Document aBLX0eqeOyLLLrM9BBg4RN2Ba

FILE N A M E : In su la to rs W o rk e rs ' C o m p C laim s (IW C ) DATE: 1963 DOC#: IW C 065 D O C U M E N T DESCRIPTION: C laim an t - Goans, R obert 0 . File Name Contract Unit Claim File: Robert 0 . Goans M ay16/63; Amended Aug. 8/63 Scanned ? yes Source JMA: NS-JM Start Year 1963 Stop Year 1981 Contents claim Notes 1 WORKERS' COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 4 EGBERT 0. GOANS, C ase N o. 63 OAK 11052 5 Applicant 6 vs. 7 LRENTZEN & COMPANY, et al, and ARGONAUT INSURANCE COMPANY, 8 et al, O l i ? I AT I ON 9 Defendant 10 11 I hereby certify that the attached documents are true 12 and correct copies of the original documents filed in the records, 13 of this office in the above-entitled matter. 14 ATTEST my hand and the Seal of the Workers1 Compensation 15 Appeals Board of the State of California. 16 17 18 19 20 Workers' Compensation Judge \ Workers' Compensatici Appeals Board' 21 22 23 24 Bated at San Francisco, 25 California, this 3*1 day 26 of March, 1981 27 FOOIRAMWnCAs B <NCW !. > DEPARTMENT O F INDUSTRIAL RELATION DIVISION O F INDUSTRIAL ACCIDENTS C ____ r r f *------ LkP '- INSTRUCTIONS t. 1. Ds aot UK tliii farm ia desib cun. Ui< Form 4JI.J. Do ooi uu is r r f Indurirai ftafiKnne fcifVSM?fk.W^ 4 i,,uT ^ 1. Iftb.injurltmplo|r botmdor J1 ynn of>t< .si .,u,,dao > lium bu ,"108118' j .p.forw -- ..(,<adl.mJ ,,,,,,,,.u, TM T '>?. pgg >. Tb. yiurdiao mu,,,,,, chu.r.rmn,. oo bcbslf of ,a imjund wkm.JJL G-g^afis ' IFtbo^issuatbovoikooii*ifLMuchmuwshouldilwiifathU|nmol *296** , t- uO L o a o a i> u __L __ I . . 1 ^ ,tP0'" B0` tabooilob.b^_ ^ ^ J & s t f a * industrial A c a p f a ^ M ^ fS *"'""b F THE STATE OF CALIFORNIA ,, , - COMPROMISE A N D RELEA ROBERT 0 . GOANS LORBNTZSH & COMPANY, et Ti>ee attached list) ikd.litMfttI AtiidSh! SifiWsSin 26(364 i22 C iLV DD CASE N O . 63 OAK JIUULLS1964 4l . 25th s tr e e t r r , **c.u*- - c o i r l i o u r e e i - O M d A c L D i ; l'Sai) Francisco. California APPLICAKT ----- i ADMIS! - 1155 " 5th Street al Oakland. California MPbOYK ' 1105? =------ ARGONAUT INSURANCE COMPANY, et al (.See attached list) IN S U R A N C X CARRIKR 550 California Street San Francisco, California'' . J The parries hereto, for the purpose of compromise only, hereby submit the following agreed statement, ,,{ fret: 1 . -Robert 0. Goans employee herein, bom on September 2. IQ O O claims that he was employed on rb. as a_ 1.oc-c-up-at-io-n) workmen's compensaiion liability hv 3rd j . t n t A p r i l ___ ,,63 , , ( UOUTUI , . , O a k la n d , . -- C a lifo r n ia (STATS) SS ee ee ITnn'ddul)Ssft.rr>i1 aa ll AIicacaiSctenViOernamis.sio__n__r__e_c_o__rdj, s--then insured a"s relative to insurance carriers and e m p lo y e r 's , ( T A T I "NAMEBOFF Ce AAMR *U! !U* AO R* wW Hu InT Hu SnR H UL .aI M. s u >, .t. p .| 1 " " he sustained an injury arieng out of and in the course of his employment as follow: P n e u m o n O C h o n lO S l S R E C E iy g p JUL 3 0 1504 Fim i} Madri m itin CepniM d.. The actual weekly wages of the employee at the time of injury were t -- ___________________ , while the average weekly wages wcj } . The employee's present disability is-- not and the employet_fc2.,Z___returned to work. *STATSrattCNTOISANIUTTULTIMOMOMTMKINJUMT) (IP SO. STATS WHEN) * (aj Temporary disability indemnity has been paid to the employee in the sum of t n n n p at j_ m g. The amount due and unpaid to the employee is $_ . per week cove (b) Permanent disability indemnity has been paid to the employee in the sum of t __ n n n p covering p e r i o d _ _ _ _ t o ______ J. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of < fi On in addition to any sums heretofore paid by the employer or the insurer to the employee, raid supr^to be payable aa follows: lira? Siin....tJ^^r^m^iLtJ_l3^-a^ornpvR fo^; loss th a i :...less .'^00.00 to Smi'-.v,. Pavrlsiv f. e;:ps:ices 500.00 < Medical and hospital expenses have been paid J-- ___ by the employee and S.HQOg__ . fey tlie employer or carric: Unpaid bills amount to 5--HSDJ?............ .......Future medical and hospital expense is estimated at t r n c s r ' . p i r, Unpiid aa future medical and hospital expense is to be assumed as follows:__ S l l u n p a i d S.nd f u t u r e p s c i t i a ' I It 1 Tie: lic a r T ; ____________________________________ - . .7.w ..a,aa,,,, *,, onuzn, Parrish,Paducl- & riann ,,w ^ an^saiinttj^ f f ^ f ..... ' Said attorney requests a fee of t . . 7 on ' . , ' -- Amount of attorney fee previously paid, f aoy, j ___________ ____ as t e j a a r a u - a u m i o n and ,,f'i--n M 1 .. . Oftbo emnlo^pnt. ^ , . , . I m i t a t i o n s ^^Sji-.LjlS^jLff^_arid_Dre^udlxe_jtnd_aaBXicant - his oeat'.P. ^ ,.. 10. The undersigned request that this Compromise Agreement and Release be approved. insurance carrier from all claims and causes of action whether now knn p y * r" ult * ." Id including a n ^ n f aU tbils^ of dependents, heirs, .outers, representatives, administrators or assign, of ^ <**?*-p- -W, .CommiuioD. y leases and forever discharges said emplov "a n i ^ T * 4 " ^ p ^ a T TM 1" " - ori " d . * * f **" " 12. It IS agreed by all parries hereto that the filing of this document the commission may in its discretion sec the matter for kn n ** rh. ci:,, . \ ^ 0. r1**0_ ............................ aPphcation. on behalf of the employee, an its, any of the fairs a d m i r e d h e r o i n n d S S f f i ' f t f ! " T "' ~ T " S * PTM t h e ' " `PV available to them ,11 defenses that w erea v a ila h u tso f * < ta o ffilta T S T S ? T * " " * 5 " ? " * 'dant thereafter either approve said Compromise Agreement and or d i s ^ m f t * docura" t'. that the commissio hearing has been held and the matter regularly submitted for decision. PP **,e uiu* pmd" P a"1 Aware ror toe upon for settlement and release of this cast: " Cod*- **" P*TM" PTMP he following division of the sum *-----CQQ n n ------- f0r temp0rlr7 disability covering the period_____ ____________ I 1 o o n n n ?" ? CrU' d Plid incurred by the employee. i f y t o n ---- *or ^uture 'ileal care. . i, 1 Q Q -for permanent disability. 