2025 Community Excellence Award Application Form

I would like to

Apply for this awardNominate someone for this award
Nomination
Full Name*

First NameLast Name
Company Name
Mobile Number*
Please enter a valid phone number.
Email*
example@example.com
In your view, what makes this person a worthy recipient of the 2025 Community Excellence Member of the Year Award?*
Your Details
Full Name*

First NameLast Name
Company Name*
Mobile Number*
Please enter a valid phone number.
Email*
example@example.com
Section 1: Personal Information
Full Name*

First NameLast Name
Company name*
Position*
Email*
example@example.com
Mobile number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / 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)*
What challenges did you face and how did you overcome them?*
What factors contributed to making this specific experience meaningful for you?*
What are the short-term/long-term effects of your contribution? *
Section 3: Reference/Testimonial
Name of referee

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Reference/Testimonial

The reference must include the referee’s name, company or organisation, position, phone number and email. The referee should be someone who has worked with, or directly observed, the nominee’s contribution to community.
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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 8 September 2025.*

Yes
I am available for all the key dates listed on the NIBA website, including the NIBA Convention.*

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*

Yes
Should be Empty:

Nomination

Your Details

Section 1: Personal Information

Section 2: Community Contribution

Section 3: Reference/Testimonial

Section 4: Acknowledgement