In witness whereof the parties hereto have signed this stipulation at.. .in the county of..

this....day of.

191...

State of Michigan,

Signed in presence of―

(Acknowledgment follows.)

(Applicant.) (Respondents.)

LETTER FORM IN RE ARBITRATION.

I herewith inclose you copy of the application for adjustment of claim and notice of arbitration of the same; also a blank form on which you are to designate your member of the arbitration committee which is to hear and decide the matter. Please select one man as your member of the committee of arbitration, write his name in the blank at the place indicated, date and sign the same and return to the industrial accident board in the inclosed stamped envelope.

You are required under the law to make selection of your member of the committee of arbitration and to notify the board of your selection in the manner set forth in said form within seven days. In case of your failure so to do it becomes the duty of the industrial accident board to make the selection of such member. It will be necessary for both parties to be present at the time and place fixed for this arbitration, and that they be prepared to proceed with the matter.

Very truly, yours,

Secretary.

To..

The industrial accident board has received notice of your appointment by

as a member of the arbitration committee in the matter of applicant, v.

at

county of

19.. commencing at

respondent, such arbitration to be held in the town of State of Michigan, on the day of o'clock in the ......noon. You are

requested to be on hand promptly at the time and place set for this arbitration, so that the matter may be heard and disposed of without unnecessary delay. INDUSTRIAL ACCIDENT BOARD,

To the Industrial Accident Board, Lansing, Mich.

GENTLEMEN: The undersigned, as provided in part 3, section 8, of act No. 10, Public Acts 1912, makes application for a review of the findings of the committee on arbitration in the claim of

v.

This claim for review is based on the following grounds:

SEC. 11. Part 3. If a claim for review is filed, as provided in part 3, section 8, the industrial accident board shall promptly review the decision of the committee of arbitration and such records as may have been kept of its hearings, and shall also, if desired, hear the parties, together with such additional evidence as they may wish to submit, and file its decision therein with the records of such proceedings. Such review and hearing may be held in its office at Lansing or elsewhere, as the board shall deem advisable.

SEC. 12. The findings of fact made by said industrial accident board acting within its powers shall, in the absence of fraud, be conclusive, but the supreme court shall have power to review questions of law involved in any final decision or determination of said industrial accident board: Provided, That application is made by the aggrieved party within 30 days after such determination by certiorari, mandamus, or by any other method permissible under the rules and practice of said court or the law of this State, and to make such further orders in respect thereto as justice may require.

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

to

CALIFORNIA.

at

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

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 innor have you notified us that this accident caused a disa

jured

bility of less than seven days. We wrote you on

and 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.

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.)

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.

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..

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

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

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.

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

No. 5. MEDICAL AND SURGICAL AID.

RECOMMENDATIONS

MADE BY

MASSACHUSETTS MEDICAL ADVISORY

COMMITTEE.

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.