Document Z4om7EMywyZJB5Lyag6EJQr3p
P 4^
A. D. WQJSS CO., rndltftftpoll* W C. Form# (or AH SUW#
STATE OP ILLINOIS
INDUSTRIAL COMMISSION ISO No. LaSalle St, Cbieigo I, IIL
EMPLOYER'S REPORT OF COMPENSABLE INJURY -------- -- -
(Copy should be seot immediately to Insurance Carrier)
Accident Number
Emolovera must report to the Commission on Form 45 between the ISch and 25th of EACH MONTH all compensable injuries In case of DEATH report IMMEDIATELY.
EMPLOYER:
1. Name AMES I CAM CYANftHIO COHWtf----------------------------------------------------------------------------------------------
2. Doing business under the name of:-- SAME
----
--
___
3.
etr~T r-J
Lcrn WC<:T 1 CTH <TPFgT------------------------------City-CHl CA&Q
4. Nature oi Business: HfcfflfftCXUBFR fiP-lEAB CHEK1CAIS___________________________________________
5. Nsmf -f --mp-f***'*" tn.n--n^e carrier-
INJURED EMPLOYEE:
1. Name:----- LARRY THOHAS-------------------------------------------------------------------------------------------------- --------------------- 2. Address, Street and No.:___ 7*9 Smith Kftnrmth-----------------------------r;^ Chicago
3. c-v Male 4. Marital Sun.. _ Hi-rlt^ s. 4g.. 21 __________ ^--------------- 6. Oen.patiftn Factory worker
7. Average Weekly Earhings:JUBBBBK----.. .
8. No. of Children under 18 years of age:------- QMg
INJURY: 1. Date of injury:.5/25/72
3. How did injury happ
4. What was employee doing when accidentoecurTed? Garfr'IftTtlni ihlM 1n**i
. th*
(Describe briefly, such as loading truck, operating drill press, shoveling sand,'etc.)
. carbon*tor.)--.-------------------------------------------------- -------- -------- -------------------------------
5. Name of machine, tool, substance, or object most closely connected with the ee!Hn>, g
f -.y '
(Name the machine, tool, appliance, gas, liquid, etc., involved;
6. If machine or vehicle, what part of it?_
7. Where: Street and No._ 8. Describe injury (if specific loss, give date of loss).
(State if gears, pulley, point oi operation, etc.) City___Chicago State-
9. E^P^nnnaeuuy (. if undetermined give estimate)
COMPENSATION IN NON-FATAL CASES: 1. Is compensation being paid?--
2. To whom?-__- n ,, 3. Rate of compensation'
--. ,
4. Intervals of payment
... ...--------
5. Are medical and hospital services being furnished?-
6.
COMPENSATION IN FATAL CASES: V. Has compensation been paid?.
2. To whom?--
,
3. State relationship to deceased:.--............
4. Rate of compensation: , ---- -
5. ft pymnt-
---
6. r
r.f <tie.Uilify prtn. Ir, A.atW-
7. Have funeral and burial expenses been paid?-......
8. Ry 9. rw ,k ;. --pH-
-HOMS-
Date of First Payment:.
CONFIDENTIAL INFORMATION
REDACTED
Date of First Payment l
10. Signed:. U. Position- RLAHT MANAGER
JC FELTER
CYWI 5-001653
N14499
INSURANCE COMPANY OF NORTH AMERICA
Policyholder*
167 WW JakMn 6lvQ.
ChlcJrA IllJnoJi 60604
Amerioaa Oynmrid Co., 4500 ?. 15th 3t* Chicago, IU
Acknowledgment Date: 6/19/72 Disposition Date: 6/20/72
Gentlemen:
Re: File No. Policy No.
Insured
9UC 820371 HWC 153255 JLaerioan Cynxunria Co.
Plant/Div. No.
Date of Event Location
4500 W. 15th St.Chicago,111.
Driver
This is a copy of both the acknowledgment and disposition letters for this claim file.
Claimant ;s) Larry Thomas
Typeis) of Claim
Disposition
Workaen*a compensation
Tours very truly,
BLTtCrS Recovery
anticipated.
CCt Brcm Croat# k Co., New York, 8Y.
PH7ua
?
a. L. TSASNBT,J2.3UFEH71308 Claims Service
`r e d a c t e d
Cf*l 5 001654 N14499.01
*StT *tV. t.0
SUPERVISORS ACCIDENT REPORT
ftsfsr to SofwtY 4 Los# Prvvomtoo OlPARTMtHf
Mo. 22 hr tk* ofoarvtlon of tfc/s f#oo#t
n o . or uoo>
BAT* or ACIO*NT
^ - 7>-
WHO WAS IHJORCD O" WHAT WAS OAMAOBO
NATUHt Or INJURY OH ACCIOBHT
/>
c u Hl ^s
Qtu$
jz+yzjsU, . u
riM* or ACCIOKNT
CAU* - OCte<t UHSkri A*Y AHB/O* UHSAF* COHOtTION
CONFIDENTIAL INFORMATION
r ed ac t ed
cxJjJtL --Qjk
uJgj&L7'
sumr viso r
OQMMKNTt Aivtcwco tv CfiMMgNTI
V J/ x.
