Document dQ71kQp6zNeMBjmgx4ME1VZQ

Forrn 45A. D. WILES CO.. Indianapolis W. C. Forms for All States STATE OF ILLINOIS INDUSTRIAL COMMISSION 160 No. LaSalle St., Chicago 1,11L EMPLOYER'S REPORT OF COMPENSABLE INJURY -9.11C 813325 (Copy should be sent immediately to Insurance Carrier) Accident Number Employers must report to the Commission on Form 45 between the 15th and 25th of EACH MONTH all compensable injuries. In case of DEATH report IMMEDIATELY. EMPLOYER; ., ,, ,, 1. American Cvanamid Company^ Successor to MacGregor Lead Company 2. Doing business under the name of:--------- S-afflO----------------------------------------------------------------------------------------------------- 3. Address, Street and NoASQQ W 1 St h Street--------------------------------- City,JLhJ-C-SigO 4. Nature Of Business: Lead Chemical Manufacturer------------------------------------------------------------------------- 5. Name of compensation insurance carrier:-------------------------------------------------------------------------------------------------------------- INJURED EMPLOYEE: 1. Name:____Saw _J_atjs---------------------------------------- ....... ...................................................................................................... 2. Address, Street and No.:--3503--CaTrol l--AV-S-.-------------------------------- City------------ Chi CagO-------------------- 3. Sex:Ma 1 e. 4. Marital StatusMarried __________________________________________________ 5, Age:-L?______ _ 6. Occupation.. Packer 7. Average Weekly Earnings:------- 1-7-3-* 60------------------------------------------------------------------------------------------------------------ 8. No. of Children under 18 years of age:------------------------------------------------------------------------------------------------------------------ INJURY: 1. Date of injury:_ .lamia ry ?R ,--192------------ 2. Hour.-. Morning 3. How did injury happen:Wh 11 e _re_pjd ring ,, Nor_-Jjp packer 4. What was employee doing when accident occurred?------R.epa Lt* ? HQ--MOT- B1 Q_packer (bagrOOm) (Describe briefly, such as loading truck, operating drill press, shoveling sand, etc.) 5. Name of machine, tool, substance, or object most closely connected with the accident: Nor-Rlo packer (Name the machine, tool, appliance, gas, liquid, etc., involved) 6. If machine or vehicle, what part of it?-------------------------------------------------------------------------------------------------------------------(State if gears, pulley, point of operation, etc.) 7. Where: Street and No. k5QQ- W. . L5-th-Sf eet_____, City.-hi.C.a.gO, State 111. 8. Describe injury (if specific loss, give date of loss) 1* **0.? tfo. IJr?----- ; Z 3 j* ^ degree OH indeg, mdle, ring, and little fingers of both hands._____________________ 9. Length of disability (if undetermined give estimate)--5--tQ--6... MQ8 RS COMPENSATION IN NON-FATAL CASES: 1. Is compensation being paid?----------- Y-O-S------------------------------------------------------------------------------------- _______ 2. To whom?Sam-late-------------------------------------------------------------------------------------------------------------------------3. Rate of compensation:___92.50/yyk.____________ _Date of First Payment:__________ __________________________ 4. Intervals of paymenj:---------Weekly-------------------------------------------------------------------- -------------------- ------------------------- 5. Are medical and hospital services being furnished?--------_____________________________________________ __ 6. pywLnm? Clearing Industr1al_C.iln?c COMPENSATION IN FATAL CASES: 1. Has compensation been paid?--------------------------------------------------_-------------------------------------------------------------------- 2. To whom?---------------------------------------------------------------------- ------- ... 3. State relationship to deceased:------------------------------------- --___ __ ___ 4. Rate of compensation:.------------------------------------------------Date of First Payment: 5. Intervals of payment:---------------------------------------------------- --__ 6. Length of disability prior to death:------------------------------------------------------------------------------------------------------------------------ 7. Have funeral and burial expenses been paid?___ 8. By whom?---------------------------------------------- ----------------------------------------------- __------------- , 9. Date of this report: 1372-(dup. ) 10` SiSned:-------------------------------------------------------------------ll. Position:--5La-ot- -Mana.ge r----------- :------------------