NOMINATION FORM Wharton

AICPCU Insurance Executive Development Program at The Wharton School September 21 - October 3,2008 Please enter nominator's contact information below: Nominated by*: Title*: Company*: Address*: Telephone*: E-mail Address*: Check if more than one person from this company will attend. Name*: Designations: Prefered Name (or Nickname): Title*: Company*: Business Address:*: City*: State*: Zip*: Country: Nominee Telephone*: Nominee E-mail Address*: Name and Title of Person Nominee Reports to: Brief Description of Nominee's Current Responsibilities*: Please tell us why you are nominating this person: Briefly tell us your expectations for this nominee and the program: Nominee's employment history (most recent first): Employer, position, major responsibilities (include dates) Nominee's education, training, and professional development background: University, school or course sponsor, degree, designation or certificate, major subjects (include dates) Submitted by (if different than nominator): * denotes a required field. Nominations must be reviewed and approved. The nominee will be notified of the status of his or her nomination after the application is reviewed. Invoice will be sent upon acceptance into the program.