# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Not specified]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** [Name not specified]
**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:
- **On Account:** Web billed $101,047 @ 40.2% = $40,620.89
- **Invoice Payment:** We Shipped $59,381 @ 40.2% = $23,871.16
- **Countersignature Fee:** $41,666 @ 0% = $0
- **Finders Fee:** $101,047
- **Difference Due Zurich:** $16,749.73

## Box A:
- **Client No.:** [Not specified]
- **Invoice No.:** [Not specified]
- **Invoice Item No.:** [Not specified]
- **Share Item No.:** [Not specified]
- **Payee No.:** [Not specified]
- **A/P Type:** [Not specified]
- **Tax Code:** [Not specified]

## Box B:
- **Amount:** $16,749.73
- **Client No.:** 23055000000
- **Invoice No.:** 250947
- **Invoice Item No.:** 008
- **Payee No.:** 15102
- **Reason Code:** [Not specified]
- **Comm. Share:** [Not specified]
- **Dept. No.:** 3010
- **A/P Type:** [Not specified]
- **Currency Rate:** [Not specified]
- **Currency Co.:** [Not specified]
- **Tax Code:** [Not specified]
- **Underwriter:** 15102
- **Attachment Date:** 05/21/87
- **Expiration Date:** 05/21/88
- **Prod L/POL T:** 40
- **POL VERIF:** P
- **Policy Status:** 1
- **Function:** [Not specified]
- **Policy No.:** CGL3218678103
- **Income:** [Not specified]
- **Premium:** $10,1047.00
- **Net Prem:** [Not specified]
- **Tax Amount:** [Not specified]
- **Share Amount:** [Not specified]
- **Share Dept.:** [Not specified]

**Stock #:** 4281A
**MM:** 009827