Document 6bN9azgxDYe76EDkJORwzbjr3

FILE NAME: Colonial Sugar Refinery (CSR) DATE: 1943 DOC#: CSR173 DOCUMENT DESCRIPTION: Insurance Proposal Form  *'' 1 PLAINTIFF'S EXHIBIT io S 3 .D Ffnn as. STA TS G O V E R N M E N T IN S U R A N C E /O l'^ 'lC li.' ---------------- - . . f ~3u? ~ 11 --- 2 IDine proposal jform. For (iisMiiuicc ntfainst oil risk s ititrfcr the W orkers Compensation Act, including Pneumoconiosis, Miners* Phthisis. Ankylostomiasis hh<1 Nystagm us. m ol Employers* T.lublHly A c t 1001. aiul a t Common Taierr*" * ~ - - From 5 - ~~~~ pjro/ AtmMmi r f * * i i w ttoo.al0t MKwwt*ymmt oww> fl ttttV'onWWii XMelw * |Si^4iiyww to 'b T ^ tU h f iW Kwplo,* w d hU S n b O e M n a in ~ --- -- -- -- -- Xo> M THlNihwm If ajr * r I -- r -' ---- I I T iilm m m h ~ h * H tto<r nfir n * * * ito auto to calcali* * to Ito iato a f to toto cS /to I* ** I n t o n i A nw km to-- a & f - ____ * V A i i & O -- v% t. liufctotoil OltoCto Til Nutt 4 Kmptuyer r ~ t.-- A t T *.l I W * . ----------- tT,..' ! g u m ) ! Itoty-------- ^ 6 ------- -- i___________ < ^ 4 ..... * X N W of Mbit 4. 1 y ou r M adrtncry. P la n t. t e ., pnpcdy fcnew l a d y . Cim p K m l ( t t l w r r i o in jewel i W m Utfcm i C E 3 & . A < tU* Xrftiw of firn rnmimiQ* trith which ymt no* ' nm r n v,m provimi dy lio iw il |e. yt fcvfo*TrflHtkw I*li im|iiilr*l tw it ft* W lrj1? / t f m , *4atr fi|tn*rinetMf iwmbtf . 1! iw ir iMpkivivw In |n m w n i o f fomiti eertitleolr*. tr.,ufo^l rvler tlic lhuW *i*M to Um W orn R ^w latfoa AH, NOt. art mnemStwetl* l l w w l t :* ------ `W * . I T H K C O V K K X SK N T O X K KUA I.P OK T IIK KTATJJ rtV KIIXM RXT OIW IW TKRIC A <TRA U A . 4* W n-l.\ n.| , ..j tim i jw i will A . .' a p o licy InH ctm ilfjtoii m e aamto- .Il Maini a l.f lite Wiwiu-- ` Vejnpontotinw A ct, tie* Ki(lVi>W 1 * 0 i . tuul a t l m im on^i'A Aw c n n ip -n M lii Ut m | i l ' ^ o l V e flu .it cw m q td *: m y h iteii** o f m ining -pnwitniivei b i a w C Inetti.' . ^ -- - ....... -- ***** , **n*r kty'" *,mt* * ***** Z j| T lte tJ*1*ltty itndvr tlto T o lle y foe n a y claim arising oth<er*U ti tlutir tro*k?f th e Wurkcre* Cumpenwttkm A ct. I t l S * X tK o r I f Ktnptoyttw' M almty A ct, I M I . fa*limited to th e mtm o f C.VKKI m n ^ t m t o f e n y o r * dt-mOcr. a w l to th e on o f U . ihK) fer c e d i imlivnluAl irumred. inclusivo o f eot end exjtnnooi tinnirm i m oonneetion tl*etTrrrth. .n |tillicy will h o iirvtiKtnl tuid Ih*M su h jeet to tlto rmulitiuiM to Iw ntitowu.nl tlnnein w itli Uta {wovioo th a t th e . volutions ornWr tin* M iitm lU vu latton A c t, rotetin to tlm lntMsrtlon m l c * amination of peroM liable t e be * * H I w ith tnSercnlodm m iw t b e ehsorved ly t h e em ploj-er, m ( th e rorrirtost therein referred t e Jproduevd t e th e ` `vitiiirtont Anttmry. o r It* A a m t. If 1 *dw ti reqn ioo l. ! T Jh* Vnnttimn Ixtve stntr*l line Ixsoo m lro l te *l o pen th e ttmooiM njtortoil to Is pM ns w f o salaries bn- the -to]4o\fr mi1 lib* K ub-C istlrertors.luring th te rm o f th e editi Vt.littj-. m l in w ibicet to detto o r terra* in d ir to My (lirTw one a n s in e fnm t rarin tim i b c t-w cn Us* nm om tt wtii*nt*d to be fwtinl en v o ijw m s l uvnr* d itn r e th e e! jv rk s l nod tlwi a rtio il nim m nt eo i*u<L l tmd*rtnke to k w p a neoount o f all tracce **** m ^* ttdoy.s** uil workers tu n jv|>or nnd n ^ v la r Wi*pw Hook, and to require m y Hub-Contractor* to keep sim ilar ' ace* A s , and o n request supply tlto G overnm ent AoUmty w itli a e orm *t m ssiunt o f oil su di w#C* atu* wilurict, end su bm it -ei, VVitccn Hooke to |Jkj irwpection f Uh G o v o m u v u t A ctuary wImiiavsc mqutrud. ritlic r fo r th e purjh of vorifyinc wrn^*tn*w o f * cluim o r esecrtain in q t4to )>ro(icr notm t o f Vrcm iuni. ) PtCLA RATlQM . ! I lirrdiv dedurci ivi warrant Unit the mmwura f torntAncntn uivi-n al*ovo am true and rorniet m vnTrj- rwpect, and '*'** liftra n* n( Minnelkiiidd any impor*tant drmtmstAuovthr1.t oudt tvt* eo'uiumicme*bto the *ttate ti*oi..x..m....m....mAnt.d v 'tdy n~rco on bchitUIf %.---'.C. .^...u.--u f&.--.r -.t.'..A....&....r..y....,...<.......^.......S.....--. r /....<...'.Z.4...S...J..T...2........--....-`.. l i . t r .....................-........... _ * tis propoli awl lorJomtem s.ell ho th. bad* of cout-mot for li.xtmg'Ufe ebove-mantionnl Jnd^vnmty, ml to * i ,M1 < policy es now. (itadicd f*r. , ! Hijmcd i < s ' _____ ^ IV*- .... y For A U 3TRA U A ffTjLU E^5Ci.ST03 u a i t ^ p --I VrojioMf' Si .^_a_g_n_*__u_`jg#J-\.lf-*>im.! a p i iiil jw rih iiiw f 'H uintol-aWNM