Document 6B0Zvn5RgD7KMxEpZ4mN8JxB6
FILE NAME Mundet Cork MCK
DATE 1977 DOC MCK102
DOCUMENT DESCRIPTION WC Claim of Cuthbertson Pt 1
PLAINTIFF EXHIBIT i
CCS 5142
ces ey
# 69
10-81
EMPLOYER'S REPORT OFINDUSTRIAL INJURYI
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
6.5 DIVISION OF LABOR STATISTICS AND RESEARCH Claim Department THE TRAVELERS INSURANCE COMPANT
cor espond- correspond- to avoid further FAILURE
FAILURE
IS
315 Montgomery St. San Francisco 4 Calif
pi
^'
yan
e
-
Please make this report in DUPLICATE so that we can ie
coples Stablades Kopiarch Every work injury to an employee which causes
lasting
the disability aid treatment must be reported within five days after theinjury
the longerinfery recolte injury to the Division of Labor Statistice and Researnoct hlater than 24
with Division of Laber
than the
the infery recolte
ofdeath
and
in your behalf
injury or which requires medical service
a report must be made by telephone or telecpr^h
.
ay
Ea fre
direct
EMPLOYER
8. Nama Give sama sesdereder which Armstrong Cork Co.
kumlevenat Market 2. Oise melden
of Nature 3. busines
St
City San Francisco CEIII
facturing trackinfogr retsltingase n In ndustrial Insulation
EMPLOYIE INJURED 4. jack CuHolbrook 4. Addr Surot 2284 Holbrook Drive be Aye 26 see 7. Bez Check v Mile,
and ;
Bustej
Femala E..Check E..Check
Soc S. No. 572-24-8568 572-4-8568 572-24-8568 572-24-8568
Concord Calif
M
Klagie
| DO NOT WRITE
IN THIS COLONX CasRee
Employer Na
seers npenasetemoees
Indeway
ea. WB WB 3.175 par beer # or
per day or 8, 127.00
ney week, If earnlage at brugnalas ruta nach
Aps
~ as plece work aa ongelegtes beste enter ended attrapa weakly warnings for omvenlest period not to anceed one year
1. lodging
in
boone nerithtlte Mi trstmmaaneg
advantage terzished addition to ungma giva estimated valna varied por dar = 1 enaren yer oak Be Led Maritai
ACCIDENT .
on
of Untu C3 12. seridseerindetnt
11. On employer's presaimo
Na presaimo Not
= 14 Departme
+
County
.
. :
.
|. Pan Weekly tttaictesig
Weekly 159
te, Des of pecl^zat
sem
Nar accident ? Yew
thle dev
-
spore
SE OF ACCIDENT
16. Hour of
E. If pee dive date las parked
20. If injured in mine chick (
day
AM
ef nen 19. Did ja ramit is dabilly be oad der
prom
8. Was tir paide la d full for
Crna
accident location
Surface
Surface
caotatstM M M arr hyerasant dernenestta .... i
BRAN Nepean
.
1 Occupatice Job
mAsbeatos mAsbeatoWsorker
5 :
yours yours Ulr unplayed unplayed Leasthan Leasthan month _______ to Describe . excupational_Check excupational_Check 4
&
meals
S
pour
4
much
loading truck operating
2. How long
by rem al th^>a
yours What was employee doing when maridont
Describe Describe shoveling dini loading truck operating Insulating Pings Dicta and excured Equipment
Ascideal Pane
:
.
Decaps Decaps Maze
How the 26.
did
socktens
Abastosis 7-14.5k for sigilar type work wriaptehrsforadina empAllolyeegredly caused Abastosis
tanto happen Describscenfutdyelingwhether theUsienjoutrheedr perso
due
insulation insulation
insulation
sigilar
adina adina adina
another material material material Pployee Pployee PployePployee voluntarily voluntarily
Lec antTypo
eeinniaaetietemmmmeeer eed
Agresy
the spsepceicfiifcic machine involved we ZE WVkat machine tool mibnizace or object was man dopoly ovchcted with the accident {NameName the
.
*
machine soul spylimon
spylimon
teresa
emsarnanesrenscorpeehrnena
Amor
Part
20.
If
apparatus
mechanical apparatus or vehicle whse prer
of
it
State
State
stc # rara
motor
pula
,
17. 20.
