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Paid-in Surplus - - - - Profit Balance - - - - Other Equity Component - - - - Difference of Values between SAK and SAP - - Non-admitted Assets - - Tot...

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Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 1

PT XYZ GENERAL INSURANCE COMPANY STATEMENT OF FINANCIAL POSITION Non-Consolidated Per …. and Per…. (in millions rupiah) Item

(1) ASSETS Investment Time Deposits and Certificates of Deposits 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 Entities Mutual Funds Asset-Backed Securities Collective Investment Contract Real Estate Investment Funds Direct Investment Buildings with Strata-title Rights or Land with Building For Investment Purchases of Receivables for Funding of Financing Companies and/or Banks Pure Gold Mortgage-backed Loan Other Investment Total Investment Non-Investment Cash and Bank Direct Premium Written Receivables Coinsurance Claim Receivables Reinsurance Receivables Investment Receivables Investment Yields Receivables Buildings with Strata-title Rights or Land with Building For Private Use Other Fixed Assets Other Assets Total Non-Investment 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 Reserve Unearned Premium Reserve Claim Reserve Total Technical Reserves Total Liabilities Subordinated Loans Equity Paid-up Capital Paid-in Surplus Profit Balance Other Equity Component Difference of Values between SAK and SAP Non-admitted Assets Total Equity TOTAL LIABILITIES AND EQUITY

Details

(2)

101 102 103 104 105

Quarter … Year … SAK Balance (3)

Quarter … Year …

SAP Balance (4)

SAK Balance (5)

SAP Balance (6)

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

201 202 203 204 205

-

-

-

-

206

-

-

-

-

207 208

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

106 107 108 109 110 111 112 113 114 115 116

301 302 303 304 305 306

401 401 402

-

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 2

PT XYZ GENERAL INSURANCE COMPANY COMPREHENSIVE PROFIT / LOSS STATEMENT For Period Ended On … Date … and Date …

Item (1) UNDERWRITING INCOME Gross Premium a. Direct Premium Written b. Indirect Premium Written c. Paid Commission Total Gross Premium Reinsurance Premium a. Reinsurance Premium Paid b. Reinsurance Commission Received Total Reinsurance Premium Net Premium Decrease (Increase) of Premium Reserves and Unearned Premium Reserves a. Decrease (Increase) of Premium Reserves b. Decrease (increase) of Unearned Premium Reserves Decrease (Increase) of Premium Reserves and Unearned Premium Reserves Total Net Premium Revenue Other Net Underwriting Revenue UNDERWRITING INCOME UNDERWRITING EXPENSES Claim Expenses a. Gross Claims b. Reinsurance Claims c. Increase (Decrease) of Claim Reserves Total Net Claim Expenses Other Net Underwriting Expenses TOTAL UNDERWRITING EXPENSES UNDERWRITING INCOME Investment Income Business Operation Expenses: a. Marketing Expenses b. General and Administrative Expenses: - Employee and Management Expenses - Training and Education Expenses - Other General and Administrative Expenses Total Business Operation Expenses PROFIT (LOSS) OF INSURANCE BUSINESS Other Income (Expenses) PROFIT (LOSS) BEFORE TAX Income Tax AFTER TAX PROFIT OTHER COMPREHENSIVE REVENUE TOTAL COMPREHENSIVE PROFIT (LOSS)

Details (2) 501

(in millions rupiah) Quarter … Quarter … Year … Year … (3) (4)

-

-

-

-

502 502 -

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

501

502

501 503

504

505

Note: The figures in this report are accumulative from the period of 1 January until the reporting date for current period

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 3

PT XYZ GENERAL INSURANCE COMPANY CASH FLOW STATEMENT Per …. and Per…. (in millions rupiah) Description (1) CASH AND BANK OPENING BALANCE CASH FLOW FROM OPERATIONS Cash Inflow a. Premium b. Coinsurance Claim c. Reinsurance Claim d. Commission e. Receivables f. Others Total Cash Inflow Cash Outflow a. Reinsurance Premium b. Claims c. Commission d. Expenses e. Others Total Cash Outflow CASH FLOW FROM OPERATIONS TOTAL CASH FLOW FROM INVESTMENSTS Cash Inflow a. Investment Yields Received b. Disbursement of Investment c. Sales of Fixed Assets d. Others Total Cash Inflow Cash Outflow a. Investment Placement b. Purchase of Fixed Assets c. Others Total Cash Outflow TOTAL CASH FLOW FROM INVESTMENT CASH FLOW FROM FINANCING Cash Inflow a. Subordinated Loans b. Deposit of Capital c. Others Total Cash Inflow Cash Outflow a. Dividend Payments b. Subordinated Loans Payments c. Others Total Cash Outflow TOTAL CASH FLOW FROM FINANCING CASH AND BANK CLOSING BALANCE

