Reserves
Reserves for Premiums Not Yet Earned Income Claim Reserves Total Liabilities - - - - - - - - -

Exchange Rate
Total Permitted Assets in Rupiah - - - - - - - - - - Total Liabilities in Rupiah - - - - - - - - - - Difference Between Permitted Assets and Liabilities - - - - - - - - - - Factor 0.3 Total Deviation in Assets and Liabilities in Each Foreign Currency Type - - - - - - - - - -

Note:
This column can be added according to the types of foreign currencies present.

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule C - Risk of Imbalance Between Asset and Liability Values in Each Foreign Currency Type

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Non-renewable (> 1 year) (in millions of rupiah) Insurance Branch CP CP* Total Deviation (1) (2) (3) (4)

Property
Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident) Transportation (Marine Cargo) Ship Hulls (Marine Hull) Aircraft Hulls (Aviation Hull) Satellites Onshore Energy (Oil and Gas) Offshore Energy (Oil and Gas) Engineering Liability Credit Suretyship Miscellaneous Life ) Total max ((CP - CP), 0) - - -

Renewable (0-1 year/ <1 year) (in millions of rupiah) Insurance Branch CAPYBMP AR fcp Total Deviation CAPYBMP ((2) - (3)) x (4) CK AR fck Total Deviation CK ((6) - (7)) x (8) Total Deviation (5) + (9) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

Property 25% - 20% - -
Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident) 25% - 20%

-
Transportation (Marine Cargo) 30% - 25% - - Ship Hulls (Marine Hull) 30% - 25% - - Aircraft Hulls (Aviation Hull) 30% - 25% - - Satellites 25% - 20% - - Onshore Energy (Oil and Gas) 35% - 30% - - Offshore Energy (Oil and Gas) 35% - 30% - - Engineering 25% - 20% - - Liability 35% - 30% - - Credit 30% - 25% - - Suretyship 25% - 20% - - Miscellaneous 25% - 20% - - Life *) 10% - 10% - - Total ((CAPYBMPi - ARi)fcpi + (CKi - ARi)fcki) - - - - - - -

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule D - Insurance Liability Risk

Note:
) filled if the company is a reinsurance company CP = premium reserves according to the statement of financial position (balance sheet) and according to the company actuary's calculations CP = premium reserves calculated with best estimates plus margin for adverse development with a 95% confidence level for premium reserve adequacy (company level) CAPYBMPi = reserves for premiums not yet earned income for business line i AR = reinsurance assets CKi = claim reserves for business line i fcpi = risk factor for reserves for premiums not yet earned income for business line i fcki = risk factor for claim reserves for business line i

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Total
(1) (2)

CPrf
CPo
Max((CPrf-CPo),0) - fRTB
RTB -

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule E - Interest Rate Risk

Note:

CPrf = premium reserves calculated with risk-free interest rates according to calculations in PER 08 Year 2012
Cpo = premium reserves calculated with actuarial interest rates according to calculations in PER 08 Year 2012
fRTB = interest rate ratio factor
fRTB Year 2013 = 5%
fRTB Year 2014 = 10%
fRTB Year 2015 = 15%

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Name of Reinsured
Technical Reserves
Reinsurance Expenses
Deposits and/or Premiums
Held by the Ceding Company
Net Reinsurance Exposure
((2) - (3))
Factor
Total
Deviation
((4) x (5))
(1) (2) (3) (4) (5) (6)

Under OJK Supervision 2.8%
… - -
… - -
… - -
Not Under OJK Supervision - - a. Cluster Rating 1 2.8% … - - b. Cluster Rating 2 4.0% … - -
c. Cluster Rating 3 6.0%
… - - d. Cluster Rating 4 12.0% … - - e. Cluster Rating 5 15.0% … - - Total - - - -

SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule F - Reinsurance Risk

PT XYZ
GENERAL INSURANCE COMPANY

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

(2) (3)
General and Administrative Expenses Education and Training Expenses Operational Complexity Proxy - Deviation - Description Total

PT XYZ
GENERAL INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Minimum Risk-Based Capital
Schedule G - Operational Risk

Note:
For Quarterly Reports, General and Administrative Expenses and Education and Training Expenses are the General and Administrative Expenses and Education and Training Expenses for the last 4 (four) quarters.

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013

I. SAP ASSET CALCULATION (in millions of rupiah)

Description	Book Balance (SAK)	Valuation Based on SAP	Difference in Valuation SAK and SAP	Disallowed Assets	Allowed Assets (SAP Balance)
(1)	(2)	(3)	(4)	(5)	(6)
Investments
Time Deposits and Certificates of Deposit	-
Stocks	-
Corporate Bonds and Corporate Sukuk	-
Securities Issued by the Republic of Indonesia State	-
Securities Issued by States Other Than the Republic of Indonesia	-
Securities Issued by Bank Indonesia	-
Securities Issued by Multinational Institutions	-
Mutual Funds	-
Collective Investment Contracts for Asset-Backed Securities	-
Real Estate Investment Funds	-
Direct Investments	-
Buildings with Strata Rights or Land with Buildings for Investment	-
Purchase of Receivables for Financing Companies and/or Banks	-
Pure Gold	-
Loans Secured by Mortgage Rights	-
Other Investments	-
Total Investments	-	-	-	-	-
Non-Investments
Cash and Bank	-	-
Direct Writing Premium Receivables	-	-
Coinsurance Claim Receivables	-	-
Reinsurance Receivables	-	-
Investment Receivables	-	-
Investment Income Receivables	-	-
Buildings with Strata Rights or Land with Buildings for Own Use	-	-
Other Fixed Assets	-	-
Other Assets	-	-
Total Non-Investments	-	-	-	-	-
TOTAL ASSETS	-	-	-	-	-

Note:
The total investments used as the basis for calculating the permissible wealth restriction and investment restrictions on one party is equal to the investment amount in column (4) except for other investments, which is equal to -

II. SAP LIABILITY CALCULATION

Description	Book Balance (SAK)	Valuation Based on SAP	Difference in Valuation SAK and SAP
(1)	(2)	(3)	(4) = (2) - (3)
Liabilities	-	-
Premium Reserves	-	-
Reserves for Premiums Not Yet Earned	-	-
Claim Reserves	-	-
TOTAL LIABILITIES	-	-
DIFFERENCE IN VALUATION BASED ON SAK AND SAP
(Total assets column 5 minus total liabilities column 5) (Transferred to line 65 of the Financial Condition Report)\

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
SAP ASSET AND LIABILITY CALCULATION Non-Consolidated

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Investment Type	Details	AYD After Restriction Per Investment Type and/or Investments Abroad
(1)	(2)	(3)
Domestic Placements
Time Deposits and Certificates of Deposit	101
Stocks	102
Corporate Bonds and Corporate Sukuk	103
Securities Issued by the Republic of Indonesia State	104
Securities Issued by States Other Than the Republic of Indonesia	105
Securities Issued by Bank Indonesia	106
Securities Issued by Multinational Institutions	107
Mutual Funds	108
Collective Investment Contracts for Asset-Backed Securities	109
Real Estate Investment Funds	110
Direct Investments	111
Buildings with Strata Rights or Land with Buildings for Investment	112
Purchase of Receivables for Financing Companies and/or Banks	113
Pure Gold	114
Loans Secured by Mortgage Rights	115
Sub Total	-
Foreign Placements
Stocks	102
Corporate Bonds and Corporate Sukuk	103
Securities Issued by States Other Than the Republic of Indonesia	104
Securities Issued by Multinational Institutions	107
Mutual Funds	108
Direct Investments	111
Sub Total	-
Total Sub A	-

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
SAP ASSET AND LIABILITY CALCULATION SUB A - INVESTMENT PLACEMENTS NOT ON ONE PARTY

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Placement on Company (Company Name)	Investment Type	Details	AYD After Restriction Per Investment Type and Investments Abroad	Disallowed Assets	AYD
(1)	(2)	(3)	(4)	(5)	(6)
PT a. Time Deposits and Certificates of Deposit	101
b. Stocks	102
c. Corporate Bonds and Corporate Sukuk	103
d. Mutual Funds	108
e. Collective Investment Contracts for Asset-Backed Securities	109
f. Real Estate Investment Funds	110
g. Direct Investments	111
Total Placement on this Company	-	-	-
PT a. Time Deposits and Certificates of Deposit	101
b. Stocks	102
c. Corporate Bonds and Corporate Sukuk	103
d. Mutual Funds	108
e. Collective Investment Contracts for Asset-Backed Securities	109
f. Real Estate Investment Funds	110
g. Direct Investments	111
Total Placement on this Company	-	-	-
PT a. Time Deposits and Certificates of Deposit	101
b. Stocks	102
c. Corporate Bonds and Corporate Sukuk	103
d. Mutual Funds	108
e. Collective Investment Contracts for Asset-Backed Securities	109
f. Real Estate Investment Funds	110
g. Direct Investments	111
Total Placement on this Company	-	-	-
Total Sub B	-	-	-

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
SAP ASSET AND LIABILITY CALCULATION SUB B - INVESTMENT PLACEMENTS ON AFFILIATED PARTIES WITH THE COMPANY

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Placement on Company (Company Name)	Investment Type	Details	AYD After Restriction Per Investment Type and Investments Abroad	Disallowed Assets	AYD
(1)	(2)	(3)	(4)	(5)	(6)
PT a. Time Deposits and Certificates of Deposit	101
b. Stocks	102
c. Corporate Bonds and Corporate Sukuk	103
d. Mutual Funds	108
e. Collective Investment Contracts for Asset-Backed Securities	109
f. Real Estate Investment Funds	110
g. Direct Investments	111
Total Placement on this Company	-	-	-
PT a. Time Deposits and Certificates of Deposit	101
b. Stocks	102
c. Corporate Bonds and Corporate Sukuk	103
d. Mutual Funds	108
e. Collective Investment Contracts for Asset-Backed Securities	109
f. Real Estate Investment Funds	110
g. Direct Investments	111
Total Placement on this Company	-	-	-
PT a. Time Deposits and Certificates of Deposit	101
b. Stocks	102
c. Corporate Bonds and Corporate Sukuk	103
d. Mutual Funds	108
e. Collective Investment Contracts for Asset-Backed Securities	109
f. Real Estate Investment Funds	110
g. Direct Investments	111
Total Placement on this Company	-	-	-
Total Sub C	-	-	-

As of …
PT XYZ
GENERAL INSURANCE COMPANY
SAP ASSET AND LIABILITY CALCULATION SUB C - INVESTMENT PLACEMENTS ON NON-AFFILIATED PARTIES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Investment Placement Type	Placement on Company (Company Name and/or Country Name)	AYD After Restriction Per Investment Type	Disallowed Assets	AYD
(2)	(3)	(4)	(5)	(6)
Stocks …	…
…
Sub Total	-	-	-
Corporate Bonds and Corporate Sukuk …	…
…
Sub Total	-	-	-
Securities Issued by States Other Than the Republic of Indonesia …	…
…
Sub Total	-	-	-
Securities Issued by Multinational Institutions …	…
…
Sub Total	-	-	-
Mutual Funds …	…
…
Sub Total	-	-	-
Direct Investments …	…
…
Sub Total	-	-	-
Total Sub D	-	-	-

Quarter … Year …
PT XYZ
GENERAL INSURANCE COMPANY
SUB D - FOREIGN INVESTMENT PLACEMENTS As of … SAP ASSET AND LIABILITY CALCULATION

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013

I. Investment Placements on Affiliated Parties with the Company

Ownership	Company Name	Ownership Relationship	Business Field	Percentage of Ownership
(1)	(2)	(3)	(4)	(5)
…
…
…

II. Investment Placements on Non-Affiliated Parties

Company Name	Group Name	Business Field
(1)	(2)	(3)
…
…
…

PT. XYZ
GENERAL INSURANCE COMPANY
SUB E - LIST OF AFFILIATED COMPANIES As of … Quarter … Year …

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Bank Name	Cluster Rating	Book Balance	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
1	PT ………………
Time Deposits
Certificates of Deposit
Sub Total
2	PT ………………
Time Deposits
Certificates of Deposit
Sub Total
3	PT ………………
Time Deposits
Certificates of Deposit
Sub Total
4	PT ………………
Time Deposits
Certificates of Deposit
Sub Total
5	PT ………………
Time Deposits
Certificates of Deposit
Sub Total
Total Time Deposits
Total Certificates of Deposit
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 101
TIME DEPOSITS AND CERTIFICATES OF DEPOSIT

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Issuer/Issuer Name	Category	Book Balance	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)
Total

Quarter … Year …
As of …
GENERAL INSURANCE COMPANY
PT XYZ
DETAIL 102
STOCKS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Issuer/Issuer Name	Cluster Rating	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)
1	PT ………………
Corporate Bonds
Corporate Sukuk
Sub Total
2	PT ………………
Corporate Bonds
Corporate Sukuk
Sub Total
3	PT ………………
Corporate Bonds
Corporate Sukuk
Sub Total
4	PT ………………
Corporate Bonds
Corporate Sukuk
Sub Total
5	PT ………………
Corporate Bonds
Corporate Sukuk
Sub Total
Total Corporate Bonds
Total Corporate Sukuk
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 103
CORPORATE BONDS AND CORPORATE SUKUK

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Security Name	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 104
SECURITIES ISSUED BY THE REPUBLIC OF INDONESIA STATE

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Issuer / Issuing Country	Cluster Rating	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
Total

Quarter … Year …
PT XYZ
GENERAL INSURANCE COMPANY
As of …
SECURITIES ISSUED BY STATES OTHER THAN THE REPUBLIC OF INDONESIA DETAIL 105

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Security Name	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 106
SECURITIES ISSUED BY BANK INDONESIA

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Security Name	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 107
SECURITIES ISSUED BY MULTINATIONAL INSTITUTIONS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Mutual Fund Name	Investment Manager	Book Balance	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)
I
Fully government bonds
Total I
---	---	---	---	---	---	---
II
Fully private bonds and/or money market securities
Total II
---	---	---	---	---	---	---
III
Fully equity securities
Total III
---	---	---	---	---	---	---
IV Mixed
Total IV
Total Mutual Funds (I+II+III+IV)

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 108
MUTUAL FUNDS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Issuer/Issuer Name	Cluster Rating	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 109
COLLECTIVE INVESTMENT CONTRACTS FOR ASSET-BACKED SECURITIES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Issuer/Issuer Name	Cluster Rating	Book Balance	Difference in Valuation SAK and SAP	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 110
REAL ESTATE INVESTMENT FUNDS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Company Name	Business Field	Ownership (%)	Book Balance	Difference in Valuation SAK and SAP	AYD	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
I Under OJK Supervision
Sub Total I
II Not Under OJK Supervision
Sub Total II
Total Direct Investments

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 111
DIRECT INVESTMENTS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Address	Book Balance	Valuation Based on SAP (Appraisal Value/NJOP)	Difference in Valuation SAK and SAP
(1)	(2)	(3)	(4)	(5)
I
Investment Results more than 4% per year
Sub Total I
---	---	---	---	---
II Investment Results 2% - 4% per year
Sub Total II
III Investment Results less than 2% per year
Sub Total III
Total (I + II + III)
IV Permissible Wealth (Maximum 10% of total investments)

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 112
BUILDINGS WITH STRATA RIGHTS OR LAND WITH BUILDINGS FOR INVESTMENT

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Company Name	Business License	Book Balance	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)
I Leasing
Total I
II Credit Cards
Total II
III Consumer Financing
Total III
Total Mutual Funds (I+II+III)

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 113
PURCHASE OF RECEIVABLES FOR FINANCING COMPANIES AND/OR BANKS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Custodian Bank	Quantity (sheets/units)	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)
Total Gold

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 114
PURE GOLD

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Debtor Name	Land Certificate Number	Guarantee Value (Appraisal Value or NJOP)	Initial Loan Value	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
I Residential Property
a. LTV<60%
b. 60%<LTV<80%
Sub Total I
II Other Commercial Property
a. LTV<60%
b. 60%<LTV<80%
Sub Total II
III Property Not Used
Sub Total III
Total (I + II + III)

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 115
LOANS SECURED BY MORTGAGE RIGHTS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)

No.	Description	Amount
(1)	(2)	(3)
Total Other Investments

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 116
OTHER INVESTMENTS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
DIRECT WRITING PREMIUM RECEIVABLES (in millions of rupiah)

No.	Debtor	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)
I Insured
Sub Total
II Insurance Brokers
Sub Total
III Coinsurance Premium Receivables
Sub Total
Total I + II + III

Details of Receivables by Age

No.	Debtor	Less than or equal to 2 months	More than 2 months up to 3 months	More than 3 months
(6)	(7)	(8)	(9)	(10)
I Insured
Sub Total I
II Insurance Brokers
Sub Total II
III Coinsurance Premium Receivables
Sub Total
Total I + II + III

PT XYZ
GENERAL INSURANCE COMPANY
As of …
DETAIL 201
Quarter … Year …

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Debtor Name	Cluster Rating	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)	(7)
I Under OJK Supervision
Sub Total I
II Not Under OJK Supervision
Sub Total II
Total I + II

Details of Receivables by Age (in millions of rupiah)

No.	Debtor Name	Less than or equal to 2 months	More than 2 months up to 3 months	More than 3 months
(8)	(9)	(10)	(11)	(12)
I Under OJK Supervision
Sub Total I
II Not Under OJK Supervision
Sub Total II
Total I + II

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 202
COINSURANCE CLAIM RECEIVABLES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Debtor	Cluster Rating	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)	(7)
A
Reinsurance Premium Receivables Inward and Claim Recovery
I Under OJK Supervision
---	---	---	---	---	---	---
Sub Total I
II Not Under OJK Supervision
Sub Total II
B Reinsurance Assets
III Under OJK Supervision
Sub Total III
IV Not Under OJK Supervision
Sub Total IV
Total I + II + III + IV

Details of Receivables by Age (in millions of rupiah)

No.	Debtor Name	Less than or equal to 2 months	More than 2 months up to 3 months	More than 3 months
(8)	(9)	(10)	(11)	(12)
A
Reinsurance Premium Receivables Inward and Claim Recovery
I Under OJK Supervision
---	---	---	---	---
Sub Total I
II Not Under OJK Supervision
Sub Total II
B Reinsurance Assets
III Under OJK Supervision
Sub Total III
IV Not Under OJK Supervision
Sub Total IV
Total I + II + III + IV

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 203
REINSURANCE RECEIVABLES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Investment Type	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)
1 Time Deposits & Certificates of Deposit
2 Stocks
3 Corporate Bonds & Corporate Sukuk
4 Securities Issued by the Republic of Indonesia State
5 Securities Issued by States Other Than the Republic of Indonesia
6 Securities Issued by Bank Indonesia
7 Securities Issued by Multinational Institutions
8 Mutual Funds
9 Collective Investment Contracts for Asset-Backed Securities
10 Real Estate Investment Funds
11 Direct Investments
12 Buildings with Strata Rights or Land with Buildings for Investment
13 Purchase of Receivables
14 Pure Gold
15 Loans Secured by Mortgage Rights
16 Other Investments
Total

Details of Receivables by Age (in millions of rupiah)

No.	Investment Type	Less than or equal to 1 month	More than 1 month up to 3 months	More than 3 months
(6)	(7)	(8)	(9)	(10)
1 Time Deposits & Certificates of Deposit
2 Stocks
3 Corporate Bonds & Corporate Sukuk
4 Securities Issued by the Republic of Indonesia State
5 Securities Issued by States Other Than the Republic of Indonesia
6 Securities Issued by Bank Indonesia
7 Securities Issued by Multinational Institutions
8 Mutual Funds
9 Collective Investment Contracts for Asset-Backed Securities
10 Real Estate Investment Funds
11 Direct Investments
12 Buildings with Strata Rights or Land with Buildings for Investment
13 Purchase of Receivables
14 Pure Gold
15 Loans Secured by Mortgage Rights
16 Other Investments
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 204
INVESTMENT RECEIVABLES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Investment Type	Book Balance	AYD	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)
1 Time Deposits & Certificates of Deposit
2 Stocks
3 Corporate Bonds & Corporate Sukuk
4 Securities Issued by the Republic of Indonesia State
5 Securities Issued by States Other Than the Republic of Indonesia
6 Securities Issued by Bank Indonesia
7 Securities Issued by Multinational Institutions
8 Mutual Funds
9 Collective Investment Contracts for Asset-Backed Securities
10 Real Estate Investment Funds
11 Direct Investments
12 Buildings with Strata Rights or Land with Buildings for Investment
13 Purchase of Receivables
14 Pure Gold
15 Loans Secured by Mortgage Rights
16 Other Investments
Total

Details of Receivables by Age (in millions of rupiah)

No.	Investment Type	Less than or equal to 1 month	More than 1 month up to 3 months	More than 3 months
(6)	(7)	(8)	(9)	(10)
1 Time Deposits & Certificates of Deposit
2 Stocks
3 Corporate Bonds & Corporate Sukuk
4 Securities Issued by the Republic of Indonesia State
5 Securities Issued by States Other Than the Republic of Indonesia
6 Securities Issued by Bank Indonesia
7 Securities Issued by Multinational Institutions
8 Mutual Funds
9 Collective Investment Contracts for Asset-Backed Securities
10 Real Estate Investment Funds
11 Direct Investments
12 Buildings with Strata Rights or Land with Buildings for Investment
13 Purchase of Receivables
14 Pure Gold
15 Loans Secured by Mortgage Rights
16 Other Investments
Total

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 205
INVESTMENT INCOME RECEIVABLES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Address	Location	Book Balance	Valuation Based on SAP (Appraisal Value/NJOP)
(1)	(2)	(3)	(4)	(5)
I Total
II Permissible Wealth (Maximum 15% of Current Year Own Capital)

Quarter … Year …
PT XYZ
As of …
LAND WITH BUILDINGS FOR OWN USE BUILDINGS WITH STRATA RIGHTS OR DETAIL 206 GENERAL INSURANCE COMPANY

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)

No.	Description	Amount
(1)	(2)	(3)
Total Other Fixed Assets

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 207
OTHER FIXED ASSETS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)

No.	Description	Amount
(1)	(2)	(3)
Total Other Assets

Quarter … Year …
As of …
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 208
OTHER ASSETS

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
PT XYZ
GENERAL INSURANCE COMPANY
DETAIL 301
CLAIM LIABILITIES
(in millions of rupiah)

No.	Creditor Name	Claim Settlement Date	Own Retention	Reinsurer Expense	Total	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)	(6)	(7)
Total

Note:
Of the total Own Retention Claim Liabilities above, those with an age of more than 30 days amount to Book Balance As of … Quarter … Year …

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Creditor Name	Cluster Rating	Total	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)
I Under OJK Supervision
Sub Total I
II Not Under OJK Supervision
Sub Total II
Total I + II

Quarter … Year …
PT XYZ
As of …
GENERAL INSURANCE COMPANY
DETAIL 302
COINSURANCE LIABILITIES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

No.	Creditor Name	Cluster Rating	Total	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)	(5)
I Under OJK Supervision
Sub Total I
II Not Under OJK Supervision
Sub Total II
Total I + II

Quarter … Year …
PT XYZ
As of …
GENERAL INSURANCE COMPANY
DETAIL 303
REINSURANCE LIABILITIES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
PT XYZ
DETAIL 304
COMMISSION LIABILITIES
(in millions of rupiah)

No.	Liability Type / Creditor Name	Total	Book Balance Current (Less than one year)
(1)	(2)	(3)	(4)
I Agents
Sub Total I
II Brokers
Sub Total II
Total I + II

GENERAL INSURANCE COMPANY
As of …
Quarter … Year …

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)

No.	Description	Amount
(1)	(2)	(3)
Total Accrued Expenses

Quarter … Year …
PT XYZ
GENERAL INSURANCE COMPANY
As of …
DETAIL 305
ACCRUED EXPENSES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
NO. DESCRIPTION AMOUNT
(1) (2) (3)
Total Other Liabilities
Quarter ... Year ...
DETAILS 306
OTHER LIABILITIES
As of ...
PT XYZ
GENERAL INSURANCE COMPANY

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Insurance Branch Quarter...
Year...
Quarter...
Year...
(1) (2) (3) (4)
I Premium Reserves
1 Property
2 Motor Vehicles (Own
Damage, Third Party Liability, and Personal Accident) 3 Transportation (Marine Cargo) 4 Hull (Marine Hull) 5 Aircraft (Aviation Hull) 6 Satellites 7 Onshore Energy (Oil and Gas) 8 Offshore Energy (Oil and Gas) 9 Engineering 10 Liability 11 Personal Accident 12 Health 13 Credit (Credit) 14 Suretyship 15 Miscellaneous 16 Life *) 17 Total I II CAPYBMP 1 Property 2 Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident) 3 Transportation (Marine Cargo) 4 Hull (Marine Hull) 5 Aircraft (Aviation Hull) 6 Satellites 7 Onshore Energy (Oil and Gas) 8 Offshore Energy (Oil and Gas) 9 Engineering 10 Liability 11 Personal Accident 12 Health 13 Credit (Credit) 14 Suretyship 15 Miscellaneous 16 Life *) 17 Total II Note *)filled if the Company is a Reinsurance Company As of ... and As of ... GENERAL INSURANCE COMPANY PT XYZ DETAILS 401 PREMIUM RESERVES AND RESERVES FOR PREMIUMS NOT YET EARNED

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Reserves for Claims in Process Reserves for IBNR Total Claim Reserves No. Insurance Branch Quarter... Year... Quarter... Year... Quarter... Year... Quarter... Year... Quarter... Year... Quarter... Year... (1) (2) (3) (4) (5) (6) (7) (8) 1 Property 2 Motor Vehicles (Own Damage, Third Party Liability, and Personal Accident) 3 Transportation (Marine Cargo) 4 Hull (Marine Hull) 5 Aircraft (Aviation Hull) 6 Satellites 7 Onshore Energy (Oil and Gas) 8 Offshore Energy (Oil and Gas) 9 Engineering 10 Liability 11 Personal Accident 12 Health 13 Credit (Credit) 14 Suretyship 15 Miscellaneous 16 Life *) Total Note *)filled if the Company is a Reinsurance Company PT XYZ GENERAL INSURANCE COMPANY As of ... and As of ... DETAILS 402 CLAIM RESERVES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description Property
(Property)
Motor
Vehicles
(Own
Damage,
Third Party
Liability, and
Personal
Accident)
Transportation
(Marine
Cargo)
Hull
(Marine Hull)
Aircraft
(Aviation
Hull)
Satellites
Onshore Energy (Oil and Gas)
Offshore Energy
(Oil and
Gas)
Engineering
(Engineering)
Liability
(Liability)
Personal
Accident
Health
Credit (Credit)
Suretyship
Miscellaneous
Life *)
Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)

UNDERWRITING INCOME
Gross Premium
a. Direct Written Premium
b. Assumed Written Premium
c. Commissions Paid
Total Gross Premium
Reinsurance Premium
a. Reinsurance Premium Ceded
b. Reinsurance Commission Received
Total Reinsurance Premium
Net Premium
Decrease (Increase) in Premium Reserves and CAPYBMP
a. Decrease (Increase) in Premium Reserves
b. Decrease (Increase) in CAPYBMP Reserves
Decrease (Increase) in Premium Reserves and CAPYBMP
Net Premium Income
Other Net Underwriting Income
UNDERWRITING INCOME
UNDERWRITING EXPENSES
Claim Expenses
a. Gross Claims
b. Reinsurance Claims
c. Increase (Decrease) in Claim Reserves
Total Net Claim Expenses
Other Net Underwriting Expenses
UNDERWRITING EXPENSES
UNDERWRITING RESULTS
Note
*)filled if the Company is a Reinsurance Company Quarter ... Year ... As of ... PT XYZ DETAILS 501 UNDERWRITING RESULTS GENERAL INSURANCE COMPANY

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
NO.
DESCRIPTION Property
(Property)
Motor
Vehicles
(Own
Damage,
Third Party
Liability, and
Personal
Accident)
Transportation
(Marine
Cargo)
Hull
(Marine
Hull)
Aircraft
(Aviation
Hull)
Satellites
Onshore Energy (Oil and Gas)
Offshore Energy
(Oil and
Gas)
Engineering
(Engineering)
Liability
(Liability)
Personal
Accident
Health
Credit
(Credit)
Suretyship
Miscellaneous
Life *)
Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
1. Decrease (Increase) in Premium Reserves
2. a. Premium Reserves from previous year/quarter
3. b. Premium Reserves from current year/quarter
4. Total Decrease (Increase) in Premium Reserves - - - - - - - - - - - - - - - - -
5. Decrease (Increase) in Reinsurance Assets for Premium Reserves
6. a. Reinsurance Assets for premium reserves from previous year/quarter
7. b. Reinsurance Assets for premium reserves from current year/quarter
Total Decrease (Increase) in Reinsurance Assets for Premium Reserves 8. - - - - - - - - - - - - - - - - -
9. Total Decrease (Increase) in Premium Reserves - - - - - - - - - - - - - - - - -
10. Decrease (Increase) in CAPYBMP
11. a. CAPYBMP from previous year/quarter
12. b. CAPYBMP from current year/quarter
13. Total Decrease (Increase) in CAPYBMP - - - - - - - - - - - - - - - - -
14. Decrease (Increase) in Reinsurance Assets for CAPYBMP
15. a. Reinsurance Assets for CAPYBMP from previous year/quarter
16. b. Reinsurance Assets for CAPYBMP from current year/quarter
Total Decrease (Increase) in Reinsurance Assets for CAPYBMP - - - - - - - - - - - - - - - - -
17. Total Decrease (Increase) in CAPYBMP - - - - - - - - - - - - - - - - -
18. Total Decrease (Increase) in CAPYBMP - - - - - - - - - - - - - - - - -
19. Increase (Decrease) in Claim Reserves
20. a. Claim Reserves from current year/quarter
21. b. Claim Reserves from previous year/quarter
22. Total Increase (Decrease) in Claim Reserves - - - - - - - - - - - - - - - - -
23. Increase (Decrease) in Reinsurance Assets for Claim Reserves
24. a. Reinsurance Assets for Claim Reserves from current year/quarter
25. b. Reinsurance Assets for Claim Reserves from previous year/quarter
Total Increase (Decrease) in Reinsurance Assets for Claim Reserves 26. - - - - - - - - - - - - - - - - -
27. Total Increase (Decrease) in Claim Reserves - - - - - - - - - - - - - - - - -
Note
*)filled if the Company is a Reinsurance Company Quarter ... Year ... As of ... PT XYZ GENERAL INSURANCE COMPANY DETAILS 502 DECREASE (INCREASE) IN PREMIUM RESERVES, CAPYBMP AND INCREASE (DECREASE) IN CLAIM RESERVES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Type of Investment Cash Received *) Receivables *) Unrealized Gain (Loss) Total Investment Income Description (Type of Income) (1) (2) (3) (4) (5) (6) (7) I Investment Placements with Non-Affiliates
1. Time Deposits and Certificates of Deposit
2. Stocks
3. Corporate Bonds and Corporate Sukuk
4. Securities Issued by the Indonesian Government
5. Securities Issued by Governments Other than the Indonesian Government
6. Securities Issued by Bank Indonesia
7. Securities Issued by Multinational Institutions
8. Mutual Funds
9. Collective Investment Contracts for Asset-Backed Securities
10. Real Estate Investment Funds
11. Direct Investments
12. Buildings with Strata Rights or Land
with Buildings for Investment
13. Purchase of Receivables for Financing Companies and/or Banks
14. Pure Gold
15.
Loans Secured by Mortgage Rights
16. Other Investments
17. Sub Total
II Investment Placements with Affiliates
18. Time Deposits and Certificates of Deposit
19. Stocks
20. Corporate Bonds and Corporate Sukuk
21. Securities Issued by the Indonesian Government
22. Securities Issued by Governments Other than the Indonesian Government
23. Securities Issued by Bank Indonesia
24. Securities Issued by Multinational Institutions
25. Mutual Funds
26. Collective Investment Contracts for Asset-Backed Securities
27. Real Estate Investment Funds
28. Direct Investments
29. Buildings with Strata Rights or Land
with Buildings for Investment
30. Purchase of Receivables for Financing Companies and/or Banks
31. Pure Gold
32.
Loans Secured by Mortgage Rights
33. Other Investments
34. Sub Total
35. Gross Investment Income (17 + 34))
36. Investment expenses
37. Net Investment Income (35 - 36)
Note:
*)Investment income after tax / before tax (cross out as necessary) Quarter ... Year ... As of ... PT XYZ GENERAL INSURANCE COMPANY DETAILS 503 INVESTMENT INCOME

Appendix I
SEOJK NUMBER: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
NO.
DESCRIPTION AMOUNT
(1) (2) (3)
I. Other Income
Sub Total I
II. Other Expenses
Sub Total II
Total I - II -
Quarter ... Year ...
As of ...
PT XYZ
GENERAL INSURANCE COMPANY
DETAILS 504
OTHER (EXPENSES) INCOME

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
NO.
DESCRIPTION AMOUNT
(1) (2) (3)

Foreign currency translation differences in financial statements
Financial assets available for sale
Revaluation gains on fixed assets
Share of other comprehensive income of associate entities
...
...
...
Total Comprehensive Income -
Quarter ... Year ...
As of ...
PT XYZ
GENERAL INSURANCE COMPANY
DETAILS 505
OTHER COMPREHENSIVE INCOME

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description Quarter...
Year...
Quarter...
Year...
(1) (2) (3) (4)
1 ASSETS
2 Investments
3 Time Deposits and Certificates of Deposit 4 Stocks 5 Corporate Bonds and Corporate Sukuk 6 Securities Issued by the Indonesian Government 7 Securities Issued by Governments Other than the Indonesian Government 8 Securities Issued by Bank Indonesia 9 Securities Issued by Multinational Institutions 10 Mutual Funds 11 Collective Investment Contracts for Asset-Backed Securities 12 Real Estate Investment Funds 13 Buildings with Strata Rights or Land with Buildings for Investment 14 Purchase of Receivables for Financing Companies and/or Banks 15 Pure Gold 16 Loans Secured by Mortgage Rights 17 Other Investments 18 Total Investments 19 Non-Investments 20 Cash and Banks 21 Direct Written Premium Receivables 22 Coinsurance Claim Receivables 23 Reinsurance Receivables 24 Investment Receivables 25 Investment Income Receivables 26 Other Current Assets Total Non-Investments 27 TOTAL CURRENT ASSETS 28 LIABILITIES 29 Liabilities 30 Technical Reserves 31 Premium Reserves 32 Reserves for Premiums Not Yet Earned 33 Claim Reserves 34 Total Technical Reserves 35 Liabilities 36 Claim Payables 37 Coinsurance Payables 38 Reinsurance Payables 39 Commission Payables 40 Tax Payables 41 Accrued Expenses 42 Other Liabilities 43 Total Liabilities 44 TOTAL CURRENT LIABILITIES As of ... and As of ... GENERAL INSURANCE COMPANY PT XYZ DETAILS 601 CURRENT ASSETS AND CURRENT LIABILITIES

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
1. Summary of Guarantee Fund Development
No. Description Amount
1. Beginning Balance of Guarantee Fund
2. New Guarantee Fund Placements:
3. a. Guarantee Fund in the Form of Deposits
4. b. Guarantee Fund in the Form of SUN/Other Securities
Issued by the State (SBN)
5. Total New Guarantee Fund Placements (3 + 4)
6. Guarantee Fund Withdrawals:
7. a. Guarantee Fund in the Form of Deposits
8. b. Guarantee Fund in the Form of SUN/Other Securities
Issued by the State (SBN)
9. Total Guarantee Fund Withdrawals (7 + 8)
10. Ending Balance of Guarantee Fund (1 + 5 – 9)
2. Annual Guarantee Fund Sufficiency Calculation
No. Description Amount
1. Minimum required paid-up capital
2. Total Net Premiums
3. Total Reinsurance Premiums
4. Minimum Guarantee Fund Limit I (20% x 1)
5. Minimum Guarantee Fund Limit II ((1% x 2) + (0.25% x 3 ))
6.
Minimum Guarantee Fund Limit Used (The higher value between 4 and 5)
7. Guarantee Fund Owned
8. Surplus (Deficiency) of Guarantee Fund (7 - 6)
PT XYZ
GUARANTEE FUND REPORT
Summary of Guarantee Fund Development and Guarantee Fund Sufficiency Calculation As of ... Quarter ... Year ... Note:
Total net premiums and reinsurance premiums are the amounts as presented in the latest annual financial statements audited by a public accountant

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
A. Deposits (in millions of rupiah) No. Custodian Bank Name Currency Bill Number Amount Exchange Rate 1) Amount in Rupiah Date of Last Issuance/ Rollover Maturity Date 1 … 2 … 3 … 4 … 5 … Total Deposits - B. Bonds or Other Securities Issued by the State (SBN) (in millions of rupiah) No. Custodian Bank Name Serial Number Currency Nominal Value Exchange Rate 1) Nominal Value in Rupiah Maturity Date 1 … 2 … 3 … 4 … 5 … 6 … 7 … 8 … Total SBN - Note:
1) 1 USD = Rp ..... (Using Bank Indonesia's Middle Exchange Rate as of the Report Date)
As of ...
Final Position Details of Guarantee Fund PT. XYZ GUARANTEE FUND REPORT Quarter ... Year ...

