Event Request Form

To request assistance from the California Department of Insurance Consumer Education and Outreach Program, please complete this form and mail or fax it to the address or fax number listed below:

California Department of Insurance
Consumer Education & Outreach Bureau
Outreach Coordinator
300 Spring Street, South Tower
Los Angeles, CA  90013
Fax:  213-897-9451

Contact Information

Today's Date: ________ /_________/_________

Organization Making the Request:

________________________________________________________________

Contact Person: ___________________________________________________

Daytime phone number:_____________________________________________

E-Mail Address:___________________________________________________

Mailing Address:
________________________________________________________________
Street City, State Zip

Event Information

Date of Event: _________/_________/_________

Event Location:
________________________________________________________________
Street City,State Zip

Purpose:_________________________________________________________

Type of Audience:_________________________________________________

________________________________________________________________

Expected Attendance:_______________________________________________

Other Important Information:
________________________________________________________________

Request For:______________________________________________________
(speaker, panel member, coordinator, etc.)

Do You Have a Special Language Need?  Yes    No

If Yes, Please Indicate Language_______________________________________