Quarter … Year … (2)

Quarter … Year … (3) -

-

-

-

-

-

-

-

-

-

-

-

-

Annex I SEOJK Number: 02/SEOJK.05/2013 Dated: 27 August 2013 Page 4

PT XYZ GENERAL INSURANCE COMPANY CHANGES IN EQUITY STATEMENT Per …. and Per….

Description (1) SAK EQUITY Opening Balance Increase: Paid-up Capital Comprehensive Profit (Loss) Current Period Other Increase: a. b. Total Increase Decrease: Dividend Payment Other Decrease: a. b. Total Decrease SAK Closing Balance SAP EQUITY Opening Balance Changes in SAK Equity Increase (decrease) in SAK and SAP Value Difference (Increase) Decrease of Non-admitted Assets SAP Closing Balance

(in millions rupiah) Quarter … Quarter … Year … Year … (2) (3) -

-

-

-

-

-

-

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 5

PT XYZ GENERAL INSURANCE COMPANY REPORT ON SOLVENCY LEVEL Solvency Ratio Attained Per …. and Per…. (in millions rupiah) Description (1)

Quarter … Year … (2)

Solvency Level Admitted 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 Over (Under) Limit of Solvency Level Solvency Ratio Attained (in %) 1)

1)

Quarter … Year … (3) -

-

-

-

-

#DIV/0!

#DIV/0!

Solvency Level divided by MMBR Total

In the event company has lack of solvency, the amount of funds needed to achieve a RBC ratio of 100,00% 120,00%

Period

2)

3)

Year ... Quarter... Quarter... Quarter...

Target % % % %

Quarter...

%

2) 3)

Current year period Minimum target for Solvency Level is 120%

Reasons for not meeting the target of solvency ratio in the current Quarter/Year:

Realization % % % % %

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 6

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

Item (1)

Total AYD (Admitted Asset)

Factor

(2)

(3)

Total Deviation (4)

INVESTMENT Time Deposits and Certificates of Deposits Specific Category (up to 2 billion per bank)

0,0%

Other Categories, according to ranking of Bank:

-

a. Cluster 1

1,2%

-

b. Cluster 2

2,1%

-

c. Cluster 3

3,0%

-

d. Cluster 4

4,5%

-

e. Cluster 5

9,0%

-

Shares

-

Incl. LQ 45 in Jakarta Stock Exchange, or its equivalent

16,0%

-

Shares traded in Indonesian stock market

20,0%

-

Shares traded in foreign stock market

-

Shares that made up the main index in major stock exchanges in Asian, Pacific, and European Countries member of World Federation of Exchanges

20,0%

-

Others

30,0%

-

Corporate Bonds and Corporate Sukuk

-

a. Cluster 1

1,6%

-

b. Cluster 2

2,8%

-

c. Cluster 3

4,0%

-

d. Cluster 4

6,0%

-

Securities Issued by the Republic of Indonesia

0,0%

-

a. Cluster 1

1,6%

-

b. Cluster 2

2,8%

-

c. Cluster 3

4,0%

-

Securities Issued by Countries other than The Republic of Indonesia

d. Cluster 4

6,0%

-

Securities Issued by Bank Indonesia

0,0%

-

Securities Issued by Multinational Entities

0,0%

-

Mutual Funds

-

All in Government bonds

0,0%

-

All in private corporate bonds or money market securities

6,0%

-

16,0%

-

rt

-

All in equity securities Others mixed

1)

Assets-Backed Securities Collective Investment Contract

-

a. Cluster 1

1,6%

-

b. Cluster 2

2,8%

-

c. Cluster 3

4,0%

-

d. Cluster 4

6,0%

-

Real Estate Investment Funds

-

a. Cluster 1

1,6%

-

b. Cluster 2

2,8%

-

c. Cluster 3

4,0%

-

d. Cluster 4

6,0%

-

Direct Investment

-

Under OJK supervision

10,0%

-

Not Under OJK supervision

20,0%

-

7,0%

-

Yield of Investment of 2% - 4%

15,0%

-

Yield of Investment of less than 2%

40,0%

-

Buildings with Strata-title Rights or Land with Building Yield of Investment of 4% or more

