. . . . .. .3 . . . unread mm. b?ww Maw?8488 <0 8N m5 Egg wwomomoz .. Exwm 2.32% . 93339? magnum z. . . .. . Spam :laimmum mummy. a m? Hugs? 3 ,3 E38 ER. ..U 3828303z?zouw?uo. STATE 0:5 WISCONSIN Department of Workforce Development (N. 0312017) Worker?s Compensation 201 Washington Ave 0 Box 7901 Madison WI 53707 RETURN SERVICE REQUESTED RECEEVED 06 201? ?mamas tompamsmou :13? In. 1&1 (@3105 . on US. FITNEY BOWES e: {in e4: 5 .. .4 ef?q: @g?m {my a? Wjjf?i?gfig?if 0: 'glf??lii memef 3 . 4" 3 we? ?55 gem more? 0001391123 29 2017 ?es-r ?233, DE lioa URN Tm SENEER ADBRESS BLE T0 FURWARD 5 1 Madigan-Doucette, Denise - DW From: Alex Jones Sent: Tuesday, August 01, 2017 2:57 PM To: Madigan-Doucette, Denise Alex Jones Subject: Fwd: 5 Attachments: 20170801155332142.pdf Dear Ms. Madigan?Doucette, Attached is the information that has been requested from the Department of Workforce Development. Please feel free to contact me if you have any questions. Regards, AlexJones I @7 WW ?ea/2% Were/972542.551: Director of Risk Management Direct: 770-242?0454 Ext. 231 Mobile: 470-839-5371 Fex: 404920?4334 ADE if out) alex. f0nes@courierds. com 7 x. REVISED INVOICE 1 FOR INVESTIGATION 651363 BIP No. Dethr's SSN WCRB No. FEIN Ul No. Class Wksheet Type 6488843 .. . 7231 Regular Employer Name SOURCE COURIER DISTRIBUTION SYSTEMS LLC UEF Claim Corporate Name DBA Name USMAN ESHAI Street Address. 6650 SUGARLOAF PKWY City State Zip Code Telephone It DULUTH WI 30097-4359 (855) 237?3274 Business Status Number of Employees Period of Lapse Coverage OOB/NoEmployees LIABILITY 757 From:02X 24/ 2017 14/ 2017 TOTAL LAPSED DAYS 111 1. Has the employer previously been penalized under s. 102.82? If yes, what were the lapse dates? From: To: 2. Did-an injury which the employer is liable for under s. 102.03 occur during the lapsed time Period? If yes, attach the claim documentation 3. Does the penalty assessment under s. 102.82(2] lag) apply? 5. Payroll Based on: ACTUAL 365 Lapse Lapse Start Lapse End Lapsed Days Daily Avg Payroll Uninsured Payroll 1 02/24/2017 06f14/2017 111 $1,196.07 - 0 Lapse Eff. Date Class Code Rate(R) Uninsured Percentage Premium Evaded 1 10/01/2016 7231 16.26 436,566.95 . 100 $70,985.79 Double Premium Evaded: $141,971.53 If under $750, invoice $250, If over $750, invoice the amount of premium 2. 6. Initial Penalty Due: $141,971.58 Preparer: MADIGDE Date: 08/02/2017 ?Rap COURIER DISTRIBUTION SYSTEMS LLC July 6, 2017 ESHAI . 6650 SUGARLOAF PKWY . BIP it: 648-8843 DULUTH, WI 30097-4359 were; #1 Our records indicate you did not have a Worker's Compensation insurance policy in force from 0212412017 to 0611412017. To verify the gross wages earned by your employees during the lapsed time period please complete the questions below, verifying the total number of empioyees working and the totai dross payroll earned by the employees during the lapsed time period indicated above. Do not count as employees or include the wages. of sole proprietors partners or members of limited liability companies and do not inoiude the wages of exempt corporate of?cers Provide the job classi?cation breakdown if applicable. The total number of employees working during the lapsed time period indicated above was: 2 A . 2. The totai gross payroll earned by your employees during the lapsed time period from 02124l2017 to 06l14l2017: Lise preteens 2a. If you have more than one job classification code on your worker's compensation insurance policy, you may provide a breakdown of the gross payroll for the lapsed period indicated in question 2, assigning it to the appropriate classi?cation code in which it was earned. (Attach a separate sheet if additional space is needed.) Job Classification Code Gross Payroll Earned During Lapse Classification Code: Classi?cation Code: . 95 Classification Code: Classi?cation Code: Classification Code: Classi?cation Code: lfyou did not have employees during the iapsed time period indicated above, what was the last date you did have employees? - 4. ,if you no longer have any empioyees, what was the last date you did have employees? Name piease print) I Title 218x? Ljd??it/J area/er a v5 224% Mme? . Signature Date Si ned Teiephone Number @6116? 7737? 2572:? Scott Walker W0 COMPENSATION STATE OF WISCONSIN P.O. BOX 7901 Governor . . Madison, WI 53707-7901 Raymond Ailen . -- (608.) 2666827 Secretary . Department of Wotkiorce Development . State of Wisconsin Department of Workforce Development DISTRIBUTION SYSTEMS LLC -- . . . 'Juiy 6, 2017 USMAN 6650 SUGARLOAF PKWY DULUTH, WI 8009744359 . . WCRB #1 Dear Employer: . Our records indicate that you did not have a worker?s compensation insurance policy in force from 02241201? to and that you may have been required to be insured during this time period. If any of this information is not correct, please advise me immediately. Please provide the information requested in the questions on the reverse side of this letter to verify the number of employees working for you and the wages earned during the lapsed time period. if it is determined that you were required to be insured during the lapsed time period identified above, you will be assessed a mandatory penalty for violation of the Wisconsin worker?s compensation law. This penalty is twice the amount of premium not paid during the uninsured time period or $750, whichever is greater. Under certain circumstances, if an employer's lapse in worker?s compensation insurance coverage is less than seven (7) days, the penalty is $100 per day. (See sections and of the Wisconsin Statutes.) . Failure to respond to this letter and to provide the requested employment and payroll information will be considered acknowledgment by you that you were required to be insured during the lapsed period and in violation of the Wisconsin Worker's Compensation Act. If you do not_provide the employment and payroll information requested, we will use the best avaiiable employment and payroll information to assess a mandatory penalty for failure to have the'required insurance Coverage in force during the lapsed time period. Please complete the questions on the reverse side of this letter and return it within 15 days of the date of this letter. Sincerely, . Denise Madigan?Doucette, Investigator Worker?s Compensation Division Unit . (608) 267-0516 Fax (608) 26645827 in: 011091) E20 ORIGINAL INVOICE FOR INVESTIGATION 651363 BIP No. Debtor?s wcea No FEIN 0: No. Class Wksheet Type . 6488843 1. 7231 Regular Employer Name SOURCE COURIER DISTRIBUTION SYSTEMS LLC - - - UEF Claim Corporate Name DEA Name USMAN ESHAI Street Address 6650 SUGARLOAF PKWY City State Zip Code I aTeIephon?? ti DULUTH WI 30097-4359 (855) 237-3274 . J2 Business Status Number of Employees Period of Lapse Coverage OOB/NoEmployees LIMITED LIABILITY 71 From:02/24/2017 TOTAL LAPSED DAYS 111 1. Has the employer previously been penalized under s; 102.82? If yes, what were the lapse dates? From: To: 2. Did an injury which the employer is liable for under s. 102.03 occur during the lapsed time Period? If yes, attach the claim documentation 3. Does the penalty assessment under 5. 1.0282(2) (ag) apply? 5. Payroll Based on: QUARTERLY WAGE PayYear Quarter Payroll Amount 2015 3 $364,140.92 2 2015 4 $325,131.71 2017 1 $322,461.51 2017 2 $389,831.25 4 $1,402,615.39 Daily Avg Total Payroll Amt/ Days in Year $3,842.78 $1,402,615.39 365 Lapse 1 Lapse . _1 Lapse Start Lapse End Lapsed Days Daily Avg Payroll Uninsured Payroll 02/24/2017 06/14/2017 111? $3,842.78 426,548.58 Eff. Date Class Code RatelR) Uninsured Percentage Premium Evaded 10/01/2016 7231 16.26 426,548.58 100 $69,356.80 Double Premium Evaded: $138,713.60 If under $750, invoice $750, If over $750, invoice the amount of premium 2. 