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59 JOHN STREET,
7 ST. PAUL STREET.
NEW YORK CITY.
BALTIMORE, MD.
SURETY
CASUALTY
CLAIM DEPARTMENT
GEORGE w. PESINGER
ASSISTANT SECRETARY
Radium Luminous Material Co. , NEW YORK, July 18th, 1918.
166 Allen Street,
Orange, N.J.
Dear Sir :-
In re: Quinn VS Radium Luminous Material Corp.
Notice of accident as above is hereby acknowledged,
and the matter will be given prompt attention.
Yours very truly,
Geo. W. Pesinger,
ADC : II
Assistant Secretary.
11
Number A.D. Lanage
of
Month
(Name of Injured Employee)
usiciden (Name of Employer) kneel
15 Day of
Month Report received.
(Street address)
Leave this blank
13
evange J
198
Year
(City of town)
no
34. If not able to work, give
30. Did emplcyee lose any time?
probable date of recovery
31. Is employee able to resume work did not
35. Has any permanent injury resulted? no
If so, describe fully on back of form.
32. If so, on what DATE? slop working
36. Has your insurance carrier arranged to file the
compensation reports with the State for you?
33. State length of disability, weeks
days
Date of preparing this blank mo..15
1818
with
Made out by
If employee is still disabled at the time of preparing FORM "C," fill in names on this supplemental report, detach it and
forward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he
is able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill
out FORM "D," but do not detach.
This report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department of Labor,
Compensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to
NEW AMSTERDAM CASUALTY COMPANY.
When in need of blanks, apply to your insurance carrier.
FORM "D." SUPPLEMENTAL REPORT. For use of insuring employers.
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"ocrText": "59 JOHN STREET,\n7 ST. PAUL STREET.\nNEW YORK CITY.\nBALTIMORE, MD.\nSURETY\nCASUALTY\nCLAIM DEPARTMENT\nGEORGE w. PESINGER\nASSISTANT SECRETARY\nRadium Luminous Material Co. , NEW YORK, July 18th, 1918.\n166 Allen Street,\nOrange, N.J.\nDear Sir :-\nIn re: Quinn VS Radium Luminous Material Corp.\nNotice of accident as above is hereby acknowledged,\nand the matter will be given prompt attention.\nYours very truly,\nGeo. W. Pesinger,\nADC : II\nAssistant Secretary.\n11\nNumber A.D. Lanage\nof\nMonth\n(Name of Injured Employee)\nusiciden (Name of Employer) kneel\n15 Day of\nMonth Report received.\n(Street address)\nLeave this blank\n13\nevange J\n198\nYear\n(City of town)\nno\n34. If not able to work, give\n30. Did emplcyee lose any time?\nprobable date of recovery\n31. Is employee able to resume work did not\n35. Has any permanent injury resulted? no\nIf so, describe fully on back of form.\n32. If so, on what DATE? slop working\n36. Has your insurance carrier arranged to file the\ncompensation reports with the State for you?\n33. State length of disability, weeks\ndays\nDate of preparing this blank mo..15\n1818\nwith\nMade out by\nIf employee is still disabled at the time of preparing FORM \"C,\" fill in names on this supplemental report, detach it and\nforward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he\nis able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill\nout FORM \"D,\" but do not detach.\nThis report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department of Labor,\nCompensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to\nNEW AMSTERDAM CASUALTY COMPANY.\nWhen in need of blanks, apply to your insurance carrier.\nFORM \"D.\" SUPPLEMENTAL REPORT. For use of insuring employers."
}