**JOHNSON & HIGGINS**
INSURANCE BROKERS, AVERAGE ADJUSTERS
EMPLOYEE BENEFIT PLANNING
95 WALL STREET - NEW YORK, N.Y. 10005
TEL: (212) 482-2000

| FIELD | DATA |
|-------|------|
| BILL NO. | 1234567890 |
| CUSTOMER NAME | Acme Corp. |
| BILL TYPE | 1 |
| BILL DATE | 1/1/2023 |
| INVOICE DATE | 1/1/2023 |
| SHIP TO | Acme Corp. |
| BILL CURE | 1 |
| ISSUE | 1 |
| CANCEL | 1 |
| SCHEDULED PAYMENT DATE | 1/1/2023 |
| DEPOSITED BY | Johnson & Higgins |
| DEPOSITED DATE | 1/1/2023 |
| DEPOSITED AMOUNT | $10,000 |
| DEPOSITED BY | Johnson & Higgins |
| DEPOSITED DATE | 1/1/2023 |
| DEPOSITED AMOUNT | $10,000 |
| TOTAL | $20,000 |

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