5. Initial Penalty Preparer: MADIGDE I. Date: 07/31/2017 Sixtittlillaikeir STATE or wrecousm "Po. Box 7901 Governor . .. .. Madison, WI 53707?7901 Raymond Allen . FAX: (608) 266?6827 Secretary Department of Workforce Development State of Wisconsin Department of Workforce Development COURIER DISTRIBUTION SYSTEMS LLC June 28, 2017 USMAN ESHAI - . 650 SUGARLOAF PARKWAY - BIP #1 648-8843 MILWAU KEE, WI 53215 . - Dear Employer: Our records indicate that you did not have a worker?s compensation insurance policy in force from 0224/2017 to 06/14l2017 and that you may have been required to be insured during this time period. if any? of this information is not correct, please advise me immediately. Please provide the information requested in the questions on the reverse side of this letter to verify- the number of employees working for you and the wages earned during the lapsed time period. [fit is determined that you were required to be insured during the lapsed time period identified above, you will be assessed a mandatory penalty for violation of the Wisconsin worker's compensation law. This penalty is twice the amount of premium not paid during the uninsured time period or $750, whichever is greater. Under certain circumstances, if an employer's lapse in worker?s compensation insurance coverage is less than seven (7) days, the penalty is $100 per day. (See sections and of the Wisconsin Statutes.) Failure to respond to this letter and to providethe requested employment and payroll information will be considered acknowledgment by you that you were required to be insured during the lapsed period" and in violation of the Wisconsin Worker?s Compensation Act. If you do not provide the employment and payroll information requested, we will use the best available employment and payroll infOrmation to assess a mandatory penalty for failure to have the required insurance coverage in force during the lapsed time period. Please complete the questions on the reverse side of this letter and return it within 15 days of the date of this letter. Sincerely, Denise Madigan-Doucette, Investigator Worker?s Compensation Division Unit (608) 267-0516 Fax (608) 266-6827 I WKC-Q229 0004) ?20. DISTRIBUTION SYSTEMS LLC June 23, 2017 visit/IAN ESI-IAI . do SUGARLOAF PARKWAY - BIP it: 648-8843 MILWAUKEE, WI 53215 - - WCRB . Our records indicate you did not have a Worker?s Compensation insurance policy in force from,02!2412017 to 06114I2017. To verify the gross wages earned by your employees during the lapsed time period, please complete the questions below, verifying the total number of employees working and the total gross payroll earned by the employees during the lapsed time period indicated above Do not count as employees or include the wages of sole proprietors partners or members of limited liability companies and do not include the wages of exempt corporate of?cers. Provide the job classi?cation breakdown if applicable. The total number of employees working during the lapsed time period indicated above was: 2. The total gross payroll earned by your employees during the lapsed time period from 02I2412017 to 06I1412017: . 2a. if you have more than one job classification code on your worker?s compensation insurance policy, you may provide a breakdown of the gross payroll for the lapsed period indicated in question 2, assigning it to the appropriate classification code in which it was earned. (Attach a separate sheet'lf additional space is needed.) Job-Classi?cation Code Gross Payroll Earned During Lapse Classi?cation Code: Classification Code: Classification Code: Classi?cation Code: Classi?cation Code: A Classification Code: 3. If-you did not have employees during the lapsed time period indicated above, what was the last- date you did have employees? - 4. if you no longer have any employees, what was the last date you did have employees? Name (please print) Title Signature Date Signed Telephone Number {ya age COMPENSATION walk? STATE 0 ~wrs come i Box 7901 overnor Madison, Wt 53707-7901 Raymond Allen ?t it} FAX: (608) 286-8827 Secretary Department of Workforce Development State of Wisconsin Department of Workforce Development COURIER DISTRIBUTION SYSTEMS LLC May 31, 2017 USMAN ESHAI 3935 WMITCHELL ST STE 800 ,g 8488843-- MILWAUKEE, WI 53215 woes Dear Employer. We have previously requested information regarding the status of your Worker's Compensation insurance policy. We have no record of a response. Our records indicate you may be an employer subject to the Wisconsin Worker?s Compensation Act and you do not currently have the required worker?s compensation insurance to Operate in Wisconsin. You appear to have employees and should have a worker's compensation insurance policy. If our records are correct, you must obtain a worker's compensation insurance policy immediately, Most Wisconsin employers are required to carry worker?s compensation insurance under the Wisconsin Worker?s Compensation Act. An employer becomes subject to the Wisconsin Worker's Compensation Act and must carry a worker?s compensation insurance policy when: 1) the employer usually employs three or more persons full?time or part-time. This employer needs insurance immediately; or 2) the employer has one or more full?time or part-time employees and has paid gross combined wages of $500 or more in any calendar quarter for work done in Wisconsin. This employer must have insurance by the 10th day of the ?rst month of the next calendar quarter; or 3) a farmer who employs six or more workers on the same day for any 20 days during a calendar year. The farmer must have insurance 10 days after the 20th day of employment. A calendar year is January through December. Some relatives of the farmer are not counted as employees. Please call (608) 266?1340 fora detailed explanation of these exceptions. It is mandatory for a subject employer to carry Worker's Compensation insurance if the employer has any employee. Failure to obtain Worker?s Compensation insurance will result in the initiation of closure proceedings by the Department of Workforce'Deveiopment, which will require you to cease operations untii you are in compliance with the Wisconsin Worker?s Compensation Act. (See section 102.28(4) of the Wisconsin Statutes.) The penalty for failure to carry Workers Compensation insurance'when required, is twice the amount of premium not paid during an uninsured time pen?od or $750, whichever is greater. An employer who has a iapse in Worker's Compensation insurance coverage can be subject to a penaity of $100 for each day they are uninsured up to 7 days. Please complete the attached form and return it within 15 days of the date this form was mailed. if you have any questions, please call me. Denise Madigan?Doucette, investigator? Worker?s Compensation Division Enforcementfinvestigation Unit (608) 267?051 6 Fax (608) 266?6827 WK09932 (R. 01:31) 648?88-43 WCRB 0513?96-07 PLEASE COMPLETE THE AND THE EMPLOYERQUARTERLY WAGE REPORT BELOW 1. What date did you apply for a worker?s compensation policy? 2. What is the name of the insurance company currently providing your workers compensation insurance coverage? 3. What date did your current policy go into effect? 4. What is the policy number of your current policy? 