# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Document Number]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** [Prepared By]
**For:** James Duddy
**Dept.:** Casualty
**Authorized By:** [Authorized By]
**Date:** 7/5/89

## Function:
- FROM & TO (A, B)
- BOUNCED CHECK (B)
- DIRECT PAYMENT (B)
- CLAIMS (B)
- INCOME & PAYABLE (B)
- PAYEE CHANGE (A, B)
- DIRECT PAYMENT-COMM ONLY (B)
- INCOME SHARE ADJUSTMENT (B)

## From & To Options:
- FROM: A/R CASH
- TO: A/R

## As:
- ON ACCOUNT
- INVOICE PAYMENT
- COUNTERSIGNATURE FEE
- FINDERS FEE
- REVERSE FINDERS FEE
- MISC. INCOME
- COMM. RECEIPT BILLED
- PAYABLE RECEIPT
- DIRECT BILL

## Box A:
- CLIENT NO.
- INVOICE NO.
- INVOICE ITEM NO.

## Box B:
- AMOUNT: $167,529.5
- ATTACHMENT DATE: 05/21/87
- EXPIRATION DATE: 05/21/88
- PROD L/POL T: 4.0
- POL VERIF: 4.0
- POLICY STATUS: 7
- FUNCTION: 0
- POLICY NO.: 05327867803
- INCOME: 10,053.00
- PREMIUM: 10,053.00
- NET PREM: 10,053.00
- TAX AMOUNT: 0
- SHARE AMOUNT: 0
- SHARE DEPT: 0
- UNDERWRITER: 15100

## Notes:
- We took 10,055 @ 40.2 = 40,624
- We sh'taken 41,674 @ 0% = -
- 59,381 @ 40.2 = 23,871.6
- Difference due Zurich $16,752.95