Document DMb5rGq22w2ezVZJQxv7yvx5a

FILE NAME: Contract Unit W orkers Comp Claims (WCC) DATE: 1967 DOC#: WCC063 DOCUMENT DESCRIPTION: W orkers Comp File - Horsman, Robert File Name Contract Unit Claim File: Robert Horsman Oct. 23/67: Amended Sept. 5/68 Scanned ? yes Source JMA: NS-JM Start Year 1967 Stop Year 1967 Contents claim Notes WORKERS' COMPENSATION APPEALS BOARD - CALIFORNIA (INDUSTRIAL ACCIDENT C O M M I S S I O N , prior to 1966) APPLICANT ROBERT HORSMAN CASE # LA 316509 Asbestos Installer DATE CLAIM FILED Oct. 23, 1967 Amended Sept. 5, 1968 INJURY ALLEGED Inhaling foreign substances .ALLEGED DATE OF INJURY 1925-1967 EMPLOYER/INSURER Thorpe Insulation Co./Firemen's Fund Ins. et. al. including J-M Insulation OTHER NOTES ________Pulmonary fibrosis secondary to asbestosis DATE OF RESOLUTION Jan. 22, 1970______________________________________ RESOLUTION Compromise & Release $19,000 settlement apportioned among 18 employers/carriers DOCUMENTS COPIED 1) Compromise & Release # OFjPAGE 2) Application showing original defendants CLAIMANT______I ^ U - t H o r - s m ^ n _________ __ __________ 4. 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 Liability Assurance Corp.Ltd. Employers Mutual Liability Ins. Co. of Wisconsin _ 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 Industrial Indemnity Co. olndustrial Indemnity Exchange olnsurance Co. of North America oLiberty Mutual Ins. Co. Lumberman's Mutual Casualty Co. Ins. 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. of Hartford (U.S. Casualty Ins. State 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. Co.) f-tart-ford de-rrt v IrtCI t m m h j Pa.----------------------- S-fcPUrrfy. Catual-bj, Cfi------------------------------- o o 5/81 1 WORKERS' COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 HOBEST J. HOBSMAN, 4 Case No. 67 LA 516-509 5 Applicata 6 vs. 7 THOEPE INSULATION COMPANY, et al, FIBEMAN'S FUND INSUHANCE 8 COMPANY, et al. CEHTIFICATIO 9 Defendant 101 I hereby certify that the attached documents are true 11 121 and correct copies of the original documents filed in the recdl 13 of this office in the above-entitled matter. 14 ATTEST my hand and the Seal of the Workers' Compenst 15 Appeals Board of the State of California. 16 17 18 19 looters' Compensation Judge 20 Workers' Compensation Appeals Board' 21 221 23 24 Dated at San Francisco, 25 California, this g day 26 of April, 1981 27 FORM 119 <NtW !.> MP**TMfrropittounniAkRruttox CHVMtON o r M fO U ttM U k a c c ic w t O 1 MCLAUGHLIN, EVANS, DALBEY & GUMMING 1717 North Highland Avenue 2 Los Angeles, California 90028 r..i .o r ; 3 466-8541 4 Attorneys for Owens-Corning Fiberglass Corn, and Aetna 5 Casualty & Surety Co., Defendants 6 7 X fe. 3 3 5 rv ? 8 WORKMEN'S COMPENSATION APPEALS BOARD i Cu -> rt; 9 STATE OF CALIFORNIA 't2 2sa *55 10 ROBERT J. H05SMAN, ) 11 SSA: 562-03-2606 ) Applicant ) 12 ) vs. ) 13 MUNDET CORK CORPORATION, at al.) 14 CASE KO. / / --Gr ess v'r* 67 LA 316 509 COMPROMISE AND RELEASE AGREEMENT Defendants ') 15 16 The parties hereto, for the purpose of compromise only, 17 hereby submit the following agreed statements of fact: 18 1. Robert J. Horsraan, born August 26, 1904, claims he 19 was employed between 1925 and June 28, 1967, at various locations 20 within the State of California as an asbestos installer as a result 21 of which he sustained an injury arising out of and occurring in the 22 course of his