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IASA Chapter Speaker Agreement
Please complete the acknowledgement form below regarding speaker responsibilities and request for possible streaming and recording of presentation for IASA on-demand educational offerings. Please provide data in all REQUIRED fields to expedite processing of your session and speaker details. Required fields left blank will generate a follow up communication to collect required data.
SPEAKER AND EVENT DETAILS:
Chapter Presenting At
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Please select
Carolinas
Central Illinois
Chicagoland
Georgia
Indiana
Land O'Lakes
Metro NY/NJ
Michigan
Mid-Atlantic
Mid South
Midwest
Northeastern
Ohio
Pacific Northwest
Show Me
Southwestern Ohio
Sunshine
Texas
Utah
Wisconsin
Chapter Event Month
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Please select
January
February
March
April
May
June
July
August
September
October
November
December
Chapter Event Year
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Speaker Name
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First
Last
Speaker's Job Title
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Company
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Company location (city, state)
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Speaker email
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Speaker Cell Phone (in case of issues during event)
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Speaker Bio - Please provide your professional bio required for CPE (Note for Ethics field of study sessions - your bio must include and clearly show your relevant experience or training in this field and please specify Regulatory or Behavioral for the Field of Study):
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Speaker photo (please submit high res photo) Photos can be most any size. 8:5:11 - generally size of a document, for 1:1, common size would be 1080 x 1080 pixels.
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PRESENTATION DETAILS
Presentation Title - Required for CPE
(80 Character limit)
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Session Description - Required for CPE, Provide 2-3 sentences describing what the attendee will gain from this session
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Learning Objectives - THREE (3) Required for every 50 minutes of content. ONLY THE FOLLOWING MEASURABLE VERBS MAY BE USED AS REQUIRED BY NASBA TO QUALIFY FOR CPE CREDIT:
OBJECTIVES MUST BEGIN WITH DEFINE, DETERMINE, DIFFERENTIATE, DISCRIMINATE, DISTINGUISH, IDENTIFY, INDICATE, INTERPRET, RECALL, RECOGNIZE.
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Field of Study Required - Please select one from the drop down box
If your content is related to ethics, please select Ethics and specify Behavioral or Regulatory. Do not select Personal Development.
Copy/Paste the link below if additional information is needed to determine the appropriate Field of Study.
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Please select
Accounting
Accounting (Governmental)
Auditing
Auditing (Governmental)
Business Law
Business Management & Organization
Communications and Marketing
Computer Software & Applications
Economics
Ethics - Behavioral
Ethics - Regulatory
Finance
Information Technology
Management Services
Personal Development
Personnel/Human Resources
Production
Specialized Knowledge
Statistics
Taxes
NASBA Fields of Study Reference Document
Program Level Required - Defined as Basic, Intermediate or Advanced (Intermediate and Advanced require pre-requisites - If selecting these options you must list prerequisites and advanced preparation fields.
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Basic
Intermediate
Advanced
Prerequisites - If Program Level above is listed as Intermediate or Advanced, you must list any prerequisites such as education or work experience or knowledge to qualify content for CPE credit.
If none, please enter "None"
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Advanced Preparation - If Program Level above is listed as Intermediate or Advanced, you must list any prerequisites such as required pre-meeting work that will be provided (or None) to qualify content for CPE credit.
If none, please enter "None"
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Level of Engagement - Required By NASBA
Please be sure your engagement type is reflected in your presentation for NASBA audit purposes such as discussion questions, polling questions, questions for reflection or discussion regarding case study lessons learned.
*If polling is selected, poll slides must be included in your presentation for NASBA audit purposes. If your session is virtual, Zoom webinars must be used and Zoom polling utilized to show attendee participation in post event reports.
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Group Discussion
Polling Questions*
Instructor-posed questions with time for participant reflection
Use of a case study with different engagement elements throughout the program
Every session offering CPE credit needs to be reviewed by an individual with content knowledge who is not involved in the development of the content.
If you do not have a presentation with written content (graphics only) or your session is a panel discussion, a document outlining discussion points is still required for review.
Accounting, Auditing or Tax Sessions (or sessions that include these topics): These sessions require a licensed CPA, Tax Attorney or IRS Enrolled Agent to participate in the review of the content being presented and can be included during the content development or review process. Please provide the following form to your qualified reviewer and have submitted before submitting your presentation.
***SESSION CONTENT MUST FILL THE ALLOTED TIME SCHEDULED FOR YOUR SESSION (minus intros and Q&A)*** to meet NASBA CPE credit requirements and maintain event schedule. (Attendees have programmed check-in/check-out times associated with CPE qualifying.)
Please copy the link below and provide to your content reviewer to be completed prior to the event.
I acknowledge that I have read the requirement for an individual with content knowledge to complete the form above and for Accounting, Auditing and Tax sessions (or sessions that include these topics), a licensed CPA, Attorney or IRS Enrolled Agent is required and that my session content must fill the duration of the time slot minus intros and wrap up.
Please reach out to your IASA event support staff (Tricia Stillman, tstillman@iasa.org, Gina Jolly, gjolly@iasa.org) if you do not have a qualified reviewer.)
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Yes
I. PARTICIPANT AGREEMENT: OBSERVANCE OF IASA CHAPTER POLICIES
Please check each box below to acknowledge that you have read and understand each section, and will satisfy all of your obligations and responsibilities as an IASA speaker.
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The content of CPE activities does not promote the proprietary interests of any commercial interests.
Content of CPE activities will be restricted to industry issues and operation of devices and should not include product or company names unless essential.
Generic/Trade Names: Presentations must give a balanced view of options. Use of generic names will contribute to this impartiality. If trade names are used, those of several companies should be used rather than only that of a single manufacturer.
Speaker shall own the copyright in all materials provided for, or created by Speaker at the Event except for materials specifically created solely for IASA’s use or materials incorporating IASA’s intellectual property.
Speaker grants IASA a nonexclusive, worldwide, royalty free license to use, reproduce, and distribute the intellectual property in connection with this Event, if they choose to provide their intellectual property.
Speaker grants IASA and its agents and employees a royalty-free, perpetual license to publish, reproduce or otherwise use the Speaker’s name, picture, likeness, comments, or voice for any lawful purpose in all media in connection with the Event.
IASA warrants that usage as described herein shall be solely related to the Event and shall remain appropriate for the insurance industry and shall not in any way be considered derogatory or damaging to the Speaker or Speaker's Company.
Speaker is knowingly and voluntarily taking part in the activities for which their image is being captured and understands the associated requirements.
Speaker releases and waives any and all claims, damages, losses and expenses as a result of, or arising from, their participation.
To the best of Speaker’s knowledge, their presentation does not violate any proprietary or personal rights of others (including any copyright, trademark, or privacy rights), is factual and contains nothing defamatory, unlawful or inappropriate.
Speaker has obtained all necessary licenses and permissions for any third party intellectual property including, but not limited to, music, video or other media shown as part of the Speaker’s presentation.
Speaker shall conduct themselves in a professional and civil manner and in accordance with the IASA's Code of Ethics.
Speaker agrees that no portion of the resulting media created at the Event, containing Speaker’s name, biographical information, quotes, photographs, or recorded interviews needs to be submitted for any approval.
I affirm that I am the speaker named above.
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Yes
No