Wert mechanics mfeog r ou theramfr egd uars ds provided No20. Wee injured using them Not or
worker
What do you recommend for presenting this type of sncident State the apache preventive mecures Specify can taken employer employer aot worker worker
=
ae
Seretermrnancnsters ete seers: | snot vttelaranaaanstnspertpempay
Uztais &
kend NATDUesRcrEiObFe INdetaJidletUailRtYhate tAacNosDd ojuiPsft tAthheeRfTinjurry uctOureFanBd OthDeY AFFtEheCbToEdyDdermatitis of cample: ssmputmaionputation Unknown
+
Formal Detac
31. Name and address of physicias
12. Name and addrate
of
isompited
Yes br
1 Hun employee returned to work No Yes
24. If yes pise deta
34 Dld lajury result in denik Yes
XY If yaz piva data
& in chat of death give same and keldrma emarea relatiez
neadehdenh Ines aiasimbihdy shecesesasamnate cod
Nature #later #later
...
14. At what wITE wITE MOAFMOAFATIN~TA mmT r I n N~ fT LaasKan
witmentria a M. add andrade drea amsm of s witmentria
tenderers oe
neonmatiedeeastLier aarent
Mt
vento erAes ct
injured evlatod is EmploNorer If so howl
--fl--
--fl--
--fl--
Dale et thia report 111011.10.54511410.54
Offal paskiom
Construction Supt
oot
EMPLOYER'S DE JY
INDUSTRIAL
COAFLIFORNIA EveryMIFSAIDLEUMREEANOR SUBJECT INJURY # PLAINTIF'S must be f a
STATE OF
wt TO 70
DEPARTMENT OF INDUSTRIAL RELATIONS
C.F. MASILFUM Saculate 6407.66 3-10-81 Chaim Department DIVISION OF LABOR OTATISTICS AND RESEARCH
Every answer ane swed red
PLAINTIFF'S FT fully
further correspond
\
MISDEMEANOR
SUBJECT
PLAINTIFF'S
RL
787 1 0 EXHIEGXHIIGTIT PLAINTIF'S
MASILFUM FINE OF Labor Coda
6800
781
THE TRAVELERS INSURANCE COMPANY
781
315 Montgomery St. San Francisco 4 Calif
eae
DUPLICATE lasting longer in Please make this report in
is that we can lie coples with Division of Labor Statistics and Research la your befzal befzall
Every work injury to an employee which causes disability
than the day of theinjury or which requires medical services other than fre
sid treatment must be
five days after theinjury
injury results death a report must be made by telaphone or telegraph direct
reported within to the Division of Labor Statistics and Ressarch not later than 24 hours after death
ManufaMctaunruinfg Armstrong Tews & Office addrees
Mat Ke Mp fCGIGCES
acturing + 2. Nature of business clothes trucking for recallimngen'msesn'ps ocmaesematece Faerie
Manufacturing for INJURED EMPLOYEE
Drian Drian Drian Concert Ne HSBC 4. *
a
et
8. Addres
AF
Sea Check 1 Spiele a 6. 26 7.
$i}
lbrock
lbrock lbrock
lbrock lbrock lbrock
Hela
aa
Be
Drian
Drian
Drian
o .
Case No.
_ Fawchnariorhetineitiasasn
Employer 572-4978
Spiele 42 6. Number of boure sporked per day
a
1 pa veck
Number of case worked per week
Pricmnnnanocesoctenmencie
3.175 3.175 a 2540 2540 $ 27,00 per t
10. Waxes
pro pro pro
ee day of
27,00
week If essulega at beregular seta each-
se
ne piece work or em coramussion basis enter actual average weekly montage for convenient perled
to emcred one year
avactewansypmmmeaasstnjerenen
KI If bound lodging or other advantagea furulubed la addition to wares give cotimated value KARIER day or nnn pt sianny rennn wee] Bss and Machi
ACCIDENT
12. of Place
emident
Yes NNooand UNKNOWUNNKNOWNUNKNOWN UNKNOWN UNKNOWNUNKNOWNUNKNOWN City of
ee
C^cats
.
Wedds Foge
premato
13. On employer's
No
16. Department
p
It 15. Date of
accident County wouldcat
!
