APPENDIX D

Due Diligence Questionnaire and Certification

The AIA Group companies and its employees (“AIA Group”) are required and committed
to comply with U.S. and non-U.S. laws applicable to the AIG Group’s worldwide
operations. In furtherance of those legal obligations and as an initial step in our due
diligence review process, please complete the following Questionnaire. Based on your
response, the AIA Group may request additional information about you and your
company.

Please answer these questions as completely and accurately as possible. Where

information is incomplete or not ascertainable, please so state. The AIA Group
appreciates your assistance with this important process.

Please contact the LCO at +622154218888, or by email at andri.hasian@aia.com, with

any questions.

I. CONTACT INFORMATION
Please provide the following information about your company, if applicable:

Legal Name:
Other Names if any
(e.g., d/b/a, o/k/a):
Principal place of business:

Address:

Phone: Fax:
Business web site if
any:
(i)
Address of other
offices (if any):
(ii)

Contact Person:

Contact’s Title:
Contact
Contact’s Phone:
Fax:
Contact’s Email:

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Name(s) and Title(s)

of other contact(s) if
any:

II. EMPLOYMENT INFORMATION (IF APPLICABLE)

Job title:
How long have you been employed in this
position?
What are your duties?

III. COMPANY INFORMATION

Please describe the nature of the company’s principal line of business:

How long has the company been in

operation?
What type of business entity is the company
(e.g., LLC, partnership)
Is the company registered to do business? YES NO

If yes, where is the company registered?

Tax Identification/Registration No.:

Registration No.:

Registered Address:

When was the company registered?

Has the company’s registration ever been terminated voluntarily or involuntarily? If so,
please provide an explanation of the circumstances of the termination, and reinstatement, if
any.

PLEASE INCLUDE A COPY OF THE REGISTRATION AND REINSTATEMENT

CERTIFICATE(S) OR OTHER REINSTATEMENT DOCUMENTS, IF ANY.

Does the company hold a license to conduct its principal line of business?

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 APPENDIX D

YES NO

IF YES, PLEASE INCLUDE A COPY OF THE LICENSE WITH THIS RESPONSE.

How many employees does the company
have?
Please describe the company’s other (non-principal) business activities, if any:

Please list all other offices of the company, with address, not listed above (add additional
sheets if necessary):

IV. COMPANY OWNERSHIP

Please provide the following information about the owners/partners of the company:
Name of Place of Percentage Date of Acquisition of
Owner/Partner incorporation Ownership Interest

Do any other persons or entities hold an interest in the company’s equity, debt, revenues or
profits, whether directly or indirectly?
YES NO
Are any other persons or entities able to exercise control over the company through any
other arrangement or relationship?
YES NO

If yes to either question, please provide names and other details:

Please provide the following information about the Officers and Directors of the Company:

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 APPENDIX D

Name Title

Does any principal, owner, partner, director, officer or employee of the company or any
affiliate currently hold any official office with or have any duties, including any consulting or
ceremonial positions, for any domestic or foreign government entity (including public
international organizations, agencies, subdivisions, wholly or partially state-owned
enterprises, etc.)?

YES NO

If yes, please provide the following:

Name Position(s) Held Government Entity

Does any principal, partner, owner, director, officer or employee currently hold any office or
position in any political party or is any a candidate for any political office?
YES NO

If yes, please provide the following:

Name Position(s) Held Political Party(ies)

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Is any member of the immediate family of any of the principals, owners, partners, directors,
officers or employees of the company or any affiliate one or more of the following:
An official of any
YES NO
government/government agency?
An employee of any
YES NO
government/government agency?
An official of a political party? YES NO

A candidate for political office? YES NO

If yes, please providing the following:

Position(s)/Office(s)
Name Familial Relationship
Held

V. JOINT VENTURES
Please provide the following information about any Joint Venture Partner with which your
company is involved.
Name of Place of Percentage Date of Acquisition of
Owner/Partner Incorporation Ownership Interest

VI. BANK ACCOUNT

Please provide the following information about the bank account in which the company will
receive payment from the AIA Group if engaged.
Bank Name Bank Location Account Number Routing Number

VII. REFERENCES
Accountants/auditors. Please provide the name and contact information for the company’s
outside accountants or auditors.

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Will the company use any non-employee contractors to perform work for the AIA Group?

YES NO

If so, please describe:

If any of these non-employee contractors have ties to government officials, officials of

political parties or candidates for political office, please identify the person, the office held or
sought, proposed duties under this representation, and whether the office
relates to those duties.

VIII. FOREIGN CORRUPT PRACTICES ACT COMPLIANCE

Has your company or any affiliated entity ever offered, promised, or given anything of value
directly or indirectly to a Government Official?

YES NO

If yes, please provide details including what was offered or given, to whom it was given, the
reason that the payment was offered or made, the date the payment was made, the location
in which the payment was made, and how your company became aware of the payment.

Have you ever received a request for payment, gift or kickback from any government
official?
YES NO
Have you ever been a party to a proceeding anywhere in the world for violation of applicable
anti-bribery laws or regulations?
YES NO

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 APPENDIX D

If yes to either of the above, please provide details:

Are you familiar with and do you understand obligations under the U.S. Foreign Corrupt
Practices Act (“FCPA”)?
YES NO

Has your company or any associated or previously associated entity, any predecessor
entity or any present or former owner, manager, partner, director, officer, employee or
consultant of your company been within the last ten years (10) years: (a) suspended from
doing business in any capacity; (b) charged or indicted with any criminal act; (c) the subject
of any allegation or investigation of fraud, bribery, misrepresentation or similar
circumstances; (d) mentioned in the press for having been involved in any improper
activity; or (e) terminated by a client because of ethical or legal concerns?

YES NO
If yes, please provide complete details including the entities, dates, and outcome or
disposition.

CERTIFICATION

The undersigned entity hereby certifies that the information provided in this Questionnaire
is complete and accurate to the best of our knowledge and belief. We certify that if we
learn of any additional information that is relevant to this questionnaire, we will promptly
report that information to the AIA Local Compliance Officer at the address below. We
further certify that we have not engaged in, nor will we in the future engage in, any conduct
that violates AIG’s Global Anti-Corruption Policy, the Foreign Corrupt Practices Act, or other
applicable anti-corruption laws. We acknowledge and agree we will be required from time
to time to certify to the AIA Group regarding our compliance with the Global Anti-Corruption
Policy, the FCPA, and any applicable anticorruption laws in our jurisdiction.

Name of
Company:

By:

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 APPENDIX D

Printed Name:

Title:

Date:

Andri Hasian
PT. AIA FINANCIAL, Menara Matahari Lt.7, Jl. Bulevar Palem Raya 7, Lippo Karawaci
+6221 54218888
+6221 5475416
andri.hasian@aia.com

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