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
(ratio in percentage)
No. Description
Quarter ...
Year ...
Quarter ...
Year ...
1 Liquidity Ratio a. Current Assets b. Current Liabilities
c. Ratio (a : b)
2 Investment Sufficiency Ratio a. Investments + Cash & Banks (See SAP Balance Sheet) b. Retention Technical Reserves
c. Retention Claim Payables + Other Payables to Policyholders
d. Ratio (a : (b + c))
3 Ratio of Investment Income to Net Premium Income a. Investment Income b. Net Premium Income
c. Ratio (a : b)
4 Ratio of Claim Expenses, Business Expenses, and Commissions a. Net Claim Expenses b. Business Expenses
c. Net Commissions
d. Net Premium Income e. Ratio a : d (ratio I) f. Ratio b : d (ratio II) g. Ratio c : d (ratio III) h. Ratio I + Ratio II + Ratio III PT.XYZ As of ... and As of ... Financial Health Ratios Other Than MMBR

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
I. Education and Training Costs (in millions of rupiah)
Budget Realization Percentage
(1) (2) (3) (4) (5) = (4) : (3) Total Note :
Column (3) is filled with the budget for education and training costs for one year Column (4) is filled with the cumulative realization of education and training costs up to the reporting period
II. Education and Training Ratio
No. Budget Realization
(1) (3) (4)
1 Employee, Board of Directors, and Board of Commissioners Costs 2 Education and Training Costs (Diklat) a. Employee Training b. Board of Directors Training
c. Board of Commissioners Training
3 Total Training Costs (a + b + c) 4 Ratio of Training Costs to Employee, Board of Directors, and Board of Commissioners Costs (3 : 1) #DIV/0! #DIV/0! PT.XYZ Education and Training Ratio As of ... Description (2) NO. Description Training Costs Quarter ... Year ...

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year #DIV/0! #DIV/0! 1 year < age < 5 years #DIV/0! #DIV/0! 5 years ≤ age < 10 years #DIV/0! #DIV/0! ≥ 10 years #DIV/0! #DIV/0! Total (in percentage) Rupiah Foreign Currency Total Ratio of Current Assets to Non-Current Assets #DIV/0! #DIV/0! Ratio of Current Liabilities to Non-Current Liabilities #DIV/0! #DIV/0! Note:
1) In millions of rupiah
2) In percentage
3) Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with an age of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with an age of more than 1 year Ratio of Assets to Liabilities 2) PT.XYZ ASSET AND LIABILITY RECAPITULATION BASED ON CURRENCY AND MATURITY AGE As of ... Description Age Assets 1) Liabilities 1) Quarter ... Year ...

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Description Direct
Marketing Agent Broker Bancassurance Affinity Telemarketing Others Total Gross Premium a. Direct Written Premium b. Assumed Written Premium
c. Commissions Paid
Total Gross Premium - - - - - - - - Claim Expenses a. Gross Claims b. Reinsurance Claims Total Claim Expenses - - - - - - - - PT. XYZ DETAILS OF PREMIUM INCOME AND CLAIM EXPENSES BASED ON DISTRIBUTION CHANNEL As of ... Quarter ... Year ...

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: August 27, 2013
GUIDELINES FOR PREPARING FINANCIAL REPORTS FOR GENERAL INSURANCE/ REINSURANCE COMPANIES
I. GENERAL

These financial reports are prepared specifically for the supervision and oversight of insurance business. Therefore, the form, content, and structure of the financial reports are made in accordance with applicable laws and regulations in the insurance business sector (Statutory Accounting Practices/SAP) as regulated in Minister of Finance Regulation Number 53 of 2012 and its implementing regulations.
The content and structure of the Financial Reports of General Insurance/Reinsurance Companies are as follows:
A. Primary Financial Reports consisting of:
1) Financial Position Report of General Insurance/Reinsurance Companies
2) Comprehensive Income/Loss Report of General Insurance/Reinsurance Companies
3) Cash Flow Report of General Insurance/Reinsurance Companies
Equity Change Report of General Insurance/Reinsurance Companies
4) Solvency Level Report of General Insurance/Reinsurance Companies:
a) Solvency Achievement Ratio b) Risk-Based Minimum Capital (MMBR)  Schedule A - Asset Management Failure Risk  Schedule B - Risk of Imbalance Between Asset and Liability Cash Flow Projections  Schedule C – Risk of Imbalance Between Asset and Liability Values in Each Currency Type  Schedule D – Insurance Liability Risk  Schedule E – Interest Rate Risk  Schedule F – Reinsurance Risk  Schedule G – Operational Risk
5) SAP Asset and Liability Calculation of General Insurance/Reinsurance Companies
a) Sub A - Investment Placements with Non-Single Parties b) Sub B - Investment Placements with Parties Affiliated with the Company c) Sub C - Investment Placements with Parties Not Affiliated with the Company d) Sub D - Investment Placements Abroad e) Sub E - List of Affiliated Companies
6) Details of Financial Reports of General Insurance/Reinsurance Companies
B. Supplementary Financial Reports consisting of:
1) Guarantee Fund Report of General Insurance/Reinsurance Companies
a) Summary of Development and Calculation of Guarantee Fund Sufficiency b) Details of Final Position of Guarantee Fund
2) Financial Health Ratios Other Than MMBR

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: August 27, 2013
3) Education and Training Cost Ratio
4) Asset and Liability Matching
5) Details of Premium Income and Claim Expenses Based on Distribution Channel
3. The form, content, and structure of these financial reports are used for both quarterly financial reports and annual financial reports.
4. For General Insurance/Reinsurance Companies that do not meet solvency requirements, the form, content, and structure of the financial reports are the same as the form, content, and structure of quarterly financial reports.
5. Companies that do not meet solvency levels, in addition to submitting the Financial Rehabilitation Report as referred to in number 4, are required to attach plans and steps for financial rehabilitation.
6. Primary financial reports are presented sequentially for two periods, namely the current period and the previous period. For quarterly reports, the previous period refers to the same period in the previous year. For example, for the second quarter report of 2013, the current period is the second quarter of 2013, while the previous period is the second quarter of 2012. Meanwhile, for annual reports, the previous period refers to one period before the current period, for example, for the 2013 report, the current period is 2013, while the previous period is 2012.
7. If there are rows or columns that must be filled but the value is 0 (zero) or does not exist, then 0 (zero) is written.
8. Rupiah amounts on all financial report formats are written in millions of rupiah with 2 (two) decimal places after the comma.
9. Negative numbers are enclosed in parentheses (xxxx).
10. Permitted Assets (AYD) are assets permitted to be calculated in the solvency level calculation as referred to in laws and regulations in the insurance business sector.
11. Reserves for Premiums Not Yet Earned (CAPYBMP) are funds that must be formed to describe the portion of premiums whose insurance period has not yet been run.
12. General Insurance/Reinsurance Companies (Companies) are Insurance Companies as referred to in Laws regarding insurance business.
13. Others
a. The company name must be clearly written on every format title available. On the front page (cover), the name and address of the General Insurance/Reinsurance Company must be filled in on the available line (XYZ in PT XYZ refers to the company name). b. The reporting periods for quarterly and annual reports must be filled in according to the end date of the current reporting period. For example, for the second quarter report of 2013, it is filled in as of June 30, 2013, while for the 2013 report, it is filled in as of December 31, 2013.
c. If the company adds pages for a detail, then the pages for that detail are numbered a, b, and so on. For example, if Detail 101 consists of two pages, the first page is numbered 19a and the next page is numbered 19b, and so on.
d. The submitted financial reports must be signed by at least one member of the Board of Directors and stated in the company profile (page ii).

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: August 27, 2013 e. The statement letter must be signed by one director representing the board of directors. f. The form, content, and structure of the financial reports cannot be changed, unless otherwise stated in the notes in each format. If the number of available rows or pages is still insufficient, the company may add as needed. g. On each format, there are several important notes that need to be understood as instructions for filling them out. h. The cover of the financial report for General Insurance and Reinsurance Companies uses blue color.
14. The procedure chart for filling out financial report formats for the purpose of calculating solvency achievement ratios is as follows:
Start
Is there Investment Abroad Sub D Sub A Yes No Sub B Affiliation with the company SAP Asset and Liability Calculation SAP Asset Calculation Details 101 - 116 Yes SAP Financial Position Report (Page 1, Column 5) Details 101 - 208 Details 501 - 505 Comprehensive Income/Loss Calculation Risk-Based Minimum Capital Schedule A - G Solvency Level Report Details 301 - 402 SAP Asset and Liability Calculation SAP Liability Calculation No Sub E List of affiliated companies Sub C Non-affiliation with the company Is there Investment with a Single Party
II. PRIMARY FINANCIAL REPORTS

Financial Position Report

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

The Balance Sheet in this report consists of a Balance Sheet prepared based on Financial Accounting Standards (SAK) and Statutory Accounting Practice (SAP), presented together with the Balance Sheet of the previous period as a comparison. The accounts in the Balance Sheet are filled based on the accounts listed in details 101 to 402.

a. SAK Balance Sheet
The accounts in this Balance Sheet have been reclassified according to the intent of their listing, so the accounts do not necessarily have to be the same as the accounts in reporting according to SAK. The purpose of listing the SAK Balance Sheet is to provide comparative figures for the SAP Balance Sheet accounts, especially for assets, so as to facilitate analysis by analysts.

b. SAP Balance Sheet
Assets listed in the SAP Balance Sheet are Statutory Available Capital (AYD), the accounts of which are filled based on the accounts listed in details 101 to 208. The determination of the amount of AYD for each type of asset is calculated based on applicable regulations. The total AYD in this report (column (4)) is subsequently filled in the Solvency Level Report – Solvency Achievement Ratio (column (2)) row AYD.

Liabilities in the SAP Balance Sheet are filled based on the accounts listed in details 301 to 402. The total liabilities in this report (column (4)) are subsequently filled in the Solvency Level Report – Solvency Achievement Ratio (column (2)) row Liabilities.

For the Equity group, accounts are adjusted as much as possible to the existing format. For the account "Difference in Valuation Based on SAK and SAP," it is filled based on the amount in the SAP Asset and Liability Calculation – Difference in Valuation Based on SAK and SAP section, while for the account "Assets Not Permitted," it is filled based on the amount in the SAP Asset and Liability Calculation – I. SAP Asset Calculation column (5).

The SAK and SAP valuation difference can arise due to differences in asset and liability valuation based on SAK and SAP. Differences in asset valuation between SAK and SAP arise due to differences in the recognition of the value of those assets. Generally, SAP recognizes assets at fair value, while SAK recognizes assets at historical cost. For liabilities, differences can arise because SAK provides several options in the technical reserve calculation method, allowing Companies to choose a technical reserve calculation method based on SAK that differs from the technical reserve calculation as regulated by legislation.

In the event of differences in asset and liability valuation between SAP and SAK, such differences can increase or decrease SAP equity. Differences in asset valuation can occur because, generally, asset valuation based on SAP results in larger amounts compared to asset valuation based on SAK, thus resulting in an increase in SAP equity. For liabilities, generally Companies will use valuation based on SAP, which can provide smaller valuations compared to liability valuation based on SAK, thus resulting in an increase in SAP equity.

Meanwhile, Non-Permitted Assets arise due to limitations in the recognition of Company assets, so not all assets recognized based on SAK can be recognized as assets based on SAP. Thus, the non-recognition of such assets results in a decrease in SAP equity.

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

The presentation of reinsurance assets in this Balance Sheet is presented as assets that are part of reinsurance receivables and included in AYD in the calculation of financial health levels. The value of reinsurance assets consists of:

The value of reinsurance assets over future policy benefits liabilities, determined consistently with the approach used in determining future policy benefits liabilities, based on the terms and conditions of the reinsurance contract.
The value of reinsurance assets over unearned premiums, determined consistently with the approach used in determining unearned premiums, based on the terms and conditions of the reinsurance contract.
The value of reinsurance assets over estimated claim liabilities, determined consistently with the approach used in determining estimated claim liabilities, based on the terms and conditions of the reinsurance contract.

Comprehensive Income Statement
The columns in this report are filled based on the figures listed in details 501 to 505. The SAP Comprehensive Income Statement may differ from the SAK Comprehensive Income Statement due to differences in recognition treatment (technical reserve expenses) and differences in account classification. Account classification for SAP reports has been adjusted to existing regulations. Thus, the final result of this Comprehensive Income Statement (i.e., profit or loss) may differ between SAP reports and SAK reports.

The Comprehensive Income Statement presented is the Comprehensive Income Statement for the beginning of the current fiscal year up to the reporting date (cumulative). For example, for the second quarter report of 2013, the recorded revenue is revenue obtained since January 1, 2013, up to June 30, 2013.

Increase (Decrease) in Premium Reserves, CAPYBMP, and Decrease (Increase) in Claim Reserves in the Comprehensive Income Statement are presented based on detail 502.

Components to determine Gross Premium in this report are gross premiums as referred to in Government Regulation Number 73 of 1992 concerning the Conduct of Insurance Business as amended by Government Regulation Number 63 of 1999.

Cash Flow Statement
The Cash Flow Statement in this report is filled based on the information in the columns provided in the existing format. The ending balance of Cash and Bank in the previous period (quarterly or annual) is the opening balance for the current period. The ending balance of cash and bank in this report must be the same as the amount of cash and bank in the Balance Sheet.
Statement of Changes in Equity
The statement of changes in equity consists of SAK Equity and SAP Equity. To be able to fill the SAP statement of changes in equity, the Company must first fill the statement of changes in equity prepared based on SAK.

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

The SAP Statement of Changes in Equity is a reconciliation statement from the SAK Equity Statement to the SAP Equity Statement. Two SAP equity components that are not SAK equity components, namely "Difference in Valuation SAK and SAP" and "Non-Permitted Assets," are two important components that affect the result of this reconciliation. These two components are filled into the SAP Statement of Changes in Equity, only by the difference between the current period and the previous period. The figures filled into the SAP Statement of Changes in Equity are the increase or decrease in "Difference in Valuation SAK and SAP" and "Assets Not Included in AYD" as stated in the Balance Sheet in column (4) and column (6).

Example:
a. If "Difference in Valuation SAK and SAP" in the first quarter of 2013 stated in the Balance Sheet is Rp 1,200 million, while for the fourth quarter of 2012 it is Rp 1,000 million, then the figure filled into "Increase (Decrease) in Difference in Valuation SAK and SAP" is Rp 200 million. b. If "Assets Not Included in AYD" for the first quarter of 2013 stated in the Balance Sheet is Rp 5,600 million, while for the fourth quarter of 2012 it is Rp 4,000 million, then what is filled into "(Increase) Decrease in Non-Permitted Assets" is (Rp 1,600) million.

Solvency Level Report
The Solvency Level Report in this report consists of:
a. Solvency Achievement Ratio
Companies are required to meet a solvency level of at least 120% of the minimum risk-based capital as referred to in Minister of Finance Regulation Number 53/PMK.010/2012. The total solvency consists of AYD and Liabilities (except subordinated loans). The total AYD (column (2)) must be the same as the total assets in the Balance Sheet (column (4) – SAP Balance). Meanwhile, the total liabilities (column (2)) must be the same as the total liabilities in the Balance Sheet (column (4) – SAP Balance).

b. Minimum Risk-Based Capital
The method of filling the schedules is as follows:
Schedule A: The total amount of AYD (column (2)) must be the same as the total assets in the SAP Balance Sheet (column (4)).
If the Company has mixed mutual funds, then an example calculation of the weighted average factor is as follows:

Portfolio Composition	Weighted Average Factor
Government Bonds	40% 0% 0%
Private bonds	40% 6% 2.4%
Equity securities	20% 16% 3.2%

The weighted average of each security is the result of multiplying the composition of each security by the risk factor. In the example above, the weighted average of the mixed fund is the sum of the weighted average of the security portfolios, which is 5.6%.

Schedule B: The columns in this schedule are filled with the values of AYD and liabilities based on book values in the Balance Sheet, classified based on their maturity dates. AYD in the form of traded securities and valued based on market value (example: stocks) is classified as assets maturing within less than 1 (one) year. Meanwhile, AYD intended to be held until maturity is classified according to its remaining life.

Schedule C: The total AYD in columns (2) to (10) must be the same as the total assets in the SAP Balance Sheet, and likewise, the liabilities in columns (2) to (10) must be the same as the total liabilities in the Balance Sheet (excluding subordinated loans).

Schedule D: The columns in this schedule are filled according to the instructions stated in the existing format. Life insurance branches are filled if the Company is a reinsurance Company.

Schedule E: The columns in this schedule are filled according to the instructions stated in the existing format.

Schedule F: The columns in this schedule are filled according to the instructions stated in the existing format. If the Company does not have deposits and/or premiums held (column (3)), this column is filled with the number 0 (zero).

Schedule G: General and administrative expenses and education and training expenses are filled with general and administrative expenses and education and training expenses for one year. For quarterly reports, general and administrative expenses and education and training expenses are filled with the general and administrative expenses and education and training expenses for the last 4 (four) quarters. For example, for the first quarter of 2013, general and administrative expenses are filled with the total general and administrative expenses of the second quarter of 2012, third quarter of 2012, fourth quarter of 2012, and first quarter of 2013. Likewise, education and training expenses are filled with the total education and training expenses of the second quarter of 2012, third quarter of 2012, fourth quarter of 2012, and first quarter of 2013.

SAP Asset and Liability Calculation
a. SAP Asset Calculation
The columns of the SAP Asset Calculation are filled with the following instructions:
Column 2: Filled according to what is stated in each asset detail for the total ledger balance (SAK). Column 3: Filled according to the valuation basis as regulated in Minister of Finance Regulation Number 53 of 2012. Column 4: Is the difference between column (2) and column (3). (Note: if there are valuation differences between SAK and SAP). Column 5: Filled with the total non-permitted assets found in each detail (101 to 208), especially for other investment accounts, other fixed assets, and other assets. Column 6: Filled from the total AYD found in each detail (detail 101 to 208). For the Cash and Bank account, the amount must be the same as the ending balance in the Cash Flow Statement.

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

The total Difference in Valuation SAK and SAP (column (4)) is an increase or decrease in equity in the preparation of the SAP Balance Sheet as explained in the Statement of Changes in Equity. A valuation surplus of assets based on SAP over SAK is an increase in SAP equity, while a valuation deficit of assets based on SAP over SAK is a decrease in SAP equity.

b. SAP Liability Calculation
The columns of the SAP Liability Calculation are filled with the following instructions:
Column 2: Filled according to what is stated in each liability detail for the total ledger balance (SAK). Column 3: Filled according to what is stated in each liability detail with valuation based on SAP. Column 4: Filled based on the total Difference in Valuation SAK and SAP found in each liability detail (Note: if there are valuation differences between SAK and SAP). A valuation surplus of liabilities based on SAP over SAK is a decrease in equity, while a valuation deficit of liabilities based on SAP over SAK is an increase in equity.

c. Difference in Valuation Based on SAK and SAP
The total Difference in Valuation SAK and SAP used in the preparation of the SAP Balance Sheet is the net difference between the valuation differences of assets and liabilities. This figure is then transferred to the balance sheet column (4) in the account difference in valuation based on SAK and SAP.

d. Sub-Sub Sections
The asset calculation form has 5 (five) sub-sections, namely:
1) Sub A, Investment Placements Not with One Party
The columns in Sub A are filled if the Company places investments in companies but are not affiliated either with the Company or with the Company.
2) Sub B, Investment Placements with Affiliated Parties with the Company
The columns in Sub B are filled if the Company places investments in companies that are part of an affiliated group where the Company is part of it. The total investment placements in such companies are at most 10% (ten percent) of the total investments.
3) Sub C, Investment Placements with Affiliated Parties not with the Company
The columns in Sub C are filled if the Company places investments in companies that are part of an affiliated group, where the Company is not part of it. The total investment placements in such companies are at most 20% (twenty percent) of the total investments.
4) Sub D, Investment Placements Abroad
The columns in Sub D are filled if the Company places investments in countries other than the Republic of Indonesia.
5) Sub E, List of Affiliated Companies
The columns in Sub E are filled according to the information in the existing format. Ownership relationships (column (2)) are filled by stating the Company's position in an affiliated group. For example, subsidiary, parent, etc.

Details

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

7.1. Detail 101
The following regulations apply to this detail:

Column (3) is filled with the bank rating. For banks that issue bonds, the bank rating can refer to rating agencies registered with the Financial Services Authority (Pefindo, Fitch Indonesia, and ICRA Indonesia). However, if the bank does not issue bonds and is not listed with the aforementioned rating agencies, this column does not need to be filled.
Column (4) is filled with the cluster corresponding to the rating in column (3). If column (3) is empty, this column is filled with the largest cluster (cluster 5).
The amount in column (7) is filled into detail 601.
Column (8) is filled as follows:
1. If there are placements of more than one type of investment in one company, this column is filled by stating the other types of investment, for example, "stocks."
2. If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group."

7.2. Detail 102
The following regulations apply to this detail:

Column (3) is filled as follows:
1. LQ45 or JII, depending on the category of the stock.
2. Other exchanges other than LQ45 and JII.
3. Foreign exchanges.
The amount in column (6) is filled into detail 601.
Column (7) is filled as follows:
1. If there are placements of more than one type of investment in one company, this column is filled by stating the other types of investment, for example, "corporate bonds."
2. If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group."
3. If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled into sub D.

7.3. Detail 103
The following regulations apply to this detail:

Column (3) is filled with the rating of corporate bonds and corporate sukuk issued by rating agencies registered with the Financial Services Authority (Pefindo, Fitch Indonesia, and ICRA Indonesia) or those that have received international recognition (Standard & Poor’s, Moody’s, AM Best, Fitch, and ICRA).
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is filled into detail 601.
Column (9) is filled as follows:
1. If there are placements of more than one type of investment in one company, this column is filled by stating the other types of investment, for example, "stocks."
2. If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group."
3. If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

into sub D.

7.4. Detail 104

The columns in this detail are filled according to the information in the existing format.
The amount in column (6) is filled into detail 601.

7.5. Detail 105

Column (3) is filled with the investment instrument rating based on rating agencies that have received international recognition (Standard & Poor’s, Moody’s, AM Best, Fitch, and ICRA). The total value of these instruments is filled into sub D.
Column (4) is filled with the cluster corresponding to column (2).
The amount in column (8) is filled into detail 601.

7.6. Detail 106

The columns in this detail are filled according to the information in the existing format.
The amount in column (6) is then filled into detail 601.

7.7. Detail 107

The columns in this detail are filled according to the information in the existing format and the total value of these instruments is filled into sub D.
The amount in column (6) is then filled into detail 601.

7.8. Detail 108
The following regulations apply to this detail:

The determination of the unit trust mutual fund grouping category must be based on the actual investment composition of the mutual fund on the Balance Sheet date, not the investment composition in the prospectus.
A mutual fund is called entirely Government bonds if 90% or more of the mutual fund's investment composition is placed in Government bonds. If the placement in one type of investment is less than 90%, the mutual fund is grouped into mixed mutual funds. This also applies to placements in other mutual fund categories.
The amount in column (6) is filled into detail 601.
Column (7) is filled as follows:
1. If there are placements of more than one type of investment in one company, this column is filled by stating the other types of investment, for example, "stocks."
2. If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group."
3. If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled into sub D.

7.9. Detail 109
The following regulations apply to this detail:

Column (3) is filled with the investment instrument rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is filled into detail 601.
Column (9) is filled as follows:
1. If there are placements of more than one type of investment in one company, this column is filled by stating the other types of investment, for example, "stocks."
2. If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group."

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

7.10. Detail 110
The following provisions apply to this detail:

Column (3) is filled with the investment instrument rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is entered into Detail 601.
Column (9) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by stating the other investment types, for example "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group".

7.11. Detail 111
The following provisions apply to this detail:

The maximum total value of Column (7) is 10% (ten percent) of the total investment amount.
Column (8) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by stating the other investment types, for example "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group".
3) If the investment type in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is entered into Sub D.

7.12. Detail 112
The following provisions apply to this detail:

The category of building types with strata rights or land with buildings as investments or for own use is determined by the company, provided that buildings with strata rights or land with buildings can be categorized as investments if they can provide returns (in the form of rent) to the company.
Column (2) can be filled by stating the city (DATI II) where the building with strata rights or land with building is located.
The amount in column (3) is entered into Detail 601.
Column (4) is filled based on the value determined by a registered appraiser institution at the competent agency, or the latest Taxable Object Value (NJOP) if no appraisal is conducted by an appraiser institution.
Column (5) is the difference between column (3) and column (4) for each unit.
Row Number IV (AYD) will be equal to the total (I + II + III) if the total value (I + II + III) is less than or equal to 10% of the total investment amount.

7.13. Detail 113
The following provisions apply to this detail:

Column (3) is filled with the financing company and/or bank license number.
The amount in column (4) is entered into Detail 601.
Column (8) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by stating the other investment types, for example "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliated Group".

7.14. Detail 114
Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

The following provisions apply to this detail:

This investment type consists of gold bars.
Column (3) is filled according to the quantity of ownership. For example, if the Company owns 10 kg of gold bars, column (3) is filled: 25 pieces/100gr, 10 pieces/250gr, 50 pieces/100gr.
Columns in this detail are filled according to the descriptions available in the format.
The amount in column (6) is entered into Detail 601.

7.15. Detail 115

Columns in this detail are filled according to the descriptions available in the format.
The amount in column (8) is entered into Detail 601.

7.16. Detail 116
Columns in this detail are filled if the Company has other investments besides those mentioned above.

7.17. Detail 201
The following provisions apply to this detail:

For the debtor detail, only debtors who owe the company an amount equal to 5% or more of the total value of Premium Receivables need to be detailed. Meanwhile, for debtors whose debt amount is below 5% of the total value of Premium Receivables, they can simply be categorized into the "Others" group.
For the "Insurance Broker" debtor category, the total premium receivables of the insurance company to the brokerage company are filled, so the debtor name listed is the name of the brokerage company.
The amount in column (5) may be larger than the amount in column (4), considering that receivables that can be entered into column (4) have a shorter receivable age than receivables that can be entered into column (5). Subsequently, the amount in column (5) is entered into Detail 601.

7.18. Detail 202
The following provisions apply to this detail:

For the debtor detail, only debtors who owe the company an amount equal to 5% or more of the total value of Co-insurance Claim Receivables need to be detailed. Meanwhile, for debtors whose debt amount is below 5% of the total value of Co-insurance Claim Receivables, they can simply be categorized into the "Others" group.
Column (3) is filled with the debtor rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (7) may be larger than the amount in column (6), considering that receivables that can be entered into column (6) have a shorter receivable age than receivables that can be entered into column (7). Subsequently, the amount in column (7) is entered into Detail 601.

7.19. Detail 203
The following provisions apply to this detail:

For the debtor detail, only debtors who owe the company an amount equal to 5% or more of the total value of Reinsurance Receivables need to be detailed. Meanwhile, for debtors whose debt amount is below 5% of the total value of Reinsurance Receivables, they can simply be categorized into the "Others" group.
Reinsurance assets are part of reinsurance receivables and are included in AYD.
Column (3) is filled with the debtor rating.

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

Column (4) is filled with the cluster corresponding to column (3).
The amount in column (7) may be larger than the amount in column (6), considering that receivables that can be entered into column (6) have a shorter receivable age than receivables that can be entered into column (7). Subsequently, the amount in column (7) is entered into Detail 601.

7.20. Detail 204
The following provisions apply to this detail:

Receivables with an age of at most 1 (one) month can be categorized as AYD.
The amount in column (5) may be larger than the amount in column (4), considering that receivables that can be entered into column (4) have a shorter receivable age than receivables that can be entered into column (5). Subsequently, the amount in column (5) is entered into Detail 601.

7.21. Detail 205
The following provisions apply to this detail:

Receivables with an age of at most 1 (one) month can be categorized as AYD.
The amount in column (5) may be larger than the amount in column (4), considering that receivables that can be entered into column (4) have a shorter receivable age than receivables that can be entered into column (5). Subsequently, the amount in column (5) is entered into Detail 601.

7.22. Detail 206
The following provisions apply to this detail:

Column (2) can be filled by stating the city (DATI II) where the building with strata rights or land with building is located.
The amount in column (3) is entered into Detail 601.
Column (5) is the difference between column (3) and column (4) for each unit.
Row Number II (AYD) is less than or equal to 15% of Own Capital under SAK for the current period.

7.23. Detail 207
Columns in this detail are filled according to the descriptions available in the format.

7.24. Detail 208
Columns in this detail are filled according to the descriptions available in the format.

7.25. Detail 301
The following provisions apply to this detail:

For the creditor detail, only creditors who have claims against the company amounting to 5% or more of the total value of claim liabilities need to be detailed. Meanwhile, for creditors whose claim amounts are below 5% of the total value of claim liabilities, they can simply be categorized into the "Others" group.
The total of column (7) is entered into Detail 601.

7.26. Detail 302
The following provisions apply to this detail:

For the creditor detail, only creditors who have claims against the company amounting to 5% or more of the total value of co-insurance liabilities need to be detailed. Meanwhile, for creditors whose claim amounts are below 5% of the total value of co-insurance liabilities, they can simply be categorized into the "Others" group.
The total of column (5) is entered into Detail 601.

7.27. Detail 303
The following provisions apply to this detail:

For the creditor detail, only creditors who have claims against the company amounting to 5% or more of the total value of reinsurance liabilities need to be detailed. Meanwhile, for creditors whose claim amounts are below 5% of the total value of reinsurance liabilities, they can simply be categorized into the "Others" group.
The total of column (5) is entered into Detail 601.

7.28. Detail 304
The following provisions apply to this detail:

For the creditor detail, only creditors who have claims against the company amounting to 5% or more of the total value of commission liabilities need to be detailed. Meanwhile, for creditors whose claim amounts are below 5% of the total value of commission liabilities, they can simply be categorized into the "Others" group.
The total of column (4) is entered into Detail 601.

7.29. Detail 305
The following provisions apply to this detail:

Column (2) only needs to be filled with cost descriptions amounting to 5% or more of the total value of accrued costs. Meanwhile, for cost amounts below 5% of the total value of accrued costs, they can simply be categorized into the "Others" group.

7.30. Detail 306
The following provisions apply to this detail:

Column (2) only needs to be filled with debt descriptions amounting to 5% or more of the total value of other debts. Meanwhile, for debt amounts below 5% of the total value of other debts, they can simply be categorized into the "Others" group.

