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(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
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Document data
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- Type
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Context sent to Scholar
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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN\nEMPLOYE\nName of Employer Radium huminous mateural Carpin\nFull Address 166 Olden\nStreet Orange n.J\nState\n1. Full name of injured employe Charles Benjamin\n2. Address\n44 Lake Street East Crange\n3.\nAge 36 4. Married\nx\n5. Number of Children?\n8\n6. Weekly wages\n$3000\n7.\nIn whose employ at time of accident Company'\n8. Date and\ntime of accident 8 day of September 18at 10 PM.\n9. Place of accident Jankhous of Company\n10.\nCause of accident, got acid in eye\n11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured)\nright eye\n12. Has the injured employe returned to work did not statemen ? working\n13. Did the injury require medical aid ?\nyes\n14.\nIf so, where rendered and by whom Dr Dowling\n15. By whom was the physician called? the injured If so, when ? at\nonce\n16. Taken home or to hospital\n-\n-\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:\nBoy Boiler\n20.\nDate of this notice September 9th\n1918\n21. Date of notice of accident by employe to employer September 8th\nAll the statements herein are made upon information merely, and are to be deemed to have been made without prejudice.\nSouph\nof Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}