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:  213-897-5961 or 213-897-9451

Today's Date: ________ /_________/_________

Organization Making the Request:

________________________________________________________________

Contact Person: ___________________________________________________

Daytime phone number:_____________________________________________

E-Mail Address:___________________________________________________

Mailing Address:
________________________________________________________________
Street City, State Zip

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_______________________________________