and the cause of said injury was as follows:. If the injury caused death, so state. Notice of said injury (or death) is hereby given pursuant to the statute known as the Workmen's Compensation Act of the State of Nebraska. Dated the. ...day of.... 191 (Signature and address of person injured or of a person in his behalf or in the event of his death, by his legal representative or a person in his behalf.) NEVADA The application for compensation must be filed with the Department within one year after the day upon which the injury occurred, or the right to compensation accrued. § 34 (d). Blanks are furnished by the Department for all applications for compensation against the said fund. (and said injuries resulted in death on the... .day of 1 The above notice should be given as soon as practicable after the happening of the accident and before the workman voluntarily leaves the employment in which he was engaged when the injury occurred and during his disability. § 5. The claim for compensation should be made within six months from the occurrence of the accident but may be made at a later date under certain circumstances specified in the statute. It may be served personally or by registered mail. § 5. New Jersey 19.) and claim is hereby made for compensation by reason of said injury (death) pursuant to the Act of the Legislature of New Hampshire known as the Workmen's Compensation You are hereby notified that a personal injury was received by (name of employé injured), who was in your employ at (place) while engaged as (nature of employment), on or about the ( day of ( ), nineteen hundred and ( ) ), and 1 The foregoing form is set forth in the statute itself. § 2, subd. 16. The notice should be given within fourteen days of the occurrence of the injury, but may be given at a later date as specified in the statute. § 2, subd. 15. The notice may be served personally on the employer or upon any agent of the employer upon whom a summons may be served in a civil action or by sending through the mail. Sec. § 2, subd. 16. A workman who was carrying a heavy article fell on June 24, 1912, and the foreman in charge of the work had knowledge of the fall. Disability did not result, however, and the man continued at work. On February 4, 1913, he sent notice to his employer of disability alleged to have been the result of the fall. It was held that inasmuch as the foreman had knowledge of the injury the notice was sufficient under the statute, but compensation was denied on the ground that the disability was not due to any injury received from the fall. Bergemann v. Schwarzenbach Huber & Co. (Morris Common Pleas), 36 N. J. Law J., 209. To the Workmen's Compensation Commission, Albany, N. Y. Notice is hereby given, pursuant to the Workmen's Compensation Law of New York of the injury (and death) of an employé of... .on the date, at the place and under the circumstances hereinafter stated. (1) The name and address of said employé is. (2) He was injured on the. .day of. 19. (and said injury resulted in his death on the. (3) The nature of said injury was as follows:.. (4) The cause of said injury was as follows:. 1 The above notice must be given to the Commission and to the employer within ten days "after disability" and in case of death of the employé resulting from such injury within thirty days after such death. The notice may be given by any person claiming to be entitled to compensation or by someone in his behalf. It may be sent to the Commission by registered mail. It must be served on the employer by delivering it to him personally or by sending it by registered mail addressed to the employer at his or its last known place of residence, but if the employer is a partnership the notice may be given to any one of the partners, and if the employer is a corporation it may be given to any agent or officers thereof upon whom legal process may be served, or to any agent in charge of the business in the place where the injury occurred. "The failure to Ohio OHIO The Act provides that the Industrial Commission shall prescribe the notices and the forms thereof which shall be given in all cases of accident, etc. § 1465-44; § 8 of Act of 1911, which remains unrepealed by the Act of 1913. By § 1465-74 of the Act as renumbered and which is § 27 of the Act of 1913, it is provided that in cases where the employer carries his own risks that the Industrial Commission shall prescribe the notices to be given. By Rule 13 of the Rules of the Industrial Commission relating to the ascertainment of the amount of compensation, etc., it is provided: "The Commission will prepare and furnish free of charge all proper forms required by these rules and the provisions of the Compensation Act and require such forms to be used in all instances where prescribed."1 give such notice, unless excused by the Commission, either on the ground that notice for some sufficient reason could not have been given, or on the ground that the State Fund, insurance company, or employer, as the case may be, has not been prejudiced thereby, shall be a bar to any claim under this chapter." § 18. By Rules 4 and 5 of the State Liability Board of Awards (now Industrial Commission) it was provided as follows: "Rule 4.-Injury not resulting in death, notice of. An employé who has been injured in the course of his employment and who contemplates filing an application for an award, shall, within one week from receiving such injury, notify or cause notice to be given the Board of the time, place and nature of his injury and the name of his employer. Forms of such notices can be obtained from the employer. Such notices should be mailed to 'State Liability Board of Awards, Columbus, Ohio.' "Upon receiving such notice the Board forthwith will mail to the injured employé proper forms and blanks for his use in perfecting his claim, and notify the employer thereof. Unless such notice is given, no application for an award will be considered by the Board." "Rule 5.-Injury resulting in death, notice of. When death results from an injury received by an employé in the course of his employment, the provisions of Rule 4 shall apply, except that notice of death must be given by the attending physician, undertaker, employer, executor, administrator, or a beneficiary, within one week from the time of death." Rhode Island By Rule 9 of the Industrial Commission it is provided that if the employer and employé, or dependents, fail to arrive at an agreement as to the amount of compensation payable, within thirty days after the injury or death, one party may file an application with the Commission to have the question determined, of which application the other party shall receive notice.1 OREGON Claim for compensation must be made on blanks furnished by the commission and the form of said blanks is entirely within the jurisdiction of the commission. To.... RHODE ISLAND FORM Notice of injury 2 (Art. 2, §§ 17, 18, 19, and 20) Name and address of employer. Please take notice that a claim for compensation is hereby made 1 In a case of the death of a workman leaving a widow and minor child, it was held not necessary for the application for compensation to be filed by the administrator or executor of the deceased; that the minor child being under disability of infancy and in the custody of her mother that part of the compensation apportioned to such child would be made payable to the mother for the use of the child. Re Laura M. Shaffer, Claim No. 41, Ohio St. Lia. Bd. Awd., June 14, 1912. The notice must be given within thirty days after the happening of the injury and the claim for compensation must be made within one year after the injury, or in case of death of the employé, or his physical or mental incapacity, within one year after death or the removal of such physical or mental incapacity. Art. II, § 17. The notice must be signed by the person injured or by a person in his behalf or in the event of his death, the legal representative or by a dependent or by a person in behalf of either. Art. II, § 18. The notice must be served by mail as stated in Art. II, § 19. Notice may be dispensed with in certain instances. See |