Document VJ6G12pZzNa53pJ4Kj91E6R28

FILE NAME Mundet Cork MCK DATE 1968 DOC MCK131 DOCUMENT DESCRIPTION WC Claim of Clark Pt 1 jp 4 im vy 7 is f ; EMPLOYER 8 DEPENDON ROOFING CO 3521 Cicero Avenue Chicago Illinois ATTACHED SHEET PAGE ONE QUARTER PERIOD EMPLOYMENT OF 3/31/40 9/30/40 6/30/40 12/31/40 THERM INSULATION 4730 Armitage Avenue Chisago Illinois CO 12/31/40 DEL E. WEBB CONSTRUCTION WHITE & MILLER CONTRS Fort Huachuca Arizona CO 3/31/41 6/30/41 O'MALLEY PLASTICS . P.O. Box 3558 Phoenix Arizona INC 3/31/41 6/30/41 A.N. BORGQUIST P.O. Box 6134 Phoenix Arizona STANDARD ROOFING & SUPPLY CO P.O. Box 2204 Phoenix Arizona 6/30/41 12/31/41 9/30/41 6/30/41 9/30/41 12/31/41 DEL E. WEBB P.O. Box 7588 Phoenix Arizona A.O. MILLER CO INC 220 Nordina Street Redlands California C.C. MOORE & CO Engineers Unit X 450 Mission Street San Francisco California MC CONKEY DOCKER 130-32 W. Madison Phoenix Arizona & CO Street INC W.A. BECHTEL CO 155 San Sansome Street Francisco California 6/30/41 6/30/41 6/30/41 9/30/41 30 41 12/31/41 12/31/41 6/30/42 3/31/41 CONSOLIDATED ROOFING & SUPPLY CO P.O. Box 614 Phoenix Arizona MARINE ENGINEERING & SUPPLY 941 Los E. 2nd Street Angeles California 12/31/41 12/31/41 3/31/46 6/30/46 3/31/47 INSURANCE CARRIER Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA Unknown STATE OF ARIZONA PACIFIC EMPLOYERS INS CO INDUSTRIAL INDEMNITY CO STATE OF ARIZONA PACIFIC EMPLOYERS INS C J.T. THORPE INC 948 E. 2nd Street - 305 Angeles California MUNDET CORK CORPORATION 7101 Tonnelle Avenue North Bergen New Jersey 12/31/41 6/30/45 9/30/45 12/31/45 3/31/46 12/31/46 3/31/49 12/31/58 3/31/59 6/30/42 9/30/44 12/31/44 3/31/45 6/30/45 6/30/46 9/30/46 12/31/46 6/30/47 9/30/47 6/30/48 3/31/48 9/30/60 12/31/47 12/31/60 THE ASBESTOS & MAGNESIA MATERIALS co 119-127 N. Peoria Street Chicago Illinois 6/30/42 9/30/42 PACIFIC EMPLOYERS INS Cl & AMERICAN COMPANY MOTORISTS MOTORISTS INS AETNA CASUALTY & SURETY INSURANCE COMPANY & PACIFIC EMPLOYERS INS CO Unknown SLATTERY & COMPANY 1726 Market Street Denver Colorado 12/31/42 FULLER CO 118 S. 5th Avenue Tucson Arizona YOUNGS SALES CORP 1054 Central Industrial St. Louis Missouri Avenue 3/31/42 12/31/42 3/31/47 6/30/47 12/31/48 12/31/49 9/30/45 UNITED CORK Ft Central Kearny New COMPANIES Avenue Jersey CORP PLANT RUBBER & ASBESTOS 537 Brannon Street WKS San Francisco California WARREN & BAILEY CO ' 3528 S. Garfield Avenue Los Angeles California 3/31/46 3/31/52 12/31/51 3/31/46 12/31/46 12/31/46 3/31/47 9/30/49 TECHNICAL SERVICE 423 N. 1st Street COMPANY Albuquerque New Mexico 6/30/47 LEROW COMPANY 5510 Sheridan Road - Chicago Illinois 6/30/48 12/31/48 9/30/48 ASBESTOS ENGINEERING & SUPPLY CO 12/31/48 3/31/49 1880 W. Fillmore 6/30/49 12/31/49 Phoenix Arizona REFINERY MAINTENANCE CO 2500 N. Alameda Street Compton California INC 3/31/49 STEARNS ROGER CORP 660 Pannock Street 6/30/49 Unknown STATE OF ARIZONA Unknown LIBERTY MUTUAL INS CO SELF INSURED Unknown Unknown Unknown STATE OF ARIZONA Unknown STANDARD ACC INS . CO THORPE INSULATION CO 2741 S. Yates Avenue Los Angeles California THOMAS H. HOGAN CO 1591 Indus Street Santa Ana California HALL INSULATION CO 2633 E. 3rd Street Tucson Arizona KIRCHER ASBESTOS & RUBBER CO Inc. Box 6652 Phoenix Arizona BARRETT & HOMES 6033 N. 10th Street Phoenix Arizona 9/30/49 12/31/49 6/30/59 3/31/63 6/30/63 9/30/63 12/31/63 6/30/64 9/30/64 9/30/49 3/31/50 12/31/50 3/31/51 6/30/51 9/30/51 3/31/52 6/30/52 9/30/52 3/31/53 6/30/53 9/30/53 3/31/54 6/30/64 3/31/55 6/30/55 9/30/55 3/31/56 6/30/56 9/30/56 6/30/57 9/30/57 3/31/60 6/30/60 12/31/50 ARMSTRONG CORK CO Liberty and Charlotte Lancaster Pa Streets 9/30/51 12/31/56 REECE INSULATION CO 4563 Valley Boulevard Los Angeles California ACCURATE INSULATION CO 900 S. Cypress La Habra California 9/30/56 12/31/56 9/30/56 3/31/63 12/31/60 6/30/63 JOHNS MANVILLE SALES 22 E. 40th Street New York N.Y. CORP COAST INSULATING PRODUCTS 2684 Lacey Street Los Angeles California OWENS CORNING P.O. Box 901 Toledo Ohio FIBERGLAS CORP 12/31/56 12/31/57 9/30/57 9/30/58 12/31/56 12/31/60 9/30/59 3/31/57 12/31/57 9/30/59 3/31/60 9/30/60 12/31/60 12/31/61 3/31/62 6/30/62 9/30/62 3/31/63 9/30/63 3/31/64 6/30/64 9/30/64 12/31/64 PACIFIC EMPLOYERS INS CO & FIREMAN'S FUND INS CO Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA STANDARD ACC RELIANCE INS THE TRAVELERS INS CO INS CO CO Unknown address moved no CASUALTY INSURANCE CALIFORNIA INC & STATE COMPENSATION FUND CO OF INS SELF -INSURED ARGONAUT STATE OF INSURANCE ARIZONA CO THE Ins THE AETNA CAS & SURETY Co. & TRAVELERS INS CO ATTACHED SHEET PAGE FOUR JAMAR OLMEN CONSTRUCTION o P.O. Box 14322 Houston Texas 9/30/57 9/30/58 ORIN A. WILLIAMS & JOHN S. GREEN 3775 N. 36th Avenue Box 11098 Glendale Arizona 12/31/57 INSULATION & SPECIALTIES Box 3428 Sta A El Paso Texas INC METAL CLAD INSULATION Box 178 Torrance California CO 12/31/57 3/31/58 6/30/58 BOB GRIFFIN ROOFING & rs INSULATION CO INC 151 E. 24th Street Yuma Arizona 3/31/58 FIBREBOARD PAPER PRODUCTS 1789 Montgomery Street San Francisco California CORP 6/30/58 9/30/58 12/31/58 WESTERN ASBESTOS CO Box 3784 Rincon Annex San Francisco California 3/31/59 6/30/59 PLANT ASBESTOS CO 1300 64th Street Emeryville California R.T. DINWIDDIE INC 8627 S. Atlantic South Gate California INSULATION SERVICE Box 4695 Tulsa Oklahoma INC LOS ANGELES CORK CO 4180 E. Washington Los Angeles California ARMSTRONG CONTRACTING & SUPPLY CORP 120 N. Lime Street Lancaster Pa 9/30/59 3/31/61 9/30/60 6/30/61 6/30/59 9/30/59 12/31/59 6/30/59 12/31/60 9/30/04 6/30/61 9/30/65 6/30/65 12/31/65 UNAFRAX CONSTRUCTION 1242 Abbot Dr. Pittsburgh Pa CO 9/30/61 Unknown STATE OF ARIZONA Unknown AETNA CASUALTY & SURETY INS CO STATE OF ARIZONA SELF INSURED STATE COMPENSATION INSURANCE FUND INDUSTRIAL INDEMNITY CO Unknown Unknown ZURICH INSURANCE CO FIREMAN'S FUND INS CO THE TRAVELERS INS CO LIBERTY MUTUAL INS CO ATTACHED SHEET PAGE FIVE UNAFRAX CONSTRUCTION 1242 Abbot Dr. Pittsburgh Pa CO INDUSTRIAL SERVICE & ENGINEERING CO OF CALIFORNIA Box 16138 . Long Beach California 9/30/61 3/31/63 LIBERTY MUTUAL INS CO LIBERTY MUTUAL INS CO KITZMANS PLUMBING & HEATING 6940 Alvarado Rd Lamesa California THE ISOTHERM CO : 605 Williams Bakersfield California THERMAL ENGINEERING INC . Hoffman & So. 10th Street Richmond California BALDWIN EHRET HILL 500 Brevnig Avenue Trenton New Jersey INC 6/30/63 INS CO OF NO AMERICA 6/30/64 12/31/64 _ SENTRY INS CO a Corp. 12/31/65 Unknown 12/31/65 1/1966 LIBERTY MUTUAL INS CO & INS CO OF NO AMERICA ImLae _ GOOD CAUSE APPEARING | The application herein is taken off calendar FIVED FIVED Department of IndustrialRelationsRelations ANGELES ANGELES Division of Industrial Accidents ANGELES an ANGELES Workmen's Compensation Appeals Board State of California ASFERCE WCKB DATE FOR APPLICATION 286 ADJUDICATION OF 286 286 CLAIM AMENDED AMENDED APPLICATION Death Case , 66 LA 292-043 Please file signed original and six copies and print or type names and addresses nO , CASE NO . meres - Mr. Mrs.Mrs. Miss Maurine Clark APPLICANT widow Dean Clark Deceased 13331 Lakewood Boulevard APPLICANT S ADDRESS Downey California 10 Dec. Dean Clark SS 327-07-9443 Dean Clark Clark IND SOCIAL SECURITY NUMBER VS. See attached CEMPLOTER sheet EMPLOYER'S EMPLOYER'S ADDRESSI See attached sheet EMPLOYER & INSURANCE CARRIER OR STATE IF INSURED OR PERMISSIBLY UNINSUREUNID NSURED TADORESS OF INSURANCE CARRIER IF ANY a . - IT IS CLAIMED THAT 1. Deceased employee born 12/2/1907 DATE OF BIRTHD Asbestos while employed as a Worker OCCUPATION AT TIME OF INJURY on 1940-1966 DATE OF INJUSTI at Various places CITY ) of and in the course of employment to lung STATED , by the employer : - STATE WHAT PARTS OF BODY WERE INJURED sustained injury . arising out 2. The injury occurred as follows and foreign substances Inhalation of asbest oo ths er EXPLAIN WHAT IMPLOTES WAS DOING AT TIME OF INJURY AND HOW INJURY WAS RECEIVED resulting in death on Mar. 4 1966 DATE OF DEATH 3. Actual earnings at time of injury were GIVE WEEKLY OR MONTHLY ~ SALARY ON HOURLY RATE AND NUMBER OF HOURS WORKED PER WEEKT injury caused disability follows 4. The as SPECIFY LAST DAY OFF WORK DUE TO THIS INJURY AND BEGINNING AND ENDING DATES OF ALL PERIODS OFF DUE TO THIS INJURY 3. Compensation was paid no . 4831 NO TOTAL PAID WEEKLY RATES IDATE OF LAST PAYMENT 6. Medical treatment was received yes TES ( __.__. IDATE OF LAST TREATMENTI All treatment was furnished by the employer or insurance company YES "___ other treatment was provided or paid for by NO Doctors not provided or paid for by employer or insurance company who treated or examined for this injury are St. Francis Hospital 3630 Imperial lighway Lynwood California_ STATE NAMES AND ADDRESSES OF SUCH DOCTORS AND NAMES OF HOSPITALE TO WHICH SUCH DOCTORS ADMITTED INJUREDI 7. Defendants have paid burial expense YES NO TOTAL PAID 8. The employee left surviving him the following dependents NAME DATE OF BIRTH if under 21 RELATIONSHIP TO THE EMPLOYEE ADDRESS None WHEREFORE and unpaid_ applicant requests a hearing and an Unpaid Medical bills Other award of Death benefit Burial expense Specify wes and all other appropriate benefits provided by Compensation law accrued California Hearing requested at Angelos- Dated at Angeles ICITYI CITY -June-1968 -1968 - -- Number of witnesses Estimated time of trial_ .-trial wanted +7837 ENG? Set now ; Set later on written request NASLIAN Miturina Miturina Miturina Clark Clark ClarkClark (7) LAW OFFICES OF STEVE NASLIAN 1543 W. Olympic Boulevard CAPPLICANTS CAPPLICANTS ATTORNEYI Boulevard AngelesLADDRESSCaliforniaAMO TELEPHONE NUMBER OF csc ATTORNEY owe ICAT Death Case ra neh OR ---- bie o FILE SIGNED ORIGINAL AND SIX COPIES PLEASE PRINT OR TYPE NAMES AND ADDRESSES MAURINE CLARK Wid ee APPLICANT DEAN CLARK Deceased CASE No. 012-472 012-472 012-472 012-472 012-472 012-472 012-472 012-472 012-472 _13331 Lakewood Boulevard 10 APPLICANT'SAPLICANT'S ADDRESS Downey California- Dean Clark Dec. 88 327-07-9443 DECEASED EMPLOYEE'S NAME AND SOCIAL SECURITY NUMBER BALDWIN EHRET EMPLOYER INC Contracting Division Box number 34126 _ EMPLOYER'S ADDRESS Post San Francisco California Office INSURANCE CO OF NO AMERICA EMPLOYER'S INSURANCE CARRIER OR STATE IF INSURED OR PERMISSIBLY UNINSURED _ 621 South Virgil Avenue INSURANCE CARRIER'S ADDRESS Los Angeles California California Dean Clark Deceased 1. It is alleged that ~ ~~ NAME OF EMPLOYER _, 12/2/1907 =, while employed as a DATE OF BIRTH Asbestos Asbestos Worker OCCUPATION AT TIME OF INJURY Baldwin by NAME OF EMPLOYER out ~ e on 1940 196 19 6 66 at DATE OF INJURY 4 Inc. _____. sustained injury arising various place California CITY W employment employment t and in the coursoef employment -- LUNG LUNG . FANTS OF BOOT , as follows INHALATION OF ASBESTOS AND OTHER | EXPLAIN HOW INJURY WAS RECEIVED FOREIGN SUBSTANCES March 4 1966 resulting in death on DATE OF DEATH 2. Employee's actual earnings at time of injury $ 2 at. WEEK OR NONTH The basis of pay was 3. Was compensation paid YES NO ---- $ TOTAL PAID WEEKLY RATE 4. Was medical treatment received YES YEB NO DATE LAST RECEIVED Was all medical treatment provided by employer or insurance company TEX DATE OF LAST PAYMENT NO If no state who provided it / Lynwood __ ST FRANCIH S OSPITAIL mperial Highway Down ALSO STATE NAMES AND ADDRESSES OF ALL DOCTORS WHO TREATED OR EXAMINED FOR THIS INJURY California 5. Has burial expense been paid $ Who paid it 6. This application is filed for _.. Death benefit Burial expense_ expense_ Compensation accrued and unpaid Other_ Specify _ 7. The employee left surviving him the following dependents 68 ' RH NAME . NONE 10 ga0 100 AGE IF UNDER 21 te RELATIONSHIP TO THE EMPLOYEE ww NONE (2 Sect ut ADDRESS IMPORTANT any applicant is under 21 years of age it will be necessary to file Petition for Appointment of Guardian ad Litem Forms for this purpose may be obtained at the office of the Industrial Accident Commission | WHEREFORE applicant requests a bearing and an award for all appropriate benefits be is entitled to by law Angeles Hearing requested at Los CITY Estimated time of trial Los Angeles | Dated March -1 California 22 1966 DATE id CITY Clarks > A inLe AW OFFICESIGNATSUTREEVEN ROSEMAN 7 , . ; Lee ik Clarks Clarks Clarks LAW OFFICES IGNATURE STEVEN LAW APPLICANT'S ATTORNEY OF ATTORNEY OR REPRESYNTATIVE REPRESYNTATIVE ~~ _ Please set now set later on written request ee W. St. Du 5-3071 __ 1621 __. 9th ARNO SM TEE eID OF aT Cs u ... f : ... ... r ... e tte? APPLICATION FILE SIGNED ORIGINAL AND SIX COPIES PLEASE PRINT OR TYPE NAMES AND ADDRESSES Dean Clark .- APPLICANY Social Security No 327-07-9443 Baldwin -Ehret Hill EMPLOYER Inc. Unknown EMPLOYER'S INSURANCE CARRIER OR STATE IS PERMISSIBLY PERMISSIBLY UNINSURED INSURED OR LA CASE No. 292043 13331 Lakewond Boulevard APPLICANT'S ADONES Downey California Telephone No. - --. Contracting Div P.O. EMPLOYER'S ADDRESS Box San Francisco California 34126 INSURANCE CARRIER'S ADDRES Dean It alleged that 1. is Dean Clarks NAME OF EMPLOYEE 12/2/1907 12/2_/ _, w1 hile9 emp0 loyed7 on DATE OF BIRTH 1940-1966 _ 1940-1966 DATE OF INJURY 19 Worker asbestos OCCUPATION AT TIME OF INJURY various places including San CITY TOWN OR PLACE WHERE INJURY OCCURRED Francisco Francisco Francisco California Francisco Baldwin Baldwin Hill_Ing Hill_Ing occurring Francisco ; of out Hill_Ing sustained injury arising out of and occurring ae in the course of the ' NAME OF EMPLOYER - employment Lung STATE WHAT PARTS OF BODY WENE INJURED AND SUBSEQUENT RESULTS ___ of other foreign Inhalation substances asbestos EXPLAIN WHAT EMPLOYEE WAS DOING AT TIME OF INJURY AND HOW INJURY WAS RECEIVED 2. Actual earnings at time of injury $ _per_ WEEK OR NONTH T. he basis of pay was - STATE PAY PERIOD ON HOURLY RATE HOURS A DAY AND DAYS A WEEK Intermittentalny d since January 3. Periods disabled for work 1966__ - SPECIFY NEGINNING AND ENDING DATES OF ALL PERIODS OFF WORK DUE TO THIS INJURY Date returned to work 4. Was compensation paid - YCH No_ ---- i TOTAL PAIO $ ~ ce WEEKLY RATE te ee ee DATE OF LAST PAYMENT eee Have you received unemployment or unemployment compensation disability benefits since the date of injury _ YI NO 5. Was medical treatment received Yes YAS __ NO State date last received currently currently Was all treatment provided by the employer or insurance company YES - no NO If not state who provided it - Also state names and addresses of all doctors who treated or examined for this injury .. St. Francis Hospital 6. This application is filed because of disagreement regarding liability for Proper Temporary disability Permanent disability yes Compensation Rate .. yes yes treatment procured medical yes Litigation costs yes Medical treatment yes . Other Specify immediate medical treatment and surgery 7. Have you ever had a case for another injury before the California Commission . . - w - ae oo _ oat oe re ee WHEREFORE applicant requests a bearing and award for all appropriate benefits provided by laur Los learing requested at Angeles ---> CIST - - -. --- Dated at Los Angeles . CITY " California February DATE 15 19 _ pebrer " nes baath 4141 APPLICANT & bIGMR TUAL Estimated time of trial Please set now set later on written request LAW ROSEMAN OFFICES OF STEVEN APPLICANT fi ATTORNEY OK REPRESENTATIVE 1621 79th 79th ADDRESS AND Lo , s TELEPHONE NUMBER Angeles Angeles California OF OR REPRESENTATIVE Claimant Claimant Claimant . Dean Clark Initial a Initial 7 Baldwin Ehret Hill a [ Armstrong Armstrong Armstrong |. Cork cee ee a | Johns Manville _ ; oe eee a _ a. OwensOwen|s _ Corning _ FibreboardFibreboardPaper Products Products ||.PlantPlantAsbestoAsbsestos Asbestos a fi " wo 1 1 a an l 2 er) p 4 = 7 8 9 WORKMEN'S COMPENSATION APPEALS BOARD STATE OF CALIFORNIA CASE NO 66 L.A. 292-043 MAURINE CLARK Widow DEAN CLARK Deceased - VS. Applicant { BALDWIN et al EHRET INC ) ) . ) ) . ORDER APPROVING COMPROMISE AND RELEASE 10 Defendants ) 11 12 13 14 15 18 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ~ The parties to the entitled action having filed a Com- promise and Release herein on June 13 1969 settling this case for 5,410.50 in addition to all sums which may have been paid previously and requesting that it be approved and this Board having considered the entire record including said Compromise and Release now finds that it should be approved and IT IS ORDERED that said Compromise and Release is approved AWARD IS AGAINST MADE in favor of MAURINE CLARK | HARDWARE MUTUAL CASUALTY COMPANY INDUSTRIAL INDEMNITY EXCHANGE INDUSTRIAL INDEMNITY COMPANY INSURANCE COMPANY OF NORTH AMERICA PACIFIC EMPLOYERS INSURANCE : . |. 7 ++. s+. COMPANY ; RELIANCE INSURANCE COMPANY THE TRAVELERS INSURANCE COMPANY FIBREBOARD CORPORATION AND PLANT RUBBER ASBESTOS WORKS FIREMAN'S FUND INSURANCE COMP- ; ANY ARGONAUT INSURANCE COMPANY ZURICH INSURANCE COMP ANY CASUALTY INSURANCE COMPANY OF CALIFORNIA AMERICA , MOTORISTS INSURANCE COMPANY STATE COMPENSATION INSUR- ANCE FUND LIBERTY MUTUAL INSURANCE COMPANY -1- Ian Aacufants Aacufants Companion Appeals Beard . of . Californ Relat ons 1 laa -_ . aaoeae ie 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 PAYABLE AS FOLLOWS By FIREMAN'S FUND INSURANCE COMPANY To Applicant Dr. John Field Attorney Steven Attorney Steven Roseman Roseman for for costs fees B 48.53 200.00 86.47 11,,003355..0000 HARDWARE NUTUAL CASUALTY COMPANY 235.00 INDUSTRIAL INDEMNITY EXCHANGE INDUSTRIAL INDEMNITY COMPANY INSURANCE COMPANY PACIFIC EMPLOYERS OF NORTH AMERICA INSURANCE COMPANY 333.00 414.00 180.00 846.00 RELIANCE INSURANCE COMPANY THE TRAVELERS INSURANCE COMPANY 67.50 67.50 621.00 FIBREBOARD CORPORATION AND RUBBER ASBESTOS WORKS PLANT 180.00 CASUALTY INSURANCE COMPANY OF CALIFORNIA 39.00 ARGONAUT INSURANCE COMPANY 65.00 ZURICH INSURANCE COMPANY 90.00 AMERICAN MOTORISTS INSURANCE COMPANY STATE COMPENSATION INSURANCE FUND LIBERTY MUTUAL INSURANCE COMPANY 450.00 585.00 270.00 TOTAL 5,410.50 marine Referee APPEALS Referee WORKMEN'S COMPENSATION APPEALS BOARD AT LOS ANGELES CALIFORNIA \ 26 August 28 1969 27 28 . 29 All parties served by mall as shown on Official Address Record M. 30 Dailey Dailey | 9/28/60 9/28/60 66LA 292-043 -2- Deperiment Deperiment ofindustrial Relations Division of Industrial Accidents WSotraktmeen'osfWorkmen's Appeals Compensation Board Hem Rebel Agener DIA PEAB ~ CAM 5-66 PEAB 5-66 ih < iy nee . . 1 2 3 4 Clarky Clarky Clarky Clarky Clarky Clarky Clarky COMPENSATION COMPENSATION COMPENSATION APPEALS STATE OF CALIFORNIA CASE NO 66 L.A. 292-043 . BOARD ' 5 MAURINE CLARK Widow > DEAN CLARK Deceased - Applicant 7 VS. ) 8 BALDWIN EHRET INC ) et al 9 ) ORDER APPROVING COMPROMISE AND RELEASE 10 Defendants > 11 12 The parties to the entitled action having filed a Com- 13 promise and Release herein on June 13 1969 settling this case 14 for 5,410.50 in addition to all sums which may have been paid prev- 15 iously and requesting that it be approved and this Board having 16 considered the entire record including said Compromise and Release 17 18 19 now finds that it should be approved and IT IS ORDERED that said Compromise and Release is approved AWARD IS MADE in favor of MAURINE CLARK s 20 21 22 23 24 28 26 27 28 29 AGAINST . HARDWARE MUTUAL CASUALTY COMPANY INDUSTRIAL INDEMNITY EXCHANGE INDUSTRIAL INDEMNITY COMPANY INSURANCE COMPANY OF NORTH AMERICA PACIFIC EMPLOYERS INSURANCE COMPANY RELIANCE INSURANCE COMPANY THE TRAVELERS INSURANCE COMPANY FIBREBOARD CORPORATION AND PLANT RUBBER ASBESTOS WORKS FIREMAN'S FUND INSURANCE COMPANY ARGONAUT INSURANCE COMPANY ZURICH INSURANCE COMP ANY CASUALTY INSURANCE COMPANY OF CALIFORNIA AMERICAL MOTORISTS INSURANCE COMPANY STATE COMPENSATION INSUR- ANCE FUND LIBERTY MUTUAL INSURANCE COMPANY 30 -1- Department of Industrial Relations Derrssen vf Industrial Accidents State Compensation State Califor WCA Relat-omy Apquey Appeals Board LA Form les 66 abt 1 Oe wie 1 2 3 4 10 8 7 8 9 10 11 12 13 14 15 18 17 18 26 N CNN 29 PAYABLE AS FOLLOWS By FIREMAN'S FUND INSURANCE COMPANY COMPANY To Applicant Dr. John Field Attorney Steven Attorney Steven Roseman Roseman for for costs fees o 48.53 200.00 86.47 1,1,003355..0000 HARDWARE MUTUAL CASUALTY COMPANY 235.00 INDUSTRIAL INDENTITY EXCHANGE INDUSTRIAL INDEMNITY COMPANY INSURANCE COMPANY OF NORTH AMERICA PACIFIC EMPLOYERS INSURANCE COMPANY 333.00 414.00 414.00 180.00 846.00 846.00 RELIANCE INSURANCE COMPANY THE TRAVELERS INSURANCE COMPANY 67.50 67.50 621.00 621.00 FIBREBOARD CORPORATION AND RUBBER ASBESTOS WORKS PLANT 180.00 CASUALTY INSURANCE COMPANY OF CALIFORNIA ARGONAUT INSURANCE COMPANY 39.00 65.00 ZURICH INSURANCE COMPANY AMERICAN MOTORISTS INSURANCE COMPANY STATE COMPENSATION INSURANCE FUND LIBERTY MUTUAL INSURANCE COMPANY 90.00 450.00 585.00 270.00 TOTAL 5,410.50 @ , fen ,, " ,, " flfl Referee Referee fen WORKMEN'S COMPENSATION AI PEALS BOARD AT LOS ANGELES CALIFORNIA August 28 1969 All parties served by mall as shown on Official Address Record 66 LA 292-043 Department Division of Weartanen5 of Industrial Relations Industrial Accidents Compensation Appeals Board tate of California MA tions Agency MA NICAS F^ ( 60m 5 56 >_> -2- DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS WORKMEN'S COMPENSATION APPEALS STATE OF CALIFORNIA BOARD MAURINE CLARK WIDOW | DEAN CLARK DECEASED Applicant vs. BALDWIN EHRET INC ct al Case COLA 292 043 Notice of Time and Place of Further Hearing ALL ISSUES Defendant s NOTICE TO ALL PARTIES You are hereby notified that further hearing will be held in the entitled action at 4107 LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAY LOS ANGELES CALIFORNIA August 27 1969 9 A.M. ALL DAY WORKMEN'S COMPENSATION APPEALS BOARD By j j ke REFERLE REFERLE # Dated at Los Angeles California NOTE CONTINUANCES AND FURTHER HEARINGS ARE NOT FAVORED SERVED BY MAIL ON PERSONS SHOWN ON THE OFFICIAL ADDRESS RECORD Date By 601101937 601101937 601101937 601101937 1 Copy of application filed Roberts and Baldwin DIA WCAB FORM 23 LA REV FORMERLY FORM 400 L. 12 661 3/25/06 % 1/26/63 Thomas & Taker served Parker McGee Peckham & T OSF wz. i? DEPARTMENT OF INDUSTRIAL RELATIONS WORKMEN'S COMPENSATION APPEALS STATE OF CALIFORNIA Asbestosia Mats BOARD MAURINE CLARK WIDOW DEAN CLARK DECEASED Case No. 66LA 292 043 NOTICE OF HEARING \ Applicant \ VS. BALDWIN EHRET INC AND OTHER DEFENDANTS AS SET FORTH ON PA~ ES 1 2 3 4 AND 5 OF ATTACHED AMENDED APPLICATION INSURANCE COMPANY OF NORTH AMERICA a corpora- tion AND OTHER DEFENDANTS AS SET FORTH ON PAGES 1 2 3 4 AND 5 OF ATTACHED AMENDED APPLICATION Defendant You are hereby notified that an application for compensation has been filed Board of the State of California You are further notified that said application with the Workmen's Compensation has been set for hearing at Appeals 4107 LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAY LOS ANGELES CALIFORNIA January 22 & 23 1969 9:00 A.M. 2 days and that at said time and place the Workmen's application in the manner prescribed by law Compensation Appeals Board will proceed to hear and dispose of the said WORKMEN'S COMPENSATION APPEALS BOARD By TEH O HI REFEREE Dated at Los Angeles California CAUSE this hearing All witnesses evidence medical reports payrolls and NOTE The parties are expected to submit all disputed issues for decision at WILL BE GRANTED ONLY UPON A CLEAR SHOWING OF GOOD be available at the hearing CONTINUANCES prouf must within 3 days of the date of this notice Requests for continuances are to be made attendance at this hearing may not be necessary Ask your insurance company NOTE TO INSURED EMPLOYERS Your other SERVED BY MAIL ON PERSONS SHOWN ON THE OFFICIAL ADDRESS RECORD Copy 6/26/68application filed 2/17/66 amended applications of application and 9/4/68 served all parties filed 3/23/66 DIA WCAB FORM 20 LA FORMERLY FORMERLY FORM 35LI ( REY 1-60 cn ee come - + - cone ee rm ee cee ee Se me a ete T nee Ae GOOD CAUSE APPEARING The application herein The takeofnf calendar #ISLIKE WCAS SATE Department of Industrial Relations Division of Industrial Accidents Workmen's Compensation Appeals State of California FOR APPLICATION ADJUDICATION OF Death Case CLAIM Please file signed original and six copies and print or type names and addresses Board filed = filed filed fiflieledd AMENDED 66 CASE NO fileSdEPA SEPA 1988 AP LICATION APPLICATION LA 292-043 M Mrsy . My Maurine Clark APPLICANT Widow 13331 Lakewood Boulevard 10 APPLICANT'SAPLICANT'S ASDRESS Dec. DECEASED EMPLOYEE'S NAME AND ... __ Ba_ldwin E ___ hret EMPLOYES SEE ATTACHED SHEET FOR EMPLOYERS EMPLOYER'S INSURANCE CARRIER OR STATE IP SELF INSURED OF PERMISSIBLY UNINSURED SEE ATTACHED SHEET FOR Box 3 P.O. 4 P.O. 12 346 341261T2 EMP6 LOYER'S ABORE16 Francisco Francisco California California California ADDRESS OF INSURANCE CARBIER IF ANY 1. Deceased employee born 1940 to 1966 DATE OF INJURT 12/2/1907 PATE OF BIRTH at CITY while of and in the course of employment to Lung employed as a STATE Asbestos Worker OCCUPATION AT TIME OF INJURY , by the employer sustained injury arising out STATE WHAT PARTS OF BOBY WERE INJURED _ Inhalation of substances 2. The injury occurred as follows EXPLAIN WHAT EMPLOYEE WAS DOING AT TIME OF INJURY AND NOW INJURY WAS RECEIVEDI resulting in death on Mar 1966- DATE OF DEATH 3. Actual earnings at time of injury were GIVE WEBELT OR MONTHLY SALARY OR HOURLY RATE AND NUMBER OF HOURS WORKED PER WEEK injury disability 4. The caused as follows SPECIFT LAST SAY OFF WORK BUE TO THIS INJURY AND SEGINNING AND ENDING DATES OF ALL PERIODS OFF BUE TO THIS INJURY paid YKB 5. Compensation was YKB NO t TOTAL PAID $ WERELY RATE BATE OF LAST PAYMENT - 6. Medical treatment was received 1983 1983 NO IMATE OF LAST TREATMENT All treatment was furnished by the employer or insurance other treatment was provided or paid for by 488 NO Doctors not provided or paid for by employer or insurance company who treated or examined for this injury are 7. Defendants have paid burial TOTAL PAID WHEREFORE applicant requests a hearing and an award of Death benefit Burial expense Compensation Compensation accrued and unpaid billa hearing UnpaiMdedical Other Specify benefits and all other appropriate benefits provided by law LosLos AngAenlgeesles Hearing requested at CITY Number of witnesses -- trial wanted Los Dated at Angeles EGITTI California Aug. 26 1968 DATE Estimated time of one full day CAPPLICANT'S SIGNATURE Set now XX Set later on written request LAW OFFICES OF STEVEN ROSEMAN CAPPLICANT'S ATTORNEY 381-3811 California ANBRENG TELEPHONE NUMBER OF ATTORNEY 90015 90015 ATTACHED SHEET PAGE ONE EMPLOYER QUARTER PERIOD EMPLOYMENT OF DEPENDON ROOFING CO 3521 N. Cicero Avenue Chicago Illinois THERM INSULATION 4730 Armitage Avenue Chicago Illinois CO DEL E. WEBB CONSTRUCTION CO & WHITE & MILLER CONTRS INC Fort Huachuca Arizona 3/31/40 9/30/40 6/30/40 12/31/40 12/31/40 3/31/41 6/30/41 O'MALLEY P.O. Box Phoenix PLASTICS 3558 Arizona INC 3/31/41 6/30/41 ; A.N. BORGQUIST P.O. Box 6134 Phoenix 6/30/41 0/30/41 12/31/41 STANDARD ROOFING & SUPPLY CO P.O. Box 2204 Phoenix Arizona 6/30/41 9/30/41 12/31/41 DEL E. WEBB P.O. Box 7588 Phoenix Arizona A.O. MILLER CO INC 220 Nordina Street Redlands California C.C. MOORE & CO Engineers Unit X 450 Mission Street San Francisco California 6/30/41 6/30/41 6/30/41 9/30/41 MC CONKEY DOCKER 130-32 W. Madison Phoenix Arizona & CO Street INC W.A. BECHTEL CO 155 San Sansome Street Francisco California 30 41 12/31/41 12/31/41 6/30/42 3/31/41 CONSOLIDATED ROOFING & SUPPLY co P.O. Box Phoenix 614 Arizona MARINE ENGINEERING & SUPPLY 941 E. 2nd Street Los Angeles California 12/31/41 12/31/41 3/31/46 6/30/46 3/31/47 INSURANCE CARRIER Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA Unknown STATE OF ARIZONA PACIFIC EMPLOYERS INS CO INDUSTRIAL INDEMNITY CO STATE OF ARIZONA PACIFIC EMPLOYERS INS CO J.T. THORPE INC 48 E. 2nd Street bs Angeles California MUNDET CORK CORPORATION 7101 Tonnelle Avenue North Bergen New Jersey 12/31/41 6/30/45 9/30/45 12/31/45 3/31/46 12/31/46 3/31/49 12/31/58 3/31/59 6/30/42 9/30/44 12/31/44 3/31/45 6/30/45 6/30/46 9/30/46 12/31/46 6/30/47 9/30/47 6/30/48 3/31/48 9/30/60 12/31/47 12/31/60 THE ASBESTOS & MAGNESIA MATERIALS co 119-127 N. Peoria Street Chicago Illinois 6/30/42 9/30/42 PACIFIC EMPLOYERS INS CO & AMERICAN COMPANY MOTORISTS INS AETNA CASUALTY & SURETY INSURANCE COMPANY & PACIFIC EMPLOYERS INS CO Unknown SLATTERY & COMPANY 1726 Market Street Denver Colorado : 12/31/42 Unknown FULLER CO 118 S. 5th Avenue Tucson Arizona : 3/31/42 12/31/42 STATE OF ARIZONA 3/31/47 6/30/47 12/31/48 12/31/49 YOUNGS SALES CORP 1054 Central Industrial St. Louis Missouri Avenue 9/30/45 Unknown UNITED CORK Ft Central Kearny New COMPANIES Avenue Jersey CORP PLANT RUBBER & ASBESTOS 537 Brannon Street WKS San Francisco California 3/31/46 3/31/52 12/31/51 3/31/46 12/31/46 LIBERTY MUTUAL INS CO SELF INSURED WARREN & BAILEY CO : 3528 S. Garfield Avenue Los Angeles California 12/31/46 9/30/49 3/31/47 Unknown TECHNICAL SERVICE 423 N. 1st Street COMPANY Albuquerque New Mexico 6/30/47 Unknown LEROW COMPANY - 5510 Sheridan Road . Chicago Illinois 6/30/48 9/30/48 12/31/48 Unknown ASBESTOS ENGINEERING & SUPPLY CO 12/31/48 3/31/49 1880 W. Fillmore 6/30/49 12/31/49 Phoenix Arizona . STATE OF ARIZONA REFINERY MAINTENANCE CO 2500 N. Alameda Street Compton California INC 3/31/49 Unknown STEARNS ROGER CORP 660 Bannock Street Denver _ Colorado 6/30/49 STANDARD RELIANCE ACC INS INS CO CO THORPE INSULATION CO 2741 S. Yates Avenue Los Angeles California THOMAS H. HOGAN CO 1591 Indus Street Santa Ana California HALL INSULATION CO 2633 E. 3rd Street Tucson Arizona KIRCHER ASBESTOS & RUBBER CO Inc. Box 6652 Phoenix Arizona BARRETT & HOMES 6033 N. 10th Street Phoenix Arizona 9/30/49 12/31/49 6/30/59 3/31/63 6/30/63 9/30/63 12/31/63 6/30/64 9/30/64 9/30/49 3/31/50 12/31/50 3/31/51 6/30/51 9/30/51 3/31/52 6/30/52 9/30/52 3/31/53 6/30/53 9/30/53 3/31/54 6/30/64 3/31/55 6/30/55 9/30/55 3/31/56 6/30/56 9/30/56 6/30/57 9/30/57 3/31/60 6/30/60 12/31/50 PACIFIC EMPLOYERS & INS CO FIREMAN'S FUND INS CO Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA ARMSTRONG CORK CO Liberty and Charlotte Lancaster Pa Streets 9/30/51 12/31/56 STANDARD ACC RELIANCE INS THE TRAVELERS INS CO INS Co. CO REECE INSULATION CO 4563 Valley Boulevard Los Angeles California ACCURATE INSULATION CO 900 S. Cypress La Habra California 9/30/56 12/31/56 9/30/56 3/31/63 12/31/60 6/30/63 JOHNS MANVILLE SALES 22 E. 40th Street New York N.Y. CORP 12/31/56 12/31/57 9/30/57 9/30/58 COAST INSULATING PRODUCTS 2684 Lacey Street Los Angeles California 12/31/56 12/31/60 9/30/59 OWENS CORNING P.O. Box 901 Toledo Ohio FIBERGLAS CORP 3/31/57 12/31/57 9/30/59 3/31/60 9/30/60 12/31/60 12/31/61 3/31/62 6/30/62 9/30/62 3/31/63 9/30/63 3/31/64 6/30/64 9/30/64 12/31/64 KANSAS CITY INAHKATION C8 TNP 9/18/4 Unknown address moved no CASUALTY INSURANCE CALIFORNIA INC & STATE COMPENSATION FUND CO OF INS SELF -INSURED ARGONAUT STATE OF INSURANCE ARIZONA CO THE Ins THE AETNA CAS Co. & & SURETY TRAVELERS INS CO Unknown ATTACHED SHEET PAGE FOUR - JAMAR OLMEN CONSTRUCTION o P.O. Box 14322 Houston Texas 9/30/57 9/30/58 ORIN A. WILLIAMS & JOHN S. GREEN 3775 N. 36th Avenue Box 11098 Glendale Arizona 12/31/57 INSULATION & SPECIALTIES Box 3428 Sta A El Paso Texas INC METAL CLAD INSULATION Box 178 Torrance California CO 12/31/57 3/31/58 6/30/58 BOB GRIFFIN ROOFING & s INSULATION CO INC 151 E. 24th Street Yuma Arizona 3/31/58 FIBREBOARD PAPER PRODUCTS 1789 Montgomery Street San Francisco California CORP 6/30/58 12/31/58 9/30/58 WESTERN ASBESTOS CO Box 3784 Rincon Annex San Francisco California 3/31/59 6/30/59 PLANT ASBESTOS CO 1300 64th Street Emeryville California R.T. DINWIDDIE INC 8627 S. Atlantic South Gate California 9/30/59 3/31/61 9/30/60 6/30/61 6/30/59 9/30/59 INSULATION SERVICE Box 4695 Tulsa Oklahoma INC . LOS ANGELES CORK CO 4180 E. Washington Los Angeles California ARMSTRONG CONTRACTING & SUPPLY CORP 120 N. Lime Street Lancaster Pa 12/31/59 6/30/59 12/31/60 9/30/64 6/30/61 9/30/65 6/30/65 12/31/65 UNAFRAX CONSTRUCTION 1242 Abbot Dr. Pittsburgh Pa CO 9/30/61 Unknown STATE OF ARIZONA Unknown AETNA CASUALTY & SURETY INS CO STATE OF ARIZONA SELF INSURED STATE COMPENSATION INSURANCE FUND INDUSTRIAL INDEMNITY CO Unknown Unknown ZURICH INSURANCE CO FIREMAN'S FUND INS CO THE TRAVELERS INS CO LIBERTY MUTUAL INS CO ATTACHED SHEET PAGE FIVE UNAFRAX CONSTRUCTION 1242 Abbot Dr. Pittsburgh Pa CO 9/30/61 INDUSTRIAL SERVICE ENGINEERING CO OF Box 16138 & CALIFORNIA Long Beach California KITZMANS PLUMBING & HEATING 6940 Alvarado Rd . California 3/31/63 6/30/63 THE ISOTHERM CO > 605 Williams Bakersfield California INC THERMAL ENGINEERING . Hoffman & Richmond So. 10th Street California | BALDWIN EHRET HILL 500 Brevnig Avenue Trenton New Jersey INC 6/30/64 12/31/64 . 12/31/65 . 12/31/65 1/1966 fo, LIBERTY MUTUAL INS CO LIBERTY MUTUAL INS ; CO . INS CO OF NO AMERICA SENTRY INS CO a Corp. Unknown LIBERTY MUTUAL INS CO ; & INS CO OF NO AMERICA : . ~ 3% _ | GOOD CAUSE APPEARING | * The application herein is taken off calendar . _- Relations EIVED Department of Industrial Accidents ANGELES Division of Industrial INDUSTRIAL J INDUSTRIAL INDUSTRIAL ooo ANGELES Workmen's Compensation Appeals Board State of California Please file signed original and six copies and print or type names and addresses APPLICATION CLAIM CLAIM 26 AMENDED APPLICATION Death Case 66 LA 292-043 , phe CASE NO Mr. Mrs. Mill 9 Maurine Clark widow APPLICANT Dean Clark Deceased 13331 Lakewood Boulevard ( APPLICANT'S ADDRESS 10 - Downey California Dec. SOCIAL Dean Clark THECERSY Or Perr Ey WE | SS 327-07-9443 SECURITY NUMBER - See attached EMPLOYER sheet EMPLOYER'SEMPLOYER'S ADDRESS See attached sheet EMPLOYER'S INSURANCE CARRIER OR STATE IF INSURED OR PERMISSIBLY UNINSURED IT IS CLAIMED THAT Low! . . nod EADDRESS OF INSURANCE CARRIER IF ANY a ada? Deceased employee born 12/2/1907 , BATE OF BIRTH while employed as a Asbestos Worker LOCCUPATION AT TIME OF INJURY on 1940-1966 DATE OF INJURTI at Various places CITY STATE by the employer sustained injury arising out of and in the course of employment to lung . aoe ISTATE WHAT PARTS OF BODY WERE INJURED 2. The injury occurred as follows Inhalation of asbestosasbestos and CEXPLAIN WHAT EMPLOYEE WAS DOING AT TINE other foreign OF INJURY AND NOW INJURY WAS substances RECEIVEDI 4 , resultingin death on Mar 19. 66 DATE OF DEATH 3. 3. Actual earnings at time of injury were GIVE WEEKLY OR MONTHLY SALARY OR HOURLY HATE AND NUMBER OF HOURS WORKED PER WEEK 4. Theinjury caused disability as follows SPECIFY LAST DAY OFF WORK BUE TO THIS INJURY AND BEGINNING AND ENDING DATER OF ALL PERIODS OFF QUE TO THIS INJURY was 5. Compensation paid ---- YES maa $ S TOTAL PAID : $ WEEBLY RATE , 6. Medical treatment was received yesA - ll treatment TES NQ IDATE OF LAST TREATMENT was IDATE OF LAST PAYNENT furnished by the employer or insurance company YES 80 other treatment was provided or paid for by Doctors not provided or paid for by employer or insurance company who treated or examined for this injury are St. Francis Hospital 3630 Imperial lighway LynwoodCalifornia_ STATE NANES AND ADDRESSES OF SUCH DOCTORS AND NAMES OF HOSPITALS TO WHICH SUCH DOCTORS ADMITTED INJURED Defendants have paid burial expense TES - . NO TOTAL PAID . 1. The employee left surviving him the following dependents NAME None DATE OF BIRTH RELATIONSHIP : if under 21 TO THE EMPLOYEE ADDRESS WHEREFORE applicant hearing requests a ~ and unpaid__ Unpaid Medical bills and an Other award of Death Specify benefit Burial expense Compensation accrued and all other appropriate benefits provided by law California " , Hearing requested at Angeles Dated at Angeles , ICITY CITY Number of witnesses Estimated time of tria trial wanted TES Marking Marking Marking Marking Marking Marking Marking Marking OFFICES OF STEVEN RN rh 1968 HEEcostar costar Set now ; Set later on written request 1543 W. Olympic Boulevard Los AngeleCsADDRESS CaliforniaCalifornia California OF ATTORNEY a a co Lo APPLICATION Death Case " FILE SIGNED ORIGINAL AND SIX COPIES __ AND PLEASE PRINT OR TYPE NAMES ADDRESSES CLARK Wid ) neers" APPLICANT . DEAN CLARK Deceased es Aa eco amet nen tt CASE No. APPLICANT'S ADDRESS Down, e Cay lifornia Dean Clark Dec. # 327-07-9443 DECEASED EMPLOYER'S NAME AND SOCIAL SECURITY NUMBER BALDWIN EHRET EMPLOYER INC Contracting Division Box number 34126 EMPLOYER'S ADDUKES Post San Francisco California Office INSURANCE CO OP NO AMERICA INSURANCE EMPLOYER'S CARRIER OR STATE IP INSURED OR FERMISSIBLY UNINSURED : i 621 Los Bouth Virgil Avenue INSURANCE CARRIER'S ADDRE Angeles California ss 1. Itis allegedthat ae Dean Clark _ Clark NAME OF Deceased EMPLOYEES os OCCUPATION AT TIME OF INJUST by i Baldwin Inc. NAME OF REPLOTES : oe Pwo LUNG a 7 . PARTS OF BODY 12/2/1907 DATE OF BIRTH , while employed as a on 1940..._ 19_66 at various place California DATE OF INJURY sustained iinnjurjy uryarising out andtthhee in course HM 201 g of employment 201 . as follows INHALATION EXPLAIN HOW INJURY WAS RECEIVED FOREIGN SUBSTANCES mot injury 2. Employee's actual earnings at timtieme of injury 2 : resulting in death on March 4 1966 DATE OF DEATH _at_ WEEK OR NONTH The basis of pay was : ampeda 3. Was compensation paid tna os treatment received YBS ah a 4. Was medical van NO NO $. TOTAL PAIR he $ WEEKLY RATI DATE LAST RECEIVED DATE OF LAST PAYMENT , 1 nan aN a wae dine Was all medical treatmentrteatment provided by employer or insurance If no state who providedit . company YES ON / Lynwood ALSO STATE NAMES AND ADDRESSES OF ALL DOCTORS WHO TREATED OR EXAMINED FOR THIS INJURY an , " | Nana! BE 4 ot 5. Has burial expense been paid ana $ Who paid it ~ 6. This application is filed for _ aemni + a ti Death benefit aaa! Burial expense einaeseR Other_ | Specify Ben The following 7. employes left surviving him the Compensation accrued and unpaid dependents 8-1-68 ee8-1-68fith NAME NONE Main ( 20 IF AGE 21 MK TO THE EMPLOYEE NONE Lu. : ohtet ~ t i mo pot i rot if ADDRESS we foo bo : et -_ IMPORTANT any applicantis under 21 years of age it will be necessary to file Petition for Appointment of Guardian a^ Litem Forms for this purpose may be obtained at the office of the Industrial Accident Commission WHEREFORE applicant requests a bearing and an award for all appropriate benefits be is entitled to by law Dated Los Angeles CITY March California Clark 22 1966 DATE Hearing requested at Estimated time of trial Los Angeles CITY feriOx FFICESSIGNATURE 222 Clark Clark Clark a LAW OFFICES OFFICES OF STEVEN ROSEMAN APPLICANT'S AT QAN^ TON REPRESENTATIVE Please set now ; set later on written request 1621 W. 9th St. 40754CHAN 40754CHAN TELEGRON^ TELGRON^ TELEGRON^ NUMBER OF ATTIONE ATTIONE Du 5-3071 OPOSENTATIVE