7.31. Detail 401
The following provisions apply to this detail:

Columns in this detail are filled according to the descriptions available in the format.
Life insurance branch (number 16) is filled if the company is a reinsurance company.

7.32. Detail 402
The following provisions apply to this detail:

Columns in this detail are filled according to the descriptions available in the format.
Life insurance branch (number 16) is filled if the company is a reinsurance company.

7.33. Detail 501
Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

This detail is a breakdown of underwriting results as stated in the Comprehensive Income Statement, but in this case, the underwriting results are broken down for each insurance branch, so the total in column (19) will be equal to the total underwriting results in the Comprehensive Income Statement on page 2. For quarterly reports:

The figures presented in this detail are figures obtained from activities during the respective quarter period (not cumulative), so the underwriting revenue and underwriting expenses presented are only revenues and expenses incurred for the stated quarterly report period.
Decrease (Increase) in Premium Reserves, CAPYBMP, and Claim Reserves in this detail are presented based on Detail 502.

7.34. Detail 502
This detail is a breakdown of Decrease (Increase) in Premium Reserves, CAPYBMP, and Claim Reserves as stated in the Comprehensive Income Statement, but broken down for each insurance branch including reinsurance assets. Subsequently, this detail is presented in Detail 501.

7.35. Detail 503

Investment results in this detail include realized investment results (net investment results) as well as unrealized gains. However, these investment results are entered into the Comprehensive Income Statement adjusted according to the PSAK governing this matter.
Column (7) is filled as follows:
Example: A General Insurance Company has corporate bonds with interest payment coupons and their valuation is based on market price. Thus, this investment type will provide results that can be categorized into two types: interest and gain due to market price increases. Therefore, column (7) is filled with how much interest was received in the report period and how much gain (realized gain as well as unrealized gain) exists.

7.36. Detail 504
Column (2) only needs to be filled with descriptions that are results (expenses) amounting to 5% or more of the total value of other results (expenses). Meanwhile, for result (expense) amounts below 5% of the total value of other results (expenses), they can simply be categorized into the "Others" group.

7.37. Detail 505
Columns in this detail are filled according to the descriptions available in the format.

7.38. Detail 601

The definition of Current Assets and Current Liabilities is all assets and liabilities of insurance companies and reinsurance companies that have a term of less than or equal to one year from the reporting date.
The total amount is then entered into the Additional Financial Report in the Financial Health Ratio Section Other than MMBR.

III. ADDITIONAL FINANCIAL REPORTS

Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

Guarantee Fund Report
The preparation of the Guarantee Fund Report is intended to monitor the Company's compliance with the minimum guarantee fund requirements, which serve as the last resort guarantee for policyholders if the relevant Company is liquidated. In the report form, the amount of guarantee funds, details of deposit certificates, and the calculation of the minimum guarantee fund amount to be held are broken down. Summary of guarantee fund developments, guarantee fund adequacy calculations, and details of the final guarantee fund position are filled according to the descriptions available in the format. The required paid-up capital used in the guarantee fund calculation is the required paid-up capital at the time of the establishment of the relevant Company. The basis for determining additional guarantee funds uses net premiums for all types of insurance products marketed by the Company.
Financial Health Ratios Other than MMBR
This ratio is an additional ratio in calculating the Company's financial health level, consisting of:
a. Liquidity ratio, to determine the Company's ability to meet short-term financial liabilities at maturity using available current assets. b. Investment adequacy ratio, to measure the Company's ability to meet potential claims.
c. Ratio of investment results to net premium income, to compare company assets originating from investment management and net income from received premiums.
d. Ratio of claim expenses, operational expenses, and commissions, to measure the amount of income received from premiums after deducting expenses. Details of the aforementioned ratios are filled according to the descriptions available in the provided format.
Education and Training Ratio
The following provisions apply to this detail:
I. Education and Training Costs

Column (2) is filled with the name of the planned or budgeted education and training.
Column (3) is filled with the budgeted cost for education and training for one year.
Column (4) is filled with the cumulative realization of education and training costs up to the reporting period.
II. Education and Training Ratio
Column (3) is filled with the budgeted costs for employees, directors, and commissioners, as well as the budgeted costs for education and training for each user, namely: employees, directors, and commissioners for the current year.
Column (4) is filled with the realized costs for employees, directors, and commissioners, as well as the realized costs for education and training for each user, namely: employees, directors, and commissioners that have been conducted up to the reporting period in the current year.

Asset and Liability Matching
Appendix I
SEOJK Number: 02/SEOJK.05/2013
Date: 27 August 2013

Matching of assets and liabilities based on currency and maturity date is required to identify differences in asset and liability values in foreign currencies, as well as fluctuations in foreign exchange rates against the rupiah. Columns in this detail are filled based on SAK values.

Breakdown of Premium Revenue and Claim Expenses by Distribution Channel
Columns in this detail are filled according to the descriptions available in the format.

Determined in Jakarta on 27 August 2013 EXECUTIVE HEAD OF NON-BANK FINANCIAL INDUSTRY SUPERVISOR FINANCIAL SERVICES AUTHORITY, Ttd. FIRDAUS DJAELANI

Copy matches the original
Head of Legal Assistance Division Financial Services Authority, Ttd. Mufli Asmawidjaja

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Page i

To
Honorable Financial Services Authority Attn: Directorate of Insurance Supervision Sumitro Djojohadikusumo Building, 14th Floor Jl. Lapangan Banteng Timur 1 - 4 Jakarta - 10710

FINANCIAL REPORTS
(Company Address)
PT XYZ
For …………./ Quarter ………. Year ………..
LIFE INSURANCE COMPANY

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Page ii

Financial Report
Life Insurance Company
PT. XYZ
For …/ Quarter … Year …
1 Company Name :
2 Full Address :
3 Telephone and Fax :
4 E-mail :
5 NPWP :
6 License No. & Date :
7 a. Number of Branches/
Representatives :
b. Number of Insured :
8 External Auditor :
9 Shareholders :
Share Ownership
Rupiah Percentage
Total
10 Directors and Commissioners:
Director Name Position Commissioner Name Position 11 Financial Reporting PIC :
Division/Department Name Phone No., ext. Email ………………, …………………. PT. Asuransi ……………………………. Director Name Director Shareholder Name

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Page iii

………………, ………………….
Director of PT XYZ
Name
Position
Board of Directors Statement
Regarding
Responsibility for Financial Reports For …/ Quarter … Year … PT XYZ We, the undersigned, declare that:

We are responsible for the preparation and presentation of the financial reports of PT XYZ (the Company);
All information in the Company's financial reports has been presented completely and in accordance with the actual conditions;
The Company's financial reports do not contain incorrect material information or facts, and do not omit material information or facts.
This statement is made truthfully.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Page iv

Page
Cover Page i
Company Profile ii
Statement iii
Table of Contents iv
I Main Reports
1.1. Balance Sheet 1
1.2. Comprehensive Income Statement 2
1.3. Cash Flow Statement 3
1.4. Statement of Changes in Equity 4
1.5. Solvency Level Report 5
a. Solvency Achievement Ratio 5 b. Risk-Based Minimum Capital Asset Management Failure Schedule A 6 Asset and Liability Projection Imbalance Schedule B 7 Asset and Liability Value Imbalance in Each Currency Type Schedule C 8 Difference Between Incurred Claim Expenses and Estimated Claim Expenses Schedule D 9 Premium Insufficiency Due to Investment Result Differences Schedule E 10 Reinsurance Risk Schedule F 11 Operational Risk Schedule G 12
1.6. SAP Asset and Liability Calculation 13
Sub A Investment Placements Not with One Party 14 Sub B Investment Placements with Affiliated Parties of the Company 15 Sub C Investment Placements with Affiliated Parties not with the Company 16 Sub D Investment Placements Abroad 17 Sub E List of Affiliated Companies 18
1.7. Details 19
101 Time Deposits and Certificates of Deposit 20 102 Stocks 20 103 Corporate Bonds and Corporate Sukuk 21 104 Securities Issued by the RI State 22 105 Securities Issued by Countries Other than RI 23 106 Securities Issued by Bank Indonesia 24 107 Securities Issued by Multinational Institutions 25 108 Mutual Funds 26 109 Asset-Backed Securities Collective Investment Contracts 27 110 Real Estate Investment Funds 28 111 Direct Participation 29 112 Buildings with Strata Rights or Land with Buildings for Investment 30 113 Purchase of Receivables for Financing Companies and/or Banks 31 114 Pure Gold 32 113 Loans Secured by Mortgage Rights 33 116 Other Investments 34 201 Direct Written Premium Receivables 35 202 Co-insurance Claim Receivables 36 203 Reinsurance Receivables 37 204 Investment Receivables 38 205 Investment Result Receivables 39 206 Policy Loans 40 207 Buildings with Strata Rights or Land with Buildings for Own Use 41 208 Other Fixed Assets 42 209 Other Assets 43 301 Claim Liabilities 44 302 Co-insurance Liabilities 45 303 Reinsurance Liabilities 46 304 Commission Liabilities 47 305 Accrued Costs 48 306 Other Liabilities 49 401 Premium Reserves 50 402 Reserves for Premiums Not Yet Earned Income 51 403 Claim Reserves 52 501 Premium Revenue 53 502 Investment Results 54 503 Other Revenue 55 504 Insurance Expenses 56 505 Other Results (Expenses) 57 506 Comprehensive Income 58 601 Current Assets and Current Liabilities 59
II. Additional Reports
Financial Report
Life Insurance Company
Table of Contents
PT XYZ

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Page iv

2.1. Guarantee Fund Report:
Summary of Guarantee Fund Developments 60 Guarantee Fund Adequacy Calculation 60 Details of Final Guarantee Fund Position 61
2.2. Financial Health Ratios Other than MMBR 62
2.3. Education and Training Ratio 63
2.4. Asset and Liability Matching 64
2.5. Breakdown of Premium Revenue and Claim Expenses by Distribution Channel 65

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Detail
SAK Balance
SAP Balance
SAK Balance
SAP Balance
(1)
(2)
(3)
(4)
(5)
(6)

ASSETS
Investments
Time Deposits and Deposit Certificates 101 - - - -

Shares
102
-
-
-
-

Corporate Bonds and Corporate Sukuk 103 - - - -

Securities Issued by the Republic of Indonesia 104 - - - -

Securities Issued by Countries Other Than the Republic of Indonesia 105 - - - -

Securities Issued by Bank Indonesia 106 - - - -

Securities Issued by Multinational Institutions 107 - - - -

Mutual Funds
108
-
-
-
-

Asset-Backed Securities Collective Investment Contracts 109 - - - -

Real Estate Investment Funds
110
-
-
-
-

Direct Investments
111
-
-
-
-

Buildings with Strata Rights or Land with Buildings for Investment 112 - - - -

Purchase of Receivables for Financing Companies and/or Banks 113 - - - -

Pure Gold
114
-
-
-
-

Loans Secured by Mortgage Rights 115 - - - -

Other Investments
116
-
-
-
-

Total Investments
-
-
-
-

Non-Investments
Cash and Banks
-
-
-
-

Direct Written Premium Receivables 201 - - - -

Coinsurance Receivables
202
-
-
-
-

Reinsurance Receivables
203
-
-
-
-

Investment Receivables
204
-
-
-
-

Investment Income Receivables
205
-
-
-
-

Policy Loans
206
-
-
-
-

Buildings with Strata Rights or Land with Buildings for Own Use 207 - - - -

Other Fixed Assets
208
-
-
-
-

Other Assets
209
-
-
-
-

Total Non-Investments
-
-
-
-

TOTAL ASSETS
-
-
-
-

LIABILITIES AND EQUITY
Liabilities
Payables
Claims Payables
301
-
-
-
-

Coinsurance Payables
302
-
-
-
-

Reinsurance Payables
303
-
-
-
-

Commission Payables
304
-
-
-
-

Tax Payables
-
-
-
-

Accrued Expenses
305
-
-
-
-

Other Payables
306
-
-
-
-

Total Payables
-
-
-
-

Technical Reserves
Premium Reserves
401
-
-
-
-

Reserves for Unearned Premiums
402
-
-
-
-

Claims Reserves
403
-
-
-
-

Total Technical Reserves
-
-
-
-

Total Liabilities
-
-
-
-

Subordinated Loans
-
-
-
-

Equity
Paid-in Capital
-
-
-
-

Share Premium
-
-
-
-

Retained Earnings
-
-
-
-

Other Equity Components
-
-
-
-

Valuation Difference Based on SAK & SAP - - - -

Assets Not Included in AYD
-
-
-
-

Total Equity
-
-
-
-

TOTAL LIABILITIES AND EQUITY
-
-
-
-

As of …. and As of ….
Quarter … Year …
Quarter … Year …

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF FINANCIAL POSITION Unconsolidated

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Detail
Quarter …
Year …
Quarter …
Year …
(1)
(2)
(3)
(4)

INCOME
Premium Income
501

Reinsurance Premium

Decrease (Increase) in CAPYBMP

Total Net Premium Income

Investment Income
502

DPLK Service Fees/Other Management Fees

Other Income
503

TOTAL INCOME

EXPENSES
Insurance Expenses
504

a. Claims and Benefits
(1) Claims and Benefits Paid
(2) Reinsurance Claims
(3) Increase (Decrease) in Premium Reserves (4) Increase (Decrease) in Claims Reserves Total Claims and Benefits Expenses

b. Acquisition Costs
(1) First-Year Commission Expenses (2) Renewal Commission Expenses (3) Overriding Commission Expenses (4) Other Expenses Total Acquisition Costs Total Insurance Expenses

Business Expenses:
a. Marketing Expenses b. Other General and Administrative Expenses:

Employee and Management Expenses
Education and Training Expenses
Other General and Administrative Expenses
Other Income (Expenses)
505

TOTAL EXPENSES

PROFIT (LOSS) BEFORE TAX
Income Tax
PROFIT AFTER TAX

OTHER COMPREHENSIVE INCOME
506

TOTAL COMPREHENSIVE PROFIT (LOSS)

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF COMPREHENSIVE INCOME/LOSS For the Period Ending On Date … and Date …

Note:
Figures in this report are cumulative figures for the period from January 1 to the reporting date of the current period.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Quarter …
Year …
Quarter …
Year …
(1)
(2)
(3)

CASH AND BANK BALANCE BEGINNING CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows a. Premiums b. Coinsurance Claims
c. Reinsurance Claims
d. Commissions e. Receivables f. Others Total Cash Inflows - -

Cash Outflows a. Reinsurance Premiums b. Claims
c. Commissions
d. Expenses e. Others
Total Cash Outflows
-
-

TOTAL CASH FLOWS FROM OPERATING ACTIVITIES - -

CASH FLOWS FROM INVESTMENT ACTIVITIES Cash Inflows a. Investment Income Receipts b. Investment Withdrawals
c. Sale of Fixed Assets
d. Others
Total Cash Inflows
-
-

Cash Outflows a. Investment Placements b. Purchase of Fixed Assets
c. Others
Total Cash Outflows
-
-

TOTAL CASH FLOWS FROM INVESTMENT ACTIVITIES - -

CASH FLOWS FROM FINANCING ACTIVITIES Cash Inflows a. Subordinated Loans b. Capital Deposits
c. Others
Total Cash Inflows
-
-

Cash Outflows a. Dividend Payments b. Subordinated Loan Payments
c. Others
Total Cash Outflows
-
-

TOTAL CASH FLOWS FROM FINANCING ACTIVITIES - -

CASH AND BANK BALANCE ENDING
-
-

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF CASH FLOWS
As of …. and As of ….

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Quarter …
Year …
Quarter …
Year …
(1)
(2)
(3)

SAK Equity
Beginning Balance
Additions:
Paid-in Capital
Current Period Comprehensive Profit (Loss) - Other Additions:
a. b.
Total Additions
Deductions:
Dividend Payments
Other Deductions:
a. b.
Total Deductions
SAK Ending Balance

SAP Equity
Beginning Balance
SAK Equity Changes
Increase (Decrease) in SAK and SAP Valuation Difference (Increase) Decrease in Assets Not Included in AYD Ending Balance

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF CHANGES IN EQUITY
As of …. and As of ….

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Quarter …
Year …
Quarter …
Year …
(1)
(2)
(3)

Solvency Ratio
Permitted Assets
Liabilities (excluding Subordinated Loans) Total Solvency Ratio - -

Minimum Risk-Based Capital (MRBC)
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Schedule G
Total MRBC
-
-

Surplus (Deficit) of Solvency Ratio Limit - -

Solvency Achievement Ratio (in %) 1) #DIV/0!
#DIV/0!

1) Total Solvency Ratio divided by Total MRBC
In the event the Company experiences a solvency deficit, the amount of funds needed to achieve a 100.00% RBC ratio 120.00%

Period 2)
Target 3)
Realization
Year ...
%
%

TW ...
%
%

2) Current year period
3) Minimum target solvency ratio 120%
Reasons for not achieving the quarterly/annual solvency ratio target:

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
Solvency Achievement Ratio
As of …. and As of ….

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
AYD Amount
Factor
Deviation Amount
(1)
(2)
(3)
(4)

INVESTMENTS
Time Deposits and Deposit Certificates Special Category (up to 2 billion per bank) 0.0%

Other Categories, according to Bank Rating:
a. Cluster Rating 1
1.2% b. Cluster Rating 2
2.1%
c. Cluster Rating 3
3.0% d. Cluster Rating 4
4.5% e. Cluster Rating 5
9.0%

Shares
Including LQ 45 on the Jakarta Stock Exchange or JII 16.0%

Shares traded on Indonesian exchanges other than letter a 20.0%

Shares traded on foreign exchanges Shares constituting the main index of the main stock exchange of Asia Pacific countries and European members of the World Federation of Exchanges 20.0%

Others
30.0%

Corporate Bonds and Corporate Sukuk a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3
4.0% d. Cluster Rating 4
6.0%

Securities Issued by the Republic of Indonesia 0.0%

Securities Issued by Countries Other Than the Republic of Indonesia a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3
4.0% d. Cluster Rating 4
6.0%

Securities Issued by Bank Indonesia 0.0%

Securities Issued by Multinational Institutions 0.0%

Mutual Funds
Entirely consisting of Government bonds 0.0%

Entirely consisting of private bonds and/or money market securities (SBPU) 6.0%

Entirely consisting of equity securities 16.0%

Mixed 1) rt

Asset-Backed Securities Collective Investment Contracts a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3
4.0% d. Cluster Rating 4
6.0%

Real Estate Investment Funds a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3
4.0% d. Cluster Rating 4
6.0%

Direct Investments
Under OJK Supervision
10.0%

Not Under OJK Supervision
20.0%

Buildings with Strata Rights, or Land with Buildings Investment Return 4% or more 7.0% Investment Return 2% - 4% 15.0% Investment Return less than 2% 40.0%

Purchase of Receivables
Leasing
3.0%
Credit Cards
20.0%
Consumer Financing
8.0%
Pure Gold
3.0%

Loans Secured by Mortgage Rights Residential Property a. LTV<60% 2.8% b. 60%<LTV<80% 4.0%

Other Commercial Property a. LTV<60% 5.6% b. 60%<LTV<80% 8.0%

Unused Property
12.0%

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
MINIMUM RISK-BASED CAPITAL
SCHEDULE A - ASSET MANAGEMENT FAILURE RISK

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
AYD Amount
Factor
Deviation Amount
(1)
(2)
(3)
(4)

NON-INVESTMENTS
Cash and Banks
0.0%

Direct Written Premium Receivables 8.0%

Coinsurance Receivables
Under OJK Supervision
2.8%
Not Under OJK Supervision:
a. Cluster Rating 1
2.8% b. Cluster Rating 2
4.0%
c. Cluster Rating 3
6.0% d. Cluster Rating 4
12.0% e. Cluster Rating 5
15.0%

Reinsurance Receivables
Under OJK Supervision
2.8%
Not Under OJK Supervision:
a. Cluster Rating 1
2.8% b. Cluster Rating 2
4.0%
c. Cluster Rating 3
6.0% d. Cluster Rating 4
12.0% e. Cluster Rating 5
15.0%

Reinsurance Assets
0.0%

Investment Receivables
2.0%

Investment Income Receivables
2.0%

Buildings with Strata Rights, or Land with Buildings 4.0%

Total

Note:
1) For mixed mutual funds, the factor is filled with the weighted average based on the composition of underlying assets as regulated in applicable provisions. If the Company does not fill in the factor, the maximum factor (10%) will be applied.
rt = risk weighted average according to calculation LTV = loan to value, LTV is calculated based on loan balances and property market value The amount of funds considered in Schedule A is as follows:
1) Year 2013 = 50%
2) Year 2014 = 75%
3) Year 2015 = 100%

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Up to
1 year
More than 1 year up to
3 years
More than 3 years up to
5 years
More than 5 years up to
10 years
More than 10 years
Total
(1)
(2)
(3)
(4)
(5)
(6)
(7)

ASSETS
Investments
Time Deposits and Deposit Certificates Shares Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia Securities Issued by Countries Other Than the Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Institutions Mutual Funds Asset-Backed Securities Collective Investment Contracts Real Estate Investment Funds Direct Investments Buildings with Strata Rights or Land with Buildings for Investment Purchase of Receivables Pure Gold Loans Secured by Mortgage Rights Total Investments

Non-Investments
Cash and Banks
Direct Written Premium Receivables Coinsurance Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Policy Loans Buildings with Strata Rights or Land with Buildings for Own Use Total Non-Investments

TOTAL ASSETS

LIABILITIES AND EQUITY
Liabilities
Payables
Claims Payables
Coinsurance Payables
Reinsurance Payables
Commission Payables
Tax Payables
Accrued Expenses
Other Payables
Total Payables

Technical Reserves
Premium Reserves
Reserves for Unearned Premiums
Claims Reserves
Total Technical Reserves

TOTAL LIABILITIES

LIABILITY AND ASSET DIFFERENCE

DEVIATION (4.0% X (Max(Li-AYDi),0)) - - - - - -

Note:
The amount of funds considered in Schedule B is as follows:
1) Year 2013 = 50%
2) Year 2014 = 75%
3) Year 2015 = 100%

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
MINIMUM RISK-BASED CAPITAL
SCHEDULE B - ASSET AND LIABILITY CASH FLOW PROJECTION IMBALANCE RISK

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
USD
SGD
J PY
GBP
DKK
FRF
HKD
EUR
IDR
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

Permitted Assets
Time Deposits and Deposit Certificates Shares Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia Securities Issued by Countries Other Than the Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Institutions Mutual Funds Asset-Backed Securities Collective Investment Contracts Real Estate Investment Funds Direct Investments Buildings with Strata Rights or Land with Buildings for Investment Purchase of Receivables Pure Gold Loans Secured by Mortgage Rights Cash and Banks Direct Written Premium Receivables Coinsurance Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Buildings with Strata Rights or Land with Buildings for Own Use Total Permitted Assets

Liabilities
Claims Payables
Coinsurance Payables
Reinsurance Payables
Commission Payables
Tax Payables
Accrued Expenses
Other Payables
Premium Reserves
Reserves for Unearned Premiums
Claims Reserves
Total Liabilities

Total Exchange Rate (3) to (11)

Total Permitted Assets in Rupiah (23 x 35) Total Liabilities in Rupiah (34 x 35) Difference Between Permitted Assets and Liabilities (36 - 37)

Factor 0.3

Total Deviation in Assets and Liabilities in Each Foreign Currency Type

Note:
This column can be added according to the types of foreign currencies present.

Total

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
MINIMUM RISK-BASED CAPITAL
SCHEDULE C - ASSET AND LIABILITY VALUE IMBALANCE RISK IN EACH FOREIGN CURRENCY TYPE

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Non renewable (> 1 year) (in millions of rupiah)

Insurance Branch
CP
CP*
Total
Deviation
(1)
(2)
(3)
(4)

Term Death
Endowment and/or Combination
Whole Life
Annuity
Single Premium Death
Health
Accidental Death
Others
Total max ((CP* - CP), 0)
-
-
-

Renewable (0-1 year/ <1 year) (in millions of rupiah)

Insurance Branch
CAPYBMP
AR fcp
Total
Deviation
CAPYBMP
((3) - (4)) x (5)
CK
AR fck
Total
Deviation CK
((7) - (8)) x (9)
Total
Deviation
(6) + (10)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)

Term Death
10%
10%

Endowment and/or Combination
10%
10%

Whole Life
10%
10%

Annuity
10%
10%

Single Premium Death
10%
10%

Health
10%
10%

Accidental Death
10%
10%

Others
10%
10%

Total ((CAPYBMPi - ARi)fcpi + (CKi - ARi)fcki) - - -

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
MINIMUM RISK-BASED CAPITAL
SCHEDULE D - INSURANCE LIABILITY RISK

Note:
CP = Premium reserves according to the statement of financial position (balance sheet) and according to the company's actuarial calculations CP* = Premium reserves calculated with the best estimate plus margin for adverse deviation with a premium reserve sufficiency confidence level of 95% (company level) CAPYBMPi = Reserves for unearned premiums for business line i AR = Reinsurance assets CKi = Claims reserves for business line i fcpi = Risk factor for reserves for unearned premiums for business line i fcki = Risk factor for claims reserves for business line i

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Description
Total
(1)
(2)

CPrf
CPo
Maks((CPrf-CPo),0)
-

fRTB
RTB
-

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
MINIMUM RISK-BASED CAPITAL
SCHEDULE E - INTEREST RATE RISK

Note:

CPrf = Premium reserves calculated with risk-free interest rates according to the calculation in PER 08 Year 2012
Cpo = Premium reserves calculated with actuarial interest rates according to the calculation in PER 08 Year 2012
fRTB = Interest rate ratio factor
fRTB year 2013 = 5%
fRTB year 2014 = 10%
fRTB year 2015 = 15%

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Reinsurer Name
Technical Reserves
Reinsured Expenses
Deposits and/or Premiums Held at the Ceding Company Net Reinsurance Exposure ((2) - (3)) Factor Deviation Amount ((4) x (5)) (1) (2) (3) (4) (5) (6)

Under OJK Supervision
2.8%
…
-
-
…
-
-
…
-
-
Not Under OJK Supervision
-
- a. Cluster Rating 1
2.8%
…
-
- b. Cluster Rating 2
4.0%
…
-
-
c. Cluster Rating 3
6.0%
…
-
- d. Cluster Rating 4
12.0%
…
-
- e. Cluster Rating 5
15.0%
…
-
-
Total
-
-
-
-

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT
MINIMUM RISK-BASED CAPITAL
SCHEDULE F - REINSURANCE RISK

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

(2)
(3)

General and Administrative Expenses Education and Training Expenses Operational complexity proxy - Deviation -

MINIMUM RISK-BASED CAPITAL
SCHEDULE G - OPERATIONAL RISK

Description
Total

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY RATIO REPORT

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
I. SAP WEALTH CALCULATION (in millions of rupiah)

Description
Book Balance (SAK)
Valuation Based on SAP
SAP and SAK Valuation Difference Assets Not Permitted Assets Permitted (SAP Balance) (1) (2) (3) (4) (5) (6)

Investments
Time Deposits and Deposit Certificates -

Shares
-

Corporate Bonds and Corporate Sukuk -

Securities Issued by the Republic of Indonesia -

Securities Issued by Countries Other Than the Republic of Indonesia -

Securities Issued by Bank Indonesia -

Securities Issued by Multinational Institutions -

Mutual Funds
-

Asset-Backed Securities Collective Investment Contracts -

Real Estate Investment Funds
-

Direct Investments
-

Buildings with Strata Rights or Land with Buildings for Investment -

Purchase of Receivables for Financing Companies and/or Banks -

Pure Gold
-

Loans Secured by Mortgage Rights -

Other Investments
-

Total Investments
-

Non-Investments
Cash and Banks
-

Direct Written Premium Receivables -

Coinsurance Receivables
-

Reinsurance Receivables
-

Investment Receivables
-

Investment Income Receivables
-

Policy Loans
-

Buildings with Strata Rights or Land with Buildings for Own Use -

Other Fixed Assets
-

Other Assets
-

Total Non-Investments
-

TOTAL ASSETS
-

Note:
The Total Investments used as the basis for calculating permitted wealth restrictions and investment restrictions on one party is equal to the sum of investments in column (4) except for other investments, which is equal to -

II. SAP LIABILITIES CALCULATION

Description
Book Balance (SAK)
Valuation Based on SAP
SAK and SAP Valuation Difference (1) (2) (3) (4) = (2) - (3)

Payables
-

Premium Reserves
-

Reserves for Unearned Premiums
-

Claims Reserves
-

TOTAL LIABILITIES
-
-
-

VALUATION DIFFERENCE BASED ON SAK AND SAP -

(Permitted wealth column 5 minus permitted liabilities column 5) (Transferred to line 68 of the Financial Position Report)

Quarter … Year …
Per …

PT XYZ
LIFE INSURANCE COMPANY
SAP ASSETS AND LIABILITIES CALCULATION Unconsolidated

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Investment Type
Detail
AYD After Restrictions Per Investment Type and/or Overseas Investment (1) (2) (3)

Domestic Placements
Time Deposits and Deposit Certificates 101

Shares
102

Corporate Bonds and Corporate Sukuk 103

Securities Issued by the Republic of Indonesia 104

Securities Issued by Countries Other Than the Republic of Indonesia 105

Securities Issued by Bank Indonesia 106

Securities Issued by Multinational Institutions 107

Mutual Funds
108

Asset-Backed Securities Collective Investment Contracts 109

Real Estate Investment Funds
110

Direct Investments
111

Buildings with Strata Rights or Land with Buildings for Investment 112

Purchase of Receivables for Financing Companies and/or Banks 113

Pure Gold
114

Loans Secured by Mortgage Rights 115

Sub Total

Overseas Placements
Shares
102

Corporate Bonds and Corporate Sukuk 103

Securities Issued by Countries Other Than the Republic of Indonesia 104

Securities Issued by Multinational Institutions 107

Mutual Funds
108

Direct Investments
111

Sub Total

Total Sub A

Quarter … Year …

PT XYZ
LIFE INSURANCE COMPANY
SAP ASSETS AND LIABILITIES CALCULATION SUB A - INVESTMENT PLACEMENTS NOT ON ONE PARTY Per …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Placement On
Company (Company Name)
Investment Type
Detail
AYD After Restrictions Per Investment Type and Overseas Investment Assets Not Permitted AYD (1) (2) (3) (4) (5) (6)

PT a. Time Deposits and Deposit Certificates 101 b. Shares 102
c. Corporate Bonds and Corporate Sukuk
103 d. Mutual Funds
108 e. Asset-Backed Securities Collective Investment Contracts 109 f. Real Estate Investment Funds 110 g. Direct Investments 111 Total Placement on this Company

Total Sub B

Quarter … Year …

PT XYZ
LIFE INSURANCE COMPANY
SAP ASSETS AND LIABILITIES CALCULATION SUB B - INVESTMENT PLACEMENTS ON PARTIES AFFILIATED WITH THE COMPANY Per …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)

Placement On
Company (Company Name)
Investment Type
Detail
AYD After Restrictions Per Investment Type and Overseas Investment Assets Not Permitted AYD (1) (2) (3) (4) (5) (6)

Total Sub C

Quarter … Year …

PT XYZ
LIFE INSURANCE COMPANY
SAP ASSETS AND LIABILITIES CALCULATION SUB C - INVESTMENT PLACEMENTS ON NON-AFFILIATED PARTIES Per …

Appendix I
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Investment Placement Type
Investment
Placement in
Company (Company Name and/or Country Name) AYD After Limit Per Investment Type Assets Not Permitted AYD (1) (2) (3) (4) (5) Stocks … … … Sub Total Corporate Bonds and Corporate Sukuk … … … Sub Total Securities issued by states other than the Republic of Indonesia … … … Sub Total Securities issued by Multinational Institutions … … … Sub Total Mutual Funds … … … Sub Total Direct Participation … … … Sub Total Total Sub D Quarter … Year … PT XYZ LIFE INSURANCE COMPANY CALCULATION OF ASSETS AND LIABILITIES UNDER SAP SUB D - INVESTMENT PLACEMENT ABROAD As of …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
I. Investment Placement in Parties Affiliated with the Company
Ownership
Company Name Ownership Relationship Business Field Percentage Ownership Value Ownership (1) (2) (3) (4) (5) … … …
II. Investment Placement in Parties Not Affiliated with the Company
Company Name Group Name Business Field (1) (2) (3) … … … PT XYZ LIFE INSURANCE COMPANY SUB E - LIST OF AFFILIATED COMPANIES As of … Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Bank Name Cluster Rating Book Balance AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) (8) 1 PT …………… Time Deposits Certificates of Deposit Sub Total 2 PT …………… Time Deposits Certificates of Deposit Sub Total 3 PT …………… Time Deposits Certificates of Deposit Sub Total 4 PT …………… Time Deposits Certificates of Deposit Sub Total 5 PT …………… Time Deposits Certificates of Deposit Sub Total Total Time Deposits Total Certificates of Deposit Total PT XYZ DETAIL 101 TIME DEPOSITS AND CERTIFICATES OF DEPOSIT As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer/Emiter Name Category Book Balance AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) Total PT XYZ DETAIL 102 STOCKS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer/Emiter Name Cluster Rating Book Balance Difference in Valuation SAK and SAP AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 PT …………… Corporate Bonds Corporate Sukuk Sub Total 2 PT …………… Corporate Bonds Corporate Sukuk Sub Total 3 PT …………… Corporate Bonds Corporate Sukuk Sub Total 4 PT …………… Corporate Bonds Corporate Sukuk Sub Total 5 PT …………… Corporate Bonds Corporate Sukuk Sub Total Total Corporate Bonds Total Corporate Sukuk Total PT XYZ LIFE INSURANCE COMPANY DETAIL 103 CORPORATE BONDS AND CORPORATE SUKUK Quarter … Year … As of …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Security Name Book Balance
Difference in
Valuation
SAK and SAP
AYD
Book Balance
Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
Total
PT XYZ
DETAIL 104
SECURITIES ISSUED BY THE REPUBLIC OF INDONESIA As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer / Issuing Country Cluster Rating Book Balance Difference in Valuation SAK and SAP AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) (6) (7) (8) Total PT XYZ As of … SECURITIES ISSUED BY COUNTRIES OTHER THAN THE REPUBLIC OF INDONESIA DETAIL 105 LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Security Name Book Balance
Difference in
Valuation
SAK and SAP
AYD
Book Balance
Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
Total
SECURITIES ISSUED BY BANK INDONESIA As of … PT XYZ DETAIL 106 LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Security Name Book Balance
Difference in
Valuation
SAK and SAP
AYD
Book Balance
Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
Total
SECURITIES ISSUED BY MULTINATIONAL INSTITUTIONS As of … PT XYZ DETAIL 107 LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Mutual Fund Name Investment Manager Book Balance AYD Book Balance Notes (1) (2) (3) (4) (5) (6) (7) I Fully government bonds Total I II Fully private bonds and/or money market securities Total II III Fully equity securities Total III IV Mixed Total IV Total Mutual Funds ( I+II+III+IV ) As of … PT XYZ DETAIL 108 MUTUAL FUNDS LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer / Manager
Name Cluster Rating Book Balance Difference in Valuation SAK and SAP AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) (8) (9) T o t a l PT XYZ DETAIL 109 ASSET-BACKED SECURITIES COLLECTIVE INVESTMENT CONTRACTS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer/Emiter Name Cluster Rating Book Balance Difference in Valuation SAK and SAP AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) (8) (9) T o t a l As of … PT XYZ DETAIL 110 REAL ESTATE INVESTMENT FUNDS LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Company Name Business Field Ownership (%) Book Balance Difference in Valuation SAK and SAP AYD Notes (1) (2) (3) (4) (5) (6) (7) (8) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total Direct Participation As of … PT XYZ DETAIL 111 DIRECT PARTICIPATION LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Address Book Balance
Valuation
Based on
SAP (Appraisal Value/NJ
OP)
Difference in
Valuation
SAK and SAP
(1) (2) (3) (4) (5)
I
Investment Results more than 4% per year Sub Total I II Investment Results 2% - 4% per year Sub Total II III Investment Results less than 2% per year Sub Total III Total (I + II + III) IV Permitted Assets (Maximum 10% of total investment) Quarter … Year … As of … PT XYZ DETAIL 112 BUILDINGS WITH STRATA RIGHTS OR LAND WITH BUILDINGS FOR INVESTMENT LIFE INSURANCE COMPANY