14. See below. _________________ ------- must fair " d asonable and must be based on the teal facts of the ease. Then. k. to deprive the ben claimant of a reasonable recovery' ccinsistent with all the amounts involved" " ' "U W " Virjnjs the Signature btrtof this.. I s ~)l 0f I / O ^ S'... i X ltMJOP wiTNtssta OISINTKRIWKSUTCMPOARAS^HONICSAONTR'IAICtOKNNAOTWULREIDGMEUDSTBESCrotitTSUA^tOliTaAuRVPUBblC. STATE OF CALIFORNIA -- County of___ tached list for signatures; employers and Insurance cnmoanlps attomies. fo*" A3i P*ci 2 (Rtv ia-e). tmiltr *mi f*r imU Cmmmty mi Halt mf Calif# i t m ij.i mm X e t* ^ : - o r n w en<i lnsuran'e > * . thr n m , ' - t o <. agree to p., the follo.lhg s ,, 5 as their proporttoaate snare of the Compromise and Release settlement. DTERT MORAN & ARNOLD. wiV h?lf 0f Mundet Cork Company; Fiberglass Engineering and simply Company; Owens-Illinois Fiberglass Company---.................................fsoo.oo By, J. Patrick Goodwin, on behalf o+ Zenith National Insurance Company! Jackson-Kopkins Company..... $ 25. 00/ & Employers Liability Assurance Lt?*' insw?ance carrier for National Insulation Inc..$ 7 5 . Hanna and Brophy, on behalf of . United States Fidelity and Guaranty.................- .$ 75.00 Hoyal Indemnity............. $ 50.00 By. California Casualty Indemnity , / f)/l / 7 ................. . w I/JMm .f 'rgonaut Insurance Company...$125.00 By W l f i j u u f - --. / , R,rxAl " Travelers Insurance Company. .$350.00 By J f h W t J i j A f a , Industrial Indemnity Company.$575.00 By S'f(i! State Compensation Insurance rUnd..................... . By P=H??,,&-F1llipi For Pacific Jimploybrs Insurance Company..... ' $1,700.00 (T * K-' WORKERS' COMPENSATION APPEALS BOARD ~ CALIFORNIA (INDUSTRIAL ACCIDENT COyvccynu ior to 1966) APPLICANT ROBERT 0. GOANS Asbestos Worker/lnsulation Mover - CASE OAK 11052 DATE CLAIM FILED INJURY ALLEGED May 16, 1963 Amended Auer. 8, 1963 Pneumonochoniosis ALLEGED DATE OF INJURY April 3, 1963 EMPLOYER/INSURER . OTHER NOTES Lorentzen & Co./Argonaut Ins. Co., et al. 27 employers & carriers Many defendants reduced to 11 including jm Sales/ Travelers No apparent Canadian insurer Royal Indemnity?) No medical reports in file DATE OF RESOLUTION July 23, 1964 RESOLUTION Compromise & Release $6,750 settlement apportioned among 11 employers /carriers DOCUMENTS COPIED D Compromise & Release # OF3PAGI CLAIMANT California Compensation Appeals Board CARRIERS INVOLVED: oThe AETNA Casualty & Surety Co. oAmerican Automobile Ins. Co. oAmerica'n Employers Ins. Co. oAmerican Motorists Ins. Co* Argonaut Ins. Co. * Associated Indemnity Corp. SSlifoin Sasualty Indemnity Exchange California Compensation & Fire Co 9 ' Casualty Ins. Co. of CalifornL S S S r m liability AssurIn1orp.Ltd oEmployers Mutual Liabllltv In. 2 S ',,. Fideiity & casualty Co. of NeS*Yo?k * Wisconsi* ' * Fireman's Fund ins. Co. k 0GlSheai ,, d ^ n i ? ^ 0!ire ` L if e A 3Suranca 0 p . ltd. Guarantee Insurance Co. oGreat American Ins. Co. Hardware Mutual Casualty Co T . Industrial Indemnity CoT (Sentry Ins` Co`> Industrial Indemnity Exchange Insurance Co. of North America Tlb?rty Mutual Ins. Co. Lumberman's Mutual Casualty Co. oMaryland Casualty Co. 2 f chf gan Mutual Liability Co. oMission Insurance Co. National Automobile & Casualty Ins c oNew Amsterdam Casualty Co. * * oOcean Accident & Guarantee Corp.Ltd Pacific Employers Ins. Co. * oPacific Indemnity Co. ^ c y a U n d S i t y 0 ' (Standa^ Accident Ins. Co.) Transport Indemnity Co. The Travelers Ins. Co. oThe United Pacific Ins. Co. *?*ST yidelity & Guaranty Co. Zenith National Ins. Co. oZurich Ins. Co. c a s u a ity * c-> 5/81 mmf