A p l a n n i n g g u i d e f o r t h e e n d o f l i f e

Transcription

1 Journey s End A planning guide for the end of life

2 Journey s End A planning guide Table of Contents Personal Information... 1 Legal Information... 6 Professional Providers... 9 Financial Information Retirement Investments Insurance Information Real Estate Information Miscellaneous Information Valuables Death Certificate Information Information Needed Following Death Funeral Planning Requests Obituary Notification of Death Notes... 43

3 Journey s End A planning guide Making arrangements and dealing with business matters at the time of death can be overwhelming for your loved ones. It is intended that this planning guide will be a valuable help at that difficult time. Because of the highly confidential nature of some of the information you will record in this planning guide, it should be kept in a safe place. The individual(s) who will need access to this information need to be advised that you have this planning guide and where it is located. It is recommended that this guide be reviewed periodically to make sure that the information is current. Updates should be made by: Making the appropriate change Sign or initial the change Indicate the date the change was made The information and directives outlined in this planning guide have been prepared by: Name: Date completed: The following individuals have copies: This is not a legal document. Information you record here is for reference only. Any decisions or directions will need to be documented in the appropriate forms or through the appropriate processes (ie. advance directives, organ donations, etc.)

4 Personal Information Full name: Legal residence address: Other address: Date of birth: Birthplace (city/county/state): Location of birth certificate: Social security number: Medicare number: Medicaid number (if applicable): If married, Spouse s name: Date of marriage and location: Location of marriage certificate: Was a pre-nuptial agreement signed? If so, state the location of document: If widowed or divorced, list date: If not married, Significant other s name (if applicable): 1

5 Family Information List parents names, including mother s maiden name; dates and locations of birth: List children s names/date of birth/address and phone number: List siblings names/addresses and phone numbers: Religious Affiliation Church attended: 2

6 Memberships (Fraternal, Service and Social Organizations, Clubs, etc.) Education Schools attended: Diplomas/Degrees: Military Service Service number: Veterans Administration claim number: Branch: Enlistment date: Discharged date: Rank at discharge: Location of discharge papers: Name of war or conflict: List any medals received: 3

7 Do you prefer: An American flag: q Draped casket q Not draped Taps be played: q Yes q No A veteran s cemetery marker: q Yes q No To be buried in a veteran s cemetery: q Yes q No If so, where? Employment Current employer or most recent employer if retired: Employment dates: Employee ID number: Job title: List benefits due: (IRA, HSA, Retirement, etc.) Location of pertinent documents: (Life insurance, pension information, etc.) Note: Check with employer for final paycheck, unpaid wages and unused vacation payments, life insurance, pension information, availability of insurance coverage held over for dependents, etc. 4

8 Previous Employers Employer name: Job title: Employment dates: List benefits due: Employer name: Job title: Employment dates: List benefits due: Employer name: Job title: Employment dates: List benefits due: Employer name: Job title: Employment dates: List benefits due: 5

9 Legal Information Durable Power of Attorney for Finances The durable power of attorney is a signed and notarized document by which you give another person (agent) authority to act on your (referred to as the principal) behalf. The authority may be general, giving the agent broad power to make decisions, or limited, giving the agent the power to do one or more specific things. Most general powers of attorney prepared today are durable, which means the authority continues even if the principal becomes disabled or incapacitated and cannot act for himself or herself. The power of attorney can be made effective immediately or at some later date or event, such as when the principal becomes incapacitated. Under most circumstances, a properly executed general durable power of attorney avoids the need for a courtappointed guardian or conservator to handle financial matters. q I have a durable power of attorney for finances q I do NOT have a durable power of attorney for finances The following individuals have a copy of my durable power of attorney for finances document: Location of the original copy: Will A will is a document that allows you to designate: Who will receive your estate (your property that does not pass by beneficiary designation or joint ownership arrangement) after you die. Who will raise your children if you die while they re still minors and your spouse is unavailable to care for them. Whether your beneficiaries receive their inheritance outright or in a trust; and Who will serve as your personal representative that is, the person who will pay your bills and taxes and distribute the rest of your estate to your beneficiaries. You may wish to contact an attorney to advise and assist you with this. 6

