Updated: 7/27/23
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 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.
Registration Process:
The registration process can take 30 to 60 days. Incomplete application(s) and/or missing documents will
further delay this process.
• Complete this 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 for which the fee is being submitted. Please only send payment by mail; do NOT mail in
your application.
• You may also drop off a completed 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.
A copy of the filed New Jersey Certificate of Incorporation, Certificate of Formation, Trade Name Certificate,
Alternate Name Certificate or a copy of approved Fictitious Name Certificate must be submitted with this
application. If the organization is an out of state firm, you MUST submit a copy of the New Jersey Certificate
of Authority from the New Jersey Department of Treasury.
The registration process can take 30 to 60 days. Incomplete application(s) and/or missing documents will
further delay this process.
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
(973) 504-6370
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 registration 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 certificate
and the original bond.
2. List all other names under which the applicant does business. If you do not use any other name(s), write “None.” If the
answer to this question is left blank, it will automatically default to “None.”
Rev. 7/27/23
Contact your local county
clerk’s office to obtain a Trade
Name Certificate.
Contact the N.J. Department
of the Treasury, Division
of Revenue, at (609) 292-9292,
if the business is a corporation.
Refer to the samples.
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3. Indicate the type of business you own.
Sole Proprietorship:
Partnership:
Corporation:
Limited Liability Co.:
Attach a copy of the business’s Trade Name Certificate. Refer to Sample #1 or #2.
Attach a copy of the business’s Trade Name Certificate. Refer to Sample #1 or #2.
Attach a copy of the business’s Certificate of Incorporation. Refer to Sample #3, #4 or #5.
Attach a copy of the business’s Certificate of Formation. Refer to Sample #5, #6 or #7.
Limited Liability Partnership: Attach a copy of the business’s Certificate of Formation. Refer to Sample #5, #6 or #7.
Additional Requirements
Out-of-State Corporation: Attach a copy of the business’s New Jersey Certificate of Authority and the
formation documents from your home state. Refer to Sample #9.
Alternate Name:
Attach a copy of the business’s Registration of Alternate Name Form C-150G. Refer to Sample #8.
Application for Registration
Choose One: Service Contract Provider
Service Contract Administrator
Service Contract Provider and Administrator
4. Business Address (Must be a street address.) E-mail Address
City State ZIP Code
Telephone No. Fax No.
(include area code) (include area code)
5. 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.
6. 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)
5(a).
E-mail AddressDirect Telephone No. and Extension
(include area code)
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8. 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 supporting documentation along with
this 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 9(a) and 9(b), ONLY if the business is a Provider.
Yes No
9(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 8;
Proof of net worth or stockholders' equity of at least $100,000,000.00, as described
in question 8; 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.
9(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
Complete questions 11(a) and 11(b), ONLY if the business is a sole proprietorship.
11(a).
Is the sole proprietor the subject of a child-support warrant or has he/she failed to pay
a court-ordered child-support obligation in an amount equal to or more than the amount
of child support payable for six months, failed to pay any court-ordered health care
coverage for the past six months, or failed to respond to a subpoena relating to a
paternity or child-support proceeding?
Yes No
7(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)
7(c).
Parent Company - Mailing Address If the address is the same as in question #7(b), write “N/A.”
□□□ □ - □ □ □ □
10.
Provide the business’s Federal Employer Identification Number
Federal Employer Identication Number (FEIN)
□ □
□
7(a).
Parent Company - Name
- 3 -
11(b). Social Security number of sole proprietor (if there is one):
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44(e) of the New Jersey
Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the
Office of Consumer Protection is required to obtain your Social Security number and federal taxpayer identification number.
You must provide both numbers if you have both. If you have neither a Social Security number nor a federal taxpayer
identification number, you must complete and submit this Certification available at https://
www.njconsumeraffairs.gov/Documents/Certification-Form-for-Applicants-with-no-Social-Security-Number-or-Individual-
Taxpayer-ID-Number.pdf with your application.
Pursuant to these authorities, the Office of Consumer Protection is also obligated to provide your Social Security number
and federal taxpayer identification number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose
of reviewing compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child-support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health
care professionals.
Federal taxpayer identification number of sole proprietor (if there is one):
□□□ □ □ - □ □ - □ □ □
□ □
□ - □ □ - □
□ □ □
12. 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
____%
➦
13. Pursuant to N.J.S.A. 56:12-95.1(b), has any officer, director, partner, or principal identified
in question 12 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
14. 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 register 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.
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
- 5 -
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
- 6 -
- 7 -
N.J. TRADE NAME CERTIFICATE
CERTIFICATE OF INCORPORATION
Page 1 Page 2
OUT-OF-STATE TRADE NAME CERTIFICATE
Note: The appearance of
these documents may vary
depending on the state and
county of origin.
SAMPLE FORMS
Page 1 Page 2
Sample #1 Sample #2
Sample #3 Sample #3
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit https://www.nj.gov/treasury/revenue/.
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 8 -
SAMPLE FORMS
Page 1 Page 2
Sample #4 Sample #4
Sample #5
Note: Sole Proprietor and Partnership documents are
issued by your local county clerk’s oce.
Certicate of Formation and Certicate of Incorporation
documents are issued by the State of New Jersey.
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit https://www.nj.gov/treasury/revenue/.
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
CERTIFICATE OF INCORPORATION
- 9 -
SAMPLE FORMS
CERTIFICATE OF FORMATION
Page 1 Page 2
Page 1 Page 2
Sample #6 Sample #6
Sample #7 Sample #7
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit https://www.nj.gov/treasury/revenue/.
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
CERTIFICATE OF FORMATION
- 10 -
CERTIFICATE OF LIABILITY INSURANCE
REGISTRATION OF ALTERNATE NAME CERTIFICATE OF AUTHORITY
SAMPLE FORMS
Sample #8 Sample #9
Sample #10
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit https://www.nj.gov/treasury/revenue/.
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
