void Injured worker information Dependents: 3 wi srij uq 101 sloup s nisida sidizzoq 118 odi Department name: Repair Department Wage rate: $17.78 hour 6 a floss mon Work schedule: Monday through Friday, 8 A.M. to 4 P.M. Job title: Senior mechanic 90 Wages and payment: None expected from other than Ohio Bureau of Workers' Compensation Treatment information 09 Employer address: 4829 West Main Street, Toledo, OH 43602-0979 Place of accident: Property of JV Trucking oilsuqet pri ai WA Date of accident: June 4, 2029 Time of accident: 10:50 A.M. Date returned to work: June 8, 2029 Date hired: April 13, 2009 State where hired: Ohio Date employer notified: June 4, 2029 Description of accident: In Mr. Puopolo's exact words, "I was working on the front driver's side wheel when it came loose off the axle and fell on my right leg. It pinned my leg against the fender and I heard and felt a crack."ste vnsM) Anil or no bibbs goll 09 219 how Type of injury/disease: Broken right leg bodygolonimist Instib 15rb Number of workdays missed: 3 days ago Injury causally related to the industrial accident: Yes y 11-digit BWC provider number: 26875943158 risM) Sotiedow Date of provider's signature: June 7, 2029veworl amol viuin! cob Employer information 'onde orions Tol stiedow or brit Jxs 8 Employer policy number: 569QH15736 Employer telephone: 555-322-4662l to oqsil denildi 650 Federal ID number: 21-2697854 owl sill to anal s() Emergency room treatment: Yes Hospitalized overnight: Yes Treatment away from work site: Valley Associates, P.C., and ini lo ho Toledo Hospital 2142 North Cove Road Toledo, OH 43606 Y