# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Document Number]
**Office Number:** OW
**Office Name:** New York
**Prepared By:** [Prepared By]
**Dept.:** Casualty
**Authorized By:** [Authorized By]
**Date:** 7/13/87

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

## Box B:
- AMOUNT: $1,6749.73
- ATTACHMENT DATE: 05.01.87
- EXPIRATION DATE: 05.01.88
- PROD L/POL T: 40.40.0
- POL VERIF: A
- POLICY STATUS: 1
- FUNCTION: 
- POLICY NO.: CGL3278107803
- INCOME:
- PREMIUM: $1,01,047.00
- NET PREM:
- TAX AMOUNT:
- SHARE AMOUNT:
- SHARE DEPT.

## Additional Information:
- Client No.: 23055000001
- Invoice No.: 220941
- Invoice Item No.: 002
- Payee No.: 15102
- Reason Code:
- Comm. Share:
- Dept. No.: 2310
- A/P Type:
- Currency Rate:
- Currency Co.:
- Tax Code:
- Underwriter: 15106

**Stock #4281A**
**MM 009821**