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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer Radim aminas Material Corporation
Full Address 166 alden Street Orange City new Juney
State
1. Full name of injured employe R. P. Kimtgman
2.
Address 36 Dodd sr. Drange
3. Age. 45
4. Married
yes
5. Number of Children?
3
6. Weekly wage $2745
7. In whose employ at time of accident Companys
8. Date and time of accident 15 day of may
19/8 at
3
P.M. (appux)
9. Place
of accident Company Plant
10. Cause of accident man was trining banes of Vamadim
and later a mytime developed man has bun
ad is in emplay of plant since that time
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
Repertine , see Dr's statement heremith.
12. Has the injured employe returned work yes
to
if so, when ? all time.
13. Did the injury require medical aid ? San a Pater.
15. By whom was the physician called ? ueman If when ?
14. If so, where rendered and by whom Dr stowling 215 Park are. Orange
so,
16. Taken home or to hospital
17. Name of hospital Address:
18. Have you advised the attending physician or the hospital that your liability for the cost of treatment
is defined and limited by the Compensation Act? yes
19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's
Collective Insurance?
steam brier.
20. Date of this notice Jenve. me 18
21. Date of notice of accident by employe to employer
All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.
Raelim deminus mall Crip
upt.
Signature of Assured.
Please use the other side of this sheet for any additional information.
Form 1743 B
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Document data
- ID
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- Core
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- Type
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer Radim aminas Material Corporation\nFull Address 166 alden Street Orange City new Juney\nState\n1. Full name of injured employe R. P. Kimtgman\n2.\nAddress 36 Dodd sr. Drange\n3. Age. 45\n4. Married\nyes\n5. Number of Children?\n3\n6. Weekly wage $2745\n7. In whose employ at time of accident Companys\n8. Date and time of accident 15 day of may\n19/8 at\n3\nP.M. (appux)\n9. Place\nof accident Company Plant\n10. Cause of accident man was trining banes of Vamadim\nand later a mytime developed man has bun\nad is in emplay of plant since that time\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nRepertine , see Dr's statement heremith.\n12. Has the injured employe returned work yes\nto\nif so, when ? all time.\n13. Did the injury require medical aid ? San a Pater.\n15. By whom was the physician called ? ueman If when ?\n14. If so, where rendered and by whom Dr stowling 215 Park are. Orange\nso,\n16. Taken home or to hospital\n17. Name of hospital Address:\n18. Have you advised the attending physician or the hospital that your liability for the cost of treatment\nis defined and limited by the Compensation Act? yes\n19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's\nCollective Insurance?\nsteam brier.\n20. Date of this notice Jenve. me 18\n21. Date of notice of accident by employe to employer\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nRaelim deminus mall Crip\nupt.\nSignature of Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}