Health Insurance and Employee Benefits Qualification

SECTION I: Personal Information

TYPE OR PRINT CLEARLY

NAIFA Member ID Number

Name (Include all designations as they should appear on list of award winners)

Mailing Address

Code Phone Number Email Address

Local NAIFA Association (Awards will be delivered to your local NAIFA Association)

SECTION II: Application Requirements

❒ I am a NAIFA member

❒ I work in the insurance business or other closely related financial service industry

❒ I adhere to NAIFA’s Professional Code of Ethics

SECTION III: Qualifications

Eligibility for the NAIFA Quality Award in the Health and Employee Benefits category is based on the total number of lives insured in effect at the end of calendar year 2017.

Please complete the table below to determine your qualifying points. A total of 150 points is needed for qualification for those in the industry for more than three years. For those in the industry three years or less, a total of 100 points is needed for qualification.

(If you qualify using the criteria above, please move to Section IV-APPLICATION FEE.)

If needed, your total points in line C above can be increased based on Multiplier Bonus credits earned. Complete the section below to determine your Multiplier Bonus and final persistency percentage.

If you meet the minimum assets under management level for the number of years you have been in the industry, enter 10% on Line D below.