001578 FILED OCT 08 2009 REPRESENTING ALEX SINK Chief Financial Officer CHIEF FINANCIAL OFFICER Docketed by:_ (42 STATE OF FLORIDA ao Qa “2 IN THE MATTER OF: a o ee 6 JAMES L. HENDERSON Case Number: 09-045-1; ¥ -WC ‘oO / Bae V GUS FINAL ORDER “ i) THIS PROCEEDING came on for final agency action and Alex Sink, Chief Financial Officer of the State of Florida, or her designee, having considered the record in this case, including the Stop-Work Order and Order of Penalty Assessment, the Amended Order of Penalty Assessment, and the 2" Amended Order of Penalty Assessment served in Division of Workers’ Compensation Case No. 09-045-1A-09-WC, and being otherwise fully advised in the premises, hereby finds that: 1. On February 17, 2009, the Department of Financial Services, Division of Workers’ Compensation (hereinafter “Department”) issued a Stop-Work Order and Order of Penalty Assessment in Division of Workers’ Compensation Case No. 09-045-1A-09-WC to JAMES L. HENDERSON. The Stop-Work Order and Order of Penalty Assessment included a Notice of Rights wherein JAMES L. HENDERSON was advised that any request for an administrative proceeding to challenge or contest the Stop-Work Order and Order of Penalty Assessment must be filed within twenty-one (21) days of receipt of the Stop-Work Order and Order of Penalty Assessment in accordance with Sections 120.569 and 120.57, Florida Statutes. 2. On February 17, 2009, the Stop-Work Order and Order of Penalty Assessment was served by personal service on JAMES L. HENDERSON. A copy of the Stop-Work Order and Order of Penalty Assessment is attached hereto as “Exhibit A” and incorporated herein by reference. 3. On May 19, 2009, the Department issued an Amended Order ‘of Penalty Assessment in Case No. 09-045-1A-09-WC to. JAMES L. HENDERSON. The Amended Order of Penalty Assessment assessed a total penalty of $105,550.73 against JAMES L. HENDERSON. The Amended Order of Penalty Assessment included a Notice of Rights wherein JAMES L. HENDERSON was advised that any request for an administrative proceeding to challenge or contest the Amended Order of Penalty Assessment must be filed within twenty-one (21) days of receipt of the Amended Order of Penalty Assessment in accordance with Sections 120.569 and 120.57, Florida Statutes. 4. On May 21, 2009, the Amended Order of Penalty Assessment was served by certified mail to JAMES L. HENDERSON. A copy of the Amended Order of Penalty Assessment is attached hereto as “Exhibit B” and incorporated herein by reference. 5. On June 5, 2009, the Department issued a 2°¢ Amended Order of Penalty Assessment in Case No. 09-045-1A-09-WC to JAMES L. HENDERSON. The 2™ Amended Order of Penalty Assessment assessed a total penalty of $105,507.05 against JAMES L. HENDERSON. The 2™ Amended Order of Penalty Assessment included a Notice of Rights wherein JAMES L. HENDERSON was advised that any request for an administrative proceeding to challenge or contest the 2"4 Amended Order of Penalty Assessment must be filed within twenty-one (21) days of receipt of the 2" Amended Order of Penalty Assessment in accordance with Sections 120.569 and 120.57, Florida Statutes. 6. On June 15, 2009, the 2"! Amended Order of Penalty Assessment was served by certified mail to JAMES L. HENDERSON. A copy of the 2" Amended Order of Penalty Assessment is attached hereto as “Exhibit C” and incorporated herein by reference. 7. On June 26, 2009, JAMES L. HENDERSON. filed a petition for administrative review with the Department. The petition for administrative review was forwarded to the Division of Administrative Hearings on July 17, 2009, and the matter was assigned DOAH Case No. 09-3833. , 8. On September 14, 2009, JAMES L. HENDERSON filed a Notice of Voluntary Dismissal with the Division of Administrative Hearings. 