Emergency Contact Information
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1EMERGENCY CONTACT INFORMATION
Work Assignment/ Location:
Date:
Name:
(Last)
(First)
(Payroll Number)
Date of Entry:
Date of Birth:
In case of death or serious injury, have a department representative contact:
Relative Information
Spouse Name:
Address:
Home Phone:
Work Phone:
Closest Relative:
Address:
Home Phone:
Work Phone:
Former Spouse:
Address:
Home Phone:
Work Phone:
Friend Information
Family Liaison:
Address:
Phone:
I would like him/her to accompany anyone sent to give injury/death notice to my family.
Religious Affiliation
Church Preference:
Religious Affiliation:
Clergyman:
Phone Number:
My family is aware of the beneficiaries listed on all my department insurance forms.
Yes
No
I have a letter written to my family explaining why I have named certain beneficiaries on my
policies. Yes
No
I would like full Fire Department honors if killed in the line of duty. Yes
No
This sheet was last updated on:
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Parent category: Business