# Johnson & Higgins BIS Financial Source Document

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

**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: We billed $101,007.40.2 = $40,620.59
- INVOICE PAYMENT: We billed $59,351.40.2 = $23,871.16
- COUNTERSIGNATURE FEE: $41,666.00
- FINDERS FEE: $101,007.23,871.16
- REVERSE FINDERS FEE: $0.00
- MISC. INCOME: Difference due $16,749.73
- COMM. RECEIPT BILLED: Zurich
- PAYABLE RECEIPT
- DIRECT BILL

**Box A:**
- CLIENT NO.
- SHARE ITEM NO.
- INVOICE NO.
- PAYEE NO.
- INVOICE ITEM NO.
- A/P TYPE
- TAX CODE

**Box B:**
- AMOUNT: $1,674,917.73
- ATTACHMENT DATE: 05/21/87
- EXPIRATION DATE: 05/21/88
- PROD L/POL T: 4.0
- POL VERIF: 4.0
- POLICY STATUS: [Blank]
- FUNCTION: [Blank]
- POLICY NO.: 05217867803
- INCOME: [Blank]
- PREMIUM: $1,010,471.00
- NET PREM: [Blank]
- TAX AMOUNT: [Blank]
- SHARE AMOUNT: [Blank]
- SHARE DEPT.: [Blank]

**Reason Code:** [Blank]
**COMM. SHARE:** [Blank]
**DEPT. NO.:** 3.01.0
**A/P TYPE:** [Blank]
**CURRENCY RATE:** [Blank]
**CURRENCY CO.:** [Blank]
**TAX CODE:** [Blank]
**UNDERWRITER:** 1510.6

**Stock #:** 4281A
**MM:** 009829