5. What is the name and phone number ofyour insurance agent or agency? Insurance Agent or Agency Name Insurance Agent or Agency Telephone Number If possible, attach?a copy of the Information or Declaration Page of your policy. Emptoyer Quarterly Wage Record Report Please complete the information requested in the spaces provided. Indicate the total gross payroll earned by your employees in each calendar quarter and the total number of employees that worked in each month of each calendar quarter. Do not count as employees or include the wages of sole proprietors or partners and do not include the wages of exempt corporate of?cers. include up-to?date 2016 information. If you no longer have any employee(s), what was the last date any employee(s) worked for you? Last date any employee worked: 2016 Year Jan Feb Mar First Quarter$ Payroll Employees Apr May June Second Quarter$ Payroll Employees July Aug Sept Third . Quaner$ Payroll Employees Oct Nov Dec Fourth Quarters; Payroll Employees Name (please print) Signature 2017 Year Jan Feb Mar First Payroll Employees Apr May June Second Quarter$ Payroll Employees July Aug Sept Third Quarter$ Payroll Employees Oct Nov Dec Founh Quarter$ Payroll Employees Title Date Signed Telephone Number UEF UNINSURED CLAIM INTAKE I TELEPHONE. REPORTING FORM. Date: '0511212017 Investigator Name Denise Open Investigation Exist Yes No BIP Set up New Investigation Yes No FEIN Transferred File To: UEF Denise Madigan-Doucette Attach UI Print out and Spectrum Print Claim and Injury Information Claimant Name, Social Security Number and DOB Claimant Telephone Number 577/, 7 Type Injury Type of Work Performed DELIVERY CARRIER Other Employees Workinngow Many! Names Hundreds of employees 75 ee's How were you paid? Weekly, Biweekly, By Check By Cash? ln?Kind?? PAID WEEKLY BY CHECK Represented By Attorney: Yes or NO If yes who: Attorney Address: Employer Information. Employer Namelor Business Name COURIER DISTRIBUTION SYSTEMS LLC 3935 MITCHELL ST STE 300 MILAUKEE, WI 53215 Employer Telephone Number 770-403?5939 Employer Address City State Zip Code Additional Information: Looked under 0509607 COURIER DISTRIBUTION SYSTEMS LLG. Policy cancelled. 02124117 Rum- aqua; ??smamm'?v mm Department of Workforce Development 5 TAT '0 Division of Worker?s Compensation 30.30:: 7901 w" Department of Workforce Development Madison, WI 53707-7901 Telephone: (608) 266?1340 Fax: (503) 267-0394 TTY: (866) 265?3142 Email: gov Walker, Governor Raymond Allen, Secretaly May 12, 2017 RE: COURIER SYSTEMS LLC BIP 6488843 Date of Injury: May 7, 2017 . On May 12, 2017 you (Eta'cted the regarding a work related injury you sustained on May 7, 2017 while employed by C?ciuner Distribution'Sys?t'?'ii?fs LLC. The Division's initial review cf the worker?s compensation insurance policy records cannot-identify a worker?s compensation insurance policy for this employer. if this employ/er was subject to the Act and did not have a valid worker?s compensation policy in effect on the date you were injured, you may be eligible to receive worker?s compensation bene?ts from the Uninsured Employers Fund. The Uninsured Employers Fund (U EF) is administeredby the Wisconsin Worker's Compensation Division. The UEF pays worker's compensation benefits on valid worker?s compensation claims ?led by employees who are injured while working for illegally uninsured Wisconsin employers. When a compensable claim is filed, the UEF pays the injured employee worker?s compensation bene?ts as if the uninsured employer had been insured. To file a UEF claim, complete and return the original enclosed Uninsured Employers Fund Claim Form (faxes or photocopies of the application are not accepted). Attach a copy of a check stub, W-2 form, payroll check, tax return, wage statement or similar employment information as documentation of your employment with this employer. if you do-not have any documentation of your employment, you must attach a notarized statement explaining how and when you were paid, how much you were paid and the reason you are unable to provide any documentation. In addition, complete and return the enclosed Substitute Taxpayer Identi?cation Number (TIN) Verification form. Failure to complete and return the Substitute form will delay payment of the claim. Mail the completed forms to the Worker's Compensation Division, P.O. Box 7901, Madison, WI 53707- 7901. After the claim is ?led you will be contacted by the UEF claims administrator, The ASU Group. The ASU Group will handle the entire claim process including any questions you may have regarding the claim. The Division will continue to investigate the status of Courier Distribution Systems LLC under the insurance requirements of the Worker?s Compensation Act. if you have any questions regarding the UEF or it you need help filling out any part of the claim form, please call me at (608)267-0516. Sincerely, Denise M. Madigan-Doucette, Investigator - Worker's Compensation Division/Uninsured Employer. Fund ph 608-267-0516 fax 266-6827 . - WKC-5134-E (R. 101251201 1) I a . .H ?grinning. c. y: ialnng?hh?. . .., l. .. in? .1. Scott Walker 9 COMPENSATION Governor STATE OF wrsconsnv P-O'Boxmm i - .- Madison, WI 53707?7901 FAX: (606) 286-8827 Department of Workforce Development Raymond Allen Secretary State of Wisconsin Department of Workforce Development COURIER DISTRIBUTION SYSTEMS LLC 9?1'295 a! ?12, 2017 USMAN ESI-IAI was 3935 MITCHELL ST STE 300 - . 6486843 MILWAUKEE WI 53215 . WCRB Dear-Employer; has indicated that she was employed by COURIER DISTRIBUTION SYSTEMS LLC USMA ESHAI and was injured while working on May 7, 2017. - To clarify our records regarding this injury and your status under the WisconsinWorkerfs Compensation Act, please complete and return the enclosed Employer?s Report, provide the information requested on page 2 of this letter and respond in writing to the following questions. 1. Was 2. If yes, did you have a valid workers compensation policy in force on the date the injury occurred? If you had a policy in force on the date in question, please attach a copy of the information or Declaration Page of the policy tothe Employer?s Report. - - employed by you? 3. if Louvenger Phillips was not employed by Iy?ou, please clarify what Louvenger Phillips?s working relationship and status was with COURIER SYSTEMS LLC USMAN include copies of any documentation you have regarding 3' . working relationship and status with you. The penalty for failure to carry worker?s corn ensation insurance?when required, is twice the amount of premium not paid during an uninsured time period or 750, whichever is greater. Under certain circumstances, an employer who has a lapse in Worker?s Compensation insurance coverage can be subject to a penalty of $100 for each day they are uninsured up to 7 days. In addition, an uninsured employer is personally liable for reimbursement to the Uninsured Employers Fund for benefit payments made by the Fund under section. ?iO2.81(1) oi the Wisconsin Statutes, to an injured employee of the uninsured employer or to the employee?s dependents. (see sections and 102.81 (1), of the Wisconsin Statutes.) Failure to respond to this letter and to provide the requested employment and payroll information will be considered acknowledgment by you that; 1) a compensable worker?s compensation injury did occur, 2) you were required to be insured at the time of the injury and 3) you were in violation of the insurance requirements of the Wisconsin Worker?s Compensation Act. If you do not provide the employment and payroll information requested, we will 'use the best available employment and payroll information to assess a mandatory penaity for failure to have the required insurance coverage in force. Finally, if you are operating without a worker?s compensation insurance policy in violation of the law, your firm must take immediate action to obtain a worker?s compensation policy issued by a Wisconsin licensed insurance carrier. Attach written documentation that your business has obtained a worker?s compensation policy to the Employer?s Report. Failure to obtain proper worker?s compensation insurance could result in a "closure order? being issued under section 102.28(4) of the Wisconsin Statutes. This order would require your firm to cease operations until you comply