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Financing Company/Bank Name Business License Book Balance AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) I Leasing Total I II Credit Cards Total II III Consumer Financing Total III Total Mutual Funds ( I+II+III) PT XYZ DETAIL 113 PURCHASE OF RECEIVABLES FOR FINANCING COMPANIES AND/OR BANKS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Custodian Bank Name Quantity (pieces/gr) Book Balance AYD Book Balance Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) Total Gold PT XYZ DETAIL 114 PURE GOLD As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Debtor Name Land Certificate Number Collateral Value (Appraisal Value or NJOP) Loan Value Initial Book Balance AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) (6) (7) (8) I Residential Property a. LTV<60% b. 60%<LTV<80% Sub Total I II Other Commercial Property a. LTV<60% b. 60%<LTV<80% Sub Total II III Property Not Used Sub Total III Total (I + II + III) PT XYZ DETAIL 115 LOANS SECURED BY MORTGAGE RIGHTS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Investments
PT XYZ
As of …
DETAIL 116
OTHER INVESTMENTS
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
DETAIL 201
(in millions of rupiah)
No. Insurance Branch Book Balance AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) I Life Insurance Term Life Endowment and/or Combinations Whole Life Sub Total II Annuities III 1-Year Term Death IV Personal Accident V Health VI Others Sub Total Total Receivables Detail by Age (in millions of rupiah) No. Insurance Branch Less than or equal to 2 months More than 2 months up to 3 months More than 3 months (1) (2) (3) (4) (5) I Life Insurance Term Life Endowment and/or Combinations Whole Life Sub Total II Annuities III 1-Year Term Death IV Personal Accident V Health VI Others Sub Total Total PT XYZ As of … DIRECT WRITING PREMIUM RECEIVABLES LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Debtor Name Cluster Rating Book Balance AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) (6) (7) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II Receivables Detail by Age (in millions of rupiah) No. Debtor Name Less than or equal to 2 months More than 2 months up to 3 months More than 3 months (1) (2) (3) (4) (5) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II PT XYZ DETAIL 202 REINSURANCE CLAIM RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Debtor Name Cluster Rating Book Balance AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) (6) (7) A Reinsurance Premium Receivables Inward and Claim Recovery I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II B Reinsurance Assets III Under OJK Supervision Sub Total III IV Not Under OJK Supervision Sub Total IV Total I + II + III + IV Receivables Detail by Age (in millions of rupiah) No. Debtor Name Less than or equal to 2 months More than 2 months up to 3 months More than 3 months (1) (2) (3) (4) (5) A Reinsurance premium receivables inward and claim recovery I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II B Reinsurance Assets III Under OJK Supervision Sub Total III IV Not Under OJK Supervision Sub Total IV Total I + II + III + IV PT XYZ DETAIL 203 REINSURANCE RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Investment Type Book Balance AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) 1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the Republic of Indonesia 5 Securities issued by countries other than the Republic of Indonesia 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real estate investment funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total Receivables Detail by Age (in millions of rupiah) No. Investment Type Less than or equal to 1 month More than 1 month up to 3 months More than 3 months (1) (2) (3) (4) (5) 1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the Republic of Indonesia 5 Securities issued by countries other than the Republic of Indonesia 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real estate investment funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total PT XYZ DETAIL 204 INVESTMENT RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Investment Type Book Balance AYD Book Balance Current (Less than one year) (1) (2) (3) (4) (5) 1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the Republic of Indonesia 5 Securities issued by countries other than the Republic of Indonesia 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real estate investment funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total Receivables Detail by Age (in millions of rupiah) No. Investment Type Less than or equal to 1 month More than 1 month up to 3 months More than 3 months (1) (2) (3) (4) (5) 1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the Republic of Indonesia 5 Securities issued by countries other than the Republic of Indonesia 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real estate investment funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total PT XYZ DETAIL 205 INVESTMENT INCOME RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description
Cash Value of Pledged
Policies
Book Balance
AYD
Book Balance
Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
I. Initial Loan Balance :
a. APL (Automatic Policy Loans) b. Non APL … … …
II. Loans During the Period :
a. APL (Automatic Policy Loans) b. Non APL … … … Total - PT XYZ DETAIL 206 POLICY LOANS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Address Location Book Balance Valuation Based on SAP (Appraisal Value/NJ OP) Difference in Valuation SAK and SAP (1) (2) (3) (4) (5) I Total II Permitted Assets (Maximum 15% of Current Year's Own Capital) Quarter … Year … PT XYZ As of … BUILDINGS WITH STRATA RIGHTS OR DETAIL 207 LAND WITH BUILDINGS FOR OWN USE LIFE INSURANCE COMPANY

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Fixed Assets
As of …
PT XYZ
DETAIL 208
OTHER FIXED ASSETS
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Assets
As of …
PT XYZ
DETAIL 209
OTHER ASSETS
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Insurance Branch
Date
Claim Settled
Retention
Self
Expense
Reinsurer
Total
Book Balance
Current
(Less than one year)
(1) (2) (3) (4) (5) (6) (7)
I Life Insurance
Term Life
Endowment and/or Combinations
Whole Life
Sub Total I
II Annuities
III 1-Year Term Death
IV Personal Accident
V Health
VI Others
Sub Total II+III+IV+V+VI
Grand Total
Note:
From the total Self-Retention Claim Liabilities above, those with an age of more than 30 days amount to PT XYZ DETAIL 301 CLAIM LIABILITIES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Creditor Name Cluster Rating Total Book Balance Current (Less than one year) (1) (2) (3) (4) (5) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II DETAIL 302 REINSURANCE PAYABLES As of … PT XYZ LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Creditor Name Cluster Rating Total Current (Less than one year) (1) (2) (3) (4) (5) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II DETAIL 303 REINSURANCE PAYABLES As of … PT XYZ LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Insurance Branch Total
Book Balance
Current
(Less than one year)
(1) (2) (3) (4)
I Life Insurance
Term Life
Endowment and/or Combinations
Whole Life
Sub Total I
II Annuities
III 1-Year Term Death
IV Personal Accident
V Health
VI Others
Sub Total II+III+IV+V+VI
Total
PT XYZ
DETAIL 304
COMMISSION PAYABLES
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Expenses Payable
PT XYZ
DETAIL 305
EXPENSES PAYABLE
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Liabilities
DETAIL 306
OTHER LIABILITIES
As of …
PT XYZ
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No.
Risk Reserve
Accumulated Fund
Reserve
Risk Reserve
Accumulated Fund
Reserve
Risk Reserve
Accumulated Fund
Reserve
(1) (2) (6) (7) (8)
A Life Insurance

Term Life
Endowment and/or Combinations
Whole Life
Others
Sub Total A
B Annuities
Sub Total B
Total Premium Reserves
PT XYZ
LIFE INSURANCE COMPANY
DETAIL 401
PREMIUM RESERVES
As of …
Quarter …
Year …
(Previous
Period)
Total
(3) + (4) + (5)
Premium Reserve
Policies Due
Within < 1 year
Quarter … Year …
(3) (4) (5)
Insurance Branch
Premium Reserve for Policies
Single Premium
Premium Reserve for Policies
Paid-up
Premium Reserve for Policies
Regular (Installments)

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Year .../Quarter …
No. Insurance Branch
Premium Reserve for Policies
Single Premium
Premium Reserve for Policies
Paid-up
Premium Reserve for Policies
Regular (Installments)
Total
(3) + (4) + (5)
Premium Reserve for Policies
Due Within
< 1 year
Quarter …
/Year ...
(Previous
Period)
(1) (2) (3) (4) (5) (6) (7) (8) I Reserve for Premiums Not Yet Earned 1 1-Year Term Death 2 Personal Accident 3 Health 4 Total CAPYBMP II Reserve for Unexpired Risks 5 1-Year Term Death 6 Personal Accident 7 Health 8 Total CARYBD Max (CAPYBMP,CARYBD) PT XYZ DETAIL 402 RESERVES FOR PREMIUMS NOT YET EARNED As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Claim Reserve IBNR Claim Reserve Quarter … / Year … No. Insurance Branch Total Claims In Process Self-Expense Claims Total IBNR Claims IBNR Claims Self-Expense Total Claim Reserve Claim Res. < 1 year Quarter … / Year … (Previous Period) (1) (2) (3) (4) (5) (6) (7) (8) (9)

1-Year Term Death
Personal Accident
Health
Total
DETAIL 403
CLAIM RESERVES
As of …
PT XYZ
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description
Term
Life
Endowment and/or
Combinatio n
Whole
Life Annuities 1-Year
Term Death
Personal
Accident Health Others Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 New Production Premium 2 a. Individual Insurance 3 - Single Premium 4 - Installment Premium (Annual, Semi-annual, etc) 5 Total Individual New Production Premium 6 b. Group Insurance 7 Total New Production Premium 8 Renewal Premiums 9 a. Individual Insurance 10 b. Group Insurance 11 Total Renewal Premiums 12 Total Premium Income 13 Reinsurance Premiums 14 Decrease (Increase) CAPYBMP 15 a. Decrease (Increase) CAPYBMP (Gross ) 16 (1) Premium Reserve current year/quarter 17 (2) Premium Reserve previous year/quarter 18 b. Decrease (Increase) Reinsurance Assets for CAPYBMP 19 (1) Reinsurance Assets for CAPYBMP current year/quarter 20 (2) Reinsurance Assets for CAPYBMP previous year/quarter 21 Total Decrease (Increase) CAPYBMP 22 Total Net Premium Income (12 - 13 + 21) DETAIL 501 PREMIUM INCOME PT XYZ As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Investment Type Unrealized
Gain (Loss)
Total Investment
Income
Remarks
(Income Type)
Cash Received Receivables
(1) (2) (3) (4) (5) (6) (7)
I Investment Placements with Non-Affiliates

Time Deposits & Certificates of Deposit
Stocks
Corporate Bonds & Corporate Sukuk
Securities issued by the Indonesian State
Securities issued by countries other than the Indonesian State
Securities issued by Bank Indonesia
Securities issued by Multinational Institutions
Mutual Funds
Asset-Backed Securities Collective Investment Contracts
Real Estate Investment Funds
Direct Investments
Buildings with Strata Rights or Land
with Buildings for investment
Purchase of Receivables for Financing Companies and/or Banks
Pure Gold
Loans secured by mortgage rights
Other Investments
Sub Total
II Investment Placements with Affiliates
Time Deposits & Certificates of Deposit
Stocks
Corporate Bonds & Corporate Sukuk
Securities issued by the Indonesian State
Securities issued by countries other than the Indonesian State
Securities issued by Bank Indonesia
Securities issued by Multinational Institutions
Mutual Funds
Asset-Backed Securities Collective Investment Contracts
Real Estate Investment Funds
Direct Investments
Buildings with Strata Rights or Land
with Buildings for investment
Purchase of Receivables for Financing Companies and/or Banks
Pure Gold
Loans secured by mortgage rights
Other Investments
Sub Total
Gross Investment Income (17 + 34)
Investment Expenses
Net Investment Income (35 - 36)
PT XYZ
After-Tax Income
LIFE INSURANCE COMPANY
As of …
Quarter … Year …
INVESTMENT INCOME
DETAIL 502

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Investments
PT XYZ
DETAIL 503
OTHER INCOME
As of …
CONVENTIONAL LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. DESCRIPTION Death Endowment Whole Life Accident Amount Term Endowment and/or Life Annuity Single Health Self Others Combined (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Claims and Benefits Paid 2 a. End of Contract (Maturity) 3 b. Death Claims 4 c. Cash Value 5 d. Others 6 Total Claims and Benefits Paid (2 + 3 + 4 + 5) 7 Reinsurance Claims 8 Increase (Decrease) in Premium Reserves 9 a. Increase (Decrease) in Premium Reserves (Gross) 10 (1) Current year/quarter Premium Reserves 11 (2) Previous year/quarter Premium Reserves 12 b. Increase (Decrease) in Reinsurance Assets for Premium Reserves 13 (1) Current year/quarter Reinsurance Assets for Premium Reserves 14 (2) Previous year/quarter Reinsurance Assets for Premium Reserves 15 Total Increase (Decrease) in Premium Reserves (9 - 12) 16 Increase (Decrease) in Claim Reserves 17 a. Increase (Decrease) in Claim Reserves (Gross) 18 (1) Current year/quarter Claim Reserves 19 (2) Previous year/quarter Claim Reserves 20 b. Increase (Decrease) in Reinsurance Assets for Claim Reserves 21 (1) Current year/quarter Reinsurance Assets for Claim Reserves 22 (2) Previous year/quarter Reinsurance Assets for Claim Reserves 23 Total Increase (Decrease) in Claim Reserves (17 - 20) 24 Total Claims and Benefits Expenses (6 - 7 + 15 + 23) 25 Acquisition Costs 26 a. Commission Expenses - First Year 27 b. Commission Expenses - Subsequent Years 28 c. Commission Expenses - Overriding 29 d. Other Expenses 30 Total Acquisition Costs 31 Total Insurance Expenses (24 + 30) PT XYZ DETAIL 504 INSURANCE EXPENSES Life Insurance Branch As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
I. Other Income
Sub Total I
II. Other Expenses
Sub Total II
Total I - II -
PT XYZ
DETAIL 505
OTHER INCOME (EXPENSES)
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)

Exchange rate differences from translating financial statements
in foreign currency
Financial assets available for sale
Revaluation gains on fixed assets
Share of other comprehensive income of associates
…
…
…
Total Other Comprehensive Income - PT XYZ DETAIL 506 OTHER COMPREHENSIVE INCOME As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description Quarter…
Year …
Quarter…
Year …
(1) (2) (3) (4)
1 ASSETS
2 Investments
3 Time Deposits and Certificates of Deposit 4 Stocks 5 Corporate Bonds and Corporate Sukuk 6 Securities Issued by the Indonesian State 7 Securities Issued by Countries Other Than the Indonesian State 8 Securities Issued by Bank Indonesia 9 Securities Issued by Multinational Institutions 10 Mutual Funds 11 Asset-Backed Securities Collective Investment Contracts 12 Real Estate Investment Funds 13 Buildings with Strata Rights or Land with Buildings for Investment 14 Purchase of Receivables for Financing Companies and/or Banks 15 Pure Gold 16 Loans Secured by Mortgage Rights 17 Other Investments 18 Total Investments 19 Non-Investments 20 Cash and Banks 21 Direct Written Premium Receivables 22 Co-insurance Claim Receivables 23 Reinsurance Receivables 24 Investment Receivables 25 Policy Loans 26 Investment Income Receivables 27 Other Current Assets Total Non-Investments 28 TOTAL CURRENT ASSETS 29 LIABILITIES 30 Liabilities 31 Technical Reserves 32 Premium Reserves 33 Reserves for Premiums Not Yet Earned Income 34 Claim Reserves 35 Total Technical Reserves 36 Payables 37 Claim Payables 38 Co-insurance Payables 39 Reinsurance Payables 40 Commission Payables 41 Tax Payables 42 Accrued Expenses 43 Other Payables 44 Total Payables 45 TOTAL CURRENT LIABILITIES PT XYZ DETAIL 601 CURRENT ASSETS AND CURRENT LIABILITIES As of … and As of … LIFE INSURANCE COMPANY

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
1. Summary of Guarantee Fund Development
No Description Amount
1. Opening Balance of Guarantee Fund
2. New Guarantee Fund Placements
3. a. Guarantee Fund in the Form of Deposits
4. b. Guarantee Fund in the Form of SUN/Other Government Securities
Issued by the State (SBN)
5. Total New Guarantee Fund Placements (3 + 4)
6. Guarantee Fund Withdrawals
7. a. Guarantee Fund in the Form of Deposits
8. b. Guarantee Fund in the Form of SUN/Other Government Securities
Issued by the State (SBN)
9. Total Guarantee Fund Withdrawals (7 + 8)
10. Closing Balance of Guarantee Fund (1 + 5 – 9)
2. Annual Guarantee Fund Adequacy Calculation
No Description Amount
1. Minimum required paid-up capital
2. Total Non-PAYDI Premium Reserves
3. Total PAYDI Premium Reserves
4. Total CAPYBMP
5. Minimum Guarantee Fund Limit I (20% x 1)
6. Minimum Guarantee Fund Limit II (2% x 3) + (5% x (2 + 4))
7. Minimum Guarantee Fund Limit Used (The greater value between
5 and 6)
8. Guarantee Fund Owned
9. Guarantee Fund Surplus (Deficit) (7 - 6)
Quarter … Year …
As of …
PT. XYZ
GUARANTEE FUND REPORT
Summary of Guarantee Fund Development and Guarantee Fund Adequacy Calculation

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
A. Deposits
No. Custodian Bank Name Currency Cheque Number Amount Exchange Rate 1) Amount In Rupiah Date of Issue / Rollover Last Maturity Date 1 … 2 … 3 … 4 … 5 … Total Deposits - B. Government Bonds or Other Securities Issued by the State (SBN) No. Custodian Bank Name Serial Number Currency Nominal Value Exchange Rate 1) Nominal Value In Rupiah Maturity Date 1 … 2 … 3 … 4 … 5 … 6 … 7 … 8 … Total SBN - Notes:
1) 1 USD = Rp ..... (Using Bank Indonesia's Mid Rate as of the Report Date)
PT. XYZ
GUARANTEE FUND REPORT
Details of Final Guarantee Fund Position As of … Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
(ratio in percentage)
No. Description Quarter …
Year …
Quarter …
Year …
1 Liquidity Ratio a. Current Assets b. Current Liabilities
c. Ratio (a : b)
2 Investment Adequacy Ratio a. Investments + Cash & Banks (See SAP Balance Sheet) b. Retained Technical Reserves
c. Retained Claim Payables + Other Payables to Policyholders
d. Ratio (a : (b + c))
3 Ratio of Investment Income to Net Premium Income a. Investment Income b. Net Premium Income
c. Ratio (a : b)
4 Ratio of Claim Expenses, Operating Expenses, and Commissions a. Net Claim Expenses b. Operating Expenses
c. Net Commissions
d. Net Premium Income e. Ratio a : d (Ratio I) f. Ratio b : d (Ratio II) g. Ratio c : d (Ratio III) h. Ratio I + Ratio II + Ratio III PT.XYZ Financial Health Ratios Other Than MMBR As of … and As of …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
I. Education and Training Costs (in millions of rupiah)
Budget Realization Percentage
(1) (2) (3) (4) (5) = (4) : (3) Total Notes :
Column (3) is filled with the budget for education and training costs for one year Column (4) is filled with the cumulative realization of education and training costs up to the reporting period
II. Education and Training Ratio
No. Budget Realization
(1) (3) (4)
1 Employee, Board of Directors, and Board of Commissioners Costs 2 Education and Training Costs (Diklat) a. Employee Diklat b. Board of Directors Diklat
c. Board of Commissioners Diklat
3 Total Diklat Costs (a + b + c) 4 Ratio of Diklat Costs to Employee, Board of Directors, and Board of Commissioners Costs (3 : 1) #DIV/0! #DIV/0! Description (2) PT.XYZ Education and Training Ratio As of … NO. Description Diklat Costs Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year #DIV/0! #DIV/0! 1 year < age < 5 years #DIV/0! #DIV/0! 5 years ≤ age < 10 years #DIV/0! #DIV/0! ≥ 10 years #DIV/0! #DIV/0! Total (in percentage) Rupiah Foreign Currency Total Ratio of Current Assets to Non-Current Assets #DIV/0! #DIV/0! Ratio of Current Liabilities to Non-Current Liabilities #DIV/0! #DIV/0! Notes:
1) In millions of rupiah
2) In percentage
3) Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with an age of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with an age of more than 1 year Description PT.XYZ RECAPITULATION OF ASSETS AND LIABILITIES BASED ON CURRENCY AND MATURITY AGE As of … Age Assets 1) Liabilities 1) Ratio of Assets to Liabilities 2) Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Description Direct
Marketing Agent Broker Bancassurance Affinity Telemarketing Others Total Gross Premium a. Direct Written Premium b. Indirect Written Premium
c. Commissions Paid
Total Gross Premium - - - - - - - - Claim Expenses a. Gross Claims b. Reinsurance Claims Total Claim Expenses - - - - - - - - PT. XYZ DETAILS OF PREMIUM INCOME AND CLAIM EXPENSES BASED ON DISTRIBUTION CHANNEL As of … Quarter … Year …

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
GUIDELINES FOR PREPARING FINANCIAL STATEMENTS LIFE INSURANCE COMPANIES
I. GENERAL

These financial statements are prepared specifically for the development and supervision of the insurance business. Therefore, the form, content, and structure of the financial statements are made in accordance with applicable legislation in the insurance business field (Statutory Accounting Practices/SAP) as regulated in Minister of Finance Regulation Number 53 of 2012 and its implementing regulations.
The content and structure of the Life Insurance Company Financial Statements are as follows:
A. Primary Financial Statements consisting of:
1) Life Insurance Company Balance Sheet
2) Life Insurance Company Comprehensive Income Statement
3) Life Insurance Company Cash Flow Statement
4) Life Insurance Company Statement of Changes in Equity
5) Life Insurance Company Solvency Level Report :
a) Solvency Achievement Ratio b) Risk-Based Minimum Capital  Schedule A - Asset Management Failure Risk  Schedule B - Risk of Imbalance Between Asset and Liability Cash Flow Projections  Schedule C – Risk of Imbalance Between Asset and Liability Values in Each Currency Type  Schedule D – Insurance Liability Risk  Schedule E – Interest Rate Risk  Schedule F – Reinsurance Risk  Schedule G – Operational Risk
6) SAP Asset and Liability Calculation for Life Insurance Companies
a) Sub A - Investment Placements with Non-Related Parties b) Sub B - Investment Placements with Parties Affiliated with the Company c) Sub C - Investment Placements with Parties Not Affiliated with the Company d) Sub D - Investment Placements Abroad e) Sub E - List of Affiliated Companies
7) Details of Life Insurance Company Financial Statements
B. Supplementary Financial Statements consisting of:
1) Life Insurance Company Guarantee Fund Report
a) Summary of Development and Guarantee Fund Adequacy Calculation b) Details of Final Guarantee Fund Position
2) Financial Health Ratios Other Than MMBR
3) Education and Training Cost Ratio
4) Asset and Liability Matching
5) Details of Premium Income and Claim Expenses Based on Distribution Channel
The form, content, and structure of these financial statements are used for both annual financial statements and quarterly financial statements.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
4. For Life Insurance Companies that do not meet solvency requirements, the form, content, and structure of the financial statements are the same as the quarterly financial statements.
5. Companies that do not meet the solvency level, in addition to submitting the Financial Rehabilitation Report as referred to in item 4, are required to attach a financial rehabilitation plan and steps.
6. Primary financial statements are presented sequentially for two periods, namely the current period and the previous period. For quarterly reports, the previous period refers to the same period in the previous year. For example, for the second quarter 2013 report, the current period is the second quarter of 2013, while the previous period is the second quarter of 2012. Whereas for annual reports, the previous period is one period before the current period, for example, for the 2013 report, the current period is the year 2013, while the previous period is the year 2012.
7. If there are rows or columns that must be filled but the value is 0 (zero) or does not exist, then 0 (zero) is written.
8. Rupiah figures in all financial statement formats are written in millions of rupiah with 2 (two) decimal places after the comma.
9. Negative numbers are given a sign in parentheses (xxxx).
10. Permitted Assets which are hereinafter abbreviated as AYD are assets that are permitted and calculated in the Solvency Level calculation as referred to in legislation in the insurance business field.
11. Reserves for Premiums Not Yet Earned Income which are hereinafter abbreviated as CAPYBMP is a sum of funds that must be formed to describe the portion of premiums whose insurance period has not yet been run.
12. Life Insurance Company (Company) is an Insurance Company as referred to in the law concerning the insurance business.
13. Others
a. The company name must be clearly written on every format title available. On the front page (cover), the name and address of the General Insurance Company/Reinsurance Company must be filled in on the available row (XYZ in PT XYZ refers to the company name). b. The period of quarterly and annual financial statements must be filled in according to the end date of the current reporting period. For example, for the second quarter 2013 report, it is filled in as of June 30, 2013, while for the 2013 report, it is filled in as of December 31, 2013.
c. If the company adds pages for a certain detail, then the pages for that detail are given sequential numbers a, b, and so on. For example, if Detail 101 consists of two pages, then the first page is given the sequential number 21a and the next page is given the sequential number 21b, and so on.
d. Submitted financial statements must be signed by at least one member of the Board of Directors and stated in the company profile (page ii). e. The statement letter must be signed by one director representing the company's board of directors. f. The form, content, and structure of the financial statements cannot be changed, unless otherwise stated in the notes available in each format. If the number of available rows or pages is still insufficient, the company may add as needed.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013 g. On every format available, there are several important notes that need to be understood as guidance in filling them out. h. The cover of the financial statement for Life Insurance Companies uses the color red. 14.The flowchart for filling out financial statement formats for the purpose of calculating the solvency achievement ratio is as follows:
Start
Is there Investment Abroad Sub D Sub A Yes No Sub B Affiliation with company SAP Asset and Liability Calculation SAP Asset Calculation Detail 101 - 116 Yes SAP Balance Sheet (Page 1, Column 5) Detail 101 - 209 Detail 501 - 506 Comprehensive Income Calculation Risk-Based Minimum Capital Schedule A - G Solvency Level Report (Page 5) Detail 301 - 403 SAP Asset and Liability Calculation SAP Liability Calculation No Sub E List of affiliated companies Sub C Affiliation not with company Is there Investment with One Party
II. PRIMARY FINANCIAL STATEMENTS

Balance Sheet

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
The Balance Sheet in this report consists of the Balance Sheet prepared based on Financial Accounting Standards (SAK) and Statutory Accounting Practice (SAP), each with the Balance Sheet of the previous period as a comparison. Accounts in the Balance Sheet are filled based on accounts listed in details 101 to 404. a. SAK Balance Sheet Accounts in this Balance Sheet have been reclassified according to the purpose of their inclusion, so that the accounts do not have to be the same as the accounts in SAK reporting. The purpose of including the SAK Balance Sheet is to have comparative figures for SAK Balance Sheet accounts, especially for assets, so as to facilitate analysis by analysts. b. SAP Balance Sheet Assets listed in the SAP Balance Sheet are AYD whose accounts are filled based on accounts listed in details 101 to 209. The determination of the amount of AYD for each type of asset is calculated based on applicable regulations. The total AYD in this report (column (4)) is subsequently filled in the Solvency Level Report – Solvency Achievement Ratio (column (2)) AYD row. Liabilities in the SAP Balance Sheet are filled based on accounts listed in details 301 to 403. The total liabilities in this report (column (4)) are subsequently filled in the Solvency Level Report – Solvency Achievement Ratio (column (2)) Liabilities row. For the Equity group, accounts are adjusted as much as possible to the existing format. For the "Difference in Valuation Based on SAK and SAP" account, it is filled based on the amount available in the SAP Asset and Liability Calculation – Difference in Valuation Based on SAK and SAP section, while for the "Non-Permitted Assets" account, it is filled based on the amount available in the SAP Asset and Liability Calculation – I. SAP Asset Calculation column (6). Differences in SAK and SAP valuation can arise due to differences in the valuation of assets and liabilities based on SAK and SAP. Differences in asset valuation between SAK and SAP arise due to differences in the recognition of the value of the assets. Generally, SAP recognizes assets at fair value, while SAK recognizes assets at historical cost. For liabilities, differences can arise because SAK provides several options in the method of calculating technical reserves, allowing Companies to choose a technical reserve calculation method based on SAK that is different from the technical reserve calculation as regulated in legislation. In the event of differences in the valuation of assets and liabilities between SAP and SAK, the difference can increase or decrease SAP equity. Differences in asset valuation can occur because generally the valuation of assets based on SAP results in larger amounts compared to the valuation of assets based on SAK, thus giving rise to the consequence of adding SAP equity. For liabilities, generally Companies will use valuation based on SAP which can provide smaller valuations compared to the valuation of liabilities based on SAK, thus giving
rise to the consequence of adding SAP equity. Whereas Non-Permitted Assets arise due to limitations in the recognition of Company assets so that not all assets recognized based on SAK can be recognized as assets based on SAP. Thus, the non-recognition of such assets gives rise to the consequence of

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013 reduction of SAP equity. Presentation of reinsurance assets in the Statement of Financial Position is presented as assets that are part of reinsurance receivables and included in assets permitted in the calculation of financial health ratios. The value of reinsurance assets consists of:

The value of reinsurance assets for future policy benefit liabilities, determined consistently with the approach used in determining future policy benefit liabilities, based on the terms and conditions of the reinsurance contract.
The value of reinsurance assets for premiums not yet earned, determined consistently with the approach used in determining premiums not yet earned, based on the terms and conditions of the reinsurance contract.
The value of reinsurance assets for estimated claim liabilities, determined consistently with the approach used in determining estimated claim liabilities, based on the terms and conditions of the reinsurance contract.

