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BCBSTX Event Attendance Request Form

Are you planning an event?

Wellness or Benefits Fair
Lunch and Learn
Conference
Wellness or Benefits Presentation

You can submit a request for a BCBSTX representative to attend your event.

Please submit this form at least six weeks prior to your event to allow enough time to fulfill your request.If your event is in less than six weeks, we will do our best to accommodate your request.

Once the form is submitted, please allow up to 72 hours for a BCBSTX representative to respond via email or phone. If you have any changes prior to your event after submitting the request form, you can contact us using the Agency Rep Contact Form with your contact information and the change to the event.

An asterisk (^*) indicates a required field.

Requestor Information

Agency name:^*

Agency ID:^*

Agency address:^*

Agency city:^*

Agency state:^*

Agency ZIP code:^*

Agency website:

Agency contact:^*

Agency contact email:^*

Agency contact phone number:^*

Preferred contact method:^* Phone
Email

Event Information if Available

Event date:

Event time:

Approximate # of attendees:^*

Type of event:

Event location:^*

Event address:^*

Event city:^*

Event state:^*

Event ZIP code:^*

Would you like BCBSTX to provide a door prize at your event?^* Yes
No

If so, do you have any limitations on the details of the door prize?

Who is the primary audience?

Is there any other information you would like to share about your request?

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