(40) Attending physicians: (Name) (Address) (41) Dependents (give name of dependents in fatal cases only): Avers Occupation when injured (machinist, carpenter, laborer, etc.) Date injured had to leave work on account of injury Describe in full how injury was sustained. State exactly part of person injured and extent of injury IF INJURED HAS RECOVERED, FILL IN BELOW Give exact date injured employé was physically able to return to work Give the actual number of working days injured was absent from work. Na of days Any permanent injury, describe fully Payments of compensation $ Payments for physicians $ No. of weeks Other medical ic Did your insurance carrier make any payments in this case? Date of death IF INJURY WAS FATAL, FILL IN BELOW Payments for burial expenses dependents, state relationship of each Made out by (Another Form) EMPLOYER'S FIRST REPORT OF INJURY Employer's name Office address county). (street and number, city or town and Business, goods produced, work done or kind of trade or transportation Location of plant or place of work where accident occurred Employer, County 19-; hour of day (A. M. If away from the Was employé injured in course of Did accident happen on premises? employment? If employé did not leave work on day of injury, on what day did incapacity begin? Give full name of injured employé (street and number, city or town and county). Speak English? Address The Sex Age Cause of Medical If not, what Married or single? If not, Was injured employé doing his regular work? Describe in full how the accident occurred State nature and extent of injury. (If amputation was necessary, state what part was amputated). Name of machine, tool, appliance, etc., in connection with which accident occurred? Hand feed or mechanical? Part of machine on which accident occurred? What guard, safety appliance or regulation in connection with Was medical attendance provided by you? Name and address of physician To what hospital was employé sent? Attendance If not sent to hospital, where is he? (give your Wages Notice of Signed, this How many working days per week? Hours per day? Wages per day at time of accident? Were you notified by the injured employé of his injury? Did you or your managing superintendent in charge of the work Employé's name ———. Date of injury When was injured employé physically able to return to work? The actual number of working days injured was absent from work Number of days employed per week as before the injury? Any permanent injury, describe fully aid $ Amounts of compensation paid $ Can injured do the same werk Hospital or other medial No. of compensation weeks Remarks concerning your method of computing rate of compensati Date of death IF INJURY WAS FATAL FILL IN BELOW If deceased left dependents, give relationship of each. § 259. Agreements We, and AGREEMENT IN REGARD TO COMPENSATION (name of injured employé), residing at city (or town) of (employer or insurer), have reached an agreement in regard to compensation for the injury sustained by said employé while in the employ This agreement conforms to the provisions of the Workmen's Compensation Act, and is a claim for compensation. It is agreed that the average weekly wages of the said employé, computed according to the terms of the Workmen's Compensation Act are $- - and that the said will pay said employé 50 per cent. of said sum within the minimum and maximum of the statute or $ per week, beginning We, ber), Insurance Carrier. (name of injured employe), residing at (P. O.), and (street and num(name of employer), have reached an agreement in regard to compensation for the injury sustained by said employé, and submit the following statement of facts relative thereto : *NOTE.-Here add appropriate words to indicate length of disability, if permanent partial, permanent total, temporary partial, or temporary total, if known; if not, add "During Disability." If death claim, add words to indicate nature of dependency and length of time during which payments are to be made. If amputations or within schedule of injury, add words to indicate statutory period. 4. Employé's average weekly wage at time of injury: $ 5. Permanent total or partial disability (If injury has caused a permanent disability, give accurate description of same.) 6. Terms of agreement as to compensation: $ (No. of weeks) beginning 7. 19-. per week for (If disability has not ended at time this agreement is filed, give estimate as to probable date employé will be able to resume work.) 8. The compensation agreed upon herein, as above set forth, is in an amont equal to or greater than is provided for by the Workmen's Compensa tion Act. 9. Said employer has furnished for said employé all medical services, etc. required by law that is reasonably necessary in the treatment of said injury, and in the amount or value as shown below: Date of injury Company. (Employer By (Employ Emploré The injury arose out of and in course of the employment, the employé Li the time being engaged as follows Employer and employé were both under the Compensation Act t the time of injury. If either party filed a rejection state when withdrawn Dismemberment Disability or partial.) (If so state what member or what part of member) (State whether temporary or permanent and whether tital |