Document OzDE03B69wdx84qmZ8mdXODVv

FILE NAME: Insulators Workers' Comp Claims (IWC) DATE: 1966 DOC#: IWC056 DOCUM ENT DESCRIPTION: Claim ant - Frederick, Kenneth M. [From J-M Archive] File Name Contract Unit Claim File: Kenneth Martin Frederick Sept. 13/66 Scanned ? yes Source JMA: NS-JM Start Year 1966 Stop Year 1966 Contents claim, letter Notes WORKERS' COMPENSATION APPEALS BOARD (INDUSTRIAL ACCIDENT c:u :;s s i o n , pr CALIFORNIA to 1966) APPLICANT KENNETH MARTIN FREDERICK (deceased) by' CASE # P 16482 Asbestos Insulation Installer sPuse & son DATE CLAIM FILED Sept. 13, 1966 ' INJURY ALLEGED Inhalation of asbestos particles to lung ALLEGED DATE OF INJURY 1960-66 extended as add'1 employers are joine r&PLOYER/INSURER ---Fiberglass Engineering/AETNA, et. ai, ' __ including J-M Sales/Travelers OTHER NOTES No apparent Canadian insurer________ "No clear cause & relation of injury to employment" State of the (medical) art discussion among AETNA doctors DATE OF RESOLUTION Nov. 2, 1972______ RESOLUTION _________ Compromise & Release $13,500 settlement DOCUMENTS COPIED D 7/9/68 Med Rpt of Miller to State Comp. Ins. Fund 2) 7/28/66 Med Rpt of Powell to AETNA 2 3) 7/26/66 Med Rpt of Lippett to AETNA 3 4) 7/26/66 Med Rpt of Ford to AETNA 2 5) 7/7/66 Med Rpt of Mau to AETNA 1 6) Compromise & Release 4 CLAIMANT----- -- fYl^shn P v * A e v `,o.le________________ _ 16 California Workers' Compensation Appeals Board CARRIERS INVOLVED: The AETNA Casualty & Surety Co. oAmerican Automobile Ins. Co. oAmerican Employers Ins. Co. oAmerican Motorists Ins. Co. Argonaut Ins. Co. oAssociated Indemnity Corp. oCalifornia Casualty Indemnity Exchange , California Compensation & Fire Co. oCasualty Ins. Co. of California oEmployers 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 oGlobe Indemnity Co. oGuarantee Insurance Co. oGreat American Ins. Co. Assurance Corp. Ltd. oHardware Mutual Casualty Co. (Sentry Industrial Indemnity Co. olndustrial Indemnity Exchange olnsurance Co. of North America oLiberty Mutual Ins. Co. oLumbermanJs Mutual Casualty Co. Ins. 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. oPacific Employers Ins. Co. oPacific Indemnity Co. oReliance Ins. Co. (Standard Accident Ins. Co.) oRoyal Indemnity oSecurity Ins. Co. of Hartford (U.S. State Compensation Insurance Fund Transport Indemnity Co. The Travelers Ins. Co. Casualty Ins. Co.) oThe United Pacific Ins. Co. U.S. Fidelity & Guaranty Co. oZenith National Ins. Co. oZurich Ins. Co. o o ' " ~ " o 1 1 ~ ~ o ~ -- ------------------------------ o ~~ " ~ ~ -- -------------------- 1 WORKERS' COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 MINNIE LOUISE FREDERICK and 4 BBUCE FREDERICK, KENNETH MARTIN FREDERICK (DECEAS 5 Applicant 6 vs. 7 FeItBEalRGLASS EN'GINEERING & SUPPLY, 8 C ase N o . 66 F 16482 CERTIFICATION 9 Defendant 10 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 Workers1 Compensation 15 Appeals Board of the State of California. 16 17 18 19 20 Compensation Judge Workers Compensation Appeals Board 21 22 23 24 Bated at San Francisco, 25 California, this 23 hay 26 of March 1981 27 OIA WCAD FO R M 118 INCW l.?|> DOa v m b w t e r i H o u m u A L tmuato** d iv is io n o r in o u o t m a l a c c id e n t* OCN CftAL UMOCMY Th O H A O C ftu R G C A V VASCLLAA *W*OC*V c c O R L A N D G D A V I E S . J R . . M. O. J A C K D. T H O R B U R N , M.O. PA RKER POW ELL. M D ' N O A T H T H C S TA 5TA C C T rMCSNO I.California J u ly 28,DT p | 6 | ln Aetna L ife & Casualty Sasualty & Surety D ivision S uite 800 Del Webb Center 2220 T u lare Street Fresno 21, C a lifo rn ia OCT 1 01966 FI. FRESNC C:=iFi.v.-: Atten: John S. Backer Claim Representative Dear Mr. Backer: Re: Kenneth M. F re d e rick , deceased Our # 10141 You have requested Information regarding the recently deceased p a tie n t, Mr. Kenneth F re d erick. Mr; Frederick was f i r s t seen by me on J u ly 6, I965, at the request of Doctor Mau because of pain h h i s rig h t c a lf . I f e l t that t h is represented pain ra d ia tin g from a herniated lumbar d is c and referred the p a tie n t to Doctor Lip p ert who subsequently operated upon him w ith r e l ie f of his symptoms. I did not see the p atient again u n t il May 24, 1966 when Doctor Mau again asked me to see the patient who was in the h o sp ita l at that time. In a d d itio n to the pulmonary problems and fever which he had had, the p atient had developed rig h t leg pain which was d iff e r e n t than the pain he had pre v iou sly had. He stated that he had again become i l l in March of I966 w ith a pulmonary in fe c tio n and that subsequent to that he had f e l t weak and had lo s t h is ap petite. The leg pain developed during the course of t h is illn e s s and had been quite severe and required pain m edication. At the time o f our examination there was no evidence of v ascu la r d i sease or interabdominal mass which could exp lain the cause of the leg pain. The evening fo llo w in g our.exam ination the patient stated that the leg pain disappeared and we did not see him subsequently. Consequently, 1 have seen the pa tien t on two occasions fo r leg p a in r but have never done a complete pulmonary examination. in answer to your question regarding the cause and e ffe c t r e la tio n ship between h is employment as a fib e r g la s worker and h is carcinoma of the lungs, I know of no proved re la tio n s h ip . An opinion from one whose main experience has been in in d u s tria l medicine might w e ll be more valuable. . Aetna L if e & Casus )ty(" ^ . Re: "Fred erick, Mr. Kenneth M.(Deceased) . Our # iOH+1 Page 2 J u ly 28, 1966 A ls o , I do not know what the p a tie n t's smoking habits were and what re la tio n ship t h is might play to h is disease. I am a fra id th is has not been too enligh ten ing a response but i t is the best that I am able to give. Yours tru ly , PP:aj t NEURO LOGICAL SURGERY ( JO H N W. P A C E , M. D. Da v id s . z e a l e a r . m . d . R O B E R T G . U F P E R T . M. D. 2840 NORTH FRC5N0 STREET F R E S N O 3, C A LIF O R N IA J u ly 26, 1966 BAlDWtM t Aetna Casualty & Surety Co. Suite 800, Del Webb Center ~ F r e s n o 21, Calif. Attn: John S Backer Dear Sir: Re: Emp: Kenneth M. Frederick Owens Corning Fiberglas * " " H o s p i t a l^ n * ? - ^ - 65^ t ^ h e ^ e q u e s t ^ f J r " p s r v i c e a t S t . Agnes i s a co p y o f my H i s t o r y & E x a m in a t io n d i e ' t i me ! S'" Lumbar s p in e film s on 7-8-65 showed n a rro w in g some h y p e r t r o p h ic a r t h r i t i c c h a n g e s . A c h e s f o b ta in e d on t h i s d a te cnese n c n is c a te . E n closed is a copy o f of L5 ci film 'l l i tiim w a s a lso these re p o rts. A pantopaque m yelogram was re v e a le d a d e fe c t at T 5 c i perform ed ,,u . o? n 7-9-65 * 6;>. Th ic j T h is study port it . i ,, " n " * r i ' h t - A W * c h i . r - ih ? " * p " o t" ' d 7-13-65 " i t h rem oval o f ,, r e t V e r t e b r 4 1 d is c a t th e lu m b o s a c ra l le v e l on the n e t ^ a t i e a i Wf Seen i n y o f f i c e f o r s e v e r a l r e c h e c k exam i fro m my *c a r b o n * 10- 2 6-65 im provenent aad dism issed b e iT ,F o e e e r i C !i WOS n e X t se e n on 5 - 9 - 6 6 . A t t h i s tim e h e had l a t e d t o I I I a p p ^o x ^m a t e ly " n th w ith pneum onia. ijn re- th i ii^ h t r il? i Ci l 4 r a c C i v i t y > he 6 egan to have a c h in g in ^ig h t c a l f and f o o t . T h is g r a d u a lly became w o rse in - l e f t 1? ! che t h ig h . T h e re was m in im a l low back p a in and no and s t a n d in g ? ' P a in t6nded tC be a8g ra v a te d by w a lk in g Re: K e n n e t h M. F r e d e r i c k Page 2 e x a m i n a t i o n on 5 9_-66 revealed the patient to be quite illa p p e a r i n g and pale. There was a fu'l 1 range 'of p a i n U s s * b k motio n s . There was no spa s m or tenderness on p a l p a t i o n of the b a c k m u s c u l a t u r e . Strai g h t le* r a i s i n g is carried to 90 on the left without pain, and on the right elevation to 90 caused slight discomfort. The sciatic nerve on the right was quite tender on palpation. The ankle jerk was absent on the right* There w a s no hypesthesia* Auscultation of the lungs suggested decreased air entry the right lung field with a suggestion of some dullness basal regions on the right. The abdomen was negative. and spleen were not palpable. over in the Liver It was felt the h i s t o r y and find i n g s were quite suggestive of an occult neoplasm. Particularly, the possibility of a retro peritoneal neoplasm was raised. The patient was referred back to Dr. Mau, his referring physician. Dr. Mau was contacted by telephone and further investigation along these lines recom m e n d e d . The patient was s u b s e q u e n t l y admitted to Fre s n o C o m m u n i t y H o s p i t a l by Dr. Ma u and e x t e n s i v e l y investigated by Dr. Mau and, additionally, by a medical consultant, Dr. Woo. Their studies failed to illustrate a neoplasm at that time. Additionall I again re-examined the patient in hospital, as did Dr. Powell w i t h o u t f i n d i n g a d e f i n i t e c a u s e for h.is problem. A repeat m y e l o gram was performed during that admission without revealing any p a t h o l o g y . D u r i n g this time the patie n t ' s pain receded .and a c t ually seemed to disappear over a matter of a day or two so that he was discharged - a diagnosis not having been es tablished. Subsequently, X was advised by Dr. Mau that he was readmitted to the hospital a few weeks later and at that time a diagnosis of an oat cell carcinoma of the lungs established The patient was not seen by this examiner on this last admission. C O M M E N T : From the neurosurgical point of view, this patient was originally treated for a lumbosacral disc extrusion - to which surgery he responded very satisfactorily. Subsequently, he p r e s e n t e d w i t h findings leading to the d i a g n o s i s of occult ret r o p e r itoneal neoplasia which could not be definitely d e mon strated, despite extensive study in hospital. On a subsequent admission a neoplasm of the lung was finally demonstrated. The patient did have findings as outlined related. Insofar as a l o n g s t a n d i n g h i s t o r y of asbestosis with above which would, of course, be