Free M E M O R A N D U M - New Jersey

State of New Jersey Department of Labor & Workforce Development Division of Workers' Compensation

IMPORTANT WORKERS' COMPENSATION LAW NOTICE ­ OCTOBER 1, 2008 $2500.00 A DAY FINE FOR FAILURE TO PROVIDE INSURANCE CARRIER OR SELF-INSURED EMPLOYER CONTACT PERSON FOR MEDICAL AND TEMPORARY DISABILITY ISSUES Governor Jon S. Corzine signed into law P.L. 2008 Chapter 96, which is now effective and applies to every workers' compensation insurance carrier and self-insured employer. The law provides that: Every carrier and self-insured employer shall designate a contact person who is responsible for responding to issues concerning medical and temporary disability benefits where no claim petition has been filed or where a claim petition has not been answered. The full name, telephone number, address, e-mail address, and fax number of the contact person shall be submitted to the division. Any changes in information about the contact person shall be immediately submitted to the division as they occur. After an answer is filed with the division, the attorney of record for the respondent shall act as the contact person in the case. Failure to comply with the provisions of this section shall result in a fine of $2,500 for each day of noncompliance, payable to the Second Injury Fund. In order to comply with this law, please complete this form and fax it to the attention of Joanne Allen at (609) 984-2515 or mail it to the address noted below. If you are completing the Adobe PDF version of this form on our website, you may save the form and then e-mail it to [email protected]. The information you provide will be posted on the Division's website. Note: · Completion of this new form is required even if this information was provided to the Division in the past. · If your company has other subsidiaries and or affiliated companies operating in New Jersey, this form must be submitted for each of those entities as well. Carrier/Self-Insurer Name: Primary Contact Name (required):
Contact: Address: Phone #: Fax #: E-Mail Address: Job Title:

Secondary Contact Name:
Name: Address: Phone #: Fax #: E-Mail Address: Job Title:

PO Box 381, Trenton, NJ 08625-0381 Tel: (609) 292-2414 Fax: (609) 984-2515 http://lwd.dol.state.nj.us/labor/wc/wc_index.html

Form rev. date 10/28/08