2011 National Healthcare Reform Leadership Award Question Title The National Healthcare Reform Magazine(NHRM) recognize a select group of individuals each year whose achievements have enhanced and brought innovation to the voluntary benefits industry. Award recipients are dynamic individuals that have helped launch the industry forward in a positive direction. The National Healthcare Reform Leadership Award will be presented to these individuals as part of the NHRM Annual Meeting held October 26-28th, 2011. * Nominations and all information provided in this form will be confidential and not shared with any third parties. Question Title * 1. Please enter the following information for the individual being nominated: Name: * Company: * Title Address: City/Town: State/Province: ZIP/Postal Code: Country: Email Address: Phone Number: Question Title * 2. How long has the nominee been promoting National Healthcare Reform? 1 - 3 Years 4 - 6 Years 7 - 10 Years 10+ Years Not sure Question Title * 3. Approximately how many employees does the nominee's company employ? 1 - 100 Employees 100 - 1,000 Employees 1,000 - 5,000 Employees 5,000 - 10,000 Employees 10,000 - 1000,000 Employees 100,0000+ Employees Not sure Question Title * 4. Why do you feel that the person being nominated is a leader in the industry? Question Title * 5. What personal/professional characteristics does this nominee possess? Question Title * 6. What outstanding qualities make this nominee an influential leader in the industry? Question Title * 7. Would you like to nominate another person? Yes No Next