9. On September 15, 2009, the Administrative Law Judge issued an Order Closing File which relinquished jurisdiction to the Department. A copy of the Order Closing File is attached hereto as “Exhibit D” and incorporated herein by reference. FINDINGS OF FACT 10. The factual allegations contained in the Stop-Work Order and Order of Penalty Assessment issued on February 17, 2009, the Amended Order of Penalty Assessment issued on May 19, 2009, and the 2nd Amended Order of Penalty Assessment issued on June 5, 2009, which are fully incorporated herein by reference, are hereby adopted as the Department’s Findings of Fact in this case. CONCLUSIONS OF LAW 11. Based upon the Findings of Fact adopted herein, the Department concludes that JAMES L. HENDERSON violated the specific statutes and rules alleged in the Stop-Work Order and Order of Penalty Assessment, the Amended Order of Penalty Assessment, and the 2nd Amended Order of Penalty Assessment, and hereby adopts the violation(s) charged in the Stop- Work Order and Order of Penalty Assessment, the Amended Order of Penalty Assessment, and the 2nd Amended Order of Penalty Assessment as the Conclusions of Law in this case. PENALTY IMPOSED 12. The Notice of Voluntary Dismissal submitted in reference to the Stop-Work Order and Order of Penalty Assessment, the Amended Order of Penalty Assessment, and the 2nd Amended Order of Penalty Assessment, taken together with the Findings of Fact and : Conclusions of Law adopted herein, constitute grounds for the Chief Financial Officer to impose the penalty as set forth herein. IT IS THEREFORE ORDERED that: a. JAMES L. HENDERSON is assessed the total penalty of $105,507.05 in full to the Department of Financial Services for deposit into the Workers’ Compensation Administration Trust Fund and; b. JAMES L. HENDERSON shall immediately cease all business operations in the State of Florida until such time as the Department issues an order releasing the Stop-Work Order and Order of Penalty Assessment. . The Department shall not issue an Order releasing the Stop-Work Order and Order of Penalty Assessment until JAMES L. HENDERSON has come into compliance with the coverage requirements of Chapter 440, Florida Statues and has paid a total penalty of $105,507.05 to the Department. DONE and ORDERED this 8°" _ day of __Getolza __, 2009. BRIAN LOND! DEPUTY CHIEF FINANCIAL OFFICER NOTICE OF RIGHTS Any party to these proceedings adversely affected by this Order is entitled to seek review of this Order pursuant to Section 120.68, Florida Statutes, and Florida Rule of Appellate Procedure 9.110. Review proceedings must be instituted by filing a Notice of Appeal with Tracey Beal, DFS Agency Clerk, Department of Financial Services, Room 612 Larson Building, 200 East Gaines Street, Tallahassee, Florida, 32399-0390 and a copy of the Notice of Appeal, a copy of this Order and filing fee with the appropriate District Court of Appeal within thirty (30) days of rendition of this Order. COPIES FURNISHED TO: MARIA SEIDLER FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS’ COMPENSATION BUREAU OF COMPLIANCE 2295 VICTORIA AVENUE, SUITE 163 FORT MYERS, FLORIDA 33901 MICHAEL RUDICELL, ESQUIRE 4303 SPANISH TRAIL ROAD PENSACOLA, FLORIDA 32504 PAIGE SHOEMAKER FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF LEGAL SERVICES 200 EAST GAINES STREET TALLAHASSEE, FLORIDA 32399-4229 EXHIBIT A STATE OF FLORIDA, DEPARTMENT OF.FINANCIAL SERVICES DIVISION OF WORKERS" COMPENSATION a | STOP-WORK ORDER No.: 09- 045-14 "| ISSUANCE DATE: 2/17/2009 EMPLOYER NAME: James L. Henderson FEIN: 264-15-5071 ‘EMPLOYER: ADDRESS: 108" Redbreast Lane- CITY: Pensacola See et WORKSITE POSTING ADDRES CITY: Pensacola! INDUSTRY OF EMPLOYER [i] failing to obtain coverage that meets the requlrements of Chapter 4 440, F. . and the Insurance Code! a C materially. understating or cohcealitig: payr : * ‘materially fnisrepresentitig of concealing infoirriatio pe experience rating modification factor. Ae Failure to produce required business records within 5 business days i in violation ofs section 440. tor(7ia), F Failuré to produce required documents within: Sibusiness days in Violation ofsection.440.05(14};F.S..: .. THIS STOP-WORK ORDER MAY BE AMENDED TO INCLUDE ADDITIONAL VIOLATIONS AND SHALL REMAIN IN EFFECT UNTIL THE DIVISION ISSUES. AN ORDER RELEASING: THE STOP: WORK | ORDER’ FOR ALL 'WORKSITES: ° ORDER OF PENALTY ASSESSMENT: PEA RB ae AER SG A penaity against the Employer is hereby ORDERED in an amount: ' (e] Equal to 1.5 tinies the amount the employer Would haveé paid in pretivn wher applyiig approved marial rates to the employer's payroll during periods for which it failed to secure the payment of workers’ compensation raured by this chapter within the preceding 3-year, -periog, o 000, whichever is greater, Section #40. A07(7){), F. 8... . go Up to $5,000 for each employee the Employer misclassified as an | independent contractor. Sections 440. 