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Forms illustrative of methods pursued by State boards without waiting for injured employee to institute proceedings to recover compensation.

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CALIFORNIA.

DEAR SIR: The industrial accident board is informed that an accident happened at on or about in the course of his employment by you. for less than one week, it is necessary to notify this

If the employee was disabled board at once.

If the disablement lasted for one week or more, it is necessary to make formal report on the inclosed blanks.

A copy of the law relating to this matter is inclosed.

Very truly, yours,

INDUSTRIAL ACCIDENT BOARD.

Statistician.

Inclosures.

DEAR SIR: We understand that you were injured in an accident on or about....

This board is required by law to get records of all industrial accidents. We desire to have you answer the following questions:

I. What is the name and address of the person or firm for whom you were working at the time you were hurt?

II. Were you laid up for one week or longer?
Very truly, yours,

INDUSTRIAL ACCIDENT BOARD,

Statistician.

who was injured

in reference to an accident to and inclosed

DEAR SIR: We wrote you on blanks to be filled in and returned to this office, informing you at the same time that all accidents which cause disability of more than seven days must be reported to this board.

To date we have received no report. It is necessary that you give this matter your prompt attention, inasmuch as failure to report to this board constitutes a misde

meanor.

Very truly, yours,

INDUSTRIAL ACCIDENT BOARD,

Statistician.

jured

nor have

you

DEAR SIR: It is again necessary for us to call your attention to the fact that you have not yet reported the accident to who was innotified us that this accident caused a disaand again on urging upon you the necessity of reporting to this board. Failure to report as requested constitutes a misdemeanor. Blanks were inclosed with our first letter.

bility of less than seven days.

We wrote you on

Very truly, yours,

INDUSTRIAL ACCIDENT BOARD,

Statistician.

DEAR SIR: Supplemental or final report is due this office in the case of

for the filing of such report has expired.

injured on

Yours, very truly,

The legal limit (60 days)

INDUSTRIAL ACCIDENT Board.

4A. FORMS-RECEIPTS FOR COMPENSATION PAYMENTS.

Illustrative of methods pursued by State boards in the filing of receipts showing that amount of compensation has actually been paid.

MICHIGAN.

SETTLEMENT RECEIPT.

Received of....

(Name of employer, insurance company, or commissioner of insurance.)

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..cents, in settlement

of compensation under the Michigan workmen's compensation law, for all injuries

received by me on or about the...

.day of..

191...,

while in the employ of.

(Name of employer, city or town, street and number.)

subject to review and approval by the industrial accident board.

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If the employer or the insurance company carrying such risk, or commissioner of insurance, as the case may be, and the injured employee reach an agreement in regard to compensation under this act, a memorandum of such agreement shall be filed with the industrial accident board, and, if approved by it, shall be deemed final and binding upon the parties thereto. Such agreement shall be approved by said board only when the terms conform to the provisions of this act.-(Sec. 5, Part III.)

Form No. 11-7-13-50,000.

Received of..

RECEIPT ON ACCOUNT OF COMPENSATION.

(Name of employer, insurance company, or commissioner of insurance.)

.dollars and...

.the sum of

..cents

being the proportion of my weekly wages from the......................day of......

to the....

..day of...

..191..., .191..., under the Michigan workmen's

compensation law, subject to review by the industrial accident board, said accident

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If the employer or the insurance company carrying such risk, or commissioner of insurance, as the case may be, and the injured employee reach an agreement in regard to compensation under this act, a memorandum of such agreement shall be filed with the industrial accident board, and, if approved by it, shall be deemed final and binding upon the parties thereto. Such agreement shall be approved by said board only when the terms conform to the provisions of this act.-(Sec. 5, Part III.)

MASSACHUSETTS.

Form No. 15.

Every agreement in regard to compensation under this act is subject to approval by the industrial accident board and a memorandum of the same must be filed with the board, whether said agreement is written or oral, and whether it is made by one or both parties, or in the form of a receipt. Any weekly payment or settlement under the act, whether purporting to be final or otherwise, may be reviewed by the board. Section 20, Part II, and sections 4 and 12, Part III, chapter 751 of the acts of 1911, and amendments thereto, and rule No. 6 adopted by the board.

