On-Line Version

FRANKLIN AWARD NOMINATION FORM - ELECTRONIC ON-LINE VERSION

You may use the following form for your Nomination. Follow the instructions and if you incur any problems you may want to use the print-out version appearing on another page.

Name of Nominee:

Company/Org.:

Phone Number:

Nominee's Address (If Known)

Street:

City,State,Zip:

Please check-mark below the area, or areas, of the Nominee's contribution:

CONTINUING EDUCATION: Advancing the professionalism of insurance through participation and improvement of the instructional process.	PROMOTING INSURANCE: Enhancement of the industry within the business community by involvement in either civic or other activities.
EXTERNAL ACHIEVEMENT: Voluntary work or accomplishments in the industry outside the scope of one's normal job responsibilities.	RESEARCH EFFORTS: Activities which have led, or will lead, to major improvements in the insurance environment such as, but not limited to, published works.
INNOVATION WITHIN THE INDUSTRY: Accomplishments which have added to the overall creative excellence of the industry.	SPECIFIC ACHIEVEMENTS WHICH BENEFIT THE INDUSTRY: Those milestones specifically targeted to improve the industry's general welfare.
LEGISLATIVE ACTIVITIES: Participation in government affairs leading to positive insurance legislation.	LEADERSHIP: Providing guidance and direction resulting in a better insurance climate.
OTHER: Check here and then specify in the space provided in the adjacent column.

Please provide a brief summary of the Nominee's accomplishments in the text box below:

Your Name:

Your Phone#:

Insert your address here

Street:

City,State,Zip: