Document RjJLrw61KNpEZVY19zebN4b1n
FILE NAME Insulators Workers Comp Claims IWC
DATE 1967 DOC IWC061
DOCUMENT DESCRIPTION Claimant - Gilbert Oscar L. From M Archive
File Name
Contract Unit Claim File Oscar L. Gilbert Apr. 19/67
Scanned ?
yes
Source
JMA NS
Start Year
1967
Stop Year
1967
Contents
claim
Notes
COMMISSION WORKERS COMPENSATION
INDUSTRIAL ACCIDENT
APPEALS
COMMISSION
COMMISSIOCOMNIS ION
BOARD - CALIFORNIA prior to 1966
APPLICANT
OSCAR L. GILBERT
DATE
CLAIM
Asbestos Insulator
FILED
April 19 1967
HO
___
CASE #ANA 19219
19219
INJURY ALLEGED
Inhalation of
asbestos to lungs
ALLEGED DATE OF INJURY
1942 28 1966
EMPLOYER INSURER
Fiberglass Engineering & Supply
Casualty et a including J.m Corp. Corp.
OTHER NOTES
... generalized infiltration of what is
apparently
fiberglass
Med Rpt to applicant's
attorney
...
believe his major
problems are
secondary to his exposures
to asbestos
fiber-
glass and the dust
surrounding themIt
DATE OF RESOLUTION Jan. 19 1968
RESOLUTION
Compromise & Release
15,000 settlement
DOCUMENTS COPIED
1 Compromise & Release
# OF
PAGE
CLAIMANT
Oscar Gilbert
__
California Workers Compensation Appeals Board
CARRIERS INVOLVED
The AETNA Casualty & Surety Co.
American Automobile Ins Co.
oAmerican Employers Ins Co.
American Motorists Ins Co.
oArgonaut Ins Co.
oAssociated Indemnity Corp. oCalifornia Casualty Indemnity Exchange
oCalifornia Compensation & Fire Co.
oCasualty Ins Co. of California Employers Liability Assurance Corp.Ltd
oEFmipdleolyietrys &MCuatsuuaalltLyiaCboi.liotfy NIenws YoCor.k of Wisconsin- _
Fireman's Fund Ins Co.
ooGGleonbeeralInAdcemcniidteyntCo.Fire & Life Assurance Corp. Ltd.
Co.
oGuarantee Insurance Co.
oGreat American Ins Co.
oHardware Mutual Casualty Co. oIndustrial Indemnity Co.
Sentry
oIndustrial Indemnity Exchange
Insurance Co. of North America
Ins
Co.
oLiberty Mutual Ins Co.
oLumberman's Mutual Casualty Co. oMaryland Casualty Co.
oMichigan Mutual Liability Co.
oMission Insurance Co.
oNational Automobile & Casualty oNew Amsterdam Casualty Co.
Ins
Co.
oOcean Accident & Guarantee Corp. Ltd. Pacific Employers Ins Co.
oPacific Indemnity Co.
oReliance Ins Co.
oRoyal Indemnity
Standard Accident Ins
Co.
oSecurity Ins Co. of Hartford U.S.
oState Compensation Insurance Fund
oTransport Indemnity Co.
The Travelers Ins Co.
Casualty
Ins
Co.
oThe United Pacific Ins Co.
OU.S. Fidelity & Guaranty Co.
oZenith National Ins Co.
oZurich Ins Co.
O0
14
5/81
1
WORKERS COMPENSATION APPEALS BOARD
2
STATE OF CALIFORNIA
3
Bfi OSCAR L. GILBERT
CASE No.
67 ANA 19219
Applicant
OO VS. ) 7 PABCO CORPORATION EMPLOYERS
8 MUTUAL INSURANCE COMPANY OF
WISCONSIN
.
9
10
Defendant |
CERTIFICATION
11 12 13 14
15
16
I hereby certify that the attached documents are true
and correct copies of the original documents filed in the records :
of this office in the entitled matter
Appeals
ATTEST my hand and the Seal of the
Board of the State of California
Workers
Compensation
17
18
19
20
21
22
3232 j
3232 Dated at San Francisco
3232 California this 31 3232 of March 1981
day
27
DIA WCAS FORM 115 NEW 1-75
COCONN T DT EP
DEPARTMENT OF INDUSTRIAL RELATIONS OF ACCIDENTS
es .
C
.
form INSTRUCTIONS C 1. Do nat use thisform in death cases Use Form 18. Do
.
injured 2.
injured Employee b^'under 21
not use in thirdparty cases Use 17
of guardian ad litem and trustee years of ageage and a guardian ad litem has not been
2. The guardian must sign this
must accompany this agreement
previously appointed a potition for appointmen
such
minor
should
also
sign
agreement this
on
behalf
of
an
injurad injurad
employee
who
is
under 21
of
agreement
+ Attach all medical reportsreports not heretofore submitted to the Workmen'sWorkmen's
years age If the minor is above the age of
Compensation Appeals Board and advise when other
reports were fi
WORKMEN'S COMPENSATION APPEALS DIVISION OF INDUSTRIAL ACCIDENTSACCIDENTS
DEPARTMENT OF INDUSTRIAL RELATIONS
BOARD
COMPROMISE AND RELEASE
STATE OF CALIFORNIA
-
SOCIAL SECURITY 432
10-4423
CASE 19A2 NA 11 921
Mr. Mrs. Miss
13
GILBERT
FIBERGLASS ENGINEERING CO ET AL FIBERGLASS
CORREST NAME OF SUPLATER
6532 Bestel Ave.
, Westminster Cali
a7ente
ATTACHED SHEET
NAME OF
stnnese
parties The
herem for the purpose of compromise only hereby submit the following agreed statements of fact
+
GILBERT
ren OSCAR L. from
claims that he was employed on the
.
asasbestos worker by COUPATION COUPATION
1942 to 1 19967 67employeeemployee herein bora
May 23 1911
day of
the
cities MONTH
19.
at various
YEAR
employers named herein
KAME OF ENPLAYER
cities
in Calif
ISTATE
then insured as :
workmen's compensation liability See attached sheet
STATE HANS OF
ON
SELF
and th
reports filed herein he sustained an injuryinjury arising out of and in the course of his employment as follows To the
i
particularlyparticularly as set forth in all all of the medical
lungs and more
herein
2. The actual weekly wages of the employee at the time of
injury
were
_maximum _maximum
while
the
average weekly wages wer
maximum
1. The employee's present disability is
in dispute
OCLOSED
- OCLOOCLSOESEDD
and the employee_has_noteturnedemployee_has_noteturned employe _has_noteturned employee_has_noteturned to workwork
IRAINY OCLOSED 031111 IETATE PREDENT BIDABILITY RESULTING FROM THE OCLOSED
17 80. STATE WHENS
4. a Temporary disability indemnity has been paid to the employee iin n the sum of $
none
OCLOSED |
ADOREADORE
\ .ar ADORE
20 20
VISION VISION
REVEIVED
17:53 17:53
17:53
PM
REVEIVED
INDUSTRIAL INDUSTRIAL
INDUSTRIAL
we
LINSERT beginning to and including
The
due and unpaid to the
LINSERT
id
$'67 dis
b Permanent disability indemnity has been paid to the employee in the sum of snone snone
4
LINSERT
snone covering period
.ta eres
1. The parties hereby agree to settle any and all claims
on account of said injury by the payment of the sum of 15,000.00
in
beretofore paid by the employer or the insurer
VO C3.96 91
VE Emote i oe 4 }
said sum to be payable as follows
RAR
follows
to Paragraph 5
by _none_ _by 6. Medical and hospital expenses have been paid $1.119.89by the employee and _
the employer or carrier
Unpaid bills
to 300.00
+ Future medical and hospital expense is estimated at 5,000.00
Unpaid and
future medical and hospital expense is to be assumed as follows All_by_applicant All_by_applicant All_by_applicant
DIA WEAB Form 15 Page 3 FORMERLY FORM 431
REV
1.661
6332 172 67 s
^ ae
C
. a
=
" .
.
4
. .
. . .
=
.
200 N. Broadway 7. Name and address of employee's attorney if
Rose Klein and Marias
Santa Ana
California
a 1,500.00 8. Said attorney requests fee of $ 1,50.0
9. Reason for
Amount of attorney fee previously paid if any $
if Compromise sustained case regarding or not the applicant has
this any
industrial
the
injury or
question
injuries
of wh
disability disability
productive to extent alleged
disability limitations limitations
of
The defendants assert the affirmaapplicant'stiveapplicant's
present
statute formidable
on both
sides
sides
Therefore
hazards
litigation
litigation are it is agreed that this
Compromise
10. The undersigned request that this Compromise Agreement and Release be approved
is by all parties herezo filing this document the filing of an application of the emploeympleoyses 12. It agreed
that the
of
.
