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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer Radim Liminous Material Cerporation
Full Address 166 alden Street
City orange MJ,
State
1. Full name of injured employe Joseph andirson.
2. Address Main Sr. Orange. Hammels Block.
3. Age 20
4. Married no
5. Number of Children? Murl.
6. Weekly wages
7. In whose employ at time of accident Company's
8. Date and time of accident 4th day of may
198 at
1030 A.M.
9. Place of accident Company
10. Cause of accident Main fainted at his unh.
MAKE
COMPENSATION
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
MAY -61918
mo injury
12. Has the injured employe returned to work
mo.
CASE
if so, when?
13. Did the injury require medical aid? yes.
14. If so, where rendered and by whom Campany dector and
15. By whom was the physician called? Supmintending If so, when 1/2 humafter attach
16. Taken home or to hospital Herfutal.
17. Name of hospital Memmal Address? Orange
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
Collective Insurance? Steam Bills
20. Date of this notice may- 4-1918
21. Date of notice of accident by employe to employer Same date
All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.
Radim Limineus matt Corp
HRRRustond supt. Signature of Assured.
Please use the other side of this sheet for any additional information.
Form 1743 B
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Document data
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer Radim Liminous Material Cerporation\nFull Address 166 alden Street\nCity orange MJ,\nState\n1. Full name of injured employe Joseph andirson.\n2. Address Main Sr. Orange. Hammels Block.\n3. Age 20\n4. Married no\n5. Number of Children? Murl.\n6. Weekly wages\n7. In whose employ at time of accident Company's\n8. Date and time of accident 4th day of may\n198 at\n1030 A.M.\n9. Place of accident Company\n10. Cause of accident Main fainted at his unh.\nMAKE\nCOMPENSATION\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nMAY -61918\nmo injury\n12. Has the injured employe returned to work\nmo.\nCASE\nif so, when?\n13. Did the injury require medical aid? yes.\n14. If so, where rendered and by whom Campany dector and\n15. By whom was the physician called? Supmintending If so, when 1/2 humafter attach\n16. Taken home or to hospital Herfutal.\n17. Name of hospital Memmal Address? Orange\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?\n19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's\nCollective Insurance? Steam Bills\n20. Date of this notice may- 4-1918\n21. Date of notice of accident by employe to employer Same date\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nRadim Limineus matt Corp\nHRRRustond supt. Signature of Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}