Updated: 4/26/24
New Jersey Office of the Attorney General
Division of Consumer Aairs
Oce of Consumer Protection
Regulated Business Section
124 Halsey Street, 7th Floor, P.O. Box 45028, Newark, NJ 07101
(973) 504-6370
Instructions for Renewal of Registration as a
Service Contract Provider or Administrator
(Please Read These Instructions Carefully)
Provider:
Provider means a person who is contractually obligated to the service contract holder under the terms of the
service contract.
Administrator:
Administrator means a person who performs the third-party administration of a service contract on behalf of
a provider.
Bond:
A surety bond is required for a Service Contract Provider that is not otherwise exempt by statute. It must
have a value of not less than five percent of the gross consideration received per annum, less claims paid, on
the sale of the service contract for all service contracts issued and in force, but not less than
$25,000.00. The bond is made payable to the State of New Jersey and must be notarized and signed
by the owner.
Renewal Process:
The renewal process can take 30 to 60 days. Incomplete renewal application(s) and/or missing documents
will
further delay this process.
• C
omplete this renewal application electronically by filling in this PDF on a computer. Once complete,
please submit the application and requested documentation via email to
[email protected]. Do not mail your application.
• Separately MAIL a certified check or money order made payable to “New Jersey Division of Consumer
Affairs” in the amount of $300.00 (non-refundable) to: Division of Consumer Affairs, Office of
Consumer Protection, Regulated Business Section, 124 Halsey Street, 7th Floor, P.O. Box 45028,
Newark, NJ 07101. When mailing payment, please include a note in the envelope indicating the name of
the business and registration number for which the fee is being submitted. Please only send payment
by mail; do not mail in your application.
• If your renewal fee is not received by June 30, 2024, you must pay a late fee of $50.00 for each 30-day
period or portion thereof that the renewal filing fee is late.
• You may also drop off a completed renewal application and/or payment in-person at the Division of
Consumer Affairs, 124 Halsey St., 7th Floor, Newark, NJ 07101, M-F 10 a.m. - 2 p.m.
Copies of your surety bond and assurance of faithful performance must be submitted with this renewal
application. If a provider is claiming an exemption from the bond you must submit documentation of the
exemption.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Ofce of Consumer Protection
Regulated Business Section
124 Halsey Street, 7th Floor, P.O. Box 46016, Newark, NJ 07101
Information that you provide on this application may be subject to public disclosure as required by the Open
Public Records Act (OPRA).
Instructions: Please print clearly. Answer all of the questions. Your application will not be processed until all of the
questions have been answered and all of the required documents, and the renewal fee, have been received by this
Division. If a question does not apply to your business, write “N/A.”
1. Business Name
The name must match the name listed on the corporate, alternate name, and trade name documents, the insurance certif icate
and the original bond.
Rev. 4/26/24
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Renewal Application for Registration as a
Service Contract Provider Service Contractor Adminstrator
Service Contract Provider/Administrator
Renewal Period July 1, 2024 to June 30, 2025
3. Business Address (Must be a street address.)
E-mail Address
City State ZIP Code
Telephone No. Fax No.
(include area code) (include area code)
4. Mailing Address If the address is the same as in question #4, write “N/A.”
Please provide the name of a contact person such as the administrative manager/supervisor, should the need arise for
the Division to contact your business.
5. Agent –
If the business is a corporation, L.L.C., or L.L.P., you must provide the name and address of an agent in New Jersey
who is authorized to accept documents on its
behalf for the service of process.
Registered Agent’s Name
Street Address
City State: New Jersey ZIP Code
Telephone No. Fax No.
(include area code) (include area code)
4 (a).
E-mail A ddressDirect Telephone No. and Extension
(include area code)
2. Registration Number:
For questions 3 through 6 complete only if information has changed since last filing.
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7. Pursuant to N.J.S.A. 56:12-90, service contract providers and administrators must maintain means of assuring faithful performance
(“AFP”) to contract holders. Indicate which AFP is applicable to your business, and submit current supporting documentation
along with this renewal application:
Reimbursement insurance policy that complies with the requirements of N.J.S.A. 56:12-92;
Funded reserve account that complies with the requirements of N.J.S.A. 56:12-90(a)(2);
Net worth or stockholders’ equity of at least $100,000,000.00, demonstrated by a copy of your, or your parent
company's or affiliated corporation's most recent Form 10-K or Form 20-F filed with the Securities and Exchange
Commission within the past 12 months, or a copy of your, or your parent company's or affiliated corporation's
audited financial statements, showing a net worth of $100,000,000.00 or greater;
For Administrators only - proof of indemnification pursuant to a Provider’s AFP.
