Document GKNQakk2deN0borKdnMKO3prr

FILE NAME Manville JMA DATE 1967 DOC JMA147 DOCUMENT DESCRIPTION Contract Unit Claim File Oscar L. Gilbert WORKERS COMPENSATION INDUSTRIAL ACCIDENT APPEALS BOARD - CALIFORNIA COMMISSION prior to 1966 APPLICANT OSCAR L. GILBERT a Asbestos Insulator DATE CLAIM FILED April 19 1967 CASECASE CASE oA T) NA 19219 INJURY ALLEGED Inhalation of asbestos to lungs ALLEGED DATE OF INJURY 1942 28 1966 EMPLOYER INSURER Fiberglass Engineering & Supply Casualty et al including m Corp. OTHER NOTES "... generalized infiltration of what is apparently fiberglass e Med Rpt to applicant's attorney " believe his major problems are secondary to his exposures to asbestos fiber- glass and the dust surrounding them DATE OF RESOLUTION Jan. 19 1968 RESOLUTION Compromise & Release . 15,000 15,000 settlement - DOCUMENTS COPIED 1 Compromise Compromise & Release # OF PAGE PAGE . CLAIMANT . Gilbert Oscar Gilbert . ; California Workers Compensation Appeals Board CARRIERS INVOLVED The AETNA Casualty & Surety Co. oAmerican Automobile Ins Co. oAmerican Employers Ins Co. American Motorists Ins Co. oArgonaut Ins Co. oAssociated Indemnity Corp. oCalifornia Casualty Indemnity Exchange oCalifornia Compensation & Fire Co. oCasualty Ins Co. of California Employers Liability Assurance Corp. Employers Mutual Liability Ins Co. of Wisconsin - oFidelity & Casualty Co. of New York , _ Fireman's Fund Ins Co. oGeneral Accident Fire oGlobe Indemnity Co. Assurance & Life Assurance Corp. Ltd. oGuarantee Insurance Co. oGreat American Ins Co. oHardware Mutual Casualty Co. oIndustrial Indemnity Co. Sentry oIndustrial Indemnity Exchange Insurance Co. of North America Ins Co. oLiberty Mutual Ins Co. oLumberman's Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co. oMission Insurance Co. oNational Automobile & Casualty oNew Amsterdam Casualty Co. Ins Co. oOcean Accident & Guarantee Corp.Ltd Corp.Ltd Pacific Employers Ins Co. oPacific Indemnity Co. oReliance Ins Co. oRoyal Indemnity Standard Accident Ins Co. oSecurity Ins Co. of Hartford U.S. Casualty Ins OState Compensation Insurance Fund oTransport Indemnity Co. The Travelers Ins Co. Co. oThe United Pacific Ins Co. OU.S. Fidelity & Guaranty Co. oZenith National Ins Co. oZurich Ins Co. co00 14 14 < 5/81 mm I WORKERS COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 hb OSCAR L. GILBERT CASE NO 67 ANA 19219 5 Applicant 6 VS. ) 7 PABCO CORPORATION EMPLOYERS B MUTUAL INSURANCE COMPANY OF WISCONSIN CERTIFICATION o Defendant } I hereby certify that the attached documents are true 12 and correct copies of the original documents filed in the records - of this office in the entitled matter 13 ATTEST my hand and the Seal of the Workers Compensation Appeals Board of the State of California 16 17 - 19 . 20 21 2 j Dated at San Francisco Board Workers Workers Compensation Judge Compensation Compensation Appeals Board California this 31 day 2 of March 1981 DIA WCAB FORM 115 NEW 1-78 SOSON NT DT EP BELATIONS DEPARTMENT OF INDUSTRIAL DIVISION OF INDUSTRIAL ACCIDENTS guardian guardian litem of guardian ad litem litem and trustee must has not been previouslypreviouslypreviously appointed apointment 2. The accompany this agreement appointed a petition petition forappoapipnotimnetnmtent guardian must a such minor should sign this agreement on behalf of an injured employse who is also sign this agreement under 21 years of age If the minor is above the + Attach all medical reports not heretofore submitted to the age of Workmen's Compensation Appeals Board and adviseadvise when other reports were fir WORKMEN'S COMPENSATION APPEALS BOARD DIVISION OF INDUSTRIAL ACCIDENTS DEPARTMENT OF INDUSTRIAL RELATIONS