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dollars and..

...cents, in settlement of compensation under the Massachusetts

workmen's compensation act, for all injuries received by me on or about the...............

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First. That a permanent advisory medical committee is necessary. Second. That we consider it inexpedient to have a medical man as a member of the industrial accident board.

Third. That the industrial accident board should have a consulting surgeon upon whom should fall the duty of detail work in preparation of matters to be laid before the advisory committee. Matters in dispute regarding services and fees of physicians should be referred to this committee for recommendation.

Fourth. That insurance companies be requested to provide suitable blanks for notifications as well as specifications of services rendered by physicians.

Fifth. That industrial insurance companies be encouraged to allow all reputable physicians to render services in industrial accidents, provided they are willing to render such services upon reasonable basis.

Sixth. That the accident board should make arrangements with which the insurance companies should cooperate, that any physician whose bill is in dispute may appear before a representative of the accident board within a reasonable distance of his home.

Seventh. That the accident board shall provide for medical referees by districts.

Eighth. That fees paid by the companies should not be less than the average minimum fee in the locality in which the service is rendered. Ninth. That charges up to $50 for major operations are not excessive.

Tenth. That physicians appearing at hearings before the board shall receive the compensation as provided for under section 8, part 3, of the act.

Eleventh. That services rendered by lodge physicians be paid for, provided it is not inconsistent with the rules of the order.

Twelfth. That specialists, established and recognized by the profession as such, may receive special rates for their work, provided the case requires special skill.

Thirteenth. That the ruling previously made by the accident board, that "fees should not be charged an injured party whose employer was insured larger than the injured party would be charged were he not insured," should be interpreted to mean that in a given accident the fee paid by the insurance companies for services should not be less than the average minimum fee for similar services in the locality in which said services are rendered.

Report to Massachusetts Industrial Accident Board of 24 insurance companies doing business under the workmen's compensation act in Massachusetts for the year ending June 30, 1913.

1

1. Number of employees receiving medical services only.
2. Number of employees receiving compensation only
3. Number of employees receiving both medical services and compen-

sation 1.

4. Number of cases reported requiring neither payment of compensation nor medical expense..

5. Number of fatal injury cases reported in which dependents totally dependent for support upon the employee were left under section 6, part 2, of the act...

6. Number of fatal injury cases in which dependents partially dependent were left...

7. Number of fatal injury cases in which no dependents were left..................

8. Total compensation paid all injured employees and dependents of
all fatally injured employees...

9. Payments covering medical and hospital services and medicines,
under section 5, part 2, of the act
10. Estimated liability on account of compensation due injured em-
ployees and their dependents, covering the amount of deferred
payments for losses incurred and the estimated cost of undeter-
mined losses 1

11. Estimated liability on account of medical services rendered, but not
yet paid 1.

1

12. Compensation paid in fatal injury cases in which dependents totally dependent survived...

13. Estimated liability on account of deferred payments under item 12 2.. 14. Compensation paid in fatal injury cases in which dependents partially dependent survived...

15. Estimated liability on account of deferred payments under item 14 2. 16. Payments covering fatal injury cases where no dependents survived, under section 8, part 2, of the act.

17. Estimated liability on account of deferred payments under section 8, part 2 of the act 2.

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MEDICAL AND SURGICAL FEE SCHEDULES ADOPTED BY TWO INSUR

ANCE COMPANIES.

SURGICAL FEE SCHEDULE.

In presenting the following fee table the company recognizes the difficulty of making any fee table that will fit all cases, but intends to interpret the following with all reasonableness.

It is understood that the usual first-aid charge for minor injuries, where the injured party comes to the surgeon's office, will be either one or two dollars, according to the severity of the injury. If the surgeon has to leave his office and go to the injured person, an additional charge may be made in accordance with the distance, etc. These fees have been established with the understanding that they include in all cases the necessary appliances, dressings, anesthetics, etc., for the proper treatment of each case, and that they will be supplied by the attending physician. It is also understood that the strictest aseptic precautions will be observed in accordance with approved methods of surgery.

1 Information not yet received from two companies. Amount estimated.
• Information not yet received from one company. Amount estimated.

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