Accident report, August 13, 1918

(Compensation) REPORT OF ACCIDENT TO AN EMPLOYE Name of Employer Full Address Street City State 1. Full name of injured employe John Higgin 2. Address 30 B burriel st range nj 3. Age 29 4. Married yes 5. Number of Children? / 6. Weekly wages 7. In whose employ at time of accident Centres 8. Date and time of accident 1B day of augus 19. 18 at 10 30 30 A M. 9. Place of accident Campay Plant 10. Cause of accident slipped offa centry 11. Nature and extent of injury (state definitely which fingers, hand, foot or eye is injured) cut an left him 12. Has the injured employe returned to work yes if so, when ? send 13. Did the injury require medical aid ? yes 14. If so, where rendered and by whom Dr. Saving 15. By whom was the physician called ? Employer If so, when ? / P.M. 16. Taken home or to hospital 17. Name of hospital 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? Butir, 20. Date of this notice aug 10-1918 21. Date of notice of accident by employe employer ang 13-18. to All the statements herein are made upon information merely, and are to be deemed to have been made without prejudice. Signature of Assured. Please use the other side of this sheet for any additional information. Form 1743 B