industrially the relation of his neoplasm to his asbestosi <r., Re: K e n n e t h M. F rederick 6. Page 3 is concerned, m y reading wou l d indic a t e an incidence as high as 137. of c a r c i n o m a of the lungs in patients wi t h asbestosis. This would, X feel, strongly suggest a direct relationship between the patient's tumor and his occupation. Such an opinion, however is s o m e w h a t far afield in m y c h o s e n s p e c i a l t y and I wou l d suggest' an opi n i o n be obtained from an Internist or surgeons specializing in the treatment of pulmonary diseases. Very truly yours, a R. G. lippert, M. D. RGL/vl ends . c c ERUCE M.EERC.M.D. CEORCE C .W O lf. M.D. oimen k.jt e in a c h . m. i max .m illar.m.d. CENTRAL CALIFORNIA MEDICAL CENTER 3004 NORTH FRESNO STREET FRESNO. CALIFORNIA 9 3 7 0 3 TELEPHONE 2 2 P -6 5 3 7 July 9, 1968 State Compensation Insurance Fund V Post Office Box K Fresno, California " in tern a l m ed icin e r ' R v;;Yr Fresno D JUL 1 61SSd FI-.SC it:' A' Boar: ' Re: A - 17003 . _ _ Kenneth M. Frederick Attention Maurice Nyberg, Claims Adjuster Gentlemen: With re gard to your inquiry of June 21, 1968, I am not aware of any " known relationship between exposure to fiberglass and development of the type cancer leading to this man's death. A period of continuous exposure to fiberglass alone, without concomitant exposure to asbestos, would not have contributed to this man's demise. MSM/wb M. S. M illar, M. D. MAURICE NYBERG JUL 11 1958 TSNO, D.O. Joseph B Forl.Jr.. M . D T h O * c C S G t Y 'csno *TecT rcNO, CAuro*N,A S37Z, July 26, 1966 OHCHOtCMr tlOHACO.COPV John S. Backer Aetna Life , and Casualty 2220 Tulare Street Fresno, C a lifo rn ia Dear Mr. Backer: Re: Kenneth Frederick Owens Corning F ib e rg la s mi id in -r t i~B*Uvui wi gardmg Mr. Kenneth Fre d erick ieducating I saw th is p a tie n t in co n su lta tio n on June 8. 1966 at Fr n n r , -* u P ita , at the request o f Or. AHen Mau. hI had been o s ^ i z ^ ^ L it h 'e r in v e stig a tio n o f h is complaints o f p e rsiste n t and increasing cough in a d d itio n rhpcTM 9reSSIv* shortness o f breath s in c e an episode o f pneumonia9in A p ril 1966 Chesc x-rays had revealed c o n so lid a tio n in the rig h t lower lobe p o s t e r i o r l y ^ there was a prominent rig h t h ila r area in a d d itio n to p le u r it is on t h L h r the^aml T p re v io" s r r0ys taken in A p ril 1966 which showed e s s e n tia lly the same changes except during the interim there had been an apparent C r e a s e o f lu id on the rig h t sid e. He had pre v iou sly been h o sp ita liz e d in May 1966 fo r two weeks and at that time he was noted to have a larg e liv e r in a d d itio n JoosseIphh WEUo,omanndn befca' nusdeiThe- waAs tcothm3pt latiinmineg hoef wpasainseeInn th"ecoringshutltaletqio n hte wlars hIrth!xe n |,n -C0nSU,ta- ' 0n ^ Dr; U p p e r t ` Hs past h is to ry revealed that he dad h^,a laminectomy in Ju ly 1965 fo r a herniated d is c . Chest x-rays dated ^a ttlryib-Iu9toe5d/ etoV" chl ro n"ic0daUs,Bbresdteonsissi.tle s in both lower lung f ie ld s which were Physical examination revealed a f a i r l y w ell developed and nourished 50 year o ld w hite male who appeared i l l . His re s p ira tio n s were shallow raoid grunting. His n a il beds appeared dusky. There was no evidence' o f adenooathv The trachea was in the m id lin e. There was d u lln ess to percussion over the lower n e -h a lf o f the rig h t chest p o s te rio rly and the lower one-third a n t e r i o r ly w ith diminished breath sounds. Rales were heard over both lower lobes The liv e r was considerably enlarged and tender to p a lp a tio n . * It was my impression that the pa tien t most lik e ly had a bronchogenic carcinoma on the rig h t sid e w ith mtastass to the liv e r . Bronchoscopy was recomnended 2 - 7/26/66' CC CC Re: Kenneth Frederick and was performed on June 0, |o6 There w , in the rig h t lower lobe bronchus a r is in q at the 1 e 9 I'0Sr y . t0 be tUfflor t is s u e and extending down the bronchus about one centim eter s ^ *uperior segment st"'09 Sr,i:as. '- "* employment as a f di ' sel a' " i ' d answer. I p ersonally b e lie v e that heavy c l J E L i \ L o f bronchogenic carcinoma but r e c o g n i z e e p o s s i b i l i lu te n ts and in d u s tria l carcinogens mav nu ,, P fs s,b l 1*ty present knowledge o f b r S S S S S f T E ,#* not related to h is employment as a fib e r g la s w o ik e r . ^ f r " ? ' P betw,en h i! V |Ue,t,OB t0 L I * ** "" j o r " USe that other a ir pol H?Wever* V ^ h' S d lsease was Sincerely yours, JBFrms Jo s e p h B. Ford, J r . , m . ~-r ( A .LE N M* D . 2939 NO. FRESNO STREET . Fr e sn o , c a lifo rn ia s s 7 o a T c i Cp m o n c 222-9270 J u l y 7, 1955 Mr. John S. Backer 2220 Tulare Suite 8000 Fresno, California Re: Mr. K. M. Frederick Dear Mr. Backer: . Mr Kenneth Frederick's present illness started about March 1966 ,,hen he developed an apparent "flu-like" illness which progressed to a lobe pneumonitis over the subsequent month. However following his recovery^ from the pneumonia, he continued to have complaints of generalized r nf ^ lai86' 1088 f W6ight' P P - ^ e , S t r e n g t h ! Diagnostic studies were started durinz Anri: i o r a v,_ ,, , , S f o e i i o f f T 1-137 ,12'27' 1966 at the Fresno Cou^unity^Hospital.^During* this period of hospitalisation no diagnosis was made, altho a susDeeted plasm was the primary consideration. While in the hospital he was also s e e n Fresno^CaHfornia?*' ^ M * ** " * - n T following his discharge he continued to do poorly and he was a 5 !!OSPihtal n JUne 8 * 1966 and was saan in consultation by Joseph Ford, M. D. f who subsequently performed a bronchoscopy the iatrT- procedure revealed a bronchogenic carcinoma of the right lower^obe of the . ,, present time Mr. Frederick is at home. He is being treated svnn_ and^r-M tKCre iS Probable sPread of the neoplasm to thf pleura li ^ and possibly the brain. It is doubtful if surperv radiation or ot.-J.it. ' would offer any hope of recovery to Mr. Frederick.* * raPy h- , - i . J ari.V"3*'16 to 8tate categorically that there is a cause and effect ' n! f i r ip betwecn M r * Frederick's work and his present illness. As you are probably aware, Mr. Frederick has worked with asbesto for 20-25 y r s at h had rediographically demonstrable asbestosis for the past few years ? * m s ? 2 0 C^ alS i T ked apprXinately 1 Package of cigarettes daily S i the past 20-- a years. There are at present, trends in medical literature which i , m s ; 1" " sh" " a - - - 5 . 