Document 15GyNQrYBpBvmNJpOR4EeJq7d
FILE NAME: DDd DATE: DOC#: Dd OCUMENT DESCRIPTION:t,Z&Z:D
File Name Contract Unit Claim File: Robert Horsman Oct. 23167: Amended Sept. 5168
Scanned? yes
Source
JMA: NS-JM
Start Year 1967
Stop Year 1967
Contents
claim
Notes
~':OP.KERS' C~HPE2~SATION A??t-;tS BOARD - CALIFORNIA
(I~Dt:STRI;'.L ACCIDENT CC::':1!SSIOH, ;:r:or to 1966)
nPPLICA.~T ___R_O_B_E_R_T__H_O_R_S_M_A_N_____________________________ CASE # LA 316509
Asbestos Installer
DATE CLAIM FILED Octo 23, 1967 Amended Sept. 5, 1968
------------------------------~--~--------------------
INJURY ALLEGED
Inhaling foreign substances
.~LEGED
DATE
OF
INJURY
1925-1967
------------------------------------------
~~PLOYER/INSURER ___T_h_o_r_p_e__I_n_s_u_l_a_t_i_o_n__C_O_o__/F_i_r_e_m_e_n_'_s_F_u_n_d__I_n_s_o__e_t_"__a_l_"___ including J-M Insulation
...
OTHER NOTES
Pulmonary fibrosis secondary to asbestosis
DATE OF RESOLUTION -J-a-n"--2-2-,--19-7-0---------------------------------
RESOLUTION
compromise & Release
$19,000 settlement
apportioned among 18 employers/carriers
DOCUMENTS
COPIED
1) Compromise & Release
---------------------------------------------------
2} Application showing original defendants
CLAIMANT
tSobe.r+ Horsman
California Workers' Compensation Appeals Board
CARRIERS INVOLVED:
.The AETNA Casualty & Surety Co.
oAmerican Automobile Ins. Co.
oAmerican Employers Ins. Co
American Motorists Ins. Co
Argonaut Ins. Co.
oAssociated Indemnity Corp.
oCalifornia Casualty Indemnity Exchange
oCalifornia Compensation & Fire Co
.casualty Ins. Co. of California
oEmployers Li~bility Assurance Corp. Ltd. .
.Employers Mutual Liability Ins. Co. of Wisconsi1) . ~
oFidelity & Casualty Co. of New York
.
Fireman's FUnd Ins. Co
General Accident, 'Fire & Life'Assurance'Corp. Ltd.
oGlobe Indemnity Co.
.Guarantee Insurance Co.
oGreat American Ins. Co. oHardware Mutual Casualty Co. (Sentry Ins. Co.) .Industrial Indemnity Co. oIndustrial Indemnity Exchange oInsurance Co. of North America oLiberty Mutual Ins. co. oLumberman's Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co Mission Insurance Co. oNational Automobile & Casualty Ins. Co. oNew Amsterdam Casualty Co. oOcean Accident & Guarantee Corp. Ltd Pacific Employers Ins. Co.
oPacific Indemnity Co.
,
oReliance Ins. Co. (Standard Accident Ins. Co.)
oRoyal Indemnity
oSecurity Ins. Co. ~f ~artford. (U.S. 9asualty Ins. Co.)
eState Compensation Insurance Fund
oTransport Indemnity Co
The Travelers Ins. Co.
oThe United Pacific Ins. Co
U.S. Fidelity & Guaranty Co.
oZenith National Ins. Co.
oZurich Ins. Co.
Hert~rd 8e&idcot ~ loet,moih.i Co.
0 ____________________________________________________
0 ____________________________________________________
5/81
,
" i ":" \
I
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I
1
WORKERS' COMPENSATION APPEALS BOARD
2
STATE OF CALIFORNIA
3 ROBm J. HORSMAN,
"~ Applicant
6
VS.
7 THORPE J:NSULATION COMPANY, et al, FIm1AN" S FOND INSURANCE
8 COMPANY, et ala
CASE No. 67 LA ;16-509
9
Defmdlmt
10
11
I hereby certify that the attached documents are truE
12 and correct eopies of the original documents filed in the recdl
13 of this office ,in the above-entitled matter.
14
ATTES~ my hand and the Seal of the Workers ' ,Compensat
1~ Appeals Board of the State of California.
16
17
18
19
20
21
22
23
24 Dated at San FrancisCo,
2e CalifoI'Ilia, this 6 day
28 of April, 1981 27
DIA WCAI 1'0... 111
fNIW"'ll
.. ".111
Ot"te"" ~ ..DrT 01' IWOUIftIA........."fO... 0' ttllKtft'IIftAL ."IIIN'r1
(
1 Hcl.AUGHLI~~, EVANS, DALBEY ii. cU".~m~G 1717 North Highland Avenue
2 Los A~geles, Cslifornia 90028 3 466-i3541
614 Attorneys for Owens-Corning Fiberglass Corp. and Aetna 5 'Casu~l:y ~ 5ura~y Co.,
!Defendants
'1
... :. - .
