Document b558yNMbN3gLk5bOZ5kG1JrG6

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1966 DOC#: WCC056 DOCUMENT DESCRIPTION: Workers Comp File - Frederick, Kenneth M File Name Contract Unit Claim File: Kenneth Martin Frederick Sept. 13/66 Scanned ? yes Source JMA: NS-JM Start Year 1966 Stop Year 1966 Contents claim, letter Notes WORKERS' COMPENSATION (INDUSTRIAL ACCIDENT PEALS BOARD - CALIFORNIA U'.ISSION, prier to 1966) APPLICANT KENNETH MARTIN FREDERICK (deceased) by' CASE # F 16482 Asbestos Insulation Installer sPuse & son DATE CLAIM FILED INJURY ALLEGED Sept. 13, 1966_______________________________________ Inhalation of asbestos particles to lung ALLEGED DATE OF INJURY 1960-66 extended as add'l employers are joine< EMPLOYER/INSURER Fiberglass Engineering/AETNA, et. al. including J-M Sales/Travelers________ No apparent Canadian insurer________________________ OTHER NOTES ________ "No clear cause & relation of injury to employment" ________ State of the (medical) art discussion among________ AETNA doctors DATE OF RESOLUTION NOV. 2, 1972________________________________________ RESOLUTION Compromise & Release $13,500 settlement DOCUMENTS COPIED D 7/9/68 Med Rpt of Miller to State Comp. Ins. Fund 2) 7/28/66 Med Rpt of Powell to AETNA 3) 7/26/66 Med Rpt o Lippett to AETNA 4) 7/26/66 Med Rpt of Ford to AETNA 5) 7/7/66 Med Rpt of Mau to AETNA 6) Compromise & Release * OF PAGE 1 2 3 2 1 4 CLAIMANT ____ Ysgjnrtekh___f Y i a i r h n r e d e s t a k . _______________________ California Workers' Compensation Appeals Board CARRIERS INVOLVED: The AETNA Casualty & Surety Co. oAmerican Automobile Ins. Co. oAmerican Employers Ins. Co. oAmerican Motorists Ins. Co. Argonaut Ins. Co. oAssociated Indemnity Corp. oCalifornia Casualty Indemnity Exchange oCalifornia Compensation & Fire Co. oCasualty Ins. Co. of California oEmployers Liability Assurance Corp,Ltd. oEmployers Mutual Liability Ins. Co. of Wisconsin oFidelity & Casualty Co. of New York oFireman's Fund Ins. Co. oGeneral Accident, Fire & Life Assurance Corp. Ltd. oGlobe Indemnity Co. oGuarantee Insurance Co. oGreat American Ins. Co. oHardware Mutual Casualty Co. (Sentry Ins. Co.) Industrial Indemnity Co. olndustrial Indemnity Exchange olnsurance Co. of North America oLiberty Mutual Ins. Co. oLumbermanJs Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co. oMission Insurance Co. oNational Automobile & Casualty Ins. Co. oNew Amsterdam Casualty Co. oOcean Accident & Guarantee Corp.Ltd. oPacific Employers Ins. Co. oPacific Indemnity Co. oReliance Ins. Co. (Standard Accident Ins. Co.) oRoyal Indemnity oSecurity Ins. Co. of Hartford (U.S. Casualty Ins. Co.) State Compensation Insurance Fund Transport Indemnity Co. The Travelers Ins. Co. oThe United Pacific Ins. Co. U.S. Fidelity & Guaranty Co. oZenith National Ins. Co. oZurich Ins. Co. o ______________________________________________ o _________________________________________________________________________________ o _________________________________________________________________________________ o _________________________________________________________________________________ o r .) / ( OCNCMAt UOCY Th o h a o c * u p *g c * y VASCUkAK V*OCV ORLAND G DAVIES. JR.. M. O. JACK D. THORBURN. M.O. PARKER POWELL. M D > * * T m THCSTA 5TRCCT rC#NO I.CALIFORNIA P*'*-J*ri h<f*July 2 8 ,-T ^ 6 p T I V Aetna L ife & Casualty Sasualty & Surety D ivision S uite 800 Del Webb Center 2220 T u lare Street Fresno 21, C a lifo rn ia OCT 1 01966 FI. FRESNC - C:np.v.^:-. . s: Atten: John S. Backer Claim Representative Dear Mr. Backer: Re: Kenneth M. F re d e rick , deceased Our # 10141 You have requested inform ation regarding the recently deceased p a tie n t, Mr. Kenneth F re d erick. Mr; Frederick was f i r s t seen by me on J u ly 6, 1965, at the request of Doctor Mau because of pain h h i s rig h t c a lf . I f e l t that t h is represented pain ra d ia tin g from a herniated lumbar d is c and referred the p a tie n t to Doctor Lip p ert who subsequently operated upon him w ith r e l ie f of his symptoms. I did not see the p atient again u n t il May 24, I966 when Doctor Mau again asked me to see the patient who was in the h o sp ita l at that time. In a d d itio n to the pulmonary problems