OUTWARD FACULTATIVE ENDORSEMENT REINSURANCE SLIP

THE CEDING COMPANY

Type of Insurance : Polis Standard Asuransi Gempa Bumi Indonesia
Policy No. : 1001220121000017
Period of Cover : December 31, 2020 to December 31, 2021
Name of Insured :
Address :

THE REINSURER
ID No. : O10PT00002
Name : PT. TrinityRE Reinsurance Brokers
Address : Cyber 2 Tower, 6th Floor Jl. H.R. Rasuna Said blok X-5 No. 13 Jakarta 12950,
Indonesia
Remarks :

SIGNED FOR AND ON BEHALF OF THE COMPANY

PT. MALACCA TRUST WUWUNGAN INSURANCE Tbk The Reinsurer

Signed at JAKARTA on April 20, 2021

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FENMI0000E.RPT / ika Page 2 of 4
 OUTWARD FACULTATIVE ENDORSEMENT REINSURANCE SLIP

THE CEDING COMPANY

Type of Insurance : Polis Standard Asuransi Gempa Bumi Indonesia
Policy No. : 1001220121000017
Period of Cover : December 31, 2020 to December 31, 2021
Name of Insured : WAHANA OTTOMITRA MULTIARTHA, PT
and/or associated and/or subsidiary and/or affiliated companies including those
acquired or incorporated during the period of insurance for their respecve rights
and interest
Address : GEDUNG ALTIRA BUSINESS PARK LANTAI 32
JL. YOS SUDARSO KAV. 85 BLOK H NO. 12-15 JAKARTA UTARA - DKI
JAKARTA

THE REINSURER
ID No. : O10PT00002
Name : PT. TrinityRE Reinsurance Brokers
Address : Cyber 2 Tower, 6th Floor Jl. H.R. Rasuna Said blok X-5 No. 13 Jakarta 12950,
Indonesia
Remarks :

SIGNED FOR AND ON BEHALF OF THE COMPANY

PT. MALACCA TRUST WUWUNGAN INSURANCE Tbk The Reinsurer

Signed at JAKARTA on April 20, 2021

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 DEBIT NOTE
Name : PT. TrinityRE Reinsurance Brokers
Address : Cyber 2 Tower, 6th Floor Jl. H.R. Rasuna Said blok X-5 No. 13 Jakarta 12950,
Indonesia
Gross Premium Reinsured : USD 203.775 Note No. : 028379/DN/10/04/21
R / I Commision : USD (106.982) Policy No. : 1001220121000017
Net Premium Reinsured : USD 96.793 Cession No. : 1001220421000004
Stamp Duty : USD 0.000
+/- : USD (0.003)
Total amount due to us : USD 96.790

Installment :
1st 05/04/2021 USD 24.200 2nd 05/05/2021 USD 24.200
3rd 05/06/2021 USD 24.200 4th 05/07/2021 USD 24.190

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