employment from inhaling foreign substances, or in 23 jured self in some other manner, resulting in injury to his lungs 24 and other injuries, symptoms, conditions and complaints set forth 25 in the medical reports on file. 26 'i h 2. During the alleged period of employment, the applicant 2 7 j; I1mas employed at various tines by Coast Insulating Company, .The 28 i. Philip Carey Mfg. Co., Owens-Corning Fiberglass Corporation, Munde; 29 ' ]Cor'.; Corporation, Fiberglass Enoir.eering and Supply Company, Frotter 30 1 G.:~.b!e Coop Company, Los Angelas Department of Mater and Power, 31 ,,J. '7. Thorpe, INC., Insulations, Inc. Marine Engineering Company, 32 ji T":.-ic-i, Inc., o cor porat !no, sutcesso- to California Petroleum Corp. ( ( I V V 1 Los Angeles Rubber Company, Los Angeles Cork Company, Plant Ash 2 Company, Coast Insulating Products, Swift Packing Co., Armstror 3 Cork Company, Metal Clad Insulation Co., Accurate Insulation Cc 4 Inc., Shell Oil Company, Johns-Manville Sales Corporation, Arms 5 Contracting and Supply Corporation and various employers set to 6il in the Application for Adjudication of Claim. 7 (3.) The actual weekly wages of the employee at the. t i t 8 injury are in dispute. 9 (4.) The. employee's present disability is in dispute. 10 (5.) Mo temporary disability indemnity has been paid tc 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 15 deducting of attorney fees and lien claims of record, excepting t 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 8, 1967)and the Department of Employment commenced 20 payments July 5, 1967. 21 (7.) The applicant's medical expense has been self-procu: 22 and none has been furnished by the employers or carriers. 23 (8.) At various times the insurance carriers for various 24 employers during the alleged period of injury were 25 26 27 28 29 SO., k 31) 32 (a) ARGONAUT INS. CO. '' ' (b) CASUALTY INS. CO. OF CALIF. (b) THE TRAVELRS INS. CO. (c) HARTFORD ACCIDENT & INDEMNITY CO. (d) MISSION INS. CO. (e) STATE COMPENSATION INS. FUND i ;) 7 (f) UNITED STATES FIDELITY i GUARANTY CO. (g) GUARANTEE INS. CO. (h) AMERICAN MOTORISTS INS. CO. (i> SECURITY MUTUAL CAS. CO. (j) INDUSTRIAL INDEMNITY CO. (k ) FIREM AN'S FUND IN S . CO. ' " (l) GENERAL ACCIDENT FIRE & LIFE A5SUR. - 2- CONTRIBUTION 1 .6 9 4 . 0 0 328.00 1.259.00 41.00 91.00 1.950.00 55.00 701.00 680.00 118.00 144.00 1.780.00 275.00 ( ( C O im iB l'T IC 1 (m) Pacific employers Ins. Co. -?//C $ 3,003. 2 (TO Employers Mutual Liability Ins.Co. 969. S (o> Aetna Casualty it Surety Co'. C/ ` ' 5, 2 6 2 . 4 (?) Proctor & Gamble Soap Co., 5 permissibly self-insured 25. 6 ( q ) Los Angeles Department of Water & Power, legally self-insured 620. 7 9. The employee's attorney is Steven Roseman, 1543 Vast. 8 Olympic Boulevard, Los Angeles, California 90015 9 10. Attorney requests the fee of $ 1600.00 10. Amount of attorney's fee previously paid, if any, $ None_______ . 11 11. Reason for Conoromise; A bona fide dispute exists 12 as to whether or not the applicant sustained injury which arose 13 out of and occurred in the course of his employment through ex 14 posure to any deleterious substances while working for the named 15 employers. The nature of the applicant's illness and the extent 16 of his disability is set forth in the medical reports on file. 17 There is a dispute as to whether or not any portion of the appli 18 cant's disability is due to causes other than industrial exposure. 