and fever which he had had, the patient had developed rig h t leg pain which was d iff e r e n t than the pain he had pre v iou sly had. He stated that he had again become i l l in March of I966 w ith a pulmonary in fe c tio n and that subsequent to that he had f e l t weak and had lo s t h is ap petite. The leg pain developed during the course of t h is illn e s s and had been quite severe and required pain m edication. At the time of our examination there was no evidence of v a scu la r d i sease or interabdominal mass which could exp lain the cause of the leg pain. The evening fo llo w in g our-.examination the patient stated that the leg pain disappeared and we did not see him subsequently. Consequently, 1 have seen the pa tien t on two occasions fo r leg p a in r but have never done a complete pulmonary examination. In answer to your question regarding the cause and e ffe c t r e la tio n ship between h is employment as a fib e r g la s worker and h is carcinoma of the lungs, I know of no proved re la tio n s h ip . An opinion from one whose main experience has been in in d u s tria l medicine might w e ll be more valuable. / i . Aetna L ife 6 Casualty^ ^ . Re: "Fred erick, Mr. Kenneth M. (Deceased) . O u r # J O H +1 r / 7 page \ ^ J u ly 28 I9&6 A ls o , I do not know what the p a tie n t's smoking habits were and what re la tio n ship t h is might play to h is disease. I am a fra id th is has not been too enligh ten ing a response but i t is the best that I am able to give. Yours tru ly , PP:aj t n c u k o l o g ic a l URGERV ( J O H N W. PACE. M. D. DAVID S. ZEALEAR. M. D. R O B E R T G. LIFPERT. M. D. 2840 NORTH TRESNO STREIT F R E S N O 3. C A LIFO R N IA July 26, 1966 c: BAcowm .e Aetna Casualty & Surety Co Suite 800, Del Webb Center Fresno 21, Calif. Re: Emp: Kenneth M. Frederick Owens Corning Fiberglas Attn: John S. Backer Dear Sir: The above named patient was admitted to my service at St. Agnes Hospital on 7-8-65 at the request of Dr. Parker Powell. Enclosed is a copy of my His t o r y & E x a m i n a t i o n d i c t a t e d at that time. Lumbar spine films on 7-8-65 showed narrowing some hypertrophic arthritic changes. A chest obtained on this date. Encl o s e d is a copy of of L5-S1 with film was also these reports. A pantopaque myelogram was revealed a defect at L5-S1 port is also enclosed. performed on 7-9-65. on the right. A copy This study of this re A laminectomy was performed on 7-13-65 with removal of an extruded intervertebral disc at the lumbosacral level on the right. Postoperatively, the patient made an uneventful r e covery and was discharged home on 7-20-65. Final diagnosis at that time was extruded intervertebral disc lumbosacral, right, asbestosis. The patient was seen in my office for several recheck exami nations, showing consistent improvement and was dismissed from my care on 10-26-65. Mr. Frederick was next seen on 5-9-66. At this time he had been off work approximately one month with pneumonia. Unre lated to any particular activity, he began to have aching in the right calf and foot. This gradually became worse, in volving the thigh. There was minimal low back pain and no left leg pain. The pain tended to be aggravated by w a l k i n g and standing. Re: Kenneth M. Frederick Page 2 Exa m i n a tion on 5-9-66 revealed the patient to be quite illa p pearing and pale. There was a full range of painless back moti o n s . There was no s p a s m or tenderness on p a l p a t i o n of the b a c k m u s c u l a t u r e . Stra i g h t leg r a i s i n g is carried to 90* on the left with o u t pain, and on the right e levation to 90 caused slight discomfort. The sciatic nerve on the right was quite tender on palpation. The ankle jerk was absent on the right. There was no hypesthesia. Auscultation of the lungs suggested decreased air entry the right lung field with a suggestion of some dullness basal regions on the right. The abdomen was negative. and spleen were not palpable. over in the Liver It was felt the h i s t o r y and findings were quite suggestive of an occult neoplasm. Particularly, the possibility of a retro peritoneal neoplasm was raised. The patient was referred back to Dr. Mau, his referring physician. Dr. Mau was contacted by