8
HORKHEN'S COHPENSATION itPPEALS BOARD
9
STATE OF Cl.L!FOIUUA
10,'
ROB~RT J. HO?SMAN,
)
\,
11 SSl:: 562-03-2606
I ~ 12 i
Applicant
;
vs.
~ 13
14
1
IIl-r~"DZT
,
ccm{
c~P..POP.ATION
.at
) al. )
)
. 15 I
Defendant:s
)
1 - - - - - - - - - 16
CASE t\O.: 67 LA 316 509
1'1
The parties hereto, for the purpose of comprOlllise only,
18 hereby submit the follo~ling agreec statet:lents of fact:
19
L Hobert J. Horsr:lan, born August 26, 1904, claims he
20 was employed between 1925 and June 28, 19~7, at various locations
21 l'lithin the S~ate of California as an asbestos installer as a result
22 of \~hich he sustOlined an inj ury arising out of and occurring in the
23 Icourse of his e:nployment fro:n inhaling foreign substances, or in-
Ijured 24 !
sa if
in
some
other
manner,
resu1tL~g
in
injury
to
his
lungs
25 11la,nd oth~r injuries, sympt~us, conditions anc co~plaints set forth
I: ~n :::1': ::I::>diC;ll reports 0:1 fil:=.
26 Ii
ii 27 I:
.
2. D".lring the alleJ~d period of e::l:>l:>yment, th~ applica:::t
I;I: 281. 'Ia& e",!)by-=,; at v.:trio'.ls ti,,::s by Coast Insubcing COI!l?any, ,The
I: !":1ili::
29 1, "
Cm:ey 1'1g.
Co.,
O-.Iens-Corning
Fiberglass
Corporsti ::m,
Hundz~
3D!: C:n::; ::::rpo~<-::bn, Fi;.lG::31,1~:; :n~ir.~orins anj S;,qply COr.l?sny, ?ro::::~::
/' -~ G.;-'.l:l~ Co~p ClJrnpa:lY, L:)s l,":lg:bs D,.partm'::1t of \:-'lt~::: and Po~;cr,
'~. ~":'J=i:l:: Sl!;J.
T!1J1:::":!, I:!G., InGulotLl:1:O, Inc.!
Engit:"e-::ing CO:!l?:m:,:,
32.ii ,:,,:.-,,;',, i::l::., C co:::pol.:l::i-"" S\J::C~5S0"" t'J C.::lif:lrr."..4 ?~trole'.Jll: Cor:'.
-1-
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1 Los Angeles Rubber Company, Los Angeles Cork Company, Plant As1: 2 Company, Coast Insulating Products, Swift Packing Co., Armstro:: ;) Cork Company, Netal Clad Insulation Co., Accurate Insulation Cc 4 Inc., Shell Oil Company, Johns-Manville Sales Corporation, Arms 5 Contractinq and Supply Corporation and various employers set fo
e in the Application for Adjudication of Claim.
7
(3.) The actual weekly wages of the employee at the. til
8 injury are in dispute.
9
(4.) The. employee's present disability is in dispute.
10
(5.) No temporary disability indemnity has been paid tc
I
\.
11 employee.
12
(6.) The parties hereby agree to settle any and all cla
13 on account of said injury by the payment of the sum of $19.000.
14 said sum, to be payable to the applicant in one lump sum, after
115 deducting of attorney fees and lien claims of record, excepthq
16 lien claim of the Department of Employment and said Dept. of Empl
17 ment lien should be denied since the applicant's condition has be
18 permanent and stationary since June 30, 1967 (Dr. Derry's report
19 of December a, 1967) and the Department of ~mployment commenced
20 payments July 5, 1967.
27121
(7.) The applicant's medical expense has been self-procu:
2 and none has been furnished by the employers or carriers.
23
(8.) At various times the insurance carriers for various
24 employers during the alle9'ed period of injury ,.,ere:
25
(a) ARGONAUT INS. CO.
nt,,!
CONTRIBUTIO~
26
(b)
(b)
CASUALT~ INS. CO. THE TRAVELRS INS.
OF CALIF. CO.
1,694.00
,~
328.00
I '" t
(c) (d)
HARTFORD ACCIDENT MISSION INS. CO.
&
'.4
INDEI-tNITY CO.
1,259.00 41.00
2811
(e) (f)
STATE Ca1PENSATION INS. UNITED STAT~S FID~LITY
FUND i & GUARANTY
~ '7 'i
co.
