form.jotform.com
Open in
urlscan Pro
35.201.118.58
Public Scan
Submitted URL: http://clicks.memberclicks-mail.net/ls/click?upn=u001.HTDfUujqDIXmD4ZZ1SWwaJxM30MRFnhN0bd2-2B9ig1z48nPEet4EdS-2BVgXEy7vVJb9wpIou2c5q...
Effective URL: https://form.jotform.com/240147110096143
Submission: On March 01 via api from US — Scanned from DE
Effective URL: https://form.jotform.com/240147110096143
Submission: On March 01 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: form_240147110096143 — POST https://submit.jotform.com/submit/240147110096143
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://submit.jotform.com/submit/240147110096143" method="post" name="form_240147110096143" id="240147110096143"
accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID" value="240147110096143"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden"
id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1709062684830=>init-started:1709316840356=>validator-called:1709316840362=>validator-mounted-true:1709316840362=>init-complete:1709316840365"><input type="hidden"
id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1709062684830">
<div id="formCoverLogo" style="margin-bottom:10px" class="form-cover-wrapper form-has-cover form-page-cover-image-align-left">
<div class="form-page-cover-image-wrapper" style="max-width:550px"><img src="https://www.jotform.com/uploads/kari.dickert/form_files/logo.61ba235436d7f3.55790426.png" class="form-page-cover-image" width="550" aria-label="Form Logo"
style="aspect-ratio:550/74"></div>
</div>
<div role="main" class="form-all">
<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_1" class="form-header" data-component="header">2024 ClaimsXchange Annual Meeting Session Proposals</h2>
<div id="subHeader_1" class="form-subHeader">Please complete this form with information on your proposed session for the Annual Meeting (October 16-18, 2024 - Crystal Springs Resort - Hamburg, NJ) Submission Deadline: March 1, 2024</div>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_15"><label class="form-label form-label-left form-label-auto" id="label_15" aria-hidden="false"> Session Type:<span class="form-required">*</span> </label>
<div id="cid_15" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_15" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_15"
class="form-radio validate[required]" id="input_15_0" name="q15_typeA15" value="Panel Discussion" required=""><label id="label_input_15_0" for="input_15_0">Panel Discussion</label></span><span class="form-radio-item"
style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_15" class="form-radio validate[required]" id="input_15_1" name="q15_typeA15"
value="Tapas Topics (fast-paced, single-speaker, 15-minute session)" required=""><label id="label_input_15_1" for="input_15_1">Tapas Topics (fast-paced, single-speaker, 15-minute session)</label></span><span class="form-radio-item"
style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_15" class="form-radio validate[required]" id="input_15_2" name="q15_typeA15" value="Deep Dive based on Case Study" required=""><label
id="label_input_15_2" for="input_15_2">Deep Dive based on Case Study</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_15"
class="form-radio validate[required]" id="input_15_3" name="q15_typeA15" value="Interactive Audience Session" required=""><label id="label_input_15_3" for="input_15_3">Interactive Audience Session</label></span><span
class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_15" class="form-radio validate[required]" id="input_15_4" name="q15_typeA15" value="Immersive Cooperative Learning"
required=""><label id="label_input_15_4" for="input_15_4">Immersive Cooperative Learning</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_15"
class="form-radio validate[required]" id="input_15_5" name="q15_typeA15" value="Interested Speaker (no session currently prepared)" required=""><label id="label_input_15_5" for="input_15_5">Interested Speaker (no session currently
prepared)</label></span><span class="form-radio-item" style="clear:left"><input type="radio" class="form-radio-other form-radio validate[required]" name="q15_typeA15" id="other_15" value="other" tabindex="0" aria-label="Other"><label
id="label_other_15" style="text-indent:0" for="other_15"><span class="jfHiddenTextLabel">Other</span> </label><input type="text" class="form-radio-other-input form-textbox" name="q15_typeA15[other]" data-otherhint="Other"
size="15" id="input_15" placeholder="Other"><br></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_16"><label class="form-label form-label-left form-label-auto" id="label_16" for="input_16" aria-hidden="false"> Your Area of Practice: <span class="form-required">*</span>
</label>
<div id="cid_16" class="form-input jf-required"> <input type="text" id="input_16" name="q16_typeA16" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" data-component="textbox"
aria-labelledby="label_16" required="" value=""> </div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_17"><label class="form-label form-label-left form-label-auto" id="label_17" for="input_17" aria-hidden="false"> Session Title <span class="form-required">*</span> </label>
<div id="cid_17" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_17" name="q17_typeA17" data-type="input-textbox" class="form-textbox validate[required]"
data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_17 sublabel_input_17" required="" value=""><label class="form-sub-label" for="input_17" id="sublabel_input_17" style="min-height:13px">Up to 20