COMPROMISE AND RELEASE STATE OF CALIFORNIA SOCIAL SECURITY 432-10-4423 oy CASE NO ANA 1921 . Miss OSCAR L. 6532 Mr. Mrs. GILBERT TL AFFLICANT 6532 Bestel Ave. Westminster Cali FIBERGLASS ENGINEERING CO ET AL CORECT NAME OF EMPLOTER ATTACHED SHEET NAME OF ADORGES parties - The hereto for the purpose of compromise only hereby submit the following agreed statements of fact 7 L. 4 GILBEGIR LBET RT 1911 _ claims that he was employed on asbestos worker OGRUPATION workmen's compensation liability from 1942 to employee herein born May 1967 23 See day of the .19 ar MONTH TEARI employers named various cities ICITTI herein in Calif . STATE NAME OF EMPLOYER then insured : as attached sheet follows particularly ISTATE NAME OF OR he sustained an injury arising out of and in the course of his employment as the as set forth in all of medical SELF WHETHER and the To the lungs and more reports filed herein 2. The actual weekly wages of the employee at the time of injury were maximum maximun $ while the average weekly wages wer : 5. The employee's present disability is in dispute and the employee noreturned to work STATE PREBENT DISABILITY REBULTING FROM THE IMAJN HIF SO STATE WHEN 4. a Temporary disability indemnity has been paid to the employee in the sum of none beginning to and including The due and none covering b Permanent disability indemnity has been paid to the employee in the sum of period inE addX itioE n to OaR nyIOsNums hIeOretoIfSSore paid by the employer or the insurer to the employee VCE CEES EX Oe EM XXXXX ~--no SeeAddendutmo Paragraph 5 2 FO. 6. Medical and hospital expenses have been paid 1.119.89 by the employee and none _by the employer or carrier Unpaid bills to 300.00 Future medical and hospital expense is estimated at 5,000.00 Unpaid and applicant future medical and hospital expense is to be assumed as follows All by DIA WCAE FORM 15 PAGE 1 FORMERLY FORM 431 ASV 1.661 eee 322 t.760m ST cur Ne 200 N. Broadway California . employee's 7. Name and address of employee's attorney if Rose Klein and Marias Santa Ana California 8.8. Sa^fldattorney requests a fee of $ 1,500.00 Amount of attorney fee previously paid if any $ -N- Compromise_A_dispute exists this case regarding the question of whe 9. Reason for Compromise_A_dispute Compromise_A_dispute or not the applicant has if to any alleged disability limitations limitations The statute formidable on both sides sustained any industrial injury or injuries and productive extent of applicant's defendants assert the present affirmative defense of the consequently the hazards of litigation are Therefore it is agreed that this Compromise : 10. The undersigned request that this Compromise Agreement and Release be approved 11. Upon approval of this Compromise Agreement by the Workmen's Compensation Appeals Board or a Referee and payment i 12. ; is by all parties hereto that the filing this document the filing of an application behalf the employee and that It agreed of is the W.C.A.B. may in its discretion set the matter for on of issue any of the facts admitted herein and that if hearing as a regular application reserving to the parties the right to put ir have available to them all defenses that hearing is held with this document used as an application the defendants shal thereafter either said were available as of the date of filing of this document and that the W.C.A.B. hearing has been haeplpdraonvde the maCtotmeprrroemgiuslaerlAygsruebemmiettnetd afnodr dReecliesaisoen or disapprove the same and issue Findings and Award amfsteyr For the purpose of determining the lien claim filed herein for the paid under or pursuant to the Californiz unemployment compensation