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(Compensation)
REPORT OF ACCIDENT TO AN EMPLOYE
Name of Employer Radium Lum mous material Carpin
Full Address 166 alden
Street Orauge n.g.
State
1. Full name of injured employe Charles Benjamin
2. Address 44 Lake Street East Orange
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 M.
9. Place of accident Jankhons of Company
10. Cause of accident got acid maye
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 stay so, when working
13. Did the injury require medical aid?
14. If so, where rendered and by whom Dr yes Dowhing
15. By whom was the physician called? the injured If so, when ? at once
16. Taken home or to hospital
17. Name of hospital
J
-
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?
Bry 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.
Supt 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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"ocrText": "(Compensation)\nREPORT OF ACCIDENT TO AN EMPLOYE\nName of Employer Radium Lum mous material Carpin\nFull Address 166 alden\nStreet Orauge n.g.\nState\n1. Full name of injured employe Charles Benjamin\n2. Address 44 Lake Street East Orange\n3. Age 36 4. Married\nX\n5. Number of Children?\n8\n6. Weekly wages\n$3000\n7. In whose employ at time of accident Company\n8. Date and time of accident 8 day of September 18at 10 PM M.\n9. Place of accident Jankhons of Company\n10. Cause of accident got acid maye\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 stay so, when working\n13. Did the injury require medical aid?\n14. If so, where rendered and by whom Dr yes Dowhing\n15. By whom was the physician called? the injured If so, when ? at once\n16. Taken home or to hospital\n17. Name of hospital\nJ\n-\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?\nBry Boiler\n20. Date of this notice September 9th 1918\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.\nSupt of Assured.\nPlease use the other side of this sheet for any additional information.\nForm 1743 B"
}