telephone and further investigation along these lines recom m e n d e d . The patient was s u b s e q u e n t l y admitted to Fre s n o C o m m u n i t y H o s p i t a l by Dr. M au and e x t e n s i v e l y investigated by Dr. Mau and, additionally, by a medical consultant, Dr. Woo. Their studies failed to illustrate a neoplasm at that time. Additionally, I again re-examined the patient in hospital, as did Dr. Powell, w i t h o u t f i n d i n g a d e f i n i t e c a u s e for h.is problem. A repeat m y e l o gram was performed during that admission without revealing any p a t h o l o g y . D u r i n g this time the p atient's pain receded .and a c t u a l l y see m e d to d i s a p p e a r over a m a t t e r of a day or two, so that he was discharged - a diagnosis not having been es tablished. Subsequently, I was advised by Dr. Mau that he was readmitted to the hospital a few weeks later and at that time a diagnosis of an oat cell carcinoma of the lungs established. The patient was not seen by this examiner on this last admission. COMMENT: From the neurosurgical point of view, this patient was originally treated for a lumbosacral disc extrusion - to which surgery he responded very satisfactorily. Subsequently, he ' p r e s e n t e d w i t h findings lead i n g to the d i a g n o s i s of occult ret r o p e ritoneal neoplasia which could not be definitely dem o n strated, despite extensive study in hospital. On a subsequent admission a neoplasm of the lung was finally demonstrated. The patient did have findings as outlined related. Insofar as a l o n g s t a n d i n g h i s t o r y of asbestosis with above which would, of course, be industrially the relation of his neoplasm to his asbestosis Re: Kenneth M. Frederick Page 3 is concerned, m y reading wou l d indicate an incidence as high as 137. of c a r c i n o m a ' o f the lungs in patients w i t h asbestosis. This would, Z feel, strongly suggest a direct relationship between the patient's tumor and his occupation. Such an opinion, however, is s o m e w h a t far afield in m y c h o s e n s p e c i a l t y and I wou l d suggest an o p i n i o n be obtained from an Internist or surgeons specializing in the treatment of pulmonary diseases. Very truly yours RGL/vl ends . R. G. lippert, H. D. c c tRUCE M.ERG.M.D. CEO RC I C.U'OLF. W.D. OVJrtEN K.STEINBa CH.M.D. Max i.M lU -A R.M .D . CENTRAL CALIFORNIA MEDICAL CENTER 3004 WORTH FRESNO 5TREET FRESNO. CALIFORNIA 9 3 7 0 3 TELEPHONE 2 2 * - 6S 37 J u l y 9, 1968 INTERNAI MEDICINE State Com pensation Insurance F u n d Post Office B o x K Fresno, California r* '**c* ; J U L 1 6 19S d F DF re sn o Re: A - 17003 Kenneth M. Frederick Attention Maur i c e Nyberg, Claims Adjuster c Gentlemen: With regard to your inquiry of June 21, 19&8, I a m not a w a r e of any k n o w n relationship between exposure to fiberglass and development of the type cancer leading to this m a n ' s death. A period of continuous exposure to fiberglass alone, without concomitant exposure to asbestos, would not have contributed to this man ' s demise. MSM/wb MAURICE NYBERG JUL 11 1958 'ISSO, 0.0. Joseph B ForJ Jr.. M . D thoracic suocr * * * M I } m O TH CCT riie sN o , c*L iro * N iA 937H -- mm- July 26, 1966 * 9 ncm o copt CSOAHACSCOAV John S. Backer Aetna U fe , and Casualty 2220 T ulare Street Fresno, C a lifo rn ia Re: Kenneth Frederick Owens Corning F ib e rg la s Dear Mr. Backer: This is in reply to your le t t e r of Ju ly 13, 1966 requesting inform ation re garding Mr. Kenneth Fre d erick. I saw th is p a tie n t in co n su lta tio n on June 8, 1966 at Fresno Community Hos p it a l at the request o f Dr. A lle n Mau. He had been h o sp ita liz e d fo r fu rth e r in v e s tig a tio n o f h is complaints of p e rsiste n t and increasing cough in a d d itio n to progressive shortness o f breath s in c e an episode of pneumonia in A p ril 1966. Chest x-rays had revealed co n s o lid a tio n in the rig h t lower lobe p o s te rio rly and there was a prominent rig h t h ila r area in a d d itio n to p le u r it is on the rig h t sid e. There were previous x-rays taken in A p ril 1966 which showed e s s e n tia lly the same changes except during the interim there had been an apparent increase of f l u i