Department of Labor & Industry - Bureau of Labor Law Compliance -Construction Workplace Misclassification Complaint

This form is used for complaints under the Pennsylvania Act 72

Claimant Information
First Name:	*		Daytime Telephone:
Initial:			Evening Telephone:
Last Name:	*		Fax:
Address - Line 1:	*		E-Mail:
Address - Line 2:			Occupation and job title:
City:	*
State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:	*

Business Information
First Name of Contact Person:	*		Company Name:	*
Initial:			Telephone:
Last Name of Contact Person:	*		Address - Line 1:	*
First Name of Owner:	*		Address - Line 2:
Initial:			City:	*
Last Name of Owner:	*		State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
			Zip:	*
			County:	*	---Select--- None Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York Out of State
			Establishment Code:

Additional Business Information
What type of construction service does the business perform?	*
Owner of the business:	*

Employment Information
For any of the questions below, you may add additional information on separate pages and include any documents that you feel are helpful:
Provide the following information (Name, Type of work performed and worksite name and location) about each worker that you believe the business misclassified, including yourself if applicable:	*
Provide the following information (worksite name and location, project, dates when work was performed, worksite supervisor, name of general contractor) about worksite where you believe the business misclassified workers:	*
What led you believe that this business misclassified employees as independent contractors?	*
Did the business have any other person who provided the workers directions or orders besides the workspace supervisor(s)?	*	YESNO
If so, please identify the(se) person(s) and worksite(s):	*
Did the business supply the workers with tools, equipment and other supplies to do their work?	*	YESNO
If yes, what tools, equipment and supplies were provided by the business:	*
What tools, if any, did the worker(s) supply?	*
Did any of the workers have their own business?	*	YESNO
If yes, please explain and provide the business location	*
Did any of the workers have their own liability insurance?	*	YESNO
If yes, when was it in effect? (Please provide a copy of the declaration page, if available)	*
How were the workers paid? (Please check all that apply and explain in detail)
Per job:
Per hour:
Per day:
Piece work:
Other:
Explain in detail:	*
Who paid the workers?	*
Do you have wage records (such as paystubs, W-2 or 1099 forms) relating to any of the workers?	*
Did any of the workers have a written agreement to perform work at any of the worksites?	*	YESNO
If yes, please attach the documents below (You can attach upto three documents):

Documents
Upload PDF or JPEG files only
UPLOAD DOCUMENT:	*

I verify that facts set forth in this complaint are true and correct to the best of my knowledge, information and belief, I sign this complaint subject to 18 Pa.C.S. 4904(relating to unsworn falsifications to authorities)