Purchases of Receivables Lease Credit Card

3,0%

-

20,0%

-

Consumer financing

8,0%

-

Pure Gold

3,0%

-

Mortgage-backed Loan

-

Residential property

-

a. LTV<60%

2,8%

-

b. 60%
4,0%

-

Other commercial properties

-

a. LTV<60%

5,6%

-

b. 60%
8,0%

-

Unused properties

12,0%

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 6 (in millions rupiah)

Item

Total AYD

Faktor

(1)

(2)

(3)

Total Deviation (4)

NON-INVESTMENT

-

Direct Premium Written Receivables

0,0%

-

8,0%

-

Coinsurance Claims Receivables

-

Under OJK supervision

2,8%

Not Under OJK supervision:

-

a. Cluster 1

2,8%

-

b. Cluster 2

4,0%

-

c. Cluster 3

6,0%

-

d. Cluster 4

12,0%

-

e. Cluster 5

15,0%

-

Reinsurance Receivables

-

Under OJK supervision

2,8%

Not Under OJK supervision:

-

a. Cluster 1

2,8%

-

b. Cluster 2

4,0%

-

c. Cluster 3

6,0%

-

d. Cluster 4

12,0%

-

e. Cluster 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: *) For balanced mutual funds, factor is filled with the weighted average based on the composition of underlying assets as regulated in prevailing rules. If company does not fill in the factor fields, maximum factor (10%) will be used. rt = average weighted risk according to calculation LTV = loan to value, LTV is calculated based on the loan balance and market value of property Total funds taken into account in Schedule A are as follows: 1) 2013 = 50% 2) 2014 = 75% 3) 2015 = 100%

-

Annex I SEOJK Number: 02/SEOJK.05/2013 Dated: 27 August 2013 Page 7

PT XYZ GENERAL INSURANCE COMPANY REPORT OF SOLVENCY LEVEL Risk-Based Minimum Capital Schedule B – Risk of Mismatch between Projected Flow of Assets and Liabilities (in millions rupiah) Item (1) ASSETS Investments Time Deposits and Certificates of Deposits Shares Corporate Bonds and Corporate Sukuk Securities Issued by the Republic of Indonesia Securities Issued by Countries other than Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Entities Mutual Funds Assets-Backed Securities Collective Investment Contract Real Estate Investment Funds Direct Investment Buildings with Strata-title Rights or Land with Buildings for Investment Purchases of Receivables Pure Gold Mortgage-backed Loan Total Investment Non-Investment Cash and Bank Direct Premium Written Receivables Coinsurance Claims Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Buildings with Strata-title Rights or Land with Buildings for Private Use Total Non-Investment TOTAL ASSETS LIABILITIES AND EQUITY Liabilities Payables Claim Payables Coinsurance Payables Reinsurance Payables Commission Payables Tax Payables Accrued Expenses Other Payables Total Payables Technical Reserve Premium Reserve Unearned Premium Reserve Claim Reserve Total Technical Reserve TOTAL LIABILITIES DIFFERENCE BETWEEN LIABILITIES AND ASSETS

More than 1 Year up to 3 Years (3)

Up to 1 Year (2)

DEVIATION (4% X (Max (Li - AYDi), 0)) Note:

AYDi = AYD book value that reaches maturity on period i Li = liabilities book value that reaches maturity on period i The total funds taken into account in schedule B are as follows: 1) 2013 = 50% 2) 2014 = 75% 3) 2015 = 100%

More than 3 Year up to 5 Years (4)

More than 5 Year up to 10 Years (5)

More than 10 Years

Total

(6)

(7)

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 8

PT XYZ GENERAL INSURANCE COMPANY REPORT OF SOLVENCY LEVEL Minimum Risk-Based Capital Schedule C – Risk of Mismatch between Values of Assets and Liabilities in All Types of Currency Description (1)

USD (2)

SGD (3)

J PY (4)

GBP (5)

DKK (6)

FRF (7)

HKD (8)

