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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer
Radium Luminous Material Corporation
Full Address
Street
City
State
166 Alden Street
Orange N.J.
1. Full name of injured employe Barney Sharkey
2. Address 17 Bradford Street
Orange N.J.
3. Age
24
4. Married no
5. Number of Children?
6. Weekly wages
$33.66
7. In whose employ at time of accident
Radium Luminous Mater ial Corpin
8. Date and time of accident
day of
19
at
M.
29
June
18
A
9. Place of accident Boiler House
10. Cause of accident Wrench slipped and hit the man above the eye
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
had cut above the right eye
12. Has the injured employe returned to work did not stop work when?
13. Did the injury require medical aid?
yes
14. If so, where rendered and by whom
Dr. Herbert Simmons
15. By whom was the physician called? Employee
If so, when? 11.30AM
16. Taken home or to hospital
no
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 15 1918.
21. Date of notice of accident by employe to employer August 15 1918.
All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.
Radium Luminous Material Corp!n
Signature of Assured.
Please use the other side of this sheet for any information.
Form 1743 B
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Document data
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- Core
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Context sent to Scholar
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer\nRadium Luminous Material Corporation\nFull Address\nStreet\nCity\nState\n166 Alden Street\nOrange N.J.\n1. Full name of injured employe Barney Sharkey\n2. Address 17 Bradford Street\nOrange N.J.\n3. Age\n24\n4. Married no\n5. Number of Children?\n6. Weekly wages\n$33.66\n7. In whose employ at time of accident\nRadium Luminous Mater ial Corpin\n8. Date and time of accident\nday of\n19\nat\nM.\n29\nJune\n18\nA\n9. Place of accident Boiler House\n10. Cause of accident Wrench slipped and hit the man above the eye\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nhad cut above the right eye\n12. Has the injured employe returned to work did not stop work when?\n13. Did the injury require medical aid?\nyes\n14. If so, where rendered and by whom\nDr. Herbert Simmons\n15. By whom was the physician called? Employee\nIf so, when? 11.30AM\n16. Taken home or to hospital\nno\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?\nyes\n19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's\nCollective Insurance?\nBoiler\n20. Date of this notice August 15 1918.\n21. Date of notice of accident by employe to employer August 15 1918.\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nRadium Luminous Material Corp!n\nSignature of Assured.\nPlease use the other side of this sheet for any information.\nForm 1743 B"
}