Document Ed5w9jaXL4JBYMEJopa8NkgXj

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1959 DOC#: WCC027 DOCUMENT DESCRIPTION: Workers Comp File - Viall, Lloyd V Contains all documents found in the Claimant's file, with one blank page between each separate document S ` C J 0 , , 4 GiM 4 U, 1/><\( $ r /-M S - 4 y ( n j Cc/rj4 G 11 c / S 'u iio F (7y S t^ W cl AJi daclc{. *0cx4- _ S h e /s '? NEVADA INDUSTRIAL COMMISSION CARSON CITY, NEVADA F o rm C -2 (R ev , 10-58) REPORT OF IN JU R Y OR O C C U P A T IO N A L DISEASE ond W O RKM AN 'S CLA IM FOR B EN EFITS CLAIM NUMBER FIRST REPORT OF ACCIDENT TO BE COMPLETED BY EMPLOYEE, PHYSICIAN AND EMPLOYER THE NEVADA INDUSTRIAL COMMISSION REQUESTS THIS COMPLETED REPORT TO BE MAILED TO THE CARSON CITY OFFICE W ITHIN FIV E (5) DAYS OF THE ACCIDENT. (IF INJURY OCCURRED IN NYE, LINCOLN OR CLARK COUNTY, SEND A COPY TO LAS VEGAS O FFIC E .) N otification of accident-- see Section 616.340 NRS. Penalty for non-compliance-- see Section 616.650 NRS. EMPLOYER--COMPLETE THE FOLLOWING: Q Name on * A rm strong C o n tr a c tin g & S u p p ly C orp, t>tl fnsufnce 9fPr i o r t o l / l / 5 8 A rm strong Cork Conpany O 2- Address 120 N. Lime S t r e e t , L a n c a s t e r , P a. Nature of Business E r e c t io n o f in s u la t i n g m a t e r i a ls Policy Account Number Telephone Number Under what classification have you been reporting employee? 10231* Name (Per Payroll) uW Address 5U8 S . 1*270 W. , Kearns 1 8 , U tah " i |0 ..Age. M Sex oa, Marital Status M u2 Occupation and I n s u l a t i o n Name state in which hired C a l i f o r n i a How Long 96 days Usual Duties M echanic Length of employment with Employed Trave1er you in Nevada By You? (Months) Accident or ) 130 Ui.lJ.tJIJLfcJ.LU d L l L p y t U ' l l * OQtt r rEUlG1 SC 0 >v a l i l ttJ (A Exposure occurred ' \ i Place Stea Crown d A .F . Z B el ., l erbao Reno, h , N A ntio evada: c h, Be C ale a li A f, ,F . B . Hour .M a r y AM svi l l e PM -. - * Date Salii < t0i0l Describe how No a c c id e n t in v o lv e d . Normal w orking 5 Accident c o n d i t i o n s a p p ly in g v a r io u s i n s u l a t i n g m a t e r ia ls to m e ta l oH occurred s u r f a c e s a t th e above l o c a t i o n s . J D cn No a c c i d e n t . working c o n d itio n s Did injured report accident or exposure at once? (Explain "No") UOriTiai , B No Yes cu A d v ised v o lu n ta r y qu i t to Mr, D avid X Did he report accident or exposure to his supervisor? (Give name) H, Hlll'tie r 5 - 2 0 - 5 9 ____ No esQ QS Were there witnesses to accident or exposure? (Give names) UnknOWn No Yes ZH Did accident or exposure to occupational disease occur while at regular work and on company time? wa (Explain "No" ) Unknown No Yes * u < Was injured intoxicated o r misconducting himself at time of accident? (Explain "Yes") Unknown Yes N o Q Date disability commenced' Unknown 1 nst day wages were paid or will be paid 5-15-59 Date back on D id n o t Job r e tu r n * QZ> <u If and when doctor says employee may do light work, will you have such work available? I f workload requiv a No Yes fjcQZ Are you paying his wages during disability? No E sca D iisn ed un ion wage r a te Wages: Give average monthly wage regardless how paid nfiT? hrmr &T.Q75 Yes X o O * (M onthly) * a Is injured furnished r o o m ................. m eals ................ (num ber) oEr osthtear badlviasnthageesdin aUddnitiioonnto wf arniesn? s(Eexplaeinx)o e n se a 1How many total dependents docs injured claim for tax purposes? No Yes 7 <t I CERTIFY TO THE TRUTH OF THE FOREGOING STATEMENTS: Name Relationship N Ago' ` Name Relationship Age * I certify the above is a true statement in order to obtain the benefits of the Nevada Industrial Insurance and Occupational Diseases Acts. ', *J" . i > * ^ 1 Workman's " Date________________________ Place_______________________________ Signature______________________________________________ PHYSICIAN-- COMPLETE THE FOLLOWING: The doctor may assist the injured workman to complete the above if necessary. Please see th at he has signed his report. N otification