EUR (9)

(in millions rupiah) Total (11)

IDR (10)

Admitted Assets Time Deposits and Certificates of Deposits 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 Entities Mutual Funds Assets-Backed Securities Collective Investment Contract Real Estate Investment Funds Direct Investment Buildings with Strata-title Rights or Land with Buildings for Investment Purchases of Receivables Pure Gold Mortgage-backed Loan Cash and Bank Direct Premium Written Receivables Coinsurance Claims Receivables Reinsurance Receivables Investment Receivables Investment Income Receivables Buildings with Strata-title Rights or Land with Buildings for Private Use Total Admitted Assets Allowable

-

-

-

-

-

-

-

-

-

Liabilities Claim Payables Coinsurance Payables Reinsurance Payables Commission Payables Tax Payables Accrued Expenses Other Payables Premium Reserve Unearned Premium Reserve Claim Reserve Total Liabilities

-

-

-

-

-

-

-

-

-

0,3

0,3

0,3

0,3

0,3

0,3

0,3

0,3

0,3

-

-

-

-

-

-

-

-

-

Foreign Exchange Total Admitted Assets in Rupiah Total Liabilities in Rupiah Difference between Admitted Assets and Liabilities Factor Deviation in Assets and Liabilities In Each Foreign Currency Note: This column may be expanded in line with the foreign currencies used.

-

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 9

PT XYZ GENERAL INSURANCE COMPANY REPORT OF SOLVENCY LEVEL Risk-Based Minimum Capital Schedule D – Insurance Liabilities Risk Non renewable (> 1 Year) Insurance Branch (1) Property Motored Vehicle (Own Damage, Third Party Liability, and Personal Accident ) Marine Cargo Marine Hull Aviation Hull Satellite Onshore Energy (Oil and Gas) Offshore Energy (Oil and Gas) Engineering Liabilities Credit Suretyship Misc.

(in millions rupiah) Total Deviation (3) (4)

CP

CP*

(2)

Life*) Total max ((CP* - CP), 0)

-

-

-

Renewable (0-1 Year/ <1 Year) Insurance Branch (1) Property Motored Vehicle (Own Damage, Third Party Liability, and Personal Accident ) Marine Cargo Marine Hull Aviation Hull Satellites Onshore Energy (Oil and Gas) Offshore Energy (Oil and Gas) Engineering Liabilities Credit Suretyship Misc.

(in millions rupiah) CAPYBMP

AR

fcp

(2)

(3)

(4) 25% 25%

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

-

-

Total Deviation CAPYBMP ((2) - (3)) x (4) (5) -

30% 30% 30% 25% 35% 35% 25% 35% 30% 25% 25%

-

10%

-

CK

AR

fck

(6)

(7)

(8) 20% 20%

-

Total Deviation CK ((6) - (7)) x (8) (9)

-

25% 25% 25% 20% 30% 30% 20% 30% 25% 20% 20%

-

-

10%

-

-

-

-

-

to be fill out if the company is a reinsurance company = Premium Reserve according to statement of financial position (balance sheet) and according to the company’s actuary calculation CP CP* = Premium Reserve calculated with the best estimate added with margin for deterioration risk with 95% of confidence level of Premium Reserve Adequacy (company level) CAPYBMP i = Unearned Premium Reserve for business line i AR CKi fcpi fcki

= Reinsurance assets = Claim Reserve for business line i = Unearned Premium Reserve risk factor for business line i = Claim Reserve risk factor for business line i

(10) -

Note: *)

Total Deviation (5) + (9)

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page10

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

Item (1)

(in millions rupiah) Total (2)

CPrf CPo

Maks((CPrf-CPo),0)

f

-

RTB

RTB

-

Note: -

CPrf = Premium Reserve calculated with risk-free interest according to the calculation PER 08 Year 2012 - Cpo = Premium Reserve calculated with actuary interest according to the calculation PER 08 Year 2012 - fRTB = interest level ratio factor - fRTB Year 2013 = 5% - fRTB Year 2014 = 10% - fRTB Year 2015 = 15%

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 11

PT XYZ GENERAL INSURANCE COMPANY REPORT OF SOLVENCY LEVEL Minimum Risk-Based Capital Schedule F – Reinsurance Risk (in millions rupiah)

