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Form 3865-N. J.
STATE OF NEW JERSEY, ACCIDENT BLANK.
Report Every Accident Immediately.
This report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau
of Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to
New Amsterdam Casualty Company
59 JOHN STREET
EXECUTIVE
7 ST. PAUL ST.
NEW YORK, N. Y.
OFFICES
BALTIMORE MD.
FORM "C." First notice of Accident. For use by insuring employers.
Railm Limines Math Carp
7 of
Number Dominuts Quim
Month
(Name of Employer)
(Name (of Injured Employee)
166 alder St.
16 Day of
Month
97 Lehnvell are
(Street Address)
(Street Address)
Orange If
1918 Year
(City or Town)
range (City
or Town)
mfor of Radium (Business)
1030 A. M. Laborrer
ammian
Hour
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
5. Sex male 52 7. Married Under
6. Age
cement wall clinel littled
cutting lurch
8. Give name of machine or appliance involved
9. Indicate kind of work done on this machine
2. Exact part of person injured, with nature and extent of injury
10. Name distinct part of machine causing injury
cut alay ride lift age
11. Was any guard protecting this portion of the machine?
12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output ? mo.
street and number cempuns plant
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary ? Jent ail
at plant went to Dr must day
32 &
14. Name and address of attending physician Dr. Parting
18. Give number of HOURS in ordinary day 111/2
Pah are Orange
15. If sent to hospital, state name and location
19. Give number of in ordinary
DAYS working week 6
20. State the amount of weekly WAGES. 24.72
Date of preparing this blank. July Fill in names 18 and 19/8 date on FORM Made "D" out by before detaching. upk
ABRewland
If employee has resumed work at time of reporting, do not detach.
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Document data
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- Core
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- Type
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"ocrText": "Form 3865-N. J.\nSTATE OF NEW JERSEY, ACCIDENT BLANK.\nReport Every Accident Immediately.\nThis report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau\nof Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to\nNew Amsterdam Casualty Company\n59 JOHN STREET\nEXECUTIVE\n7 ST. PAUL ST.\nNEW YORK, N. Y.\nOFFICES\nBALTIMORE MD.\nFORM \"C.\" First notice of Accident. For use by insuring employers.\nRailm Limines Math Carp\n7 of\nNumber Dominuts Quim\nMonth\n(Name of Employer)\n(Name (of Injured Employee)\n166 alder St.\n16 Day of\nMonth\n97 Lehnvell are\n(Street Address)\n(Street Address)\nOrange If\n1918 Year\n(City or Town)\nrange (City\nor Town)\nmfor of Radium (Business)\n1030 A. M. Laborrer\nammian\nHour\n3. (Occupation)\n4. (Nationality)\nDate report received\nLeave this line blank\n1. State fully how accident occurred\n5. Sex male 52 7. Married Under\n6. Age\ncement wall clinel littled\ncutting lurch\n8. Give name of machine or appliance involved\n9. Indicate kind of work done on this machine\n2. Exact part of person injured, with nature and extent of injury\n10. Name distinct part of machine causing injury\ncut alay ride lift age\n11. Was any guard protecting this portion of the machine?\n12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output ? mo.\nstreet and number cempuns plant\n17. If the wages were fixed by the hour, state RATE per hour\n13. Was medical attention necessary ? Jent ail\nat plant went to Dr must day\n32 &\n14. Name and address of attending physician Dr. Parting\n18. Give number of HOURS in ordinary day 111/2\nPah are Orange\n15. If sent to hospital, state name and location\n19. Give number of in ordinary\nDAYS working week 6\n20. State the amount of weekly WAGES. 24.72\nDate of preparing this blank. July Fill in names 18 and 19/8 date on FORM Made \"D\" out by before detaching. upk\nABRewland\nIf employee has resumed work at time of reporting, do not detach."
}