with the insurance re uirements of the Wisconsin Worke Compensation Act. We nge that the Worker?s Compensation Division wi I not have to take such actions. Please respond by June 6, 7' . Sincerely. Denise Madigan-Doucette, Investigator - Workers Compensation Division Enforcement/Investigation Unit (608) 287-0518 FaxiiE (808) 266-6827. WKC-10493 (N. O?il?i) E30 6348?88?43 - WCRB 050?96-07 PLEASE COMPLETE THE QUESTIONS AND THE EMPLOYER QUARTERLY WAGE REPORT BELOW 1. What was the first date any employee worked for you? . What was the first date 3 or more employees worked for you? I 2 3. How many employees currently work for you? 4 . If you no longer have any employee(s), what was the last date any employee(s) worked for you? Last date any employee worked: 9 Employer Quarterly Wade Record Report Please complete the information requested in the spaces provided. indicate the total gross. payroll earned by your employees in each calendar quarter and the total number of employees that worked in each month of each calendar ?quarter. Do not count as employees or include the wages of sole proprietors or partners and do not include the wages of exempt corporate of?cers. Include up-to?date 2016 information. 20l6 Year Jan Feb Mar First Quarter$ . Payroll Employees Apr May June Second Quarter$ Payroll Employees July Aug Sept Third Quarter$ Payroll' . Employees Oct Nov Dec _Foudh Quarter Payroll Employees Name (please print) Signature (R. can 4) E30 2017 Year Jan Feb, Mar First Quarters Payroll Employees Apr May June I Second Quarter$ Payroll Employees - July Aug Sept Third Quarter$ Payroll Employees Oct Nov Dec Foudh Quarter$ Payroll Employees Title Date Signed Telephone Number THE COMPENSATION UNINSURED EMPLOYERS FUND What is the Uninsured Employers Fund? The Uninsured Employers Fund (UEF) pays worker?s compensation benefits on valid worker?s compensation claims filed by employees who are injured while working for illegally uninsured Wisconsin employers. When a compensable claim is filed, the UEF pays the injured employee worker?s compensation benefits as if the uninsured employer had been insured. The ninsured employer is responsible to reimburse the UEF for all costs of a claim paid by the fund. How is the UEF funded? it is funded through penalties assessed against employers for illegally operating a business without worker?s compensation insurance. The penalties are mandatory and non?negotiable. in addition, the department pursues reimbursement from each uninsured employer of benefit payments made by the UEF under s. Wis. Stats, to the employee of that uninsured employer or to the employee?s dependents. The UEF uses aggressive collection action (including warrants, levies, garnishment and execution against property) to secure satisfaction of penalty assessments and reimbursement of claims paid by the fund. When was the UEF implemented? The UEF applies only to injuries occurring on or after July 1, 1996. Uninsured Employers Fund claims filed for injuries occurring prior to July 1, 1996 are not valid and will be denied. How is a UEF claim form filed? To file a claim, an injured worker must complete an Uninsured Employers Fund Claim Form and provide the required documentation. in addition, a claimant is expected to provide assistance to the department or its agent, including copies of relevant payroll checks, check stubs, bank records, wage statements, tax returns or other similar documentation in determining whether their employer is liable for the injury. A claimant is also required to document any medical treatment, vocational rehabilitation services and other bills or expenses related to a claim. Will the department verify the information provided in a UEF claim form? Yes, the claim will be thoroughly investigated. in verifying information submitted in support of a claim for compensation. the department or its agent may share information related to a claim with other government agencies, including those responsible for tax collection, unemployment insurance, medical assistance, vocational rehabilitation, family support or . general relief. What if an alleged uninsured employer refuses to cooperate with the department? An employer who is alleged to be uninsured is required to cooperate with the department or its agent in the investigation of a claim by providing any records related to payroll, personnel, taxes, ownership of the business or its assets or other documents the department or its agent requests from the employer to determine the employer?s liability under s. 102.03 of the Wisconsin Statutes. If an employer fails to provide requested information, the department may presume the employer is an uninsured employer and assess the appropriate penalties. Once a UEF claim form is filed, how long does it take to process the claim? Within 14 days after receiving a completed UEF claim form, the department or its agent will mail the first indemnity payment to the injured employee, deny the claim or explain to the employee who filed the claim the reason that the claim is still under review. The department or its agent will report to the employee regarding the status of the claim at least once every 30_days from the date of the first notification that the claim is under review until the first indemnity payment is made or the claim is denied. Who can I contact for more information regarding the Call or write the Wisconsin Workers Compensation Division, Bureau of Insurance Programs. our mailing address is PO. Box 7901, Madison,-Wisconsin 53707?7901. Our telephone number is (608) 266?1340 or you can reach us by fax at (608) 266-6827. - (R. 08l93) ?30 3 Important Information Regarding The Worker?s Compensation Division?s Closure Procedure What is a Closure Order? Under section 102.28 (4) of the Wisconsin Statutes, the department may order an employer to cease operations in Wisconsin until the employer complies with the insurance requirements of the Worker's Compensation Act. What happens if an uninsured employer' Ignores a Closure Order and continues to operate without workers compensation insurance? The Wisconsin Department of Justice Office of the Attorney General, will bring action in any court of competentjurisdiction for an injunction against the uninsured employer to enforce the department?s order to cease operations. Are there penalties if I ignore a Closure Order and continue to operate without worker?s compensation insurance? Yes they are substantial and severe. Under section 102. 85 (3) of the Wisconsin Statutes an employer who violates an order to cease operation under section 102 28 (4) may be fined not more than $10, 000 or imprisoned for not more than 2 years or both In addition under section 102 85 (1) and of the Wisconsin Statutes an employer who fails to comply with the insurance requirements of the Act for less than 11 days shall forfeit not less than $100 nor more than $1000. An employer who fails to comply for more than 10 days shall forfeit not less than $10 nor more than $100 for each day on which the employer fails to comply. Finally, under section 102.85 (4) of the Wisconsin Statutes, if the court imposes a fine or forfeiture under sections 102.85 (3) andlor 102.85 (1) and the court shall also impose an uninsured penalty assessment against the employer equal to 75% of the amount of the fine or forfeiture. It operating with employees andl don?t have a worker?s compensation policy, what can I do to avoid closure proceedings against my business? Obtain a worker' compensation insurance policy immediately. Attach written documentation to this letter showing your business has obtained a worker's compensation insurance policy and the date the policy went into effect. Mail or fax the information to the Worker's Compensation