Reinsurer Name

Deposit Or Premium

Reinsurer’s Technical Reserves

Held in Ceding Company (3)

Expenses (1) Under OJK supervision … … … Not under OJK supervision a. Cluster 1 … b. Cluster 2 … c. Cluster 3 … d. Cluster 4 … e. Cluster 5 … Total

Net Reinsurance Exposure ((2) - (3))

(2)

Factor

Total Deviation ((4) x (5))

(4)

(5) 2,8% -

(6) -

2,8% -

4,0%

-

6,0%

-

12,0%

-

15,0%

-

-

-

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 12

PT XYZ GENERAL INSURANCE COMPANY REPORT OF SOLVENCY LEVEL Minimum Risk-Based Capital Schedule G – Operational Risk (in millions rupiah) Item (2) General and Administrative Expenses Training and Education Expenses Operational complexity proxy Deviation

Total (3)

Note: For Quarterly Statement, General and Administrative Expenses as well as Training and Education Expenses are the General and Administrative Expenses and Training and Education Expenses of the last 4 (four) Quarters.

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 13

PT XYZ GENERAL INSURANCE COMPANY SAP ASSETS AND LIABILITIES CALCULATION Non Consolidated Per … Quarter … Year … I. SAP ASSETS CALCULATION

Item (1) Investment Time Deposits and Certificates of Deposits Shares Corporate Bonds and Corporate Sukuk Securities Issued by Republic of Indonesia Securities Issued by Countries other than Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Entities Mutual Funds Assets-Backed Securities Collective Investment Contract Real Estate Investment Funds Direct Investment Buildings with Strata-title Rights or Land with Buildings for Investment Purchases of Receivables for Financing Companies and/or Bank Pure Gold Mortgage-backed Loan Other Investments Total Investment Non-Investment Cash and Bank Direct Premium Written Receivables Coinsurance Claims Receivables Reinsurance Receivables Investment Receivables Investment Yields Receivables Buildings with Strata-title Rights or Land with Buildings for Private Use with Buildings for Private Use Other Fixed Assets Other Assets Total Non-Investment TOTAL ASSETS

(in millions rupiah) Difference between SAK and SAP Valuation (4)

Valuation Based on SAP (3)

Balance in Ledger (SAK) (2)

Admitted Assets (SAP Balance) (6)

Non-admitted Assets (5)

-

-

-

-

-

-

-

-

-

-

-

-

Note: Total Investment used as the basis for calculating the limit of admitted asset and the limit of investment on one entity is in the same amount as the amount of investment in column (4), except for other investments, namely

-

-

II. SAP LIABILITIES CALCULATION

Item (1) Payables Premium Reserve Unearned Premium Reserve

Difference between SAK and SAP Valuation (4) = (2) - (3) -

Valuation Based On SAP (3)

Balance in Ledger (SAK) (2)

Claim Reserve TOTAL LIABILITIES Difference SAK and SAP Valuation (Total Assets in Column 5 minus Total Liabilities in Column 5)

-

-

-

(Moved to Line 65 of Statement of Financial Position )

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 14

PT XYZ GENERAL INSURANCE COMPANY SAP ASSETS AND LIABILITIES CALCULATION SUB A - INVESTMENT PLACEMENT NOT ON ONE ENTITY Per … Quarter … Year … (in millions rupiah)

Investment Type

(1) Domestic Placement Time Deposit and Deposit Certificates Shares Corporate Bonds and Corporate Sukuk Securities Issued by Republic of Indonesia Securities Issued by Countries other than Republic of Indonesia Securities Issued by Bank Indonesia Securities Issued by Multinational Entities Mutual Funds Assets-Backed Securities Collective Investment Contract Real Estate Investment Funds Direct Investment Buildings with Strata-title Rights or Land with Buildings for Investment Purchases of Receivables for Financing Companies and/or Bank Pure Gold Mortgate-backed Loan Sub Total Overseas Placement Shares Corporate Bonds and Corporate Sukuk Securities Issued by Countries other than Republic of Indonesia Securities Issued by Multinational Entities Mutual Funds Direct Investment Sub Total Total Sub A

Details

(2)

AYD after Limitation Per Investment Type and/or Investment Overseas (3)

101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 102 103 104 107 108 111 -

