LIFE INSURANCE BEQUEST As codicil and amendment to my will, dated ___________________, and witnessed by ______________________________, __________________________________, and ______________________________, I, ______________________________ declare the following: My executor shall be directed to pay $ ____________ to _______________________ ______________________ for my insurance policy number ___________________ as established with ______________________________________ insurance company on ___________________ (date). _____________________________________ ______________ Signature Date _____________________________________ ______________ Witness Date _____________________________________ ______________ Witness Date _____________________________________ ______________ Witness Date