19 The applicant has expressed the desire of resolving the litigation 20 by obtaining a lump sum amount and controlling his own- medical 21 treatment in the future. All parties desire to resolve the dis 22 puted issues by this settlement, thereby avoiding protracted cslay 23 and expense of litigation. 24 12. The undersigned request that this Compromise and 25 Release Agreement be approved. 26 \ 13. Upon approval of this Compromise Agreement by the 27 Workmen's Compensation Appeals 3oard or a Referee, and payment in 28 ' accordance with the provisions hereof, said employe releases and ' 29 i. forever dischargessaid employer and insurance carrier from all j 301 claims and censes of action, whether no'.' ::nr.m or ascertained, or which, m ay her setter arise or develop as a result or said injury, *4 32 j. including any end all liability of said employer and said insursne ii -3- ( ( 1 carriers and each of them to che dependents, hairs, executors, 2 representatives, administrators or assigns of said employee. 5 WITNESS this i^-day of 4 Angeles, California. 5 < //. 1970, at Los ' 6 OBSST J-.HORSMAN, AppIicanF 7 V. 8 SToVEN ROSE^iAN, App'licant s att: 9 ARGONAUT INSURANCE COMPANY 10 SBEyC:UHRANINTAY.MAUNTDUABLR0CAHYSUALTY/jC/O>. 11 By. 12 THE TRAVELERS INSURANCE CO. By: PARKER & DALLY 13 14 By. CASUALTY INSURANCE CO. OF CALIF. 15 16 By 17 HARTFORD ACCIDE^ &,INDEMNITY CO 18 By ________ 19 <'JAMS yOODS*- 20 MISSION INSURANCE COMPANY 21 3y % } H d T Y ' _______________ 22 STATE COMPENSATION. INSURANCE FUN! 23 24 25 U. S. FIDELTY & GUARANTY CO. By: H3ELIHY.HERLIKY,JONES & NELSC 26 27 28 29 30 31 I, 32; LOS ANGELES DEPARTMENT OF WATER Sc PO'.'SR _ . By. Piiocxor. & g/.mole s o a p c o . Bv: >!ENL:"V,UERLIHY,RONES & NILS. > Jy* 4? t 0 ( { 1 GUARANTEE INSURANT COMPANY By: GONZALE 2 3 4 AMERICAN M0T0RiSTS''IN5u7jfNCE CO.; LUMBERMEN'S MUTUAL INSURANCE CO. 5 (./ .'/C ! 6 i INDUSTi]T^rlAL INDEMNITY COMPANY 7 8 i1 Bv L" ----~~~_______ 9 FIRMAN'S FUND INSURANCE COMPANY 10 By:(/ VJE^JGAND, KENDIG ^STOCKWELL 11 By ' 0? 12 GENERAL ACCIDENT F & LIFE ASSURANCE COMPANY 13 By; HERB GARAB2DIAN 14 15 16 17 18 19 20 AETNA SURETY & CASUALTY CO. By;MCLAUGHLIN,EVANSDALBSY & CUMMIb 21 22 23 24 STATE OF CALIFORNIA ) ( ss. 25 COUNTY OF LOS ANGELES ) 26 j r/ On this -? day A .D.. 1970, before na, 27 the undersigned, a Notary public in an<^ tor the said County and jState, residing therein, duly commissioned and sworn, personally 28 'appeared ROBERT J. HORSMAN, known to ne to be the person whose i name is subscribed to the within Instrument, and acknowledged that 29 'he executed the same. 30 my n Iracial sc 31 32 :J (5 -2 A L) ; M*- i > /OV.VtSSU ( l.'- ... - ' ' L' K. . . J.j;. It ,' iyj. . Mr. .` . 7 s.-.---'\ Ki:.! . m' h i.,.'. .-.j M.fU ..................... S. <-' C. ' r-. i c a s e x o . r~ Vi . ___________ c .v .n r m'.sfSt T*-t* . I'hcruc Ir.sulsticr. Cc. -i5 :!--1ta c ia il- s iig a i ) _______ .tote. 27i l .V att-s (tFI.OTtft Fireuan's Fur.i. Ir.surar.ca Co _________Corr t?>a g.tffC:iod sheeJ i-'.s*I :>*4ile(> c sm.ma. s;; .T IS CLAIMED THAT: Los r.r.r*fl1nr,. C -1iforr.ia.______ , a 322 _______ :_ Los l.r.^clcs, California I. Tr.r injurej b c r n _ _ 2 /-* /! kj'2,- -- while employed is 3 . islvdxii-,:r.WiLinr- iTIV AT T<M(r IN. . o r ---------1--S----2-----i--o-- aCt _/_2_2_/__.S_C__7___ __ . v...a..r..i..o....u...s... ................ caTC 0 by the employer u n tiin iJ injury . c i ir t i in the eo jr>; of employment to . Occupational Disease itnit*>atfkTsc>i?:t1*1 2,. TThue i.n.jury oecjrrec.31 froullows: __I_n_h__a_l_i__n_'_;:___f_o__r_e__i_g: _n___c_u__u_s__t_a_r__c_e_r__._ iIasiaim waat twnem . as csikc at t mse* im.mayamms. imas. tai Atst-kt: 3. Actual c.irnmj i : time of injury were: .'axinur. (<vc wu>. 01 u u x en u i r ttA-rt <,( u v ;t( c* >:sia 0im . i;t s thm c 4. The injury earned disability 25 follow*: Jur.c 23, 12C7 to ciato r et 0rt * ejt to r** r J. Compensation wa> paid S ^ . $ , _ ... -- - -- ( < (No I ftom m t. iwcgKkttatc. ioati or utr w n ( 6. Medical treatment was received . VOS All treatment was furnished by the rrnir. c isu n TJ. (MOi 4?ATt or tali TKlATftNt t ermpans ----- tt* othe- treatment was provided or paid for b y ------------------------------------------------------------------- V? lH A M t P<$0N S* t tk C T S / . S l N i 0> ,A ' . 5 T* * t 5 2* . { * ! Dvctcr r.o: p.-.-.. ,.!i j cr paid for by employer or insurance c e n tu m . v.ho treated or evsmjr.cJ for this injury are _ - ___ D r. vcoryo D e r r y cine" .*?A T | N W J an; a s. * :s * f * D r . f l e i r a l c * F r . n r t ________________ a *. 3 w * n i a ' i * t c - .*> * . c * s ; : * 5 . * .,* * ? Crwi-ji'ic;. r*.cnt * ''..r.'^ eo r Vn.*r.pl'j; m;nt Coi.'p:r. Dlsal'iht;. ben.fi: t have born rteei.ed since the date of injury-- ,- ' __ it * S. O '' -.7 n.>'ls b ..r filed for indu\:ria injurlo by this emploscv .a foW v. ,-- CAti Dor.. '! 'jv'- y h c " I* "`d . *. Pm< >! . . , I.r*: 1 1 -.1 i-f ; h'bdt. for: Tcm;`*rar. , v\ . '* M.'d'.'.'l tV'.UU'i't . m 'S. SS . :K>. ipp'oj.i . n- * IC'VI . l-i'.tN md-.niria. '* Pcrr.-'r.-it : ' : Ca(r- j r . ' ' -** -r .m.- i b-. : a . c il, `.*i n.i.*.* . 1 ' `r ^, 5. - . Is T."-* /T / ............................. I ( r.:r:."v r:n Irsulation Co. 27 :i 5. Ictus Av Lo" Anyo'. ~ ?, California ctalc.'ad Insuliticn Co. 21754 i . 'Cosier- Avenue I'crrr. co, C* 'ifo.rr,5.u The Ihiiiy. Ca-.:y Mfg. Co. 532 G. Monterey Pa.ss Ad. Mentor- 0175.'= Cf.li2o-r.ir. Western Asbestos Co. 240 valley Drive isbare, California, 04005 Insulations Ir.c. (sole1 to) , ilio Carey Mfg. Co. v 2 S. Montarey Pass D. Monterei- Park, California Ov;er.s Cornine Fiberglas Coro. P.O. Bo:: SOI* Toledo, Ohio Los Angeles Cork Co. ,,.T. Thorpe, Ir.c. 94C B. 2nd Street Los P.r.noles, California, 012 Arm,strong Contracting & Supply 120 u. Lime Street Lancaster, Pa. Commercial Contracting Core. 32217 stephenscr. Kvy. Madison '.eights, Michigan The Isotherm Co. 05 Williams Street B a k e r c . l d . California Murdot Cork. Cc rscratior. 7105 '.c-.rollc .'.venue, Wo. Icryo:., '...I. c CAMAt-r i?i--:,:.f':i, 1 1 1 *>/if>r? 1 -> *> .* ` f - April, lr67 Gv, i: Fireman's Fan:' Inivyone Co--irr.y 3223 fth Street - Los An.ro'.c?, Califcr Fartford Ir.s.- ''rout ; 50.2 f. Spring Street" Los 'r.gelep, Sr.lifcrv.ir General Accident Ir.s I 0 3535 W. Cth Street Los Areelcs, California 6/12/65 1/ 2/66 3,4/65 and Fob'., 1966 10,11/1952 11,12/1953 1-7/1954 1-12/1957 3-12/1953 1955,1961,1962, 2,3,4,5,6/1963 3-12/1964 and 8-10/19GC 12/19C4 end 1,2/1965 1961, 1963 6 1964 Pacific Bmoloyers Ir.s. Co. 4053 Wilshire Boulevard Los Angeles, California The Aetna Casualty f Surety Ir.s, Co., 2404 Wilshire Boulevard Los Anceles, California and Fr-.ployers .VirtueIs cf Vai 3540 Uilshire Boulevard Los Argeles, California Fireman 's Fund Ir.s. Co. 3223 !:. 