Fill out the following worksheet and give it to the person who will be given the responsibility of your finances in the event of your death and place a copy with your will.

The following policies will be affected by my death:

Policy #                                          Company                                                      Agent Phone #

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I have the following bank accounts:

Account #                                          Bank Branch                                                      Phone #

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Accountant's name ___________________ Phone ______________________________

Lawyer's name ______________________ Phone ______________________________

Comments_______________________________________________________________

________________________________________________________________________

Name ______________________________

Social Security # ______________________