Document N22wx0XN8aOZGMgV4aXd6NrDw

FILE NAME: WR Grace (WRG) DATE: March 9, 1966 DOC#: WRG135 DOCUMENT DESCRIPTION: 1966 Correspondence from Claims Examiner to California Zonolite Company regarding workmens compensation claim \\A 1001 WILSHIRE B O U LE V A R D LOS ANGELES, C A L IF O R N IA 90017 March 9, 1966 California Zonolite Company 5kk0 San Fernando Road Los Angeles, California File No Employee Employer Inj.Date :: 02X-19797^ : William A* Locke : California Zonolite : 8/30/63 approx. Company Gentlemen : Mr. William A. Locke has filed an application before the Industrial Accident Commission in which he alleges an apparent lung condition resulting iron employment with your concern, between October of 1956 and March 3, 1965. This application was originally filed against your current carrier, Aetna Casualty & Surety Company and this firm has nor been joined in that application. All records indicate that we apparently had coverage for your concern from 1953 through 9/1/63 and thus we would appreciate receiving certain information from you so that a proper defense may be made in this matter. Would you please advise the exact periods of time that Mr. Locks worked for you, a complete description of his job duties and his rate of pay. We would also appreciate your advising the circumstances surrounding his Injury of 3/3/65. Any other information that you may have would be greatly appreciated. Yours very truly, CLAIMS EXAMINER m cc: Mr. John Granger EMPLOYER'S REPORT C INDUSTRIAL INJURY STATE O F CA LIFORN IA Department of Industrial Relations Division of Labor Statistics and Research Com plete in Triplicate and send immediately to The /Etna Casualty and Surety Company LOS ANCEltS 2404 Wllthlrt Blvd. SANTA ANA 2215 No. Broadway U N FUMANDO VALUT BISS Van Nuys Blvd. SAN DICCO WOO F ifth Ave. SAN BERNARDINO 157 West 5th Street IN6LEWOOO 2930 West Imperia! 04210809 E very question m ust be answ ered fully to avoid fu rth e r corretpondenee. F A I L U R E T O F IL E IS A M ISDEM EANOR SUBJECT TO M AX IM U M F IN E OF i 100. (Labor Code, Sections 0407.641) Every work injury to an employee which causes disability lasting longer than the day of the injury or which requires medical services othe than first aid treatment must be reported within five days after the injury. If the injury results in death, a report must be made by tel ephone or telegraph directly to the Division of Labor Statistics and Research, San Francisco, not later than 24 hours after death. EMPLOYER <Gvt name uoder which .California 1. Name concern doe* business) (No. and ,.Cl9rdQ. 2 . Office address Stm t) .... (Maoufscturing ahoci, retailing men ..P.ro.c.e.0.a.o.p....o.r...Y.miQi^.ite.............. ;........ 3. N ature of business clothe*, trucking for hire, etc.) ...............................policy n o . .3.3. r M ^ A 74 . (? : : nv . M f l . . . . A n a e w . 8 ............................................. IN JU R ED EMPLOYEE 4. N i m e 'W B .................................... . L O C K e ..................................................................................................... Sociil Security N o. ,, . $ 3 " 1 .Q t T .P 9 .T .5 _________ .... ^ . 7 . 0 . 1 . . . . I i 9 M l l . . . A Y . e n u e . ......................................l& ....G i* f & * .n $ & ._________________ DO NOT WRITE IN TH IS COLL Mf Case No. E m pl o y er No. Industry i . Age ........ 6_Q_................ 7. Sex: Check (V ) Male ....... ............ Female ......... .......... I . Check (V ) Married ___ .