156 Yours truly, " J'y Allen Mau, M, D, \ ( ' c JRKMEN'S COMPENSATION APPEA1S BOARD DIVISION o r INDUSTRIAL ACCIDENT* oeraatmsnt o r industrial relation* , S'" ATE OF CALIFORNIA COMPROMISE AND RELEASE (Dependency Claim) IU . A 17 0 0 3 CASE NO. 6 $ F 1 6 4 8 ? __ (M ^) MINNIE LOUISE FREDERICK . so c ia l se c u r it y N o-- 3^3^:1 ^ - 5 7 0 3 (Miss)-- ^*NRjTH__MARTIN FREDERICK-DECEASED 2021 Glendon. Los Anaeles. Calif. ..VARIOUS EMPLOYERS (SEE ADDENDUM) M i t e r m a h b mr B M P h o rw VARIOUS CARRIERS (SEE ADDENDUM) n m e r a h o r i m m * a h r m m i m Th e parties hereto, fo r the purpose o f compromise oolyt agree u follows: The above-named applicant___claim fL . A * .KENNETH MARTIN FREDERICK ^ t s s a p . ' Mtiervm -- ---------------- whilt'ra^feyiS at various placed in California -iHCJtr.ogLljQvemb.er.^igRg. - July 8. nofifi Kv Various employers________ .........................-- . then insured as to workmen's compensation liability by_Various carriers CAMIBII t l W M ITM It BILF.IMtlHIlD) ------.---------- nutained injury arising out o f and in the course o f such employment as foilow i:--. ^ 8 ^ * 115 to have suffered lung damage resulti^._4n^cl^ath. Pv VM { t .' 2. The death o f said employee occurred on Ju ly 8 66 WOV 1 19------ - as a result of the claimed injury. --, 3* The actual weekly wages o f the employee a t die tune o f claitw^d injury were. (statutory) were- Maximum M SXiltm iP. , W EFm gc-w eeky -wages 4. Payments o f compensation to tile employee in bis lifetim e on account o f tbe claimed injury we N o n a Tbe applicant--- herein claim---- to have been dependent upon said employee a t the tim e o f claimed injury, and state____ the i ages, relationship to, and the extent o f dependency upon said deceased employee to have been as follow s: NAME Minnie Louise Frederick AQI Adult RELATIONSHIP Widow EXTENT OF DEPENDENCY Total Bruce Frederick 20 Son Partial i . The parties hereby agree to settle any and all claims o f said dependent .JL on account o f the claimed injury and the death o f said employee by payment of tbe sum of l-13.x5QO.00___ _ payable as follows $500.00 to Bruce Frederick. -- fe.al.an.ee to Minnie Louise Frederick, less $1,177.55 payable to Fresno .. -C-Pmunlty.-.Hospital. less $4o8.QQ payable to Dr. Allen Mau and less a .. .reasonable-attorney1s f e e . ___________ _____________________________ ' The parties hereby agree (if such items o f expense be claimed) that medical, hospital and burial expense required by reason o f the alleged injury and the death of the employee shall be borne as fo llo w s :__ All fey applicant ____________ f t A V. C A B F o e ' F a b C 1> <**V .> ( n* name Uid address of applicant's attorney (if any) i_ g g g .r ,. J & r r _ & _ Millett. lggQ " if " s t r e s s * , *ho request, a fee of S.1,J.5.CL.Q0------- - having been previously paid ....NONE. 9. Reawn for compromiwJgis^ut^exists__as to whether or not injury or death AOE/COF. -- P i . ^ u t g _ _ g ^ s ^ _ a ^ t o _ p ^ ^ o d s _ o f _ ^ ^ i o ^ gnt w l t h v a r i o n g OTr,? ^ y a ^ g 5iLsil. u t e _ e j d ^ s t s _ a s _ _ t o ^ h e t J i e j ^ ^ n o t _ ^ l c h ^ l j f ^ ^ y t peri o d nf emplnVfflpn+ --- g . g M r . l b j i j ^ d - j ^ _ t , b , g _ a il l tg ^ e j . i n . l u r y .gr_j.f.g.t,b.,_____________________________ 10. The undersigned request that this compromise agreement and release be approved. 