Request for CPCU Society Representative

The purpose of this form is to gather details about your chapter’s upcoming event to assist in securing a CPCU Society representative to attend. Please provide event information to the best of your ability, and allow up to 10 business days for a Society staff member to connect with you.

Once connected with a Society representative, it is the responsibility of the chapter and the Society representative to confirm event logistics and expectations with one another.

Please note: Our Society representatives are available to discuss CPCU Society initiatives, updates, and the value of the CPCU designation and Society membership for local conferment ceremonies and I-Days. Unfortunately, we are unable to accommodate requests for RMI or specific topic-based speaking opportunities. If your chapter is seeking a speaker on a specific topic, we encourage you to post a request on our INteract community to find a suitable speaker.

Thank you for your understanding, and we look forward to collaborating with you for a successful event.

Chapter Name

Chapter Contact's Name

First NameLast Name

Chapter Contact's Email

example@example.com

Chapter Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Event Date

Date

Attendance for this event is

Event Start Time (according to event location)

Hour Minutes

AM/PM Option

Event End Time (according to event location)

Hour Minutes

AM/PM Option

How many people do you expect to have in attendance?

This event is a/an (select all that apply)

Other

Have you booked a venue for this event?

Event Location

Street Address

Street Address Line 2

CityState / Province

Name of venue

Event/Venue Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you plan to partner with other CPCU Society Chapters or organizations to plan this event?

Name of partner chapter or organization

Expectations for your speaker / CPCU Society representative are (select all that apply):

Other

Would you like to request a specific speaker / CPCU Society representative?

Name of specific speaker / CPCU Society representative

Have you contacted this CPCU Society representative?

What are the expectations of the CPCU Society representative?

Please be as specific as possible.

Any additional comments/questions....

Would you like to request a specific CPCU Society representative?

Request for CPCU Society Representative

Chapter Contact Information

Chapter Event Information

Speaker / CPCU Society Representative Information