Insurance Contracts Participant Application Form


Please take a moment to complete the roundtable application form.

* = Required field

* Last Name:
* First Name:
Middle Initial:
* Title/Position:
* Company/Firm/Organization:
* Category:
Other (Describe)
* Email address:
* Daytime Phone:
Evening Phone:
* Location and Time Preference:
December 2, 2013–Norwalk, CT–9:00 a.m. – 12:00 p.m. EST (discussion will include topics
     specific to the Building Block Approach)

December 2, 2013–Norwalk, CT–1:00 p.m. – 4:00 p.m. EST (discussion will include topics
     specific to the Premium Allocation Approach)

December 16, 2013–Rosemont, IL–9:00 a.m. – 12:00 p.m. CST (Nonpublic and Medium-Sized
     Entity Roundtable)

December 16, Rosemont, IL–1:00 p.m.–5:00 p.m. CST (discussion will include scope 
     considerations and topics related to the BBA and PAA)


If you are flexible with your location and/or time preference, please indicate below:


Please provide the main topics you would like to discuss at the roundtable:


Please provide any additional comments/suggestions for the staff to consider:


Please Note: The roundtable meetings will be held in public and will provide an opportunity for those that have submitted a comment letter, or who still intend to submit a comment letter, to discuss the proposals with the Boards in further detail.