# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Blank]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** James Duddy
**Dept.:** Casualty
**Authorized By:** [Signature]
**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
- 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: $167,491.73
- ATTACHMENT DATE: 05/15/87
- EXPIRATION DATE: 05/15/89
- PROD L/POL T: 4.0
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO.: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00
- CURRENCY RATE: 1.0
- CURRENCY CO: 1.0
- A/P TYPE: 1.0
- TAX CODE: 1.0
- REASON CODE: 1.0
- COMM. SHARE: 1.0
- DEPT. NO: 30.0
- PAYEE NO: 151.0
- INVOICE NO: 002
- INVOICE ITEM NO: 002
- CLIENT NO: 2305500000
- POLICY NO: 16321467803
- POL VERIF: A
- POLICY STATUS: 11
- FUNCTION: 11
- POLICY NO: 16321467803
- INCOME: $101,047.00
- PREMIUM: $101,047.00
- NET PREM: $101,047.00
- TAX AMOUNT: $23,871.12
- SHARE AMOUNT: $40,620.89
- SHARE DEPT.: 151.00
- UNDERWRITER: 151.00