<....... Single 3.0 9. Number of hours worked per day ___ ............ - ...........; per week ... ................... - Ndmber of days worked per week . 3 . Age 10. V ases: %2La . 7 3 . . ......- ...... . per hour, or $.............. - ............... -- per day, or S...................................... per week. (If earnings at irregular rate, such as piece work or on commission basis, enter actual average weekly earnings for convenient period not to exceed one year.) 11. If board, lodging, or ocher advantages furnished in addition to wages, give estimated value $....................... per day, or $.......................... per week A C C ID EN T (No. and (Gy 1 2 . Place o f ac cid en t S tm t) ................................................................ Town)-. (Ytt or 13. O n em ployer*! prem ises No) .................. - 14. D epartm ent. ( C o u n ty ) . Ho...Accldant. 15. Date of accident .. (Yn or accident? (YNo) ~...-.-..-.-..-.-..-.-.-.------- ..... 16. H our of day ...................... A .M ./P.M . 17. Did injury IB. If yes, give date last worked ...... ................................................................. .... result in disability beyond day of 19. Was injured paid in full for, Sex and Manta) Statua Weekly Wage County this day? No) .......... 2 0 . If in ju red in a m ine, check ( V ) accident lo cation: S u rface . .. Mill .......... U nderground ........... Shaft .... C>Tt<?E OF ACCIDENT . occupation (job title) .-- J t t U M U x Q U & a n a n ........................................... .......................................... 22 . How long employed by you at this .X... occupation? Check (V ) Leas than 6 months -- ....... ; 6 months to 2 y e ars............. ; over 2 years ...... (Describe brieAy, such : loading truck, operating 23. W hat was employee doing when accid en t o ccurred? drill press, beveling dirt, wtlking down stairs, e tc .)...................................................................................................................................................... Accident Date Occupation (Describe folly, stating whether tbe iniured person fell. ws struck, etc. ; give til 2 4 . H o w d id th e ac cid en t happen? factors OMttriboog to accident. Um other side of report for additional space) Accident Type ___ 0 ( S a a r the specific m achint. to o i. appliance. 2 3 . w h a t m achine, tool, substance, or object was most closely connected w ith the accident? g, liquid, etc . involved) ,. , , (State if gears, pulley, 2 6 . If mechanical apparatus or vehicle, w hat part of it? motor, etc.) ......................................................................................................... (Yes or (Yes or 2 7 . W ere m echanical g u a rd s, o r o th e r safeguards provided? N o) ............................................. 2 1 . W as in ju red using them ? N o) - 2 9 . In w h at w ay waa th e m achine, tool, o r object defective? ..................................................................................................................................... ' _ 3 0 . W hat d o you recom mend for preventing this type of accident? (S tate the specific preventive measures th at can be taken by employer and workers. Do ao t say, " Ay being m ore c a re f u l." Specify w hat should or should not be done) N A T U R E OF INJURY AND PART OF BODY AFFECTED (Describe in detail the nature of the injury and the part of the body affected. For example: amputation 3 1 . of ngkt index Anger at aocond joint, fracture of ribs, lead possorting, dermatitis of left hand, etc.) .. 