Complete questions 8(a) and 8(b), ONLY if the business is a Provider.
Yes No
8(b).
Are you claiming an exemption from the surety bond requirement?
If "Yes," submit one of the following:
Reimbursement insurance policy, as described in question 7;
Proof of net worth or stockholders' equity of at least $100,000,000.00, as
described in question 7; or
Proof that the Department of Banking and Insurance has determined that your
business meets the financial solvency standards established under Title 17 of the
New Jersey Statutes.
8(a).
Does your business maintain a surety bond pursuant to N.J.S.A. 56:12-90(b)?
If "Yes," submit the original surety bond with this application.
Yes No
6(b).
Parent Company - Business Address (Must be a street address.)
E-mail Address
City State ZIP Code
Telephone No.
(include area code)
Fax No.
(include area code)
6(c).
Parent Company - Mailing Address If the address is the same as in question #6(b), write “N/A.”
6(a).
Parent Company - Name
9. Complete question 9, ONLY if there have been any changes since your last application submission.
List the full name, business street address and business telephone number of each owner, officer, director, and principal
of the business and, if applicable, all principals of any parent company and/or other affiliated entity that provides or
administers service contracts in the United States. If the applicant is a partnership, each member of the partnership must be
listed. (Use additional sheets of paper if necessary.)
Please print clearly.
_______________________________________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
_______________________________________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
_______________________________________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
(Note: You may photocopy this page and attach additional pages to this application if there are more than three (3) owners,
officers, directors, or principals)
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You must indicate
Percentage of Ownership
____%
➦
10. Pursuant to N.J.S.A. 56:12-95.1(b), has any officer, director, partner, or principal identified
in question 9 been named or involved in any litigation or enforcement matters concerning
service contracts filed or prosecuted in the past five (5) years?
If “Yes,” please provide the following:
Yes No
11. Provide the following information regarding your business operations for the past year:
Total amount collected in provider’s fees
Payment of the Registration Fee:
The nonrefundable fee to renew is $300.00. The certified check or money order should be made payable to “New Jersey
Division of Consumer Affairs.” Please see the cover page of this application for instructions on how to submit your
completed application and payment. If your renewal fee is not received by June 30, 2024, you must pay a late fee of $50.00
for each 30-day period or portion thereof that the renewal filing fee is late.
NOTE: Please be advised that any application that is missing required information will be rejected. The entire application
must be completed. All of the requested documentation must be submitted with the application.
Name of
person against whom
action was taken
Action taken
Name and address of the
government agency or
entity that took action
Nature of the
allegation or
litigation
Date of action
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Total amount paid out in claims or charges
for services under the contracts issued
CERTIFICATION
I have reviewed the applicants practices related to the transportation of temporary laborers and have confirmed
that those practices comply with the requirements of N.J.S.A. 34:8D-5; and
I have reviewed and am responsible for the surety bond posted pursuant to N.J.S.A. 34:8D-8(b) and its renewals.
I agree to cooperate fully with any request by the Attorney General or the Division to provide any assistance or
information and to produce any records requested by the Division, and to cooperate in any inquiry, investigation
or hearing conducted by the Division.
_____________________________________________
I, as a principal officer of the applicant, understand that this registration will be accepted only if the requirements
of N.J.S.A. 56:12-87 et seq., and the regulations promulgated thereunder, have been met.
I certify that I have reviewed all of the information provided in connection with the application and it is true and
accurate to the best of my information, knowledge, and belief. I understand that any omissions, inaccuracies,
or failure to make full disclosures may be deemed sufficient to deny registration or to withhold renewal of
or suspend or revoke a registration issued by the Division of Consumer Affairs (“the Division”).
I agree to cooperate fully with any request by the Attorney General or the Division to provide any assistance or
information and to produce any records requested by the Division, and to cooperate in any inquiry, investigation,
or hearing conducted by the Division.
_____________________________________________
Name of applicant
_____________________________________________________________________________
Your name (please print)
_____________________________________________________________________________
Your signature
_____________________________________________________________________________
Your title
_____________________________________________________________________________
Date
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