Document MJk3jo0jLB0M3paM95oKmdRZa

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1963 DOC#: WCC065 DOCUMENT DESCRIPTION: Workers Comp File - Goans, Robert 0 File Name Contract Unit Claim File: Robert 0. Goans May16/63; Amended Aug. 8/63 Scanned ? yes Source JMA: NS-JM Start Year 1963 Stop Year 1981 Contents claim Notes 1 WORKERS' COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 BOBERT 0. GOANS, 4 C ase N o . 6 3 OAK 1 1 0 5 2 5 Applicant 6 vs. 7 LOEEHTZEN & COMPANY, et al, and ARGONAUT INSURANCE COMPANY, 8 et al, 9 Defendant 10 CEHTIFICATION 11 I hereby certify that the attached documents are true 12 and correct copies of the original documents filed in the records, 13 of this office in the above-entitled matter. 14 ATTEST my hand and the Seal of the Workers' Compensation 15 Appeals Board of the State of California. 16 17 18 19 Workers' Compensaron Judge \ 20 Workers' Compensatih Appeals Board 21 22 23 24 Bated at San Francisco, 25 California, this 3*1 day 26 of March, 1981 27 OIA WCAB F<ONCRWMI.tYISS) &KARTHMTF tMOUSTMAl RELATION MVttlON OF INOVOTOIAL AOClMNT f t ^ j c 1& > ^ INSTRUCTIONS ^duifriil Rghfii I. Do aoi <u< tbi, farm ia d a ih cun. Uh Form 4I-1. Do ooi uu is :hhiirritVyKK>Hl^9oilw.i.. oht m ; * J TM 1. ti niiorsd ampio? b* und., J | y,, n , f ,, d ,u.rdun lium bai o o r W n , f * ^ i i 'I" ' poistid. pernios for ppoistfsesi of ruardian td litem ind truiut n uu ucompinr ib i IreffieJJ . \ > Tie (uudioo mull ii|s thU |retwtu os bebil o is injured omi !i If kminIOr*U:<obw--oelk--|e of'l-l*, l--uch min--o-r-i*h-o--u'ld*10lijo ib j.|'TZmoL* S1^ * 9^** ^ R g te ''. tlfflifictl repofu not heretofore mbmittcd to the commi oa, tod tdvitt v b it B o *m IN D U S TR IA L >W I II Mi lOIak1/l a J "" "1 {!* cffX F TH E STATE OF CALIFO RNIA COMPROMISE AND RELEf udilMfisI E C il ! V D - ' CASE NO. 63 OAK 11052 JUl2Si9S 2J2 _ 25th Street ROBERT 0 . GOANS - 0 j l 4 $ f t c L D r Franci sco, C a lifo r n ia _______ ARRUCANT LORSNTZEH & COMPANY, e t a l__________ (see attached l i s t ) ENRbOTE* ARGONAUT INSURANCE COMPANY, e t a l (See attached l i s t ) INSURANCECARRICO 1155 " 5th S treet Oakland, C a lifo rn ia ADAMO! 550 C alifornia Street San F rancisco, C aliforn ia' The parti hereto, for the purpose of compromise only, hereby submit the following agreed atatements of fact; Robert 0 . Goans_____________________________ employe herein, born ,, September 2, 1900 claims tb it he was employed on the__ 3rd_____ diy 0f .A p ril____ t s 6 3 o r Oakland, C a lifo r n ia (YKAR) t*TATCl (OCCUPATION) See I n d u s t r ia l AccidewtseGmcwtijssion records then insured as workmen's compensation liability hy r e l a t i v e t o in su ran ce c a r r ie r s and employers (TATENAMEOfCARRIERORWHETHER*ELR*INURS> and tii He sustained an injur}- arising out of and in the course of his employment as fnlinwii p n e u m o n O C h o n i O S lS _________R E C E I V E D ________________________________________________________________________ _____ 3 0 1S64_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ten l l`M>*-->Cao.i,Ti)>________________________________________________________________ _ d. The actual weekly wages of the employee at the tune of injury were : while the avenge weekly waget wcj $ -------------------------------. a. The employee's present disability is-- not T H S d ii?A L .X STPA.PTSHPiR(I.RENTD>!AAIUTTRESULTINOPROMTHEINJURY) and the employee_il2.S,Z__ returned to work-- (If !OoSTATEWHEN) 4. (aj Temporary disability indemnity has been paid to the employee in the sum of $-- HODfi--- at .per week COVtt mg The amount due and unpaid to the employee is $. ____ --. (b) Permanent disability indemnity Has been paid to the employee in the sum of $-- DQHfi-- covering period. 5. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of 3 -6 , 7 ? 