Required fields are marked with asterisks (*)

Update your Emergency Contact(s)

Please use this form if you require any changes to your emergency contact(s) on file.

Prior to requested changes taking effect, Human Resources will contact you to verify changes.

Employee First and Last Name

Effective Date of Change

New Emergency Contact Name(s)

Relationship to New Emergency Contact(s) (ie: spouse, mother, father etc)

New Emergency Contact(s) Contact Number

Would you like current emergency contacts removed/replaced?

No - please keep existing and add

Yes - please replace

Additional Comments (if applicable)