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Than (Name Rad of Employer) Mr. the
11
Number
of
Month
Thomas the tugh
(Name of Injured Employee)
49 balland Blace
21 Day of
Month Report received.
(Street address)
1918
Leave this blank
Year
(City of town)
30. Did emplcyee lose time? no
34. If not able to work, give
any
probable date of recovery
31. Is employee able to resume work ? Keeps working 35. Has If so, any describe permanent fully on injury back resulted of form. ? afforently not
32. If so, on what DATE?
36. Has your insurance carrier arranged to file the
compensation reports with the State for you
33. State length of disability, weeks
days
Date preparing this blank 11-27- 1918 : Made out by
of
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.
LOST
DI
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"ocrText": "Than (Name Rad of Employer) Mr. the\n11\nNumber\nof\nMonth\nThomas the tugh\n(Name of Injured Employee)\n49 balland Blace\n21 Day of\nMonth Report received.\n(Street address)\n1918\nLeave this blank\nYear\n(City of town)\n30. Did emplcyee lose time? no\n34. If not able to work, give\nany\nprobable date of recovery\n31. Is employee able to resume work ? Keeps working 35. Has If so, any describe permanent fully on injury back resulted of form. ? afforently not\n32. If so, on what DATE?\n36. Has your insurance carrier arranged to file the\ncompensation reports with the State for you\n33. State length of disability, weeks\ndays\nDate preparing this blank 11-27- 1918 : Made out by\nof\nIf employee is still disabled at the time of preparing FORM \"C,\" fill in names on this supplemental report, detach it\nand\nforward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he\nis able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill\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 of Labor,\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.\nLOST\nDI"
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