10 Advance Directives An advance directive is a written instruction that you make while you are mentally competent. The advance directive states how you want health care decisions to be made for you if you become incapacitated. Wisconsin laws recognize two forms of advance directives the health care power of attorney and the living will. Advance Directive Health Care Power of Attorney A health care power of attorney allows you to appoint someone to be your agent to make all health care decisions, not just those involving life support, for you if you lose the ability to make decisions for yourself. You also may include a description of your treatment preferences and special desires in this document, to help guide the person making decisions for you. In this document you also may authorize your agent to admit you to a nursing home or community-based residential facility and you may indicate your wish to donate body parts after death. q I have completed a health care power of attorney document q I do NOT have a completed health care power of attorney document. The following individuals have a copy of my health care power of attorney document: Location of the original copy: Advance Directive Living will ( declaration to physicians ) A living will describes the kind of life-sustaining care you would want if injury or illness leaves you in a terminal condition (dying) or a persistent vegetative state (permanent unconsciousness) with no hope of recovery. q I have completed a living will. q I do NOT have a completed living will. 7

11 The following individuals have a copy of my living will document: Location of the original copy: Do-Not-Resuscitate (DNR) Order & Bracelet Doctors may issue a DNR order for certain adults who have a terminal condition or who would not likely survive a resuscitation attempt if they had cardiac or pulmonary failure outside of a hospital setting. These patients receive DNR bracelets, which direct emergency medical technicians (EMTs) and emergency room personnel not to attempt resuscitation. 8

12 Professional Providers Attorney Name: Firm: Physician Name: Clinic: Name: Clinic: Pharmacy Name: 9

13 Dentist Name: Hospital Name: Home Health Care Service Name: Other 10

14 Executor of Will Name: Accountant Name: Financial Advisor Name: Stock Broker Name: 11

15 Financial Information Checking Account Financial institution: Financial institution: Savings Account Financial institution: Financial institution: 12

16 Debit Card Financial institution: Location of card(s): PIN number: Safe Deposit Box Financial institution: Location of key to box: Certificate of Deposit Financial institution: Financial institution: 13

17 Money Market Financial institution: Financial institution: Other Investments 14

18 Credit Card(s) Company: Company: Company: Company: Company: 15

19 Charge Account(s) Business Name: Business Name: Business Name: Business Name: Income Tax Records Location of records: Name of tax preparer: 16

20 Loans Name: Type/Description: Name: Type/Description: Name: Type/Description: 17

21 Debts Name: Type/Description: Name: Type/Description: 18

22 Retirement Investments Annuities 401(k) IRA 19

23 Stock Options Keogh 20

24 Pensions Employer: Employer: Employer: Social Security Local office: Phone: Toll-free phone number: Disability benefits: Dependent benefits: Survivor benefits: Other 21

25 Insurance Information Life Company name: Amount: Company name: Amount: Company name: Amount: 22

26 Health Company name: Amount: Company name: Amount: Homeowners Company name: Amount: 23

27 Credit or Mortgage Company name: Account type/number: Vehicle Company name: Account type/number: Amount: Account type/number: Amount: Other Insurances 24

28 Real Estate Information Primary Residence Town/City of: Location of deed: Mortgage company: Appraisal of property: Is property included in life estate: q Yes q No Real estate taxes are paid at: Rental Property Town/City of: Other pertinent information: 25

29 Other Real Estate (time share, land, etc.) Residence/Land: Town/City of: Location of deed: Mortgage company: Appraisal of property: Residence/Land: Town/City of: Location of deed: Mortgage company: Appraisal of property: 26

30 Miscellaneous Information Power company: Phone: Telephone company: Phone: Cell phone company: Phone: Gas/Oil company: Phone: Garbage removal: Phone: Well/Septic: Phone: Water: Phone: Plumber: Phone: Electrician: Phone: Mechanic: Phone: Housecleaning service: Phone: Handyman: Phone: Location of warranties (Appliances, etc.) Fuse/Circuit box location: Water turn-off location: Furnace/Hot water heater: 27

31 Valuables Location: Instructions: Location: Instructions: Location: Instructions: 28

32 Death Certificate Information A funeral director will obtain one death certificate. (Funeral director may order more death certificates upon request.) additional copies may be needed, for purposes of: Life insurance benefits Veteran s benefits Other benefits Financial accounts Change ownership of property/assets Photocopies are NOT ACCEPTABLE for many after-death tasks. Certified copies are required. Certified copies can be ordered by: Calling the office of the registrar in the county of residence Calling the register-of-deeds office in the county of residence (Note: If the deceased died in a county different than the county of residence, the death certificate needs to be obtained from the county in which he/she died.) There is a cost for each certificate. There may be a discount if a number of copies are ordered. 29

