**Johnson & Higgins**

**MAIN TO DEPT NO:**  
**BUS FUNCTION:**  
**RATING:**  
**INSURANCE:**  
**SHIPPING CO.:**  
**HARVEY CARRIAGE:**  
**CASH:**  
**SCHEDULED:**  
**WIZARDS:**  

**CLIENT NO:**  
**INVOICE NO:**  
**BILLING DATE:**  
**AMOUNT:**  

**PLEASE ATTACH RECEIPT, ATTACHMENT DATE:**  
**OR BILLING DATE, INVOICE NO. LATER:**  

**DEPARTMENT:**  
**POLICY NUMBER:**  
**DESCRIPTION:**  
**AMOUNT:**  

**BANK:**  
**LAST NAME:**  
**FIRST NAME:**  
**ADDRESS:**  
**CITY:**  
**STATE:**  
**ZIP CODE:**  

**TOTAL:**  
**JOHNSON & HIGGINS**  

**MM 009557**