Section 1: Personal Information
Full Name
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First Name
Last Name
Company name
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Position
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Email
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example@example.com
Mobile number
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-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section 2: Community Contribution
Describe where you made a meaningful difference to help the community in the last 12 months. (N.B. This is outside of your role as a Broker or family activity)
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What challenges did you face and how did you overcome them?
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What factors contributed to making this specific experience meaningful for you?
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What are the short-term/long-term effects of your contribution?
*
Section 3: Reference/Testimonial
Name of referee
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Reference/Testimonial
*
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The reference must include their name, company, position, phone number and email and must address how you have demonstrated professionalism and integrity in understanding their business and providing suitable advice.
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Section 4: Acknowledgement
I acknowledge that should I be shortlisted to move to the next phase of the award, I will be required to participate in a video interview W/C 23 September 2024.
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Yes
I acknowledge and agree that entries to the award may be used for promotional purposes across NIBA's channels including NIBA Insurance Adviser magazine, Broker Buzz and NIBA’s LinkedIn channel
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Yes
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