40(1\(f) and - 440.107(7)(f), F. S. ae - The penalty may be amended until a Final Order or an Order of Conditional Release from Stop-Work Order is issued. Pursuant to section 440.107(11), F.S., the Department may initiate lien proceedings to collect any penalty due that has not been paid. In addition, the Department may refer any unpaid penalty that is due to a collection agency for the initiation of proceedings to collect the unpaid penalty. Please see the Notice of Rights on the reserve side that pertains to your rights regarding this action. CERTIFICATE OF SERVICE Pursuant to section 440.107(4), F.S., Michelle Newcomer, Compliance Investigator ~~ fprint name and Ute of serve served a true copy of this Stop-Work Order: [i] By posting at the Worksite: Date. 2/17/2009: Time: 11:13:56 AM; Server._M.L. Newcomer [i] By hand delivery: Date: 2/17/2009: Time: 11:13:56 AM; Server. _M. L. Newcomer COBy certified mail: Date: ; Time: > Article: January 3, 2006 20 “NOTICE OF RIGHTS You have a righ Florida Statutes, «° =" |, present aviderios ‘and ‘argument on thé issiie(s),: examine. with) id di tive Law ui you may. be represented:by. couns action. ion 120.569 and 120. 57, Florida Statutes, must conform to rules ain 2015, A petition for a hearing un é facsimile Florida. :Administratiy eS number (if any) of the petitione lacsim : qualified representative of the petitioner (if any) upon ‘vom service of pleadings and ‘other papers shall be made; c) a statéitiént-requesting’an. administrative hearing identifying those: material facts that are in-displite: If there are none, the petition must so indicate; d).a staterient of when the petitioner received notice of the agency action; and e) a statemerit Including th the fi le mber to the agency 3 acti n; receipt of: this agency niThezpetition must-be-filed'wi of Financial Service, 612 Lafson Building, 200 East Gaines ‘Stre A PETITION FOR'HEAR! iG: WITHIN: THE TWENTY-ONE:(21}" DAYS CONSTI | T Division of Workers' Compensation, Bureau of Complianc: 610 E, Burgess Road, Pensacola, FL 32504-6320 Attn; Michelle Newcomer, Compliance Investigat January 3, 2006 21 EXHIBIT B STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS‘ COMPENSATION . CO STOP-WORK ORDER No.: 09:045-1A ISSUANCE DATE: 5/1 9/2009 EMPLOYER NAME: James L. Henderson FEIN: 264-15-5071 EMPLOYER ADDRESS: 108 Redbreast Lane CITY: Pensacola. AMENDED ORDER OF PENALTY ASSESSMENT The Division of Workers' Comibénsation issueda Stop-Work Order i in this’ case on .. The Stop- Work Order included an Order of Penalty Assessment that identified the penalties assessable under sections 440.10 and 440.107, F.S. The Division hereby amends the Order of Penalty Assessment based on the following penalties: Ce Failure to secure the payment of workers’ compensation within the meaning of section 440. 107(2), F:S., by: failing to obtain overage that meets the féquirements of Chapter 440, F.S., and the Insurance: Code; : materially understating or concealin payroll; [J materially misrepresenting or concealing employee’ duties $0 as to avoid proper. classification for premium Galgulations; : : . +E] materially misrepresenting or concealifig information. ettiner experience rating modification factor.” - . nd. sppiaton of;.an to the For such violation(s) the Employer is assessed a penalty of $ 105,550.73 (section 440, ‘o7(7V(d), F.S. .) as detailed i in the attached PENALTY WORKSHEET, which is incorporated herein by reference;.: : 7 G.