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Report Of Non Compliance SCF-528 - New Jersey
|Report Of Non Compliance Form. This is a New Jersey form and can be used in Misc Workers Comp .||
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State of New Jersey Department of Labor and Workforce Development REPORT OF Office of Special Compensation Funds P O Box 399 NON-COMPLIANCE Trenton, New Jersey 08625-0399 Form SCF-528 (R 07/04) The Report of Non-Compliance may be used by any individual or organization to report allegations of failure on the part of any employeroperating in the State of New Jersey to provide for the protection of its workers by maintaining workers compensation insurance orobtaining authorization to self-insure. The following employing entities are required, by law, to maintain workers compensation insurance coverage or to obtain authorizationto self-insure: S All corporations, regardless of type, operating in New Jersey that compensate any one or more individuals, including corporate officers, for services to the corporation. S All partnerships or limited liability companies (LLCs) operating in New Jersey that compensate any one or more individuals, other than partners or members of the LLC, for services to the partnership. S All sole proprietorships operating in New Jersey that compensate any one or more individuals, other than the principal business owner, for services to the business. Compensation means any remuneration for services and includes cash or other remuneration in lieu of cash such as products, services,meals and/or lodging. Individuals means all persons including family members, minors and persons working full or part time.* Denotes Required Information Business Name*: Name(s) of Principals: Street Address / P O Box*: City / State*: Zip Code*: Telephone: Nature of Business: Number of Employees: Last Date Insured: Carrier: Policy #: The following information is optional - Please see note on reverse. Your Name: Organization: Address: Telephone: Fax: Please submit this form to the address shown above. Thank you. <<<<<<<<<********>>>>>>>>>>>>> 2 IMPORTANT NOTE ON RELEASE OF INFORMATIONThe Office of Special Compensation Funds will accept and invesigt ate allegations of non-compliance from anonymous sources.Therefore, while it would be helpful if further information is required in our investigation, it is not necessary for you to completeinformation about yourself at the bottom of the Report of Non-Compliance.As investigations initiated by the Report of Non-Compliance may lead to civil and/or criminal action against the reported employerand/or others, the Office of Special Compensation Funds may be legally required to release a copy of the original Report of Non-Compliance to the reported employer or other parties and/or their legal representatives. In such cases, all information providedon the Report of Non-Compliance, including any information that you have provided on yourself, must be released.