32. Name and address o f physician .fiP -A __M C I Y A H . . . . 3 3. Name and address of ho sp ital........................._ J (`E h o . n e . . . . M" o . . . . . . . Z 9 0>r-53141......................... 34. H u employee returned to work? *\io* 3 5. If yes, give d a te ................................... 36. A t what wage? J.. 3 7. Did injury result in death? N o ) ............... 3S. If yes, give date . 39. In caw of death, give name and address of nearest relative .............. 40. la injured employee related to employer? N o. ned b y __--.... .................................. .... ........................... Official position . Signature Date of this report Agency Agency Part Mech. Defect Unsafe Act Peraonai Defect N ature of Injury Extent of Injury Insurance Carrier Report Lag Filing o f this report is not an admission of liability. Coded by r X T O R 'S FIRST REPORT OF WORK INJURY FTATI Of CAUMUOA 4 ? 1 0 si<? DEPARTM ENT OF IN D USTR IA L RELATIONS DIVISION OF LABOR STATISTICS A N D RESEARCH *. 0 . 1 * (i, S o FrmacUe* I Immediately eftcr fim examination null one copy directly to the Diruion of Labor Stausticj end ReecercR. Failure to file t report wit the Division is a misdemeanor.' (Labotode, Sections t407-<4ll.) Answer all questions fully. ' ` A. INSURANCE 7. D i m injured I. Injured at ... I4 4 g J fr r iT fT i n d o R oad W ea t __ ___ _____ ______ ___ , ry--^ I o A n g o la * 9. Date of your f i r r t . r r a n r i i u r i r i f t . Hour---- 8 -- A l V h o neaped your serricaa? 10. Name other doctors'who tw ated ediployee for this injury A lB B i J . iB f t lt l A l a n n aiw'Lo. F tU z .z n r 11. ACCIDENT OR.EXPOSUREyDid employee notify employerat tb..i.e..i.n..j.u..r.y..!., X bb. of caw. of njurf+iPtmf / H t i w t M ^ fajo w u # lEmployes'i statement 17 NATURE AND EXTENT OF INJURY OR DISEASE (IaeladetIIabitedefiaams.iefciMi** S-- ^mrei.rtne.1Maea.aadO--a) On0t- 3/7/85 ynwmociftiikMAi,duato.lnhalaUon of.a gqmblnatlon of duponolRond/ar/ odium nitrat* and/or titanium and/or aabaatos and/or vermicullta and/or ' 09e , [ " " Dogma of axpcfur: 7 yaara of blending acoiatical matariaia-ftrnaca running 2 y f V |^ ^ / l/f S giving axpoaura to varmlduUta* C9 and aabaatoa. ronas B O X t 4210811 DOCTOR'S FIRST REPORT OF WORK INJURY A r<-- t Z a t. IfiCQL lila h ir a TATK OF CALIFORNIA STATE COMPENSATION INSURANCE FUND e o o SOUTH LAFAYETTE PARK PLACE. LOS ANGELES 54 H*d* M U OUT AND EOWA*D 1 COPY IMMEDIATELY AFTE* Mt$T SEEING PATIENT AUO. leuwdlelety ft first examlnalion mall on* copy directly to Iho Division of labor Statistics ind Research, P. 0. Box 963. San Francisco I. Failure to file a report with the Division it a misdemeanor. (Labor Code, Sections <407-<413.) Answer all questions fa tly . CASE No.______ 1. EMPLOYER eiiif. -- l i 2a. Anudvdurwes*s AR(NCCaii.cc.Syr))c. --.......... ...... s. ^^*i w^TMw(M2ia55tf2aLrhtw2iSaiiiASmIJ,SM5ML5taSiSoSo^o*5Si U Ao l F 11. ACCIDENT OR EXPOSURE: Did employee notify employer of this injury?, of cause of injury or illness: . Employee's statement 1 ' N A TU R E A N D EXTENT OF IN JU R Y OR DISEASE (Isulndc all objectivefisuiinft, tubjsctiTt complaints, and diajnoaa. If occupations! disease state daw of onset, occupatioei] history, and czpensns.) Brala af -- 1-- m-- i arsa af 13. X-rays: By whom taken? (J u t. if > Findings: M. Treatment: II. Kind of Case ,, * -Estimated stay. Name and address of hospital.' * 1. Further treatment sS S iy 17. Estimated period of disability for: Regular work T Mlllt I ! -Modified work. t w i ; 1. Describe any permanent disability or disfigurement expected (<< -----ONLY UNDER EXCEPTIONAL CIRCUMSTANCES WILL A HERNIA BE INJURED SHOULD BE ADVISED TO CONTINUE WORK, IF POSSIBLE, Name. darla J . -- lila -Degree-- M H r - Date of report. 