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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer
Radium Luminous Material Corproation.
Full Address #166 Alden Street Street Orange City New Jersey.
State
1. Full name of injured employe Benjamine Rorke
2. Address #3 Watson Avenue, West Orange, New Jersey.
3. Age 47
4. Married
Yes
5. Number of Children? 1
6. Weekly wages
7. In whose employ at time of accident Company's
8. Date and time of accident 15
day
of
August
19 1918 at 18 at 2 P. M. M.
9. Place of accident Company's Plant, assembling machine parts
10. Cause of accident Caught between a hanger and shafting
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
2 nd finger on right hand (bad bruise)
12. Has the injured employe returned to work kept working 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? August 17th
--
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
Yes
is defined and limited by the Compensation Act?
19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's
Collective Insurance?
Boiler
August 23rd, 1918.
20. Date of this notice
August 23rd, 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.
RADIUM LUMINOUS MATERIAL COP'N
Signature of Assured.
Please use the other side of this sheet Superintendent. for any additional information.
Form 1743 B
Page data
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- Source index
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- Type
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- Size
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Document data
- ID
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- Core
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- Type
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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 Corproation.\nFull Address #166 Alden Street Street Orange City New Jersey.\nState\n1. Full name of injured employe Benjamine Rorke\n2. Address #3 Watson Avenue, West Orange, New Jersey.\n3. Age 47\n4. Married\nYes\n5. Number of Children? 1\n6. Weekly wages\n7. In whose employ at time of accident Company's\n8. Date and time of accident 15\nday\nof\nAugust\n19 1918 at 18 at 2 P. M. M.\n9. Place of accident Company's Plant, assembling machine parts\n10. Cause of accident Caught between a hanger and shafting\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\n2 nd finger on right hand (bad bruise)\n12. Has the injured employe returned to work kept working if 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? Employee\nIf so, when? August 17th\n--\n16. Taken home or to hospital\n--\n17. Name of hospital\nAddress?\n--\n18. Have you advised the attending physician or the hospital that your liability for the cost of treatment\nYes\nis defined and limited by the Compensation Act?\n19. Do you carry any other Compensation or General Liability, Steam Boiler, Elevator or Workmen's\nCollective Insurance?\nBoiler\nAugust 23rd, 1918.\n20. Date of this notice\nAugust 23rd, 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.\nRADIUM LUMINOUS MATERIAL COP'N\nSignature of Assured.\nPlease use the other side of this sheet Superintendent. for any additional information.\nForm 1743 B"
}