Form SCF-528 "Report of Non-compliance" - New Jersey

What Is Form SCF-528?

This is a legal form that was released by the New Jersey Department of Labor & Workforce Development - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2007;
  • The latest edition provided by the New Jersey Department of Labor & Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SCF-528 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

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Download Form SCF-528 "Report of Non-compliance" - New Jersey

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State of New Jersey
REPORT OF
Department of Labor and Workforce Development
NONCOMPLIANCE
Office of Special Compensation Funds
PO Box 399
Form SCF-528 (R 09-07)
Trenton, New Jersey 08625-0399
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:
Number of Employees:
Last Date Insured:
Carrier:
Policy #:
The following information is optional - Please see note at bottom of form.
Your Name:
Organization:
Address:
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 Non-
Compliance 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.
State of New Jersey
REPORT OF
Department of Labor and Workforce Development
NONCOMPLIANCE
Office of Special Compensation Funds
PO Box 399
Form SCF-528 (R 09-07)
Trenton, New Jersey 08625-0399
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:
Number of Employees:
Last Date Insured:
Carrier:
Policy #:
The following information is optional - Please see note at bottom of form.
Your Name:
Organization:
Address:
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 Non-
Compliance 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.