Document jB5wQrV9gdx5mVro44Xxdwy2Q

`Form 45- A. 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 (Copy should be seat 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. Name_ AMERICAN- CVANAM10 COMPANY-------------------------------------------------- 2. Doing business under the name of:----------- SAME----------------------------------------------------------------------- 3. Address, Street and No. 4500 WEST 1 5TH STREET--------------------------City CHICAGO 4. Nature of Business: MANUFACTURER OF LEAD CHEMICALS--------------------------- 5. Name of compensation insurance carrier:----------------------------------------------------------------------------------------------------------- INJURED EMPLOYEE: .1 Name:-- LARRY THOMAS--------------------------------------------------------------------- 2. Address, Street and No.:_ 769 South Kp.nneth------------------------City--Chicago------- ----------- 3. Male__________ 4. Marital Status___________________________________ Marrled 5. Age:_2J___________ 6. Occupation____________________________________ Factory worker 7. Average Weekly Earnings:. $1 Q4.QQ___________ 8. No. of Children under 18 years of age:-------- ONE------------------------------------------------------------------------------------------------ INJURY: 1. Date of injury: 5/25/7-2------------------------------- 2. Hour:----- 2. ; 1 5 A . M----------------------------------------- 3. How did injury bnrpPn Sp II1 ed some acetic acid on top of new carbonate and dripped some on his thigh------- --------------------------------------------------------------------- 4. What was employee doing when accident occurred?.-- Ca rbona 11 ng -Wh 1 te--lead .----( Tend I ng--the (Describe briefly, such as loading truck, operating drill press, shoveling sand, etc.) ca rbona tor-*-)----------------------- --------------------------------------------------------------------------------------- 5. Name of machine, tool, substance, or object most closely connected with the accident:_____Ca rbonatOT (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__4500 West 15th Street----- , City-------Chicago, State____________ 111. 8. Describe injury (if specific loss, give date of loss)------- Acetic Add--bll m--OPI ml dd 1 e_3 rd_of_1 ef t ------- thigh--------------------------------------------------------------------------------------------------------------------- 9. Length of disability (if undetermined give estimate)------ HONE------------------------------------------------------------------------------------COMPENSATION IN NON-FATAL CASES: 1. Is compensation being paid?---------------------------------------------------------- --------------------------------------------------------------------------- 2. To whom?------- ---------------------------------------------------------------------- ------- --- ---------------------------------------------------------------------- 3. Rate of compensation:------------------------------------------------ Date of First Payment: 4. Intervals of payment:----------------------------------------------------------------------------------------------------------------- -----------------------------5. Are medical and hospital services being furnished?--------------------------------------------------------------------------------------- --------------- 6. By whom ?______________________________________________ __________________________________________________ ___ __ __ 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:--------------------------------------------- -------- 10. Signed:. R. Kj FELTER 11. Position: PLANT MANAGER------------------------- --