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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer Radim Liminous Material Corporation
Full Address 166 alden Street Oranger City New Juney.
State
1. Full name of injured employe R. P. Kintyman
2. Address 36 Dodd sr. Orange
3. Age 45 4. Married yes 5. Number of
Children? 3
6. Weekly wage 2765
7. In whose employ at time of accident Companys.
8. Date and time of accident 15 day of may
19/8 at 3 P.M. (appix)
9. Place of accident Companys Plant
10. Cause of accident Man was storing banels of Uomadim
and later a nuptine clearlofud. Man has been
and is in emplay of plant sime that time.
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
Rufitine, see Dr's statement heremith.
12. Has the injured employe returned to work yes.
if so, when all time
13. Did the injury require medical aid? Sawa D arter.
14. If so, where rendered and by whom dr Davling 215Porb Ave. Orange
15. By whom was the physician called? If so, when?
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? steam trilm.
20. Date of this notice Jeme-
21. Date of notice of accident by employe to employer
All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.
Roelim Limines Mail corp.
Gujit.
Signature of Assured.
Please use the other side of this sheet for any additional information.
Form 1743 B
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer Radim Liminous Material Corporation\nFull Address 166 alden Street Oranger City New Juney.\nState\n1. Full name of injured employe R. P. Kintyman\n2. Address 36 Dodd sr. Orange\n3. Age 45 4. Married yes 5. Number of\nChildren? 3\n6. Weekly wage 2765\n7. In whose employ at time of accident Companys.\n8. Date and time of accident 15 day of may\n19/8 at 3 P.M. (appix)\n9. Place of accident Companys Plant\n10. Cause of accident Man was storing banels of Uomadim\nand later a nuptine clearlofud. Man has been\nand is in emplay of plant sime that time.\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nRufitine, see Dr's statement heremith.\n12. Has the injured employe returned to work yes.\nif so, when all time\n13. Did the injury require medical aid? Sawa D arter.\n14. If so, where rendered and by whom dr Davling 215Porb Ave. Orange\n15. By whom was the physician called? If so, when?\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? steam trilm.\n20. Date of this notice Jeme-\n21. Date of notice of accident by employe to employer\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nRoelim Limines Mail corp.\nGujit.\nSignature of Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}