Liberty Mutual Firemark Award Nomination Form Complete this form online, or download an offline form. Requestor's name: Requestor's title: Requestor's email: Requestor's phone: Date requested: Type of Firemark Award requested (select one): Heriosm Award Community Service and Public Education Award Type of rescue: Home Auto Water Other N/A Did it involve a life-threatening event? Yes No Were there any fatalities? Yes No Was a fire fighter injured? Yes No Describe the rescue (if applicable): Is there a newspaper article about the story? Yes No Please submit a hyperlink or mail a copy of the article (if applicable): Did it air on the local news? Yes No If so, when did it air? Date  Time  Station  Will you be able to obtain a copy (if applicable)? Yes No Please describe the work the fire fighter has done in the community: Name of fire fighter: Department: Address: City  State  Zip  Country  If multiple fire fighters are being submitted for one event, please describe: Submit form.