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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer Radium Luminous Material Corp'n
Full Address #166 Alden Street Street Orange City New Jersey
State
John Higgins
1. Full name of injured employe
#30 Burnside St., Orange, New Jersey.
2. Address
3. Age 29
Yes
1
4. Married
5. Number of Children?
$29.85
6. Weekly wages
7. In whose employ at time of accident
Company's
13
August
18 10:30-A.
8. Date and time of accident
day of
19
at
M.
Company's Plant
9. Place of accident
10. Cause of accident Slipped off a carboy
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
Cut on Left Shin
Yes
Same Day
12. Has the injured employe returned to work
if SO, when
13. Did the injury require medical aid ? Yes
14. If so, where rendered and by whom Dr. Dowling
15. By whom was the physician called?
Employee
If so, when 1:P. M.
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?
19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's
Boiler
Collective Insurance?
20. Date of this notice August 13-1918
August 13-1918.
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.
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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- Core
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer Radium Luminous Material Corp'n\nFull Address #166 Alden Street Street Orange City New Jersey\nState\nJohn Higgins\n1. Full name of injured employe\n#30 Burnside St., Orange, New Jersey.\n2. Address\n3. Age 29\nYes\n1\n4. Married\n5. Number of Children?\n$29.85\n6. Weekly wages\n7. In whose employ at time of accident\nCompany's\n13\nAugust\n18 10:30-A.\n8. Date and time of accident\nday of\n19\nat\nM.\nCompany's Plant\n9. Place of accident\n10. Cause of accident Slipped off a carboy\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nCut on Left Shin\nYes\nSame Day\n12. Has the injured employe returned to work\nif SO, when\n13. Did the injury require medical aid ? Yes\n14. If so, where rendered and by whom Dr. Dowling\n15. By whom was the physician called?\nEmployee\nIf so, when 1:P. M.\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?\n19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's\nBoiler\nCollective Insurance?\n20. Date of this notice August 13-1918\nAugust 13-1918.\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.\nSignature of Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}