Employee Emergency Contact & Beneficiary Form

Creating Lasting Memories Through Beautiful Photography.

Emergency contact roster and beneficiary designations for life insurance, retirement, and final wages.

BTL-PBL-05.017

Form

Vol 05 — Human Resources & Talent

Employee

Full name *

Employee ID

Home address & ZIP *

Personal phone *

Personal email

Full name *

Relationship *

Primary phone *

Secondary phone

Address

Full name

Relationship

Phone

Known medical conditions / allergies first responders should know

Preferred hospital

Blood type

Beneficiary name / relationship / % / phone *

I authorize the Company to contact the individuals listed in the event of an emergency and to share relevant information with first responders. *

Yes / N/A

Employee signature *

Date *

Prepared by

Name · Title · Date

Reviewed by

Name · Title · Date

Approved by

Owner · Katheryn L. Wilkins · Date

Controlled document — BTL-PBL-05.017. Complete all required fields (marked *). Retain per Volume 15 retention schedule.