69 p n a t ) .Address <$*! U W La F o a u 1 0 -UA U te m e r i t tide if snore sp e cs required 0421081? S T A T E O F C A L IF O R N IA DOCTOR'S FIRST REPORT STATE COMPENSATION INSURANCE FUND OF WORK INJURY eoo s o u t h l a f a y e t t e p a r k p l a c e , l o s A n g e l e s 54 AUO, kaaediaMy iff first amination Bill on copydirectly toIho Division of Labor Statistics ind Research, f. 0. Bos 965, Sen Francisco I. Failure to file a report with the Division is s misdemeanor. (Labor Code, Sections <407-6413.) Answ er all questions fu lly . A f|M I U l tti ( M m . L -R - C ase N o. . 1. E M P LO Y E R 2, Address 3 . B"* ,[ t t l l l * C t. ItM M B t M e e f a t l t a i a lao A 39 , * * ! K la ............. Do bm w r i t e la tkia ipact 4. E M PLO Y E E , rsL ft-y iw a n a a s u L < O ^.parien l M N . C P m f i r " T 7. D au injured a i m . c iir . J iou r__ 1 1 1 a . M " ^ " Ago 0 k M , Date last worked__ s k t f a f l l ___________ _____ 9. ftf yiti frwf w im yiA h^ J ^ ^ ____ HourJEMSLZM Who engaged your aernc?J M M K 1 ------------------ 10. Name 'forihii^tijury f a t ' ' - ' . ' - 11. A O C P E N T M U D ^ ^ ^ ^ ^ ^ p i iiy w notify employer of this idjdry? -8 f t C a , ' ` F.mployee's statement m o r t f lu n ^ fa ^ ie e T ? h ea t tftS a au* a se fa U sS S u a e u " X X 5T ^ 1* N A T U R E A N D EXTENT OP IN JU R Y OR DISEASE (Include all objsctive findingssubjective complaints, and diagnoacs. i occupational distaae autc date of onset, occupational bistory, and exposures.) 13. X-rays: By whom taken?. O lW l o l R lB B y i j L O ______ l****^1"- * * **--*" fw im tm 14 fatal* frarUau t fat$r of M tf arriaai M ittfatay, lafaaU tM l 17. Estimated p erio d d f__ _ T__ r It. Describe any perm anm tjwuffity'ofdis^rttfem ehtexpected (Sm> m >J _________ r-me, ' 1?. If death ensued, fire < i, 20. XM ARXS (Net*acy iifatorJ iw , eaadfarspacialcsaeiaatiM orLboratorj'tam. otlier pennant informarioo.) -- ONLY UNDER EXCEPTIONAL CIRCUMSTANCES WILL A HERNIA BE CONSIDERED D w i r e s PRIOR TO OPERATION. The INJURED SHOULD ^BEVADVISED TO CONTINUE WORK, IF POSSIBLE, N . A U r l J. h m ^ f e V a . e i T (T rsaV " Daw of repoi ----- -r--Addreti F o r m .l a -Degree. 1369 Pattfain n * a , La U a r r r w r r r tid t i f aaore tp+c* rtq uh-td M.U. A liU AJJWVIA i L> 6 6 0 W EST BROADWAY. GLENDALE 4. CALIF. CITRUS 2 - 4 1 6 6 c h a p m a n 5-2B12 0 < l^ >lO < N 'l O v i u c 'A O DOCTOR'S FIRST REPORT OF WORK INJURY Im m ediately after first exam ination m ail one copy directly to the Division of Labor Statistics and Research. P. O Box 965 San Francis: Failure to file a report with the Division is a m isdem eanor. (Labor Code. Sections 6407-6413.) A nswer all questions fully A. INSURANCE CARRIER * * * * * iaS V lT S D O S i em ployer C a l l f o m U a l i U C onpany 2. A ddress <AHor i V 5U *1*0 S a il *CTOMPO M . o (Manuiaeturtna hoaa, building cod o. ousinoss jtruetjon. ratailina men' cloth**, *tc ) .e n d * !* Pb,,n. i>c not w;r. this sr 4. EMPLOYEE ! 