EXTERNAL ENTITY MANAGEMENT (EEM) DOCUMENTS CHECK LIST

Company Name/Nama Perusahaan : ________________________________________________________________

Type of Legal Entity/Jenis Badan Hukum
NPWP Number/Nomor NPWP
Company Address/Alamat Perusahaan
Contact Person
Phone/Email/Facsimile/Mobile Phone
Summary Description of Services
: ________________________________________________________________
: ________________________________________________________________
: ________________________________________________________________
________________________________________________________________
: ________________________________________________________________
: ________________________________________________________________
:

Check
No. Type of Document/Jenis Dokumen Notes/Catatan
List
1. Copy of Business License/
Salinan Surat Izin Usaha
2. Copy of Company Registration Number/
Salinan Tanda Daftar Perusahaan (TDP)
3. Copy of Taxpayer Registration Number/
Salinan Nomor Pokok Wajib Pajak (NPWP)
4. Copy of Registered Statement Letter/
Salinan Surat Keterangan Terdaftar Wajib Pajak
5. Copy of Domicile Statement/
Salinan Surat Keterangan Domisili Perusahaan (SKDP)
6. Copy of Deed of Establishment (DOE)/
Salinan Akta Pendirian Perusahaan
7. Copy of Minister of Law and Human Rights Approval for Deed of
Establishment (DOE)/
Salinan Surat Pengesahan dari Menteri Kehakiman Untuk Akta Pendirian
8. Copy of the latest Articles of Association (AOA) of the Company/
Salinan Akta Perubahan Anggaran Dasar terakhir
9. Copy of Minister of Law and Human Rights Approval for the latest Articles
of Association (AOA) of the Company/
Salinan Surat Pengesahan dari Menteri Kehakiman untuk Akta Perubahan
Anggaran Dasar terakhir
10. Copy of the latest composition of the Board of Directors/Board of
Commissioners of the Company/
Salinan Akta Notaris Susunan Terakhir Dewan Direksi Dan Dewan
Komisaris Perusahaan
11. Copy of Notification from the Minister of Law and Human Rights/
Salinan Surat Penerimaan Pemberitahuan Dari Menteri Kehakiman Untuk
Akta Notaris Susunan Terakhir Dewan Direksi dan Dewan Komisaris
Perusahaan
12. Copy of Other License (if any)/
Salinan Izin-izin lain (jika ada)
13. Copy of Audited Financial Statement for the last 2 years/
Salinan Laporan Keuangan 2 tahun terakhir

Prepared by, Checked and Approved by,

(________________) (________________) (________________) (________________)

User Name & Dept. Legal Compliance Finance Controller
PT Asuransi Cigna PT Asuransi Cigna PT Asuransi Cigna PT Asuransi Cigna
Date: Date: Date: Date:
Note: Note: Note: Note:

Confidential, Unpublished property of Cigna. Do not duplicate or distribute.

Use and distribution limited solely to authorized personnel.
(c) Copyright Cigna Corporation