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 15

PT XYZ GENERAL INSURANCE COMPANY SAP ASSETS DAN LIABILITAS CALCULATION SUB B - INVESTMENT PLACEMENT IN ENTITIES AFFILIATED WITH THE COMPANY Per … Quarter … Year … (in millions rupiah) Admitted Assets After Limit Per

Placement in Company (Name of Company) (1) PT

PT

PT

Details Investment Type

(2) a. Time Deposit and Deposit Certificates b. Shares c. Corporate Bonds and Corporate Sukum d. Mutual Funds e. Assets-Backed Securities Collective Investment Contract f. Real Estate Investment Funds g. Direct Participation Total Placement in this Company a. Time Deposit and Deposit Certificates b. Shares c. Corporate Bonds and Corporate Sukuk d. Mutual Funds e. Assets-Backed Securities Collective Investment Contract f. Real Estate Investment Funds g. Direct Investment Total Placement in this Company a. Time Deposit and Deposit Certificates b. Shares c. Corporate Bonds and Corporate Sukuk d. Mutual Funds e. Assets-Backed Securities Collective Investment Contract f. Real Estate Investment Funds g. Direct Investment Total Placement in this Company Total Sub B

(3) 101 102 103 108 109 110 111

Type of Investment and Investment Overseas (4)

Non-admitted Assets (5)

AYD (Admitted Asset)

(6)

-

-

-

-

-

-

-

-

-

101 102 103 108 109 110 111 101 102 103 108 109 110 111

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 16

PT XYZ GENERAL INSURANCE COMPANY SAP ASSETS AND LIABILITIES CALCULATION SUB C - PLACEMENT IN ENTITIES UNAFFILIATED WITH COMPANY Per … (in millions rupiah) Admitted Assets After Limit Per

Placement in Company (Name of Company)

Details

Type of

AYD (Admitted

Investment and Investment

Investment Type

Asset)

Non-Admitted Assets

Overseas

(1) PT

PT

PT

(2) a. Time Deposit and Deposit Certificates b. Shares c. Corporate Bonds and Corporate Sukuk d. Mutual Funds e. Assets-Backed Securities Collective Investment Contract f. Real Estate Investment Funds g. Direct Investment Total Placement in this Company a. Time Deposit and Deposit Certificates b. Shares c. Corporate Bonds and Corporate Sukuk d. Mutual Funds e. Assets-Backed Securities Collective Investment Contract f. Real Estate Investment Funds g. Direct investment Total Placement in this Company a. Time Deposit and Deposit Certificates b. Shares c. Corporate Bonds and Corporate Sukuk d. Mutual Funds e. Assets-Backed Securities Collective Investment Contract f. Real Estate Investment Funds g. Direct investment Total Placement in this Company Total Sub C

(3) 101 102 103 108

(4)

(5)

109 110 111

(6)

-

-

-

101 102 103 108 109 110 111

-

-

-

101 102 103 108 109 110 111 -

-

-

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 17

PT XYZ GENERAL INSURANCE COMPANY SAP ASSETS AND LIABILITIES CALCULATION SUB D – INVESTMENT PLACEMENT OVERSEAS Per … Quarter … Year … (in millions rupiah) Placement in Investment Placement Type

Company (Name Of Company and/or

Admitted Assets After Limit Per Type of

Asset)

Investment and

Non-Admitted

Investment (2) Shares

Name of Country) (3) … … …

Sub Total Corporate Bonds and Corporate Sukuk

Assets

(4)

(5)

(6)

-

-

-

-

-

-

-

-

-

Sub Total … … …

-

-

-

Sub Total … … …

-

-

-

Sub Total Total Sub D

-

-

-

… … …

Sub Total Securities Issued by Contries other than Republic of Indonesia

AYD (Admitted

… … …

Sub Total Securities Issued by Multinational Entities … … …

Mutual Funds

Direct Investment

Annex I SEOJK Number: 2/SEOJK.05/2013 Dated: 27 August 2013 Page 18

PT. XYZ GENERAL INSURANCE COMPANY SUB E – LIST OF AFFILIATED COMPANIES Per … Quarter … Year … I. Investment Placement in Entities Affiliated with Company Ownership Company Name (1)

Ownership Relations (2)

Line of Business (3)

… … … II. Investment Placement in Entities Unaffiliated with Company Company Name (1) … … …

Group Name (2)

Line of Business (3)

Percentage (4)

Value of Ownership (5)