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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer
Full Address
Street
City
State
1.
Full
name of injured employe John Higgin
2. Address 30 B burriel st range nj
3. Age 29
4. Married yes
5. Number of Children?
/
6. Weekly wages
7.
In whose employ at time of accident Centres
8. Date and time of accident 1B day of augus
19. 18 at 10 30 30 A M.
9.
Place of accident Campay Plant
10.
Cause of accident slipped offa centry
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
cut an left him
12. Has the injured employe returned to work
yes
if so, when ? send
13. Did the injury require medical aid ? yes
14. If so, where rendered and by whom Dr. Saving
15. By whom was the physician called ? Employer If so, when ? / 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? yes
19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's
Collective Insurance?
Butir,
20.
Date of this notice aug 10-1918
21. Date of notice of accident by employe employer ang 13-18.
to
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
Page data
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- Source index
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- Size
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Document data
- ID
- 75718310
- Core
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- Type
- document
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Context sent to Scholar
Document identity
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Document source extras
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer\nFull Address\nStreet\nCity\nState\n1.\nFull\nname of injured employe John Higgin\n2. Address 30 B burriel st range nj\n3. Age 29\n4. Married yes\n5. Number of Children?\n/\n6. Weekly wages\n7.\nIn whose employ at time of accident Centres\n8. Date and time of accident 1B day of augus\n19. 18 at 10 30 30 A M.\n9.\nPlace of accident Campay Plant\n10.\nCause of accident slipped offa centry\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\ncut an left him\n12. Has the injured employe returned to work\nyes\nif so, when ? send\n13. Did the injury require medical aid ? yes\n14. If so, where rendered and by whom Dr. Saving\n15. By whom was the physician called ? Employer If so, when ? / P.M.\n16. Taken home or to hospital\n17. Name of hospital\nAddress?\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?\nButir,\n20.\nDate of this notice aug 10-1918\n21. Date of notice of accident by employe employer ang 13-18.\nto\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nSignature of Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}