0 . PQ____ in addition to any sums heretofore paid by the employer or the insurer to the employee, said supr^to be payable as follows: T.nrp s u n t o a p p l i c a n t ; l e s s a t . f . w n p y s 1 fs s $ t:hp Tlpppr^mq-it .Cf. "."'nlnympn-.; Ip^r, 'n^Ofi HPl t n e;:ps:ises 5CO.OO i. Medical and hospital expenses have been paid 3--S f i l S -- Pavrislij ffla-sey ftiM H u ' n ? by the employee and S.HC.3S-----------by tb. mploy.r or carric: Unpaid bills amount to 5._.tlSDJ?..................Future medical and hospital expense is estimated at 3J '.HC .1?-- j.R-- Unpaid an future medical and hospital expense is to be assumed as follows:-- g-i - KDB a l f l - & 3 P f U 'W r e p e ^ C S l b i l l s . - o b e -c-.c o b i i r - a . A . L Q r L - u f - . v .L s - r ^ l l v a r . T i ----------------------------------------------------------------------- . . c X Smith, Parrish,Paduck & Clancy 7. Jiameand addressofemploye*'attorney, ifany....3.15 -Pinanrl a,1 -.Cantg.r Bnnriin^ noVan^ 8. Said attorney requests a fee of $ - --.........-- Amount of attorney fee previoualy paid, if any, * 9. ReasonforCnmpmmiu. dispute as to naturs. duration and extent of aisahiii t.y ,' injuring arising out of .an In the course of the employment; Statute. Limitations; lack of notice and prejudice and applicant wishes r.o hv, his peace.____________________ ______________________ 10. The undersigned request that this Compromise Agreement and Release be approved. 11. Upon approval of this Compromise Agreement by the Industrial Accident Commission, a panel thereof, a Commissions: Referee, and payment in accordance with the provisions hereof, said employee releases and forever discharges said employ insurance carrier from all claims and causes of action, whether sow known or ascertained, or which may hereafter arise or*t as a result of said injury, including any and all liability of said employer and said insurance carrier end ereh of dependents, beirs, executors, representatives, administrators ot assigns of said employee. 12. It is agreed by all parties hereto that the ling of this document is the ling of an application on behalf of the employee, an the commission may in its discretion set the matter for hearing as a regular application, reserving to the parties the right to issue any of the facts admitted herein, and that if hearing is held with this document used as an application the defendant have available to them all defenses that were available as of the date of ling of this document, and that the commissio thereafter either approve said Compromise Agreement and Release or disapprove the same and issue Findings and Aware hearing has been held and the matter regularly submitted for decision. 13. For the purpose of determining the lien claim led herein for the unemployment compensation disability benefit, which hav paid under or pursuant to the California Unemployment Insurance Code, the parties propose the following division of the sum upon for settlement and release of this case: 2_______________ for temporary disability covering the perimi m : accrued medical expense paid ot incurred by the employee, io t future medical care. , ________________ for permanent disability. 14. See below. (The above segregation must be lair and reasonable and must be based on the real face of the ease. There should he no attempt to deprive the lien claimant of a reasonable recovery' consistent with all the a(mounts minvoilvecdo. . VrWESS the Si^naturt btrtof this-- Q/CJjydoy of A a L J . tached l i s t for signatures employers and Insurance companies attom ies. 14. Applicant hereby r e le aas e s x * any claim s known or un known a gain st the above On this ^ day of . . Q itn y y . ,,, ---- ---- A23. 