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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer
Full Address
Street
City
State
1. Full name of injured employe John Heggis
2. Address 30 range nj
3. Age 29
4. Married yes
5. Number of Children? /
6. Weekly wages
7. In whose employ at time of accident Cenfress
8. Date and time of accident 13 day of anges
1918 at 1030 A M.
9. Place of accident Canpuy Plant
10. Cause of accident S lipped offa Carly
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
Cutan left Slim
12. Has the injured employe returned to work yes
if so, when ? suidey
13. Did the injury require medical aid? yes
14. If so, where rendered and by whom Dr. Daving
15. By whom was the physician called? Employee If so, when ? / 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? yes,
19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's
Collective Insurance? B its,
20. Date of this notice ang/5-1918
21. Date of notice of accident by employe to employer ang 13-18.
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
Page data
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Document data
- ID
- 75718310
- Core
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- Type
- document
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Context sent to Scholar
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer\nFull Address\nStreet\nCity\nState\n1. Full name of injured employe John Heggis\n2. Address 30 range nj\n3. Age 29\n4. Married yes\n5. Number of Children? /\n6. Weekly wages\n7. In whose employ at time of accident Cenfress\n8. Date and time of accident 13 day of anges\n1918 at 1030 A M.\n9. Place of accident Canpuy Plant\n10. Cause of accident S lipped offa Carly\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nCutan left Slim\n12. Has the injured employe returned to work yes\nif so, when ? suidey\n13. Did the injury require medical aid? yes\n14. If so, where rendered and by whom Dr. Daving\n15. By whom was the physician called? Employee If so, when ? / 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? yes,\n19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's\nCollective Insurance? B its,\n20. Date of this notice ang/5-1918\n21. Date of notice of accident by employe to employer ang 13-18.\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"
}