16. Hour of day TAM / PIK
IL If yes diva data bet worked
17. Dd tnjury result la debility beyond day & Wan Injured paid in full for
KKeem m the day
stints
rie Underground CAUSE OF ACCIDENT ISBESTOS WORKER employed St. Occupatles job title
20. If injured in ming chock y Beeldent incation Surin
ISBESTOS ISBESTOS WORKER
L^ NGA
.... strane eSl hirl Rasscnmnnrsor,
17. How long employed by you at thi
Laminat Exte
accupation Check Less than 6 month truck 6 months months to 1 yey ari eari evar I
IA What
emydey n emydey n
when acciden
briefly such as operating emydey n occurred Describeloading
NAUL
ATLAIGEden ATLAIGEden ATLAIGEden
QuemQuemeeshoveling ANG ANG QUIPQUIMPMENTEQNUIPMTENT QUIPMENT QUIPMENT
Corus
24. How did the happent w<cident
EQ cranes CAUSER
TARILY INSULATION MATERIAL MATERIAL MATERIAL EMPLAYGE EMPLAYGE FKALON- TARILY TARILY QUIT WITH Se eee 3,
Describceontributing contributing stating accident Uus injured puro fall was struck aditional spaca all
ASBESTOS INSULATIINSOULANTION
18
QUE
Te
EMPLAYGE
ALLEG
ALLEG
FKALON-
7-14- ON
7-14-
lame
lame the
SIMILAR SIMILAR SIMILAR SIMILAR TYPE
resclic macalne tack sopilates
TYPE
WITH WITH loose7-14- 7-1B4W- seriFtee: eeelaUmequid UquYid ER Involved sopilates
pare
.
Accident Type
Agency
RA RON re
Pan
State il zora
pulley 26. If mechanical apparatug ez veli~ itwhat part of it
motor
etc.
motor Yes or
or Koj Hay J
17. Were mechanical guard othaer exfequsures provided
weamencemcenmeemmnnnn
23. Was injured using them
; :
Moch
Danc
20. What do you recommend for preventing this type of accident
DancyDancy
spectie the
permitive measures
Dancy Ay b^ngcareful
that can be taken by
Specifywhat should
employer and workers
or should not be done
renfeAca
_
MATUREOF INJURY in 3A, of right indes ^"ngeral
AND
sencature ond
AFFECTED PARTinjury OF BOthDeY
sint fractunard e taa^ ^ e^>scaingdemelitis
of left
example:amputation
UNKNOWN UNKNOWN UNKNOWN
UNKNOWN
)
Portal
Name zoad JL
s^dress
of physicine
Natura ef lajnry
Name and of 32.
address
hospital
He employee returned to work Yes 33.
36. Di lajury in deatdeh atf hf
34. If you adve date No | 47. Il you give data
38. At whel we @
por,
Locxtee
28. In cums of death give aame and rel ofa neat restirev late ive
Extent of ar
_
oS, Name and addresofspe itessses
. _.
Iepuranes Cart
,
40. lafuered related Empinyvet Na His His bowl
1-10-54 1-10-54 1-10-54
meging req1ui-red10-54 shall admissible vulng of this report is not an admision
"
lability
by an employer or an insurer by this chanter
be
injury No report of
to be
as evidencein any adversary @
Report Lag
. +
3-10-81 3-10-81
CC.F.
ms Coal BYOTHE
POR MOTHERN CALIFORNIA kett kett Envafyt Envafyt
285 MIG0jon kinky SAN FRANCLOCO &
.
UTATE OF CALIF^ RNIACALIF^ RNIA
BYOAAT ut SP 1404OPHIAL MILASTO MILASTO
AC IDENT
INDUSTRIAL ACCIDENT COMMISSION
FOR SACRAMENTO COUNTS SPUM 18010OR 18010OR Y ARRAID Awe
ONLY
FOR SOUTHSAN CALIFORNIA
NCAP GAN ~ " s I>ng
Auldito 801 v40
Auldito
LOS ANGELIO &
OPGiDoInGos FOR
DIEGO COUNTY DHL
SNHDAY
APPLICATION FOR HEARING
tion
. 161-870
Can No 555 555 161-870 161-870 Filed March , 1955
DO NOT WRITE IN THIS SPAGE
ENTENED IN DOCKET BY
EmployeNAaD'IAs NADIA NADIA SP SP1
sears meseneensvenetsaerraseentey wt
Employes's
Address 22 ~ m~ ~z m~ A z LM
ST^ RSTANA Avgena
eee
Social Security No. to wi
ee
VI
THMI
Name of
II
Employer wots II ore
exveeneer eammer
,
-
Name
+
4
ers
Employer's
zulifarukhan
"er" ae
950
.