d on the rig h t sid e , he had p reviously been h o sp ita liz e d In May T966 fo r two weeks and at that time he was noted to have a larg e liv e r In a d d itio n to the pulmonary fin d in g s . At that time he was seen in co n su lta tio n by Dr. Joseph Woo and because he was complaining o f pain In the rig h t leg, (te was a ls o seen in co n su lta tio n by Dr. Lip p e rt. His past h is to ry revealed that he had had a laminectomy in Ju ly 1965 fo r a herniated d is c . Chest x-rays dated Ju ly 1965 revealed nodular d e n s itie s in both lower lung f ie ld s which were attributed to chronic asbestos!s. Physical examination revealed a f a i r l y w ell developed and nourished 50 year o ld w hite male who appeared i l l . His re s p ira tio n s were shallow, rapid and grunting. His n a il beds appeared dusky. There was no evidence o f adenopathy. The trachea was in the m id lin e. There was d u lln ess to percussion over the lower one-half o f the rig h t chest p o s te rio rly and the lower one-third a n t e r i o r ly w ith diminished breath sounds. Rales were heard over both lower lobes. The liv e r was considerably enlarged and tender to p a lp a tio n . It was my Impression that the pa tien t most lik e ly had a bronchogenic carcinoma on the rig h t sid e w ith metastases to the liv e r . Bronchoscopy was recormiended 4 2 - 7/26/66 CC Re: Kenneth Frederick and was performed on June 9, 1966. There appeared gro ssly to be tumor tis s u e in the rig h t lower lobe bronchus a r is in g at the le ve l o f the su p erior segment and extending down the bronchus about one centim eter. Several small biopsies were taken and the p a thological diagnosis was small c e ll a n a p la s tic carcinoma o f bronchogenic o rig in . Mr. Frederick was not considered a candidate f o r surgery because o f the presence o f pleu ral f lu id and the fa c t that he most lik e ly had extensive metastases to the liv e r . It was a lso f e l t that ir r a d ia t io n would not re s u lt in any appreciable pal 1ia tio n . As you have already ind icated , the cause and e ffe c t re la tio n s h ip between his employment as a fib e rg la s worker and h is disease Is a d i f f i c u l t question to answer. 1 p ersonally b e lie v e that heavy c ig a re tte smoking is the major cause o f bronchogenic carcinoma but recognize the p o s s ib ilit y that o th e r a i r p o l lu ta n ts and in d u s tria l carcinogens may play some ro le . However, from my present knowledge o f bronchogenic carcinoma I would say that h is d isease was not related to h is employment as a fib e r g la s worker. JBFrms a: a l l e n m a u m *d . 2 9 3 9 NO. FRESNO STREET . ( FRESNO. CALIFORNIA 9 3 7 0 3 TCLCPHONC J J J 5 J 7 0 July 7, 1956 Mr. John S. Backer 2220 Tulare Suite 8000 Fresno, California Re: Mr. K. M. Frederick Dear Mr. Backer: Mr. Kenneth Frederick's present illness started about March 1966, when he developed an apparent "flu-like" illness which progressed to a right lower lobe pneuoonitis over the subsequent month. However following his recovery from the pneumonia, he continued to have complaints of generalized lethargy, weakness, malaise, loss of weight, appetite, strength, and low grade after noon fevers. Diagnostic studies were started during April 1966 and Mr. Frederick was hospitalised from May 12-27, 1966 at the Fresno Community Hospital. During this period of hospitalization no diagnosis was made, altho a suspected neo plasm was the primary consideration. While in the hospital he was also seen by Joseph Woo, M. D., Robert Lippert, M. D. and Parker Powell, M. D. all of Fresno, California. Following his discharge he continued to do poorly and he was readmitted to the Fresno Community Hospital on June 8, 1966 and was seen in consultation by Joseph Ford, M. D., who subsequently performed a bronchoscopy; the latter procedure revealed a bronchogenic carcinoma of the right lower lobe of the lung, At the present time Mr. Frederick is at home. He is being treated symp tomatically and there is probable spread of the neoplasm to the pleura, liver, and possibly the brain. It is doubtful if surgery,radiation, or chemotherapy would offer any hope of recovery to Mr. Frederick. I am unable to state categorically that there is a cause and effect relationship between Mr. Frederick's work and his present illness. As you are probably aware, Ur. Frederick has worked with asbesto for 20-25 years and has had radiographically demonstrable asbestosis for the past few years. Mr. Frederick has also smoked approximately 1 package of cigarettes daily for the past 20-25 years. There are at present, trends in medical literature, which would suggest a statistically higher incidence of lung cancer in smokers and in persons with asbestosis. Mr. Frederick was readmitted to the Fresno Community Hospital on July 7, . 1966 and expired on the morning of July S, 1966. Yours truly, Allen Mau, M. D c JRKM EN'S C O M PE N SA T IO N A PPEA 1S B O A R D DIVISION OF INDUSTRIAL ACCIDENTS OEFARTKSNT O F INDUSTRIAL RELATIONS 5" ATE OF CALIFORNIA COMPROMISE A N D RELEASE (D ep.ndency Claim) S C I F N O . A I 7 OO3 CASE N O . _6_6.. . F _ l 6482___ , tWOOS LOUISE FKEDEEIOK . *XlAi " CDMri N' fy tin ) KENNETH MARTIN FREDERICK-DECEASED 2021 Glendon, Los Angeles, Calif. ______ V A R I O U S E M P L O Y E R S ( S E E A D D E N D U M ^ utterM 4HBmw*m f4vu ____ V A R IO U S C A R R IE R S (S E E ADDENDUM) Miner**orivack aim ninni .c,,, f C>^tD es The pirtiei hereto, for the purpose o f compromise only, agree as follows: 1,. fR P < kVinItEaD /' c,, Orfice The above-named a p p lic a n t s c la im !_ rha^ N p T H various placed In California M A R T IN F R E D E R I C K ____________ (NAM or IMtiOmt ifiic_fx.ogLJHovemb.ex.f^ 19.36_T- July. 8^ 1Q66 bv Various employers ----- -- ..._____ _ then insured as to workmen's compensation liability by_Various carriers or AMIBA WHITMIIt BlkP'INAUMB) .sustained injury arising out o f and in the cou n t of such employment as follow.r Claims to have suffered lung damage resulting,.j.n.d^ath, .. 2. The death o f said employee occurred on_______8 ________________ , 19---6--6--- as s result of the clai.med i.njury. ` 3. The actual weekly wages of the employee at die time o f claimed injury were.. Maximum iFEN 1`. _ ... , WES?r r g weekly w a g e (statutory) w ere- Maximum 4. Payments o f compensation to the employee in his lifetim e on account o f the claimed injury were N o n a ' The applicant___ herein claim____ to have been dependent upon said employee at the tim e o f claimed injury, aod staa ages,' relationship to, and the extent o f dependency upon laid deceased employee to have been as follows: . the names. NAME Minnie Louise Frederick AOI Adult RELATIONSHIP Widow EXTENT O F DEPENDENCY Total Bruce Frederick. 20 Son Partial 6. The parties hereby agree to settle any and all claims o f said dependent .JL on account o f the claimed injury and the death of said employee by payment o f the sum of 1 - 1 3 * 5 0 0 . 0 0 ______ p y . b l . as follow , J S Q Q . O O t O _ B r U C e F r e d e r i c k . balance to Minnie Louise Frederick, less $1.177.55 payable to Fresno .. .C.9 m r o u n i .t y .. K p g p _ i t g .. l .A _ l e s .s _$4o8.00 p a y a b l e t o D r . A l l e n Ma u a n d l e s s a .........r e a s o n a b l e a t t o r n e y ' s f e e . _______________________ ____________________________________________________ / , The parties hereby agree (if such items of expense be claimed) that medical, hospital and burial expense required by reason o f the alleged injury and the death of the employee shall be borne as fo llo w s : h ii__1?,2 S*P P ----------- O A V. C A B Fores* I i p * o t > > | > | V > : - ( ...... ' ( The name and address o f applicant's attorney (if any) :_FrySr_,._K&TT Sc Millett, 1 2 2 9 "H 11 Street. __ Er^jio^_^aii.omia_23221_____________ _______________________ ho requests a fee o f J .I .,3 .5 .0 . ,..Q.Q---------- - baring been previously paid ___________ 9. Reason for enmpromb,^Dispute exjsts as to whether or not Injury or death AOE/COE. __ Dispute exists as to periods of employment with various employers.____ __ Dispute exists as to whether or not wRich, if anv. period of employment __ c.oMribuied_t2_tb.^slleti_inJimr._ezLJlestk,___ ____________________ 10. The undersigned request that this compromise agreement and release be approved. 11. Upon approval o f this compromise agreement as provided by law, and payment in accordance with the provisions of said order o f approval, said applicants and each o f them do hereby release and forever discharge said employer and said insurance company o f and from all claims, demands, actions or causes o f action, of every kind or nature whatsoever, on account of, or by season of the injury and death sustained as aforesaid by the employee, and in particular o f any, all and every claim or cause o f action which the undersigned, heirs, executors, representatives, or administrators may have had, now have, or shall hereafter have against said employer, said insurance carrier, and each of them under D ivision IV o f Labor Code o f the State o f California. It is agreed by all parties hereto that the filing o f this document is the filing o f an application on behalf o f the applicant___ , and that it may be set for hearing as a regular application, reserving to the parties the right to put in issue any of the facts admitted herein, and that if hearing is held w ith this document used as an application the defendants' shall have available to them all defenses that were available as o f the date o f filing o f this document, and that it may thereafter be approved, disapproved, or a decision issued after a hearing has been held and the matter regularly admitted. 1 ). For the purpose o f determining the lien claim filed herein for the unemployment compensation disability and/or unemployment compensation benefits which have been paid under or pursuant to the California Unemployment Insurance Code, the parties pro pose the following division o f the sum agreed upon for settlement and release o f this case: _for temporary disability covering the period__ N o n e ^ f i l e d i- crued medical expense paid or incurred b y the employee. t. _for future medical care. ..for permanent disability. ib Provisions of Labor Code Section 53^3 are waived. (The above segregation must be fair and reasonable and must be based on the real facts o f the case. There should be no attempt made to deprive the lien claimant o f s reasonable recovery consistent w ith all the amounts involved.) W itness the signature hereof th -day OR TMK A .P A lC A .T 'l , 'O N A T U ! MUST A T T S S T IO ST TWO DM tM TO N ll A tttO M * A CK M O W kffM SO I M M I A NCTAJIV PVAWie. STATE OF CALIFORNIA .County of -a * FREDERICK, Applicant J5 R , KARR & MILLETT Attorneys See Addendum, "of carriers.` On th i s ..jS i________ day __________A.D. 19?.A-- before me, f j d ' A - ' i ----- A j .-- ................... N otary Public in arid for the aid C ounty and State, residing therein, duly commissioned and sworn, personally appeared /-//A /V / A c 'a , C / Jc xd S/ y? /- v cs? ^ s ; ' S - - < V know n to me to be the person..S. whose iu * f _ i ____________ -----------------------------------------------------------------------------------------------------------------------subscribed to the w ithin Instrum ent, and acknowledged to m e that JZ--h e . ^ executed the same. \- Witness Whereof, l have hereunto set my hand and affixed my official seal the day and year in this Crrtifreatr *bvt mitten. D R H :jp !-M SE.-W COLL'tPP r C A l i r C 0 . i t ft: -a Id. I V .-- .Cd.j Notary public m and for u td County and State of California O I A V dC A fe FOAM 1 6 ` P a c e 2 I (ACV F o r w ia lv Form 43 t 6 - r ( ADDENDUM INSURANCE CARRIER U. S. Fidelity and Guaranty Co. Transport Indemnity Co. Adjusting Agent for Industrial Indemnity EMPLOYER Thomas B. Douglas dba Douglas Insulation oo CONTRIBUTION 25.00 Lone Star Industries Successor to Pacific Cement & Aggregates Lorentzen Company $ 25.00 $ 200.OQ Aetna Casualty and Surety Co. Owens Corning Fiber glass Corp. *' 500.00 Argonaut Insurance Co. Travelers Insurance Co. State Compensation Insurance Fund Western Asbestos Co. Armstrong Contracting & Supply Corp. Johns Mansville Corp. Armstrong Cork Co. Western Asbestos Co. See Page 2 of Addendum for signatures of various carriers. $ 1,000.00 $ 1,000.00 $10,750.00 'Jv *J'PT ` A ll,*,tCoKj c c ADDENDUM - K* M* Frederick Page 2 U. S.FIDELITY JUTD GUARANTY CO. i \ PY^fllts A tto ri ARGONAUT INSURANCE CO. i By : ' /. f EMa r i and co! e } Its Attorneys TRAVELERS INSURANCE CO. C- H N ?O r& j ______________ ^/^AKPBELL/& McF E E ^ , I t s A tto rn e y s STATE %LL, I i I