Document ba5X7VvnR0Zv7M2M4N54VgR43

FILE NAME: Metalclad (METC) DATE: 1967 DOC#: METC012 DOCUMENT DESCRIPTION: WC Claim - Horsman [From J-M Archive] File Name Contract Unit Claim File: Robert Horsman Oct. 23/67: Amended Sept. 5/68 Scanned ? yes Source JMA: NS-JM Start Year 1967 Stop Year 1967 Contents claim Notes WORKERS' COMPENSATION APPEALS BOARD - CALIFORNIA (INDUSTRIAL ACCIDENT COMMISSION, pr or to 1966) APPLICANT ROBERT HORSMAN Asbestos Installer CASE # LA 316509 DATE CLAIM FILED Oct. 23, 1967 Amended Sept. 5 , 1968 INJURY ALLEGED Inhaling foreign substances ALLEGED DATE OF INJURY 1925-1967 EMPLOYER/INSURER . Thorpe Insulation Co./Firemen's Fund Ins. et. al. including J-M Insulation , OTHER NOTES ________Pulmonary fibrosis secondary to asbestosis DATE OF RESOLUTION Jan. 22, 1970__________ RESOLUTION _________Compromise & Release $19,000 settlement apportioned among 18 employers/carriers DOCUMENTS COPIED 1) Compromise & Release * OF^PAGE 2) Application showing original defendants CLAIMANT nl?6Y & Hairs m-ar, ___________ _ _________ _____________^ California Workers' Compensation Appeals Board CARRIERS INVOLVED! The AETNA Casualty & Surety Co. oAmerican Automobile Ins. Co. oAmerican Employers Ins. Co. American Motorists Ins. Co. Argonaut Ins. Co. oAssociated Indemnity Corp. California Casualty Indemnity Exchange , California Compensation & Fire Co. Casualty Ins. Co. of California Employers Liability Assurance Corp.Ltd. Employers Mutual Liability Ins. Co. of Wisconsin oFidelity & Casualty Co. of New York Fireman's Fund Ins. Co. General Accident* Fire & Life Assurance Corp. Ltd. oGlobe Indemnity Co. Guarantee Insurance Co. , oGreat American Ins. Co. -J oHardware Mutual Casualty Co. (Sentry Industrial Indemnity Co. olndustrial Indemnity Exchange olnsurance Co. of North America oLiberty Mutual Ins. Co. Lumbermans Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co. Mission Insurance Co. Ins. Co.) oNational Automobile & Casualty Ins. Co. oNew Amsterdam Casualty Co. oOcean Accident & Guarantee Corp.Ltd. Pacific 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. - fart-ferJ flrAidfrrt v i n d t m n i h j / V ________________ ' ' _ Sex-on-fi} flW.ial C.O. _________________________ __ O O " ------- --- ----------------------------- -- ---------------------- - 5 /8 1 1 WORKERS' COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 SOBERS J. HOESMAN, 4 Case N o. 67 LA 316-509 5 Applicant 6 vs. > 7 THOEPE INSULATION COMPANY, ( et al, FIBEMAN'S FUND INSUEANCE I 8 COMPANY, et al. 1 CERTIFICATI 0 ~ 9 Defendant I 10 11 I hereby certify that the attached documents are true 12 and correct copies of the original documents filed in the recdt 13 of this office in the above-entitled matter. ' 14 ATTEST my hand and the Seal of the Workers' Compensat 15 Appeals Board of the State of California. 16 17 18 19 20 21 22 23 24 Dated at San Francisco, 25 California, this g day 26 o f April, 1981 27 OCPAKTMtWT OF IttOUmilAl. ItUYtON* otvMtoNormoutmut.aocixmt* 1 McLAUGHLLN, EVANS, DALBEY & CJMMING 1/17 North Highland Avenue 2 Los Angeles, California 90028 3 466-3541 r..f .0 z: 4 Attorneys for Owens-Corning Fiberglass Corp. and Aetna 5 Casualty & Surety Co., ` Defendants 6 7 8 WORKMEN'S COMPENSATION APPEALS BOARD 9 STATE OF CALIFORNIA .. ' 10 11 ROBERT J. HORSMAN, SSA: 562-03-2606 12 Applicant JC* 3 3 / Z y < k. . * _ L Cu ;f; yy* 4-*r U; / S* 55 / *! C-5s3? v'r* 67 LA 316 509 vs. ' 13 14 MUNDET CORK CORPORATION, at al.) COMPROMISE AND RELEASE AGREEMENT 15 Defendants ')*1 16 17 The parties hereto, for the purpose of compromise only, hereby submit the following agreed statements of fact: 18 19 1. Robert J. Horsraan, born August 26, 1904, claims he was employed between 1925 and June 28, 1967, at various locations 20 21 within the State of California as an asbestos installer as a result 22 of which he sustained an injury arising out of and occurring in the course of his employment from inhaling foreign substances, or in 23 jured self in some other manner, resulting in injury to his lungs 24 and other injuries, symptoms, conditions and complaints set forth 25 Iin the medical reports on file. 