NAIC Speaker Request Form

Thank you for your interest in inviting a representative from the NAIC to speak at your event. Please complete the information below and provide as much detail as possible in order that we may expedite your request. Once you submit this information, an NAIC staff member will contact you within 2 business days to discuss the details and begin to work on confirmation of a speaker for you.


* Event Date:   * Event Time: * Number Attending:
* Name of Group or Organization:

Requestor Contact Information:
* Name:
* Email:
* Telephone:
Cell Phone:
Fax:

Event Information:
Event Name:
Address:
City: State: Zip Code:
Event Contact Name:
Event Contact Cell Phone:
Event Contact Email:
Who does the audience primarily consist of (i.e. industry, Consumers, Regulators)?
Is the event open to the public? Yes    No
Will a meal be served during the speech? Yes    No
Special directions to the event:
Type of Appearance:

Keynote Speaker Break-out Presentation Panel Presentation Other
(if other, please elaborate)

Exact Start Time of Speech:
Are there other dignitaries invited to this event?
(Willing to sign no conflict interest form)
Yes    No
Time allowed for Speech:
Q&A Time:
What time does the speaker need to arrive in order to do A/V and sound check?
If this is a panel presentation, please indicate others that will be serving on the panel with this speaker?
What is the topic of the speech? Please be very detailed and specific so that we may expedite your request.:
Do you have a specific Commissioner or other individual in mind who you would like us to ask to make this speech?
Has anyone from NAIC spoken at this event or to this group in the past? If so, when, where and what was the topic?
Will LCD projector, screen, and laptop with wireless mouse be available?
Who will introduce the speaker?
Do you need a bio of the speaker?
Do you need a photo of the speaker? Please indicate color or black and white.
What expenses will be covered for the speaker?
Will media be present (TV, radio, print)? If so, who do you expect?
What is the deadline for acceptance of the speaking request?
Any additional information you can provide that has not been addressed above would be very helpful?