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Form 3865-N. J.
STATE OF NEW JERSEY, ACCIDENT BLANK.
Report Every Accident Immediately.
This
report
of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau
of Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to
New Amsterdam Casualty Company
59 JOHN STREET
EXECUTIVE
7 ST. PAUL ST.
NEW YORK, N.Y.
OFFICES
BALTIMORE MD.
FORM "C." First notice of Accident. For use by insuring employers.
RLA
Number
11 Month of
Herbert Marsh
Beliedu
(Name of Employer) PC
of
45 New Street
(Name of Injured Employee)
27 Day Month
(Street Address)
avuy
1918
ear
arany
(Street B D
Address)
or
Plant
P. M.
A. M. fallow
(City
10
or Town) american
of
(Business)
Hour
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
5. Sex male 6. Age 75 7. Married yes
Citing Planks , blank
8. Give name of machine or appliance involved
sliffed Injured
9. Indicate kind of work done on this machine
Minshed
z fungr
pilmy planks
2.
Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury
middle famous
mygets hand
11. Was any guard protecting this portion of the machine?
12. Exact location of accident. If away from plant, give town,
16. Were the wages fixed by the output ?
m
street
and tankhouse number Hel
17. If the wages were fixed by the hour, state RATE per hour
13. yes
Was medical attention necessary ?
40c
14.
Name and address of attending physician Arlowly 18. Give
number of HOURS in ordinary day
11h.
6
15. If sent to hospital, state name and location
19. Give number of DAYS in ordinary working week
20. State the amount of weekly WAGES
26,40
Date of preparing this blank. 1235 18 19
Made out by
#
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
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"ocrText": "Form 3865-N. J.\nSTATE OF NEW JERSEY, ACCIDENT BLANK.\nReport Every Accident Immediately.\nThis\nreport\nof accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau\nof Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to\nNew Amsterdam Casualty Company\n59 JOHN STREET\nEXECUTIVE\n7 ST. PAUL ST.\nNEW YORK, N.Y.\nOFFICES\nBALTIMORE MD.\nFORM \"C.\" First notice of Accident. For use by insuring employers.\nRLA\nNumber\n11 Month of\nHerbert Marsh\nBeliedu\n(Name of Employer) PC\nof\n45 New Street\n(Name of Injured Employee)\n27 Day Month\n(Street Address)\navuy\n1918\near\narany\n(Street B D\nAddress)\nor\nPlant\nP. M.\nA. M. fallow\n(City\n10\nor Town) american\nof\n(Business)\nHour\n3. (Occupation)\n4. (Nationality)\nDate report received\nLeave this line blank\n1. State fully how accident occurred\n5. Sex male 6. Age 75 7. Married yes\nCiting Planks , blank\n8. Give name of machine or appliance involved\nsliffed Injured\n9. Indicate kind of work done on this machine\nMinshed\nz fungr\npilmy planks\n2.\nExact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury\nmiddle famous\nmygets hand\n11. Was any guard protecting this portion of the machine?\n12. Exact location of accident. If away from plant, give town,\n16. Were the wages fixed by the output ?\nm\nstreet\nand tankhouse number Hel\n17. If the wages were fixed by the hour, state RATE per hour\n13. yes\nWas medical attention necessary ?\n40c\n14.\nName and address of attending physician Arlowly 18. Give\nnumber of HOURS in ordinary day\n11h.\n6\n15. If sent to hospital, state name and location\n19. Give number of DAYS in ordinary working week\n20. State the amount of weekly WAGES\n26,40\nDate of preparing this blank. 1235 18 19\nMade out by\n#\nFill in names and date on FORM \"D\" before detaching.\nIf employee has resumed work at time of reporting, do not detach."
}