- Conducting business » -operations " in. violation. of the Stop ‘Work “Order ‘as “detailed i a ‘PENALTY d--a .penalty of WORKSHEET, which’ is iroofporated herein by reference, for fenich the Empl er. is. $ "(section 440,107(7)(c), F.S.); : me Oo Misrepresenting the status of the employee(s) as an independent, contractor(s), as. detailed on. the attached PENALTY WORKSHEET, which is incorporated herein’ by-reference, for which the Employer is “assessed a ‘penalty of $ (section 440,10(1)(f), F.S.,). It is hereby ORDERED that the Employer is. assessed a TOTAL PENALTY of $ 105,550.73 The penalties assessed herein supersede any penalties previously assessed i in this case. The Employer shall pay the TOTAL PENALTY by money order or cashier's check, made payablé-to the DFS-Workers' Compensation Administration Trust Fund. The Stop-Work Order issued in this case shall remain in effect,until.either:(a) The Division.issues‘an order:- releasing the Stop-Work Order upon finding that the employer has come into compliance with the coverage requirements of the workers’ compensation law and pays the total penalty in full, or (b) The Division issues an Order of Conditional Release From Stop-Work Order pursuant to the employer coming into compliance with the coverage requirements of the workers’ compensation law and entering into a Payment Agreement Schedule For Periodic Payment of Penalty. Pursuant to section 440.107(11), F S, the Department may initiate lien proceedings to collect any penalty due that has not been paid. In addition, the Department may refer any unpaid penalty that is due to a collection agency for the initiation of proceedings to collect the unpaid penalty. Please see the Notice of Rights on the reserve side that pertains to your rights regarding this action. CERTIFICATE OF SERVICE Pursuant to section 440.107(4), F.S., Michelle Newcomer, Compliance Investigator ; pant name and tile of server) served a true copy of this Amended Order of Penalty Assessment: eds hand delivery: Date: ; Time: ; Server: By certified mail: Date: AlD| | OF : Time: (VAD) Articte:“100 51 IleDD0094-59'24] January 3, 2006 22 4 “NOTICE OF RIGHTS You have a right to administrative review of this action by the Department under sections 120.569 and 120.57, Florida Statutes, ; To obtain review, you must file a written petition requesting review. If you dispute a'rhaterial fact containéd in a thig action, you are entitled to a hearing under Sections'120.569 and 120. 57( 1) Florida Statutes, at which you maybe represented Eons resent n ibmit a proposed recommended:6! ind file exceptions to the recommended order of the Administrative Law Judge. If you do not dispute a material fact contained i in this action, you are entitled toa pessoa under section 120. 57(2), Florida Statutes, at which you may be represented by Couns oppésition fotthis action. — Rule 28-106.2015, umber, and facsimile d telephone numb er, and facsimile number of the attorney or ats ied representative “of the’ :patiioner (fan) u upoi whom service of pleadings and other papers. ‘shall be made; noite; the pétition must $0 indicat en ne pettioner received notice of the agency action; and e) a statement including the file number to the agency action. Tracey Beal, DFS Agency Clerk, Tallahassee, Florida 32399-0390. F, _ ISSUING AGENCY NAME AND ADDRESS Division of Workers' ‘Gompensation, Bureau. of Compliance: 6 610 E. Burgess Re Pensacola FL 22504 Attn: Michelle L. Newcomer, Telephone: (850) 453-7853 ** January 3, 2006 Notice of Rights updated 4/15/2009 23 USPS - Track & Confirm Page 1 of 1 Home | Help | Signin Track & Confirm Search Results Label/Receipt Number: 7005 1160 0003 4522 4699 Status: Delivered Your item was delivered at 12:19 pm on May 21, 2009 in PENSACOLA, FL 32503. A proof of delivery record may be available through your local Post Office for a fee. Additional information for this item is stored in files offline. o~, sine 5 Track & Confirm oe Enter Label/Receipt Number. Y Site Map Customer Service Forms Gov't Services Careers Privacy Policy Copyright© 2009 USPS. All Rights Reserved. No FEAR Act EEO Data FOIA 2 i 9/24/2009 http://trkenfrm1.smi.usps.com/PTSInternetWeb/InterLabelInquiry.do State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet DWC Case No. _09-045-1A BUSINESS NAME: JAMES L. HENDERSON 5022 03/31/2008 4 12/15/2006 scesacracnamoensnsunciliaencmacsaecsaimernienst erect ARCIANO RAMIREZ | 12/15/2006 | | 12/34/2006 02/24/2006 02/24/2006 | 3 | 12/31/2008 | 4 SERAFIN GALINDO * — \f the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. s440.107(d)(1) State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON EMILY STYLES \RRY HENDERSON OSE CRISPIN SANCHEZ — 01 01 72007 ] 12131 12007, MIKE JOHNSON ~ueracrrerenmnar enya name If the employer has failed to provide business