# Document Image

The document appears to be a financial or billing form, likely related to insurance or a similar service. Here is the transcription of the visible information:

---

**JOHNSON & Higgins**

G. P. O., BOX 5830  
NEW YORK, NEW YORK 10007  
(212) 574-7000  

**INTL BUSINESS MACHINES CORP.**  
ATT MR J COSTELLO DIRECTOR  
209 HARBOR PLAZA-P O BOX 10501  
STANFORD CT 06901  

**BILL TO**  
MAIL TO  
FUNCTION  
BILL TYPE  
INCOME CALC  
CURRENCY  
ORIGINAL INV  
SUSPENSE  
ISSUE  
INSTALLMENT  
PERIODS  
DEPOSIT  
CONTROL NO  

**BSD NO**  
PROCESS DATE  
PARENT  
OVERRIDE  

**CLIENT NO**  
INVOICE NO  
DATE  
AMOUNT  

**TOTAL**  
COMMISSION  
.00  
.00  

**INS CO**  
INS CO  
LOC  
CODE  
RATE  

**CLASS**  
B  
TCA VET  
51106  
511AF  
51199  
51199  
51199  

**POLICY NUMBER**  
DESCRIPTION  
AMOUNT  

**POLICY NUMBER**  
DESCRIPTION  
AMOUNT  

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DESCRIPTION  
AMOUNT  

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