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    Emergency Information Form

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    Please note: This sample Emergency Information Form is provided for you by HR.com as a free service. The free hr templates and forms on this site are general in nature and not based on the laws of any specific state or other jurisdiction. Prior to using these policies or forms, we recommend that you consult with an attorney or other expert knowledgeable in the laws of the applicable jurisdiction and the specific intended use of those documents.

     

    Emergency Information Form

    [Company Name]

    Employee Information:

     

    Name:

     

     

    SS#:

    Address:

     

     

    Phone:

    Physician Name:

    Physician Address:

     

     

    Phone:

     

     

    Emergency Contacts:

    In the event of an emergency, I, the undersigned employee, authorize [Company Name] to contact the following person(s):

     

    Contact #1 Name:

     

     

    Phone (H):

     

    Address:

     

     

    Phone (W):

     

    Relationship to Employee:

     

     

    Other method of contact:

     

    Contact #2 Name:

     

     

    Phone (H):

     

    Address:

     

     

    Phone (W):

    Relationship to Employee:

     

     

    Other method of contact:

     

     

    _________________________________________________________________________________

    Employee Signature

     

    ________________________

    Date

     



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