33 Information Needed Following Death This list of documents/information is not all-inclusive, but is intended as an aid. Life insurance policies. (It is important to keep old insurance policies. Even though an individual may no longer be paying a premium, the insurance may still be in force.) Financial accounts (e.g. savings, checking, stocks, etc.) Birth certificate Titles to vehicles Social security numbers for deceased, spouse, any dependent children Veteran s discharge papers Mortgage records House/Land deed Copy of the will Earning statements for the last year Copies of the last three income tax returns filed Retirement plan, 401K and IRA information 30

34 Funeral Planning Requests Organ Donation: q Yes, I wish to be an organ donor q Driver s license sticker q Directive in my health care power of attorney q No, I do not want to donate any of my organs/tissue Donation of Body: Check with your medical college of choice for more information. Prearrangements are needed. The Medical College of Wisconsin s Web site: healthlink.mcw.edu. Anatomical Gifts Registry: Phone: q Yes, I wish to donate my body q To a medical institution Name of institution: q Immediately upon death q After a ceremony q No, I do not want to donate my body 31

35 Interment q Burial (complete Earth Burial section below) q Entombment (complete Earth Burial section below) q Cremation (complete Cremation section below): q Direct cremation (without a viewing or other ceremony with body present) q Cremation after a ceremony Earth Burial Name of cemetery: Contact person: Name the plot is reserved under: Plot: Section: Block: Location of deed: Cremation I prefer: q Urn q Container Indicate the location of the container if pre-purchased: Individual to receive the ashes: 32

36 Funeral Home Name: Pre-arranged funeral plans made: q Yes q No Pre-arranged contract: q Yes q No Location of this information: Individual(s) responsible for my arrangements: Name: Name: 33

37 Visitation Choices q Immediate Burial no Public Visitation Memorial service to be held at: Address: Phone: q Funeral with Visitation Location of visitation: q Funeral Home q Church q Other: Name/Address: q Public q Private q Open casket q Closed casket Personal Item Choices For a viewing you will need to be dressed in a complete set of clothing. My choices are: Clothing: Jewelry: Glasses: Other: Flowers: q Yes q No If yes, description: Memorials to be directed to: 34

38 Clergy of Choice Name: Name: Special Wishes for Funeral Service q Song(s): q Vocalist(s): q Other: Special readings (Poems, letters, etc.): Designated person to read eulogy: Scripture/Holy readings: 35

39 Other wishes: Military/Lodge Name: Casket/Pall Bearers (names/relationship/address/phone numbers) 36

40 Grave Stones/Markers q Flat q Upright (Note: Cemetery regulations may apply) If a marker has already been purchased, indicate: Purchased from: Epitaph: If a military marker is preferred, indicate: Have arrangements been made: q Yes q No Veterans Administration Service Officer contact information: Note: Veterans and spouses are entitled to a military marker at no charge. Contact your county s Veterans Administration Service Officer, funeral director or the county clerk of court. Other: Special Wishes 37

41 Obituary Information Needed for the Obituary Name of deceased Complete address Where death occurred Who he/she was under the care of Where/When/Time the services will be held Newspapers to Carry Obituary Notice 38

42 Information that may be Included in the Obituary Parents Spouse(s) name(s), marriage location(s) Children (names, spouses names, addresses if desired) Siblings (names, spouses names, addresses if desired) Number of grandchildren and great-grandchildren (names and addresses if desired) Special friends Any other survivors you want listed in the obituary (names, relationship, addresses if desired): Predeceased by: (name and date of death) Where memorials are to be sent, if in lieu of flowers Date/Place of birth Educational background Employment background Military Services (branch, dates of service, awards, decorations) Membership in clubs, fraternal organizations Hobbies/Interests 39

43 Notification of Death Individuals to Receive Notification Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: 40

44 Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: 41

45 Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: Name: City/State/Zip: Phone: Relationship: 42

46 Notes 43

47 44

48 H5211_MC C HP (03/08) 2008 Security Health Plan of Wisconsin, Inc.