MCCB Employee Handbook 2019

P a g e | 53

EMERGENCY CONTACT INFORMATION

This information will be extremely important in the event of an accident or medical emergency.

Please be sure to sign and date this form.

Employee Information

First Name _______________________ Last Name_________________________________

Emergency Contact Name

Primary Contact Name/Phone Number___________________________________________

Relationship to Employee ______________________________________________________

Secondary Contact Name/Phone Number_________________________________________

Relationship to Employee ______________________________________________________

Preferred Local Hospital: _____________________________________________________

Insurance Information:

Company:_____________________________ Policy#: _____________________________

Comments Text: (include any information you would want an emergency care provider to know)

______________________________ _________________________ ___________________ Print Name Signature Date