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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
Rad. been mat Corp
12 Month of
Number James (Namp Iniured Employee)
Roosey
# 16balden street
(Name of Employer),
15 Day Month of
125 (Street Address) aug.
orange new Tovn) Jevery
(Street Address)
18 Year West n.f.
Watching
orange
chemical or Plant
(City or Town)
3:30 P. M. Carpenter
american
(Business)
Hour
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
throking
5. Sex
6.
Age 35 7. Married yes
ow tank & free of and
8. Give name of machine or appliance involved
feel on foot
all mentioning
9. Indicate kind of work done on this machine
X
2. Exact part of person injured, with nature and extent of injury
10. Name distinct part of machine causing injury
Smarked the toes of
left fort
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 ? no
-
street and number
company's plant
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary ?
was
socents
18. Give number of HOURS in ordinary day
11
14. Name and address of attendir;
Legan
15. If sent to hospital, state name and location
X
19. week
Give number of DAYS in ordinary working 6
20. State the amount of weekly WAGES
32.00
Date of preparing this blank 12/19/18 19 18 Made out by
no
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
OK
NV
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Document data
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- Core
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- Type
- document
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"ocrText": "Form 3865-N. J.\nSTATE OF NEW JERSEY, ACCIDENT BLANK.\nReport Every Accident Immediately.\nThis\nreport of 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\nRad. been mat Corp\n12 Month of\nNumber James (Namp Iniured Employee)\nRoosey\n# 16balden street\n(Name of Employer),\n15 Day Month of\n125 (Street Address) aug.\norange new Tovn) Jevery\n(Street Address)\n18 Year West n.f.\nWatching\norange\nchemical or Plant\n(City or Town)\n3:30 P. M. Carpenter\namerican\n(Business)\nHour\n3. (Occupation)\n4. (Nationality)\nDate report received\nLeave this line blank\n1. State fully how accident occurred\nthroking\n5. Sex\n6.\nAge 35 7. Married yes\now tank & free of and\n8. Give name of machine or appliance involved\nfeel on foot\nall mentioning\n9. Indicate kind of work done on this machine\nX\n2. Exact part of person injured, with nature and extent of injury\n10. Name distinct part of machine causing injury\nSmarked the toes of\nleft fort\n11. Was any guard protecting this portion of the machine?\n12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output ? no\n-\nstreet and number\ncompany's plant\n17. If the wages were fixed by the hour, state RATE per hour\n13. Was medical attention necessary ?\nwas\nsocents\n18. Give number of HOURS in ordinary day\n11\n14. Name and address of attendir;\nLegan\n15. If sent to hospital, state name and location\nX\n19. week\nGive number of DAYS in ordinary working 6\n20. State the amount of weekly WAGES\n32.00\nDate of preparing this blank 12/19/18 19 18 Made out by\nno\nFill in names and date on FORM \"D\" before detaching.\nIf employee has resumed work at time of reporting, do not detach.\nOK\nNV"
}