# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Not specified]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** [Name not specified]
**Dept.:** Casualties
**Authorized By:** [Name not specified]
**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

## Box A:
- Client No.
- Invoice No.
- Invoice Item No.
- Share Item No.
- Payee No.
- A/P Type
- Tax Code

## Box B:
- Amount: $1,674,917.3
- Client No.: 2305500000
- Invoice No.: 920950
- Invoice Item No.: 011
- Payee No.: 1514F
- Reason Code: [Not specified]
- Comm. Share: [Not specified]
- Dept. No.: 2010
- A/P Type: [Not specified]
- Currency Rate: [Not specified]
- Currency Co.: [Not specified]
- Tax Code: [Not specified]
- Underwriter: 1510G
- Attachment Date: 052187
- Expiration Date: 052188
- Prod L/POL T: 40 400
- POL VERIF: [Not specified]
- Policy Status: [Not specified]
- Function: [Not specified]
- Policy No.: [Not specified]
- Income: $1,047,000.00
- Premium: $1,047,000.00
- Net Prem: [Not specified]
- Tax Amount: [Not specified]
- Share Amount: [Not specified]
- Share Dept.: [Not specified]

**Webitted 101,047 @ 40.2 = 40,620.**
**Webhibited 59,381 @ 40.2 = 23,871.16**
**41,662 0 = 23,871.16**
**Difference due Zurich 16,749.73**

**Stock #4281A**
**MM 009830**