Accident report, August 25, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radium Luminous Material So Full Address 16b alder treet Street City crange State 1. Full name of injured employe James Chamberlin n.g. 2. Address 238 bleveland Street Drange 3. Age 65 4. Married yes 5. Number of Children? no 6. Weekly wages $2300 7. In whose employ at time of accident Radium huminors material 8. Date and time of accident 25 day of august 19/8at 10 A M. 9. Place of accident barpenter shop 10. Cause of accident got caught in the planer 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) cut on left thoush 12. Has the injured employe returned to work did not if so, when working stop 13. Did the injury require medical aid ? zes 14. If so, where rendered and by whom or Dowling 15. By whom was the physician called ? employee If so, when ? august 27 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? Boiler 20. Date of this notice august 27-1918 21. Date of notice of accident by employe to employer august 26-1918 All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. Form 1743 B use the other side of this sheet Super for any additional Signature of Assured. Please information.