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After you give an insurance-related speech or presentation, please complete this form. This information will help us keep an accurate record of the speeches you have given, and will ensure that you receive credit for the NW Insurance Council’s Annual Speaker Award Program. Speakers representing the NW Insurance Council are encouraged to identify us as a nonprofit public-education organization funded by member insurance companies inWashington, Oregon and Idaho.

Your Contact Information

Name


Title


Company


Email


Phone Number


Address


City


State/Province


Zip Code

Speech Information

Was your speech initiated by NWIC staff?
Yes No

Date of Speech


Organization Spoken To


Contact At Organization


Contact Phone Number


Contact Address


Contact City


Contact State


Contact Zip Code


Topics


Audience Type


Audience Size


Comments