Document Rp4VdprQ0xeBoJLv2MVg9aj0a

FILE NAME Manville JMA DATE 1967 DOC JMA154 DOCUMENT DESCRIPTION Contract Unit Claim File Robert Horsman WORKERS ' COMPENSATION APPEALS BOARD - CALIFORNIA INDUSTRIAL ACCIDENT COMMISSION prior prior prior to 1966 APPLICANT ROBERT HORSMAN . Asbestos Installer CASE #LA #LA 316509 DATE CLAIM FILED INJURY ALLEGED | Oct. 23 1967 Amended Sept. 5 1968 Inhaling foreign substances ALLEGED DATE OF INJURY 1925-1967 EMPLOYER INSURER Thorpe Insulation Co./Firemen's Fund Ins et al including M Insulation OTHER NOTES ; Pulmonary fibrosis secondary to asbestosis DATE OF RESOLUTION Jan. 22 1970 RESOLUTION Compromise & Release 19,000 settlement apportioned among 18 employers DOCUMENTS COPIED Compromise 1 Compromise & Release 2 Application showing original defendants # OF OF 5PAGPAGEE CLAIMANT _ Robert Horsman : California Workers Compensation Appeals Board CARRIERS INVOLVED The AETNA Casualty & Surety Co. oAmerican Automobile Ins Co. oAmerican Employers Ins Co. American Motorists Ins Co. Argonaut Ins Co. oAssociated Indemnity Corp. oCalifornia Casualty Indemnity Exchange oCalifornia Compensation & Fire Co. Casualty Ins Co. of California Employers Liability Assurance Corp.Ltd Employers Mutual Liability Ins Co. of Wisconsin - oFidelity & Casualty Co. of New York | 7 Fireman's Fund Ins Co. General Accident Fire & Assurance Life Assurance Corp. Ltd. oGlobe Indemnity Co. Guarantee Insurance Co. oGreat American Ins Co. oHardware Mutual Casualty Co. . Sentry Industrial Indemnity Co. oIndustrial Indemnity Exchange oInsurance Co. of North America oLiberty Mutual Ins Co. oLumberman's Mutual Casualty Co. oMaryland Casualty Co. Ins . Co. Michigan Mutual Liability Co. Mission Insurance Co. oNational Automobile & Casualty Ins ONew Amsterdam Casualty Co. Co. oOcean Accident & Guarantee Corp.Ltd Corp.Ltd Pacific Employers Ins Co. oPacific Indemnity Co. Standard oReliance Ins Co. oRoyal Indemnity Standard Accident Ins Co. oSecurity Ins Co. of Hartford U.S. State Compensation Insurance Fund oTransport Indemnity Co. The Travelers Ins Co. oThe United Pacific Ins Co. U.S Fidelity & Guaranty Co. oZenith National Ins Co. oZurich Ins Co. Accident Indemnity - Indemnity Co. Casualty Ins Co. 5/81 mum 2 WORKERS COMPENSATION APPEALS BOARD STATE 2 OF CALIFORNIA 3 ROBERT J. HORSMAN . . . 4 . | CASE No. . 67 LA 316-509 5 Applicant ^' ) VS. 7 THORPE INSULATION COMPANY , et al FIREMAN'S FUND INSURANCE 8 COMPANY et al 9 10 Defendant CERTIFICATIO 11 correct tru 12 and I hereby certify that the attached documents are copies of the original documents filed in the recor i } 13 of this office in the entitled matter : i iH 14 ATTEST my hand and the Seal of the Workers Compensat 16 Appeals Board of the State of California 16 17 Pa i _ 19 | Board 20 Workers Workers Compensation Compensation Judge Compensation Appeals Board 21 , 222 23 24 Dated at San Francisco 25 California this 6 day 26 of April 1981 27 DIA WCAS FORM 5 NEW 1.961 GEP DEPARTMENT OF INDUSTRIAL RELATIONS OF ACCIDENTS ~ 7 4 1 MCLAUGHLIN EVANS DALBEY & 1717 North CUMMING Los Highland Avenue Angeles California 90028 3466-3541 wpe Wi cw LP Aa at Ss Attorneys for Owens Corning Fiberglass Corp. and Aetna Casualty & Surety Co. Defendants 6 7 8 9 10 |! WORKMEN'S COMPENSATION APPEALS BOARD . STATE OF CALIFORNIA ' ROBERT J. HORSMAN SSA 562-03-2606 12 Applicant 13 vs. MUNDET CORK 14 CORPORATION et . 15 Defendants > ) ) ) ) ) al , ) CASE NO 67 LA 316 COMPROMISE AND RELEASE AGREEMENT ; 16 . ; ; The parties hereto for the _ 17 purpose of compromise only -18 hereby submit the following agreed statements of fact 19 l. Robert J. Horsman born August 26 1904 claims he 20 was employed between 1925 and June 28 1967 at various locations within the State of California as 21 an asbestos installer as a result of which he sustained . an injury arising out of and 22 occurring in the 2 course of his employment from inhaling foreign substances or in- jured self in some other 2 manner resulting in injury to his lungs and other injuries symptoms conditions and ' 2 complaints set forth . in the medical reports on file 2 fi 2 |: [i bas 28 2 employed During the alleged alleged , at various times by period of employment the applicant Coast Insulating Company The | Philip Carey Mfg Co. Corning Fiberglass 29 . Corporation Mundet Cork E 33 Corporation Fiberglass Engineering and Supply Company Proctor - 4 33 Gumble Gumble Soap Company Los Angeles Department of Water and Power J. F. Thorpe 32 Tenen Inc. INC Insulations a corporation corporation Inc. Marine Engineering Engineering Company California Petroleum Corp. ~ Be yet i Los Angeles Rubber Company Angeles Cork Company 2 Angeles Rubber Plant Asbe Asbe: Products Insulating Packing Co. Armstrong Armstrong 3 Company Coast Metal Insulation Accurate Insulation Accurate 4 Cork Company oi1 Company Manville Insulation Co. 5 Shell Corporation Corporation : and Supply Corporation various 5 Contracting the various employers for for: Application Adjudication Adjudication claim claim 6 3. The actual weekly wages the employee 8 injury are in dispute employee the time time 9 4. 190 5. 11 employee ; dispute The employee's present disability in dispute No temporary disability indemnity been been paid to 12 6. The parties hereby agree settle settle 13 of and 19.000 clai 14 15 16 17 18 deducting of attorney fees and lien claims of lien claim of the Dept. Empl t Department of Employment and ment lien should condition condition has be be denied since the 1967 Derry's report be 19 of December 9 1967 and the Department of 20 Employment commenced payments July 5 1967 21 2 23 24 25 26 27 28 29 30) x 31ii 32 i [ { ( (b) (b) (c) (d) {e) () {g) (h) (i) (3) (k) (1) CASUALTY INS CO THE TRAVELRS INS HARTFORD HARTFORD ACCIDENT MISSION INS STATE COMPENSATION COMPENSATION CO INDEMNITY & COMPENSATION FUND _ 0O 7 . Pa?* 7077 UNITED STATES FIDELITY GUARANTY GUARANTEE GUARANTEE MOTORISTS . 7:77 AMERICAN MOTORISTS MUTUAL CO co, SECURITY INDEMNITY INDEMNITY . INDUSTRIAL INDUSTRIAL INS CO FIREMAN'S ACCIDENT FIRE GENERAL ACCIDENT INS, co. GENERAL ACCIDENT -2- -2- LIFE a Fe AssuR, -2- 328.00 1,259.00 41.00 91.090 1.00 1,950.00 55.00 680.00 118.00 144.00 1,780.00 275.00 275.00 2,780.00 275.00 ! ; i , N 3 4 5 6 7 8 Olympic 9 m n Pacific Employers Ins Co. 3/16 Employers Mutual Liability Ins CONTRIBUTIC $ 3,003 969 0 Aetna Casualty & Surety Co. Co. 5,262 p Proctor & Gamble Soap Co. permissibly insured c Los Angeles Department of Water & Power legally insured 25.1 620.0 9. The employee's attorney is Steven Roseman Boulevard Los Angeles California 90015 1543 West 10 Attorney requests the fee of $ 1600.00 attorney's Amount of 11 11. 237 at orney's Reason fee for previously paid if any $ None Compromise Compromise A bona fide dispute . exists| as to whether or not the applicant sustained 13 injury which arose out of and occurred in the course of his 14 employment through ex- applicant's posure to any deleterious substances while 15 working for the named employers The nature of the aplicant's illness and the extent 16 of his disability is set forth in the medical reports on file 17 There is a dispute as to whether or not 18 any portion of the appli- cant's disability is due to causes other than industrial exposure 19 The applicant has expressed the desire of 20 resolving the litigation by obtaining a lump sum amount and controlling his own medical 21 treatment in the future All parties desire to resolve the dis- 22 puted issues by this settlement 23 and expense of litigation thereby avoiding protracted delay 24 25 Release 12. The undersigned request Agreement be approved that this Compromise and 26 | 27 28 29 30 31 32 13. Upon approval of this Compromise Agreement by the Workmen's Compensation Appeals Board or a Referee and payment in said accordance with the provisions hereof employee releases and and forever discharges said employer insurance carrier from all claims and causes of action whether now know of ascertained or which may hereafter arise or developas a result of said injury - including any and all liability liability of said employer and said insurance 1 carriers and each of them to the dependents heirs 2 executors 3 representatives administrators or assigns of said employee &fi 5 Angeles WITNESS this < CCalifornia alifornia day of108 ai, 108 1970 at Los 7 7 g 10 11 . 12 , : Applicant's atty ow a STEVEN ROSEMAN = Applicant's Ap licant's - ARGONAUT INSURANCE INSURANCE SECURITY MUTUAL COMPANY CO CASUALTY By HANNA AND BROPHY Full Full AND By THE TRAVELERS By PARKER & INSURANCE DALLY CO 15 16 17 18 | 19 20 222 22 23 24 25 |; 26 | 27 ; 28 29 : 32 CASUALTY INSURANCE CO OF CALIF By Hill ta ACCIDENT HARTFORD ACCIDENT &INDEMNITY CO WO DS By JAMESpe JAMESJAMES WOODS MISSION INSURANCE COMPANY Harrington By FW Harrington Harrington Robertson INSURANCE COMPENSATION STATE STATE COMPENSATION FUNI YRobertson . Robertson By RobertsonRobertsonRobertson - U. S. FIDELTY & GUARANTY CO - H By HERLIHY By 7. H & NELS LOS ANGELES POWER & Prag Sm DEPARTMENT DEPARTMENT lily OF WATER a ee TU Le. = fut, By : PROCTOR & GANDLE By HEALTHY HEALTHY MERLIHY SOAP CO Halily .1 GUARANTEE INSURANCE COMPANY 20 By ; DOJSKEP 3 By DDDOJSKEP AMERICAN MOTORISTS 5 LUMBEaRn)MEN'S MUTUAL INSURANCE C COO Ey il INDUSTRIAL 7 00 FIREMAN'S INSURANCE 1010 By WEINGFAUNNDD KENDIG & COSTMOPCKAWNELYL 11 11 12 12 By Boe FIRE GENERAL ACCIDENT 13 13 ASSURANCE COMPANY LIFE By HERB GARABEDIAN 14 14 15 15 16 17 18 19 i, By Beet 20 AETNA SURETY & CASUALTY CO 21 By MCLAUEGVAH NS LDAI LBN EY & CUMMIN .22 .22 2323 242424 STATE OF CALIFORNIA ) 25 COUNTY OF LOS ANGELES ) 26 SS ry off Public | On this 2 day off 27 27 the undersigned a Notary Notary Public and A.D. 1970 before me State residing thereintherein 2828 - appeared ROBERT J. HORSMAN duly duly in and for the said County and commissioned and sworn personally name is subscribed HORSMAN known to me to be the person whose . 29 29 he executed the to the within Instrument and acknowledged that sam",, 3 IN my official 3 ee eee ee 32 SEL SEL SEL WITNESS WHEREOF , seal the day and and coe Me 1 Sere rrf ;Soy 1 ose, re " ROMANISSI ROMANISSI ee toe tere ne -ie I have hereunto set my hand year first above written 4 and affixed - TU. | : Notary ar _ : Ce Pa ow oo in Notary Public and for said . County State __/ . ooo ae . _ Seven oe Teer weer lk ( Ce. . totaa gy ~ - Dyn ex . se . . . te Pars oor yt Ll. ges far. aes mee ror. she - on ~ eat Can Co ae . tee ted toe re ome ONE ~ oe . - we . . ee . KAPATIZANTI KAPATIZANTI assarss: EMPLOTER * 2741_E_Katos 27412_E_7Ka4tos1_E2741_E__Katos Kat27o41s_E_Kat27o4s1_E_Katos E Ev ve errnnaann 7 ITPLOTER'S ITPLOTER'S EST . Fireman's Fireman's FunFudnd Insurance Insurance Los : Co. 2223_r Angalas CaliforCanliiafornia California California sheat 7 attached SE 2223_r _ctb_gt cp^' PONSORED OF . ^ ' J 162993626 * OT OT of of and in in the employes employes born 1/1903 1/1903 to 5/20/1907 5/20/1907 5/20/1907 5/20/1907 , at whiwhlile e employed as a various various California Asbestos Asbestos Installer Installer LOCCUPATION AT TIME OF INJURED INJURED . Occupational course of employment to Occupational Occupational Oc upational ESTATE ESTATE by DisDiesaea ssee the employer employer arising arising aass follows: Inhaling STATE 'AT PATYS OF BOOT WERE INJURE T foreign substances EXPLAIN WHAT EMPLOYEE WAS DOING AT TIME OF INJURY 454 454 ZUPT 38 FE ES 3. 