Illinois FORM NO. 41 Notice of Claim for Partial Permanent Disability after Return to Work To The Industrial Board, Chicago, Illinois. Take notice, that the undersigned, an employé in the service of an employer engaged in this business of...... . Illinois, was accidentally injured in the course of such employment, on the. at. .at. ...day of .of said employer, 19.., at the.... and the nature of the injury is.. on account of which the undersigned employé is partially though permanently incapacitated from pursuing his usual and customary line of employment; that on the... ... day of 19., the undersigned employé returned to the employment of said employer.. he was injured as aforesaid. in whose service Further take notice, that the undersigned employé hereby makes formal claim for compensation against said employer. on account of said accidental injury, of... weeks day, 19.., and the Industrial Board is hereby requested to immediately send a copy of this notice by registered mail to said employer. . . . .at. as provided. by Section 8 (d) of the Workmen's Compensation Act, Laws of Illinois 1913, page 335. Dated... 19... (Employé) P. O. Address. . Illinois FORM NO. 42 Received of. the sum of... and... Settlement Receipt (Name of employer.) ...dollars .cents, making in all, with weekly payments already received by me, the total sum of.. .dollars .cents, in settlement of compensation under the Illinois Workmen's Compensation Law, for all injuries received by me on or about the... day of. 19., Illinois Workmen's Compensation Act, subject to review by the Industrial Board, said accident occurring on the.. Illinois FORM NO. 44 General Release in the County of.. KNOW ALL MEN BY THESE PRESENTS, That I,. of... of Illinois have received of the.. the sum of... in the State DOLLARS ($..... ...) in full payment, satisfaction, compensation and indemnity, for all injuries, loss or damage by me sustained or suffered, in mind, body or estate, having especial reference to the injuries hereinafter described, but hereby expressly including all other loss, incapacities or injuries by me suffered, claimed to have been occasioned by an accident which occurred on the... day of...... ..A. D. 19.. at..... (Where accident occurred.) .in the County of. in the town of.......... and by which I was otherwise hurt and injured. ..and And in consideration of the prompt payment of said sum of money and the further consideration of the compromise and settlement, without suit or proceedings of any kind, of my claim, by me made against said... I, the said.... for myself, my heirs, executors and administrators, do hereby forever release and hold harmless the said... of and from any and all rights of action, claims of compensation for disability, incapacity, disfigurement, and medical, surgical and hospital service and expense in connection with said injury, and all other claims, demands or liability in any way arising out of, or which in any manner hereafter may arise out of or result from, said accident for injuries occasioned, loss of time, loss of service, loss of property, loss of earning capacity, moneys expended, or liability incurred, and any and all claims, demands or liability, of whatever nature, for or on account of any act or thing done or omitted to be done by said... officers, agents, servants or employés, or any one of them, in its behalt; including all claims or demands due or which may or might Illinois become due under the Workmen's Compensation Act, 1913. (Laws Ill., 1913, p. 335.) I further represent and covenant that at the time of receiving said payment and signing and sealing this Release, I am of lawful age and legally competent to execute it, and that before signing and sealing the same, I have fully informed myself of its contents and executed it with full knowledge thereof, including the knowledge that I sign away all right to begin any suit, proceeding or action arising by reason of injuries sustained in said accident, whether such injuries exist now or shall develop hereafter. Witness my hand and seal this... .. A. D. 19... WITNESSES: .day of.... .[SEAL] person who executed the within Release, and acknowledged the same to be his free act and deed; and I certify that before the execution thereof, the foregoing Release was read over and fully explained to the same person by me, and that he declared before execution thereof that he fully understood the same. Notary Public. TRANSLATION CERTIFICATE I,... do hereby certify that I have translated the foregoing Release from the English to the ..language, to the within named... and that he signed the same with a full understanding of its contents and legal effect. Iowa FORM NO. 46 Report of Permanent Disability STATE OF ILLINOIS-INDUSTRIAL BOARD The undersigned hereby reports accidental injury in which permanent disability has resulted to the employé as follows: Occupation when injured (machinist, carpenter, laborer, etc.).. If non-fatal, the length of disability:. Permanent disability of employé resulted or will result on....19.. Attending physician, surgeon or hospital. Has compensation been paid?.. Amount paid. Amount.... Date of report.. . By whom. To whom. Made out by. IOWA The administration of the Iowa Act is under the supervision of a single officer known as the Iowa Industrial Commissioner who may appoint necessary assistants. Part II, |