5. A ddress 7 G S M l ^ T M C M ltS 6. O ccu p a tio n fw m a c m C O a r s t o r Aff. 5 2 Ph,,n. ' O h P-2 C2 6 s,, H 8. Injured a t SU bO S a n F a rn a n d o O la n d s X a r ,, ,, n(y I o a * a a e l a a 10. Nam e o th er doctors w ho tre a te d em ployee for this Injury f t f f l b l l U S R Z 'S B B B 11. ACCIDENT OR EXPOSURE: Did em ployee notify em ployer of this injury?________________________________________ Em ployee's statem ent oi cause oi injury or illnees: m L a s t D s o s a f e a r Z a a t i a a d a b r s a k l n g a t o o mgr R A N D S , t e f e r s t h i s I h a d w e r k a d in a f i l l i n g s ta tio n b a rs I had tb s nans tro u b le f r o a an a ll-rg g r to a s c iin t. a 12. NATURE AND EXTENT OF INJURY OR DISEASE (lncluda all objactiva finding. ubjactiva complaints, and diagnoaaa. If occupational disoaso tala dot of onaat, occupational history, and exposure.} lu re i s an e ry th e m a te v t e x f o lia tin g e ru p tio n o f b o th hands an~ fo rearm s a c o n ta c t a lle rg ic d e rm a titis* su ^ g e stln i 13. X-rays: By w hom taken? Findings: (State if none) t> P iff 14. Treatment To be t e s t e d - o r c o n t a c t e . 15. Kind of case (Offlca, hom, or h o sp ital)__ of f i ce Name a n d a d d ress of hospital_______ If hospitalized, date 16. Further treatm ent depoads on t e at s 17. Estim ated period of disability for: R egular work_______ __________________ 18. D escribe a n y perm anent d isability or disfigurem ent expected (Stat* li non.) Xstimcrted stay. Modified Work. 19 If d eath e n sued, give date 20. BEMARKS (Note any pre-existing Injun*. or du.asM , need tor special examination or laboratory tests, other pertinent information.) DATE 6 c - 7* a e 3 -1 2 -5 7 ^ By. EMPLOYER'S COPY S. AUSTIN JONES, M.D. AND ASSOCIATES 04210794 1 0 0 1 WILSHIRE BOULEVARD LOS ANGELES, CALIFORNIA 90017 March 9 1966 California Zonollte Company 5 ^ 0 San Fernando Road Los Angeles, California File No Employee Employer Inj.Date :: 02X-197971* : William A. Locke : California Zonollte : 8/30/63 approx. Company Gentlemen : Mr. William A. Locke has filed an application before the Industrial Accident Commission In which he alleges an apparent lung condition resulting from employment with your concern, between October of 1956 and March 3, 1965. This application was originally filed against your current carrier, Aetna Casualty & Surety Company and this firm has now been joined In that application. All records indicate that we apparently had coverage for your concern from 1953 through 9/l/^3 and thus we would appreciate receiving certain information from you so that a proper defense may be made in this matter. Would you please advise the exact periods of time that Mr. Locke worked for you, a complete description of his job duties and his rate of pay. We would also appreciate your advising the circumstances surrounding his injury of 3/3/65 Any other information that you may have would be greatly appreciated. Yours very truly, -y ' R . B. WINDLING CLAIMS EXAMINER m cc: Mr. John Granger 40071354 D O C T O R 'S J I R S T 4R E P O P w ork: - -3T :* th* 6 mv9< 4210735 DEPARTMENT'Of D^UYTRIAI^REIATiqNS * sT A m n cs and research r.a i " *" *-- -- 1 " ^ . .-v- .,. / .. Ffto tbilKniaQ of LsbaSts&tifia 1<407*^413.) ill quewinnfolly. "< to fib * report wit A. lU M L o a O U R ,I . A . 11. ACCIDENT OB.EJu'OSUSEy Didemployeenotifyemployerof thb injury?__Ymm 'l u i m t dtd not know tu** . ' 'V*- E m p la y ' ratem ent 12. N A T U R E A N P E X X m fr O F IN JU R Y O R D ISEA SE Uc-mrimil .na t^ d g iiTef*. --i f iria il U-- y.eodb,-- .) ililuriw iiio p ,w tjw H w w ilik n . m i iBnmi-- O n a u t- 3 /7 /6 5 Ww O fagagblnationof dupcnpland**/ odium n itrato an d /o r titanium and/or aabaatoa and/or varm ieuilta and/or C i * . ./ Oagroa of axpasurai 7 yaara of blanding acoustical aatariala-furnacarunning 2 y aarrto * 4 /l/6 5 giving axpoaura to varm lcolita, C9 and aabaatoa. 