Document k9dbjkyYEN25B9Xooowpa79YE

Form 45A. D. WILES CO.. Indianapolis W. C. Forms for All States STATE OF ILLINOIS - -r .* INDUSTRIAL COMMISSION 160 No. LaSalle St., Chicago 1,11L EMPLOYER'S REPORT OF COMPENSABLE INJURY (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. NameAmerican Cy^namirl Company , t-n 2. Doing business under the name of:-----MacGregor--Lflfld--Company---------------------------------- 3. Address, Street and No.____4500 W.I 5th-Street-------------------------- City--Chicago 4. Nature of Business:-----------.------------- lead manufac tur-or---------------------- -------------------------- 5. Name of compensation insurance carrier:---------------- HWt-------------------------------------------------------------------------------------- INJURED EMPLOYEE: 1. Name:------------Erv i ne-G i v&n-s----------------------------------------------------------------------------------------------------------------- 2. Address, Street and No.:______757 S. Kolmar--------------------------------------City Chicago 3. Sex _______________ male---------------------------------- 4. Marital Status Married 5. Age:?7 ___________________ 6. Qcrnpatinn Ball Mill Operator 7. Average Weekly Earnings:------------------------------------------------------------------------------------------------------------------------------- -- 8. No. of Children under 18 years of age:_----------------------------------------------------------------------------- --------------____------- INJURY: 1. Date of injury:------October--23 >--197-3------------- 2. Hour:----------------- 1 1 ; 30 PM----------------------------------- 3. How did injury happen:____while Loading, cut lead on elevator to ball mill, he dropped a small piece on his finger. 4. What was employee doing when accident occurred?--I Qaditlg--CUt--1 8,ad_On elevator (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: (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--kL--1 5th--St ---------------------- , City___ Ch I CS0O, State_Ll_l_L 8. Describe injury (if specific loss, give date of loss) CofttU-S Lon -Of distal phalanx of right middle* fingpr with format ion of basal anhungai hpmatnma. 9. Length of disability (if undetermined give estimate)--HOPS----------------------------------------------------------- -------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:___October--2l --1 972 10. Signed:________________________ 11. Potion- Plant Manager