Comprehensive Income Statement
The columns in this report are filled based on the figures listed in details 501 to 506. The SAP Comprehensive Income Statement may differ from the SAK Comprehensive Income Statement due to differences in recognition treatment (technical reserve expenses) and differences in account classification. The account classifications for the SAP report have been adjusted to existing regulations. Thus, the final result of this Comprehensive Income Statement (i.e., profit or loss) may differ between the SAP report and the SAK report. The Comprehensive Income Statement presented is the Comprehensive Income Statement for the beginning of the current fiscal year up to the reporting date (cumulative). For example, for the Q2 2013 report, the income recorded is income earned from January 1, 2013, to June 30, 2013. Decrease (Increase) in CAPYBMP, Increase (Decrease) in Premium Reserves and Claim Reserves in the Comprehensive Income Statement are presented based on detail 501 and detail 504. Components for determining Gross Premium in this report are gross premiums as referred to in Government Regulation Number 73 of 1992 concerning the Conduct of Insurance Business as amended by Government Regulation Number 63 of 1999.
Cash Flow Statement
The Cash Flow Statement in this report is filled based on information in the columns provided in the existing format. The ending balance of Cash and Bank at item 45 for the previous period (annual, quarterly, or monthly) is the opening balance at item 1 for the current period. The ending balance of cash and bank in this report must be the same as the total cash and bank in the Statement of Financial Position.
Statement of Changes in Equity
The Statement of Changes in Equity consists of SAK Equity and SAP Equity. To fill out the SAP Statement of Changes in Equity, the company must first fill out the Statement of Changes in Equity prepared based on SAK. The SAP Statement of Changes in Equity is a reconciliation report from the SAK Equity Statement to the SAP Equity Statement. Two SAP equity components that are not SAK equity components, namely "Difference in Valuation between SAK and SAP" and "Assets Not Permitted," are two important components affecting the result of that reconciliation. These two components are entered into the SAP Statement of Changes in Equity, only for the difference between the current period and the previous period. The figures entered into the SAP Statement of Changes in Equity are the increase or decrease in "Difference in Valuation between SAK and SAP" and "Assets Not Permitted" as stated in the Statement of Financial Position in column (5) and column (7). Example:
a. If "Difference in Valuation between SAK and SAP" in Q1 2013 stated in the Statement of Financial Position is Rp 1,200 million, while for Q4 2012 it is Rp 1,000 million, then the figure entered into "Increase (Decrease) in Difference in Valuation between SAK and SAP" is Rp 200 million. b. If "Assets Not Permitted" for Q1 2013 stated in the Statement of Financial Position is Rp 5,600 million, while for Q4 2012 it is Rp 4,000 million, then the figure entered into "(Increase) Decrease in Assets Not Permitted" is (Rp 1,600) million.
Solvency Ratio Report
The Solvency Ratio Report in this report consists of:
a. Solvency Achievement Ratio
Companies are required to meet a minimum solvency level of 120% of the minimum risk-based capital as referred to in Minister of Finance Regulation Number 53/PMK.010/2012. The total solvency referred to consists of RBC (Risk-Based Capital) and liabilities (excluding subordinated loans). The total RBC (column 3) must be equal to the total assets in the Statement of Financial Position (column 5 – SAP Balance). Meanwhile, the total liabilities (column 3) must be equal to the total liabilities in the Statement of Financial Position (column 5 – SAP Balance). b. Minimum Risk-Based Capital The method for filling out the schedules in the Financial Statements of Property Insurance Companies/Reinsurance Companies is as follows:
Schedule A: The total RBC (column (2)) must be equal to the total assets in the SAP Statement of Financial Position (column (4)).
If the company has mixed mutual funds, an example calculation of the weighted average factor is as follows:
Portfolio Composition Weighted Average Factor Government Bonds 40% 0% 0% Private Bonds 40% 6% 2.4% Equity Securities 20% 16% 3.2% The weighted average of each security is the result of multiplying the composition of each security by the risk factor. In the example above, the weighted average of the mixed mutual fund is the sum of the weighted average portfolio of securities, which is 5.6%.
Schedule B: The columns in this schedule are filled with RBC and liability values based on book values in the Statement of Financial Position, grouped by their maturity dates. RBC in the form of traded securities and valued at market value (example: stocks) is classified as assets maturing in less than 1 (one) year. Meanwhile, RBC intended to be held until maturity is classified according to its remaining life.
Schedule C: The total RBC in row 14 columns total (3) to (11) must be equal to the total assets in the SAP Statement of Financial Position, and likewise, the liabilities in row 22 columns total (3) to (11) must be equal to the total liabilities in the Statement of Financial Position (excluding subordinated loans).
Schedule D: The columns in this schedule are filled according to the instructions contained in the existing format.
Schedule E: The columns in this schedule are filled according to the instructions contained in the existing format.
Schedule F: The columns in this schedule are filled according to the instructions contained in the existing format. If the company does not have deposits and/or held premiums (column (4)), this column is filled with the number 0 (zero).
Schedule G: General and administrative expenses and education and training expenses are filled with general and administrative expenses and education and training expenses for one year. For quarterly reports, general and administrative expenses and education and training expenses are filled with the general and administrative expenses and education and training expenses of the last 4 (four) quarters. For example, for Q1 2013, general and administrative expenses are filled with the total general and administrative expenses of Q2 2012, Q3 2012, Q4 2012, and Q1 2013. Likewise, education and training expenses are filled with the total education and training expenses of Q2 2012, Q3 2012, Q4 2012, and Q1 2013.
Calculation of SAP Assets and Liabilities
a. SAP Asset Calculation
The columns for SAP Asset Calculation (page 12) are filled with the following instructions:
Column 3: filled in accordance with what is stated in each asset detail for the general ledger balance amount (SAK). Column 4: filled in accordance with the valuation basis as regulated in Minister of Finance Regulation Number 53 of 2012. Column 5: is the difference between column (4) and column (3). Column 6: filled with the total amount of non-permitted assets found in each detail (101 to 209), especially for other investment accounts, other fixed assets, and other assets. Column 7: filled from the total RBC found in each detail (detail 101 to 209). For the Cash and Bank account, the amount must be the same as the ending balance in the Cash Flow Statement.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
The total Difference in Valuation between SAK and SAP (column 5) is an add-on or deduction to equity in the preparation of the SAP Statement of Financial Position as explained in the Statement of Changes in Equity. An asset valuation surplus based on SAP over SAK is an add-on to SAP equity, while an asset valuation deficit based on SAP over SAK is a deduction from SAP equity. b. SAP Liability Calculation The columns for SAP Liability Calculation are filled with the following instructions:
Column 3: filled in accordance with what is stated in each liability detail for the general ledger balance amount (SAK). Column 4: filled in accordance with what is stated in each liability detail with valuation based on SAP. Column 5: filled based on the total Difference in Valuation between SAK and SAP found in each liability detail (note: if there is a valuation difference between SAK and SAP). A liability valuation surplus based on SAP over SAK is a deduction from SAP equity, while a liability valuation deficit based on SAP over SAK is an add-on to SAP equity.
c. Valuation Difference Based on SAK and SAP
The total Difference in Valuation between SAK and SAP used in the preparation of the SAP Statement of Financial Position is the net difference between asset and liability valuation differences. This figure is then transferred to the statement of financial position column (4) in the account for valuation difference based on SAK and SAP. d. Sub-Sub Sections The asset calculation form has 5 (five) sub-sections, namely:
1) Sub A, Investment Placements Not with One Party
The columns in Sub A are filled if the Company places investments in companies but are not affiliated either with the Company or with the Company.
2) Sub B, Investment Placements with Affiliated Parties of the Company
The columns in Sub B are filled if the Company places investments in companies that are part of an affiliate group where the Company is part of it. The total investment placements in the aforementioned companies are maximum 10% (ten percent) of the total investments.
3) Sub C, Investment Placements with Affiliated Parties Not of the Company
The columns in Sub C are filled if the Company places investments in companies that are part of an affiliate group, where the Company is not part of it. The total investment placements in the aforementioned companies are maximum 20% (twenty percent) of the total investments.
4) Sub D, Investment Placements Abroad
The columns in Sub D are filled if the Company places investments in countries other than the Republic of Indonesia.
5) Sub E, List of Affiliated Companies
The columns in Sub E are filled in accordance with the information available in the existing format. Ownership relationship (column (3)) is filled by stating the Company's position in an affiliate group. For example, subsidiary, parent, etc.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
7. Details
7.1. Detail 101
The following regulations apply to this detail:

Column (3) is filled with the bank rating. For banks that issue bonds, the bank rating can refer to rating agencies registered with the Financial Services Authority (Pefindo, Fitch Indonesia, and ICRA Indonesia). However, if the bank does not issue bonds and is not listed in the aforementioned rating agencies, this column does not need to be filled.
Column (4) is filled with the cluster corresponding to the rating in column (3). If column (3) is empty, this column is filled with the largest cluster (cluster 5).
The amount in column (7) is entered into detail 601.
Column (8) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

7.2. Detail 102
The following regulations apply to this detail:

Column (3) is filled as follows:
1) LQ45 or JII, depending on the stock category.
2) Other exchanges besides LQ45 and JII.
3) Foreign exchanges.
The amount in column (6) is entered into detail 601.
Column (7) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "corporate bonds".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the investment type in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is entered into sub D.

7.3. Detail 103
The following regulations apply to this detail:

Column (3) is filled with the rating of corporate bonds and corporate sukuk issued by rating agencies registered with the Financial Services Authority (Pefindo, Fitch Indonesia, and ICRA Indonesia) or those that have obtained international recognition (Standard & Poor’s, Moody’s, AM Best, Fitch, and ICRA).
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is entered into detail 601.
Column (9) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the investment type in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is entered into sub D.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
7.4. Detail 104

The columns in this detail are filled in accordance with the information available in the existing format.
The amount in column (6) is entered into detail 601.

7.5. Detail 105

Column (3) is filled with the investment instrument rating based on rating agencies that have obtained international recognition (Standard & Poor’s, Moody’s, AM Best, Fitch, and ICRA). The total value of these instruments is entered into sub D.
Column (4) is filled with the cluster corresponding to column (2).
The amount in column (8) is entered into detail 601.

7.6. Detail 106

The columns in this detail are filled in accordance with the information available in the existing format.
The amount in column (6) is then entered into detail 601.

7.7. Detail 107

The columns in this detail are filled in accordance with the information available in the existing format and the total value of these instruments is entered into sub D.
The amount in column (6) is then entered into detail 601.

7.8. Detail 108
The following regulations apply to this detail:

Determination of the unit trust fund classification category must be based on the actual investment composition of the mutual fund on the date of the Statement of Financial Position, not the investment composition in the prospectus.
A mutual fund is called entirely Government Bonds if 90% or more of the mutual fund's investment composition is placed in Government Bonds. If the placement in one type of investment is less than 90%, the mutual fund is grouped into mixed mutual funds. This also applies to placements in other mutual fund categories.
The amount in column (6) is entered into detail 601.
Column (7) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the investment type in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is entered into sub D.

7.9. Detail 109
The following regulations apply to this detail:

Column (3) is filled with the investment instrument rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is entered into detail 601.
Column (9) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
7.10. Detail 110
The following regulations apply to this detail:

Column (3) is filled with the investment instrument rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is entered into detail 601.
Column (9) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

7.11. Detail 111
The following regulations apply to this detail:

Column (7) total value is maximum 10% (ten percent) of the total investments.
Column (8) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the investment type in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is entered into sub D.

7.12. Detail 112
The following regulations apply to this detail:

The category of building type with strata rights or land with buildings as investment or for own use is determined by the company, with the note that buildings with strata rights or land with buildings can be categorized as investments if the buildings with strata rights or land with buildings can provide returns (in the form of rent) to the company.
Column (2) can be filled by mentioning the city (DATI II) where the building with strata rights or land with buildings is located.
The amount in column (3) is entered into detail 601.
Column (4) is filled based on the value determined by a registered appraiser institution at the competent agency, or the Latest Taxable Object Value (NJOP) in case no appraisal is done by an appraiser institution.
Column (5) is the difference between column (3) and column (4) for each unit.
Row Number IV (RBC) will be equal to the total (I + II + III) if the total value (I + II + III) is less than or equal to 10% of the total investments.

7.13. Detail 113
The following regulations apply to this detail:

Column (3) is filled with the financing company and/or bank license number.
The amount in column (4) is entered into detail 601.
Column (8) is filled as follows:
1) If there are placements of more than one type of investment in one company, this column is filled by mentioning the other investment types, e.g., "stocks".
2) If the investment type in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

7.14. Detail 114

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
For this detail, the following provisions apply:

This type of investment consists of gold bars.
Column (3) is filled according to the quantity of ownership. For example, if the Company owns 10 kg of gold bars, column (3) is filled with: 25 pieces/100gr, 10 pieces/250gr, 50 pieces/100gr.
Columns in this detail are filled according to the information available in the existing format.
The amount in column (6) is entered into detail 601 7.15. Detail 115
Columns in this detail are filled according to the information available in the existing format.
The amount in column (8) is entered into detail 601 7.16. Detail 116
Columns in this detail are filled if the Company has other investments besides those mentioned above.

7.17. Detail 201

For debtor details, it is sufficient to detail debtors who owe the company an amount of 5% or more of the total value of Premium Receivables. Meanwhile, for debtors whose debt amount is below 5% of the total value of Premium Receivables, it is sufficient to categorize them into the "Others" group.
For the "Insurance Broker" debtor category, what is filled is the total premium receivables of the insurance company to the brokerage company, so the debtor name listed is the name of the brokerage company.
The amount in column (5) may be greater than the amount in column (4), considering that receivables that can be entered into column (4) have a shorter receivable age than receivables that can be entered into column (5). Subsequently, the amount in column (5) is entered into detail 601.

7.18. Detail 202
For this detail, the following provisions apply:

For debtor details, it is sufficient to detail debtors who owe the company an amount of 5% or more of the total value of Co-insurance Claim Receivables. Meanwhile, for debtors whose debt amount is below 5% of the total value of Co-insurance Claim Receivables, it is sufficient to categorize them into the "Others" group.
Column (3) is filled with the debtor rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (7) may be greater than the amount in column (6), considering that receivables that can be entered into column (6) have a shorter receivable age than receivables that can be entered into column (7). Subsequently, the amount in column (7) is entered into detail 601.

7.19. Detail 203
For this detail, the following provisions apply:

For debtor details, it is sufficient to detail debtors who owe the company an amount of 5% or more of the total value of Reinsurance Receivables. Meanwhile, for debtors whose debt amount is below 5% of the total value of Reinsurance Receivables, it is sufficient to categorize them into the "Others" group.
Reinsurance assets are part of reinsurance receivables and are included in Current Assets.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013

Column (3) is filled with the debtor rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (7) may be greater than the amount in column (6), considering that receivables that can be entered into column (6) have a shorter receivable age than receivables that can be entered into column (7). Subsequently, the amount in column (7) is entered into detail 601.

7.20. Detail 204
For this detail, the following provisions apply:

Items that can be categorized as Current Assets are receivables with an age of at most 1 (one) month.
The amount in column (5) may be greater than the amount in column (4), considering that receivables that can be entered into column (4) have a shorter receivable age than receivables that can be entered into column (5). Subsequently, the amount in column (5) is entered into detail 601.

7.21. Detail 205
For this detail, the following provisions apply:

Items that can be categorized as Current Assets are receivables with an age of at most 1 (one) month.
The amount in column (5) may be greater than the amount in column (4), considering that receivables that can be entered into column (4) have a shorter receivable age than receivables that can be entered into column (5). Subsequently, the amount in column (5) is entered into detail 601.

7.22. Detail 206
For this detail, the following provisions apply:

Current period loans are filled for policy loans that occurred in the reporting period (new policy loans) by stating the policy number (this detail per policy is only for non-APL policy loans).
This detail per policy only applies to quarterly reports. Meanwhile, for annual reports, only the total addition of policy loans that occurred in the reporting period is filled.
The amount in column (6) is then entered into detail 601.

7.23. Detail 207
For this detail, the following provisions apply:

Column (2) can be filled by stating the city (DATI II) where the building with strata rights or land with a building is located.
Column (5) is the difference between column (3) and column (4) for each unit.
Row Number II (Current Assets) is less than or equal to 15% of Own Capital SAK for the current period.

7.24. Detail 208
Columns in this detail are filled according to the information available in the existing format.

7.25. Detail 209
Columns in this detail are filled according to the information available in the existing format.

7.26. Detail 301

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013

For creditor details, it is sufficient to detail creditors who have claims against the company in an amount of 5% or more of the total value of claim liabilities. Meanwhile, for creditors whose claim amount is below 5% of the total value of claim liabilities, it is sufficient to categorize them into the "Others" group.
The amount of column (7) is entered into detail 601.

7.27. Detail 302
For this detail, the following provisions apply:

For creditor details, it is sufficient to detail creditors who have claims against the company in an amount of 5% or more of the total value of claim liabilities. Meanwhile, for creditors whose claim amount is below 5% of the total value of claim liabilities, it is sufficient to categorize them into the "Others" group.
The amount of column (5) is entered into detail 601.

7.28. Detail 303
For this detail, the following provisions apply:

For creditor details, it is sufficient to detail creditors who have claims against the company in an amount of 5% or more of the total value of claim liabilities. Meanwhile, for creditors whose claim amount is below 5% of the total value of claim liabilities, it is sufficient to categorize them into the "Others" group.
The amount of column (5) is entered into detail 601.

7.29. Detail 304
For this detail, the following provisions apply:

For creditor details, it is sufficient to detail creditors who have claims against the company in an amount of 5% or more of the total value of commission liabilities. Meanwhile, for creditors whose claim amount is below 5% of the total value of commission liabilities, it is sufficient to categorize them into the "Others" group.
The amount of column (4) is entered into detail 601.

7.30. Detail 305
For this detail, the following provisions apply:

Column (2) is sufficient to be filled with cost information whose amount is 5% or more of the total value of accrued costs. Meanwhile, for cost amounts below 5% of the total value of accrued costs, it is sufficient to categorize them into the "Others" group.

7.31. Detail 306
For this detail, the following provisions apply:

Column (2) is sufficient to be filled with debt information whose amount is 5% or more of the total value of other debts. Meanwhile, for debt amounts below 5% of the total value of other debts, it is sufficient to categorize them into the "Others" group.

7.32. Detail 401
Columns in this detail are filled according to the information available in the existing format.

7.33. Detail 402
Columns in this detail are filled according to the information available in the existing format.

7.34. Detail 403

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Columns in this detail are filled according to the information available in the existing format.

7.35. Detail 501
This detail is a breakdown of underwriting income as stated in the Comprehensive Income Statement, but in this case, it is broken down for new production and deferred premiums, both individual and group. Therefore, the amount in row 18 column (12) will be the same as the amount in the Comprehensive Income Statement.

7.36. Detail 502

Investment results in this detail include realized investment results (net investment income) and unrealized results (unrealized gain). However, these investment results are entered into the Comprehensive Income Statement adjusted according to the PSAK governing this matter.
Column (7) is filled as follows:
Example: A General Insurance Company has corporate bonds with interest payment coupons and their valuation is based on market price. Thus, this type of investment will provide results that can be categorized into two types, namely interest and gain due to market price increases. Therefore, column (7) is filled with how much interest was received in the reporting period and how much gain (realized gain and unrealized gain) exists.

7.37. Detail 503
For other income, it is sufficient to detail income with an amount of 5% or more of the total value of other income. Meanwhile, for income amounts below 5% of the total value of other income, it is sufficient to categorize them into the "Others" group.

7.38. Detail 504
In this detail, for each insurance branch, it is broken down by type of claim/benefit payment such as: contract end, single value, death, and others.

7.39. Detail 505
For other (expense) results, it is sufficient to detail (expenses) results with an amount of 5% or more of the total value of other (expenses) results. Meanwhile, for (expenses) results amounts below 5% of the total value of other (expenses) results, it is sufficient to categorize them into the "Others" group.

7.40. Detail 506
Columns in this detail are filled according to the information available in the existing format.

7.41. Detail 601

The definition of Current Assets and Current Liabilities is all assets and liabilities of Life Insurance Companies that have a duration of less than or equal to one year from the reporting date.
The amount is then entered into Additional Financial Statements item 1a and 1b (Liquidity Ratio).

III. ADDITIONAL FINANCIAL STATEMENTS

Guarantee Fund Report

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
The preparation of the Guarantee Fund Report is intended to monitor the Company's compliance with minimum guarantee fund requirements, which are the last resort guarantee for policyholders if the respective Company is liquidated. In the report format, the amount of guarantee funds, details of deposit certificates, and the calculation of the minimum amount of guarantee funds that must be held are broken down. Summary of guarantee fund developments, calculation of guarantee fund adequacy, and details of final guarantee fund positions are filled according to the information available in the existing format. The required paid-up capital used in the guarantee fund calculation is the required paid-up capital at the time of establishment of the respective Life Insurance Company. For Life Insurance Companies, the basis for determining additional guarantee funds is the net premium for all types of insurance products marketed by that insurance company.

Financial Health Ratios Other than MMBR
This ratio is an additional ratio in calculating the financial health level of the Company, consisting of:
a. Liquidity ratio, to determine the Company's ability to meet short-term financial liabilities when due using available current assets. b. Investment adequacy ratio, to measure the Company's ability to meet potential claims.
c. Ratio of investment results to net premium income, to compare company assets from investment management and net income from received premiums.
d. Claim expense, operating expense, and commission ratio, to measure the amount of income received from premiums after deducting expenses. Details of the aforementioned ratios are filled according to the information available in the existing format.
Education and Training Ratio
For this detail, the following provisions apply:
I. Education and Training Costs

Column (2) is filled with the name of the planned or budgeted education and training.
Column (3) is filled with the budgeted cost of education and training for one year.
Column (4) is filled with the cumulative realization of education and training costs up to the reporting period.
II. Education and Training Ratio
Column (3) is filled with the budgeted costs for employees, directors, and commissioners, as well as the budgeted costs for education and training for each user, namely: employees, directors, and commissioners for the current year.
Column (4) is filled with the realization of costs for employees, directors, and commissioners, as well as the realization of education and training costs for each user, namely: employees, directors, and commissioners that have been carried out up to the reporting period in the current year.

Appendix II
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
4. Asset and Liability Matching
Matching assets and liabilities based on currency and maturity is required to know the difference in asset and liability values in foreign currencies, as well as fluctuations in foreign exchange rates against the rupiah. Columns in this detail are filled based on SAK values.

Breakdown of Premium Income and Claim Expenses by Distribution Channel
Columns in this detail are filled according to the information available in the existing format.

Established in Jakarta on August 27, 2013 EXECUTIVE HEAD OF NON-BANK FINANCIAL INDUSTRY SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed. FIRDAUS DJAELANI Copy matches the original Head of Legal Assistance Division Financial Services Authority, Signed. Mufli Asmawidjaja

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page i
To
Financial Services Authority
Attn. Insurance Supervision Directorate Sumitro Djojohadikusumo Building, 14th Floor Jl. Lapangan Banteng Timur 1 - 4 Jakarta - 10710 FINANCIAL STATEMENTS (Company Address) PT XYZ For …………./ Quarter ………. Year ……….. AND INSURANCE PRODUCTS LINKED WITH INVESTMENT LIFE INSURANCE COMPANY

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page ii
Financial Statements
Life Insurance Company and Products Linked With Investment PT. XYZ For …/ Quarter … Year … 1 Company Name :
2 Full address :
3 Telephone and Fax. :
4 E-mail :
5 NPWP (Tax ID) :
6 No. & Date of Business License :
7 a. Number of Branches/
Representatives :
b. Number of Insured :
8 External Auditor :
9 Shareholders :
Share Ownership
Rupiah Percentage
Total
10 Board of Directors and Commissioners:
Director Name Position Commissioner Name Position 11 Financial Reporting PIC :
Division/Section No Phone, ext. Email ………………, …………………. PT. Insurance ……………………………. Director Name Director Shareholder Name

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iii
………………, ………………….
Director of PT XYZ
Name
Position
Board of Directors Statement Letter Regarding Responsibility for Financial Statements For …/ Quarter … Year … PT XYZ We, the undersigned, declare that:

Responsible for the preparation and presentation of PT XYZ (Company) financial statements;
All information in the Company's financial statements has been presented completely and in accordance with the actual conditions;
The Company's financial statements do not contain incorrect material information or facts, and do not omit material information or facts.
Thus, this statement is made truthfully.

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iii
Board of Directors Statement Letter Regarding Responsibility for Financial Statements For …/ Quarter … Year … PT XYZ
2. All information in the Company's financial statements has been presented completely and in accordance with the actual conditions
3. The Company's financial statements do not contain incorrect material information or facts, and do not

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iv
Page
Cover Page i
Company Profile ii
Statement Letter iii
Table of Contents iv
I Main Reports
1.1. Traditional Product Financial Statements
1.1.1. Statement of Financial Position 1
1.1.2. Comprehensive Income Statement 2
1.1.3. Statement of Cash Flows 3
1.1.4. Statement of Changes in Equity 4
1.1.5. Solvency Level Report
a. Solvency Achievement Ratio 5 b. Risk-Based Minimum Capital
Schedule A Asset Management Failure 6
Schedule B Imbalance between Asset and Liability Cash Flow Projections 7
Schedule C Imbalance Between Asset and Liability Values in Each Currency Type 8
Schedule D Difference Between Incurred Claim Expenses and Estimated Claim Expenses 9
Schedule E Premium Insufficiency Due to Investment Result Differences 10
Schedule F Reinsurance Risk 11
Schedule G Operational Risk 12
Schedule H PAYDI Operational Risk 13
1.1.6. SAP Asset and Liability Calculation 14
Sub A Investment Placements Not on One Party 15 Sub B Investment Placements on Parties Affiliated with the Company 16 Sub C Investment Placements on Parties Not Affiliated with the Company 17 Sub D Investment Placements Abroad 18 Sub E List of Affiliated Companies 19
1.1.7. Details
101 Time Deposits and Certificates of Deposit 20 102 Stocks 21 103 Corporate Bonds and Corporate Sukuk 22 104 Securities Issued by the RI State 23 105 Securities Issued by Countries Other than the RI State 24 106 Securities Issued by Bank Indonesia 25 107 Securities Issued by Multinational Institutions 26 108 Mutual Funds 27 109 Asset-Backed Securities Collective Investment Contracts 28 110 Real Estate Investment Funds 29 111 Direct Investments 30 112 Buildings with Strata Rights or Land with Buildings for Investment 31 113 Purchase of Receivables for Financing Companies and/or Banks 32 114 Pure Gold 33 115 Loans Secured with Mortgage Rights 34 116 Other Investments 35 201 Direct Writing Premium Receivables 36 202 Co-insurance Claim Receivables 37 203 Reinsurance Receivables 38 204 Investment Receivables 39 205 Investment Result Receivables 40 206 Policy Loans 41 207 Buildings with Strata Rights or Land with Buildings for Own Use 42 208 Other Fixed Assets 43 209 Other Assets 44 301 Claim Liabilities 45 302 Co-insurance Liabilities 46 303 Reinsurance Liabilities 47 304 Commission Liabilities 48 305 Accrued Costs 49 306 Other Liabilities 50 401 Premium Reserves 51 402 Reserves for Premiums That Are Not Yet Income 52 Financial Statements Life Insurance Company
Table of Contents
PT XYZ and Products Linked With Investment

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iv
403 Claim Reserves 53
501 Premium Income 54
502 Investment Results 55
503 Other Income 56
504 Insurance Expenses 57
505 Other (Expenses) Results 58 506 Comprehensive Income 59 601 Current Assets and Current Liabilities 60

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Page iv
1.2. PAYDI Financial Statements
1.2.1. Statement of Financial Position 61
1.2.2. Comprehensive Income Statement 62
1.2.3. Risk-Based Minimum Capital 63
Schedule A Asset Management Failure 64
Schedule B Imbalance between Asset and Liability Cash Flow Projections 65
Schedule C Imbalance Between Asset and Liability Values in Each Currency Type 66
1.2.4. Sub D Investment Placements Abroad 67
1.2.5. Details
1101 Time Deposits and Certificates of Deposit 68 1102 Stocks 69 1103 Corporate Bonds and Corporate Sukuk 70 1104 Securities Issued by the RI State 71 1105 Securities Issued by Countries Other than the RI State 72 1106 Securities Issued by Bank Indonesia 73 1107 Securities Issued by Multinational Institutions 74 1108 Mutual Funds 75 1109 Asset-Backed Securities Collective Investment Contracts 76 1110 Pure Gold 77 1401 Premium Reserves 78
1.3. Consolidated Financial Statements
1.3.1. Statement of Financial Position 79
1.3.2. Comprehensive Income Statement 80
1.3.3. Solvency Level Report 81
1.3.4. Sub A Investment Placements Abroad 82
II. Additional Reports
2.1. Guarantee Fund Report
Summary of Guarantee Fund Developments 83 Calculation of Guarantee Fund Adequacy 83 Details of Final Guarantee Fund Positions 84
2.2. Financial Health Ratios Other than MMBR 85
2.3. Education and Training Ratio 86
2.4. Asset and Liability Matching 87
2.5. Breakdown of Premium Income and Claim Expenses by Distribution Channel 88

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Description
Detail
SAK Balance
SAP Balance
SAK Balance
SAP Balance
(1) (2) (3) (4) (5) (6)
ASSETS
Investments
Time Deposits and Certificates of Deposit 101 - - - - Stocks 102 - - - - Corporate Bonds and Corporate Sukuk 103 - - - - Securities Issued by the RI State 104 - - - - Securities Issued by Countries Other than the RI State 105

Securities Issued by Bank
Indonesia 106 - - - -
Securities Issued by Multinational Institutions 107

Mutual Funds 108 - - - -
Asset-Backed Securities Collective Investment Contracts 109 - - - - Real Estate Investment Funds 110 - - - - Direct Investments 111 - - - - Buildings with Strata Rights or Land with Buildings for Investment 112

Purchase of Receivables for Financing Companies and/or Banks 113 -

-
Pure Gold 114 - - - -
Loans Secured with Mortgage Rights 115 - - - - Other Investments 116 - - - - Total Investments - - - - Non-Investments Cash and Banks #REF! #REF! - - Direct Writing Premium Receivables 201 - - - - Co-insurance Claim Receivables 202 - - - - Reinsurance Receivables 203 - - - - Investment Receivables 204 - - - - Investment Result Receivables 205 - - - - Policy Loans 206 Buildings with Strata Rights or Land with Buildings for Own Use 207 - - - - Other Fixed Assets 208 - Other Assets 209 - - Total Non-Investments #REF! #REF! - - TOTAL ASSETS #REF! #REF! - - LIABILITIES AND EQUITY Liabilities Liabilities Claim Liabilities 301 - - - - Co-insurance Liabilities 302 - - - - Reinsurance Liabilities 303 - - - - Commission Liabilities 304 - - - - Tax Liabilities - - - - Accrued Costs 305 - - - - Other Liabilities 306 - - - - Total Liabilities - - - - Technical Reserves Premium Reserves 401 - - - - Reserves for Premiums That Are Not Yet Income 402 - - - - Claim Reserves 403 - - - - Total Technical Reserves - - - - Total Liabilities - - - - Subordinated Loans - - - - Equity Paid-up Capital - - - - Share Premium - - - - Retained Earnings - - - - Other Equity Components - - - - Difference in Valuation Based on SAK & SAP - - Assets Not Included in Current Assets - - Total Equity - - - - TOTAL LIABILITIES AND EQUITY - - - - For …. and For …. Quarter … Year … Quarter … Year … PT XYZ LIFE INSURANCE COMPANY STATEMENT OF FINANCIAL POSITION Non-Consolidated

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Details	Quarter …	Year …	Quarter …	Year …
(1)	(2)	(3)	(4)

INCOME
Premium Income 501
Reinsurance Premium
Decrease (Increase) CAPYBMP
Net Premium Income Total
Investment Results 502
Fees from DPLK/Other Management Services Other Income 503 TOTAL INCOME

EXPENSES
Insurance Expenses 504 a. Claims and Benefits (1) Claims and Benefits Paid (2) Reinsurance Claims (3) Increase (Decrease) Premium Reserves (4) Increase (Decrease) Claim Reserves Total Claims and Benefits Expenses b. Acquisition Costs (1) Commission Expenses - First Year (2) Commission Expenses - Subsequent Years (3) Commission Expenses - Overriding (4) Other Expenses Total Acquisition Costs Total Insurance Expenses Business Expenses:
a. Marketing Expenses b. Other General and Administrative Expenses:

Employee and Executive Expenses
Education and Training Expenses
Other General and Administrative Expenses
Other Income (Expense) 505
TOTAL EXPENSES
INCOME (LOSS) BEFORE TAX
Income Tax
INCOME (LOSS) AFTER TAX
OTHER COMPREHENSIVE INCOME 506 TOTAL COMPREHENSIVE INCOME (LOSS)

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF COMPREHENSIVE INCOME (LOSS) For the Period Ending Date … and Date …

Note:
The figures in this report are cumulative figures for the period from January 1 to the reporting date of the current period.

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Quarter …	Year …	Quarter …	Year …
(1)	(2)	(3)

BEGINNING CASH AND BANK BALANCE CASH FLOWS FROM OPERATING ACTIVITIES Cash Inflows a. Premiums b. Co-insurance Claims
c. Reinsurance Claims
d. Commissions e. Receivables f. Others Total Cash Inflows - - Cash Outflows a. Reinsurance Premiums b. Claims
c. Commissions
d. Expenses e. Others
Total Cash Outflows - -
TOTAL CASH FLOWS FROM OPERATING ACTIVITIES - -

CASH FLOWS FROM INVESTING ACTIVITIES Cash Inflows a. Investment Income Receipts b. Investment Withdrawals
c. Sale of Fixed Assets
d. Others
Total Cash Inflows - -
Cash Outflows a. Investment Placements b. Purchase of Fixed Assets
c. Others
Total Cash Outflows - -
TOTAL CASH FLOWS FROM INVESTING ACTIVITIES - -

CASH FLOWS FROM FINANCING ACTIVITIES Cash Inflows a. Subordinated Loans b. Capital Contributions
c. Others
Total Cash Inflows - -
Cash Outflows a. Dividend Payments b. Subordinated Loan Payments
c. Others
Total Cash Outflows - -
TOTAL CASH FLOWS FROM FINANCING ACTIVITIES - -

ENDING CASH AND BANK BALANCE - -

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF CASH FLOWS
As of …. and As of ….

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Quarter …	Year …	Quarter …	Year …
(1)	(2)	(3)

SAK Equity
Beginning Balance
Additions:
Paid-in Capital
Current Period Comprehensive Income (Loss) - Other Additions:
a. b.
Total Additions
Deductions:
Dividend Payments
Other Deductions:
a. b.
Total Deductions
Ending SAK Balance

SAP Equity
Beginning Balance
Changes in SAK Equity
Increase (Decrease) Difference in Valuation between SAK and SAP (Increase) Decrease in Assets Not Included in AYD Ending Balance

PT XYZ
LIFE INSURANCE COMPANY
STATEMENT OF CHANGES IN EQUITY As of …. and As of ….

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Quarter …	Year …	Quarter …	Year …
(1)	(2)	(3)

Solvency Level
Permitted Assets
Liabilities (excluding Subordinated Loans) Total Solvency Level - -

Risk-Based Minimum Capital (RBMC)
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Schedule G
Schedule H
Total RBMC - -

Surplus (Deficiency) of Solvency Level Limit - - Solvency Achievement Ratio (in %) 1) #DIV/0! #DIV/0!
1) Total Solvency Level divided by Total RBMC

In the event that the Company experiences a solvency deficiency, the amount of funds needed to reach the RBC ratio 100.00% 120.00%

Period 2)	Target 3)	Realization
Year ... %	%
Q ... %	%
Q ... %	%
Q ... %	%
Q ... %	%

2) Current year period
3) Lowest target solvency level 120%

Reasons for not achieving the quarterly/current year solvency ratio target:

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
Solvency Achievement Ratio
As of …. and As of ….

