# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Not specified]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** James Duddy
**Dept.:** Casualty
**Authorized By:** [Name not specified]
**Date:** 7/16/87

## Function:
- **From & To (A,B):** No
- **Bounced Check (B):** No
- **Direct Payment (B):** No
- **Claims (B):** No
- **Income & Payable (B):** Yes
- **Payee Change (A,B):** No
- **Direct Payment - Comm Only (B):** No
- **Income Share Adjustment (B):** No

## From & To Options:
- **From:**
  - A/R Cash: No
  - A/R Credit: No
  - A/P On Acct: No
- **To:**
  - A/R: No
  - A/P: No
  - Income: No

## AS:
- **We billed:** 101,047 @ 40.2 = 40,620.89
- **West billed:** 59,381 @ 40.2 = 2,3571.16
- **41,666.00**
- **Difference due:** 16,749.73

## Box A:
- **Client No.:** [Not specified]
- **Invoice No.:** [Not specified]
- **Invoice Item No.:** [Not specified]

## Box B:
- **Amount:** 16,749.73
- **Client No.:** 2055000000
- **Invoice No.:** 920944
- **Invoice Item No.:** 0.0
- **Payee No.:** 15180
- **Reason Code:** [Not specified]
- **Comm. Share:** [Not specified]
- **Dept. No.:** B1210
- **A/P Type:** [Not specified]
- **Currency Rate:** [Not specified]
- **Currency Co.:** [Not specified]
- **Tax Code:** [Not specified]
- **Underwriter:** 15106
- **Attachment Date:** 05/21/87
- **Expiration Date:** 05/21/89
- **Prod L/POL T:** 40 40.0
- **POL VERIF:** [Not specified]
- **Policy Status:** [Not specified]
- **Function:** [Not specified]
- **Policy No.:** 6397867803
- **Income:** [Not specified]
- **Premium:** 101047.09
- **Net Prem:** [Not specified]
- **Tax Amount:** [Not specified]
- **Share Amount:** [Not specified]
- **Share Dept.:** [Not specified]

**Stock #:** 4281A
**MM:** 009825