Document JJaY4j9v9GBNQJO6zzmGBpz9X
STATE OF NEW J ERSEY
File answer at........ Hearing to be held at
DEPARTMENT OF LABOR AND INDUSTRY ^
...
divisionriO?.xP-S^
[ PLAINTIFFS < EXHIBIT
COHPtWSATJON TREH fON.NJ.
NG108D
&s*IS 9U
EMPLOYEE'S CLAEO^SIHIQW^Hk 1COMPENSATION
cc:r:
BEET GIBBS
vs. NATIONAL GYPSUM CO.
'Petitioner,
JRespondent,
B. C. KcCDY OCT 5
'AMERICAN MOTORISTS INS. CO. (Name of Insurance Company)
KPEK. KIRSCH ..&^:SSSgI.S^SC-S ______
(Attorney for Petitioner)
Academy St., Newark, K.J. C71C2
(Address)
To the Division op Workmen's Compensation:
Petitioner, alleging that be sustained an injury by an accident arising out of and in the course c: his employment with die respondent, compensable under R. S. 54:15-7, etseq., supplements and amendments, resoectfullv states:
1. Name
BERT GIBBS.
Soc. Security No. 135-14-5930
2. Residence Address: (a) Street Address__ !LiisSSESP.TX^S.tT:gSt.
(b) County___ fcerris_______________--_-_--_-_-cthis euuM pcrmoN cannot ac moesssco without
(c) City or Town this information!
--Morrirtowri----------
-- -
3. Sex It
a4. Aagme-- 56 5. Marital Status.. ______ 6. Occupation,--
(at teas ofoeesdest)
7. Name of employer
NATIONAL GYPSUM CO,
vM' -
(a) Address ....... (b) Business ____
Division Ave.., aillerton, New Jersey' manufacture-
8. Did employer bare notice or knowledge of injury?.
On what date?_cc?ut:atlor.-al di
9. Place of occidental injury
ft- pr'iHTiisfrr
- cBg5SSffant .pr.ss.gnt.--
10. Describe the accident
.sxsGxmtisaualj&i s.ea.^A&_the_
, gpsnlt, nf rgT>fttt7Trp.tn 3nud tair .duafef...fmn^gr_ca
and other deleterious substances
11. Date petitioner stopped
____Date returned to ttwlc.
nftSemiMi ^
12. Describe extent and character of injury. If there has been amputation or loss of usefulness of anr member or impairment of any physical function, explain fully --ggg.R^JSags. nose, throat f lunos, internal organs and other parts of fcodv
15. Wages or earnings--aP?rQ3CCompensaoon paid: Rate Temporary disability---------------------------------------.-- Permanent disability_________
I k Was medical aid required?-----------------Was employer requested to fumisn same?
Was it furnished?----------If so. between what dates?
If not, what sum was expended?___
__________
cmri.ov*:c*s cwaim renrioN for compi *j**tion
2S* SHfjriELO mitt
tt-AL
15* Give names and addresses of physicians and hospital
16. What other facts are there which you believe important?
Your petitioner therefore prays that the Division of Workmen's Compensation will determine the
amount of compensation due your petitioner from said respondent, under Revised Statutes of New Jersey,
Title 34, Chapter 15, and the Acts supplemental thereto and amendatory thereof, and that your petitioner
mav be awarded his costs in this proceeding, and such other or further relief as may be proper.
,,
STATE OF NEW JERSEY COUNTY OF RSSSR
55.
........................ , (Pcmituu'r)
of full age. being duly, sworn, according to law. deposes ami
says that:
Deponent is the petitioner named in the foregoing Claim Petition; has read the same: is familiar with
the contents thereof: and the matters and things therein set forth are true according to the best of
deponent's knowledge and belief.
_--, /
/ - .,
............................................................................................... (PetitwMT)
Subscribed and sworn to before me
lllis 16til
August
19 74
x . MAJOC E. FEINITttl iir. Attorncy-at**lav cf Hew Jersey
tThts affidavit may be sworn to before any person authori/.cd to administer an oath)
NOTICE TO THE RESPONDENT;
* >%
The foregoing Claim Petition has been presented by the petitioner to the Division of Workmen's Compensation for hearing and determination. Unless an Answer is filed within 20 days of the date of ->ervicc of the Claim Petition upon you. with the assignment clerk at the office to which the claim is arrived as indicated on the reverse side, and a copv served upon the petitioner's attorney. THE PETITIONER WILL
Px/RtsOt rCEED WITH PROOF OF CLAIM ACCORDING TO LAW AND MAY OBTAIN JUDGMENT-AGAINST
DIVISION O WORKMEN'S COMPENSATION