Request Commissioner Chaney

If you would like to make a request for the Commissioner to attend or speak at an event, please fill out the following request form. After you have filled in the information, click on the 'Submit' button and you will receive a confirmation that your request has been received by the Mississippi Insurance Department. Please submit your scheduling request for an event that is at least two weeks from today's date. Thank you.

Items denoted by an * are required

Prefix     *  
First Name     *  
Last Name     *  
Home Phone     xxx-xxx-xxxx   
Work Phone     xxx-xxx-xxxx *    
Email     *  
Event Name     *
Event Location     *  
Date Requested    mm/dd/yyyy *  
Commissioner's Purpose at Event      *
Speech Topic       
Speech Begin Time     xx:xx am/pm   
Speech Length     
Person Introducing the Commissioner   
Other Speakers     
Event Begin Time     xx:xx am/pm *  
Event End Time     xx:xx am/pm *   
Inside or Outside     *    
Facility Name     *  
Facility Address: Line 1     *
Line 2   
City     *
State     *
Zipcode     xxxxx *   
Directions To Facility Airport   
Sponsor Group Organization   
Contact Person 1   
Contact Person 2   
Emergency Event Locate Number     xxx-xxx-xxxx  
Estimated Attendance   
Media Attending   
Bio Request     
Additional Notes
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