Employee Emergency Contact Form

I am an:

Employer Employee (filling out this form for myself)

Employee's Name

Name of Employer / Company

Enter your phone number:

Home Address

Do you want to enter your address now?

YesNo — I will fill it out later.

Street Address

Address Line 2

City

State

ZIP Code

How many Emergency Contacts do you want to require?

12 (Recommended)

To fill out later, leave blank and click "Next."

Name

Relationship

Phone Number

Do you want to add a Secondary Emergency Contact?

Yes (Recommended)No

Name

Relationship

Phone Number

Do you want to add a Medical Emergency Contact?

Yes (Recommended)No

Doctor's Name

Phone Number

Do you want to electronically sign this form?

Yes No — I will sign it later.

Signature

Clear

Please write your signature to the area above.

Enter today's date: