Document a1NGp30e50REBRqkbpL1eKM7Y

FILE NAME: Insulators Workers' Comp Claims (IWC) DATE: 1959 DOC#: IWC027 DOCUMENT DESCRIPTION: Claimant - Viali, Lloyd, V. S ` d p t '! U, 1/><\( $ r /-M S - 4 y ( n j C c /r j4 Ci i l C`/ ^ y ? /y S A W t. A h d a clc{. * c x 4 - _ S h e / s '? NEVADA INDUSTRIAL COMMISSION CARSON CITY, NEVADA Form C -2 (Rev. 10-58) REPORT OF INJURY OR OCCUPATIONAL DISEASE and WORKMAN'S CLAIM FOR BENEFITS CLAIM NUMBER FIRST REPORT OF ACCIDENT TO BE COMPLETED BY EMPLOYEE, PHYSICIAN AND EMPLOYER THE NEVADA INDUSTRIAL COMMISSION REQUESTS THIS COMPLETED REPORT TO MAILED TO THE CARSON CITY OFFICE W ITHIN FIV E (5) DAYS OF THE ACCIDENT. (IF INJURY OCCURRED IN NYE, LINCOLN OR CLARK COUNTY, SEND A COPY TO LAS VEGAS O FFIC E .) N otification of accident-- see Section 616.340 NRS. Penalty for non-compliance--see Section 616.650 NKb. EMPLOYER--COMPLETE THE FOLLOWING: Name on * A r m s t r o n g C o n t r a c t i n g & S u p p l y C o r p * Q ttl certificate of p r ^ o r t o l / l / 5 8 A p i n s t r o n g C o r k C o n p a n y >- O cl S *Hi 120 nfRusiness N . L im e S t r e e t , L a n c a s t e r , P a . E re c tio n of in s u la tin g m a te ria ls Policy Account Number Telephone Number Under what classification have you been reporting employee? 1023U Name (Per Payroll) Wu Address 5 H 8 5 S . U 2 7 0 W . , K e a r n s 1 8 , U t a h >o< )|0 Age M Sex Marital Status M Occupation and I n s u l a t i o n . Nam<*, state in which hired C f i l i i * How Long 9 6 d a y s Usual Duties M ocha Flic T ra v e le r . Length of employment with . . you in Nevada Employed By You? (Months) . ------^ B e i i l i l e h e m - ^ h l p y a r d , S a n F r u n c n a c O f U a m Exposure0 ' l Place C rO V in Z e l l e r b a c h , A n t i o c h , C a l i f . Hour AM PM * Date LU l R eno. N evada! B eale A.F .B . .M a ry s v ille t <U) 00 ' No a c c id e n t in v o lv e d . N orm al w o rk in g Q Accident w c o n d i t i o n s a p p l y i n g v a r i o u s i n s u l a t i n g m a t e r i a l s t o m e t a l O occurred H su rfa c e s a t th e above lo c a tio n s . ul Dcn No a c c i d e n t . w o rk in g c o n d itio n s Did iniiired reDort accident or exposure at once? (Explain "No") n o r m a l . g No Yes oCL . A d v i s e d v o l u n t a r y a u l t t o Mr , D a v i d X n;n hf rpnort accident or exposure to his supervisor? (Give name) H . H a m e r 5 - 2 0 - 5 9 _____ No tfesQ U1 ai Were there witnesses to accident or exposure? (Give names) U n k n o w n No Yes O H Did accident or exposure to occupational disease occur while at regular work and on company time? No Yes * Z w (Explain "No") U nknow n a uu < Was injured intoxicated or misconducting himself at time of accident? (Explain "Yes") Unknown Yes N oQ __________________________________________ ------------- Date disability commenced U nknow n ' Inst day wages were paid or will be paid 5 -1 5 -5 9 Date back on Job D id n o t re tu rn * Q z > If and whpn doctor savs employee may do light work, will you have such work available? I f w o r k l o a d r e q u i t E No Yes > U1 fca Are vou paving his wages during disability? No . J Z ------ ;-- -- ------------ E s ta b lis h e d u n io n --ul Wages: Give average monthly wage regardless how paid p o r h o u r & "^ 9 7 5 w age ru b e ..... Yes X o Q * (Monthly) * 2a 0 Tiss iinnjiuurreedd tfuurrnniissnheeod rroooomm............................. meals.(..n.u..m...b.c..r.)..oEr ostht ear badlviasnthageesdin aUddnitiioon nto^ wi Sanens?g e(E_xpela^inp)e j a s e . a ---------- No Yes How many total dependents docs injured claim for tax purposes? 7 I CERTIFY TO THE TRUTH OF THE FOREGOING STATEMENTS: Name ' ' < Address J.'1i1.1.