**Johnson & Higgins**

| Field | Description |
|-------|-------------|
| Client No. | [ ] |
| Invoice No. | [ ] |
| Billing Date | [ ] |
| Amount | [ ] |

**Payable Upon Receipt, Attachment Date, or Installment Date, Whichever is Latest**

**Insurance Description** | **Department** | **J & H Contact** | **Amount** |
|------------------------|---------------|-------------------|------------|
| Insurance Company | Dates | Policy Number | Description | Amount |

**Attachment Expiration**

**Total** | [ ] |

**Johnson & Higgins**

MM 009647