Insurance Carrier Or Self-Insured Employer Contact Person Form

State of New Jersey Department of Labor & Workforce Development Division of Workers' Compensation IMPORTANT WORKERS' COMPENSATION LAW NOTICE $2500.00 A DAY FINE FOR FAILURE TO PROVIDE INSURANCE CARRIER OR SELF-INSURED EMPLOYER CONTACT PERSON FOR MEDICAL AND TEMPORARY DISABILITY ISSUES P.L. 2008 Chapter 96, effective October 1, 2008, 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 to the attention of Elizabeth Boltersdorf at (609) 984-2515 or mail to the address noted below. If you are completing the PDF version of this form on our website, you may save the form and then email it to Joanne.Gannon@dol.nj.gov. The information you provide will be posted on the Division's website at the next update of the Contact List available to the public. Note: · If the insurance carrier or self-insurer identified below has other subsidiaries and or affiliated companies authorized to operate in New Jersey, this form must be submitted for each of those entities. · If you are an employer that has workers' compensation insurance coverage, there is no need to submit this form. Date: Carrier or Self-Insurer Name: I. Primary Contact Name (required): Name: Company: Address: Phone #: Fax #: E-Mail Address: Job Title: II. Secondary Contact Name: Name: Company: Address: Phone #: Fax #: E-Mail Address: 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 2/17/2017 Job Title: American LegalNet, Inc. www.FormsWorkFlow.com