Division by the date indicated on the pnorpage if ve closed or sold my business or I?m operating without any employees what can I do to avoid closure proceedings against my business? if you have closed or sold your business or you are operating without any employees or have filed a corporate officer option form with the Worker? Compensation Division complete the appropriate information on the prior page of this letter. Be sure to include the last date any employee worked for your business if applicable. Mail or fax the information to Worker?s Compensation Division by the date indicated on the prior P399- currently have a worker?s compensation policy. What shouldl do to help the Worker?s Compensation Division?s update their records to show I have a policy? Attach a copy of the Information Page or Declaration Page of your current policy to this letter and mail or fax it to the Worker?s Compensation Division by the date indicated on the prior page. Who can I contact for more information regarding my business?s status under the insurance requirements of the Worker?s Compensation Act? Call the investigatorthat' Is handling this investigation You will find their name telephone number and fax number on the prior page. . WKC-10493 (R. 08198} 630 4 wo ?no gg?g?ilker STATE OF wrsconszn now?oxreoi A Madison, WI 53707?7901 FAX: (608) 266-6827 Raymond Allen Secretary Department of Workforce Development State of Wisconsin Department of Workforce DeveIOpment COURIER DISTRIBUTION SYSTEMS LLC - May 3, 2017 USMAN ESHAI . . . -- - 2200 NORCROSS PKWY STE 200 BIP 6?48?8843- NORCROSS. GA 30071-3671 WCRB Dear Employer: Our records indicate we do not currently have an active Workers compensation insurance policy on tile as required for your business. We have no record of a reinstatement, renewal or replacement of a worker?s compensation insurance policy for you. You appear to have employees and appear to have no insurance. To clarify our records regarding your worker?s compensation insurance coverage and your status under the Wisconsin Worker?s compensation Act, please complete and return the information requested on the enclosed form. if you currently have a worker?s compensation insurance policy, attach a copy of the information page, declaration page or reinstatement of your current worker?s compensation insurance policy. The following penalty information is provided only to advise you about the potential cost of lapsed worker?s compensation insurance coverage. Lapsed coverage may not apply to you. The penalty for failure to carry worker?s compensation insurance when required is twice the amount of premium not paid during an uninsured time period or $750.00, whichever is greater. Under certain circumstances, an employer who has a lapse in worker?s compensation insurance coverage can be subject to a penalty of $100 for each day they are uninsured up to 7 days. In addition, an uninsured employer is personally liable for reimbursement to the Uninsured Employers Fund for bene?t payments made by the Fund under section 102.81 (1) of the Wisconsin Statutes, to an injured employee of the uninsured employer or to the employee?s dependents. Please complete and return the enclosed form within 15 days of the date this form was mailed. Replies to these questions are required by law. Failure to respond will be considered acknowledgment that our records are correct and will be considered evidence that you are in violation of the Wisconsin Worker?s Compensation Act. If you have any questions regarding the Wisconsin Workers Compensation Act and your requirement to carry a worker?s compensation insurance policy, please call me. Sincerely, Chad OConnor, Investigator - Worker?s Compensation Division Entorcement?nvestigation Unit (608) 266-0317 chad.oconnor@dwd.wisconsin.gov (R. E3-Z BI 648?88?43 WCRB ?0 READ CAREFULLY From time to time the Worker?s Compensation Division may require specific information from individual employers. if an employer receives a questionnaire or inquiry concerning its worker?s compensation or employer status from the division, the employer is required by law to provide the requested information. "Every employer shall upon request of the department report to it the number of employees and the nature of their work and also the name of the insurance company with whom the employer has insured iiability under this chapter and the number and date of expiration of such policy.? (5. 102.2863), Wis. Stats.) Atso every employer who fails to make the reports required by the Workers Compensation Act shall be subject to monetary penalties (5.102 35(1), Wis. Stats WKC-9228 (R. OBIQB) E3-Z State of Wisconsin COMPENSATION INSURANCE REQUIREMENTS Department of Workforce Development REPORT Want-? May 3, 2017 - - 848-8 - - WC RB 9:33-3:35 COURIER DISTRIBUTION SYSTEMS LLC -- USMANESHAY RE: WISCONSIN 2200 PKWY STE 200 EMPLOYEES NORCROSS, GA 30071?3671 ONLY Wisconsin?s Worker?s Compensation Act protects employees from undue hardship and employers from liability which may result from a job-related injury. That law requires most employers of Wisconsin workers to carry private worker?s compensation insurance and to respond to our requests for information. The same law requires us to make sure that employers comply. Please complete and return pages 1 8. 2 of the following form to us within 15 days of receipt to comply with the laws regulating worker?s compensation. The rest of this form will answer your questions about the purpose of the Worker?s Compensation Act, conditions that make an employer liable, penalties for noncompliance, and special exemptions. Call us at (608) 266-1 340 if you have any other questions. Send the completed form within 15 days to: Worker?s Compensation Division, Bureau of Insurance Programs, PO. Box 7901, Madison, WI 53707?7901 Personal information you provide may be Used for secondary purposes [Privacy Law, S. 1. Name by which your business is known 2. Legal name, if different from ?i 3. Business street address City State Zip Code 4. Telephone Number 5. Federal Employer Identi?cation Number 6. How many employees do you now have Working in Wisconsin? if you do ?0t currently have any employees working in Wisconsin, what was the last date any employee worked . Count corporate of?cers, family members, minors and part-time for you in Wisconsin? em pioyees Do not count soie proprietors, partners, mem bers of limited liability companies or dorn es?c servants Date: 7. How many em ployees do you usualiy have? 8. Hate you paid a com bined total of $500 or more in wages for work performed in Wisconsin This year? [3 Yes No during any calendar quarter (Jan - March; April - June; July Sept; Oct Dec) Last year? Yes No 9. What is the nature of your business? chsarn. 1212001) (continued on page 2) . Worker?s Compensation Division, Bureau of insurance Programs 201 EastWashington Avenue, Room 161 (13.0. Box 7901), Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 266-6827 Page 1 State of Wisconsin COMPENSATION INSURANCE REQUIREMENTS Department of Workforce Development EM REPORT BIP 648-338-415 WCRB 10- What type of ownership is your business? If other, please explain: Cl Sole Proprietorship El Limited Liability Company CI Partners ?1 Farm Operation El Corporation Other, please expiain 11. Namethe soie proprietor, partners, corporate of?cers, or members of a limited iiability company. Name and Titie please pri? Social Security Number: 12. What insu ranoe company currently provides your worker?s Name of Insurance Company: compensation insurance coverage? Attach a copy of the Information Page or Declaration Page of your current worker?s compensation policy. 13. Policy Number. 