# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Not specified]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** William F James Duddy
**Dept.:** Casualty
**Authorized By:** [Name not specified]
**Date:** 7/6/87

## 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: AS:
- FROM: A/R CASH
- TO: A/R
- A/P ON ACCT
- A/P
- INCOME
- 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: $16,749.73
- ATTACHMENT DATE: 05/21/87
- EXPIRATION DATE: 05/21/88
- PROD L/POL T: 4.0
- POL VERIF: 1.0
- POLICY STATUS: 1
- FUNCTION: [Blank]
- POLICY NO.: CG-L397X67803
- INCOME: [Blank]
- PREMIUM: $1,047.30
- NET PREM: [Blank]
- TAX AMOUNT: [Blank]
- SHARE AMOUNT: [Blank]
- SHARE DEPT.: [Blank]

## Additional Information:
- We billed: 101,047 @ 40.2 = 40,620.89
- Us shield: 59,381 @ 40.2 = 23,871.16
- Difference due Zurich: 16,749.73