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Referral Submission Checklist

This checklist includes the forms and information you need to sign your clients up with Lightsource HR. Download the forms, fill, and submit the information to brokerrelations@lightsourcehr.com.


Initial Data

For your convenience, we have reduced the amount of documentation and data we require to begin the registration process. We have settled on the list below.

  • ACORD Application – Download
  • 3 years of Loss Runs valued within last 30 days

Additional Data

  • Loss History Affidavit – Download
  • Height & Depth Affidavit – Download
  • Class Code Affidavit – Download
  • Worksite Detail Template – Download
  • Request for Proposal Questionnaire – Download
  • Current Payroll Register
  • Current policy declaration page
  • Most recent invoice of submissions currently with a PEO
  • State Unemployment Tax Rates

Supplemental Questionnaires by Industry

Documentation for Benefit Recipients

The documentation listed below is required for prospective clients who elect to provide benefits to their employees through Lightsource HR.

  • Employee Benefits Group Universal Large Group Medical Questionnaire – Download
  • Personal Health Questionnaire – Download
  • Group Health Questionnaire – Download
  • Group Medical Census – Download
  • Current invoices for Medical Insurance
  • Plan descriptions for Medical Insurance
  • Current invoices for Ancillary Benefits like Dental, STD, LTD, Life, and Vision
  • Plan descriptions for Ancillary Benefits
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