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_______________________________________