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Radim Sminer Matl Curp
Number
7 Month of
Dominis grim
(Name of Employer)
(Name of Injured - Employee)
166 aldenst
16 Day of
Month Report received.
(Strect address)
Orange
(City of town) M.J.
Leave this blank
1918 Year
30. mt
34. If not able to work, give
Did employee lose any time?
probable date of recovery
at work
31. employee resume yes
Is able to work?
35. Has any permanent injury resulted ? Mo.
32. If so, on what DATE? Same date
If so, describe fully on back of form.
36. Has your insurance carrier arranged to file the
compensation reports with the State for you?
33. State length of disability, weeks
days
Date of preparing this blank of uty is 1910 Made out by
ARR
If employee is still disabled at the time of preparing FORM "C," fill in names on this supplemental report, detach it and
forward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he
is
able
to
work before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill
out FORM "D," but do not detach.
This report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department of Labor,
Compensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to
NEW AMSTERDAM CASUALTY COMPANY.
When in need of blanks, apply to your insurance carrier.
FORM "D." SUPPLEMENTAL REPORT. For use of insuring employers.
combsua
or
og
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Document data
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- Core
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- Type
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"ocrText": "Radim Sminer Matl Curp\nNumber\n7 Month of\nDominis grim\n(Name of Employer)\n(Name of Injured - Employee)\n166 aldenst\n16 Day of\nMonth Report received.\n(Strect address)\nOrange\n(City of town) M.J.\nLeave this blank\n1918 Year\n30. mt\n34. If not able to work, give\nDid employee lose any time?\nprobable date of recovery\nat work\n31. employee resume yes\nIs able to work?\n35. Has any permanent injury resulted ? Mo.\n32. If so, on what DATE? Same date\nIf so, describe fully on back of form.\n36. Has your insurance carrier arranged to file the\ncompensation reports with the State for you?\n33. State length of disability, weeks\ndays\nDate of preparing this blank of uty is 1910 Made out by\nARR\nIf employee is still disabled at the time of preparing FORM \"C,\" fill in names on this supplemental report, detach it and\nforward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he\nis\nable\nto\nwork before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill\nout FORM \"D,\" but do not detach.\nThis report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department of Labor,\nCompensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to\nNEW AMSTERDAM CASUALTY COMPANY.\nWhen in need of blanks, apply to your insurance carrier.\nFORM \"D.\" SUPPLEMENTAL REPORT. For use of insuring employers.\ncombsua\nor\nog"
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