14. Effective dates of the policy: 15. Name of your insurance agent or agency: Telephone number of your insurance agent or agency: 16. Has your business closed? if yes, on what date did it if yes, what is the test date any employee worked? close? Last date employee worked: Yes, date ciosed: No Is the business closed permanently? Is the business seasonal? If yes, which months do you norm . operate17. Has your business been sold or transferred? if yes, what date was your business sold or transferred? Yes No Date sold or transferred Provide the name and address of the person or organization who bought or received the transfer of your business: Nam e: Address: Authorized Signature Title Printed Name Teiephone Number Date Signed Thank you for completing this form. Please mail pages 1 2 to us within 15 days of receipt. The pages that follow will answer most of your questions, but call us if we can help. We are the Worker?s Compensation Division of the Wisconsin Department of Workforce Development at (608) 266?1340. Worker?s Compensation Division, Bureau of Insurance Programs 201 East Washington Avenue, Room 161 (PO. Box 7901), Madison, WI 53707-7901 Telephone: (608} 255-1340 Fax: (508) 266-6827 Page 2 State of Wisconsin COMPENSATION INSURANCE REQUIREMENTS Department of Workforce Development Corporate Of?cer Option A closely heid corporation having no more than two corporate of?cers and no other employees may elect not to be subject to the Wisconsin Worker's Compensation Act by completing the Corporate Officer Option Notice below. Attach the completed notice to the Employer?s Report fonn on pages 1 2 and malt or fax it to us within 15 days. . Please see page 5 for a detailed explanation of the Corporate Of?cer Option Notice and the eligibility requirements to ?le one. if you have any questions about whether you qualify to ?le a Corporate Of?cer Option Notice, please call (608) 266-3046 before you complete and return this form. I 34'4" CORPORATE OFFICER OPTION NOTICE Federal Employer identification Number Corporation Name (Please Print) Corporation Address City, State, Zip Code As an of?cer of the above named corporation elect not to be subject to provisions of the Wisconsin Workers Compensation Act until such election is rescinded by written notice to the Wisconsin Worker's Compensation Division or the corporation obtains a worker's compensation insurance policy. I understand that buying a policy wilt cancel this election. The corporation has no other employees or corporate of?cers than those listed below. Before any employee is hired, the corporation wiil obtain a worker's compensation policy. I also understand that the failure to obtain a worker's compensation insurance policy, if required by the Wisconsin Worker?s Compensation Act, will result in a mandatory penaity assessed by the State of Wisconsin. The penalty for failure to carry worker?s compensation insurance, if required, is twice the amount of premium not paid during an uninsured time period or $750, whichever is greater. Under certain circumstances, an employer who has a lapse in worker?s compensation insurance coverage can be subject to a penalty of $100 for each day they are uninsured up to 7 days. (53. and Wis. Stats.) Corporate Officer Name (Please Print) Corporate Of?cer Name (Please Print) Corporate Of?cer Signature Corporate Of?cer Signature Title I Title Telephone Number Telephone Number Date Signed Date Signed Worker?s Compensation Division, Bureau of Insurance Programs 201 East Washington Avenue, Room 161 (P0. Box Madison, Wl 53707-7901 Telephone: (608) 266-1340 Fax: (608) 266?6327- Page 3 State of Wisconsin COMPENSATION INSURANCE REQUIREMENTS Department of Workforce Development AS an em ?0 er, when am Ire aired to car com ensation insurance? Under the Workers Compensation Act (Act), you must carry worker's compensation insurance if you do any one of the following: 1. Usually employ three or more full?time or part?time employees. You must have insurance immediately upon employing a third person. 2. Employ one or more full?time or part-time employees to whom you have paid combined gross wages of $500 or more in any calendar quarter for work done at one or more locations in Wisconsin. You must have insurance by the 10th day of the ?rst month of the next calendar quarter. 3. if you are a farmer who employs 6 or more workers on the same day for any 20 days during the calendar year You must have' insurance by the 10th day after the 20th day of employment. A calendar year is January through December. Note: Some of your relatives may not count as employees. Call us at (608) 266- 3046 to see whether you need to count all your relatives among your employees. Must outlet-state employers carry Wisconsin worker?s compensation insurance? Yes, you must carry the insurance if you have employees working in Wisconsin. The policy must be with an insurance company licensed to write worker?s compensation in Wisconsin and endorsed to name Wisconsin as a covered state in section 3-A. Your insurance company must file the properly endorsed policy with the Wisconsin Compensation Rating Bureau. The Bureau's mailing address is PO. Box 3080, Milwaukee, Wisconsin 53201?3080. The telephone number is (262) 795-4540. The Bureau's internet address is Who is considered an employee and coVered by? the. Worker?s. Compensation Act? Nearly all private and public employees in Wisconsin are considered employees and covered under the Act, including: Part-time employees. Whether an employee works part-time or full?time has no bearing on the requirement to carry worker?s compensation insurance. Family members. An employee' 3 relationship to the owner has no bearing on the requirement to carry worker?s compensation insurance (except for certain relatives of a farmer). in Minors. An employee' 3 age has no bearing on the requirement to cany worker?s compensation insurance. )5 Corporate of?cers. Who is not considered an" "employee under the Worker?s. Compensation Act? The following are the only workers who are not considered employees under the Act. Call us if you are not sure. Domestic servants. Any person whose employment is not in the trade, business, profession or occupation of the employer. Some farm employees (certain relatives of a farmer). Sole proprietors, partners and members of limited liability companies. Quali?ed and certi?ed members of certain religious sects. Volunteers of non?pro?t organizations receiving salary or Err-kind compensation totaling not more than $1 0 per week. Employees of Native American tribal enterprises (including casinos), unless the tribe elects to waive its sovereign immunity and voluntarily become subject to the Act. All worker?s compensation policies exclude sole proprietors, partners or members of limited liability companies unless there is a speci?c written endorsement to include them. Sole proprietors, partners and members of limited liability companies may voluntarily purchase worker?s compensation insurance to cover their own work-related injuries and illnesses. What about independent contractors? Under the Act, a person is required to meet a nine-part test before he or she is considered an independent contractor rather than an employee. A person is not an independent contractor for worker?s compensation purposes just because the person says they are, or because the contractor over them says so, or because they both say so, or even if other regulators (including the federal government and other state agencies) say so. The nine-part statutory test set forth under 3. 102.0763), Wis. Stats, must be met before a person working under another person is considered not to be an employee. Worker?s Compensation Division, Bureau of insurance Programs 201 East Washington Avenue, Room 161 (RC. Box 7901), Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 255-5827 Page 4 State of Wisconsin COMPENSATION INSURANCE REQUIREMENTS . - Department of Workforce-Development i What aborit carporation's?an'd corporate offiCer52..