Request a Speaker

Please complete the following information to request a speaker from the Kansas Department of Insurance.
Request subject to availability.

Event Date:

Event Time:

Number Attending:

Group or Organization:

Contact Information:

Name:

Email:

Phone: (XXX) XXX-XXX format

Cell Phone: (XXX) XXX-XXXX

Fax: (XXX) XXX-XXXX

Event Information:

Event Name:

Address:

City: State: Zip:

Contact at Event:

Phone: (XXX) XXX-XXXX

Is the event open to the public? Yes: No:

Will a meal be served? Yes: No:

Is this a request for the Commissioner only? Yes: No:

If the Commissioner is not available, would another department representative be OK? Yes: No:

Special Directions to the Event:

Type of Appearance:

Appearance Only:

Keynote Speaker:

Welcome:

Brief Remarks:

Drop by:

Exact Speaking
Time:

Time Allowed for
Speech:

Q & A
Time:

The Commissioner, or designated speaker, is available to speak on one of these topics. Please select one:

Health, Life or Long Term Care Insurance	Securities
Property and Casualty Insurance	Legislative Issues
Consumers and General Insurance Issues	Firefighter Relief

Other Speakers:

Who Introduces?

Who will greet the Commissioner or speaker?

Attire:

Is there an LCD Projector, Screen and Laptop Available? Yes: No:

Media Contact:

Bio requested? Yes: No:

Photo Requested? Yes: No:

Additional Information: