Request A Speaker

The New York State Insurance Department provides speakers on a variety of insurance matters. Please submit the following form in its entirety so that Department staff may coordinate your needs with available resources. When submitted, this form will be sent to our Public Affairs Bureau for processing. If you need to contact them or send a PDF version of the request form, please select this link.

For international requests, please contact our Public Affairs Bureau at: publicaf@dfs.ny.gov

Organization (if website is available, please include in this field):

Contact Information:

First Name: Last Name:

Phone number (xxx-xxx-xxxx):

Fax number (xxx-xxx-xxxx):

E-mail address:

Street Address:

Mailing Address:

City: State (two-letter abbreviation): Zip Code:

Date & Location:

Date Requested (format: mm/dd/yyyy):

Time Requested:
Start Time (hh:mm:pm or am): End Time (hh:mm:pm or am):

Alternate Date Requested: (format: mm/dd/yyyy):

Alternate Time Requested:
Start Time (hh:mm:pm or am): End Time (hh:mm:pm or am):

Location

Facility:

Street Address:

City: State (two-letter abbreviation): Zip Code:

Speaker & Type of Speech:

Speaker Requested:

Format (select all that apply):

Keynote Interactive Panel Other

Length:

Questions and Answers: Yes No If Yes, Length:

Topic:

Audience Size (approximate):

Briefly describe the audience:

Other Invited Guests/Media:

Co-sponsors:

Comments:

To clear all fields and start over, select 'Reset Form'. Select 'Submit Request' to send in your request.

|

You will be re-directed to our website Home Page and receive confirmation email shortly after your request submission.