# 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:** 7/16/82

## 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

## Box A:
- Client No.
- Invoice No.
- Invoice Item No.

## Box B:
- Amount: $16,749.93
- Client No.: 23055000000
- Invoice No.: 220948
- Invoice Item No.: 0.09
- Payee No.: 1516.0
- 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: 15106

## Additional Information:
- Web billed: 101,047 @ 40.2 = 40,620.89
- Net billed: 59,381 @ 40.2 = 23,871.16
- Finders Fee: 41,666.00
- Difference due Zurich: 16,749.73

**Attachments:**
- Attachment Date: 05/21/87
- Expiration Date: 05/21/88
- Prod L/POL T: 4.0
- POL VERIF: 1.8
- Policy Status: 71
- Function: [Not specified]
- Policy No.: 6327867803
- Income: 101047.00
- Premium: 101047.00
- Net Prem: [Not specified]
- Tax Amount: [Not specified]
- Share Amount: [Not specified]
- Share Dept.: [Not specified]

**Stock #: 4281A**
**MM 009828**