91.00 1,950.00
29
(q) GUARANTEE INS. CO.
1
(h) Al-IERICAl~ MOTORISTS INS. CO.
55.00
701.00
30"
~
(i) (j)
SEcunIT MUTUAL CAS. WDUST RIAL INDEMNITY
CO. CO.
680.00
llS.OO
3:521jI,: ((1k)) GFEIRNEERIAWLJ'SACFCUIDNEDNTINFSI.RECO&. LIF~ lI.':sS3U~"R. 1,712847045...000000
1\ II
-2-
I.
i
I
, ~
(
(
i
i
11I (m) Pacific ~~ployers Ins. Co . ;I/~
C0:!n!E~"T!(
$ 3,00'3.
61 0: 2'11
(n) E:nployers ~1utual Liabili:;y Ins .Co.
969,
:5
(0) Aetna Casualty':;' Surety Co',
5,202.
4
(p) Proctor & Gacble Soap Co.,
5,
permissibly 5~lf-1nsured
25.'
I (q) Los ~nseles Department
I
~:ater 6. PO\'ler, legally self-insured
620.1
9. The employee's attorney is Steven Roseman, 15431':est. .,
: llymPi' Boulevard, Los Angeles, California 90015
I 9
10. Attorney requests the fee of $ 1600.00
10. ~mount
I
of attorney's
fee
previously paid,
if any,
$
None
111 1 ,
11. Reason for Compro~ise:
-~"'-----
1\ bona fide dispute exists
12 as to \/hether or not the applicant sustained injury t~hich aros'
13 o~t of and occurred in the course of his e~ploy~ent throu3h ex-
14 posure to any deleterious substances t'lhile \~orking for the named
15 employers. The nature of the applicant's illness and the e~ttent
161 of his disability is set forth in the medical reports on file. 17 There is a dispute as to ~lhether or not any portion of t!1e app li-
18 cant's disability is due to causes other than industri.al a:~p:)s ..:ra. 19 The applicant has expressed the desire of resolving the litigation
20 by obtaining a lump sum amount and controlling his otm' ~:dical 21 treatment in the future. All parties desire to resolve the dis-
221
23 I
241
25 I
26.11!
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27i
28!'
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29 ;,
!
puted issues by this settlement, thereby avoiding protracted c~lay and expense of litigation.
12. The undersignac request Relc<lse Agreement be approved .
that this Compro~ise a~d
13. Upon approval :) t~is Co~?ro~ise A3reement by the
'olorkmen's CO:il?cnsation Appeals 30ard or '" r~e:er~~, and pay~:::1t in acco:::c!ance .:ith th(! provisions !lcreof, s.:ti.~ (?~l?~Oy'~~ re~~a5;s ane! forcv~r discharges, said employer and ins:.l::~:1.ce carrier r,)-:1 aE
30i
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II11' carriers .:and each of the:n to the dependents, h-eirs, executors,
21 representatives, ad:ninistrators or assigns of said e:n?l~yee.
'i/' :3
HIn;ESS this~ay of (..kuG.
4
5;I Angeles, California.
~
1970, at Los
V/LV1 ~ 6i \
vllR'~PfihJ,,-.r.HORSNAN, J.pplicanC-
. 7
,,'~
c~\--zL~Z~.ekl"~ - 8
STEVEN ROS:;~\N, Applie~t I s a tt:
9
.10 I
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12
13
14
t ARGONAUT INSURA~'lCE CD:f!?ANY
SECURITY MUTUAL CASUALTY CO By: HbNNA Ar--."D BRO~H ''!Y/
By ..f-l~
I /
THE TRAVEIZRS INSURANCE CO.
By: PARKSR & DALLY
.I -",""
By
.'/ ( , ,'. .' ... : ... -.....
,
15
CASUALTi INSURANCE CO. OF CJ.UF.
16
17
l8
19
20
21
22
23
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241
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271!
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AHERICAN HOTon ST I,.m1B:::rJ1E~ f S !1"~rruAL
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co. ; co,
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OF CALIFo:mI.A )
25 1 COtJ:1TY OF LOS Al'lGELSS )< SSe
26
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On t,1,1..S --.?,,">- day 0 ~?~GH.~i/ "h .D., 197,0'oe f ore na,
27 il the ~njersigr:ed, a Hotary PtlbiC 1.n andl fo:: the! said County and
Ii Stat.?, residing therein, duly co:nmissioned and s;1Orn, pe!'st"nally
28 " Bpp.:a:: ~d RODE?! J. HORS:,jJIN, kno\m to oe to be the per s 0:1 \,:hose I nam~ is subsc~i:'ed to the \lithin !nstrl.l::l~nt, and ackno\)lecged :::-;at
29 1; he e,::::cutec th.a same.