disability benefits which have been _ upon for settlement and release of this caUsneemployment Insurance Code the parties propose the following division of the sum agreed period $ for temporary disability covering the $ _for accrued medical .to expense paid or incurred by the employee $ _for future medical care $. for permanent disability involved The above segregation must be fair and reasonable and must be based on the real facts of the made to deprive the lien claimant of a reasonable recovery consistent with all the case There should be no attempt amounts WITNESS the signaturebereof day of \ Opens Jilb WITHESERS THE INJURED APPLICANT'S SIGNATURE MUST BE ATTROFES BY TWO DISINTERESTED DISINTERESTED PERSONS OR ACKNOWLESSED BEFORE A NOTART PUBLIC ORANGE STATE OF CALIFORNIA of County CALFERNIA CALFERNIA CALFERNIA CALFERNIA By Puled $$ Its Attorneys Attorneys Its Attorneys On this 1971 1971 day of JANUARY JANUARY said County Joseph FARENBAUE _4 Notary Public in and for the __A.D KS before me W. FARENBAUE and State residing therein duly commissioned and sworn personally appeared CSCAR CSCAR known to me to be the person whose name is L GILBERT GILBERT same bscribed to the within Instrument and acknowledged to me that _... be executed the IN WITNESS WHEREOF I have hereunto set hand and written my affixed my official seal the day and year in this Certificate first ebove j OFFICIAL SEAL 4 JOSEPH W. FARENBAUCH orphis PRINCIPAL OFFICE CALIFORNIA| NOTARY PUBLIC CALIFORNIA | orphis BRANGE COUNTY ! orphis Mly Commission Expires Sept. 1971 DIA WCAB FORM $ PAGE 2 IFnsuraLY FORM 431 PEY 1.041 orphis orphis , p- orporhpihiss ; retire , Cre A Notary Public in end for said Countaynd State of Californi 9900B7 670ac0 e 8 (i) iT, 00s i MANVILLE CORPORATION Travelers ; Insurance Company David Taylor 7 , 7 J. T. THORPE & COMPANY American Motorists Insurance Company BY G the the John Henderson a, PLANT ASBESTOS COMPANY BALDWIN INC INSULATION INC Pacific Employers Company Insurance Company of North America PLANT RUBBERRUBER ASBESTOS WORKS , permissibly insured By sogood sogood sogood sogo d int ques ques v SYDNEY LOUIS CARPENTER THORPE INSULATION COMPANY PLANT INSULATION COMPANY Fireman's American Insurance Company FIBERGLASS ENGINEERING COMPANY Aetna Casualty and Surety Company Weingand Kendig & Stockwell ache By 2 U/ AL Abia - * . .f . . ; - ; RE OSCAR L. GILBERT C C ADDENDUM TO COMPROMISE AND RELEASE : LINE 5 The Compromise and Release is to be paid as follows Aetna Casualty and Surety Company 2404 Wilshire Boulevard Los Angeles Fiberglass Engineering Co. 6,771.49 . Street Firemen's American Insurance Company Sixth Los Angeles California Sydney Louis Carpenter Thorpe Insulation Company Plant Insulation Company 5,502.99 Works Plant Rubber and Asbestos Company 537 Brannon Street San Francisco California permissibly insured 1,811.88 Pacific Employers Company Inarance Company of North American plant Asbestos Company Baldwin Inc. Insulation Inc. : < 161.06 American Motorists Insurance Company J. T. Thorpe & Co. 87.60 Travelers Insurance Company Manville Corporation 664.98 TOTAL 15,000.00 It is intended by this Compromise any and all liability of each and herein for any periods of insured unknown to release all of the employment and forever settle named insurance carriers whether or nowknown All payable in a lump sum less the following sums to be Aetna Casualty & Surety Company 269.00 to Morton paid by 226.00 to Dr. Smart 20.00 to Dr. Weinstein Kritzer M.D .; 100.00 to Schubin 504.89 to Occidental Life Insurance Dr. 500.00 to the Department of Employment all Company in full and of their respective Liens and less attorneys fees satisfaction