-i All worker?s compensation policies covering corporations include corporate of?cers. However, in a closely held corporation, de?ned as a corporation with not more than to shareholders, no more than 2 of?cers may exclude themselves from coverage. If the corporation has other employees, and/or of?cers, an insurance policy is required and the exclusion for of?cers must be made by endorsement on the worker's compensation policy. The name(s) of the of?cer(s) must be given. The exclusion will remain in effect for the policy period. Of?cers who are excluded will still be counted in determining whether the employer is subject to the Act under s. Wis. Stats. if a closely held corporation has no more than 2 corporate of?cers and has no other employees, a worker's compensation policy is not required if both of?cers elect not to be subject to the Act by completing and ?ling with the Department a Corporate Of?cer Option Notice. A qualified corporation must complete and return a copy of the Corporate Officer Option Notice found on page 3. Attach the completed notice to the Employer?s Report form on pages 1 8r. 2 and mail or fax it to us within 15 days. Note: A corporation with more than two corporate of?cers or any other employee or employees is not eligible to ?le a Corporate Of?cer Option Notice with the department and must obtain andfor maintain a worker's compensation insurance policy. workerscompensa onnrancepohcybutwhorsn ow: hat does-the. mire'meirofdoa An employer whose worker's compensation insurance has lapsed or who has never had worker's compensation insurance is subject to penalties and closure action under and 10228010, Wis. Stats, and must: immediately obtain a worker?s compensation policy. Return the completed Employer?s Report form to us within 15 days of receipt. 3e When assessed the penalty forthe uninsured time period, pay the penalty the law requires. What penalties may-r i?ec'eiVe foril'hOtf We must and do enforce mandatory penalties if an employer does not obtain and maintain a worker?s compensation insurance policy when required to have one. if you do not comply, you risk one or all of the following: You are subject to a penalty of double the insurance premiums you should have been paying during the uninsured period, or $750, whichever is greater. Under certain circumstances, you may be subject to a penalty of $100 for each day you're uninsured up to 7 days. (ss. and Wis. Stats.) You face closure of your business, including a suspension of all operations. (5. Wis. Stats.) You are personally liable for uninsured bene?t claims forwhich your injured employees are eligible. ?3228(5), Wis. Stats.) How ?do robe-in workers compe'nsa'tion'i?instuance? To obtain worker?s compensation insurance, contact an insurance company or its agent and ask whether the company writes worker?s compensation insurance for Wisconsin. if you have or know an insurance agent, you may contact him or her. if you are refused insurance coverage by a company, you may obtain coverage from the Wisconsin Compensation Rating Bureau through the Worker's Compensation Insurance Pool upon prepayment of premium. The Wisconsin Compensation Rating Bureau is located at 20700 Swanson Drive, Suite 100, Waukesha, Wisconsin. The mailing address is P.O. Box 3080, Milwaukee, Wisconsin 53201- 3080. The telephone number is (262) 796?4540. The Bureau's intemet address is Note: The Wisconsin Compensation Rating Bureau is not a State agency and is not part of the Wisconsin Worker's Compensation Division. The State of Wisconsin does not write or provide worker's compensation insurance coverage. "What ?can I doto'h'ei . Com . ensation Dir/laid [riparrentiy ha ya a workers compensationpolic' iipdate its records td?show I have'a policy? Please attach a copy of the Information Page or Declaration Page of your current worker?s compensation policy to the Employer?s Report form found on pages 1 2 and mail or fax it to us within 15 days. Worker's Compensation Division, Bureau of insurance Programs 201 East Washington Avenue, Room 161 (PD. Box 7901), Madison, WI 53707-7901 Telephone: {608) 266-1340 Fax: (508) 266?6827 Page 5 State of Wisconsin COMPENSATION INSURANCE REQUIREMENTS Department of Workforce Development Once an employer is required to get a worker?s compensation insurance policy, how long does the employer have t- Quite a while. Once an em ployer becomes subject to the Wisconsin Worker's Compensation Act (Act) under s. Wis. Stats, he or she remains subject to the Act unless the employer withdraws from the provisions of the Act under s. 1 0205(1), Wis. Stats. A subject employer is required to have a worker?s compensation policy as long more part-time or full- time employees. Even if a subject employer has only one part-time employee making less than $500 per quarter, the employer must maintain the insurance for the remainder of that calendar yeah?and forthe next calendar year--(a calendar year is January through December) before he or she is eligible to withdraw from being subject to the provisions of the Act. if a subject employer lays off all his or her employees, the employer may drop their worker's compensation insurance while they have no employees, however, the employer remains subject to the Act. Therefore, because the employer has already become subject to the Act, if the employer hires an employee at a later date, the employer must have a worker?s compensation insurance policy in place on the date any employee begins working, unless the employer has withdrawn from the Act. Once a farmer is subject to the Act, the farmer is required to have a worker?s compensation policy as long more part-time or full-time employees. Even if a subject farmer has only one part?time employee, the farmer must maintain the insurance until he or she has gone a full calendar year without employing 6 or more employees on 20 or more days before he or she is eligible to withdraw from being subject to the provisions of the Act. Note: Corporations can not withdraw from the provision of the Act. Closely held corporations (a corporation with not more than 10 stockholders) that have no more than two corporate of?cers and no other employees, may elect to exclude themselves from coverage underthe Act by completing and tiling with the Department a Corporate Of?cer Option Notice. A corporation with more than two corporate of?cers or any other employee is not eligible to file a Corporate Officer Option Notice and must obtain andlor maintain a worker's compensation insurance policy. Call us at (608) 265? 