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	AYD Amount	Factor	Deviation Amount
(1)	(2)	(3)	(4)

INVESTMENTS
Time Deposits and Certificates of Deposit Special Category (up to 2 billion per bank) 0.0% Other Categories, according to Bank Rating:
a. Cluster Rating 1 1.2% b. Cluster Rating 2 2.1%
c. Cluster Rating 3 3.0%
d. Cluster Rating 4 4.5% e. Cluster Rating 5 9.0%

Stocks
Including LQ 45 on the Jakarta Stock Exchange or JII 16.0% Stocks traded on the Indonesian exchange other than letter a 20.0% Stocks traded on foreign exchanges Stocks forming the main index of the main stock exchanges of Asia-Pacific and European countries that are members of the World Federation of Exchanges 20.0% Others 30.0%

Corporate Bonds and Corporate Sukuk a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%

Securities Issued by the Republic of Indonesia (RI) State 0.0% Securities Issued by States other than the Republic of Indonesia (RI) a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%

Securities Issued by Bank Indonesia 0.0% Securities Issued by Multinational Institutions 0.0%

Mutual Funds
Completely consisting of government bonds 0.0% Completely consisting of private bonds and/or money market securities (SBPU) 6.0% Completely consisting of equity securities 16.0% Mixed 1) rt

Collective Investment Contracts for Asset-Backed Securities a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%

Real Estate Investment Funds a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%

Direct Investments
Under OJK Supervision 10.0%
Not Under OJK Supervision 20.0%

Buildings with Strata Rights, or Land with Buildings Investment Results 4% or more 7.0% Investment Results 2% - 4% 15.0% Investment Results less than 2% 40.0%

Purchase of Receivables
Leasing 3.0%
Credit Cards 20.0%
Consumer Financing 8.0%
Pure Gold 3.0%

Loans Secured by Mortgage Rights Residential Property a. LTV<60% 2.8% b. 60%<LTV<80% 4.0% Other Commercial Property a. LTV<60% 5.6% b. 60%<LTV<80% 8.0% Unused Property 12.0%

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE A - ASSET MANAGEMENT FAILURE RISK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	AYD Amount	Factor	Deviation Amount
(1)	(2)	(3)	(4)

NON-INVESTMENTS
Cash and Bank 0.0%
Directly Closed Premium Receivables 8.0% Co-insurance Claim Receivables Under OJK Supervision 2.8% Not Under OJK Supervision:
a. Cluster Rating 1 2.8% b. Cluster Rating 2 4.0%
c. Cluster Rating 3 6.0%
d. Cluster Rating 4 12.0% e. Cluster Rating 5 15.0%

Reinsurance Receivables
Under OJK Supervision 2.8%
Not Under OJK Supervision:
a. Cluster Rating 1 2.8% b. Cluster Rating 2 4.0%
c. Cluster Rating 3 6.0%
d. Cluster Rating 4 12.0% e. Cluster Rating 5 15.0%

Reinsurance Assets 0.0%
Investment Receivables 2.0% Investment Income Receivables 2.0% Buildings with Strata Rights, or Land with Buildings 4.0% Total

Note:
1) For mixed mutual funds, the factor is filled with the weighted average based on the composition of underlying assets as regulated in applicable provisions. If the company does not fill in the factor, the maximum factor (10%) will be imposed.
rt = weighted average risk according to calculation LTV = loan to value, LTV is calculated based on loan balances and property market value

The amount of funds considered in Schedule A is as follows:
1) Year 2013 = 50%
2) Year 2014 = 75%
3) Year 2015 = 100%

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Up to 1 year	More than 1 year up to 3 years	More than 3 years up to 5 years	More than 5 years up to 10 years	More than 10 years	Total
(1)	(2)	(3)	(4)	(5)	(6)	(7)

ASSETS
Investments
Time Deposits and Certificates of Deposit Stocks Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia (RI) State Securities Issued by States other than the Republic of Indonesia (RI) Securities Issued by Bank Indonesia Securities Issued by Multinational Institutions Mutual Funds Collective Investment Contracts for Asset-Backed Securities Real Estate Investment Funds Direct Investments Buildings with Strata Rights or Land with Buildings for Investment Purchase of Receivables Pure Gold Loans Secured by Mortgage Rights Total Investments

Non-Investments
Cash and Bank
Directly Closed Premium Receivables Co-insurance Claim Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Policy Loans Buildings with Strata Rights or Land with Buildings for Own Use Total Non-Investments TOTAL ASSETS

LIABILITIES AND EQUITY
Liabilities
Debts
Claim Payables
Co-insurance Payables
Reinsurance Payables
Commission Payables
Tax Payables
Accrued Expenses
Other Payables
Total Debts
Technical Reserves
Premium Reserves
Reserves for Premiums Not Yet Earned Income Claim Reserves Total Technical Reserves TOTAL LIABILITIES DIFFERENCE BETWEEN LIABILITIES AND ASSETS DEVIATION (4% X (Max (Li-AYDi), 0)) - - - - - -

Note:
The amount of funds considered in Schedule B is as follows:
1) Year 2013 = 50%
2) Year 2014 = 75%
3) Year 2015 = 100%

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE B - RISK OF IMBALANCE BETWEEN ASSET AND LIABILITY PROJECTION CASH FLOWS

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	USD	SGD	JPY	GBP	DKK	FRF	HKD	EUR	IDR	Total
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)

Permitted Assets
Time Deposits and Certificates of Deposit Stocks Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia (RI) State Securities Issued by States other than the Republic of Indonesia (RI) Securities Issued by Bank Indonesia Securities Issued by Multinational Institutions Mutual Funds Collective Investment Contracts for Asset-Backed Securities Real Estate Investment Funds Direct Investments Buildings with Strata Rights or Land with Buildings for Investment Purchase of Receivables Pure Gold Loans Secured by Mortgage Rights Cash and Bank Directly Closed Premium Receivables Co-insurance Claim Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Buildings with Strata Rights or Land with Buildings for Own Use Total Permitted Assets

Liabilities
Claim Payables
Co-insurance Payables
Reinsurance Payables
Commission Payables
Tax Payables
Accrued Expenses
Other Payables
Premium Reserves
Reserves for Premiums Not Yet Earned Income Claim Reserves Total Liabilities

Total Exchange Rate (3) to (11) Total Permitted Assets in Rupiah (23 x 35) Total Liabilities in Rupiah (34 x 35) Difference Between Permitted Assets and Liabilities ( 36 - 37 ) Factor 0.3 Total Deviation in Wealth and Liabilities in Each Type of Foreign Currency

Note:
This column can be added according to the types of foreign currency present.

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE C - RISK OF IMBALANCE BETWEEN ASSET AND LIABILITY VALUES IN EACH TYPE OF FOREIGN CURRENCY

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Insurance Branch	CP	CP*	Total
(1)	(2)	(3)	(4)

Non-renewable (> 1 year)
Deviation
Term Mortality
Endowment and/or Combinations
Whole Life
Annuity
Single Premium Mortality
Health
Personal Accident
Others
Total max ((CP - CP), 0)* - - -

Renewable (0-1 year/ <1 year) (in millions of rupiah)

Insurance Branch	CAPYBMP	AR	fcp
(2)	(3)	(4)	(5)

CAPYBMP
((3) - (4)) x (5)

Insurance Branch	CK	AR	fck
(6)	(7)	(8)	(9)

CK
((7) - (8)) x (9)

Total	Deviation
(10)	(11)

(6) + (10)

Term Mortality	10%	10%
Endowment and/or Combinations	10%	10%
Whole Life	10%	10%
Annuity	10%	10%
Single Premium Mortality	10%	10%
Health	10%	10%
Personal Accident	10%	10%
Others	10%	10%

Total ((CAPYBMPi - ARi)fcpi + (CKi - ARi)fcki) - - -

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE D - INSURANCE LIABILITY RISK

Note:
CP = premium reserves according to the financial position report (balance sheet) and according to the company's actuarial calculations CP* = premium reserves calculated with the best estimate plus margin for deterioration of risk with a premium reserve adequacy confidence level of 95% (company level) CAPYBMPi = reserves for premiums not yet earned income for business line i AR = reinsurance assets CKi = claim reserves for business line i fcpi = risk factor for reserves for premiums not yet earned income for business line i fcki = risk factor for claim reserves for business line i

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Amount
(1)	(2)

CPrf
CPo
Maks((CPrf-CPo),0) - fRTB
RTB -

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE E - INTEREST RATE RISK

Note:

CPrf = premium reserves calculated with risk-free interest rates according to the calculation in PER 08 Year 2012
Cpo = premium reserves calculated with actuarial interest rates according to the calculation in PER 08 Year 2012
fRTB = interest rate ratio factor
fRTB year 2013 = 5%
fRTB year 2014 = 10%

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Reinsurer Name	Technical Reserves	Reinsurer Expenses	Deposits and/or Premiums Held at Ceding Company	Net Reinsurance Exposure ((2) - (3))	Factor	Deviation Amount ((4) x (5))
(1)	(2)	(3)	(4)	(5)	(6)

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE F - REINSURANCE RISK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Amount
(1)	(2)

General and Administrative Expenses Education and Training Expenses Operational Complexity Proxy - Deviation -

RISK-BASED MINIMUM CAPITAL
SCHEDULE G - OPERATIONAL RISK

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Description	Amount
(1)	(2)

Total PAYDI Investments
Factor Deviation 0.1%
Deviation (1x2)

PT XYZ
LIFE INSURANCE COMPANY
SOLVENCY LEVEL REPORT
RISK-BASED MINIMUM CAPITAL
SCHEDULE H - PAYDI OPERATIONAL RISK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
I. SAP WEALTH CALCULATION (in millions of rupiah)

Description	Book Balance (SAK)	Valuation Based on SAP	Difference in SAP and SAK Valuation	Assets Not Permitted	Permitted Assets (SAP Balance)
(1)	(2)	(3)	(4)	(5)	(6)

Investments
Time Deposits and Certificates of Deposit - Stocks - Corporate Bonds and Corporate Sukuk - Securities Issued by the Republic of Indonesia (RI) State - Securities Issued by States other than the Republic of Indonesia (RI) - Securities Issued by Bank Indonesia - Securities Issued by Multinational Institutions - Mutual Funds - Collective Investment Contracts for Asset-Backed Securities - Real Estate Investment Funds - Direct Investments - Buildings with Strata Rights or Land with Buildings for Investment - Purchase of Receivables for Financing Companies and/or Banks - Pure Gold - Loans Secured by Mortgage Rights - Other Investments Total Investments -

Non-Investments
Cash and Bank -
Directly Closed Premium Receivables - Co-insurance Claim Receivables - Reinsurance Receivables - Investment Receivables - Investment Income Receivables - Policy Loans - Buildings with Strata Rights or Land with Buildings for Own Use - Other Fixed Assets Other Assets Total Non-Investments - TOTAL ASSETS -

Note:
Total Investments used as the basis for calculating permitted wealth limits and investment limits on one party is the sum of investments in column (4) except for Other Investments, amounting to -

II. SAP LIABILITIES CALCULATION

Description	Book Balance (SAK)	Valuation Based on SAP	Difference in SAK and SAP Valuation
(1)	(2)	(3)	(4) = (2) - (3)

Debts -
Premium Reserves -
Reserves for Premiums Not Yet Earned Income - Claim Reserves - TOTAL LIABILITIES - - -

DIFFERENCE IN VALUATION BASED ON SAK AND SAP (Wealth sum in column 5 minus liability sum in column 5) (Transferred to line 68 of Financial Position Report) Quarter … Year … PT XYZ LIFE INSURANCE COMPANY SAP ASSET AND LIABILITY CALCULATION Non-Consolidated As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Investment Type	Details	AYD After Limits Per Investment Type and/or Foreign Investment
(1)	(2)	(3)

Domestic Placements
Time Deposits and Certificates of Deposit 101 Stocks 102 Corporate Bonds and Corporate Sukuk 103 Securities Issued by the Republic of Indonesia (RI) State 104 Securities Issued by States other than the Republic of Indonesia (RI) 105 Securities Issued by Bank Indonesia 106 Securities Issued by Multinational Institutions 107 Mutual Funds 108 Collective Investment Contracts for Asset-Backed Securities 109 Real Estate Investment Funds 110 Direct Investments 111 Buildings with Strata Rights or Land with Buildings for Investment 112 Purchase of Receivables for Financing Companies and/or Banks 113 Pure Gold 114 Loans Secured by Mortgage Rights 115 Sub Total

Foreign Placements
Stocks 102
Corporate Bonds and Corporate Sukuk 103 Securities Issued by States other than the Republic of Indonesia (RI) 104 Securities Issued by Multinational Institutions 107 Mutual Funds 108 Direct Investments 111 Sub Total Total Sub A Quarter … Year … PT XYZ LIFE INSURANCE COMPANY SAP ASSET AND LIABILITY CALCULATION SUB A - INVESTMENT PLACEMENTS NOT ON ONE PARTY As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Placements on Company (Company Name)	Investment Type	Details	AYD After Limits Per Investment Type and Foreign Investment	Assets Not Permitted	AYD
(1)	(2)	(3)	(4)	(5)	(6)

PT a. Time Deposits and Certificates of Deposit 101 b. Stocks 102
c. Corporate Bonds and Corporate Sukuk 103
d. Mutual Funds 108 e. Collective Investment Contracts for Asset-Backed Securities 109 f. Real Estate Investment Funds 110 g. Direct Investments 111 Total Placements on this Company

Total Sub B
Quarter … Year …
PT XYZ
LIFE INSURANCE COMPANY
SAP ASSET AND LIABILITY CALCULATION SUB B - INVESTMENT PLACEMENTS ON AFFILIATED PARTIES WITH THE COMPANY As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Placements on Company (Company Name)	Investment Type	Details	AYD After Limits Per Investment Type and Foreign Investment	Assets Not Permitted	AYD
(1)	(2)	(3)	(4)	(5)	(6)

Total Sub C
Quarter … Year …
PT XYZ
LIFE INSURANCE COMPANY
SAP ASSET AND LIABILITY CALCULATION SUB C - INVESTMENT PLACEMENTS ON NON-AFFILIATED PARTIES WITH THE COMPANY As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

Investment Placement Type	Placements on Company (Company Name and/or Country Name)	AYD After Limits Per Investment Type	Assets Not Permitted	AYD
(1)	(2)	(3)	(4)	(5)

Stocks …
…
…
Sub Total
Corporate Bonds and Corporate Sukuk … … … Sub Total Securities Issued by States other than the Republic of Indonesia (RI) … … … Sub Total Securities Issued by Multinational Institutions … … … Sub Total Mutual Funds … … … Sub Total Direct Investments … … … Sub Total Total Sub D Quarter … Year … PT XYZ LIFE INSURANCE COMPANY SAP ASSET AND LIABILITY CALCULATION SUB D - FOREIGN INVESTMENT PLACEMENTS As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
I. Investment Placements on Affiliated Parties with the Company

Ownership	Company Name	Ownership Relationship	Business Field	Ownership Percentage	Ownership Value
(1)	(2)	(3)	(4)	(5)

…
…
…

II. Investment Placements on Non-Affiliated Parties with the Company

Company Name	Group Name	Business Field
(1)	(2)	(3)

…
…
…

PT XYZ
LIFE INSURANCE COMPANY
SUB E - LIST OF AFFILIATED COMPANIES As of … Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)

No.	Bank Name	Cluster Rating	Book Balance	AYD	Book Balance Current (Less than one year)	Notes
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)

1 PT ………………
Deposits
Certificates of Deposit
Sub Total
2 PT ………………
Deposits
Certificates of Deposit
Sub Total
3 PT ………………
Deposits
Certificates of Deposit
Sub Total
4 PT ………………
Deposits
Certificates of Deposit
Sub Total
5 PT ………………
Deposits
Certificates of Deposit
Sub Total
Total Deposits
Total Certificates of Deposit Total

PT XYZ
DETAILS 101
TIME DEPOSITS AND CERTIFICATES OF DEPOSIT As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer/Issuer Name Category Book Value Gross AYD Book Value Gross Current (Less than one year) Notes (1) (2) (3) (4) (5) (6) (7) Total PT XYZ DETAIL 102 SHARED As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer/Issuer Name Cluster Rating Book Value Gross Difference Valuation SAK and SAP AYD Book Value Gross Current (Less than one Year) Notes (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 PT …………… Corporate Bonds Corporate Sukuk Sub Total 2 PT …………… Corporate Bonds Corporate Sukuk Sub Total 3 PT …………… Corporate Bonds Corporate Sukuk Sub Total 4 PT …………… Corporate Bonds Corporate Sukuk Sub Total 5 PT …………… Corporate Bonds Corporate Sukuk Sub Total Total Corporate Bonds Total Corporate Sukuk Total Quarter … Year … As of … PT XYZ LIFE INSURANCE COMPANY DETAIL 103 CORPORATE BONDS AND CORPORATE SUKUK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Security Name Book Value
Gross
Difference
Valuation
SAK and SAP
AYD
Book Value
Gross Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
Total
PT XYZ
DETAIL 104
SECURITIES ISSUED BY THE STATE OF THE REPUBLIC OF INDONESIA As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer / Issuing Country Cluster Rating Book Value Gross Difference Valuation SAK and SAP AYD Book Value Gross Current (Less than one year) (1) (2) (3) (4) (5) (6) (7) (8) Total PT XYZ As of … SECURITIES ISSUED BY COUNTRIES OTHER THAN THE REPUBLIC OF INDONESIA DETAIL 105 LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Security Name Book Value
Gross
Difference
Valuation
SAK and SAP
AYD
Book Value
Gross Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
Total
SECURITIES ISSUED BY BANK INDONESIA As of … PT XYZ DETAIL 106 LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Security Name Book Value
Gross
Difference
Valuation
SAK and SAP
AYD
Book Value
Gross Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
Total
SECURITIES ISSUED BY MULTINATIONAL INSTITUTIONS As of … PT XYZ DETAIL 107 LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Mutual Fund Name Investment Manager Book Value Gross AYD Book Value Gross Notes (1) (2) (3) (4) (5) (6) (7) I Fully government bonds Total I II Fully private bonds and/or money market securities Total II III Fully equity securities Total III IV Mixed Total IV Total Mutual Funds ( I+II+III+IV ) As of … PT XYZ DETAIL 108 MUTUAL FUNDS LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Issuer / Manager
Investment Cluster Rating Book Value Gross Difference Valuation SAK and SAP AYD Book Value Gross Current (Less than one Year) Notes (1) (2) (3) (4) (5) (6) (7) (8) (9) T o t a l PT XYZ DETAIL 109 ASSET-BACKED SECURITIES COLLECTIVE INVESTMENT CONTRACTS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Company Name Business Field Ownership (%) Book Value Gross Difference Valuation SAK and SAP AYD Notes (1) (2) (3) (4) (5) (6) (7) (8) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total Direct Participation As of … PT XYZ DETAIL 111 DIRECT PARTICIPATION LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Address Book Value
Gross
Valuation
Based on
SAP (Appraisal Value/NJ
OP)
Difference
Valuation
SAK and SAP
(1) (2) (3) (4) (5)
I
Investment Results more than 4% per year Sub Total I II Investment Results 2% - 4% per year Sub Total II III Investment Results less than 2% per year Sub Total III Total (I + II + III) IV Permitted Wealth (Maximum 10% of total investment) Quarter … Year … As of … PT XYZ DETAIL 112 BUILDINGS WITH STRATA RIGHTS OR LAND WITH BUILDINGS FOR INVESTMENT LIFE INSURANCE COMPANY

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Company Name
Financing/Bank Business License Book Value Gross AYD Book Value Gross Current (Less than one Year) Notes (1) (2) (3) (4) (5) (6) (7) I Leasing Total I II Credit Cards Total II III Consumer Financing Total III Total Mutual Funds ( I+II+III) PT XYZ DETAIL 113 PURCHASE OF RECEIVABLES FOR FINANCING COMPANIES AND/OR BANKS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Custodian Bank Quantity
(pieces/grams)
Book Value
Gross AYD
Book Value
Gross Current
(Less than one Year)
Notes
(1) (2) (3) (4) (5) (6) (7)
Total Gold
PT XYZ
DETAIL 114
PURE GOLD
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Debtor Name Land Certificate Number Collateral Value (Appraisal Value or NJOP) Loan Value Initial Book Value Gross AYD Book Value Gross Current (Less than one Year) (1) (2) (3) (4) (5) (6) (7) (8) I Residential Properties a. LTV<60% b. 60%<LTV<80% Sub Total I II Other Commercial Properties a. LTV<60% b. 60%<LTV<80% Sub Total II III Unused Properties Sub Total III Total (I + II + III) PT XYZ DETAIL 115 LOANS SECURED BY MORTGAGE RIGHTS As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Investments
PT XYZ
As of …
DETAIL 116
OTHER INVESTMENTS
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
DETAIL 201
(in millions of rupiah)
No. Insurance Branch Book Value Gross AYD Book Value Gross Current (Less than one year) (1) (2) (3) (4) (5) I Life Insurance Term Life Endowment and/or Combinations Whole Life Sub Total II Annuities III 1-Year Term IV Personal Accident V Health VI Others Sub Total Total Receivables Breakdown by Age (in millions of rupiah) No. Insurance Branch Less than or equal to 2 months More than 2 months up to 3 months More than 3 months (1) (2) (3) (4) (5) I Life Insurance Term Life Endowment and/or Combinations Whole Life Sub Total II Annuities III 1-Year Term IV Personal Accident V Health VI Others Sub Total Total PT XYZ As of … DIRECT WRITING PREMIUM RECEIVABLES LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Debtor Cluster Rating Book Value Gross AYD Book Value Gross Current (Less than one Year) (1) (2) (3) (4) (5) (6) (7) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II Receivables Breakdown by Age (in millions of rupiah) No. Debtor Name Less than or equal to 2 months More than 2 months up to 3 months More than 3 months (1) (2) (3) (4) (5) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II PT XYZ DETAIL 202 REINSURANCE RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Debtor Cluster Rating Book Value Gross AYD Book Value Gross Current (Less than one Year) (1) (2) (3) (4) (5) (6) (7) A Reinsurance Premium Receivables Inward and Claim Recovery I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II B Reinsurance Assets III Under OJK Supervision Sub Total III IV Not Under OJK Supervision Sub Total IV Total I + II + III + IV Receivables Breakdown by Age (in millions of rupiah) No. Debtor Name Less than or equal to 2 months More than 2 months up to 3 months More than 3 months (1) (2) (3) (4) (5) A Reinsurance Premium Receivables inward and claim recovery I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II B Reinsurance Assets III Under OJK Supervision Sub Total III IV Not Under OJK Supervision Sub Total IV Total I + II + III + IV PT XYZ DETAIL 203 REINSURANCE RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Investment Type Book Value
Gross AYD
Book Value
Gross Current
(Less than one Year)
(1) (2) (3) (4) (5)
1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the State of RI 5 Securities issued by countries other than the State of RI 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real Estate Investment Funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total Receivables Breakdown by Age (in millions of rupiah) No. Investment Type Less than or equal to 1 month More than 1 month up to 3 months More than 3 months (1) (2) (3) (4) (5) 1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the State of RI 5 Securities issued by countries other than the State of RI 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real Estate Investment Funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total PT XYZ DETAIL 204 INVESTMENT RECEIVABLES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Investment Type Book Value
Gross AYD
Book Value
Gross Current
(Less than one Year)
(1) (2) (3) (4) (5)
1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the State of RI 5 Securities issued by countries other than the State of RI 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real Estate Investment Funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total Receivables Breakdown by Age (in millions of rupiah) No. Investment Type Less than or equal to 1 month More than 1 month up to 3 months More than 3 months (1) (2) (3) (4) (5) 1 Time Deposits & Certificates of Deposit 2 Stocks 3 Corporate Bonds & Corporate Sukuk 4 Securities issued by the State of RI 5 Securities issued by countries other than the State of RI 6 Securities issued by Bank Indonesia 7 Securities issued by Multinational Institutions 8 Mutual funds 9 Asset-Backed Securities Collective Investment Contracts 10 Real Estate Investment Funds 11 Direct Participation 12 Buildings with Strata Rights or Land with Buildings for investment 13 Receivables Purchase 14 Pure Gold 15 Loans secured by mortgage rights 16 Other Investments Total PT XYZ DETAIL 205 INVESTMENT INCOME RECEIVABLES LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description
Cash Value
Policies
Collateralized
Book Value
Gross AYD
Book Value
Gross Current
(Less than one year)
(1) (2) (3) (4) (5) (6)
I. Beginning Loan Balance :
a. APL (Automatic Policy Loans) b. Non APL … … …
II. Loans During the Period :
a. APL (Automatic Policy Loans) b. Non APL … … … Total - PT XYZ DETAIL 206 POLICY LOANS LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Address Location Book Value Gross Valuation Based on SAP (Appraisal Value/NJ OP) Difference Valuation SAK and SAP (1) (2) (3) (4) (5) I Total II Permitted Wealth (Maximum 15% of Own Capital current year) Quarter … Year … PT XYZ As of … BUILDINGS WITH STRATA RIGHTS OR DETAIL 207 LAND WITH BUILDINGS FOR OWN USE LIFE INSURANCE COMPANY

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Fixed Assets
As of …
PT XYZ
DETAIL 208
OTHER FIXED ASSETS
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Assets
As of …
PT XYZ
DETAIL 209
OTHER ASSETS
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Insurance Branch
Date
Claim
Settled
Retention
Own
Expense
Reinsurer
Total
Book Value
Gross Current
(Less than one year)
(1) (2) (3) (4) (5) (6) (7)
I Life Insurance
Term Life
Endowment and/or Combinations
Whole Life
Sub Total I
II Annuities
III 1-Year Term
IV Personal Accident
V Health
VI Others
Sub Total II+III+IV+V+VI
Grand Total
Note:
From the total Self-Retention Claim Liabilities above, those with an age of more than 30 days amount to PT XYZ DETAIL 301 CLAIM LIABILITIES As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Creditor Name Cluster Rating Total Book Value Gross Current (Less than dr one year) (1) (2) (3) (4) (5) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II DETAIL 302 REINSURANCE PAYABLES As of … PT XYZ LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Creditor Name Cluster Rating Total Current (Less than one year) (1) (2) (3) (4) (5) I Under OJK Supervision Sub Total I II Not Under OJK Supervision Sub Total II Total I + II DETAIL 303 REINSURANCE PAYABLES As of … PT XYZ LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Insurance Branch Total
Book Value
Gross Current
(Less than one year)
(1) (2) (3) (4)
I Life Insurance
Term Life
Endowment and/or Combinations
Whole Life
Sub Total I
II Annuities
III 1-Year Term
IV Personal Accident
V Health
VI Others
Sub Total II+III+IV+V+VI
Total
PT XYZ
DETAIL 304
COMMISSION PAYABLES
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Expenses to be Paid
PT XYZ
DETAIL 305
EXPENSES TO BE PAID
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Liabilities
DETAIL 306
OTHER LIABILITIES
As of …
PT XYZ
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No.
Risk
Reserve
Accumulated
Fund
Reserve
Risk
Reserve
Accumulated
Fund
Reserve
Risk
Reserve
Accumulated
Fund
(1) (2) (6) (7) (8)
A Life Insurance

Term Life
Endowment and/or Combinations
Whole Life
Others
Sub Total A
B Annuities
Sub Total B
Total Premium Reserves
PT XYZ
LIFE INSURANCE COMPANY
DETAIL 401
PREMIUM RESERVES
As of …
Quarter …
Year …
(Previous
Period)
Total
(3) + (4) + (5)
Premium Reserve
Policies
Due
< 1 year
Quarter … Year …
(3) (4) (5)
Insurance Branch
Premium Reserve Policies
Single Premium
Premium Reserve Policies
Paid-up
Premium Reserve Policies
Regular (Installments)

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Quarter .../Year …
No. Insurance Branch
Premium Reserve Policies
Single Premium
Premium Reserve Policies
Paid-up
Premium Reserve
Policies Regular
(Installments)
Total
(3) + (4) + (5)
Premium Reserve Policies
Due
< 1 year
Quarter
…/Year ...
(Previous
Period)
(1) (2) (3) (4) (5) (6) (7) (8) I Reserve for Premiums Not Yet Earned Revenue 1 1-Year Term 2 Personal Accident 3 Health 4 Total CAPYBMP II Reserve for Risks Not Yet Incurred 5 1-Year Term 6 Personal Accident 7 Health 8 Total CARYBD Maks (CAPYBMP,CARYBD) PT XYZ DETAIL 402 RESERVES FOR PREMIUMS NOT YET EARNED REVENUE As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Claim Reserve IBNR Claim Reserve Quarter … / Year … No. Insurance Branch Total Claims In Process Claims Expense Own Total IBNR Claims IBNR Claims Expense Own Total Claim Reserve Claim Res. < 1 year Quarter … / Year … (Previous Period) (1) (2) (3) (4) (5) (6) (7) (8) (9)

1-Year Term
Personal Accident
Health
Total
DETAIL 403
CLAIM RESERVES
As of …
PT XYZ
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Description
Death
Term
Endowment and/or
Combinations
Whole
Life Annuity 1-Year
Term
Personal
Accident Health Others Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 New Production Premium 2 a. Individual Insurance 3 - Single Premium 4 - Installment Premium (Annual, Semi-annual, etc) 5 Total Individual New Production Premium 6 b. Group Insurance 7 Total New Production Premium 8 Renewal Premium 9 a. Individual Insurance 10 b. Group Insurance 11 Total Renewal Premium 12 Total Premium Revenue 13 Reinsurance Premium 14 Decrease (Increase) CAPYBMP 15 a. Decrease (Increase) CAPYBMP (Gross ) 16 (1) Premium Reserve current year/quarter 17 (2) Premium Reserve previous year/quarter 18 b. Decrease (Increase) Reinsurance Assets for CAPYBMP 19 (1) Reinsurance Assets for CAPYBMP current year/quarter 20 (2) Reinsurance Assets for CAPYBMP previous year/quarter 21 Total Decrease (Increase) CAPYBMP 22 Total Net Premium Revenue (12 - 13 + 21) DETAIL 501 PREMIUM REVENUE PT XYZ As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
No. Investment Type Unrealized
Gain (Loss)
Total Investment
Income
Notes
(Type of Income)
Cash Received Receivables
(1) (2) (3) (4) (5) (6) (7)
I Investment Placements with Non-Affiliates

Time Deposits & Certificates of Deposit
Stocks
Corporate Bonds & Corporate Sukuk
Securities issued by the State of RI
Securities issued by countries
other than the State of RI
Securities issued by Bank Indonesia
Securities issued by Multinational
Institutions
Mutual funds
Asset-Backed Securities Collective Investment Contracts
Real Estate Investment Funds
Direct Participation
Buildings with Strata Rights or Land
with Buildings for investment
Receivables Purchase for Financing
Companies and/or Banks
Pure Gold
Loans secured by mortgage rights
Other Investments
Sub Total
II Investment Placements with Affiliates
Time Deposits & Certificates of Deposit
Stocks
Corporate Bonds & Corporate Sukuk
Securities issued by the State of RI
Securities issued by countries
other than the State of RI
Securities issued by Bank Indonesia
Securities issued by Multinational
Institutions
Mutual funds
Asset-Backed Securities Collective Investment Contracts
Real Estate Investment Funds
Direct Participation
Buildings with Strata Rights or Land
with Buildings for investment
Receivables Purchase for Financing
Companies and/or Banks
Pure Gold
Loans secured by mortgage rights
Other Investments
Sub Total
Gross Investment Income (17 + 34))
Investment Expenses
Net Investment Income (35 - 36)
Income After Tax
LIFE INSURANCE COMPANY
PT XYZ
DETAIL 502
INVESTMENT INCOME
As of …
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(In millions of rupiah)
No. Description Amount
(1) (2) (3)
Total Other Investments
PT XYZ
DETAIL 503
OTHER INCOME
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. DESCRIPTION Death Endowment Whole Life Death Accident Total Term and/or Life Annuity Single Premium Health Other Combined (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 1 Claims and Benefits Paid 2 a. End of Contract (Matured) 3 b. Death Claims 4 c. Cash Value 5 d. Others 6 Total Claims and Benefits Paid (2 + 3 + 4 + 5) 7 Reinsurance Claims 8 Increase (Decrease) in Premium Reserves 9 a. Increase (Decrease) in Premium Reserves (Gross) 10 (1) Current year/quarter premium reserves 11 (2) Previous year/quarter premium reserves 12 b. Increase (Decrease) in Reinsurance Assets for Premium Reserves 13 (1) Current year/quarter reinsurance assets for premium reserves 14 (2) Previous year/quarter reinsurance assets for premium reserves 15 Total Increase (Decrease) in Premium Reserves (9 - 12) 16 Increase (Decrease) in Claim Reserves 17 a. Increase (Decrease) in Claim Reserves (Gross) 18 (1) Current year/quarter claim reserves 19 (2) Previous year/quarter claim reserves 20 b. Increase (Decrease) in Reinsurance Assets for Claim Reserves 21 (1) Current year/quarter reinsurance assets for claim reserves 22 (2) Previous year/quarter reinsurance assets for claim reserves 23 Total Increase (Decrease) in Claim Reserves (17 - 20) 24 Total Insurance Expenses and Benefits (6 - 7 + 15 + 23) 25 Acquisition Costs 26 a. Commission Expenses - First Year 27 b. Commission Expenses - Subsequent Years 28 c. Commission Expenses - Overriding 29 d. Other Expenses 30 Total Acquisition Costs 31 Total Insurance Expenses (24 + 30) PT XYZ DETAILS 504 INSURANCE EXPENSES Life Insurance Branch As of … LIFE INSURANCE COMPANY Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. DESCRIPTION Total
(1) (2) (3)
I. Other Income
Sub Total I
II. Other Expenses
Sub Total II
Total I - II -
PT XYZ
DETAILS 505
OTHER INCOME (EXPENSES)
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. DESCRIPTION Total
(1) (2) (3)

Foreign currency translation differences
Financial assets available for sale
Revaluation surplus of fixed assets
Share of other comprehensive income of associates
…
…
…
Total Comprehensive Income -
PT XYZ
DETAILS 506
OTHER COMPREHENSIVE INCOME
As of …
LIFE INSURANCE COMPANY
Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. DESCRIPTION Quarter…
Year …
Quarter…
Year …
(1) (2) (3) (4)
1 ASSETS
2 Investments
3 Time Deposits and Certificates of Deposit 4 Stocks 5 Corporate Bonds and Corporate Sukuk 6 Securities Issued by the Indonesian Government 7 Securities Issued by Governments Other than the Indonesian Government 8 Securities Issued by Bank Indonesia 9 Securities Issued by Multilateral Institutions 10 Mutual Funds 11 Collective Investment Contracts for Asset-Backed Securities 12 Real Estate Investment Funds 13 Buildings with Strata Rights or Land with Buildings for Investment 14 Purchase of Receivables for Financing Companies and/or Banks 15 Pure Gold 16 Loans Secured by Mortgage Rights 17 Other Investments 18 Total Investments 19 Non-Investments 20 Cash and Banks 21 Direct Written Premium Receivables 22 Co-insurance Claim Receivables 23 Reinsurance Receivables 24 Investment Receivables 25 Policy Loans 26 Investment Income Receivables 27 Other Current Assets Total Non-Investments 28 TOTAL CURRENT ASSETS 29 LIABILITIES 30 Liabilities 31 Technical Reserves 32 Premium Reserves 33 Reserves for Premiums Not Yet Earned Income 34 Claim Reserves 35 Total Technical Reserves 36 Payables 37 Claim Payables 38 Co-insurance Payables 39 Reinsurance Payables 40 Commission Payables 41 Tax Payables 42 Accrued Expenses 43 Other Payables 44 Total Payables 45 TOTAL CURRENT LIABILITIES PT XYZ DETAILS 601 CURRENT ASSETS AND CURRENT LIABILITIES As of … and As of … LIFE INSURANCE COMPANY

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
DESCRIPTION Details Quarter …
Year …
Quarter …
Year …
(1) (2) (3) (4)
ASSETS
Investments
Time Deposits & Certificates of Deposit 1101 Stocks 1102 Corporate Bonds & Corporate Sukuk 1103 Securities issued by the Indonesian Government 1104 Securities issued by Governments other than the Indonesian Government 1105 Securities issued by Bank Indonesia 1106 Securities issued by Multilateral Institutions 1107 Mutual Funds 1108 Collective Investment Contracts for Asset-Backed Securities 1109 Pure Gold 1110 Total Investments Non-Investments Cash and Banks Direct Written Premium Receivables Investment Income Receivables Other Assets Total Non-Investments TOTAL ASSETS LIABILITIES Liabilities Payables Claim Payables Commission Payables Other Payables Total Payables Premium Reserves 1401 TOTAL LIABILITIES PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS BALANCE SHEET As of …. and As of ….