30,,'~
III ~;rTi;:ss ~r."i:;:-.,;O: I I hDVe hereunto set "S!y :1and at\j ~:i::2,
:n!: ::1y '):;:'::ial s~al the d.::y .:l~d )"e<Jr 7~!t 3:JO,;e ~!:ri.tt:'::t.
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The IEcther:li Co.
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Co. COS!') Hi1shire ~ou1everd Los An~eles, Cal~fo~~i~
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f,urety Ins. Co., 24nc ~ilshire So~!~~art Los An~elcs, C~lifc=r.ia
and
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Fi~~~an's Fune I~~. Co. 3223 ~. 6t~ Street Los hn,!ele:;, Ca1iro::"rcii!'
A!:leriean :!otori!:ts !ns.
35~5 Hi1s~ire Rl~~.
Los An~cles, Cali:o=~ia
1961, 1%2, 1963 I< 1964
1962
~he ~~avc!ers Ins. Co. 3600 Wilshire Eou1e~ard
Los Anseles. Cal:i.fo:':lia
1962
1939/1~5~/!95!,
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207 S. !lroa"::~':a ,. Los ~ngQles, Ca1i=ornia
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Joh:1 :ianville !r:sullltion Co. Sout11 Caro1i!".:l
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Houston, Te::as
North ~rot:1crz "tli"r:t~, Gil.
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5-10/196~1
S-10/B5-1
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!'.':l. Eo:~ 2B.;
r,os l\ngcles I . C~li:c~:,ia:
n . l.rgon.:lt~t !!:s'..!::ar:.cE: Co.
H:l Shatto
Los An~e1cs, Ca1i:o=~ia
and
Guarantee Ins. Co. 1671 eilshire ~lvd. Los hn~c1es, Cali=o=~ia
11,12/1954
The Travelers !n~. Co. 36~1') ~':ils~ire noule-:.nrt" Los ;~ge!es, Cali: .
1951, 1-4/1952
:'!?'~2, H47 11N~ H'!), 6-9/1!l52
(Sel: Insurec)
B51
!.~~a, 1-3/195,:'
1940,l~41 1~50
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!:CC:,~, riS:le= :~sulatic:: Co. Alo:.n::;,~, Ga.
;!arj no !:~gincc:i~.g Co.
Los J~So1es, C~l!:orniu
\
Pla:~t. ~~.l::~~:r t :':.sbGstos Co. 5a~ ~runcisco, Ca1iforniu ~S37 9ranno~ E:rcet)/ trJ~:~ if t ? acY.ir.,;: Co .. Los ~~;e1es, C~!i!ornia
t;a:-rc::--. !, n~i!c:' I~sula tion Co. Los :.:::~le$, :ali;:or:d.~.
GC:'l,~'.:-,.l Petro1cu!~ CO.
TOS ~~~e:cs, Californiz 1:: "~:ic1e:; !:ul::;cr Co.
~~s ;~~Qles, Cali!or~ia
Pro:::t~r nnc': G~!:.~'!.c 500,=' Co. l60l- .:~st 7:'~. Stre~t Lor-.s: :,cac!i,Cali:ornia Tc~~c~ Oil Co., Inc.
(;":\ai:-, o:'::icc)
335~ .7il:;~irc:
Los .:_:::~lo::, :-a~i forrd ..:. 'I'~...o:: '; ::,..,c.~~~ ~!:':i.'!: ir-:. Co. Lo~ ." ~.. :~lcz, \.'.!ifo!:lli;
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1938, 193.9
?~cif ic i:.1!")lov'ers !:-- s . 4050 ~;ils!1i::s-.~ulc\~~rl': Los l~~eles, Cali:o~~i~
1938 1937
1937 H34, 19:35 r; 1936 B33
1931 al11 1932
(Self Insurct:)
Scc:urit~.. ~lutu~l Ceo.s. Cc c/o ~eeves ~ U~y A~j~st( 113S' \'!. Gth St. L0_"~J.n~eJ.es" Ca.,..J.-::. State Co~pensetion ~ns. p tj. !\o:~ :!13!
Los :\n7e1oti, Cnli=o!':~i:!
Occi':~~to.l !n.:!c-::~it:~ (ad'~ress un!~!'.o~,m)
Stntc Co~~~ns~tion !~~. P.O. Bo;.:: 213~ Los I.l1,:clot;, Ce>.li:o::-r.ic:
a~~ q
Lu:~r.erman I s ::ut~~(l1 :1 :-.$ 3545 !':il~!;irc =,odc','c!"c' Lo~ 1'.I1:,e:!.cs, Ca1ifo::-:.ia
193fJ
E27,19?8,1~~~
r.:~c: ~~1:2
417 S. !~ill ft:cct Lo ~r":t:~"~lns, C~li::c::;.i~
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