Accident report, September 8, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Radium huminous mateural Carpin Full Address 166 Olden Street Orange n.J State 1. Full name of injured employe Charles Benjamin 2. Address 44 Lake Street East Crange 3. Age 36 4. Married x 5. Number of Children? 8 6. Weekly wages $3000 7. In whose employ at time of accident Company' 8. Date and time of accident 8 day of September 18at 10 PM. 9. Place of accident Jankhous of Company 10. Cause of accident, got acid in eye 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) right eye 12. Has the injured employe returned to work did not statemen ? working 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? the injured If so, when ? at once 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: Boy Boiler 20. Date of this notice September 9th 1918 21. Date of notice of accident by employe to employer September 8th All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. Souph of Assured. Please use the other side of this sheet for any additional information. Form 1743 B