6th Street Los Angeles, California American Motorists Ins. 3545 Wilshire Plvd. Los A.r.coles, California 1961, 1962, 1963 t 1964 1962 The Travelers Ins. Co. 3600 Kilshire Boulevard Los Angeles, California 1962 1939,1952,195? 1PC1 The Aetna Ccr.ur.ltv : Sur Ir.s. Co. 2404 Vilshiro ri-c. I.os Angeles,- Crl iforr.ir ( -~2-\ :'. Chico `:-j, California P1?**- r.D..o3tt c Co. isi'-.m. ?th si. Lone hunch, Calif. Acci-.r;'ic insulation Co., Inc. Los clos, California Air Conditioning Inc. -- ?n01 Kettr.er Boulevard in Diego, California Const.Insulating Products o longer in business) v .C< Lacy 2t. Los Angeles, California Department of mater s ?ct;er of the City of Lcs Angeles 207 S. Sroachray Los Angeles, California Art.-.strong Cerh Co. 120 Li:.;s St. Lancaster, California ro'.-n s P.oot Construction Co. >'..'ston, Texas Johns Uanville insulation Co. South Carolina ( sas City, Texas Houston, Texas Korth brothers Atlmtti, Gci. Pittsburg, Pa. Denver, Colorado Stern Brothers Denvnv, Colorado St-?;..":r s V c tr.? l i j r i '. - r . r . ' . i ? y.'Vv MOvi# -vr. / Cc::r ~ ; : : r.'-ii.'isr.' r _ Co. ( : ; -.*'-j j1. 7- /--tvf\//i*o. * i i ,12/I9:r* f- r; 1 2,3,4/1900 3 ''3 So. v:. Los 3-r/.rclor, Coli *crr.i- Casualty Ir.s. Cc. of Ce P.2. Ton 3195 '.r.aViir-., Cali'orr.i-r ar.d State Ccr.rcr.satier. Ir.s. P.O. Box 2134 Los Angeles, California; 12/1954, 1-12/1955 1-12/1950 1959 and 5-10/196$ S-10/1954 Argonaut Insurance Co. 443 Shatto PI. Los \ngeles, California and Guarantee Ins. Co. 1671 V.'ilshire r.lvcl. Los Angeles,. California (LEGALLY u ::i:;s l t a 3) 11,12/1954 The Travelers Ins. Co. 3600 milshire Boulevard Los ingeles, Calif. 1951, 1-4/1952 1942,1947,1949 1949, 6-9/1952 (Self Insured) 1951 1943, 1-3/1950 1940,1941 6 1950 % 6-9/195 9-11/1950 i o V. 1940, 1947 i:.;n 1" *. 5 c < i::;a . s ::.;r:.zzsz$ Tarr. Kate: H o u r a n . Terree ?0 Tipa and Teat inn Co. Korlb' Carc'in:. Peulsborough, rev: Jersey ?.ic'.v.o V i r g i n i a SrocT.-., risher Insulation Co. Altar.ta, Ga. ;iar3 no engineering Co. Los Argeles, California " Badger Construction Co. i' chita, Kansas \ Plant liulrbcr l- ."sbostes Co, San francisco, California ,537 Branr.or. Street)/ Los Angeles, California Warrer. Bailey Insulation Co. Los Angeles, California General Petroleum Co. fos Angelos, California >3 Angeles Lubber Co. .os Angeles, California Proct or and Gamble Soap Co. leor Test 7th Street Long Acach,California Ter-raco Oil Co., Inc. (main office) 3359 Vilohiro Los A.ngele.c, California Thor: T-rvcrf Plumbing Co. Lor. :r.gclos, Californi (::o : I" '*JTI"r5S) .-.ce An'-'.rtcr Co . 1.0 r. ; geler , Cal ifornic : co. -1 Cn) ir 7 .Y . r-och Cr. r . -, Ce)':' r-v.'l / * . * . n -^/ -. - / 1 ?: <. 10v5 1041 1 ftV ` *>.0 - i r ' o 1940 : : C 1933, 1539 193? Pacific Kr.nlovers 1 rs. 4059 piishire Boulevard Los Angeles, California 1938 (Self Insurer.) 1937 1937 1934, 1535 r. 1936 1933 1931 and 1932 Security Kutual Cas. Ce c/o P.eeves Iiav Ad juste 113? 47. 6th St. Los Angeles, Calif. State Cor.tensEticr. Ins. P.O.Pc:: 2134 Los Angeles-, California Occidental Ir.dev.r.ity (aderess ur.):noT.-;n) State Compensation Ir.n. P.O. Box 2134 Los Angeles, California and Lur.berm.an's "utu.al Ir.s'. 3545 vrilshire Boulevard Los Angeles, California (Soif Insured) 1930 1527,1928,1929 California Cas. Indnrnit r::cV?r.7 2 417 3. Kill Street Los Angeles, California 1935 r.r.1 1920 192C ] 52c Pt-nLc Cc.T'.ar.rat: or In-. P.O. :`.c:: 2134