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
DESCRIPTION
Quarter …
Year …
Quarter …
Year …
(1) (2) (3)
Income
Premium Income
Investment Income
Total Income
Expenses
Unit Redemption Claims
Acquisition Costs
Mortality Costs
Management Costs
General and Administrative Expenses Other Expenses Total Expenses Increase (Decrease) in Asset Value PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS INCOME STATEMENT For the Period Ending On Date … and Date …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
Description
Quarter …
Year …
Quarter …
Year …
(1) (2) (3)
Schedule A
Schedule B
Schedule C
Total MMBR - -
As of …. and As of ….
PT XYZ
INVESTMENT-LINKED INSURANCE PRODUCTS Minimum Risk-Based Capital

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
DESCRIPTION
Assets
Counted
Deviation
Factor
Total
(1) (2) (3) (4)
INVESTMENTS
Time Deposits and Certificates of Deposit Special Category (up to 2 billion per bank) 0.0% Other Categories, according to Bank Rating:
a. Cluster Rating 1 1.2% b. Cluster Rating 2 2.1%
c. Cluster Rating 3 3.0%
d. Cluster Rating 4 4.5% e. Cluster Rating 5 9.0% Stocks Including LQ 45 on the Jakarta Stock Exchange, or equivalent 16.0% Stocks traded on Indonesian exchanges 20.0% Stocks traded on foreign exchanges:
Stocks constituting the main index of the main stock exchange of Asia-Pacific and European countries members of the World Federation of Exchanges 20.0% Others 30.0% Corporate Bonds and Corporate Sukuk a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%
Securities Issued by the Indonesian Government 0.0% Securities Issued by Governments Other than the Indonesian Government a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%
Securities Issued by Bank Indonesia 0.0% Securities Issued by Multilateral Institutions 0.0% Mutual Funds Entirely consisting of government bonds 0.0% Entirely consisting of private bonds and/or money market securities (SBPU) 6.0% Entirely consisting of equity securities 16.0% Mixed 1) rt Collective Investment Contracts for Asset-Backed Securities a. Cluster Rating 1 1.6% b. Cluster Rating 2 2.8%
c. Cluster Rating 3 4.0%
d. Cluster Rating 4 6.0%
Pure Gold 3.0%
NON-INVESTMENTS
Cash and Banks 0.0%
Direct Written Premium Receivables 8.0% Investment Income Receivables 2.0% Total PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS SOLVENCY LEVEL REPORT MINIMUM RISK-BASED CAPITAL
SCHEDULE A - ASSET MANAGEMENT FAILURE RISK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
DESCRIPTION Total Deviation
Factor
Total
(1) (2) (3) (4)
Premium Reserves 0.01 -
PT XYZ
INVESTMENT-LINKED INSURANCE PRODUCTS SOLVENCY LEVEL REPORT MINIMUM RISK-BASED CAPITAL
SCHEDULE B - ASSET AND LIABILITY CASH FLOW PROJECTION IMBALANCE RISK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
Description USD SGD JPY GBP DKK FRF HKD EUR IDR Total (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) Countable Assets Time Deposits & Certificates of Deposit Stocks Corporate Bonds & Corporate Sukuk Securities issued by the Indonesian Government Securities issued by Governments other than the Indonesian Government Securities issued by Bank Indonesia Securities issued by Multilateral Institutions Mutual Funds Collective Investment Contracts for Asset-Backed Securities Pure Gold Cash and Banks Direct Written Premium Receivables Investment Income Receivables Total Countable Assets Liabilities Claim Payables Commission Payables Other Payables Premium Reserves Total Liabilities Exchange Rate Total (3) to (11) Total Countable Assets in Rupiah Total Liabilities in Rupiah Difference between Countable Assets and Liabilities Factor 0.3 Total Deviation in Assets and Liabilities in Each Foreign Currency Type PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS SOLVENCY LEVEL REPORT MINIMUM RISK-BASED CAPITAL
SCHEDULE C - ASSET AND LIABILITY VALUE IMBALANCE RISK IN EACH FOREIGN CURRENCY TYPE

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
Investment Placement Type
Placement On
Company (Name
Company and/or
Country Name)
Countable Assets After
Limits Per
Investment Type
Countable Assets Not
Countable Assets
Countable Assets
(1) (2) (3) (4) (5)
Stocks …
…
…
Sub Total
Corporate Bonds and
Corporate Sukuk …
…
…
Sub Total
Securities issued by governments other than the Indonesian Government … … … Sub Total Securities issued by Multilateral Institutions … … … Sub Total Mutual Funds … … … Sub Total Total Placements Abroad Quarter … Year … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS SAP ASSET AND LIABILITY CALCULATION SUB D - FOREIGN INVESTMENT PLACEMENTS As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Bank Name Cluster Rating Book Balance Countable Assets (PAYDI Guarantee) Book Balance Current (Less than one year) Description (1) (2) (3) (4) (5) (6) (7) (8) 1 PT …………… Deposits Certificates of Deposit Sub Total 2 PT …………… Deposits Certificates of Deposit Sub Total 3 PT …………… Deposits Certificates of Deposit Sub Total 4 PT …………… Deposits Certificates of Deposit Sub Total 5 PT …………… Deposits Certificates of Deposit Sub Total Total Deposits Total Certificates of Deposit Grand Total Quarter … Year … As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1101 TIME DEPOSITS AND CERTIFICATES OF DEPOSIT

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Issuer / Issuer Name Category Book Balance Countable Assets (PAYDI Guarantee) Countable Assets (PAYDI Guarantee) Description (1) (2) (3) (4) (5) (6) (7) Total Quarter … Year … As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1102 STOCKS

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Issuer / Issuer Name Rating Book Balance Valuation Difference SAK and SAP Countable Assets (PAYDI Guarantee) Book Balance Current (Less than one Year) Description (1) (2) (3) (4) (5) (6) (7) (8) 1 PT …………… Corporate Bonds Corporate Sukuk Sub Total 2 PT …………… Corporate Bonds Corporate Sukuk Sub Total 3 PT …………… Corporate Bonds Corporate Sukuk Sub Total 4 PT …………… Corporate Bonds Corporate Sukuk Sub Total 5 PT …………… Corporate Bonds Corporate Sukuk Sub Total Total Corporate Bonds Total Corporate Sukuk Total Quarter … Year … As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1103 CORPORATE BONDS AND CORPORATE SUKUK

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Security Name Book Balance
Valuation Difference
SAK and SAP
Countable Assets
(PAYDI
Guarantee)
Countable Assets
(PAYDI
Guarantee)
(1) (2) (3) (4) (5) (6)
Total
Quarter … Year …
As of …
PT XYZ
INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1104 SECURITIES ISSUED BY THE REPUBLIC OF INDONESIA GOVERNMENT

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Issuer / Issuing Country Cluster Rating Book Balance Countable Assets (PAYDI Guarantee) Countable Assets (PAYDI Guarantee) Book Balance Current (Less than one year) (1) (2) (3) (4) (5) (6) (7) (8) Total Quarter … Year … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS As of … SECURITIES ISSUED BY GOVERNMENTS OTHER THAN THE REPUBLIC OF INDONESIA DETAILS 1105

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Security Name Book Balance
Valuation Difference
SAK and SAP
Countable Assets
(PAYDI
Guarantee)
Countable Assets
(PAYDI
Guarantee)
(1) (2) (3) (4) (5) (6)
Total
Quarter … Year …
SECURITIES ISSUED BY BANK INDONESIA As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1106

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Security Name Book Balance
Valuation Difference
SAK and SAP
Countable Assets
(PAYDI
Guarantee)
Countable Assets
(PAYDI
Guarantee)
(1) (2) (3) (4) (5) (6)
Total
Quarter … Year …
SECURITIES ISSUED BY MULTILATERAL INSTITUTIONS As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1107

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Mutual Fund Name Investment Manager Book Balance Countable Assets (PAYDI Guarantee) Countable Assets (PAYDI Guarantee) Description (1) (2) (3) (4) (5) (6) (7) I Entirely government bonds Total I II Entirely private bonds and/or money market securities Total II III Entirely equity securities Total III IV Mixed Total IV Total Mutual Funds (I+II+III+IV) Quarter … Year … As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1108 MUTUAL FUNDS

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Issuer / Manager
Investment Cluster Rating Book Balance Countable Assets (PAYDI Guarantee) Countable Assets (PAYDI Guarantee) Book Balance Current (Less than one Year) Description (1) (2) (3) (4) (5) (6) (7) (8) (9) Total Quarter … Year … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1109 COLLECTIVE INVESTMENT CONTRACTS FOR ASSET-BACKED SECURITIES As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No. Account
Code Bank Name Custodian Quantity (shares/units) Book Balance Countable Assets (PAYDI Guarantee) Book Balance Current (Less than one Year) (1) (2) (3) (4) (5) (6) (7) Total Gold Quarter … Year … As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1110 PURE GOLD

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
No.
Risk
Reserves
Accumulated
Fund
Reserves
Risk
Reserves
Accumulated
Fund
Reserves
Risk
Reserves
Accumulated
Fund
Reserves
(1) (2) (6) (7) (8)
A Life Insurance

Term Life (Term Life)
Endowment and/or Combined
Whole Life (Whole Life)
Others
Sub Total A
B Annuities
Sub Total B
Total Premium Reserves
Quarter …
Year ...
(Period previous)
(3) (4) (5)
Insurance Branch
Single Premium Policy Reserves
Paid-up Policy Reserves
Regular Policy Reserves (Installments) Total (3) + (4) + (5) Premium Reserves for Policies Mature < 1 year Quarter … Year … As of … PT XYZ INVESTMENT-LINKED INSURANCE PRODUCTS DETAILS 1401 PREMIUM RESERVES

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
DESCRIPTION Details
SAK Balance SAP Balance SAK Balance SAP Balance (1) (2) (3) (4) (5) (6) ASSETS Investments Time Deposits and Certificates of Deposit 101,1101 Stocks 102,1102 Corporate Bonds and Corporate Sukuk 103,1103 Securities Issued by the Indonesian Government 104,1104 Securities Issued by Governments Other than the Indonesian Government 105,1105 Securities Issued by Bank Indonesia 106,1106 Securities Issued by Multilateral Institutions 107,1107 Mutual Funds 108,1108 Collective Investment Contracts for Asset-Backed Securities 109,1109 Real Estate Investment Funds 110 Direct Participation 111 Buildings with Strata Rights or Land with Buildings for Investment 112 Purchase of Receivables for Financing Companies and/or Banks 113 Pure Gold 114,111 Loans Secured by Mortgage Rights 115 Other Investments 116 Total Investments Non-Investments Cash and Banks Direct Written Premium Receivables 201 Co-insurance Claim Receivables 202 Reinsurance Receivables 203 Investment Receivables 204 Investment Income Receivables 205 Policy Loans 206 Buildings with Strata Rights or Land with Buildings for Personal Use 207 Other Fixed Assets 208 Other Assets 209 Total Non-Investments TOTAL ASSETS LIABILITIES AND EQUITY Liabilities Payables Claim Payables 301 Co-insurance Payables 302 Reinsurance Payables 303 Commission Payables 304 Tax Payables Accrued Expenses 305 Other Payables 306 Total Payables Technical Reserves Premium Reserves 401 Reserves for Premiums Not Yet Earned Income 402 Claim Reserves 403 Total Technical Reserves Total Liabilities Subordinated Loans Equity Paid-in Capital Share Premium Retained Earnings Other Equity Components Valuation Difference Based on SAK & SAP Assets Not Included in Countable Assets Total Equity TOTAL LIABILITIES AND EQUITY Quarter … Year … Quarter … Year … PT. XYZ CONSOLIDATED BALANCE SHEET Non-Consolidated As of …. and As of ….

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
DESCRIPTION Quarter …
Year…
Quarter …
Year…
(1) (2) (3)
INCOME
Premium Income
Reinsurance Premiums
Decrease (Increase) in CAPYBMP
Total Net Premium Income
Investment Income
Fees from DPLK/Other Management Services Other Income Total Income EXPENSES Insurance Expenses Claims and Benefits a. Claims and Benefits Paid b. Reinsurance Claims
c. Increase (Decrease) in Premium Reserves
d. Increase (Decrease) in Claim Reserves Total Claims and Benefits Expenses Acquisition Costs a. Commission Expenses - First Year b. Commission Expenses - Subsequent Years
c. Commission Expenses - Overriding
d. Other Expenses
Total Acquisition Costs
Business Expenses:
a. Marketing Expenses b. Other General and Administrative Expenses:

Employee and Executive Expenses
Education and Training Expenses
Others
Other Income (Expenses)
Total Expenses
INCOME (LOSS) BEFORE TAX
Income Tax
INCOME AFTER TAX
OTHER COMPREHENSIVE INCOME
TOTAL COMPREHENSIVE INCOME (LOSS) PT. XYZ CONSOLIDATED COMPREHENSIVE INCOME STATEMENT For the Period Ending On Date … and Date …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
(in millions of rupiah)
Investment Placement Type
Placement On
Company (Name
Company and/or
Country Name)
Countable Assets After
Limits Per
Investment Type
Countable Assets Not
Allowed
Countable Assets
(1) (2) (3) (4) (5)
Stocks …
…
…
Sub Total
Corporate Bonds and
Corporate Sukuk …
…
…
Sub Total
Securities issued by governments other than the Indonesian Government … … … Sub Total In the event the Company experiences a solvency deficiency, the amount of funds needed to … reach the RBC ratio … … Sub Total Mutual Funds … … … Sub Total Sub Total Direct Participation … … … Sub Total Total Placements Abroad PT. XYZ SAP ASSET AND LIABILITY CALCULATION CONSOLIDATED SUB D - FOREIGN INVESTMENT PLACEMENTS As of … Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Description
Quarter …
Year…
Quarter …
Year…
(1) (2) (3)
Solvency Level
Countable Assets
Liabilities (excluding Subordinated Loans) Total Solvency Level - - Minimum Risk-Based Capital (MMBR)
Schedule A
Schedule B
Schedule C
Schedule D
Schedule E
Schedule F
Schedule G
Schedule H
Total MMBR - -
Surplus (Deficiency) of Solvency Level Limit - - Solvency Achievement Ratio (in %) 1) #DIV/0! #DIV/0! 1)Total Solvency Level divided by Total MMBR In the event the Company experiences a solvency deficiency, the amount of funds needed to reach the RBC ratio 100.00% 120.00% Period 2) Target 3) Realization Year ... % % Q ... % % Q ... % % Q ... % % Q ... % % 2)Current year period 3)Minimum solvency level target 120% Reason for not achieving the solvency ratio target for the current quarter/year :
PT. XYZ
CONSOLIDATED SOLVENCY LEVEL REPORT Solvency Achievement Ratio As of …. and As of …. Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
1. Summary of Guarantee Fund Development
No. DESCRIPTION Total
1. Beginning Balance of Guarantee Fund
2. New Guarantee Fund Placements
3. a. Guarantee Fund in the Form of Deposits
4. b. Guarantee Fund in the Form of SUN/Other Securities
Issued by the Government (SBN)
5. Total New Guarantee Fund Placements (3 + 4)
6. Guarantee Fund Withdrawals
7. a. Guarantee Fund in the Form of Deposits
8. b. Guarantee Fund in the Form of SUN/Other Securities
Issued by the Government (SBN)
9. Total Guarantee Fund Withdrawals (7 + 8)
10. Ending Balance of Guarantee Fund (1 + 5 – 9)
2. Annual Guarantee Fund Adequacy Calculation
No. DESCRIPTION Total
1 Minimum required paid-in capital 2 Total Non-PAYDI Premium Reserves 3 Total PAYDI Premium Reserves 4 Total CAPYBMP 5 Minimum Guarantee Fund Limit I (20% x 1) 6 Minimum Guarantee Fund Limit II (2% x 3) + (5% x (2 + 4)) 7 Minimum Guarantee Fund Limit Used (The greater of 5 and 6) 8 Guarantee Fund Owned 9 Surplus (Deficiency) of Guarantee Fund (7 - 6) Quarter … Year … PT. XYZ GUARANTEE FUND REPORT Summary of Guarantee Fund Development and Guarantee Fund Adequacy Calculation As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
A. Deposits
No. Bank Name Custodian Currency Bill Number Amount Exchange Rate 1) Amount in Rupiah Date Issuance / Last Rollover Maturity Date 1 … 2 … 3 … 4 … 5 … Total Deposits - B. Bonds or Other Securities Issued by the Government (SBN) No. Bank Name Custodian Series Number Currency Nominal Value Exchange Rate 1) Nominal Value in Rupiah Maturity Date 1 … 2 … 3 … 4 … 5 … 6 … 7 … 8 … Total SBN - Notes:
1) 1 USD = Rp ..... (Using Bank Indonesia's Mid Rate as of the Report Date)
PT. XYZ
GUARANTEE FUND REPORT
Details of Final Guarantee Fund Position As of … Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
(ratio in percentage)
No. Description Quarter …
Year …
Quarter …
Year …
1 Liquidity Ratio a. Current Assets b. Current Liabilities
c. Ratio (a : b)
2 Investment Sufficiency Ratio a. Investments + Cash & Bank (See SAP Balance Sheet) b. Technical Reserves of Own Retention
c. Claims Payable of Own Retention + Other Payables to Insured
d. Ratio (a : (b + c))
3 Ratio of Investment Income to Net Premium Income a. Investment Income b. Net Premium Income
c. Ratio (a : b)
4 Ratio of Claims Expense, Operating Expense, and Commission a. Net Claims Expense b. Operating Expense
c. Net Commission
d. Net Premium Income e. Ratio a : d (Ratio I) f. Ratio b : d (Ratio II) g. Ratio c : d (Ratio III) h. Ratio I + Ratio II + Ratio III PT.XYZ Ratio of Financial Health Level Other Than MMBR As of … and As of …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
I. Education and Training Costs (in millions of rupiah)
Budget Realization Percentage
(1) (2) (3) (4) (5) = (4) : (3) Total Notes:
Column (3) is filled with the budget for education and training costs for one year Column (4) is filled with the cumulative realization of education and training costs up to the reporting period
II. Education and Training Ratio
No. Budget Realization
(1) (3) (4)
1 Employee, Board of Directors, and Board of Commissioners Costs 2 Education and Training Costs (Diklat) a. Employee Training b. Board of Directors Training
c. Board of Commissioners Training
3 Total Training Costs (a + b + c) 4 Ratio of Training Costs to Employee, Board of Directors, and Board of Commissioners Costs (3 : 1) #DIV/0! #DIV/0! Description (2) PT.XYZ Education and Training Ratio As of … NO. Description Training Costs Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total Rupiah Foreign Currency 3) Total ≤ 1 year #DIV/0! #DIV/0! 1 year < age < 5 years #DIV/0! #DIV/0! 5 years ≤ age < 10 years #DIV/0! #DIV/0! ≥ 10 years #DIV/0! #DIV/0! Total (in percentage) Rupiah Foreign Currency Total Ratio of Current Assets to Non-Current Assets #DIV/0! #DIV/0! Ratio of Current Liabilities to Non-Current Liabilities #DIV/0! #DIV/0! Notes:
1) In millions of rupiah
2) In percentage
3) Already converted to Rupiah currency
Current assets/liabilities are assets/liabilities with an age of less than 1 year up to 1 year Non-current assets/liabilities are assets/liabilities with an age of more than 1 year Description PT.XYZ RECAPITULATION OF ASSETS AND LIABILITIES BASED ON CURRENCY AND MATURITY DATE As of … Age Assets 1) Liabilities 1) Ratio of Assets to Liabilities 2) Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
(in millions of rupiah)
Description Direct
Marketing Agent Broker Bancassurance Affinity Telemarketing Others Total Gross Premium a. Direct Written Premium b. Indirect Written Premium
c. Commission Paid
Total Gross Premium - - - - - - - - Claims Expense a. Gross Claims b. Reinsurance Claims Total Claims Expense - - - - - - - - PT. XYZ DETAILS OF PREMIUM INCOME AND CLAIMS EXPENSE BASED ON DISTRIBUTION CHANNEL As of … Quarter … Year …

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
GUIDELINES FOR PREPARING FINANCIAL REPORTS FOR LIFE INSURANCE COMPANIES AND INSURANCE PRODUCTS LINKED WITH INVESTMENT
I. GENERAL

These financial reports are prepared specifically for the supervision and regulation of the insurance business. Therefore, the form, content, and structure of the financial reports are made in accordance with applicable legislation in the insurance business field (Statutory Accounting Practices/SAP) as regulated in Minister of Finance Regulation Number 53 of 2012 and its implementing regulations.
The content and structure of the Financial Reports of Life Insurance Companies marketing Investment-Linked Insurance Products are as follows:
A. Primary Financial Reports consisting of:
1) Life Insurance Company Financial Position Report
2) Life Insurance Company Comprehensive Income Statement
3) Life Insurance Company Cash Flow Statement
4) Life Insurance Company Equity Change Report
5) Life Insurance Company Solvency Level Report :
a) Solvency Achievement Ratio b) Risk-Based Minimum Capital  Schedule A - Asset Management Failure Risk  Schedule B - Imbalance Risk Between Asset and Liability Cash Flow Projections  Schedule C – Imbalance Risk Between Asset and Liability Values in Each Currency Type  Schedule D – Insurance Liability Risk  Schedule E – Interest Rate Risk  Schedule F – Reinsurance Risk  Schedule G – Operational Risk  Schedule H – PAYDI Operational Risk
6) Calculation of SAP Assets and Liabilities of Life Insurance Companies
a) Sub A - Investment Placements Not with One Party b) Sub B - Investment Placements with Parties Affiliated with the Company c) Sub C - Investment Placements with Parties Not Affiliated with the Company d) Sub D - Investment Placements Abroad e) Sub E - List of Affiliated Companies
7) Details of Life Insurance Company Financial Reports
B. Financial Reports of Investment-Linked Insurance Products consisting of:
1) Financial Position Report of Investment-Linked Insurance Products
2) Income Statement of Investment-Linked Insurance Products
3) Solvency Level Report
 Schedule A - Asset Management Failure Risk  Schedule B - Imbalance Risk Between Asset and Liability Cash Flow Projections

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
 Schedule C – Imbalance Risk Between Asset and Liability Values in Each Currency Type
4) Sub D - Investment Placements Abroad
5) Details of Investment-Linked Insurance Product Financial Reports
C. Combined Reports consisting of:
1) Financial Position Report of Life Insurance Companies and Investment-Linked Insurance Products
2) Income Statement of Life Insurance Companies and Investment-Linked Insurance Products
3) Sub D - Investment Placements Abroad
4) Solvency Level Report
D. Additional Financial Reports consisting of:
1) Life Insurance Company Guarantee Fund Report
a) Summary of Development and Calculation of Guarantee Fund Sufficiency b) Details of End Position of Guarantee Fund
2) Ratio of Financial Health Level Other Than MMBR
3) Education and Training Cost Ratio
4) Matching Assets and Liabilities
5) Details of Premium Income and Claims Expense Based on Distribution Channel
3. The form, content, and structure of these financial reports are used for both annual financial reports and quarterly financial reports.
4. For Life Insurance Companies that do not meet solvability requirements, the form, content, and structure of financial reports are the same as the form, content, and structure of quarterly financial reports.
5. Companies that do not meet solvency levels, in addition to submitting financial rehabilitation reports as referred to in item 4, are required to attach a financial rehabilitation plan and steps.
6. Primary financial reports are presented sequentially for two periods, namely the current period and the previous period. For quarterly reports, the previous period refers to the same period in the previous year. For example, for the second quarter report of 2013, the current period is the second quarter of 2013, while the previous period is the second quarter of 2012. Whereas for annual reports, the previous period refers to one period before the current period, for example, for the 2013 report, the current period is 2013, while the previous period is 2012.
7. If there are rows or columns that must be filled but the value is 0 (zero) or non-existent, then 0 (zero) is written.
8. Rupiah figures in all financial report formats are written in millions of rupiah with 2 (two) decimal places after the comma.
9. Negative numbers are given signs in parentheses (xxxx).
10. Permitted Assets which are subsequently abbreviated as AYD are assets permitted to be calculated in the Solvency Level calculation as referred to in legislation in the insurance business field.

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
11. Reserves for Premiums Not Yet Earned Income which are subsequently abbreviated as CAPYBMP is a sum of funds that must be formed to describe the portion of premiums whose insurance period has not yet been run.
12. Life Insurance Companies (Companies) are Insurance Companies as referred to in laws regarding the insurance business.
13. Others
a. The company name must be clearly written on every format title available. On the front page (cover), the name and address of the General Insurance Company/Reinsurance Company must be filled in the available row (XYZ in PT XYZ refers to the company name). b. The periods for quarterly and annual financial reports must be filled in according to the end date of the current reporting period. For example, for the second quarter report of 2013, it is filled in as of June 30, 2013, while for the 2013 report, it is filled in as of December 31, 2013.
c. If the company adds pages for a certain detail, then the pages for that detail are given sequential numbers a, b, and so on. For example, if Detail 101 consists of two pages, then the first page is given the sequential number 21a and the next page is given the sequential number 21b, and so on.
d. Submitted financial reports must be signed by at least one person from the Board of Directors and stated in the company profile (page ii). e. The statement letter must be signed by one director representing the company's board of directors. f. The form, content, and structure of financial reports cannot be changed, unless otherwise stated in the notes available in each format. If the number of available rows or pages is still insufficient, the company can add as needed. g. On every format available, there are several important notes that need to be understood as instructions for filling them out. h. The cover of the financial report for Life Insurance Companies uses the color red.
14. The procedure chart for filling out financial report formats in the context of calculating the solvency achievement ratio is as follows:

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Start
Is there Investment Abroad Sub D Sub A Yes No Sub B Affiliation with company Calculation of SAP Assets and Liabilities Calculation of SAP Assets Detail 101 - 116 Yes SAP Financial Position Report (Page 1, Column 5) Detail 101 - 209 Detail 501 - 506 Calculation of Comprehensive Income / Loss Risk-Based Minimum Capital Schedule A - H Solvency Level Report (Page 5) Detail 301 - 403 Calculation of SAP Assets and Liabilities Calculation of SAP Liabilities No Sub E List of affiliated companies Sub C Non-affiliation with company Is there Investment with One Party
II. PRIMARY FINANCIAL REPORTS

Financial Position Report
The Financial Position Report in this report consists of the Financial Position Report prepared based on Financial Accounting Standards (SAK) and Statutory Accounting Practice (SAP), each with the Financial Position Report of the previous period as a comparison. Accounts in the Financial Position Report are filled based on accounts listed in details 101 to 404. a. SAK Financial Position Report Accounts in this Financial Position Report have been reclassified according to the purpose of their listing, so the accounts do not have to be the same as accounts in SAK reporting. The purpose of listing the SAK Financial Position Report is to have comparison figures for SAP Financial Position Report accounts, especially for assets to facilitate analysis by analysts. b. SAP Financial Position Report Assets listed in the SAP Financial Position Report are AYD whose accounts are filled based on accounts listed in details 101 to 208. The determination of the amount of AYD for each type of asset is calculated based on applicable regulations. The total AYD in this report (column (4)) is subsequently filled in the Solvency Level Report – Solvency Achievement Ratio section (column (2)) row AYD. Liabilities in the SAP Financial Position Report are filled based on accounts listed in details 301 to 403. The total liabilities in this report (column (4)) are subsequently filled in the Solvency Level Report – Solvency Achievement Ratio section (column (2)) row Liabilities. For the Equity group, accounts are adjusted as much as possible to the available format. For the account "Difference in Valuation Based on SAK and SAP," it is filled based on the amount available in the SAP Asset and Liability Calculation section – Difference in Valuation Based on SAK and SAP, while for the account "Non-Permitted Assets," it is filled based on the amount available in the SAP Asset and Liability Calculation section – I. SAP Asset Calculation column (6). Differences in SAK and SAP valuation can arise due to differences in asset and liability valuation based on SAK and SAP. Differences in asset valuation between SAK and SAP arise due to differences in the recognition of the value of the asset. Generally, SAP recognizes assets at fair value, while SAK recognizes assets at historical cost. For liabilities, differences can arise because SAK provides several options in technical reserve calculation methods, allowing Companies to choose technical reserve calculation methods based on SAK that differ from technical reserve calculations as regulated in legislation. In the event of differences in asset and liability valuation between SAP and SAK, the difference can increase or decrease SAP equity. Differences in asset valuation can occur because generally, asset valuation based on SAP results in larger amounts compared to asset valuation based on SAK, thus resulting in the consequence of adding SAP equity. For liabilities, generally, Companies will use valuation based on SAP which can provide
smaller valuations compared to liability valuation based on SAK, thus resulting in the consequence of adding SAP equity. Whereas Non-Permitted Assets arise due to limitations in the recognition of Company assets so that not all assets recognized based on SAK can be recognized as assets based on SAP. Thus, the non-recognition of these assets results in the consequence of reducing SAP equity. The presentation of reinsurance assets in this Financial Position Report is presented as assets that are part of reinsurance receivables and included in assets permitted in the calculation of financial health levels. The value of reinsurance assets consists of:
 The value of reinsurance assets for future policy benefit liabilities, determined consistently with the approach used in determining future policy benefit liabilities, based on the terms and conditions of the reinsurance contract.  The value of reinsurance assets for premiums not yet earned income,

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013 determined consistently with the approach used in determining premiums not yet earned income, based on the terms and conditions of the reinsurance contract.  The value of reinsurance assets for estimated claim liabilities, determined consistently with the approach used in determining estimated claim liabilities, based on the terms and conditions of the reinsurance contract.
2. Comprehensive Income Statement
Columns in this report are filled based on figures listed in details 501 to 506. The SAP Comprehensive Income Statement may differ from the SAK Comprehensive Income Statement due to differences in recognition treatment (technical reserve expenses) and differences in account classification. Account classification for SAP reports has been adjusted to existing regulations. Thus, the final result of this Comprehensive Income Statement (i.e., profit or loss) can differ between SAP reports and SAK reports. The Comprehensive Income Statement presented is the Comprehensive Income Statement for the beginning of the current fiscal year up to the reporting date (cumulatively). For example, for the second quarter report of 2013, the income recorded is income obtained since January 1, 2013, up to June 30, 2013. Decrease (Increase) in CAPYBMP, Increase (Decrease) in Premium Reserves and Claim Reserves in the Comprehensive Income Statement are presented based on detail 501 and detail 504. Components for determining Gross Premium in this report are gross premiums as referred to in Government Regulation Number 73 of 1992 concerning the Conduct of Insurance Business as amended by Government Regulation Number 63 of 1999.
3. Cash Flow Statement
The Cash Flow Statement in this report is filled based on information in the columns provided in the available format. The ending balance of Cash and Bank at number 45 for the previous period (annual, quarterly, or monthly) is the opening balance at number 1 for the current period. The ending balance of cash and bank in this report must be the same as the total cash and bank available in the Financial Position Report.
4. Equity Change Report
The equity change report consists of SAK Equity and SAP Equity. To be able to fill in the SAP equity change report, the company must first fill in the equity change report prepared based on SAK. The SAP Equity Change Report is a reconciliation report from the SAK Equity Report to the SAP Equity Report. Two SAP equity components that are not SAK equity components, namely "Difference in Valuation SAK and SAP" and "Non-Permitted Assets," are two important components that affect the result of the reconciliation. These two components are filled into the SAP Equity Change Report, only by the difference between the current period and the previous period. Figures filled into the SAP Equity Change Report are the increase or decrease in "Difference in Valuation SAK and SAP" and "Non-Permitted Assets" as listed in the Financial Position Report in column (5) and column (7).

