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'art s. Form 1. Rev. 18-41
10
STANDARD FORM FOR
State's
Number
File:
EMPLOYER'S SUPPLEMENTAL
REPORT OF INJURY
Carrier:
28
Approved by A. I. A R. "
For:
Send to INDUSTRIAL ACCIDENT ROARD, AUSTIN, TEXAS
Employer:
Penalty of $1000 for failure to file.
See Section 7. Article 8307. Employer's Liability Law.
Copy to LIBERTY INSURANCE COMPANY OF TEXAS
Carrier's File No.
Mitchell. Gartner & Thompeon, Managers
(The spaces above not to be filled in by Employer)
P. o. Bes 939
Texas at Summit
Fert Werth, Texas
If Employer's First Report of Injury did not show that the injured had returned to work. an Employer's Supplemental Report
of
Injury should be completed and filed immediately after return to work of the employee, or at the end of sixty days. In the
event of the death of the employee. this report should be filed immediately.
1.
Name of Imployer: King Candy Company
SOCIAL SECURITY NO.
004231
2. Office Address: No. and St. 11 is Ninth Ct.
City or Town Fort ,orth
State Texas
3. Insured by: Name of
Libe. ty usurance Company
$. Name of Injured (in full)
:larguerite
Lie
Oswald
Social Security No. 435-22-5686
(First Name)
(Middle Initial)
thant Name)
5. Present Address: No. and St. 3006 Bristol id.
City or Town
Fort orth
State Texas
6. Date of Injury December 5,
1958 Day of week Friday
Hour of day
A.M 1:30 P.M.
7. Date Disability began Friday December 5,
10.58 A.M
P.M. 1:30
8. Has injured returned to work? tes
If so, date and hour 12/11/53
8:00 A.M.
P.M.
9. Is injured person earning same wages as before injury?
Yes
If not. explain
10. If disability has not terminated. state probable date of termination of disability
11. Has injured died?
If so. date of death
A.M.
P.M.
a - / reject to 27-2-59
punk of a /
pot imarite
final part
6/12/1994
2
Date of this report 11/3/5
Firm name:
fing C ndy Company
Signed by
Wayne Goodmor
Official Title: Personal
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"ocrText": "'art s. Form 1. Rev. 18-41\n10\nSTANDARD FORM FOR\nState's\nNumber\nFile:\nEMPLOYER'S SUPPLEMENTAL\nREPORT OF INJURY\nCarrier:\n28\nApproved by A. I. A R. \"\nFor:\nSend to INDUSTRIAL ACCIDENT ROARD, AUSTIN, TEXAS\nEmployer:\nPenalty of $1000 for failure to file.\nSee Section 7. Article 8307. Employer's Liability Law.\nCopy to LIBERTY INSURANCE COMPANY OF TEXAS\nCarrier's File No.\nMitchell. Gartner & Thompeon, Managers\n(The spaces above not to be filled in by Employer)\nP. o. Bes 939\nTexas at Summit\nFert Werth, Texas\nIf Employer's First Report of Injury did not show that the injured had returned to work. an Employer's Supplemental Report\nof\nInjury should be completed and filed immediately after return to work of the employee, or at the end of sixty days. In the\nevent of the death of the employee. this report should be filed immediately.\n1.\nName of Imployer: King Candy Company\nSOCIAL SECURITY NO.\n004231\n2. Office Address: No. and St. 11 is Ninth Ct.\nCity or Town Fort ,orth\nState Texas\n3. Insured by: Name of\nLibe. ty usurance Company\n$. Name of Injured (in full)\n:larguerite\nLie\nOswald\nSocial Security No. 435-22-5686\n(First Name)\n(Middle Initial)\nthant Name)\n5. Present Address: No. and St. 3006 Bristol id.\nCity or Town\nFort orth\nState Texas\n6. Date of Injury December 5,\n1958 Day of week Friday\nHour of day\nA.M 1:30 P.M.\n7. Date Disability began Friday December 5,\n10.58 A.M\nP.M. 1:30\n8. Has injured returned to work? tes\nIf so, date and hour 12/11/53\n8:00 A.M.\nP.M.\n9. Is injured person earning same wages as before injury?\nYes\nIf not. explain\n10. If disability has not terminated. state probable date of termination of disability\n11. Has injured died?\nIf so. date of death\nA.M.\nP.M.\na - / reject to 27-2-59\npunk of a /\npot imarite\nfinal part\n6/12/1994\n2\nDate of this report 11/3/5\nFirm name:\nfing C ndy Company\nSigned by\nWayne Goodmor\nOfficial Title: Personal"
}