words</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_textarea" id="id_18"><label class="form-label form-label-left form-label-auto" id="label_18" for="input_18" aria-hidden="false"> Session Description<span class="form-required">*</span>
</label>
<div id="cid_18" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><textarea id="input_18" class="form-textarea validate[required] custom-hint-group form-custom-hint" name="q18_typeA18"
cols="40" rows="6" data-component="textarea" required="" aria-labelledby="label_18 sublabel_input_18" data-customhint="Type here..." customhinted="true" placeholder="Type here..." spellcheck="false"></textarea><label
class="form-sub-label" for="input_18" id="sublabel_input_18" style="min-height:13px">Up to 75 words</label></span> </div>
</li>
<li id="cid_14" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container" style="width: 128px;"></div>
<div class="form-pagebreak-next-container"><button id="form-pagebreak-next_14" type="button" class="form-pagebreak-next form-submit-button-simple_green_apple jf-form-buttons" data-component="pagebreak-next">Next</button></div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_14"></div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li id="cid_8" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_8" class="form-header" data-component="header">Presenter Information: </h2>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_fullname" id="id_4"><label class="form-label form-label-left form-label-auto" id="label_4" for="first_4" aria-hidden="false"> Name<span class="form-required">*</span> </label>
<div id="cid_4" class="form-input jf-required">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_4" name="q4_name[first]" class="form-textbox validate[required]" data-defaultvalue=""
autocomplete="section-input_4 given-name" size="10" data-component="first" aria-labelledby="label_4 sublabel_4_first" required="" value=""><label class="form-sub-label" for="first_4" id="sublabel_4_first" style="min-height:13px">First
Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_4" name="q4_name[last]" class="form-textbox validate[required]" data-defaultvalue=""
autocomplete="section-input_4 family-name" size="15" data-component="last" aria-labelledby="label_4 sublabel_4_last" required="" value=""><label class="form-sub-label" for="last_4" id="sublabel_4_last" style="min-height:13px">Last
Name</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_6"><label class="form-label form-label-left form-label-auto" id="label_6" for="input_6" aria-hidden="false"> Company/Employer<span class="form-required">*</span> </label>
<div id="cid_6" class="form-input jf-required"> <input type="text" id="input_6" name="q6_typeA" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" data-component="textbox"
aria-labelledby="label_6" required="" value=""> </div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_26"><label class="form-label form-label-left form-label-auto" id="label_26" for="input_26" aria-hidden="false"> Job Title<span class="form-required">*</span> </label>
<div id="cid_26" class="form-input jf-required"> <input type="text" id="input_26" name="q26_jobTitle" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" data-component="textbox"
aria-labelledby="label_26" required="" value=""> </div>
</li>
<li class="form-line jf-required" data-type="control_email" id="id_5"><label class="form-label form-label-left form-label-auto" id="label_5" for="input_5" aria-hidden="false"> Email<span class="form-required">*</span> </label>
<div id="cid_5" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_5" name="q5_email" class="form-textbox validate[required, Email]" data-defaultvalue=""
autocomplete="section-input_5 email" size="30" data-component="email" aria-labelledby="label_5 sublabel_input_5" required="" value=""><label class="form-sub-label" for="input_5" id="sublabel_input_5"
style="min-height:13px">example@example.com</label></span> </div>
</li>
<li class="form-line" data-type="control_divider" id="id_20">
<div id="cid_20" class="form-input-wide">
<div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div>
</div>
</li>
<li id="cid_21" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container" style="width: 128px;"><button id="form-pagebreak-back_21" type="button" class="form-pagebreak-back form-submit-button-simple_green_apple jf-form-buttons"
data-component="pagebreak-back">Back</button></div>
<div class="form-pagebreak-next-container"><button id="form-pagebreak-next_21" type="button" class="form-pagebreak-next form-submit-button-simple_green_apple jf-form-buttons" data-component="pagebreak-next">Next</button></div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_21"></div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li id="cid_22" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_22" class="form-header" data-component="header">Presenter #2 (Skip if N/A): </h2>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_23"><label class="form-label form-label-left form-label-auto" id="label_23" for="first_23" aria-hidden="false"> Name </label>
<div id="cid_23" class="form-input">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_23" name="q23_name23[first]" class="form-textbox" data-defaultvalue=""
autocomplete="section-input_23 given-name" size="10" data-component="first" aria-labelledby="label_23 sublabel_23_first" value=""><label class="form-sub-label" for="first_23" id="sublabel_23_first" style="min-height:13px">First
Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_23" name="q23_name23[last]" class="form-textbox" data-defaultvalue=""
autocomplete="section-input_23 family-name" size="15" data-component="last" aria-labelledby="label_23 sublabel_23_last" value=""><label class="form-sub-label" for="last_23" id="sublabel_23_last" style="min-height:13px">Last
Name</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_25"><label class="form-label form-label-left form-label-auto" id="label_25" for="input_25" aria-hidden="false"> Company/Employer </label>
<div id="cid_25" class="form-input"> <input type="text" id="input_25" name="q25_companyemployer" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_25" value="">
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_7"><label class="form-label form-label-left form-label-auto" id="label_7" for="input_7" aria-hidden="false"> Job Title </label>
<div id="cid_7" class="form-input"> <input type="text" id="input_7" name="q7_typeA7" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_7" value=""> </div>
</li>
<li class="form-line" data-type="control_email" id="id_24"><label class="form-label form-label-left form-label-auto" id="label_24" for="input_24" aria-hidden="false"> Email </label>
<div id="cid_24" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_24" name="q24_email24" class="form-textbox validate[Email]" data-defaultvalue=""
autocomplete="section-input_24 email" size="30" data-component="email" aria-labelledby="label_24 sublabel_input_24" value=""><label class="form-sub-label" for="input_24" id="sublabel_input_24"
style="min-height:13px">example@example.com</label></span> </div>
</li>
<li id="cid_29" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container" style="width: 128px;"><button id="form-pagebreak-back_29" type="button" class="form-pagebreak-back form-submit-button-simple_green_apple jf-form-buttons"
data-component="pagebreak-back">Back</button></div>
<div class="form-pagebreak-next-container"><button id="form-pagebreak-next_29" type="button" class="form-pagebreak-next form-submit-button-simple_green_apple jf-form-buttons" data-component="pagebreak-next">Next</button></div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_29"></div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li id="cid_30" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_30" class="form-header" data-component="header">Presenter #3 (Skip if N/A) </h2>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_40"><label class="form-label form-label-left form-label-auto" id="label_40" for="first_40" aria-hidden="false"> Name </label>
<div id="cid_40" class="form-input">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_40" name="q40_name40[first]" class="form-textbox" data-defaultvalue=""
autocomplete="section-input_40 given-name" size="10" data-component="first" aria-labelledby="label_40 sublabel_40_first" value=""><label class="form-sub-label" for="first_40" id="sublabel_40_first" style="min-height:13px">First
Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_40" name="q40_name40[last]" class="form-textbox" data-defaultvalue=""
autocomplete="section-input_40 family-name" size="15" data-component="last" aria-labelledby="label_40 sublabel_40_last" value=""><label class="form-sub-label" for="last_40" id="sublabel_40_last" style="min-height:13px">Last
Name</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_42"><label class="form-label form-label-left form-label-auto" id="label_42" for="input_42" aria-hidden="false"> Company/Employer </label>
<div id="cid_42" class="form-input"> <input type="text" id="input_42" name="q42_typeA42" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_42" value=""> </div>
</li>
<li class="form-line" data-type="control_textbox" id="id_43"><label class="form-label form-label-left form-label-auto" id="label_43" for="input_43" aria-hidden="false"> Job Title </label>
<div id="cid_43" class="form-input"> <input type="text" id="input_43" name="q43_companyemployer43" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_43" value="">
</div>
</li>
<li class="form-line" data-type="control_email" id="id_41"><label class="form-label form-label-left form-label-auto" id="label_41" for="input_41" aria-hidden="false"> Email </label>
<div id="cid_41" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_41" name="q41_email41" class="form-textbox validate[Email]" data-defaultvalue=""
autocomplete="section-input_41 email" size="30" data-component="email" aria-labelledby="label_41 sublabel_input_41" value=""><label class="form-sub-label" for="input_41" id="sublabel_input_41"
style="min-height:13px">example@example.com</label></span> </div>
</li>
<li id="cid_27" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container" style="width: 128px;"><button id="form-pagebreak-back_27" type="button" class="form-pagebreak-back form-submit-button-simple_green_apple jf-form-buttons"
data-component="pagebreak-back">Back</button></div>
<div class="form-pagebreak-next-container"><button id="form-pagebreak-next_27" type="button" class="form-pagebreak-next form-submit-button-simple_green_apple jf-form-buttons" data-component="pagebreak-next">Next</button></div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_27"></div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li id="cid_28" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_28" class="form-header" data-component="header">Presenter #4 (Skip if N/A)</h2>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_44"><label class="form-label form-label-left form-label-auto" id="label_44" for="first_44" aria-hidden="false"> Name </label>
