# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Document Number]
**Office Number:** 001
**Office Name:** NY
**Prepared By:** [Name]
**Dept.:** Casualty
**Authorized By:** [Name]
**Date:** 7/15/87

## Function:
- FROM & TO (A,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, A/R CREDIT, A/P ON ACCT
- TO: A/R, A/P, INCOME

## Box A:
- CLIENT NO.
- SHARE ITEM NO.
- INVOICE NO.
- PAYEE NO.
- A/P TYPE
- TAX CODE
- INVOICE ITEM NO.

## Box B:
- AMOUNT: $16,749.73
- ATTACHMENT DATE: 05/21/87
- EXPIRATION DATE: 05/21/87
- PROD L/POL T: 40
- POL VERIF: A
- POLICY STATUS: 1
- FUNCTION: 
- POLICY NO.: CGL321867803
- INCOME: $10,049.00
- PREMIUM: $10,049.00
- NET PREM: 
- TAX AMOUNT: 
- SHARE AMOUNT: 
- SHARE DEPT: 

## Additional Notes:
- We took 101,047 @ 40.2 = 40,620.59
- We sh'take 59,381 @ 41.2 = 23,871.60
- 41,666 @ 0 - 
- FINDERS FEE: 101,047
- REVERSE FINDERS FEE: 
- MISC. INCOME: Difference due Zurich 16,749.73
- COMM. RECEIPT BILLED: 
- PAYABLE RECEIPT: 
- DIRECT BILL: 

**Stock #: 4281A**
**MM 009820**