Request a Free PEO Services Quote

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 #:
*PEO Services Needed: Check all that apply

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?
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


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?

Benefits you provide:

Other Benefits Provided:

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

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

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.
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