# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Blank]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** [Handwritten Name]
**Dept.:** Casualty
**Authorized By:** [Handwritten Name]
**Date:** 9/16/87

## 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
- 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: $16,749.73
- ATTACHMENT DATE: 05/21/87
- EXPIRATION DATE: 05/21/88
- PROD L/POL T: 40
- POL VERIF: 74
- POLICY STATUS: 1
- FUNCTION: [Blank]
- POLICY NO.: 66327867803
- INCOME: [Blank]
- PREMIUM: $10,104.71.00
- NET PREM: [Blank]
- TAX AMOUNT: [Blank]
- SHARE AMOUNT: [Blank]
- SHARE DEPT.: [Blank]

## Additional Notes:
- We billed 101,047 @ 40.2 = 40,620.89
- We sh billed 59,381 @ 40.2 = 23,871.16
- Difference due Zurich: $16,749.73