Information
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LODD packet for
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Conducted on
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Prepared by
Personal Information
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Full name
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Home address
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Home phone
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Cell phone
Emergency Contacts
- Emergency Contact
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Name
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Home Address
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Home phone
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Cell phone
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Pager
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Employer
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Employer Address
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Work Phone
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Is this person your primary beneficiary?
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Special circumstances (age, health, etc.) or instructions:
Children
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Children
Child
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Name
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Date of Birth
Notification
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Department members, if any, that you would like to help make the notification.
Department Member
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Name
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Identify anyone else you would like to assist with the notification
Other Assistant
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Name
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Relationship
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Add location
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Home phone
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Cell phone
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Employer
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Employer address
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Work phone
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Other information
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Note
Funeral / Memorial Services
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Do you wish to have a fire service funeral, as described in department policy?
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May the department hold a public memorial service if the death is duty related?
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Disposition
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Funeral Home
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Funeral Home
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Add location
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Funeral Home Phone
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Will you be interred at a cemetary?
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Has a plot been purchased?
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Cemetary
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Cemetery Address
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Are flowers to be omitted in lieu of donation to charity or organization?
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Pease identify the charity or organization
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Favorite songs
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Favorite poems
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Favorite readings
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Favorite scriptures / verses
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List preferences for pallbearers (in order)
Pallbearer
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The first 6 available pallbearers shall be utilized, with the balance of the list used as alternates.
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Are you a United States military veteran?
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Which branch?
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If entitled to a military funeral, do you wish to have one?
Other Critical Information
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Are you a member of a union?
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Would you like a union representative present at notification?
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To which union do you belong?
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Do you have a will?
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Do you have a living will / medical directive?
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Do you have life insurance?
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Agent and policy #
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Do you have death and/or disability insurance?
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Agent and policy #
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Are you an organ donor?
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Does your drivers license indicate you are an organ donor?
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Do you have any special requests, wishes, or directions that you would like to be cared for in the event of your death or disability?
Signatures
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Employee signature
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Next of kin signature
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It is recommended that this document be printed, notarized, and kept on file to assure it's validity.
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Notary:
