Texas pursuant to the law of Rhode Island of 1912, known as the Workmen's Compensation Act, by the employé who was injured in your service as hereinafter specified. (1) Said injury occurred on the... 19... .day of.. (2) The cause of said injury was as follows:.. (3) The nature of said injury was as follows:. (4) The name and address of the person injured was as follows: The foregoing form was prescribed by the Industrial Accident Board of Texas. See Part 2, § 4 (a). The notice must be given as soon as practicable after the injury. Part 2, § 4 (a). Name of employer or the association or company with which employer is insured. that I claim compensation from you under the Employers' Liability Act for personal injury sustained while in the employ of The place of injury was... State name or description of building, or place, where injury was sustained, The foregoing form was prescribed by the Industrial Accident Board. of Texas. The original claim should be filed with the Industrial Accident Board and may be sent by mail to the Board at Austin, Texas. At the same time of filing a copy should be served on the employer or on the insurance company which insures the compensation payments of the employer. The claim must be made within six months after the occurrence of the injury or in case of the death of the employé or his physical or mental incapacity within six months after death or the removal of such physical or mental incapacity. Part 2, § 4 (a). If it is contended that the injury was caused by the violation by the employer of any statute enacted for the safety of employés the facts should be stated in the foregoing notice. The cause of my injury was. West Virginia Describe cause of injury. The nature of my injury is as follows:... Describe injury with such exactness as possible. Signature of injured employé. Street and number. City or town. Date of making this claim. WASHINGTON Claims for compensation against the State Fund must be made on blanks furnished by the Department. See § 12. WEST VIRGINIA The application for compensation must be made on forms prescribed by the Department to the State Insurance Fund. See § 39. Wisconsin WISCONSIN FORM Notice to employer of claim for injury under Workmen's (§ 2394-11) To... Write name of employer plainly on above line. Write address of employer plainly on above line. You will take notice that according to the provisions of the Workmen's Compensation Act, Laws of Wisconsin..... 1 This notice should be filled out by injured employé or some one in his behalf. In case of death of the employé the notice is to be filled out by the dependent. The notice should be served within 30 days of accident on the employer by delivering a copy of the above notice to the employer personally or by registered mail. Fill out in duplicate. Hand or mail one copy to the employer; mail the other copy to the Industrial Commission, Madison, Wis. The foregoing is a note to the blank as furnished by the Industrial Commission. The notice must be served within thirty days after the accident unless excused as provided in § 2394–11. A workman employed to assist in unloading bridge iron had his ankle bruised by a falling beam. He did not claim compensation until four months later when he claimed permanent disability for six weeks. The employer, being a municipal corporation, defended the claim on the ground, among others, that it was not made within thirty days. The Commission held that the delay in making the claim was not because the workman intended to defraud and mislead and that the employer had not in fact been misled and compensation was granted in the amount of $33.14 for six weeks' disability. Thomas J. Brown v. City of Mauston, Wis. Indus. Com., Feb. 29, 1912. |