`' Birthdate Age Sex Marital status Occupation at time of accident-exposure Period employed this firm Name of Employer reported reported Accident Place of Accident Hour AM PM Date or Last Known Type and cause: Briefly describe the accident o r exposure causing injury Exposure To Cause of Disease Injury or Disease Type of injury or disease Body part(s) affected Degree of Disability No lost time Unable to work Date last worked Date returned to work List persons residing in United States who are totally dependent on you for financial support. Name Relationship N A o' * , Name ' Relationship Age - I certify the above is a true statement, in order to obtain the benefits of the Nevada Industrial Insurance and Occupational Diseases Acts. . . ', v_f . i , * Workman's Date Place ___________ Signature . PHYSICIAN--COMPLETE THE FOLLOWING:: The doctor may assist the injured workman to complete the above if necessary. Please see th at he has signed his report. Notification by physician--see Section 61S.345 NRS. Penalty for non-compliance-- see Section 616.650 NRS. First treatment: Place Name of Hospital Diagnosis and description of injury or occupational disease: Hour Date Describe treatment used: X-ray findings: From information given you by employee, together with medical evidence, can you directly connect this accident or disease as job incurred? ___ - --------------------- Will patient be disabled from work 5 days or more? Estimated Degree of Disability Estimate how long patient will be off work due to this injury or disease Will injury or occupational disease likely result in permanent disability? No QNo YesQ Yes * (Weeks) * Yes N o n Did any previous injury or disease contribute to this disability: (Explain Yes ) Yes N o O atC Doctor's name Address ___________________________________ Doctor's signature__________ ___________________________Degree---- Mr* J. S. Taylor - 2- August 5, 1959 I n c id e n ta lly , oar f i l e s d is c lo s e th e f a c t th a t th e Commission was informed by John S. Murphy th a t a l l sen were h ir e d in C a lifo r n ia fo r work in Hevada. I f th e number o f lu n g claim s keep on in c r e a sin g as th ey hare in th e p a st se v e r a l weeks, moat o f your tim e w i l l be spent on a a b esto a ia and pneumoconiosis claims* Seriou sly though, i t i s Important th at ve cooperate w ith our insurance c a r r ie r s and g iv e them a l l th e h elp v e can fo r two rea so n s, f i r s t , th ese claim s u s u a lly r e s u lt in t o t a l permanent d is a b i lit y which means maximum compensation awards o f which v e w i l l pay our prop ortion ate share. 8econd, th ere i s some doubt th a t our typ e o f work could cause a s b e s to s is . However, s in c e one employee c o lle c t e d under th e C a lifo r n ia O ccupational D isea se Law, we have had q u ite a few a s b e s to s is cla im s. Our o n ly concern, where an award has been made, i s to be sure ve are n o t charged w ith more than our p rop ortion ate share. I f you have a d u p lic a tin g machine, w i l l you send u s a copy o f th e C-2 form subm itted. Very tr u ly you rs, . ABMSTBOSG COBH COMPANT JEZ Enclosure J . E. Z e lle r , AC&S, L ancaster R. C. S c h ie d t, J r . Insurance Department ' ' > gant saw yer Governor STATE OF NEVADA NEVADA INDUSTRIAL COMMISSION T. L. HUTCHINGS COM M ISSIONER REPRESENTINO W . G. EMMINGER COM MISSIONER REPRESENTINO LABOR INDUSTRY Carson City, Nevada August 24, 1959 ^ chaTM ' " 8 ADDRESS ALL CORRESPONDENCE TO NEVADA INDUSTRIAL COM MISSION REPLY TO Armstrong C & S Company 120 E. Lime Street Lancaster, Pennsylvania Re: Lloyd V . Viall Claim No^OD-59-14826 Gentlemen: Upon receipt of a completed claim form and notice of claim on the above named it is shown that he was hired in California. Therefore, we suggest that you report this claim to the California Carrier as it would not be handled through the Nevada Industrial Commission. Trusting this explains the handling. cc: Mr.Lloyd V. Viall 20 East Liberty St. Reno, Nevada Robert K. Myles, M.D 975 Ryland Street Reno, Nevada ( A r m s t r o n g ^ -- +S cC O N T R A C T I N G A N D S U P P L Y ' co r po r a tio n Subsidiary of ____ p , Armst rong Cork Company 304 SHAW ROAD SOU TH SAN FRANCISCO. CA LIFORNIA August 10, 1959 im t ^ cr* wls Mr. R. C. S c h i e d t , J r , Insurance Department Armstrong Cork Company Lancaster, Pennsylvania , Subject: L lo v d V. V ia 11 't>/k - v f T s i g s r Workmen' s Compensation - Nevada Dear Mr. S c h ied t: Enclosed copy of Report of Inju ry or Occupational D isease, Form C-2 a s r e q u e s t e d i n y o u r l e t t e r o f A u g u s t 5* 1 9 5 9 . Very t r u ly yours, * * NEVADA INDUSTRIAL COMMISSION CARSON CITY, NEVADA Form C-2 (Rev. 10-58) REPORT OF INJURY OR OCCUPATIONAL DISEASE and WORKMAN'S CLAIM FOR BENEFITS CLAIM NUMBER theFnevadT industrial commission requests t h j s e d Ein0 n y e j LINCOLN orDclarkHcountysend2 EMPLOYER--COMPLETE THE FOLLOWING: Name on . A rm stro n g C o n t r a c t in g & s u p p ly a m Certificate of ox* t o 1/ 1/58 A r m str o n g C ork C onpany > Insurance & ________ _____________ _________________ o Mailing X 20 N . Lim e S t r e e t . L a n c a s t e r , P a . eu Address s a Nat,,re of Business E r e c t i o n o f i n s u l a t i n g m a t e r la X a Policy Account Number Telephone Number Under what classification have you been reporting employee? X023U Name (Per Payroll) 4 0 Ag i a UJ Address 5U 8g S . U 270 W ,, K ea rn s 1 8 , U ta h >o- a eu Sa Occupation 'and I n s u X a t i o n NJiaimlle sastautiev itnu w" h"i*c'*h* h...i.re--d-.- Length of employment with C aX lf o r a la Usual Duties you in Nevada M Sex Marital Status How Long Employed By You? -- Accident or SaU ialieia S h ip y a r d / San F r m ic lscOyCariT AM PM - Date Exposure CoDn Occurred <a CO N. . o_ a c o jl dj e. n- at* Ia n. . .v. .o. 1l vw ea d^ . NM oowrmm aaIl wu ftoyrr Ikr linntg? S e n t 110' " c o n d i t i o n s a p p l y i n g v a r i o u s i n s u l a t i n g m a t e r i a l s t o m e t a l Occurred s u r f a c e s a t t h e a b o v e l o c a t i o n s . M 96 d a y s (Months)____ Was injured intoxicated o r misconducting himself at time of accident? (Explain Yes ) U nknow n Yes N o Q Date disability commenced ' U n k n o w n Inst day wages were paid or will be paid Date back on D id n ot return * If and when doctor says employee may do light work, will you have such work availabje? I f w o r k lo a d requfre E No Y esQ *>h-Zquj AArree yyoouu ppaayyiinngg hhiiss wwaaggeess dduurriinngg ddiissaabbiilliittyy??---------------- N* Eo s t a b r r a h e d ``l u f l . o n w a g e r a t e _1Z 3g Wages: Give average monthly wage regardless how paid p a r h O U T --S 3 9 7 5 ----------------------------- . 220 Is injured furnished room................ . meals,,. -- y- f O . . _ _ 1 i : . : __ . _ . . . . /.a t-1) ( C v n l m n l naea nY es 3HoD * (M onthly) No YesQ How many total dependents does injured claim for tax purposes I CERTIFY TO THE TRUTH OF THE FOREGOING STATEMENTS: Pomaded1 AU.rftlS t 1 0 . 19 5.9. tie D i s t r i c t M a n a g e r I tit r 8 /at Ti i c r r i x i m TTTE! AND TFIGTRLE. * EMPLOYEE--COMPLETE THE FOLLOWING: Name Relationship Age \ Name Relationship Age I certify the above is a true statement in order to obtain the benefits of the Nevada Industrial Insurance and Occupational Diseases Acts. "" ' Date________________________ Place_____________________ Workman's . Signature " ____________________________________ PHYSICIAN--COMPLETE THE FOLLOWING:. The doctor may assist the injured workman to complete the above if necessary. Please see th at he has signed his report. Notification by physician--see Section 616.345 NRS. P enalty for non-compliance-- see Section 616.650 NRS. First treatment: Place Name of Hospital Diagnosis and description of injury or occupational disease: Hour Date Describe treatment used: X-ray findings: From information given you by employee, together with medical evidence, can you directly connect this accident or disease as job incurred? Will patient be disabled from work 5 days or more? Estimated Degree of Disability Estimate how long patient will be off work due to this injury or disease Will injury or occupational disease likely result in permanent disability? No No Yes Yes ' (Weeks) * Yes N o n Did any previous injury or disease contribute to this disability: (Explain "Yes") Yes N o n Date Print Doctor's name Address / Doctor's signature ; Degree