Accident report, August 13, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radium Luminous Material Corp'n Full Address #166 Alden Street Street Orange City New Jersey State John Higgins 1. Full name of injured employe #30 Burnside St., Orange, New Jersey. 2. Address 29 4. Married Yes 1 3. Age 5. Number of Children? $29.85 6. Weekly wages 7. In whose employ at time of accident Company's 13 August 18 10:30-A. 8. Date and time of accident day of 19 at M. Company's Plant 9. Place of accident 10. Cause of accident Slipped off a carboy 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) Cut on Left Shin Yes Same Day 12. Has the injured employe returned to work if so, when ? Yes 13. Did the injury require medical aid? 14. If so, where rendered and by whom Dr. Dowling 15. By whom was the physician called ? Employee If so, when ? 1:P. M. 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? 19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's Boiler Collective Insurance? 20. August 13-1918 Date of this notice August 13-1918. 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. Signature of Assured. Please use the other side of this sheet for any additional information. Form 1743 B