<div id="cid_44" class="form-input">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_44" name="q44_name44[first]" class="form-textbox" data-defaultvalue=""
autocomplete="section-input_44 given-name" size="10" data-component="first" aria-labelledby="label_44 sublabel_44_first" value=""><label class="form-sub-label" for="first_44" id="sublabel_44_first" style="min-height:13px">First
Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_44" name="q44_name44[last]" class="form-textbox" data-defaultvalue=""
autocomplete="section-input_44 family-name" size="15" data-component="last" aria-labelledby="label_44 sublabel_44_last" value=""><label class="form-sub-label" for="last_44" id="sublabel_44_last" style="min-height:13px">Last
Name</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_46"><label class="form-label form-label-left form-label-auto" id="label_46" for="input_46" aria-hidden="false"> Company/Employer </label>
<div id="cid_46" class="form-input"> <input type="text" id="input_46" name="q46_typeA46" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_46" value=""> </div>
</li>
<li class="form-line" data-type="control_textbox" id="id_47"><label class="form-label form-label-left form-label-auto" id="label_47" for="input_47" aria-hidden="false"> Job Title </label>
<div id="cid_47" class="form-input"> <input type="text" id="input_47" name="q47_typeA47" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_47" value=""> </div>
</li>
<li class="form-line" data-type="control_email" id="id_45"><label class="form-label form-label-left form-label-auto" id="label_45" for="input_45" aria-hidden="false"> Email </label>
<div id="cid_45" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_45" name="q45_email45" class="form-textbox validate[Email]" data-defaultvalue=""
autocomplete="section-input_45 email" size="30" data-component="email" aria-labelledby="label_45 sublabel_input_45" value=""><label class="form-sub-label" for="input_45" id="sublabel_input_45"
style="min-height:13px">example@example.com</label></span> </div>
</li>
<li id="cid_31" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container" style="width: 128px;"><button id="form-pagebreak-back_31" type="button" class="form-pagebreak-back form-submit-button-simple_green_apple jf-form-buttons"
data-component="pagebreak-back">Back</button></div>
<div class="form-pagebreak-next-container"><button id="form-pagebreak-next_31" type="button" class="form-pagebreak-next form-submit-button-simple_green_apple jf-form-buttons" data-component="pagebreak-next">Next</button></div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_31"></div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li id="cid_32" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_32" class="form-header" data-component="header">ClaimsXchange Proposal Considerations</h2>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_33"><label class="form-label form-label-left form-label-auto" id="label_33" for="input_33_0" aria-hidden="false"> If selected, I agree to present the proposed session at the
2024 ClaimsXchange conference.<span class="form-required">*</span> </label>
<div id="cid_33" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_33" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_33"
class="form-radio validate[required]" id="input_33_0" name="q33_typeA33" value="I agree" required=""><label id="label_input_33_0" for="input_33_0">I agree</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_34"><label class="form-label form-label-left form-label-auto" id="label_34" for="input_34_0" aria-hidden="false"> If selected, I agree to present the proposed session in the
time slot set by the committee.<span class="form-required">*</span> </label>
<div id="cid_34" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_34" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_34"
class="form-radio validate[required]" id="input_34_0" name="q34_ifSelected" value="I agree" required=""><label id="label_input_34_0" for="input_34_0">I agree</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_35"><label class="form-label form-label-left form-label-auto" id="label_35" for="input_35_0" aria-hidden="false"> I understand that any person involved in an undocumented
cancellation of his/her session cannot be selected as a presenter at future ClaimsXchange conferences for two years.<span class="form-required">*</span> </label>
<div id="cid_35" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_35" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_35"
class="form-radio validate[required]" id="input_35_0" name="q35_ifSelected35" value="I understand" required=""><label id="label_input_35_0" for="input_35_0">I understand</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_36"><label class="form-label form-label-left form-label-auto" id="label_36" for="input_36_0" aria-hidden="false"> I agree to register and pay my 2024 registration fees, travel
and lodging costs.<span class="form-required">*</span> </label>
<div id="cid_36" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_36" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_36"