by physician--see Section 61S.345 NRS. Penalty for non-compliance-- see Section 616.650 NRS. First treatment: Place Name of Hospital Diagnosis and description of injury or occupational disease: Hour Date Describe treatment used: X-ray findings: From information given you by employee, together with medical evidence, can you directly connect this accident or disease as job incurred? Will patient be disabled from work 5 days or more? Estimated Degree of Disability Estimate how long patient will be off work due to this injury or disease Will injury or occupational disease likely result in permanent disability? No No Yes Yes * (Weeks) * Yes N o n Did any previous injury or disease contribute to this disability: (Explain "Yes") Yes N o Date Print Doctor's name Address Doctor's signature .} Degree Mr* J. 8 Taylor - 2- August 5, 1959 In c id e n ta lly , our f i l e s d isclo se th e fa c t th a t the Coomisalon was informed by John S* Murphy th a t a l l sen were h ire d in C a lifo rn ia fo r work in Nevada. I f th e number o f lung claims keep on Increasing as they hare in th e p a st sev eral weeks, most o f your time w ill be spent on a sb e sto sis and pneumoconiosis claims* Seriously though, i t i s Important th a t ve cooperate with our insurance c a r r ie r s and give them a l l the help ve can f o r two reasons, f i r s t , these claims u su a lly r e s u lt in t o t a l permanent d is a b ility which means maximum compensation awards o f which ve w ill pay our p ro portionate share. 8econd, th e re i s some doubt th a t our type o f work could cause a sb e sto sis. However, since one employes c o lle c te d under the C a lifo rn ia Occupational Disease Law, we have had q u ite a few a sb esto sis claim s. Our only concern, where an award has been made, i s to be sure ve are n o t charged with more than our p ro p o rtio n ate share. I f you have a d u p lic atin g machine, w ill you send n s a copy o f th e C-2 form subm itted. Very t r u ly yours, . ABMSTBOHG COBH COMPANY JEZ Enclosure J . E. Z e lle r, AC&S, L ancaster R. C. Schiedt, J r . Insurance Department ' > gant saw yer Governor STATE OF NEVADA NEVADA INDUSTRIAL COMMISSION T. L. HUTCHINGS COMMISSIONER REPRESENTING W . G. EMMINGER COMMISSIONER REPRESENTING LABOR INDUSTRY Carson C ity , Nevada August 24, 1959 OUY . PERKINS C hairman ADDRESS ALL CORRESPONDENCE TO NEVADA INDUSTRIAL COMMISSION REPLY TO Armstrong C & S Company 120 E. Lime S t r e e t Lancaster, Pennsylvania Re: Lloyd V. V ia ll Claim No^OD-59-14826 Gentlemen: Upon r e c e ip t o f a com pleted cla im form and n o t ic e o f cla im on th e ab ovenamed i t i s shown th a t he was h ir e d in C a lifo r n ia T h erefo r e, we su g g e st th a t you report th is claim to the C a lifo r n ia C arrier as i t would not be handled through th e Nevada I n d u s tr ia l Commission Trusting th is exp lains the handling c c : Mr.Lloyd V. V ia ll 20 East L iberty St Reno, Nevada Robert K. M yles, M.D 975 Ryland S tr e e t Reno, Nevada Arm strong C O N T,R A C T I N G A N D S U P P L Y C O R P O R A T I O N S u b s i d i a r y of Ar ms t r ong Cork Co mp a n y 304 SHAW ROAD SO U T H SAN F RAN CISCO . CA LIFORN IA August 10, 1959 m ^ cr` wo> Mr. R. C. S c h ie d t, J r , Insurance Department Armstrong Cork Company Lancaster, Pennsylvania Subject: Llovd V. V ia ll 'M ' -- f o g - s g Workmen' s Com pensation - Nevada Dear Mr. S c h ie d t: Enclosed copy o f Report of Injury or O ccupational D ise a se , Form C-2 as r e q u e s te d in your l e t t e r o f A ugust 5* 1 9 5 9 . Very tr u ly y o u rs, ISTRONO CONTRACTING & SUPPLY CORP, John S. Taylor D i s t r i c t Manager DJM Enel. J . E. Z e l l e r , ACVS, L a n c a s t e r . * * NEVADA INDUSTRIAL COMMISSION CARSON CITY, NEVADA Form C-2 (Rev. 10-58) REPORT OF INJURY OR OCCUPATIONAL DISEASE CLAIM NUMBER and WORKMAN'S CLAIM FOR BENEFITS_____________________________ FIRST REPORT OF ACCIDENT TO BE COMPLETED BY EMPLOYEE, PHYSICIAN AND EMPLOYER THE NEVADA INDUSTRIAL COMMISSION REQUESTS THIS COMPLETED REPORT TO BE MAILED TO THE CARSON CITY OFFICE WITHIN FIVE (5) DAYS OF THE ACCIDENT. (IF INJURY OCCURRED IN NYE, LINCOLN OR CLARK COUNTY, SEND A COPY TO LAS VEGAS OFFICE.) Notification of accident--see Section 616.340 NRS. Penalty for non-compliance--see Section 616.650 NRS. EMPLOYER EMPLOYER--COMPLETE THE FOLLOWING: Name on * Arm strong C o n tr a c tin g & Su pp ly Corp* insurance6 f Pr i o r l / l / 5 8 Ajjnstrong Cork Conpany Policy Account Number Address 1 2 0 N. Lime S t r e e t , L a n c a s t e r , P a , _ Nature of Business E r e c t io n Of i n s u l a t i n g m a t e r i a ls dum ber Under what classification have you been reporting employee? 