Employee's Claim for Compensation 49 9. Piece or time worker full time Employer 1. Employer Slawson & Hobbs 2. Office address: Street and No. 162 W 72St City or Town NY 3. Nature of business Real estate Place and Time 1. Location of place where accident occurred 50 304 W 75 St NYC 2. Name of Foreman Mr. Cooper 3. Date of accident, the 19 day of October, 1935, at 10:25 o'clock P. M. The Accident 1. How did the accident happen? A car parked in front of door and blocked entrance. I requested the driver to move from front of door. He got out and struck me with some instrument over right eye. Nature and Extent of Injury 1. State fully nature of injury about 1 1/2 inch of a cut over my right eye 2. On what date did you stop work because of injury? Oct. 19th, 1935 3. Have you returned to work (Yes or No) yes If "Yes," on what date Nov. 9th, 1935 4. Does injury keep you from work? not now (Yes or No) 51 52 53 54 Employee's Claim for Compensation 5. Have you done any work during period of disability? no 6. Have you received any wages since your accident? since Nov 9 If so, from and to what date? from Nov 9th 1935 7. Has injury resulted in amputation? no If so, describe same... 8. Did you request your employer to provide medical attendance? Yes Has he done so? Yes 9. Attending physician (Name) Dr. M. L. Janos (Address) 48 W 74 St NYC 10. Hospital (Name)...--------------- (Address) .----------- Notice 1. Have you given your employer notice of injury? (Yes or No) yes When? Oct 19th 1935 2. If such notice was given, to whom? Mr. Cooper 3. Was it given orally or in writing? orally I hereby present my claim to the Industrial Commissioner for compensation for disability resulting from an accident arising out of and in the course of my employment and not occasioned by my willful intention or solely through intoxication, and in support of it, I make the foregoing statement of facts. Dated, November 20th, 1935. Signed by CHRISTOPHER HANIFY (Claimant) Mail address 230 W 99 St New York Employer's First Report of Injury. STATE OF NEW YORK DEPARTMENT OF LABOR DIVISION OF WORKMEN'S COMPENSATION Send notice on this form to Dept. of Labor at address on reverse side. And to Employer 1. Name of Employer West End Ave & 75th St. Corp. Slawson & Hobbs, Agents 2. Office address: No. and St. 162 W. 72 City or Town N. Y. State N. Y. 3. Insured by Travelers 4. Give nature of business (or article manufactured) Time and Place 5. (a) Location of plant or place where accident occurred Department premises State if employer's (a) If injured in a mine, did accident occur on surface, underground, shaft, drift or mill 6. Date of Injury Oct. 19th 1935 Day of week Saturday Hour of day.......A. M. 10:30 P. M. 7. Date disability began Oct/19th 1935 A. M. 10:30 P. M. 8. Was injured paid in full for this day.......... 9. When did you or foreman first know of injury Immediately 55 56 57 58 59 Employer's First Report of Injury 10. Name of foreman J. Douglas Cooper Injured Person 11. Name of Injured (First Name) Christopher (Middle Initial)...... (Last Name) Hanify 12. Address: No. and St. 230 W. 99 City or 13. Check (V) Married......, Single x, Widowed 14. Nationality Irish American Speak English 15. Age 29 Did you have on file employment certificate or permit 16. (a) Occupation when injured Doorman (b) Was this his or her regular occupation Yes (If not, state in what department or branch of work regularly employed) 17. (a) How long employed by you.... (b) time worker........ 60 $80. 18. (a) No. hours Wages per day $2.67 week....... ings $------------- (c) Wages per month worked per day 6. (b) (c) No. days worked per (d) Average weekly earn(e) If board, lodging, fuel or other advantages were furnished in addition to wages, give estimated value per day, week or month Cause of Injury 19. Machine, tool or thing causing injury........ Employer's First Report of Injury 20. Kind of power (hand, foot, electrical, steam, etc.) 21. Part of machine on which accident occurred 22. (a) Was safety appliance or regulation provided...... (b) Was it in use at time 23. Was accident caused by injured's failure to use or observe safety appliance or regulation 24. Describe fully how accident occurred, and state what employee was doing when injured Doorman asked party who parked car in front of door to move. Car owner became abusive and struck doorman about right eye with some sharp weapon, inflicting a deep cut over eye, requiring medical aid. Patrick 25. Names and addresses of witnesses Little, 565 West 125th St. Pete Butler, 612 W. 137 St. J. D. Cooper, 304 W. 75th St. Nature of Injury. 26. Nature and location of injury (describe fully exact location of amputations or fractures, right or left) 27. Probably length of disability 28. Has injured returned to work Yes If so, date and hour 11/9/35 At what wage $80 mo. At what occupation Same 29. Did you provide medical attention Yes When Immediately 61 62 63 |