records sufficient to enable the Department fo determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). Premium multiplied by statutory factor of 1.5 a *** Greater of penalty under column (g) or $1000. $440.107(d)(1) DWC Case No. 09-045-1A State of Florida, Department of Financial Services Division of Workers’ Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON CAMILLA REAVES : 04/01/2008 4 04/11/2008 | Recerca Seem eee GILBERT NELSON TAMES L HENDERSON JUAN H MONTIEL IARCIANO RAMIREZ IKE BENSON If the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. s440.107(d)(1) DWC Case No. 09-045-1A State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON 09/28/2008 [ 10/20/2008 IUAN H MONTIEL ELSON PLUMBING wt | . 01/01/2009 02/13/2009 scuumsneanasnie Ioeeoes is * — Ifthe employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. $440.107(d)(1) DWC Case No. 09-045-1A 7 State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON DWC Case No. _09-045-1A PELES PEREZ _ nue me i. = a S022 J 02/14/2009 | 02/17/2008 ALINDO HERNANDO 02/14/2009 * — If the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. $440.107(4)(1) Page 5 of 5 EXHIBIT C STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS’ COMPENSATION STOP-WORK ORDER Neo.: 09-045-1A ISSUANCE DATE: 6/5/2009 EMPLOYER NAME: James L. Henderson FEIN: 264-15-5071 | EMPLOYER ADDRESS: 108 Redbreast Lane city: Pensacola STATE: _2nd_AMENDED ORDER OF PENALTY ASSESSMENT The Division of Workers' Compensation issued a Stop-Work Order against the above-referenced Employer on _2/1712009_, The Stop-Work Order included an Order of Penalty Assessment that identified the penalties assessable under sections 440.10 and 440.107, F.S. Based upon additional information provided = __, the Division hereby amends the Amended Order of Penalty Assessment issued on 71972008 __ and assesses the penalty(s) as specified in the Penalty Worksheet, which is attached hereto and made a part hereof. It is ORDERED that the Employer is hereby assessed a TOTAL PENALTY of $ 105,507.05 The penalty(s) assessed herein supersedes any penalty(s) previously assessed in this case. The Employer shall pay the TOTAL PENALTY by money order or cashier's check, made payable to the DFS-Workers' Compensation Administration Trust Fund, or enter into a Payment Agreement Schedule for Periodic Payment of Penalty with the Division of Workers’ Compensation. If the total penalty assessed in this Amended Order of Penalty Assessment is less than the total penalty assessed in the Amended Order of Penalty Assessment issued on __£/19/2009_ the Division will mail a refund in the amount of the difference to the Employer. Pursuant to section 440.107(11), F.S, the Department may initiate lien proceedings to collect any penalty due that has not been paid. In addition, the Department may refer any unpaid penalty that is due to a collection agency for the initiation of proceedings to collect the unpaid penalty. Please see the Notice of Rights on the reserve side that pertains to your rights regarding this action. CERTIFICATE OF SERVICE Pursuant to section 440.107(4), F.S., Michelle Newcomer, Compliance Investigator , an served a true copy ofthis 2x¢ Amended Order of Penalty Assessment: (1 By personal service: Date: ; Time: | Server: {BJ By certified mail: Date: ; Time: ; Article: January 3, 2006 NOTICE OF RIGHTS You have a right to administrative review of this action by the Department under Sections 120.569 and 120.57, Florida Statutes. To obtain review, you must file a written petition requesting review. If you dispute a material fact contained in this action, you are entitled to a hearing under Section 120.569 and 120.57(1), Florida Statutes, at which you may be represented by counsel, present evidence and argument on the issue(s), examine witnesses, submit a proposed recommended order, and file exceptions to the recommended order of the Administrative Law Judge. If you do not dispute a material fact contained in this action, you are entitled to a hearing under section 120.57(2), Florida Statutes, at which you may be represented by counsel, present documentary evidence, and present a written statement in apposition to this action. A petition for a hearing under Section 120.569 and 120.57, Florida