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prin
Number
11
of
arth a Britton
Month
(Name
/ of %backed Employer)
(Name of Injured Employee)
n
Day of
Month Report received.
(Street address)
be
99
Leave this blank
Year
(City ofltown)
3days
34. If not able to work, give
+
30. Did emplcyee lose any time
probable date of recovery
31. Is employee able to resume work?
35. Has any permanent injury resulted ? no
11-26-18
If so, describe fully on back of form.
32. If so, on what DATE?
36. Has your insurance carrier arranged to file the
33. State length of disability, weeks
days 3
compensation reports with the State for you?
Date of preparing this blank
11-27 1918
Made out by
If employee is still disabled at the time of preparing FORM "C," fill in names on this supplemental report, detach it and
forward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns,
if
he
is able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of
reporting,
fill
out FORM "D," but do not detach.
This report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department
of
Labor,
Compensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to
NEW AMSTERDAM CASUALTY COMPANY.
When in need of blanks, apply to your insurance carrier.
FORM "D." SUPPLEMENTAL REPORT. For use of insuring employers.
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Document data
- ID
- 75718358
- Core
- doc
- Type
- document
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"ocrText": "prin\nNumber\n11\nof\narth a Britton\nMonth\n(Name\n/ of %backed Employer)\n(Name of Injured Employee)\nn\nDay of\nMonth Report received.\n(Street address)\nbe\n99\nLeave this blank\nYear\n(City ofltown)\n3days\n34. If not able to work, give\n+\n30. Did emplcyee lose any time\nprobable date of recovery\n31. Is employee able to resume work?\n35. Has any permanent injury resulted ? no\n11-26-18\nIf so, describe fully on back of form.\n32. If so, on what DATE?\n36. Has your insurance carrier arranged to file the\n33. State length of disability, weeks\ndays 3\ncompensation reports with the State for you?\nDate of preparing this blank\n11-27 1918\nMade out by\nIf employee is still disabled at the time of preparing FORM \"C,\" fill in names on this supplemental report, detach it and\nforward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns,\nif\nhe\nis able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of\nreporting,\nfill\nout FORM \"D,\" but do not detach.\nThis report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department\nof\nLabor,\nCompensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to\nNEW AMSTERDAM CASUALTY COMPANY.\nWhen in need of blanks, apply to your insurance carrier.\nFORM \"D.\" SUPPLEMENTAL REPORT. For use of insuring employers."
}