MACHINERY. 30. Was accident caused by fault of machines or devices?_. 31. Name of machine, device, etc., causing accident?______ Condition? 32. Were all safeguards in their 34. Name of manager of said plant__‒‒‒‒‒‒‒‒‒Address__. 35. Name of foreman or superintendent in charge of the department in which injury was sustained------Address___ 36. Names of three witnesses who witnessed the accident: 37. Have you previously received any compensation from the State Insurance Fund?______ If so, when and how much?__ 38. Do you carry any accident insurance?______ If so, how much and in what companies?‒‒‒‒‒ 39. Are you a mem ber of any lodge?______ If so, what lodge or lodges? Witness: (Signed) State of Ohio, day of OATH. Before me, a notary public, in and for said county, on this---. 191--, personally appeared‒‒‒‒‒ the above named claimant, who, being first duly sworn, declared that the facts set forth in the foregoing application are true. (Seal.) My commission expires--- Notary Public. (Following oath to be made by person representing claimant because of the latter's disability and consequent inability to make application in person.) State of Ohio, OATH. County, ss: Before me, a notary public in and for said county, on this----. day of 19, personally appeared---. representing the above named claimant, who first being duly sworn, declared that the above named claimant, is physically unable to make this application in person and that he therefore acts in this representative capacity by authority----and he further declared that the facts set forth in the foregoing application are true. (Seal.) Notary Public. My commission expires--- $ 200. Form of employer's certificate and oath. (b)14 State Liability Board of Awards, Columbus, Ohio. Married, single, or divorced?_______. Wife or husband living? --- 5. What weekly wage was he receiving at time of injury?---6. How long had he been receiving such wages?-------- 7. What work was he engaged in when injured?__‒‒‒‒‒‒‒‒ 8. How long had he been doing this work?_____. 9. Was this his regular employment?-------- If not, what was his regular employment? 10. Was he skilled in the labor - being performed when injury happened?______ 11. When did 13. What statement, if any, has injured person made?‒‒‒‒‒‒‒ 15. Did permanent disability ensue immediately after injury was sustained?______ If not, when did permanent disability ensue? 16. Did injured person return to work before permanent disability ensued?______ When?‒‒‒‒‒‒‒‒‒‒ How long did he work?_____ At what weekly wage?------- - 181 17. What impairment of earning capacity resulted from injury and lasted through period last mentioned? Answer: He was able to earn ------ per cent., and no more, of his former wage. This statement is based upon his actual disability. 18. Give accurate description of injury----- 19. Where was injured person taken after accident? (If to a hospital give name and address) ___. 20. Who furnished medicines? Address 14 All the questions in this blank form must be answered, or if any question can not be answered, reason for not answering must be given. This requirement must be complied with. Otherwise, the blank will be returned for correction. While all the information asked for may not be necessary to make up full proof in every instance, yet it is necessary for other requirements of this department. Fill out blank in ink, using pen or typewriter. 24. Give full details as to how accident happened____. 25. Was accident caused by fault of fellow workman?. 26. Did accident happen on the premises, or at the plant, or in the course of employment, or away from plant?---------- 27. If away from the plant, state when, how and by whom injured? 28. Was injured person acting under direction of a superintendent? 29. Names and addresses of witnesses: 30. Was accident caused by fault of machines or devices?____. 31. Name of machine, device, etc., causing accident?______ Condition? 32. Were all safeguards in their places at time of accident?_. 34. Manager of said plant------ 33. If any safeguard was re Address 35. Foreman or superintendent in charge of department where de Before me, a notary public in and for said county, on the----- 191_-, personally appeared‒‒‒‒ day of who, first being duly sworn, declared that the facts set forth in the foregoing certificate, to which he has signed his name in my presence, are true. (Seal.) Notary Public. My commission expires--- § 201. Form of physician's fee bill. (c) The following is an itemized account of professional services rendered in connection with the treatment of injury to-‒‒‒ (Items should be written out fully. Do not abbreviate.) OATH. (Signature of Affiant.) State of Ohio, County, ss: being first duly cautioned and sworn, says that he treated the injury to the above named person and that his services were required and furnished on account of the purpose above mentioned, and the same were necessary therefor, and that the charges are reasonable and not more than the charges for like services in other instances. Sworn to before me and subscribed in my presence, this---- § 202. Form of druggist's cost bill. (d) The following is an itemized account of medicines furnished and services rendered in connection with the treatment of injury to together with charges of (Items should be written out fully. Do not abbreviate.) (Signature of Affiant.) being first duly cautioned and sworn, says that the above articles or services were required and furnished on account of the purpose above mentioned, and the same were necessary therefor, and that the charges are reasonable and not more than he charges for like services in other instances. Sworn to before me and subscribed in my presence, this-----day of 191__. Notary Public. (Seal.) My commission expires-- 203. Form of medical fee bill and hospital charges. (e) The following is an itemized account of medicines furnished and services rendered in connection with the treatment of injury to (Items should be written out fully. Do not abbreviate.) ises; that the above articles or services were required and furnished on account of the purpose above mentioned, and the same were necessary therefor, and that the charges are reasonable and not more than is charged by affiant for like services in other instances. Sworn to before me and subscribed in my presence, this-----day of.. 191__. (Seal.) 32-BOYD W C Notary Public. My commission expires--‒‒‒ |