Do you have an Insurance Submission that may fit our Program?

There are several ways you can submit a risk—choose the one that works best for you.

ONLINE FORM

Fill out the form below to submit a risk.

Submit A Risk

Agent / Broker Contact Information
Please provide your contact information and some general information about the risk.
Agency
Agent / Broker Name*
First Last
Agent / Broker Phone*
Agent / Broker Email*
Name of Risk / Organization*
Description of Risk / Organization*
Website of Risk / Organization
Effective Date
If you know the actual or desired effective date, please enter it or select it using the calendar.
MM slash DD slash YYYY
How would you prefer to be contacted?
How did you hear about us?
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Name
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PHONE

Contact us at 800.622.8272 and speak directly to one of our Underwriters.

EMAIL, MAIL, OR FAX

Send your contact information and the website address of your risk by e-mail to siegel@siegelagency.com. Our underwriting department will contact you.

You may also submit a brochure, website address, or application to ISA by mail or fax:

Irwin Siegel Agency
P.O. Box 309
25 Lake Louise Marie Road
Rock Hill, NY 12775-0309

Fax: 845.796.3661