Document Loy71mXbzoB7MRY13Grj8Ooqq

FILE NAME Insulators Workers Comp Claims IWC DATE 1966 DOC IWC057 DOCUMENT DESCRIPTION Claimant - Taylor Lawrence J. Sr. From M Archive File Name Contract Unit Claim File Lawrence J. Taylor Sr. Scanned ? yes Source JMA NS Start Year 1966 Stop Year 1966 Contents claim Notes err oO 4 COPY WORKMEN'S COMPENSATION UEPARIMEIN UEPARIMEIN LANSING MICHIGAN EMPLOYER'S BASIC REPORT OF COMPENSABLE INJURY SHALL BE GIVEN IMMEDIATELY TO INJURED EMPLOYEE AND INSURANCE CARRIER Employers must report immediatety to the Department on Form 109 all injuries mcluding diseases which arise out of and in the ourse of the employment and cause 1 An aggregate of seven ( ) or more days of disability not including Sundays or the day of injury 2. Death 3. Specific Lost In case of DEATH also file immediately an additional report on Form 106 See Additional Instructions un Beverse Side The Travelers Insurance Company EMPLOYER nville Sales Corporation =, ne % 832 Fisher Blig Abdreve-~tereet ent Namber Detroit 2 Menigan | CHT (testes Insulation TYPE OF BUSINESS Industrial Insulation - eta werenetesenes opera 8 CARRIER TRAVELERS INSURANCE COMPANY INSURANCE EMPLOYEE Laurence ... ILJURED THE Pirst native 719 Griswold Street Detroit 26 Mich J. Taylor Sr. phason re fi Stoc Sec saeses coeewes (hjodie itwl) Last name 374-01-6553 16854 Beaverland Addrem (Bers and anmbes Detroit Michigan Marital states. Mo... City Rete LEAVE BLANK : - } ' . Qumber of injured employee's children under age 16 living with injured ve . If injured is a married man in wife living with him Yea dete ae - Number of other family members or relatives at least % sapported by injured BATE INJURY 6-10-66 Last day worked 6.1 -. Describe injury or disease Collapsed Lung pmo en ermme nee ene tee tee eee sees sees eee swcamans we ates : Le - Bf pecific ions give date of las Wow did injury or discase happen 6-13-66 ge cone nnn none After moving a load of material this man had to sit down because he was all out of wind av cacwecmbesans mets antete ssoces eobarmaganeeese wees Pee raeee se enp oeenoonme: ~ b memerebbeee tee tre dese tan eewes o eebre o CASE N EMPLOYER INSURANCE . P NATURE ~ LOCATION mampremsce DISABILITY _ Physician Atiren. .. Hospital New Grace Hospital | | OCCUPATION Straight Time Earnings Hourly rate Overtime Earnings Hourly rate If board room furnished give value Hours per week .Hours per week Total $ 0 .. Total $ Total 3 Combined weekly earnings $ Boom piece work or commission explain fully eee ae wn . Estimated length of disability Stuart MAS A COPY OF THIS BEEN GIVEN TO EMPLOYEE Stuart Stuart Stuart Yes Signature in ini EMPLOYER or Representative Not No Insurance Carrier ; WEBELY wags : AGENCY MJURY TYPE CODED #T QELS NG 7 60printed printed in 4.3 4 - SUPERVISOR'S INVESTIGATION REPORT , F The unsafe och of persons cnd the unsafe conditions that couse accidents can be corrected only when they are known specifically is your responsibility to find them and sume them and to state the remedy for them in this report sae mam compeen Johns- taville Sales moration Seana Johns- Johns- taville taville w Sales Sales bnding, wore owt Metro Airport _ _ tame OF Laurence Laurence Laurence J. Taylor Taylor sr ee sce THE Collapsed BARNEY Collapsed Lung = i I | On | et Sen emARY roit Menigan alus Menigan AND hn ACCIDENT | wth | MeN Ind Ind GrvERCN Ind PORTForemaI n PORO TION N Foreman a ny After moving a load of insulating material this man was struggling to get his breath about that time I happened on the job and saw him I asked what was wrong and he told mo he was having trouble getting : is treats this was on Friday be worked the following Monday still having a little trouble ut on Tuesday morning he came in and had to go back no He went to the doctor and the doctor put him in the hospital HaequeersN caueacnU faaarten on aN ly Govt, paw Galrta,ytUerk Giof pguualrdasnaxgbailyeaaenrd gaunen,yteoanrtaan edurn,oote}TS Ne } Jone ee Ce BEASE ACT- rel ACT- GAME WOE PROCITE (Damrbed a: remered geerd, adwdet woving mauhim, or '@ealle hem of enante promnture, tack of plumed safety, ot.) Hone TT ae ee ' quar Lo cpardanr, wae? exfion tures you Winn er dy pos orwoase habing to ruven apes eoubienrt) manne mv eh coon oes additional datat wim MUHING MUHING 16-18 me 16-18 aE Bours ~ CHANGE IN SEG AMOUNT APPROVALAPROVAL APPRFIN AL APPV R VA ALAP R VL AL EXPENSE CATE DETRO Exament CQV | nes enn ne i" 150 MG Ci \ MG a . 4 32 LINE COV WAGE CODER CLASS | \ 32 COV TYPELOSS . ee UND SERVICI , ~ ASACEL CHANGES NOTICE = | ove at imagesee unnumbered - unnumbered images ~ ... unumbered ... im... ag es image... s et eg