3. Actual Actual Actual Actual Actual earningsearnings earningsearnings earnigs time injury at time of injury were MMaaxxiimmuum m WEERLY CHIVE WEERLY OF MONTHLYMONTHLY SALARY OR HOUPET PATE AND NUMBER OF HOURS WORKED FOR * injury disability follows 11990707 to The 4. The caused GEPORSTELY GEPORSTELY STARI VAZHE VAZHE P^ RWZIK OP MONTH OF TIPS MEALS LOBZINS 2 OTHER disabilty disability follows ADVANTAGED REGULARLY REGULARLY RESSIVES RESSIVES JJuunne e 20 as 20 date date SPECIFT LAST DAY OFF WORK SJE TO THIS INJURE AND BEGINKIND AND ESPING DATES B ALL PERIONS DEF DU,,TO TO THIS IN - 1. Compensation was paid no $ { IYES ND 1967AL PAIB \ 6. Medical treatment was received ves s WEERLY RATE ~ DATE OF MAST PATMENT 1435 48 LATE OF LAST TREATHEN All treatment was furnished by the employer company IYES ----other 185 treatment was provided or paid for by Ductors not provided or paid for by employer or insurance company who CHAN^ PEPSON GINET PO IZING BP PANGUS PANGUS created or examined for this injury KOP MES Derry and Dr. Reginald Smart 201TOPS AND NAV~ S MJPITALS 70 WITH SC- 002724242MITTED 002724242MITTED 002724242MITTED INJURE have been received by have bun filed for industrial injuries this employee as follows ~ received since the date of for Temporary Modical treatment a - . s . a. tle - te : Doon > . we rr Se ees ee ee ree eee . ome na 240 Valley isbane California Co. California 04005 6/12/65 1/2/66 . - ~ - Insulations | ilip Carey 2 S. Monterey Monterey Park , sold to Co. Pass Rd California | Owens Corning P.O. Box 901 Toledo Ohio Fiberglas Corp. , _ : Los Angeles Cork Co. .T Thorpe Inc. 940 E. 2nd Street Los Angeles California Diz Armstrong Armstrong Contracting & Supply 120 N. Lime Street 3,4 and Feb., 1966 10,11 11,12 1954 1957 1959 1959,1961,1962 2,3,4,5,6 1964 and 8-10 Pacific Employers Ins Co. 4050 Wilshire Boulevard Los Angeles California The Aetna Casualty & Surety Ins Co. 2404 Wilshire Boulevard Los Angeles California and Employers Mutuals of War 3540 Wilshire Boulevard Los Argeles California 12/1904 and 1965 1961 1963 & 1964 , Fireman's Fund Ins . Co. 3223 W. 6th Street Los Angeles California American Motorists Ins 3545 Wilshire Blvd. Los Angeles California - 1961 1962 1963 & 1964 1962 The Travelers Ins Co. 3600 Wilshire Boulevard Los Angeles California 1962 1939,1953,1950 & 1961 The hotne Casualty 2 Sur Ins Co. Wilshire See - Accurale 3223 3223 0953 | 11,12 135i Casualty 2.0 2.0 2.0 2.0 Box Box Anaheim Ins 3105 California Co. of Ca Armstrong N. N. Johns South (. (. kas Manville Insulation Insulation Carolina City Texas Co. Houston Texas 2,3,4 12/1954 1-12 1956 1959 and 1966 1954 Argonaut Insurance Co. 443 Shatto Fl Angeles Los and California Guarantee Ins Co. 1671 Wilshire Elvd Los Angeles California LEGALLY UNINSURED UNINSURED The 3600 Los Angeles Travelers Wilshire Ins . Co. Co. Boulevard Calif Self Insured 6-871950 6-871950 6-871950 6-871950 6-871950 7 -11/1950 6-871950-1/1950 -1/1950 -1/1950 -1/1950 -11/1950-11/1950 1549 151544 9 9 1646 1646 1047 1047 1045 1045 2145 2145 Paulsborough Paulsborough Paulsborough New New Jersey Fisher Insulation Co. Ca. Marine Marine Engineering Co. Los Angeles California Construction Co. , Kansas Plant Rubber San Francisco Swift Brannon Street Swift PackingPacking Los Angeles Angeles California California California 1939 1939 1939 1939 1940 , 1940 1540 1540 1540 1540 1940 1940 1940 1940 1938 1939 1939 1937 Dailey Warren & Los Angeles Angeles Angeles Insulation Insulation California California California California Co. 1937 1934 1935 & 1936 1933 Proctor and Gamble * 1601 Host 7th Street California Co. 1931 and 1932 Veet oe Security Mutual Cas Co. / Reeves & Day 1139 W. 6th St. Adjustc Los Angeles Calif Calif Calif Calif Calif . State Compensation P.O.Box 2134 Los Angeles Angeles California Occidental Indemnity address unknown State Compensation Ins P.O. Box 2134 Los Angeles California and Lumberman's Mutual Ins 3545 Wilshire Boulevard Los Angeles California Self Insured Co.