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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer Raduim Luminous Material to
Full Address 166 alder feet Sweet City Orange State
1. Full name of injured
employe James Chamberlin n.J.
2. Address 238 bleveland Street Orange
3. Age 65 4. Married yes 5. Number of Children?
no
6. Weekly wages
$2300
7. In whose employ at time of accident Radium Lummins Material
8. Date and time of accident 26 day of. august 1918 at 10 A M.
9. Place of accident Carpenter shop
10. Cause of accident
got caught in the planer
11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)
cut on left thank
12. Has the injured employe returned to work did not if so, top when working
13. Did the injury require medical aid?
zes
14. If so, where rendered and by whom Dr Dowking
15. By whom was the physician called? employee If so, when ? august 27
16. Taken home or to hospital
I
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 27-1918
21. Date of notice of accident by employe to employer august 26-1918
All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.
Signature of Assured.
Form 1743 B
Please use the other side of this sheet Supt for any additional information.
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Document data
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer Raduim Luminous Material to\nFull Address 166 alder feet Sweet City Orange State\n1. Full name of injured\nemploye James Chamberlin n.J.\n2. Address 238 bleveland Street Orange\n3. Age 65 4. Married yes 5. Number of Children?\nno\n6. Weekly wages\n$2300\n7. In whose employ at time of accident Radium Lummins Material\n8. Date and time of accident 26 day of. august 1918 at 10 A M.\n9. Place of accident Carpenter shop\n10. Cause of accident\ngot caught in the planer\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\ncut on left thank\n12. Has the injured employe returned to work did not if so, top when working\n13. Did the injury require medical aid?\nzes\n14. If so, where rendered and by whom Dr Dowking\n15. By whom was the physician called? employee If so, when ? august 27\n16. Taken home or to hospital\nI\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\naugust 27-1918\n21. Date of notice of accident by employe to employer august 26-1918\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nSignature of Assured.\nForm 1743 B\nPlease use the other side of this sheet Supt for any additional information."
}