Address M 2 4.
ne
cette
"
ANO DODDD^ ODD^ A A
gute ceneieet
01610
:
nese KABA
re
ae
pd ee
cathe
NAUSRAGE
Me
LETA GO REG ATI Rew areRe LETA
anced BInSMO vented
W
GIGIFT FT
1500
IFA MU NEAME PGV4
090489 ** SUNBAN
LARVENE AMON y
e tense
ae
wen
ite
ave
...
S ... e
K... VINNA VAN KVINNA -
Bova
9476
name ... UBp ects 1925 El
Employee's
lpgOLED oe nee
nee Employee's date of birth marek ' REE
1925 versrmeneen
.
ot
Employee's occupation
Date of injury
... 1945-1954 1945-1954 -
.
.
Mace where
se time of injury L^,bestosKorker Korker OZ
When did you leave work
E 19 pete
injury occurred Frane Frane 1800 Calif 2177 AND STATU
Jeptember as result of this injury Jotuler JJotuolertuler
30 1353. 17,1954 17,1954
breabakre the bine How didinjury occur breabakbrerabaekre
What part of parta
4 GeO aidetreseed
akanth Lunge
of your body were injured instagra mies oe case seen
CAMP
.
Full or pare si^-w work
we
mnie ne
ese
prerepenenine
+42046
When did you return to work . Still dissblad
and at what wIRT
TREES! {5 eas Sey
Your wages or salary before deductions be be work per per
per hour n^t
per wiek oz
.
If paid an hourly rate how many hours did you work per week
Nfi Did you receive any of the following Board YesYes No Q Lodging
Yes No \ State their weekly value I ..
\\
.
Other advantages
:
we
CoRR
LLAte
a per month
Yes [ N
(1) Q Have you been paid any compensation Ya No .
How much 1
.
10366 kwau
Date when lus payment was made o.....- seat tener aber 012444 64 691 19
furnished Has the employer the insurance carries
you with any medical treatment
or given Date when lare treatment was
.. msccesnutem cnet mune
eee
.15 .15 cae
List of names sil doctor who have trested you and who wera fumished by the employer
medicalmedical expense Yar~fi obtained
Have you obtained my
-of txttformie
treatment be your own
List names of all doctors who have treated you at your own
daar
N
c pene
Weekly rate of
YfiOYfiO N"^N"^
ar insurance carrier
prynents 1.
oe er wees
.
--
teens
ae cere entre ot
Jad
Anjuna s STROLLE
Of
re
rrr
Are you claiming any of the following benebu
Yes or No
a Temporary disability payment
in
'
Answer c
treatment
Further medical mentioned mentioned stor e List other benefits claimed and nos mentioned stor
16 MAY ND wenn
b Permanent disability payment d Cost of your medical expense
...
... ... ...
- ... ...
en aT aor ee
Cre or Stet
:
eT
Mr
ITINE
cS ok tt
tery
ert
TER Te PR SS RE ZT RO el
Have you ever befort filed a claim with this Commission Yo Yo
No ) If , when was it filed a
pee
cece
te . . atte mananees Peet
PELE & A tee
OURDESERT89909 v^ AFYDDENY DOG APTLIEKT
financial
financial
ildg
Caklunt Caklunt
ADAS BAS
Alencourt
2 2000
, TELEPHON RewReEs
"
Caklunt .
of Jacz currYBLYTHE currYBLYTHE 441 currYBLYTHE * REPLIKANT
norton
Dice ee
|
me
aw
fae
ey teen
:
195
$
INU A
se spallaboo has baza Abed with the badunchal
- bilerno de baperooktatapika^nby bilerno bebet sports
Arnl^vs Arnl^vs 0 ueainscue the peaches test~ eumelbad ja willing n~ she then und plows + Goring
Dessous Dessous Dessous la
AHIWIKI AHIWIKI The defendpa orntut^j^ dhe jo malez vad^^rje dose oltre sister at sony of
t^ th^r and the
carrier je pomporio armsad je she appkrosini na srown paid te blad by ita amplura
marshva marshva die...a y i che da purpose 16 puplesse should unarly tho saria die...a y
propol prow dao
blod
spylicstend anun~ the form frendshed lip that purpose
u that od be done by thevarning her of the
16 befestene maplanca la kanunod trtiead ww am award they obe
SAYE OF SKAVICA
PRAVICA OM
EXHIBIT
Western Asbestan de
675 Tousand A. de FranciCsacliaf
J. T. Theren & Son
Emeryville Calif
Matt Bregman Corp.
