Endswell Comprehensive End-of-Life Planning Form (pages)

Basic Personal Information
Welcome to Endswell's Comprehensive End-of-Life Planning Form. The questions and prompts that follow are intended to help you make arrangements for personal and practical matters that may arise before and after your death. The content in this form should not be construed as legal advice, nor does this document replace a valid will.

The only required fields are in the Basic Information Section. If you do not wish to provide certain information, simply skip that field or section. We have also included blank fields to accommodate matters we have not considered or matters that might be unique to your personal circumstances.
Full Legal Name*

First NameMiddle NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Is the legal residence the same as mailing address?
Please provide the legal residence.

Street Address

Street Address Line 2

CityState

Zip Code
In what County is the legal residence located?
Please provide the mailing address.

Street Address

Street Address Line 2

CityState

Zip Code

Family Information
MarriedWidowedDivorcedSeparatedNever Married
Please provide spouse's full legal name.*

First NameMiddle NameLast Name
Please provide spouse's full name prior to first marriage.*

First NameMiddle NameLast Name
Last name prior to first marriage*
Are there any aliases or chosen names?
Mother's full name prior to first marriage.

First NameMiddle NameLast Name
Father's full name prior to first marriage.

First NameMiddle NameLast Name
Next of Kin (add as many as you'd like)
Do you have any pets?
Please provide information about your pets and any plans you have in case you are no longer able to care for them.

Medical Information
Do you have any current medical conditions or diagnoses that you would like to note? (e.g., Rheumatoid arthritis, diabetes)
List any current medical conditions or diagnoses.
Are you currently in hospice care?
Hospice Name*
Hospice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Medical Providers (add as many as you like)
Medical Insurance Companies (add as many as you like)
Do you have a MOST (Medical Orders for Scope of Treatment) Document?
Where is your MOST document located?
Upload your MOST document (optional)

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Do you have an Advance Directive?
Where is your Advance Directive located?
Would you like upload documents pertaining to your Advanced Directive (optional)

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Do you have a Medical Power of Attorney?
Name of Medical Power of Attorney

First NameLast Name
Phone Number of Medical POA
Please enter a valid phone number.Format: (000) 000-0000.
Location of Medical POA Document
Would you like upload documents pertaining to your Medical Power of Attorney? (optional)

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Legal
Do you have an attorney(s)?
List your attorney(s)*
Do you have a last will and testament?
Where is your will located?
When was your will written or updated?

MonthDayYear
Date
What is the name of your Executor?

First NameLast Name
What is the Phone Number of your Executor?
Please enter a valid phone number.Format: (000) 000-0000.
If you would like to upload your last will and testament, you may do so here.

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Financial
Do you have a Financial Power of Attorney?
Name of Financial Power of Attorney

First NameLast Name
Phone Number of Financial POA
Please enter a valid phone number.Format: (000) 000-0000.
Location of Financial POA Document
If you'd like to upload your Financial Power of Attorney Document, you may do so here. (optional)

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Would you like to list your CPA, Bookkeeper, or Financial Advisors?
List your CPA, Bookkeeper, or Financial Advisor(s)*
Would you like to list your Financial Institution(s)? Such as checking, savings, investment, mortgage, credit card, and/or retirement accounts.
Financial Institution(s). Please list the account type, financial institution name, and location of checking, savings, investment, mortgage, credit card, and/or retirement accounts.
Would you like to add details about Benefits, Pensions or Entitlements?
Would you like to add information about your Benefits, Pensions, or Entitlements
Would you like to list large assets?
List your large assets

Other Insurance
Would you like to list other insurance policies?
for example, life insurance or rental insurance
List your insurance policies. e.g. Car, Life, Homeowners, Pet, Rental*
Other Bills
Would you like to add utility providers?
For example, Duke Power
Add your utility providers. For example, you can add Electricity, Power, Gas, Phone*
Would you like to add other Bills, Payments, Memberships, or Subscriptions?
Add your Bills, Payments, Memberships, or Subscriptions here*

Other Important Documents and Accounts
Would you like to list important documents such as Birth Certificate, Marriage Certificate, Passport, etc?
Add Important Documents, their location and notes.*
If you'd like to upload your Important Documents listed above, you may do so here.

e.g. Birth Certificate, Marriage Certificate, Passport
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Would you like to list digital accounts such as social media or email accounts?
For example Gmail, Facebook, LinkedIn
Add Digital Accounts*

Other Practical Matters
Do you own firearm(s)?
Add firearm(s)*
Do you own a Safe?
Location of Safe
Do you own a Safety Deposit Box?
Location of Safety Deposit Box
Is there a Spare Key to your home?
Location of Spare Key
Do you have a journal or diary?
Location of journal or diary
Are there any matters in your planner or on your To Do list that may be unresolved at the time of your death?
Indicate those matters in your planner or on your todo list that may be unresolved at the time of your death. (e.g., pay taxes)
Would you like to add a note about any other practical matters that should be handled if you are no longer able to handle them? (e.g., car oil change)
Add your notes about any other practical matters that should be handled if you are no longer able to handle them (e.g., car oil change)

Final Disposition and Funeral Plans
Have you selected a funeral home?
Name of Funeral Home
Funeral Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Funeral Home Notes
Do you have a cemetery plot?
Name of Cemetery
Location of Cemetery Plot
Method of Disposition
Other Method of Disposition
Would you like your remains to be buried or scattered in a particular location?
Which location would you like your remains to be buried or scattered. Also describe any special considerations for the final disposition.
Are there any specific spiritual, religious, or ritual practices that should be observed in the time leading up to death, at the time of death, after death, or at the time of final disposition?
Observances
Do you have any notes or special requests relating to your final disposition? E.g. (music to play, poetry to read, items to be buried with, etc.)
Final Disposition Special Requests

The following information is required to complete a death certificate and should be made available to those responsible for your final disposition.
County, State, Country of Birth
Race
Gender
Military Service?
Highest level of education completed?
Occupation and Industry?

Personal, Social, and Emotional Matters
Would you like to add close friends or family to contact in case of your death?
Close Friends and Family*
Have you completed a 5 Wishes Document or other type of Advance Directive that addresses personal, emotional, and spiritual needs?
Name of Document
Location of Document
If you'd like to upload your 5 Wishes Document or other type of living will, you may do so here (optional)

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Would you like to include information about medical treatments that you would or would not want? (e.g. mechanical ventilation, artificial nutrition, etc.)
Medical Treatment Preferences
Would you like to include your personal wishes for pain management and how you are cared for leading up to the time of death? (e.g. dying at home, pain management, etc.)
Personal wishes for pain management
Would you like to document how you want to be treated by those around you leading up to death? (e.g visitors, human touch, music, etc.)
How do you want to be treated?
Would you like to include information about your personal, emotional, and spiritual needs leading up to death?
Your needs leading up to death
Are there any messages of love, forgiveness, reconciliation, or general life advice that you would like to leave behind for your loved ones?
Messages to leave behind
Would you like to provide information for your obituary or write about your legacy?
Provide information for your obituary or write about your legacy.
Would you like Endswell to receive a copy of this form?
Would you like to receive a copy of this form, when completed?
We will send a copy of this form to the address you specified at the top of this form.
Should be Empty:

Basic Personal Information

Family Information

Medical Information

Legal

Financial

Other Insurance

Other Bills

Other Important Documents and Accounts

Other Practical Matters

Final Disposition and Funeral Plans

The following information is required to complete a death certificate and should be made available to those responsible for your final disposition.

Personal, Social, and Emotional Matters