Document 7Zz0Om36O0zgBxoJkMO46Zkg

;k ; V > Redacted ui. That the following is a statement of particulars relative to this application: 1. Name of Injured or diseased employee. Address. Occupation. ^Age. a. Name of employer. Address. Place of business. Business address. .. 929 Stnne street Louisville- Kentucky 40217 Chemical Operator 55---------- : F. Goodrich * |p - Bells Lane Louisville, Kentucky 8. Name and address of all other parties to this application and reason why each party Is Joined. Name and address of employer's Insur ance carrier. If known. Self-Insured 4. Place of accident or exposure, City, County and State. Louisville, leffers^^ S. Nature of work on which Injured or diseased person was engaged at time fcorkin^ in plant which uses vinyl chloride of accident or exposure. 6. How did accident or disease occur? (Describe in detail.) Exposure to harmful chemicals If occupational disease, give your work history with the names, addresses, and dates of employment where you received injurious exposure. Employer and Address Date Type of Work Present employer Be Fe Goodrich Bells Lane, 1956 to Present chemical7 opera 7. Nature of Injury or disease. (Describe In detail) (II occupational disease, list name of doctors whose reports . are attached.) Liver damage 8. Has Injured or diseased person fully recovered? If so, when? When did such person return to work? No....... ....................... ....... Co. transferred employee " p^SJffii"n,"u^SSrt5SrriaS Permanent-future extent unknown at this time thereof. If death resulted, so state giving date of death. ___________________ ___ __ ______ ________ _______ ________ --____ ______________ _______________ NGC39366 0-M > r . t10. Was medical and surgical treatmen. required? Was It furnished by employer? If not, did employer have opportunity to furnish It? 11. Name and addresses of attending phy sicians. 12. Wages of employee *t time of accident, (State whether paid by day, week, ngBnth, ir year.) <.flow long did Injured person work for this employer at this wage prior to ~ the accident? State whether employment waa for 5, 5tt, 6 or 7 days per week. IS. Amount Injured person Is earning, or U able to earn in some suitable em ployment or business after the acci dent. 14. Payment, allowance or benefit received from employer. 15. Additional amount claimed as compen sation. ^ Redacted Yes / Yes Dr. Creech -- Dr. Stanley Smith plant physician fronton Highway T.pu KY | .......... S5.16^j'lap n.r hour...... Prof resstve vase tosrfeftseB.jmder_.CQlle^ bargaining agreement 5 ..yeerJLes.&rkhaa before discovery Af 1 i lrnr HicaSQA 2g............ ___ .for...... ......____________ weeks' medical care and attendance. ."Q*.g ...._________ ____.per week for . ... .......weeks' disability compensation. for...lMXimUm,___weeks' medical care and attendance. 16. When was the employer notified of the accident or disease? Titeml^rexjMndTture made by you "(or this purpose) maximum_____ per week (or___PU3XiTOUnV..week* disability. If employer was not notified promptly after date of accident or dtsease, give reason for failure to notify him. 18. State name, address and relationship of all dependents. If to adjust claim for medical attendance or funeral expenses, state name and address of alt other such creditors and amount of claim, If known. Name..!. Address.. (This paragraph must be filled out completely.) .529..Stone.street,...iAauiflville,...Kentucky Name...'. Jdress...............same... Name... Name.... ......... .........Address------- ..,,...s.eme.. ...^...............--Address____________ ... .same.. Name........ . Name. Address-- Name. Address__ Name----------------------------------------------------------------------- -------------Address. WHEREFORE PLAINTIFF PRAYS, That the above-named defendant__be required to answer this petition; that a time and place be fixed for hearing hereof and due notice thereof given, and that upon such hearing, an order or award be made by your Honorable Board granting such relief as the said applicant__ may be entitled to in the premises. 7 Dated ____ ....... this....lZth-day of...... April.............. :-i 19-74 (Signed;----- -------------------------- iriamuii) 'vj Address.... .929-.-Soue...tree-t- plaintiff hereip^eingdulyswam^says" foregoing application are true. Subscribed and sworn to before me, this.v..12fch...day of (Plaintiff) ___ , 19.7.4.. My commission expires ........ 11/9/77 Public or other authorized officer County State at Large,..K.enttu:Vy NGC39367