LIST OF INSURANCE COMPACOMPANNIESICOMEPANSIES
Travelers Insurance Co.
Industrial Irimuity Co.
350 imsons St.
San Francisco Calif
State Compensation Compensation Compensation Compensation Ing Fund Me11ister 11ister St. San Framsipes Calif
Oakland Call Pacific Employers Insurance Co.
3770 Piedms00 AT
California Gecipensation Gecipensation Insurance Co.
24 Geary St.
STATE OF CALIPORNIA
INDUSTRIAL ACCIDENT COMMISSION
pertin
clarin
900 MicroM RUDEST DAN PRAWOreon ^ 41 HELM Bustassa Panwa &
_ *** 200 01 Joe Joe BacamSME
STATE BUILDING LODp Lead 12
neoa 14 160 & DUAK BA99 Laws MacA &
9 NI DANDAY BV #PSK +
F .
, ,
CLAIM No. Save Pa, 101 870
Applicant
,
ve,
PLAAT UNEH RED AMETUS LURKS nMOTHNEG
COAK GUXSAMY GUXSAMY MINULY CORK CITUALTION CITUALTION ASBESTOS
PART ASBESTOS COMPANY WESTERN ASBESTOS
CULANT J. T. THORE ANY IM and
TRAVELERS
TRAVELERS INSURANCE QUANT INCHISTRIALITY INCHISTRIALITY
;
| GORRAKY et al
Defendant
NOTICE OF HEARING OF APPLICATION
FOR ADJUSTMENT OF CLAIM
an You are hereby notified that application na adjust claim for compensation a copy of which is attached herero bes of brem hlad with cha Industrial Accident Commission of the State California You are further notified that sz^dapplication
has been set for hearing at .
Rm 206 1531 hebster , Oakland California on the
_ 23rd day of May 1955 at 1:30 o'clock o'clock p.n. All you
and that be said time and place the
Industriel Accident Commission of the Sure of Californie will proceed to hear and
dispose of the said application in the manner prescribed by law
:
Neri The part^>mare rapexta co vsbae ll r issi uestin esatesvaray for decisina at this bearing therefore aft suchmary with primot docwotempoi docwotempoi vaedic p^reporta payvolio and miker essentiel proad masa be nemilebis nemilebis and reedy for submei t sn kai bro adin ng
Dated
25
ApriApril l 25 1995
,
INDUSTRIAL ACCIDENT COMMISSION
09 AINGUNU J. Blinks Silo Asdotuad Seceq Lary
The undersigned certifie that es en amplaycs of the Industrial Accident Commission she served the foregoing on noticte h
parties hereina^termentioned at the time cet opposite their respective nomes by depositing a copy of said notica attached so a
copy of the application therein nentiamad in mealed envelepo in the United States mail na mid day de bunness goa California with the postage therson fully prepaid and maldressed to the mid porsica at chair lust known plica of bunness a
ravi as d falm lowa ~ tt e ve u
NAMES OF PARTIES SERVEJD
.
DATE OF SERVICE
ses atlechod sbest
SIONATUR..A... ove
EXHIBIT
3-10-83-110-81 C.F. )
-7-7-81 -7-7-81
Dept. of Employ sox 1857 Oakland Calif
4/25/55
Occidental Life Ins Co. 300 Montgomery St. 3.F. Calif
Jack Cuthbertson 2284 Holbrook Dr. Concord Calif
Smith & Parrish Fin Center
Oakland Calif
Bldg Plant Aubuer & Asbestos Works 5309 5309 Horton St. Emeryvillo
Armstrong Cork Co. 1355 Market St. 3.F. calls
.
Mundet Oork Corp. 440 Brannan St. S.F. Calif
St. * Plant Asbestos Co. 5309 Horton St. 5309 Horton Hmaryville
:
Western Ambostos Co.
Everyville J.
San
675 Townsond
Calif
S.P. Calif
.
Travelers Thorpe & Travelers Indem . Co. Latham Square Bldg . , Oakland Oakland , Calif
Indus Indem Co. 350 Sansome St. S.F. Calif
Fund State Comp Ins
Personal Service
* raeifis Employ Ins Co. 3770 Piedmont Ave. Oakland Calif
Calif Cexpensation Ins Co. 20 Geary St. 3.F. Calir
FUE