Employee Classification Act Complaint Form

The Employee Classification Act requires that every individual working for a contractor (individual, business entity engaged in construction, or trucking/delivery services, including all subcontractors) has the right to be properly classified as an employee rather than an independent contractor if the individual does not meet the requirements of an independent contractor under the law.

Your Information


First Name *:
Last Name *:
Social Security No *:
- -
Address *:
City *:
State *:
Zip *:
Phone *:
- -
Email *:
Dates of Employment *:
to

Complaint Details


Enter any details you wish to share with the Department of Labor:

Contractor Information


Business Name *:
Owner:
Business Phone *:
- -
Email:
Address *:
City *:
State *:
Zip *:
Contractor Registration Number:
Location/Address of Jobsite or where work was being performed:

If you are an employee, list other contractors you have worked for in the previous 12 months.


Contractor 1
Name:
Contractor Registration Number:
Address:
Phone:
- -


Contractor 2
Name:
Contractor Registration Number:
Address:
Phone:
- -


Contractor 3
Name:
Contractor Registration Number:
Address:
Phone:
- -

I hereby certify that the information entered is correct to the best of my knowledge and belief. I authorize the Nebraska Department of Labor to share the information contained in this complaint with any other government office or agency necessary to fully resolve this complaint.


Signature *:
Date