Statutes, must conform to rules 28-108.2015, Florida Administrative Code. The petition shall contain a) the name, address, and telephone number, and facsimile number (if any) of the petitioner; b) the name, address, and telephone number, and facsimile number of the attorney or qualified representative of the petitioner (if any) upon whom service of pleadings and other papers shall be made; c) a statement requesting an administrative hearing identifying those material facts that are in dispute. If.there are none, the petition must so indicate; d) a statement of when the petitioner received notice of the agency action; and e) a statement including the file number to the agency action; You must file the petition for hearing so that it is received by the Department within twenty-one (21) days of your receipt of this agency action. The petition must be filed with the General Counsel acting as the Agency Clerk, Department of Financial Service, 612 Larson Building, 200 East Gaines Street, Tallahassee, Florida 32399-0333. FAILURE TO FILE A PETITION FOR HEARING WITHIN THE TWENTY-ONE (21) DAYS CONSTITUTES A WAIVER OF YOUR RIGHT TO ADMINISTRATIVE REVIEW OF THE AGENCY ACTION. Mediation under section 120.573, Florida Statutes, is not available. ISSUING AGENCY NAME AND ADDRESS Division of Workers’ Compensation, Bureau of Compliance: 610 E. Burgess Road, Pensacola, FL 32504-6320 Attn: Michelle Newcomer, Compliance Investigator , Telephone: (850) 453-7853 January 3, 2006 USPS - Track & Confirm Page 1 of 1 Home | Help | Signin Track & Confirm FAQs Track & Confirm Search Results Label/Receipt Number: 7005 1160 0003 4522 4767 Status: Delivered Your item was delivered at 12:52 pm on June 15, 2009 in PENSACOLA, FL 32503. A proof of delivery record may be available through your local Post Office for a fee. Additional information for this item is stored in files offline. ee e Site Map Customer Service Forms Gov't Services Careers Privacy Policy Terms of Use usiness Custos itewa' Copyright® 2009 USPS. All Rights Reserved. No FEAR Act EEO Data FOIA 9/24/2009 http://trkenfrm1.smi.usps.com/PTSInternet Web/InterLabelInquiry.do State of Florida, Department of Financial Services Division of Workers’ Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON FERMIN HERNANDEZ 03/31/2006 | ] Tait 5/2006 NOSE | CRISEIN SANTHEC — NATALIE HENDERSON * — Ifthe employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ke Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. s440.107(d)(1) DWC Case No. 09-045-1A State of Florida, Department of Financial Services Division of Workers’ Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON DWC Case No. _ 09-045-1A [2 [I iz I J iz a a [J [I J [J a fl a J 4 06/11/2007 | 06/19/2007 05/03/2007 | 06 TM 04/24/2007 10/19/2007 eevee, Reema NATALIE POLLARD TW * — If the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penatty under column (g) or $1000. s440.107(d)(1) State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON j DWC Case No. ___09-045-1A PETE MADONADO- a - 3 . Fo1/0172007 [08/27/2008 | 10/31/2008 | JAMES L HENDERSON a zi 12/31/2008 | : Seen * — If the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shail be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.muttiplied by 1.5, (440.107(7)(e)). ae Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. s440.107(d)(1) State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON DWC Case No. _09-045-1A ERAFIN GALINDO — 01/01/2009 500.00; sonra TAMES ; HENDERSON | oa/ta/2009 [027 712009 * If the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7)(e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. s440.107(d)(1) [GALINDO HERNAND' State of Florida, Department of Financial Services Division of Workers' Compensation, Bureau of Compliance Penalty Worksheet BUSINESS NAME: JAMES L. HENDERSON DWC Case No, 09-045-1A * If the employer has failed to provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be imputed to be the statewide average weekly wage as defined in s.440.12(2) F.S.multiplied by 1.5, (440.107(7){e)). ** Premium multiplied by statutory factor of 1.5 *** Greater of penalty under column (g) or $1000. s440.107(d)(1) Page 5 of 5 EXHIBIT D

Docket for Case No: 09-003833

Orders for Case No: 09-003833