11. Upon approval o f hi, comproome agreement a , provided by law. and payment in accordance with the o r TM ! TM , t o f approval, said applicant, and each o f them do hereby releaw nd forever ducharge said u n p lo m ind L d > a o f and from all claims, demands, actions or causes o f action, of every kind or nature v l u n v V d r m5'" * nc* " apan y injury and death the undersigned, sunained ,, aformrid by the e m p l o y e d in ^ heirs, executors, representatives, or adm inistrators cX may o have f^ had, Z uZ Z now have Z Z ZZT ^ 1 shall h e r e a f ^ * ^ ^ employer, sa.d insurance carrier, and each of them under Division IV o f Labor Code o f the S u te o f California. * * lg " K ^ ! ' " agr" d ^ * U hertt0 * " * ^ 8 * this docum ent i, the filing o f an application on behalf o f the annlican^ a issued after a hearing has been held and the m atter regularly adm itted. ' PP ' decision 13 For the purpose o f determining the lien claim filed herein for the unemployment compensation d isability and/or c l a r i o n benefit, which have bmn paid under or punuanr to the C a h Jr n ia U n e m ^ l t Z Z Z ^ Z Z ^Z pose the following division o f the sum agreed upon fo r settlement and release o f this case: P t ------------------------ fo r temporary disability covering the |wri~ ) N o n e f i l e d ___________ ___________ fo r accrued medical expense paid or incurred b y the employee. * ---------------------- -fo r future medical care. $-- =---- ---- :------ fo r permanent disability. 1 4 Provisions of Labor Code Section 5313 are waived. * 1 (T!!* ,b T " " ** In<J r a i 0 'ub le " d " > based on the real facts o f the case. There should be no attemnt made to deprive the lien claimant o f a reasonable recovery consistent with all the amounts involved.) P V n K E ss thesignaturehereof thrs^ . Z , day o f J ^ x x > Z X X ------ , nr. q J imugant'natukc must attiitu artwo dwimtcuci Fswee* O K ackmowicmcd bmomk a nota* * ruawic. STATE OF CALIFORNIA ------- -- Ccounty or,,-TL--T^/;*: _CK, Applicant FRYERf KARR & MILLETT ____ X&Lu*/ 1 Att orneys^for Api icants _See Addendum, Page * , for signatures of carrie'fs. On ________ day of____ ------------ A..D. befort me, ^ ^ T ^ s i s O ...... ...-- * N o t a r y A / / * /v / P u b/l i c in ,,, a . l 0rJ he ^ C o u n t y and State, residing therein, Ju ly commissioned and rworn, personally appeared known to me to be the pen on..S. whose nam e-X S : / " subscribed to the within Instrument, and acknowledged to me that T hr y executed the same. x W itness W h e r eo f, l have hereunto set my hand and affixed my official seal the day and year in this Certificate u- 1 itten. * .W , DRH:jp ! *\I COLl r -:m >: id CC N otary tubhc m m i ja r m i County m i S tall of California OlA WCAb Form |( 'Pace 2i rpcv fopmialv Foam 0 e< >'OI.C)(.*C otxlBfc ADDENDUM INSURANCE CARRIER U. S. Fidelity and Guaranty Co. Transport Indemnity Co. Adjusting Agent for - Industrial Indemnity EMPLOYER C ONTRIBUT ION Thomas B. Douglas dba Douglas Insulation Co. $ 25.00 Lone Star Industries Successor to Pacific Cement & Aggregates Lorentzen Company $ 25.00 $ 200.OQ Aetna Casualty and Surety Co. Owens Corning Fiberglass Corp. $' 500.00 Argonaut Insurance Co. Travelers Insurance Co. State Compensation Insurance Fund Western Asbestos Co. Armstrong Contracting & Supply Corp. Johns Mansville Corp. Armstrong Cork Co. Western Asbestos Co. See Page 2 of Addendum for signatures of various carriers. $ 1,000.00 $ 1,000.00 $10,750.00 ADDENDUM - K M. Frederick Page 2 Attorney TRANSPORT INDEMNITY CO. AETNA CASUALTY BY f * CkEEDE, d a W S : ARGONAU^ INSURANCE CO. t s m a n , ^ Its Attorneys f PRa u ^a N d ^Ct2 7 TRAVELERS INSURANCE CO. By xCh-ZL. 7s`< L u f f i its Attorney's" 'mA Prrn rr\in-iTri^ .....______ _