PIAW Agent of the Year Nomination Form Candidate's Name*Please list name exactly as it would appear on an awardTitleDesignationAgency NamePhoneFAXEmail Website Top Three Companies RepresentedDoes agent have a valid P&C license?YesNoHas agent ever had action taken against him or her by OCI?YesNoNominated by Standing as a Professional Insurance Agent Current AgencyOutline agency growthInclude dates where applicableHow has the candidate encouraged education of agency staff?Describe the level of professionalism and engagement the candidate has with companies represented.Professional insurance organizations to which candidate belongs, including honorary. Contributions to American Agency System Participation in PIA and other state/regional/national insurance organizations (include dates if possible)Offices heldCommittee appointments and describe contributions to committeesAchievements, honors/awards Promotion of PIA / 1752 ClubHave any insurance professionals joined PIA or the 1752 Club as a result of the candidate’s recruiting efforts?YesNoDoes the candidate display the PIA logo on business cards, letterhead, advertising, etc.?YesNo Community AffairsList contributions made in serving the publicExamples: charitable, business, community, religious, civic/governmental, etc. (include dates if possible.) Performance as Industry SpokespersonGive specific examples (include dates if possible)Share examples of your candidate’s efforts to tell the insurance industry’s story to the public, such as speaking to civic organizations and schools; interviews with media; legislative testimony; published articles or letters-to-the-editor, etc. In SummaryIn your opinion, why should this nominee be selected as PIAW Agent of the Year?
