State of New Jersey REPORT OF NONCOMPLIANCE Department of Labor and Workforce Development Office of Special Compensation Funds PO Box 399 Trenton, New Jersey 08625-0399 Form SCF-528 (R 09-07) The Report of Non-Compliance may be used by any individual or organization to report allegations of failure on the part of any employer operating in the State of New Jersey to provide for the protection of its workers by maintaining workers’ compensation insurance or obtaining authorization to self-insure. The following employing entities are required, by law, to maintain workers’ compensation insurance coverage or to obtain authorization to self-insure: All corporations, regardless of type, operating in New Jersey that compensate any one or more individuals, including corporate officers, for services to the corporation. All partnerships or limited liability companies (LLC’s) operating in New Jersey that compensate any one or more individuals, other than partners or members of the LLC, for services to the partnership. 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: Last Date Insured: Number of Employees: Carrier: Policy #: The following information is optional - Please see note at bottom of form. Your Name: Address: Organization: Telephone: Fax: IMPORTANT NOTE ON RELEASE OF INFORMATION The Office of Special Compensation Funds will accept and investigate 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 complete information 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 employer and/or others, the Office of Special Compensation Funds may be legally required to release a copy of the original Report of NonCompliance to the reported employer or other parties and/or their legal representatives. In such cases, all information provided on the Report of Non-Compliance, including any information that you have provided on yourself, must be released. Please submit this form to the address shown above. You may also e-mail it to oscf@dol.state.nj.us. Thank you. American LegalNet, Inc. www.FormsWorkflow.com