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RLM
11
Number
of
Hubul Manle
Month
16leall
(Name of Employer) her
(Name of Injured Employee)
27
Day of
Month Report received.
(Street address)
Leave this blank
Year
30. Did employee
(City lose of any town) time
34. If not able to work, give
probable date of recovery
31. Is employee able work? yes
to resume
35. Has any permanent injury resulted ?
no
12-3-18
If so, describe fully on back of form.
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 of preparing this
blank 12-5
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.
or
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- Type
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"ocrText": "RLM\n11\nNumber\nof\nHubul Manle\nMonth\n16leall\n(Name of Employer) her\n(Name of Injured Employee)\n27\nDay of\nMonth Report received.\n(Street address)\nLeave this blank\nYear\n30. Did employee\n(City lose of any town) time\n34. If not able to work, give\nprobable date of recovery\n31. Is employee able work? yes\nto resume\n35. Has any permanent injury resulted ?\nno\n12-3-18\nIf so, describe fully on back of form.\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 of preparing this\nblank 12-5\n1918\nMade out by\nIf\nemployee 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, 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,\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 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.\nor"
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