§ 254. Notices-Acceptance, rejection, and withdrawal EMPLOYER'S NOTICE OF ACCEPTANCE To the Employés of the Undersigned, and the (Administrative Officers): You and each of you are hereby notified that the undersigned elects to accept the terms, conditions and provisions to provide, secure and pay compensation to employés of the undersigned for injuries received as provided in the Workmen's Compensation Act, and that the undersigned elects to pay damages for personal injuries received by such employé under the terms, conditions and provisions of said Act. STATE OF By SS: (state where posted). County of 19, The undersigned being duly sworn deposes and says that a true, correct and verbatim copy of the foregoing notice was on the posted at day of (Administrative Officers): To the Employer of the Undersigned, and the You and each of you are hereby notified that the undersigned makes voluntary election to accept the terms, conditions and provisions to provide, secure and pay compensation to employés for injuries received as provided in Workmen's Compensation Act and that the undersigned elects to liquidate claims for personal injuries received by the undersigned as an employé of under the terms, conditions and provisions of said Act. The undersigned being duly sworn deposes and says that a true, correct and verbatim copy of the foregoing notice was on the 19, served upon day of (employer's name). Take notice that the undersigned employer of labor in the state of hereby elects not to accept the provisions of the Workmen's Compensation Act. Dated at this day of 19. By (P. O. Address) EMPLOYER'S NOTICE OF WITHDRAWAL FROM OPERATION Under WORKMEN'S COMPENSATION ACT Industrial Commission, : Take notice that the undersigned employer of labor in the state of hereby withdraws his (her) (its) election to become subject to the provisions of the Workmen's Compensation Act of the state of NOTICE OF EMPLOYÉ UPON ENTERING EMPLOYMENT THAT HE ELECTS NOT TO BE SUBJECT TO THE WORKMEN'S COMPENSATION ACT ΤΟ (Write name of employer plainly on above line.) (Write address of employer plainly on above line.) You will take notice that, being about to enter your employ, I elect not to be subject to the provisions of the Workmen's Compensation Act of the state § 255. Notices to be posted, and certificate In accordance with the provisions of section 6, part I, of the Michigan Act, the Industrial Accident Board prepared the following, printed on cardboard, 12x20 inches: NOTICE TO EMPLOYÉS All workmen or operatives employed by the undersigned in or about this establishment are hereby notified that the employer or employers owning or operating the same have filed with the Industrial Accident Board, at Lansing, notice of election to become subject to the provisions of Act No. 10 of Public Acts, Extra Sessions 1912. (This Act is commonly known as the Workmen's Compensation Law.) You are further notified that unless you serve written notice on your employer of your election not to come under the law. the act will immediately apply to you. If you do notify your employer that you elect not to come under said act, you may afterwards waive such claim by a notice in writing, which shall take effect five days after it is delivered to the employer, at the expiration of which period the law will apply to you. Injury Not Resulting in Death-Notice of An employé who has been injured in the course of his employment and whose incapacity extends over a period of two weeks (sec. 3, part 2) shall serve written notice of such injury on his employer (from whom blank forms may be obtained), which notice shall be signed by the person injured and shall state in ordinary language the time, place and cause of the injury (sec. 16, part 2). Injury Resulting in Death-Notice of When death results from an injury received by an employé in the course of his employment, notice shall be served by his dependents, or by a person in their behalf (sec. 16, part. 2). Limit of Period of Notification. Notice of the injury shall be given to the employer within three months after the happening thereof, and claim for compensation shall be made within six months, or in case of death or in the event of physical or mental incapacity, notice shall be given within six months after the death or removal of such mental or physical incapacity. No proceeding for compensation under this Act shall be maintained unless these rules are observed (sec. 15, part 2). Date Employer. HON.COMP.-54 The Industrial Accident Board has prepared the following cer tificate, to be executed by the employer and filed with the Board, showing that such notices were actually posted as required by the section of the law above quoted. This certificate should be promptly filed with the Board, and the signature to the same is required to be that of the employer himself or if made by an officer or agent of a corporation, the appropriate designation of the official character of the person signing must accompany signature. CERTIFICATE Industrial Accident Board, Lansing, Mich. : day of We do hereby certify that on the most prominent places in and around our (insert workrooms, mines, stations, etc.) of our acceptance of the provisions of Act No. 10 of Public Acts Extra Session 1912, the same being notices furnished by the Industrial Accident Board; and we further certify that said notices were conspicuously posted and securely fastened. (state), (Name of Employer): (workman), You will take notice that according to the Workmen's Compensation Act of (claimant) hereby makes claim for compensation for injury (or gives notice of injury for which compensation will be claimed), received by (post office address), while in your (place). The accident occurred (place). The cause of the injury is as follows: gree of the injury is as follows: employ at (date), at The nature and de(and said injury resulted in death § 257. First report of accident Name of person furnishing information (month and day) 19—. or industry (yes or no). (4) Nature of business (city or town). (5) Location of plant or place where accident occurred (13) If not, what language (14) Did injured person make use of guards or safety devices (yes or no). (15) Was injury due to willful misconduct on part of employé (yes or no). (16) What was the occupation of the person injured (have in mind work done). (17) Length of experience here in this occupation occupation (19) Working days per week (20) Date of accident (18) Piece or day worker Wages per day M. (21) Day of week of day when injured began work (23) What was it (give the maker's name as well). (24) Could injured person start and stop the machine (25) How (26) Part causing the accident provided with safeguards (yes or no). properly attached at the time of the accident removed them (30) Describe the guard or safety device (31) How did the accident occur Elsewhere in this Per week (22) Hour (yes or no). (27) Was machine (28) Were safeguards (29) If not, who (32) What would you suggest to prevent similar accidents or no). (yes or no). Partial ble duration in days (38) Has the accident resulted in any permanent physical injury (39) Disability: Total (yes (yes or no). Proba |