Nominate your Fire Department Form

Are you an agent?
Thank you for your interest in nominating a fire department, please contact Jade Rodemeyer at rodemej@nationwide.com or (515) 508-5776 or Paul Stevenson at stevenp8@nationwide.com or (816) 587-1891 for your options; since agents aren’t eligible to nominate per our contest rules.
Are you a NW employee?
Nationwide employees aren’t eligible to nominate per our contest rules.
Nominations are now closed. The contest begins on January 1 at 8:00 a.m. CT and extends through April 30 at 11:59 p.m. CT. Only entries submitted during this time will be considered for the contest.
Nominator:
First Name is a required field
Last Name is a required field
Occupation is a required field
Mailing Address is a required field
City is a required field
State is a required field
Zip is a required field
Phone Number (xxx-xxx-xxxx) is a required field
Email Address is a required field
Nominee:
Fire Department Name is a required field
Fire Dept Contact Name is a required field
Fire Dept Mailing Address is a required field
Fire Dept City is a required field
Fire Dept State is a required field
Fire Dept ZIP is a required field
Fire Dept Phone Number (xxx-xxx-xxxx) is a required field
Fire Dept Email Address is a required field
Nomination:
Describe how your local fire department or emergency rescue team and community would benefit from grain entrapment training and a rescue tube, and how the tube and training could be shared with nearby departments.
Max 9999 chars