Front:
The Industrial Insurance Commission
OF THE
State of Washington
ACKNOWLEDGMENT OF CLAIM AND ASSIGNMENT OF NUMBER
THIS COMMISSION HAS RECEIVED CLAIM PRESENTED BY YOU, FORM 22.
59004.
THE SAME HAS BEEN GIVEN NUMBER
IN WRITING ABOUT
CLAIM ALWAYS GIVE THIS NUMBER.
THE THREE THINGS NECESSARY WHEN MAKING CLAIM ARE:
INJURED WORKMAN'S CLAIM---EMPLOYER'S REPORT---DOCTOR'S REPORT.
REPORT PROMPTLY WHEN YOU RETURN TO WORK, OR AS SOON AS
30 DAYS HAVE PASSED AFTER ACCIDENT IF NOT AT WORK.
Yours
YOURS VERY TRULY,
INDUSTRIAL INSURANCE COMMISSION,
OLYMPIA, WASH.
Back:
می
گاه
CLYMPIA
NOV 30
5-30P
19
15
WASH.
۹۰
Erick Engations
يمها الهام تنقيه من ليا
ها
له
بود
Wash