class="form-radio validate[required]" id="input_36_0" name="q36_iUnderstand" value="I agree" required=""><label id="label_input_36_0" for="input_36_0">I agree</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_37"><label class="form-label form-label-left form-label-auto" id="label_37" for="input_37_0" aria-hidden="false"> I understand that the ClaimsXchange cannot compensate me in any
way for expenses associated with this presentation.<span class="form-required">*</span> </label>
<div id="cid_37" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_37" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_37"
class="form-radio validate[required]" id="input_37_0" name="q37_iAgree" value="I understand" required=""><label id="label_input_37_0" for="input_37_0">I understand</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_38"><label class="form-label form-label-left form-label-auto" id="label_38" for="input_38_0" aria-hidden="false"> I understand that presenters cannot promote or sell presenter
products or services during the presentation.<span class="form-required">*</span> </label>
<div id="cid_38" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_38" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_38"
class="form-radio validate[required]" id="input_38_0" name="q38_iUnderstand38" value="I understand" required=""><label id="label_input_38_0" for="input_38_0">I understand</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_39"><label class="form-label form-label-left form-label-auto" id="label_39" for="input_39_0" aria-hidden="false"> I understand that presenters who are service providers or
vendors are required to become a sponsor should their session be selected.<span class="form-required">*</span> </label>
<div id="cid_39" class="form-input jf-required">
<div class="form-single-column" role="group" aria-labelledby="label_39" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_39"
class="form-radio validate[required]" id="input_39_0" name="q39_iUnderstand39" value="I understand" required=""><label id="label_input_39_0" for="input_39_0">I understand</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_2">
<div id="cid_2" class="form-input-wide">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField"><button id="input_2" type="submit"
class="form-submit-button form-submit-button-simple_green_apple submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content="" aria-live="polite">Submit Your Proposal</button></div>
</div>
</li>
<li style="display:none">Should be Empty: <input type="text" name="website" value=""></li>
<li class="form-input-wide">
<div class="form-pagebreak">
<div class="form-pagebreak-back-container"><button id="form-pagebreak-back_14" type="button" class="form-submit-button-simple_green_apple form-pagebreak-back jf-form-buttons" data-component="pagebreak-back">Back</button></div>
</div>
</li>
</ul>
</div>
<script>
JotForm.showJotFormPowered = "new_footer";
</script>
<script>
JotForm.poweredByText = "Powered by Jotform";
</script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="240147110096143-240147110096143">
<script type="text/javascript">
var all_spc = document.querySelectorAll("form[id='240147110096143'] .si" + "mple" + "_spc");
for (var i = 0; i < all_spc.length; i++) {
all_spc[i].value = "240147110096143-240147110096143";
}
</script>
<input type="hidden" name="event_id" value="1709316840356_240147110096143_OoKQYSa"><input type="hidden" name="timeToSubmit" value="3">
<div></div>
</form>Text Content
* 2024 CLAIMSXCHANGE ANNUAL MEETING SESSION PROPOSALS Please complete this form with information on your proposed session for the Annual Meeting (October 16-18, 2024 - Crystal Springs Resort - Hamburg, NJ) Submission Deadline: March 1, 2024 * Session Type:* Panel DiscussionTapas Topics (fast-paced, single-speaker, 15-minute session)Deep Dive based on Case StudyInteractive Audience SessionImmersive Cooperative LearningInterested Speaker (no session currently prepared)Other * Your Area of Practice: * * Session Title * Up to 20 words * Session Description* Up to 75 words * Next * PRESENTER INFORMATION: * Name* First NameLast Name * Company/Employer* * Job Title* * Email* example@example.com * * Back Next * PRESENTER #2 (SKIP IF N/A): * Name First NameLast Name * Company/Employer * Job Title * Email example@example.com * Back Next * PRESENTER #3 (SKIP IF N/A) * Name First NameLast Name * Company/Employer * Job Title * Email example@example.com * Back Next * PRESENTER #4 (SKIP IF N/A) * Name First NameLast Name * Company/Employer * Job Title * Email example@example.com * Back Next * CLAIMSXCHANGE PROPOSAL CONSIDERATIONS * If selected, I agree to present the proposed session at the 2024 ClaimsXchange conference.* I agree * If selected, I agree to present the proposed session in the time slot set by the committee.* I agree * I understand that any person involved in an undocumented cancellation of his/her session cannot be selected as a presenter at future ClaimsXchange conferences for two years.* I understand * I agree to register and pay my 2024 registration fees, travel and lodging costs.* I agree * I understand that the ClaimsXchange cannot compensate me in any way for expenses associated with this presentation.* I understand * I understand that presenters cannot promote or sell presenter products or services during the presentation.* I understand * I understand that presenters who are service providers or vendors are required to become a sponsor should their session be selected.* I understand * Submit Your Proposal * Should be Empty: * Back