) -1 _
OAT C
j-
BAT*
7- S'
CtWX S-0016S
N14499.02
Philip Fa*
CERTIFIED 0Y AMERICAN BOARD OF PREVENTIVE MEDICINE IN OCCUPATIONAl AND AVIATION MEDICINE
CLEARING INDUSTRIAL CLINIC
554* WEST SIXTY-FIFTH STREET CHJCAQO. ILL <063*
PHONES 767-6600 AREA COOE 312
SURGEON'S REPORT
CASE NO.
CLINICAL LABORATORY STATE OP ILLINOIS REGISTRY *329
FEDERAL IDENTIFICATION NO. 36-2702358
C
I e mp l o y e r
rnmSsmimmM
INJURED EMPLOYEE __JiiHLSH8iPHONE
ADDRESSatf --_____________________________________________ CITY
M
DATE OF INJURYDATE OF 1st TREATMENT __________________________ TIMFi !*< AJfc
AGEM.S-W-D- MF__________________ ICHILDREN UNOER lfl
1
NATURE OF INJURY
ESTIMATED DISABILITY THfc flltlWTOTAL TEMPORARY DISABILITY
XHa V
TREATMENT
CONFIDENTIAL INFORMATION
REDACTED
P----------------------------------------------------------- -----
Mo Ml * PERMANENT INJURY
wmmmmm
STATEMENT OF INJURE6
gjUH---
PREVIOUS INJURIES APPARENT
* TS
. --_
. This is a copy of my report of accident to your Insurance Carrier, (t is necessary that you also forward a report to protect your interests and those of your employee.
CYWI 5-001656
N14499.03
INSURANCE COMPANY OF NORTH AMERICA
217 W* MctaM ChidfO, llllnsti COW*
American Cyanaoid Co., 4500 ,7. 15TSt. Chicago,111.
Date: 6/19/72
Gentlemen:
Re: File No.
Policy No. Insured
911C 328371 OTC 153255 American Qyanamid Co.
Plant/Div. No. 9301
Date of Event Location
5/25/72 4500 Vf. 15th St,,Chicago,111.
Driver
We have received notification of this event and have assigned the file number shown. Please refer to it in any future correspondence. ?
Listed below are the claimants, and the typeisi of claim presented.
Claimant <s > Larry Thomas
Type <s i. of Claim Workman's compensation
RLIsGB
CC: Brown Crosby- & Co.,
J
New York, If.Y.
PHTWa.1
Yours very truly,
3. L. XEARNEY, JR. SUF]
50R HQ
Claims Service
CYWI 5-001657
N14499.04
r>? Phil 1 Id Fal k
AMERICAN CYANAMIO COMPANY
REQUEST FOR PHYSICAL. EXAMINATION
! n in
p it
May 1? IQ7?
p*ppeM a
C iocie 1 1 SPCCIAL
-
o n ______ Larry_Thc*nas ro c v a u v a t c PHvaieAb f it n c s s .
TV PC OP **
General Factory
"COUCSTCO T
C. A. Oadko
CflWCJTOfl'J AQDPCSa
4500 West 15th Street
AY (COMPANY LOCATION!
MacGreaor - Chlr.aoo
Plant SuoerlntendAnt Organic Chemicals - IntermeHl
tgc TO COOC flip UNKNOWN. (NOlCATC Qi V 0T'
Cbicaao
PHYSICIANS REPORT
CYWI 5*001658
N14499.05
APPLICATION FOR EMPLOYMENT
OO NOT WRITE IN THIS SPACE
Ary record of gaavl.wian? _
Hove you friends or relatives in our emplay?
?aJ
In an emergency, whom shall wo notify?.
_Rz 4LZtSL
_For what offense?. .Who?.
Addne
Grade SchooLv
EDUCATION
High School. <*hr
Phon*"^
A * +7
tM9iav*9--///.ar2
Ad<w
LJ. -ftfJ-U
EXPERIENCE
-- Fram (date).
tn ____________
?o
- Qfy- <!-/>'<?<?<?/? <at,_ X/4
What wa your |nh?
%s yo.y A & .<*
Why did you leave?,
r.&-
nwpmvra
7r >\ t
31*
Add*<
^7 / /__
g-ftr
______________________Salary
from (date). ? /
_2_
What wax your job?. Why did you leave?. EMPLOYER_________ Adrlr.
??..q
.From (date).
Clfy.
Whot wax your job?.
Why did you leave?. EMPLOYES_________
Addrar.
CONFIDENTIAL INFORMATION
REDACTED
-From (date). -Ofy.
.Salary.
Whet wax your job?.
-Salary-
Why did you leave?.
Armed Force? Serial No_______ ^ ^__________________ Length of Service--^C.
What kind of work da you do bexfl.
tz ml
?ro _sMBad Eut?
READ OVER THE DATA YOU HAVE GIVEN AND MAKE CERTAIN AU THE REQUESTED INFORMATION HAS
BEEN ACCURATELY AND COMPLETELY SUPPLIED.
___'P$&?nL&
It additional space Is needed, use reverse side.
Signature.
CYWI 9-001659
^14499.06