9Je.fi/. befo0 . linoolauon r _____ a Notary Public to and for tt employer and insurance County and State, rending therein, duly commissioned end sworn, personally afipts companies fo r a pneumono- .............................nobcrt'.O . Goans and_________________ chcnicsis d isa b ility . ____ ___ ______ 7.. Smith____________________________ known to me to be the personS lubose name S - subscribed to the v Instrument, and acknowledged in me tb it he executed the same. In Witness Whereof, 1 hair hereunto set rsy hand and affixed myOOf.dal scat thr da year in this Certificate first above written. K ff-- j ftbUr ,mMed ____________ 14si C-- >J 4i SUtt / Oh/<*> p i 2 i*iv star n.i X C' The attorneys and insurance companies hereunder sign their name hereto and agree to pay the following sums as their proportionate share of the Compromise and Release settlement. SEDGWICK, D2TERT, HORAN & ARNOLD, on.behalf of Mundet Cork Company; Fiberglass Engineering and Supply Company; Owens-Illinois Fiberglass Company................. . $800.00 Byv J. Patrick Goodv?in, on behalf of Zenith National Insurance Company; Jacks on-Hopkins Company..... $ 25.OO/B; Employers Liability Assurance Company, Ltd,, insurance carrier for National Insulation Inc..$ 75-fcO Hanna and Brophy, on behalf of . United States Fidelity and Guaranty..................... $ 75-00 By Royal Indemnity..............$ 50.00 By J / J / l t j A r California Casualty Indemnity / / It VV, mia C - Q * J L A Exchange..................... $125.00 By / / ftX fJ L M K 1 y ** Argonaut Insurance Company...$125.00 By_ Travelers Insurance Company..$350.00 By_ I} l .(rf; Industrial Indemnity Company.$575.00 By, 1\1 u-( d .i|7id --- State Compensation Insurance Fund ...................... $2,8p0.00 By. "tt/ Mullen 8s Fillipi For Pacific Employers Insurance Comoar.y...... ............... $1,700.00 Ej . / $ . G2 er WORKERS' COMPENSATION APPEALS B O A R D - CALIFORNIA (INDUSTRIAL ACCIDENT COMMISSION, prior to 1966) APPLICANT ROBERT 0. G O A N S ____________________CASE # OAK 11052 Asbestos Worker/Insulation Mover - DATE CLAIM FILED May 16, 1963 Amended Aug. 8, 1963_________________ INJURY ALLEGED Pneumonochonios is_____________ ALLEGED DATE OF INJURY April 3, 1963 EMPLOYER/INSURER Loreritzen & Co./Argonaut ins. CO ft l* 27 employers & carriers Many defendants reduced to 11 including JM Sales/ Travelers No apparent.Canadian insurer Royal Indemnity?) OTHER NOTES No medical reports in file DATE OF RESOLUTION RESOLUTION July 23, 1964 Compromise & Release $6,750 settlement apportioned among 11 employers/carriers DOCUMENTS COPIED 1) Compromise & Release # O F 3PAGI CLAIMANT_______ &nbe-rt jflAnc._____________ He California Workers* Compensation Appeals Board CARRIERS INVOLVED: oThe AETNA Casualty & Surety Co. oAmerican Automobile Ins. Co. oAmerican Employers Ins. Co. oAmerican Motorists Ins. Co. Argonaut Ins. Co. oAssociated Indemnity Corp. California Casualty Indemnity Exchange oCalifornia Compensation & Fire Co. oCasualty Ins. Co. of California Employers Liability Assurance Corp.Ltd. oEmployers Mutual Liability Ins. Co. of Wisconsin oFidelity & Casualty Co. of New York oFireman's Fund Ins. Co. oGeneral Accident, Fire & Life Assurance Corp. Ltd. oGlobe Indemnity Co. oGuarantee Insurance Co. oGreat American Ins. Co. oHardware Mutual Casualty Co. (Sentry Ins. Co.) Industrial Indemnity Co. olndustrial Indemnity Exchange olnsurance Co. of North America oLiberty Mutual Ins. Co. Lumberman's Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co. oMission 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.) Royal Indemnity oSecurity Ins. Co. of Hartford (U.S. Casualty Ins. Co.) State Compensation Insurance Fund oTransport Indemnity Co. The Travelers Ins. Co. oThe United Pacific Ins. Co. U.S. Fidelity & Guaranty Co. Zenith National Ins. Co. oZurich Ins. Co. o_______________________________ |_______ [__________ ' o ___________________________________________________________________________________________ o o ________________________________________________________________________________________________ o 5/81 mmf