the W.C.A.B. may in its discretion set the matter for hearing asisa regular application
on
reserving
issue any of the facts admitted herein and that if hearing is held with this
have available to them all defenses that were available as of the
thereafter either approve said
date of filing of this document and that the
Compromise Agreement and Release or disapprove
hearing has been held and the matter regularly submitsed for decision
and tha
the for 13. For the purpose of determining the lien claim filed herein for the
paid
under or pursuant to the
unemployment
California Unemployment Insurance Code the
compensation
disability
benefits
which
have
beer
upon for settlement and release of this case
parties propose the following division of the sum agreed
$
_for
temporary disability coveripenrigod
for accrued medical
t
expense paid or incurred by the employee
_for _for future medical care
for permanent disability
be based on the real facts of the case There should be no attempt The above segregamtusitobne fair and reasonabalned must
made to deprive the lien claimant of a reasonable recovery consistent with all the amounts involved WITNESS the signature bereof ___day of
Xogan Siilbert
WITNESSSS
THE INJURED APPLICANT'S GIONATURE MUST BE ATTRETED ATTRETED BY TWO
Q~B~NTERESTED PUBLIC Q~ B~ NTERESTEPDERSONS
ACKNOWLESSED BEFORE A NOTARY
STATE OF CALIFORNIA
ORANCE ORANCE ORANCE
Ferria
_County of CAL Ferria Ferria
By Bebed P Attorneys Nop Attorneys
On
1971 1971 JANUARY sald County eeneee.
_ day of
JANUARY JANUARY
Notary Public in and for the
A.D. 19. before me Joseph W. FARENBLUES FARENBLUES
FARENBLUES
and State residing therein duly commissioned and sworn personally appearedappeared
known to me to be the person whose name TECAR
L GILBERT
bscribed to the within Instrument and acknowledged to me that
be
IN WITNESS WHereor I have hereunto
....
executed the same
written
set my hand and affixed my official seal the day and year in this Certificate first above
JOSEPH W. FARENBAUCH
ASS | by, ERINCIPAL OFICE CALIFORNIA
OFFICE | BRANGE COUNTY
f
My Commission ~ zbiraSept. 23,1971 .
) DIA WCAB foou 15 PAGE ICADIALY FORM 431
REV
1-70
aigih,yf 2 be
}
/ and 1 County Stair Notary Public in and for send Countaynd Stair of California
eavenden 5.09 sow (1) 'T. on
JOHNS MANVILLE CORPORATION
Travelers ; Insurance Company
~ aviTdaylor Ly Ae
J. TTHORPE & COMPANY
American Motorists Insurance Company
John Henderson
PLANT ASBESTOS COMPANY
BALDWIN , INC
INSULATION INC Pacific Employers Company
Insurance Company of North
America
, PLANT RUBBER
ASBESTOS WORKS
permissibly insured
SYDNEY LOUIS CARPENTER THORPE INSULATION COMPANY PLANT INSULATION COMPANY
Fireman's American Insurance
Company
By Lb he dona
FIBERGLASS ENGINEERING COMPANY
Aetna Casualty and Surety Company Weingand Kendig &
Company
Stockwell Kendig By
MAF
thd
7]
ve
.
CE
RE OSCAR L. GILBERT
ADDENDUM TO COMPROMISE AND RELEASE
.
LINE 5
The Compromise and Release is to be paid as follows
Aetna Casualty and Surety Company 2404 Wilshire
Angeles Fiberglass Engineering Co. 6,771.49
Boulevard Los
;
Fund Firemen's
American Insurance Company
Sixth
Angeles
California
Sydney Louis Carpenter
Street Los Thorpe Insulation
Company Plant Insulation Company 5,502.99
. Works
Plant Rubber and Asbestos Company 537 Brannon
Francisco
California
Street
permissibly insured
San
1,811.88
Pacific Employers Company Insrance Company of North
Plant Asbestos Company Baldwin Inc.
American
161.06
Insulation Inc.
-
American Motorists Insurance Company J. T. Travelers Insurance Company Manville
Thorpe & Co. 87.60 Corporation 664.98
TOTAL
15,000.00
It is intended by this Compromise any and all liability of each and herein for any periods of insured
unknown
to release all of the
employment
and forever settle named insurance carriers whether now known or
20.00 All payable in a lump sum less the following sums to be
Aetna Casualty & Surety Company 269.00 to Morton
paid
226.00 to Dr. Smart ;
to
Dr.
Weinstein
Kritzer 100.00
M.D
Schubin 504.89 to Occidental Life Insurance
to Dr.
500.00
to
the
Department
of Employment
all
Company
in full
and
of their respective Liens and less attorneys fees satisfaction