Office of Insurance Commissioner
SHIBA HelpLine
Speaker Request Form

Organization Requesting a Speaker (please print): _________________________________

Organization Contact Person (please print): ______________________________________

Phone: (     ) ____________ FAX: (    ) ______________ E-mail: _______________________

Name of Event: ___________________________ Date of Event: ______________________

Please allow ample time for the scheduling of a speaker.

Location: _________________________________________________________________

Please provide a map or directions to location, including building, room name or number.

Format of Presentation:
Panel Discussion Speech Length:____________________

Number of Expected Attendees: ________

Equipment Available:

Overhead Projector & Screen
Microphone Podium
Other: ______________

Please Check Topic of Interest:

Managed Care Disability Homeowner
Life Auto Women's Health
Health Actuarial Earthquake
Sales Practices Rates & Filings Claims Practices
Agent Licensing Medicare  
Retirement Plans Long-Term Care  

Please return completed form to:

Speaker Request
SHIBA HelpLine
PO BOX 40256, Olympia, WA 98504-0256
Fax Number (360) 407-0186
Phone Number (360) 407-0729