Become a Summit Insurance Agent/Agency

Join forces with Summit now by completing the Agency Application below:

We can’t wait to strengthen your workers’ comp business and make life easier for your producers and clients.
After your application is reviewed, a Summit agency specialist will reach out to you within four business hours to learn more about your agency.
A meeting with the business developer in your state will be scheduled. And you’ll learn about the team of workers’ comp underwriting, claims, and loss prevention/safety specialists who will serve your agency. You will then be guided through our agency onboarding process.
Thank you for deciding it’s time to know the people who know workers’ comp.

Agency Application

Have questions? Contact Summit’s Sales and Agency Relations department at 1-800-282-7648.

* indicates required field.

Company *

Doing Business as (DBA) Name

Phone Number *

Fax Number

Street Address of Main Location *

City *

State/Province *

Zip Code *

Number of Locations

Number of Worker's Comp Producers

Number of Worker's Comp CSRs

Agency Principal First Name *

Agency Principal Last Name *

Agency Principal Title *

Agency Principal Phone Number *

Agency Principal Email *

Is the Designated Contact the Same as the Agency Principal? *

Yes No

Agency's Books of Business

Total (all lines) *

Commercial Lines *

Personal Lines

Benefits

Total Worker's Comp Book *

Total Number of Worker's Comp Accounts *

Average Policy Size

Workers' Comp Carrier 1

Carrier Name

Amount

3-Year Loss Ratio

Workers' Comp Carrier 2

Carrier Name

Amount

3-Year Loss Ratio

Workers' Comp Carrier 3

Carrier Name

Amount

3-Year Loss Ratio

Workers' Comp Carrier 4

Carrier Name

Amount

3-Year Loss Ratio

Workers' Comp Carrier 5

Carrier Name

Amount

3-Year Loss Ratio

How many years has your agency been in business? *

Is any of your workers' comp business written through a PEO?

Yes No

Is your agency a wholesaler, broker, or aggregator?

Yes No

Is your agency part of a larger group? *

Yes No

Are you appointed with any member of Great American Insurance Group? *

Yes No

What types/classes of business do you write most often? *

How did you hear about us?

Additional Comments and/or Information