10231* EMPLOYEE Name (Per Payroll) Addiess S , 1*270 W ., Kearns 1 8 , U tah _____ lip. Ay. M Sex . Occupation *and Usual Duties Accident or i Exposure T } Occurred J Marital Status In su lation Name state in which hired......_ C a l i f o r n i a How Lone Mechanic - Length of employment with Employed T raveler you in Nevada By You? .....Isa c h i ehem -s h ip y a r d , s a n F r a n c !s c o , Ua i ii" . Place Stea Crown d A .F . Z ell B. * erbao Reno. h, N A ntio evada; c h, Be C ale a li A f. .F . B . Hour .M a r v AM svi l l PM e. -D ate GpliJ M 96 day (Months) Describe how No a c o id e n t in v o lv e d . Normal w orking Accident occurred co n d itio n s applying various in su la tin g m a teria ls to m etal su rfaces a t the above lo c a tio n s, t Did injured report accident or exposure at once? (Explain "No" ) Nnoor ma cacl i d e n t . Working c o n d itio n s A dvised Did he report accident or exposure to his supervisor? (Give name) Hv o. luHnatrapreyr gS--u2i0t " StQo Mr, David Were there witnesses to accident or exposure? (Give names) U nJCHOWTl B No No No Yes tfes Yes Did accident or exposure to occupational disease occur while at regular work and on company time? (Explain "No" ) Unknown No Yes * ACCIDENT OR EXPOSURE TO DISEASE Was injured intoxicated -or misconducting himself at time of accident? (Explain "Yes") Unknown Yes No DISABILITY AND DEPENDENCY Date disability commenced ~ Unkno~wn ' ' pInasidt doarywwilIag%ees pwaeidre ?*ti_?C?(Q7 Date backJoobn Did not return * If and when doctor says employee may do light work, will you have such work available? I f WOrklo&d re Q U l> S SO No Yes Are you paying his wages during disability? No E stab lish ed " un ion wage r a te Wages: Give average monthly wage regardless how paid pAY* Finny Yes o n * (Monthly) * Is injured furnished room................ . meals................ o r other advantages in addition to wages? (Explain) (number) E s ta b lis h e d U nion f r in g e ex p en ses No How many total dependents does injured claim for tax purposes? . 7 I CERTIFY TO THE TRUTH OF THE FOREGOING STATEMENTS: Yes n i * io rn M D T F T P ANT) T .E E T R L E * EMPLOYEE--COMPLETE THE FOLLOWING: Name Relationship Age \ Name Relationship Age I certify the above is a true statement in order to obtain the benefits of the Nevada Industrial Insurance and Occupational Diseases Acts. Workman's - Date________________________ Place_______________________________ Signature__________________________________________ PHYSICIAN-- COMPLETE THE FOLLOWING:; The doctor may assist the injured workman to complete the above if necessary. Please see th at he has signed his report. N otification by physician--see Section 616.345 NRS. P enalty for non-compliance-- see Section 616.650 NRS. First treatment: Place Name of Hospital Diagnosis and description of injury or occupational disease: Hour Date Describe treatment used: X-ray findings: From information given you by employee, together with medical evidence, can you directly connect this accident or disease as job incurred? Will patient be disabled from work 5 days or more? Estimated Degree of Disability Estimate how long patient will be off work due to this injury or disease Will injury or occupational disease likely result in permanent disability? No No Yes Yes ' (Weeks) * Yes N o n Did any previous injury or disease contribute to this disability: (Explain "Yes") Yes N o n Date Print Doctor's name Address / Doctor's signature > Degree