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
Example :
a. If "Difference in Valuation SAK and SAP" in the first quarter of 2013 listed in the Financial Position Report is Rp 1,200 million, while for the fourth quarter of 2012 it is Rp 1,000 million, then the figure filled into "Increase (Decrease) in Difference in Valuation SAK and SAP" is Rp 200 million. b. If "Non-Permitted Assets" for the first quarter of 2013 listed in the Financial Position Report is Rp 5,600 million, while for the fourth quarter of 2012 it is Rp 4,000 million, then what is filled into "(Increase) Decrease in Non-Permitted Assets" is (Rp 1,600) million.
5. Solvency Level Report
The Solvency Level Report in this report consists of:
a. Solvency Achievement Ratio
Companies are required to meet a solvency level of at least 120% of the risk-based minimum capital as referred to in Minister of Finance Regulation Number 53/PMK.010/2012. The total solvency mentioned consists of AYD and liabilities (except subordinated loans). The total AYD (column 3) must be the same as the total assets in the Financial Position Report (column 5 – SAP Balance). While the total liabilities (column 3) must be the same as the total liabilities in the Financial Position Report (column 5 – SAP Balance). b. Risk-Based Minimum Capital The method of filling out schedules on the Financial Reports of General Insurance Companies/Reinsurance Companies is as follows:
Schedule A: The total amount of AYD (column (2)) must be the same as the total assets in the SAP Financial Position Report (column (4)).
If the company has mixed mutual funds, then an example calculation of the weighted average factor is as follows:
Portfolio Securities Composition Weighted Average Factor Government Bonds 40% 0% 0% Private bonds 40% 6% 2.4% Equity securities 20% 16% 3.2% The weighted average of each security is the result of multiplying the composition of each security with the risk factor. In the example above, the weighted average of the mixed mutual fund is the sum of the weighted average of the securities portfolio, which is 5.6%.
Schedule B: Columns in this schedule are filled with AYD and liability values based on book values in the Financial Position Report grouped by their maturity dates. AYD in the form of traded effects and valued based on market value (example: stocks) is classified as assets maturing in a period of less than 1 (one) year. Whereas AYD

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013 which are intended to be held until maturity, are classified according to their remaining maturity.
Schedule C: The amount of Assets Eligible for Deduction (AYD) in row 14, total columns (3) to (11) must be equal to the total assets in the SAP Balance Sheet, as well as liabilities in row 22, total columns (3) to (11) must be equal to the total liabilities in the Balance Sheet (excluding subordinated loans).
Schedule D: The columns in this schedule are filled in according to the instructions contained in the existing format.
Schedule E: The columns in this schedule are filled in according to the instructions contained in the existing format.
Schedule F: The columns in this schedule are filled in according to the instructions contained in the existing format. If the company does not have deposits and/or premiums held (column (3)), this column is filled with the number 0 (zero).
Schedule G: General and administrative expenses and education and training expenses are filled with general and administrative expenses and education and training expenses for one year. For quarterly reports, general and administrative expenses and education and training expenses are filled with general and administrative expenses and education and training expenses for the last 4 (four) quarters. For example, for the first quarter of 2013, general and administrative expenses are filled with the total general and administrative expenses of the second quarter of 2012, third quarter of 2012, fourth quarter of 2012, and first quarter of 2013. Similarly, education and training expenses are filled with the total education and training expenses of the second quarter of 2012, third quarter of 2012, fourth quarter of 2012, and first quarter of 2013.
Schedule H: The columns in this schedule are filled in according to the instructions contained in the existing format. PAYDI managed funds are the amount of PAYDI assets found in the PAYDI balance sheet.

Calculation of SAP Assets and Liabilities
a. SAP Asset Calculation
The columns for SAP Asset Calculation (page 12) are filled with the following instructions:
Column 3: filled in according to what is stated in each asset detail for the general ledger balance amount (SAK). Column 4: filled in according to the valuation basis as regulated in Minister of Finance Regulation Number 53 of 2012. Column 5: is the difference between column (4) and column (3). Column 6: filled with the amount of non-permissible assets found in each detail (101 to 209), especially for other investment accounts, other fixed assets, and other assets. Column 7: filled from the amount of AYD found in each detail (detail 101 to 209). For the Cash and Bank account, the amount must be equal to the ending balance amount in the Cash Flow Statement. The Total Difference in SAK and SAP Valuation (column 5) is an increase or decrease in equity in the preparation of the SAP Balance Sheet as explained in the Statement of Changes in Equity. A valuation surplus of assets based on SAP over SAK is an increase in SAP equity,

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013 while a valuation deficit of assets based on SAP over SAK is a decrease in SAP equity. b. SAP Liability Calculation The columns for SAP Liability Calculation are filled with the following instructions:
Column 3: filled in according to what is stated in each liability detail for the general ledger balance amount (SAK). Column 4: filled in according to each liability detail with valuation based on SAP. Column 5: filled based on the amount of SAK and SAP Valuation Difference found in each liability detail (note: if there is a valuation difference between SAK and SAP). A valuation surplus of liabilities based on SAP over SAK is a decrease in SAP equity, while a valuation deficit of liabilities based on SAP over SAK is an increase in SAP equity.
c. Valuation Difference Based on SAK and SAP
The Total SAK and SAP Valuation Difference used in the preparation of the SAP Balance Sheet is the net difference between the asset valuation difference and liability valuation difference. This number is then transferred to the balance sheet in column (4) of the SAK and SAP valuation difference account. d. Sub-Sub Sections The asset calculation form has 5 (five) sub-sections, namely:
1) Sub A, Investment Placements Not with One Party
The columns in Sub A are filled if the Company places investments in companies but are not affiliated either with the Company or with the Company.
2) Sub B, Investment Placements with Affiliated Parties of the Company
The columns in Sub B are filled if the Company places investments in companies that are part of an affiliate group where the Company is part of it. The total investment placement in the aforementioned companies is a maximum of 10% (ten percent) of the total investment amount.
3) Sub C, Investment Placements with Affiliated Parties Not Including the Company
The columns in Sub C are filled if the Company places investments in companies that are part of an affiliate group, where the Company is not part of it. The total investment placement in the aforementioned companies is a maximum of 20% (twenty percent) of the total investment amount.
4) Sub D, Investment Placements Abroad
The columns in Sub D are filled if the Company places investments in countries other than the Republic of Indonesia.
5) Sub E, List of Affiliated Companies
The columns in Sub E are filled in according to the information available in the existing format. Ownership relationship (column (3)) is filled by stating the Company's position in an affiliate group. For example, subsidiary, parent, etc.

Details
7.1. Detail 101
The following regulations apply to this detail:

Column (3) is filled with the bank rating. For banks issuing bonds, the bank rating can refer to rating agencies registered with the Financial Services Authority (Pefindo, Fitch Indonesia, and ICRA Indonesia). However, if the bank does not issue bonds and is not listed with the aforementioned rating agencies, this column does not need to be filled.
Column (4) is filled with the cluster corresponding to the rating in column (3). If column (3) is empty, this column is filled with the largest cluster (cluster 5).
The amount in column (7) is filled into detail 601.
Column (8) is filled as follows:
1) If there is a placement of more than one type of investment in one company, this column is filled by stating the other types of investment, for example "stocks".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

7.2. Detail 102
The following regulations apply to this detail:

Column (3) is filled as follows:
1) LQ45 or JII, depending on the stock category.
2) Other exchanges besides LQ45 and JII.
3) Foreign exchanges.
The amount in column (6) is filled into detail 601.
Column (7) is filled as follows:
1) If there is a placement of more than one type of investment in one company, this column is filled by stating the other types of investment, for example "corporate bonds".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled into sub D.

7.3. Detail 103
The following regulations apply to this detail:

Column (3) is filled with the rating of corporate bonds and corporate sukuk issued by rating agencies registered with the Financial Services Authority (Pefindo, Fitch Indonesia, and ICRA Indonesia) or those that have obtained international recognition (Standard & Poor’s, Moody’s, AM Best, Fitch, and ICRA).
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is filled into detail 601.
Column (9) is filled as follows:
1) If there is a placement of more than one type of investment in one company, this column is filled by stating the other types of investment, for example "stocks".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013
3) If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled into sub D.

7.4. Detail 104

The columns in this detail are filled in according to the information available in the existing format.
The amount in column (6) is filled into detail 601.

7.5. Detail 105

Column (3) is filled with the investment instrument rating based on rating agencies that have obtained international recognition (Standard & Poor’s, Moody’s, AM Best, Fitch, and ICRA). The total value of these instruments is filled into sub D.
Column (4) is filled with the cluster corresponding to column (2).
The amount in column (8) is filled into detail 601.

7.6. Detail 106

The columns in this detail are filled in according to the information available in the format.
The amount in column (6) is then filled into detail 601.

7.7. Detail 107

The columns in this detail are filled in according to the information available in the existing format and the total value of these instruments is filled into sub D.
The amount in column (6) is then filled into detail 601.

7.8. Detail 108
The following regulations apply to this detail:

The determination of the mutual fund unit share grouping category must be based on the actual investment composition of the mutual fund on the Balance Sheet date, not the investment composition in the prospectus.
A mutual fund is called entirely Government bonds if 90% or more of the mutual fund's investment composition is placed in Government bonds. If the placement in one type of investment is less than 90%, the mutual fund is grouped into a mixed mutual fund. This also applies to placements in other mutual fund categories.
The amount in column (6) is filled into detail 601.
Column (7) is filled as follows:
1) If there is a placement of more than one type of investment in one company, this column is filled by stating the other types of investment, for example "stocks".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled into sub D.

7.9. Detail 109
The following regulations apply to this detail:

Column (3) is filled with the investment instrument rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is filled into detail 601.
Column (9) is filled as follows:
1) If there is a placement of more than one type of investment in one company,

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: August 27, 2013 the company, this column is filled by stating the other types of investment, for example "stocks".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

7.10. Detail 110
The following regulations apply to this detail:

Column (3) is filled with the investment instrument rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (8) is filled into detail 601.
Column (9) is filled as follows:
1) If there is a placement of more than one type of investment in one company, this column is filled by stating the other types of investment, for example "stocks".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".

7.11. Detail 111
The following regulations apply to this detail:

Column (7) the total value is a maximum of 10% (ten percent) of the total investment amount.
Column (8) is filled as follows:
1) If there is a placement of more than one type of investment in one company, this column is filled by stating the other types of investment, for example "stocks".
2) If the type of investment in this detail is placed in an affiliated company, this column is filled with the description "Name of Affiliate Group".
3) If the type of investment in this detail is placed abroad, this column is filled with the description "Abroad" and the total value is filled into sub D.

7.12. Detail 112
The following regulations apply to this detail:

The category of building type with strata rights or land with buildings as investment or used by itself is determined by the company, with the note that buildings with strata rights or land with buildings can be categorized as investments if the buildings with strata rights or land with buildings can provide returns (in the form of rent) to the company.
Column (2) can be filled by stating the city (DATI II) where the building with strata rights or land with buildings is located.
The amount in column (3) is filled into detail 601.
Column (4) is filled based on the value determined by a registered appraiser institution at the competent agency, or the Latest Taxable Object Value (NJOP) in case no appraisal is done by an appraiser institution.
Column (5) is the difference between column (3) and column (4) for each unit.
Row Number IV (AYD) will be equal to the total (I + II + III) if the total value (I + II + III) is less than or equal to 10% of the total investment amount.

7.13. Detail 113
The following regulations apply to this detail:

Column (3) is filled with the financing company and/or bank license number.
The amount in column (4) is filled into detail 601.
Column (8) is filled as follows:
1) If there is a placement of more than one type of investment in one company,

7.14. Detail 114
The following regulations apply to this detail:

This type of investment consists of gold bars.
Column (3) is filled according to the ownership quantity. For example, if the Company has 10 kg of gold bars, column (3) is filled: 25 pieces/100gr, 10 pieces/250gr, 50 pieces/100gr.
The columns in this detail are filled in according to the information available in the existing format.
The amount in column (6) is filled into detail 601.

7.15. Detail 115

The columns in this detail are filled in according to the information available in the existing format.
The amount in column (8) is filled into detail 601.

7.16. Detail 116
The columns in this detail are filled if the Company has other investments besides those mentioned above.

7.17. Detail 201

For the debtor detail, only debtors who owe the company an amount of debt equal to 5% or more of the total Premium Receivables value need to be detailed. Whereas for debtors whose debt amount is below 5% of the total Premium Receivables value, they can simply be categorized into the "Others" group.
For the "Insurance Broker" debtor category, what is filled is the total premium receivables of the insurance company to the brokerage company, so the debtor name stated is the name of the brokerage company.
The amount in column (5) may be larger than the amount in column (4), considering that receivables that can be included in column (4) have a shorter receivable age than receivables that can be included in column (5). Subsequently, the amount in column (5) is filled into detail 601.

7.18. Detail 202
The following regulations apply to this detail:

For the debtor detail, only debtors who owe the company an amount of debt equal to 5% or more of the total Co-insurance Claim Receivables value need to be detailed. Whereas for debtors whose debt amount is below 5% of the total Co-insurance Claim Receivables value, they can simply be categorized into the "Others" group.
Column (3) is filled with the debtor rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (7) may be larger than the amount in column (6), considering that receivables that can be included in column (6) have a shorter receivable age than receivables that can be included in column (7). Subsequently, the amount in column (7) is filled into detail 601.

7.19. Detail 203
The following regulations apply to this detail:

For the debtor detail, only debtors who owe the company an amount of debt equal to 5% or more of the total Reinsurance Receivables value need to be detailed. Whereas for debtors whose debt amount is below 5% of the total Reinsurance Receivables value, they can simply be categorized into the "Others" group.
Reinsurance assets are part of reinsurance receivables and are included in AYD.
Column (3) is filled with the debtor rating.
Column (4) is filled with the cluster corresponding to column (3).
The amount in column (7) may be larger than the amount in column (6), considering that receivables that can be included in column (6) have a shorter receivable age than receivables that can be included in column (7). Subsequently, the amount in column (7) is filled into detail 601.

7.20. Detail 204
The following regulations apply to this detail:

Receivables with a maximum age of 1 (one) month can be categorized as AYD.
The amount in column (5) may be larger than the amount in column (4), considering that receivables that can be included in column (4) have a shorter receivable age than receivables that can be included in column (5). Subsequently, the amount in column (5) is filled into detail 601.

7.21. Detail 205
The following regulations apply to this detail:

Receivables with a maximum age of 1 (one) month can be categorized as AYD.
The amount in column (5) may be larger than the amount in column (4), considering that receivables that can be included in column (4) have a shorter receivable age than receivables that can be included in column (5). Subsequently, the amount in column (5) is filled into detail 601.

7.22. Detail 206
The following regulations apply to this detail:

Current period loans are filled for policy loans that occurred in the reporting period (new policy loans) by stating the policy number (this per-policy detail is only for non-APL policy loans).
This per-policy detail only applies to quarterly reports. Whereas for annual reports, only the total addition of policy loans that occurred in the reporting period is filled.
The amount in column (6) is then filled into detail 601.

7.23. Detail 207
The following regulations apply to this detail:

Column (2) can be filled by stating the city (DATI II) where the building with strata rights or land with buildings is located.
Column (5) is the difference between column (3) and column (4) for each unit.
Row Number II (AYD) is less than or equal to 15% of Current Period SAK Own Capital.

7.24. Detail 208
The columns in this detail are filled in according to the information available in the existing format.

7.25. Detail 209
The columns in this detail are filled in according to the information available in the existing format.

7.26. Detail 301

For the creditor detail, only creditors who have claims against the company with a claim amount equal to 5% or more of the total claim liabilities value need to be detailed. Whereas for creditors whose claim amount is below 5% of the total claim liabilities value, they can simply be categorized into the "Others" group.
The amount in column (7) is filled into detail 601.

7.27. Detail 302
The following regulations apply to this detail:

For the creditor detail, only creditors who have claims against the company with a claim amount equal to 5% or more of the total claim liabilities value need to be detailed. Whereas for creditors whose claim amount is below 5% of the total claim liabilities value, they can simply be categorized into the "Others" group.
The amount in column (5) is filled into detail 601.

7.28. Detail 303
The following regulations apply to this detail:

For the creditor detail, only creditors who have claims against the company with a claim amount equal to 5% or more of the total claim liabilities value need to be detailed. Whereas for creditors whose claim amount is below 5% of the total claim liabilities value, they can simply be categorized into the "Others" group.
The amount in column (5) is filled into detail 601.

7.29. Detail 304
The following regulations apply to this detail:

For the creditor detail, only creditors who have claims against the company with a claim amount equal to 5% or more of the total commission liabilities value need to be detailed. Whereas for creditors whose claim amount is below 5% of the total commission liabilities value, they can simply be categorized into the "Others" group.
The amount in column (4) is filled into detail 601.

7.30. Detail 305
The following regulations apply to this detail:

Column (2) only needs to be filled with cost descriptions whose amount is 5% or more of the total accrued costs value. Whereas for cost amounts below 5% of the total accrued costs value, they can simply be categorized into the "Others" group.

7.31. Detail 306
The following regulations apply to this detail:

Column (2) only needs to be filled with debt descriptions whose amount is 5% or more of the total other liabilities value. Whereas for debt amounts below 5% of the total other liabilities value, they can simply be categorized into the "Others" group.

7.32. Detail 401

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
The columns in these details are filled in according to the information available in the existing format.

7.33. Detail 402
The columns in these details are filled in according to the information available in the existing format.

7.34. Detail 403
The columns in these details are filled in according to the information available in the existing format.

7.35. Detail 501
This detail constitutes the underwriting income detail as stated in the Comprehensive Income Statement, but in this case, it is detailed for new production and renewal premiums, both individual and group. Therefore, the amount in row 18, column (12) will be the same as the amount in the Comprehensive Income Statement.

7.36. Detail 502

Investment results in this detail include realized investment results (net investment income) as well as unrealized gains. However, these investment results are entered into the Comprehensive Income Statement adjusted according to Financial Accounting Standards (PSAK) governing such matters.
Column (7) is filled as follows:
Example: A General Insurance Company has corporate bonds with interest payment coupons and their valuation is based on market price. Thus, this type of investment will provide results that can be categorized into two types: interest and gain due to market price increases. Therefore, column (7) is filled with the interest received during the reporting period and the gain (realized gain as well as unrealized gain) present.

7.37. Detail 503
For other income, only income amounting to 5% or more of the total value of other income needs to be detailed. Meanwhile, for income amounts below 5% of the total value of other income, it is sufficient to categorize them into the "Others" group.

7.38. Detail 504
In this detail, for each insurance branch, it is detailed by type of claim/benefit payment such as: contract end, single value, death, and others.

7.39. Detail 505
For the detail of other (expenses) results, only results (expenses) amounting to 5% or more of the total value of other (expenses) results need to be detailed. Meanwhile, for results (expenses) amounts below 5% of the total value of other (expenses) results, it is sufficient to categorize them into the "Others" group.

7.40. Detail 506
The columns in these details are filled in according to the information available in the existing format.

7.41. Detail 601

The definition of Current Assets and Current Liabilities is all assets and liabilities of Life Insurance Companies that have a duration of less than or equal to one year from the reporting date.
The amounts present are then entered into the Financial Statements

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
Additional numbers 1a and 1b (Liquidity Ratio).

III. FINANCIAL STATEMENTS FOR INSURANCE PRODUCTS LINKED WITH INVESTMENT
On principle, the form, content, and structure of financial statements for insurance products linked with investment are the same as the main financial statements, but they are more concise and there is no solvency level calculation. Therefore, the instructions for filling out this report can refer to the instructions explained above. This format is only intended for companies marketing insurance products linked with investment, while companies that do not market this type of product do not need to attach this format in their financial statements.

IV. CONSOLIDATED FINANCIAL STATEMENTS
Consolidated financial statements are a combination of the main financial statements of Life Insurance Companies and the financial statements of insurance products linked with investment. This format is only intended for life insurance companies marketing insurance products linked with investment.

V. ADDITIONAL FINANCIAL STATEMENTS

Guarantee Fund Report
The preparation of the Guarantee Fund Report aims to monitor the Company's compliance with minimum guarantee fund requirements, which serve as the final guarantee for policyholders if the respective Company is liquidated. In the report format, the amount of guarantee funds, details of deposit certificates, and the calculation of the minimum amount of guarantee funds that must be held are detailed. Summary of guarantee fund developments, calculation of guarantee fund adequacy, and details of the final position of guarantee funds are filled in according to the information available in the existing format. The paid-up capital required used in the guarantee fund calculation is the paid-up capital required at the establishment of the respective Life Insurance Company. For Life Insurance Companies, the basis for determining additional guarantee funds is the net premium for all types of insurance products marketed by that insurance company.
Financial Health Ratios Other than MMBR
This ratio is an additional ratio in calculating the financial health level of the Company, consisting of:
a. Liquidity ratio, to determine the Company's ability to meet short-term financial liabilities when due using available current assets. b. Investment adequacy ratio, to measure the Company's ability to meet potential claims.
c. Ratio of investment results to net premium income, to compare company assets from investment management with net income from received premiums.
d. Claim expense, operational expense, and commission ratio, to measure the amount of income received from premiums after deducting expenses. Details of the aforementioned ratios are filled in according to the information available in the existing format.

Appendix III
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
3. Education and Training Ratio
For this detail, the following regulations apply:
I. Education and Training Costs

Column (2) is filled with the name of planned or budgeted education and training.
Column (3) is filled with the budgeted cost of education and training for one year.
Column (4) is filled with the actual cost of education and training cumulatively up to the reporting period.
II. Education and Training Ratio
Column (3) is filled with the budgeted cost of employees, directors, and commissioners, as well as the budgeted cost of education and training for each user, namely: employees, directors, and commissioners for the current year.
Column (4) is filled with the actual cost of employees, directors, and commissioners, as well as the actual cost of education and training for each user, namely: employees, directors, and commissioners that have been carried out up to the reporting period in the current year.

Asset and Liability Matching
Matching of assets and liabilities based on currency and maturity is required to determine differences in asset and liability values in foreign currencies, as well as fluctuations in foreign exchange rates against the rupiah. The columns in this detail are filled based on SAK values.
Detail of Premium Income and Claim Expenses by Distribution Channel
The columns in this detail are filled in according to the information available in the existing format.

Established in Jakarta on 27 August 2013 EXECUTIVE HEAD OF NON-BANK FINANCIAL INDUSTRY SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed, FIRDAUS DJAELANI

Copy matches the original
Head of Legal Assistance Division Financial Services Authority, Signed, Mufli Asmawidjaja

Appendix IV
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
PT GENERAL INSURANCE
Head Office: Jalan ……………………………………..
...…………………………………………….
...…………………………………………….
ASSETS 20X0 20X1 LIABILITIES AND EQUITY 20X0 20X1 DESCRIPTION 20X0 20X1 20X0 20X1 A. Solvency Level a. Permitted Assets b. Liabilities Total Solvency Level B. Minimum Risk-Based Capital (MMBR) 2) a. Asset Management Failure (Schedule A) b. Imbalance between Asset and Liability Cash Flow Projections (Schedule B)
c. Imbalance between Asset and Liability Values in Each Type of Foreign Currency (Schedule C)
d. Incurred Claim Expenses and Estimated Claim Expenses (Schedule D) e. Interest Rate Risk (Schedule E) f. Reinsurance Risk (Schedule F) g. Operational Risk (Schedule G) Total MMBR
C. Surplus (Deficiency) of Solvency Level Limit
D. Solvency Achievement Ratio (%) 3) a. Guarantee Fund Amount b. Liquidity Ratio (%)
c. Investment Adequacy Ratio (%)
d. Ratio of Investment Results to Net Premium Income f. Expense Ratio (Claims, Operations, and Commissions) to Net Premium Income (%)

DIRECTORSHIP AND COMMISSIONERS
PRINCAL REINSURER
BOARD OF COMMISSIONERS
CHIEF COMMISSIONER: ……………………. … COMMISSIONER: ……………………. … COMMISSIONER: ……………………. … DIRECTORSHIP CHIEF DIRECTOR: ……………………… DIRECTOR: ……………………… DIRECTOR: ……………………… COMPANY OWNERS

…………………………………… ……..% 1. ………………………………………….
…………………………………… ……..% 2. ………………………………………….
…………………………………… ……..% 3. ………………………………………….
…………………………………… ……..% 4. ………………………………………….
Directors
Reinsurance Outside Indonesia

Established in Jakarta on 27 August 2013 Copy matches the original Head of Legal Assistance Division Financial Services Authority, Signed, Mufli Asmawidjaja EXECUTIVE HEAD OF NON-BANK FINANCIAL INDUSTRY SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed, FIRDAUS DJAELANI

Notes
Financial Statements
As of 31 December 20X0 and 20X1 STATEMENT OF FINANCIAL POSITION (BALANCE SHEET) AS OF 31 DECEMBER 20X0 AND 20X1 PT XYZ Other Information Solvency Achievement (in millions of rupiah) AS OF 31 DECEMBER 20X0 AND 20X1 FINANCIAL HEALTH LEVEL (in millions of rupiah) Directorship, (in millions of rupiah) COMPREHENSIVE INCOME STATEMENT FOR THE YEAR ENDED 31 DECEMBER 20X0 AND 20X1 Jakarta, ……………………………. Notes:
1) Presentation of the Statement of Financial Position (Balance Sheet) and Comprehensive Income Statement is adjusted to the generally applicable Financial Accounting Standards (SAK) regulations.
2) Financial health level is the financial health level with conventional principles.
3) MMBR = Minimum Risk-Based Capital is a minimum solvency level amount established, namely funds needed to anticipate potential loss risks arising from deviations in asset and liability management.
4) According to Article 2 of the Minister of Finance Regulation Number 53/PMK.010/2012 concerning Financial Health of Insurance and Reinsurance Companies, the lowest solvency level target is 120% of the minimum risk-based capital.
Remarks:
a. Audited by Public Accountant ……………………… with opinion "……..." b. Technical Reserves calculated by actuary "...................."
c. Figures (values) presented in the Statement of Financial Position (Balance Sheet) and Income Statement are based on SAK (Audit Report)
d. Exchange rate on 31 December 20X0, 1 US $ : Rp. ……… e. Exchange rate on 31 December 20X1, 1 US $ : Rp. ……… f. Others (filled with other information related to transparency and accountability of financial statements)

Appendix V
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
PT LIFE INSURANCE
Head Office: Jalan ……………………………………..
...…………………………………………….
...…………………………………………….
ASSETS 20X0 20X1 LIABILITIES AND EQUITY 20X0 20X1 DESCRIPTION 20X0 20X1 20X0 20X1 A. Solvency Level a. Permitted Assets b. Liabilities Total Solvency Level B. Minimum Risk-Based Capital (MMBR) 2) a. Asset Management Failure (Schedule A) b. Imbalance between Asset and Liability Cash Flow Projections (Schedule B)
c. Imbalance between Asset and Liability Values in Each Type of Foreign Currency (Schedule C)
d. Incurred Claim Expenses and Estimated Claim Expenses (Schedule D) e. Interest Rate Risk (Schedule E) f. Reinsurance Risk (Schedule F) g. Operational Risk (Schedule G) Total MMBR
C. Surplus (Deficiency) of Solvency Level Limit
D. Solvency Achievement Ratio (%) 3) a. Guarantee Fund Amount b. Liquidity Ratio (%)
c. Investment Adequacy Ratio (%)
d. Ratio of Investment Results to Net Premium Income f. Expense Ratio (Claims, Operations, and Commissions) to Net Premium Income (%)

DIRECTORSHIP AND COMMISSIONERS
BOARD OF COMMISSIONERS
CHIEF COMMISSIONER: ……………………. … COMMISSIONER: ……………………. … COMMISSIONER: ……………………. … DIRECTORSHIP CHIEF DIRECTOR: ……………………… DIRECTOR: ……………………… DIRECTOR: ……………………… COMPANY OWNERS

…………………………………… ……..% Directors
…………………………………… ……..%
…………………………………… ……..%
…………………………………… ……..%

PT XYZ
COMPREHENSIVE INCOME STATEMENT
Notes
FOR THE YEAR ENDED 31 DECEMBER 20X0 AND 20X1 Other Information FINANCIAL HEALTH LEVEL Jakarta, ……………………………. (in millions of rupiah) (in millions of rupiah) Financial Statements As of 31 December 20X0 and 20X1 Solvency Achievement Directorship, AS OF 31 DECEMBER 20X0 AND 20X1 STATEMENT OF FINANCIAL POSITION (BALANCE SHEET) AS OF 31 DECEMBER 20X0 AND 20X1 (in millions of rupiah)

Notes:
1) Presentation of the Statement of Financial Position (Balance Sheet) and Comprehensive Income Statement is adjusted to the generally applicable Financial Accounting Standards (SAK) regulations.
2) Financial health level is the financial health level with conventional principles.
3) MMBR = Minimum Risk-Based Capital is a minimum solvency level amount established, namely funds needed to anticipate potential loss risks arising from deviations in asset and liability management.
4) According to Article 2 of the Minister of Finance Regulation Number 53/PMK.010/2012 concerning Financial Health of Insurance and Reinsurance Companies, the lowest solvency level target is 120% of the minimum risk-based capital.
Remarks:
a. Audited by Public Accountant ……………………… with opinion "……..." b. Technical Reserves calculated by actuary "...................."
c. Figures (values) presented in the Statement of Financial Position (Balance Sheet) and Income Statement are based on SAK (Audit Report)
d. Exchange rate on 31 December 20X0, 1 US $ : Rp. ……… e. Exchange rate on 31 December 20X1, 1 US $ : Rp. ……… f. Others (filled with other information related to transparency and accountability of financial statements)

Appendix VI
SEOJK Number: 2/SEOJK.05/2013
Date: 27 August 2013
PT LIFE INSURANCE
Head Office: Jalan ……………………………………..
...…………………………………………….
...…………………………………………….
ASSETS 20X0 20X1 LIABILITIES AND EQUITY 20X0 20X1 DESCRIPTION 20X0 20X1 20X0 20X1 A. Solvency Level a. Permitted Assets b. Liabilities Total Solvency Level B. Minimum Risk-Based Capital (MMBR) 2) a. Asset Management Failure (Schedule A) b. Imbalance between Asset and Liability Cash Flow Projections (Schedule B)
c. Imbalance between Asset and Liability Values in Each Type of Foreign Currency (Schedule C)
d. Incurred Claim Expenses and Estimated Claim Expenses (Schedule D) e. Interest Rate Risk (Schedule E) f. Reinsurance Risk (Schedule F) g. Operational Risk (Schedule G) h. PAYDI Operational Risk (Schedule H) Total MMBR
C. Surplus (Deficiency) of Solvency Level Limit
D. Solvency Achievement Ratio (%) 3) a. Guarantee Fund Amount b. Liquidity Ratio (%)
c. Investment Adequacy Ratio (%)
d. Ratio of Investment Results to Net Premium Income f. Expense Ratio (Claims, Operations, and Commissions) to Net Premium Income (%)

The Balance Sheet includes assets and liabilities from insurance products linked with investment, detailed as follows:
DIRECTORSHIP AND COMMISSIONERS
BOARD OF COMMISSIONERS
CHIEF COMMISSIONER: ……………………. … DESCRIPTION 20X0 20X1 COMMISSIONER: ……………………. … ASSETS COMMISSIONER: ……………………. … a. Investments DIRECTORSHIP b. Non-Investments CHIEF DIRECTOR: ……………………… Total Assets DIRECTOR: ……………………… Liabilities DIRECTOR: ……………………… a. Payables COMPANY OWNERS b. Technical Reserves 1. …………………………………… ……..% Total Liabilities 2. …………………………………… ……..% Premium Income 3. …………………………………… ……..% Investment Results Directors Claims and Benefits Directors 4. …………………………………… ……..%

Insurance Products Linked With Investment Jakarta, ……………………………. Directorship, PT XYZ (in millions of rupiah) (in millions of rupiah) (in millions of rupiah) Notes Solvency Achievement Other Information STATEMENT OF FINANCIAL POSITION (BALANCE SHEET) COMPREHENSIVE INCOME STATEMENT FINANCIAL HEALTH LEVEL AS OF 31 DECEMBER 20X0 AND 20X1 FOR THE YEAR ENDED 31 DECEMBER 20X0 AND 20X1 AS OF 31 DECEMBER 20X0 AND 20X1 Financial Statements As of 31 December 20X0 and 20X1

Notes:
1) Presentation of the Statement of Financial Position (Balance Sheet) and Comprehensive Income Statement is adjusted to the generally applicable Financial Accounting Standards (SAK) regulations.
2) Financial health level is the financial health level with conventional principles.
3) MMBR = Minimum Risk-Based Capital is a minimum solvency level amount established, namely funds needed to anticipate potential loss risks arising from deviations in asset and liability management.
4) According to Article 2 of the Minister of Finance Regulation Number 53/PMK.010/2012 concerning Financial Health of Insurance and Reinsurance Companies, the lowest solvency level target is 120% of the minimum risk-based capital.
Remarks:
a. Audited by Public Accountant ……………………… with opinion "……..." b. Technical Reserves calculated by Actuary "...................."
c. Figures (values) presented in the Statement of Financial Position (Balance Sheet) and Income Statement are based on SAK (Audit Report)
d. Exchange rate on 31 December 20X0, 1 US $ : Rp. ……… e. Exchange rate on 31 December 20X1, 1 US $ : Rp. ……… f. Others (filled with other information related to transparency and accountability of financial statements)

Similar documents from other regulators