13. X-rayi: Byw h o m D T I . OfflCQ ~ flit ! UV3/17,,4/1, fi/lS, S/12---- F in d in g * t P a r t v o p d i t a l f i b f o a i a a n d a v id a n e a o f P n a u m o c o n io a ia 14. Treatment: acpaetatiw u? |nchlal dllttora; Hatarii IM AvoidancaoX abova inritanta (itam 12) 15. Kind o f caie hoepitalized, date. Name and addrea^ o f 16. Further treatment. ^S 17. Eetimated period o f 1S. Describe any Eethrtated ttsy- 20. REMARKS (Nou a? (maxima ja m c Lab: HUtopUaod&asid oocmidloAbnskin ta s ta . Sputum cultura antibiotic aanaitlvity Bafiniivawpapanicoiou amaar. 8021 WORK INJURY r . O . k n I, h i F n i i i l Injnodinteiy after f a i ikaiaitiga s a il one copy diroctly to the D iruioc of Labor Statisrics a ^ Xm h SL Failure to file a report the Dirinoa k a mieHemunor. (Ihbotjfcode, Sections < 40^ #4U .) Answer ali quosrion folly. ' 'I'****:' - W A . INSURANCE CA R*TM ?* Awtftn T-tfn A C a x u iliK 1. em plo yer. , 2. Address f o i i - ^ h w u m 5. B u n d - ^ lk * r J ? C ^ ^EMPLOYER*" 5. Adi i. Occupati 7. Data injured^_ _________ _______________________ t. injured at ^ f r ^ if t T a r n a n d a ftnad W a tt 9. Date of your i 10. Name other doctoo' who treated employee for thia injury- _Vbo engeped year swrieert___ IM6L U-JBlt Rftbtifm IntanUat.fi/15/6S- U S T iaiTfalli.LeA. 11. ACCIDENT OR.EXPOSURE/\!nDuid employee notify t p loyur of Ait injury?, Y ll, of c u m of injury or Upaatt / H t i n X ^ m t f c * * , M u | | *Employt*!statement 12. NATURE A N D EXTENT OF INJURY OR DISEASE p --*~*- -*-|--* - * - ~ r ' i J - l n a i'i'm. n l J2aM*stasileS efaneweosupsaj-- IMwasy. and^ e e -- 0 O n set-J/7 /6' 5 ` *** rftaumnanntalla.(to jo jn h al0 o a of a .combination of dunonol and/hr/ odium nitrate and/or tlunlum and/or u b u to i and/or vsrmlculite and/or 0 * 1 :'"' Degree of aacpeeirfai 7 years of blending aoouttieal aatarlala-fwnaosrunning 2 yaarrtfc-4/1/15 giving exposure to varmlcollte, C9 and asbestos. 1). X-rays: fly r-hnm tdnT^ii^i ffir an T** flffia - BA Of C h e a t ^ay.a/1 7 4 /1 i / i t t / n Findings: Parbraoehlaljibroaia and evidence of P&euaeeonioeis " Tm" "U! Dcpoetaraata; bronchial dilators; Heteril Iftf Avoidance of above irritants (item 12) 15. Rind of cu t (2hXiST-- O f f k a , -- ...-- .If hnepitalrted, daw . Name and addraw of hoapitaL 1. Further treatment 17. Estimated period of II. Describe any permtnantffl Eerhrttfnrf j 20. REMAKES (W eueoy>aitohriwW inee i>< Lab: HUtopiaaml nd poccldlgA l akin taata. Sputum culture antlbl$Lip aapamvlty.JBaflnttlva.papanloolaou asoar. ~ Nime Melvin JrSahlUtag-- y: C hm m *tt*i r Dec of j 0M SOZI -D ejret- M a ^ [ g g g & ) ik td u i iJ ? J llv d i i t Cina p - P w m e r M aide i f w ar* t p t n r f u i r t d Ju fy - llltM SOSOTSl-O ZONOLITE CONSTRUCTION PRODUCTS DIVISION INTER-OFFICE CORRESPONDENCE 04210773 Pr>fN SBP 71982 TO: FROM: cc: Richard Jung T. E. Winkel M. M. McDaniel W. R. Wright P. B. Rief date: September 2, 1982 s u b j e c t : Employee Files , Find enclosed the personnel files for Williams Locke and Frank Alverdrez (Los Angeles plant employees) which yourequested. The file for Bill Moody (Sacramento plant) can not be located. Please return these files to the attention of Milt McDaniel upon completion of your need. TEW/jdy PACIFIC REGION 328 P