OPOSENTATIVE OPOSENOPOTSENTAATIVTE OPIOSEVNTAETIVE . J > AL^ MA^ SzO da rabbitent ConIIIIISSAUTI APPLICATION ^' f ey oe FILE SIGNED ORIGINAL AND SIX COPIES a PLEASE PRINT OR TYPE NAMES AND ADDRESSES Dean Clark APPLICANT Social Security 327-07-9443 Baldwin -Ehret Hill EXPLOTER Inc. Unknown EMPLOYER'S INSURANCE CARRIER ON STATE IF INSURED OR PERMISSIBLY PERMISSIBLY PERMISSIBLY UNISSURES 6LA CASE No. 292043 13331 Lakewood Boulevard APPLICANT'S ADDRES ADDRES Downey California Telephone Na Contracting Div P.O. EMPLOYER'S EMPLOYER'S ADDRESS Box San Francisco California 34126 INSURANCE CARRIEN'S ADDRESS 1. It is alleged that Dean Clark NAME OF CHPLOTEE 12/2/1907 DATE OF BIRTH while employed on DATE OF INJURY asbestos Worker : OCCUPATION AT TINE OF INJURY Hill Baldwin Inc. employment NAME OF EMPLOYER Lung at various places including San California Francisco sustained arising CITY TOWN OR PLACE occurrinFgrancisco injury INJURY WHERE OCCURRED out of and in the course of the - Lung STATE WHAT PARTS OF BOOT WERE INJURED AND SUBSEQUENT RESULTS Inhalation of . asbestos substances EXPLAIN WHAT EMPLOYEE WAS DOING AT TIME OF INJURY AND HOW INJURY WAS RECEIVED 2. Actual earnings at time of injury $ -per WEEK OR MONTH The basis of pay was STATE PAY PERIOD ON NOUELT RATE HOURS A DAY AND DAYS A WEEK Intermittently 3. Periods disabled for work . SPECIFY SPECIFY since JanuPa ERIrODyS BEGINNING AND ENDING DATES OF ALL 1966 OFF WORK DUE TO THIS INJURY Date returned to work 1 ; paid 4. Was compensation compensation NO $ $ ves NO TOTAL PAID WEEKLY RATE DATE OF LAST PAYNENT an oy 3 Have you received unemployment or unemployment compensation disability benefits since the date of injury i YES NO 3. Was medical treatment received Yes State date last received _ currently Was all treatment provided by the employer or insurance company YES If not state who provided it no ---- Also state names and addresses of all doctors who treated or examined for this injury St. Francis Hospital 6. 6. This application is filed because of disagreement regarding liability for Temporary disability Permanent disability Proper Compensation Rate .yes Specify and procured medical costs Litigation costs yestreatment Medical treatment Other_ immediate medical treatmse urn get ry 7. Have you ever had a case for anotherinjury before the California Commission WHEREFORE pplicant requests a bearing and award for all appropriate benefits provided by law Hearing requested Los Angeles CITY Estimated time of trial 1 a Please set now ; set later on written request Dated at Los Angeles _. ., California February 15 19 stion APPLICANT'SSIGNATURE APPLICANT'S SIGNATURE SIGNATURE errereen OF OFFICE STES VEN ROSEMAN APPLICANT'S ATTORNEY OR REPRESENTATIVE 414 Angeles 9th StTELEPHONE ADDRESS ANO Los NUMBER OF California California OR REPRESENTATIVE _ 1956 ACCIDENT STAMOREN INS TTRARVELERS AVELERS INS CoCo Co. = AZ 118480 14 STATES STATES I CALIE POLICY RUB- 4991518 rt ee iF 4 ate tet " a oes teen, a 4 14, Bee on me = ann Neri RN ES Re mitt meee enn ee ee ene me te * Nawab, TH te A February 23 1967 AIR MAIL ; . Steven RoseMan / Los Angeles California 90015 ; - Gentlemen Subject m . Dean Clark Decedent Case 66 LA 292-043 In reply to your letters of February 16 addressed to us and our subsidiary Armstrong Contracting and Bupply Corporation we wish to advise that our workman'a compensation insurance carrier was Standard Accident Insurance Company in 1951 and The Travelers Insurance Company in 1956 and 1961 a Very . truly , B. HoffeHr offt erh th Insurance Hanager - ao STEVEN ROSEMAN ANTHONY J. BRADISSE HERMAN FEUERSTEIN JAMES J.WALSH J.WALSH 1621 Law Offices STEVEN ROSEMAN ATTORNEYS AND COUNSELORS AT LAW WEST NINTH STREET LOS ANGELES 90015 February 16 1967 pod 5-3071 TELEPHONE DUNKIRK 2/23/67 2/23/67 Armstrong Contracting & 120 North Lime Street Lancaster Pennsylvania Supply Corporation Re Dean Clark Decedent 66 LA 292-043 Maurine Clark Widow Gentlemen We are the attorneys for the widow of Dean Clark We are representing Mrs. Clark before the Workmen's Compen- sation Appeals Board in connection with a claim which alleges exposure to foreign substances such as asbestos during the period of 1940 through 1965. Social Security records indicate that Mr. Dean Clark was employed by your company during the following period or periods The second quarter of 1961 Would you kindly furnish us your Workmen's Compensation insurance noted period or periods with the name of carrier for the Thank you SR 1m STEVEN ROSEMAN _ a 4 i ra . : > ", H STEVEN ROBEMAN ANTHONY J. BRADISSE HERMAN FEUERSTEIN JAMES J.WALSH J.WALSH 1621 Law Offices STEVEN ROSEMAN ATTORNEYS AND COUNSELORS AT LAW WEST NINTH STREET LOS ANGELES 90015 February 16 1967 t / f TELEPHONE DUNKIRK 5-3071 2/22/67 2/22/67 2/22/67 2/22/67 Armstrong Cork Company Liberty and Charlotte Streets Lancaster Pennsylvania Re Dean Clark Decedent 66 LA 292-043 Maurine Clark Widow Gentlemen We are sation We are the attorneys for the widow of Dean Clark representing Mrs. Clark before the Workmen's CompenAppeals Board in connection with a claim which alleges exposure to foreign substances such as asbestos during the period of 1940 through 1965. Social Security records indicate that Mr. Dean Clark was employed by your company during the following period or periods The second and third quarters of 1951 quarter of 1956 the last Would you kindly furnish us your Workmen's Compensation insurance noted period or periods with the name of carrier for the Thank you SR 1m Mer 90 21 1997