DATE: ADDRESS:

 IMPORTANT HOUSEHOLD INFORMATION

HUSBAND'S full name:  
Social security number: Date of birth:
Driver's license#: Passport #:
Important medical information:  
   
WIFE'S full name:  
Social security number: Date of birth:
Driver's license#: Passport #:
Important medical information:  
   
FAMILY MEMBERS    
Name: SSN: Date of birth:
Important medical information:    
     
Name: SSN: Date of birth:
Important medical information:    
     
Name: SSN: Date of birth:
Important medical information:    
     
Name: SSN: Date of birth:
Important medical information:    
     
     

BANK:
Checking account number:
Savings account number:

 BANK:
Checking account number:
Savings account number:
   
MORTGAGE COMPANY:
Account/loan number:
 
 

Insurance

Agent

Telephone

Policy number

Medical Insurance

 

 

 

Dental Insurance

 

 

 

Vision Insurance

 

 

 

Life Insurance

 

 

 

 

 

 

 

Disability Insurance

 

 

 

Homeowner’s/Rental

 

 

 

Auto Insurance

 

 

 

 

 

 

 

Flood Insurance

 

 

 

Regular prescription medication
              Name of medication:                                     Prescription number:
             Pharmacy:                                                       Telephone:  

 

Name

Address

Telephone

Lawyer

 

 

 

Accountant

 

 

 

Financial Advisor

 

 

 

SAFETY deposit box
             Key location:
             Location of box:
             Contents:


CREDIT CARD:
Account number
Customer Service phone #

CREDIT CARD:
Account number
Customer Service phone #
   

CREDIT CARD:
Account number
Customer Service phone #

CREDIT CARD:
Account number
Customer Service phone #

 

Utility

Account number

Customer Service telephone

Electricity

 

 

Natural Gas

 

 

Water

 

 

Cable television

 

 

Telephone

 

 

Trash pick-up

 

 

Document Check List
(include copies or originals with this record in a waterproof container in your 72-hour kit)

___ Driver’s license
___ Social Security card
___ Passport
___ Visa
___ Birth certificate
___ Marriage certificate
___ Immunization records
___ Will
___ Legal contracts		 ___ Car title
___ Real Estate title
___ Extra blank checks
___ Computer back-up CD’s
___ Household inventory
___ Family history and religious records
___ Extra car and house keys
___ Cash in small denominations
___ Emergency contact information

Keep this record as safe as you would your wallet!  Avoid identity theft!