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dmDickason Staff Leasing Company will treat all information as confidential, and will use it exclusively for the purpose of preparing a tailored business proposal.

For assistance, please call:
Martha Dickason
dmDickason Human Resources
(915) 532-1981

Please provide the following information:

* Indicates a required field

Company Information:

*Company Name:

Years in Business:

*Street Address:

*City, State, Zip:

*Contact Name:

Title:

*Phone:

Fax #:

*Email:

*PEO Services Needed: Check all that apply

Safety Programs	Human Resources Mgmt Services
Safety Training	Human Resources / EEO training
Risk Management / Loss Prevention	Simplifying New Employee Enrollment
Workers' Compensation Claims Admin	Regulatory Compliance with Labor Laws
Keeping Workers' Comp costs down	Staying out of employee lawsuits & fines
Standard Payroll Services	Employee Handbooks (English)
Certified Payroll Services	Employee Handbooks (Spanish)
Garnished Administration	Unemployment Claims Administration
Tax deposits and reporting	Finding cost-effective group insurance

Other / Special Services Needed:

*Description of Operations:

*Tell us about your Worker's Compensation Program:

Average Gross Payroll per Week: $ Annual Payroll: $

Does your company currently have workers' compensation coverage?

Yes

Current Workers Compensation Carrier:

Policy Renewal Date: Experience Modifier Rate:

Number of Claims in:	2007			2006
	2005			2004

*Employee Workers' Compensation Classification / Code / Annual Payroll

Classification(s):	Comp Code	Annual Payroll	Rate Per $100 of Payroll

Example:


1.
2.
3.
4.
5.
Total Annual Payroll:	$

*State Unemployment:
Current Number of Employees: W-2s processed last year:

Current State Unemployment Rate (SUI)

Number of unemployment claims in last 12 months:

Tell us about your Employee Benefits:

Do you currently provide Benefits to your Employees?

Yes

Benefits you provide:

Medical Dental Vision AD&D LTD 401(K) EAP

Other Benefits Provided:

Tell us about your current Business Insurance coverage: (Check all that apply)

General Liability	Errors & Omissions
Employer Practices Liability (EPLI)	Owned / Non-owned Automobile
Umbrella

Estimate of Present Administrative Costs (as a percent of payroll):

Administrative costs should include all costs associated with your company providing complete (1) Human Resources administration, (2) Workers' Compensation, Risk Management & injury claims administration, (3) Payroll processing and payroll tax compliance, (4) Unemployment Claims processing & (5) Group Benefits administration. (These costs must include all staff & management payroll, associated payroll taxes, benefits for staff employees in these departments; including vacation pay, holiday pay, the equipment and supplies they utilize, rent space, departmental utilities, legal fees, professional fees (all operating costs associated with the specific departments mentioned above).

For assistance in calculating your administrative costs, click here: Administrative Cost Calculator

10%

11%

12%

More than 12%

Note: A recent Small Business Administration study showed an expenditure in the range of 4 - 12%, with an average of 8.43% of payroll costs to provide the above administrative services.

Any specific questions or comments:

How did you hear of dmDickason Staff Leasing Company?
If by a referral, please tell us who.