3046 if you are not sure whether or not you are subject to the Act or if you are not sure when you are required to have a worker's compensation policy 4? an employer, how do benefit from the Wisconsin Worker?s Compensation Act? You receive bene?ts that can mean the difference between the success or failure of your business. If one of your employees gets hurt while working for you, you could be sued for damages, medical care, lost wages, and much more. By complying with the law and naming appropriate worker?s compensation insurance, you receive: Protection from most law suits brought by an employee because of a work-related illness or injury. Fair and prompt delivery of bene?ts to your employee who is injured on the job. Fair adjudication of disputes by a Worker?s Compensation Division Administrative Law Judge. Fair and standard insurance premium rates approved by the Of?ce of the Commissioner of Insurance. Does my employee benefit from the Worker?s Compensation Act? if your employee does get hurt on the job, he or she can look to the worker?s compensation system for prompt payment of bene?ts and fair adjudication of disputes. have additional questions regarding the requirement to obtain worker?s compensation inshrance.? Who can I- contact? If you have questions regarding your obligation to obtain worker?s compensation insurance, please write or call the Wisconsin Worker?s Compensation Division, Bureau of Insurance Programs. Our mailing address is P.O. Box 7901, Madison, Wisconsin 53707-7901. Ourtelephone number is (608) 288-3046 or you can reach us by fax at (608) 286-6827. The Division's internet address is DWD is an equal opportunity employer and service provider. If you have a disability and need information in an alternate format, or need it translated to another language, please contact (608) 266-1340 voice or 1?866-265?31 42 IY. Worker?s Compensation Division, Bureau of Insurance Programs 201 East Washington AVenue, Room 161 (PO. Box 7901), Madison, WI 537073901 Telephone: (608) 266-1340 Fax: (608) 266?6827 Page 6 Courier Distribution Systems Madison Courier Distribution Systems Dzifrery Experts Home Services Locations About Us Home Locations Madison Madison, WI Contact: Customer Service 1 {770} 242-0454 customerse rvice@courierds.com Madison Is the capital ofthe US. state of Wisconsin and the county seat of Dane County. As Madison Career News customerservice@courierds.com had an estimated population of 240,323, making it the second largest city in Wisconsin, after Miiwaukee, and the largest in the United States. The Madison Metropolitan Statistical Area had a 2010 population of 558.593. Wikipedia Piece an Order Get a Quote Contact Us Page 1 of 1 1 770 242 0454 Locations Atianta Indianapoiis Louisville Milwaukee Pittsburgh San Diego St. Louis We are Reiiabie Companies across the country have trusted Courier Distribution Systems for over 15 years. Track your order We are fast About Us Footer Navigation Courier Distribution System15 is a Home courier company determined to Services provide the best service to all its About Us customers and to ful?li all its Locations customers needs. Careers More Contact Us Latest News CBS opened two new locations. 3 Sept, 2013 2 Sept, 2013 a. We are adding more Q3: services in the near future. Get in Touch with Us [770) 242 0454 customerservice@courierds.corn 2200 Norcross Pkwy. Suite 200. Norcross, GA 30071 Courier Distribution Systemib 2015 i Design by 208 Production: I 07f06/2017 Page 1 of 2 Employer Notes _Prim 1723/2019 i ?Spoke with the Er. There was cons. about Recalculation of the 9:31 :38 IArnount, understands that If They want Int. Free, $2,500.00 AM 1 . IS a ADD 11:90am i Er Rep called stated that the Co. is Operating at?. a s1gn1?cant loss 89/133308 ,but sees better days ahead ,They agreed to 2, 500. 00to show good AM ffaith hoping by Years end They can address it more realistically. Requested that We add STE. 300 to Their ADD: 0-. we?, w? V, Spoke with 3 rd. Party We discussed Their Options He Will-? meet 7/27/2018 Them get back to Me A. A if it's an Install. Agree. I was: 2:28:06 EECULBEPA PM Epushing a 500 00 Month Minimum we'll see. Ph. (770} 242? 045433; 61/; 85%01118 GAL Updated address ?om WI to GA. Added owner, Usnian Eshai, ?om AM UI Registration and James Blanchard from pol1cy exclusion. 1173/2017 . . . . 8 32 T-culbepa igReviewed for Coverage, Lapse stands as of Today, I have Not rec any: AM Corr on Wage Adjustment by Class Code 812112017 7: 56: 36 AM File Co?verage has Not been Added to date has not seen 1any Actual Wages by Speci?c Class. I called and spoke w1th Alex Jones Directoi of R13k Management at #770 242 0454 x231 Alex had not received the penalty noti?cation and was very surprised by the liability amount. We discussed the actual wages estimated wages and went through the penalty . calculatlon The policies included two class codes, 7231 and 8810, but 35/2917 the penalty worksheet included only the 7231 code. Alex will review 11.00.40 E=galaraa 5 AM igthe wage total to make sure all wages were earned 1n WI and were earned by ee's and he will attempt to break down the wages into the i ifcorrect class codes. We discussed the possibility of obtaining Ebackdated coverage to eliminate the lapse period. Alex is making this ?a priority and will be in contact with the wage information in the near future 1 - -- .41.: I have put in the ?gures into another worksheet that shows the 8535:9517? 1ncrease in the penalty amount ifI use the actual provided to me by AM Alex ones I have printed it out and provided it to Aaron, deputy collector to contact the employer 872/2017 MADIGDE I have recelved an emall from Alex Jones, D1rector {11? Risk 9:23:57 Management with the completed E20. The completed E20 has more AM wages and she lists 757 ee' 3. This would probably Increase the penalty; amount 11th ://dwdwebapps/UEF .. 04X 1 0/ 201 9 3:00:13 PM I i 1 7/6/201 7 MADIGDE 1 1 i i- ?The Website states that they operate in Madison Milwaukee Page 2 of 2 1/6/2011 21:77612017 2. 31: 54 PM 5/11/2011 EEOCONNCH 30: 45 3/24/2016 8. 54: 54 AM 3/23/2016 11? .43 42 6M. 3/23/2016 114.3:29 HAM MADIGDE -. 1 UEF App sentMay 12 201110? v?rw n- D01 5/7/2017 7/6/2017 sman Eshai EE20bdbuth EEMADIGDE I sent the E30 to: 3935 Mitchell St Ste 300, Milwaukee, WI 1s what the previous policy had for an address I have changed address and resent the E20 New address 6650 Sugarloaf PkwaEE ste 300, Duluth GA 30097. Old address 2200 Norcross Pkwy ste 200, Norcross GA 300713671. 3/16/2016 EEGREENSB PM 4112950 . . GREENSE I received a call from Matt, agent GREENSE I sent E64 to customerservice@courierds.com GREENSE EEGROUP LCF ESHAI CORPORATION DBA COURIER DISTRIBUTION SYSTEMS Pollcy found 111 WCRB 0505836 AVITUS INC DBA AVITUS 04/10/2019 - - STATE OF WISCONSIN Department of Workforce Development Worker?s Compensation Division, Uninsured Employers Fund DWD 201 E. Washington Ave, Rm. 1 00 P. 0. BOX 7948 Department of orkforce Development Madison, WI 53707-7948 Telephone: (608) 268?5459 Fax: (608) 288?6827 08/31/2017 COURIER DISTRIBUTION SYSTEMS LLC 96 USMAN Customer No_; 6488343 6650 SUGARLOAF PKWY vvcae No; DULUTH WI 30097?h359 .Account No; 64888430 PAST DUE NOTICE Dear Employer: Our records indicate you have not made satisfactory arrangements to pay your liability in the amount of 140,100.74 This liability was assessed under section 102.82 of the Wisconsin Statutes for faiiure to carry Worker?s Compensation Insurance as required by law. Your account is therefore PAST DUE and requires you to make payment immediately. Failure to respond to this notice will be considered acknowiedgment that you do not intend to pay this debt and judicial action will be required to secure payment. Judicial action may include (but is not limited to) a warrant placing a lien on ali real and personal property and/or a levy against all bank accounts and attachment of any income tax refund for which you may be eiigible from the Wisconsin Department of Revenue to secure satisfaction of the liability. To avoid these collection proceedings, one of the following needs to take place WITHIN 15 DAYS. 1. The amount due on this account statement is paid in full. 2. If your firm is unable to make full payment, you will have to call my office to see if you qualify to establish a payment pian. in the case of a non~response, the division will initiate the of a warrant against you with the clerk of circuit court in your county to secure satisfaction of this liability. NO FURTHER NOTICES WILL BE SENT. If you have any questions regarding your account or estabiishing an installment payment plan, please contact me at the number listed below. Sincerely, PATRICK R. CULBERT, DEPUTY COLLECTOR COMPENSATION DIVISION (608) 266?5169 FAX NO. (608) 266?6827 (R. IWOD7I5)