26 1 2. D u rin g th e 27 : 1w a s e o p l o y e d a t v a r i o u s 28 ip h iii p 29 C arey o o V 0.0 , Mun c ; C o r -. ; 30 C orp o rat io n , F ib e rg ' rj v; . ;' - l e C o o p C o m p a n y , L 31 ` T * T h o rp e, IN C ., In e u 32 n ' Inc., a co rp o ra; -Z Csltrorni^ Petroleum Coro. I - e "7 " CW ' Plant ssl Cor " I" "Utln9 P r M "'" ' " - i , CO.. Arustrc- r 7 7 M*t*1 c i - -- -- .. . .XX o u c p ,, y . doh,,s-,,.nviu. Sal,, -- tt,,, a,,a Snpply CerpotKion snd ^ . ^ u ,, cc Corpotation_ set & 6j in the Application for Adjudication of Claim. - (3., Th. actual ...kly of a . ^ loy,, ,, the ui injury are in dispute. 9 > 10 (5.) 11 employee. Th. Ploy..', present disabUity is ih dispute h o r a r y disability ind.s,ity baa b a M 12 13 (*> Th. patties hereby apt.e tp settie ^ ^ >ii ^ .CO., of ..ia injury by h,, payM,,t o ^ sia ^ sis 14 s.id sum, to b. p.y.bla tp th. applicant in one ^ 15 ducting of attorney fee. ,, a u . claim ot ^ ; 16 lien claim of the Department of p_. partment of Enploynt ,, a said Dept. ot c , 17 " t " " *h" " * -- 18 p . TM and stationary since applicant's condition ha, h. 3, m , (or. rap=pt 19 Of Oecanbar a, la,-* th. Depart. of Duplo,TM co.c.d 20 payments July 5, 1967. 21 (3.) Th. applicant1s oedical pans, ,,as b..n s.if-p,, c,, 22 and non. ha. b.,,, furnished by th. .ploy. ,,urriers. te.) At various ti.es th. insurance carriers for various Ployers during the au.g.a period o injury (a) ARGONAUT INS. CO. no (b) CASUALTY INS. CO. OF CALIF, CONTRIBUT TO' 17394.00 ; b) THE TRAVELRS INS. CO. 328.00 27 1.259.00 is x r ^ j r s m m '' 41.00 91.00 1.950.00 29 !,'! X E . S I B . ' S " " TM ^ v - c o ! 55.00 (h) AMERICAN MOTORISTS INS. CO 701.00 U) SECURITY MUTUAL CAS. CO. * 80.00 (3) INDUSTRIAL INDEMNITY CO. 118.00 31; MI JIREilAlJ'S FUND INS. CO. K J<" 144.00 (1) GENERAL ACCIDENT FIRE S LIFE A5SUR. 1.780.00 321 275.00 - 2- ( ( (m) Pacific tiplayers Ins. Co. ?//,' s/o i m i B m r $ 3,003. (n) Employers Mutual Liability Ins.Co. 969. (o) A'Stna Casualty cc Suirsty Co". A"-'" 5,262. (?) Proctor & Gamble Soap Co., permissibly self-insured 25. (q) Los Angeles Department of Water & Power, legally self-insured 620. The employee's attorney is Steven Roseman, 1543 West. Olympic Boulevard, Los Angeles, California 90015 10. Attorney requests the fee of $ 1600.op 10. Amount of attorney's fee previously paid, if any, $ None 11 11 * Reason for Compromise; A bona fide dispute exists 12 as to whether or not the applicant sustained injury which arose 13 out of and occurred in the course of his employment through ex 14 posure to any deleterious substances while working for the named 15 employers. The nature of the applicant's illness and the extent 16 of his disability is set forth in the medical reports on file. 17 There is a dispute as to whether or not any portion of the appli 18 cant's disability is due to causes other than industrial exposure. 19 The applicant has expressed the desire of resolving the litigation 20 by obtaining a lump sum amount and controlling his own medical . 21 treatment in the future. All parties desire to resolve the dis 22 puted issues by this settlement, thereby avoiding protracted celav 23 and expense of litigation. * 24 25 12. The undersigned request Release Agreement be approved. that this Compromise and 26 13. Upon approval of this Compromise Agreement by the 27 Workmen's Compensation Appeals 3oard or a Referee, and payment in 28 accordance with the provisions hereof, said employee relessas and f forever dischargessaid employer and insurance carrier from all 30j cl.sums and causes of action, whether now ::nr.n or ascercoined. or which, m ay hereafter arise or develop as a result or said injury, j; inclu..ng un^ and all liability of said employer and said insurance *1} > < ( ( carriers and each of them to the dependents, heirs, executors, representatives, administrators or assigns of said employ.*. WITNESS this^^day of>^r^,. ^ Angeles, California. 7 1970j at Los 10 11 12 13 14 15 16 17 16 19 20 21 22 23 24 25 26 27 28 29 30 31 I, 32: y V lnVaN SliS^VN^^Appl.icauit 's att' ARGONAUT INSURANCE COMPANY SECURITY MUTUAL CASUALTY CO. | ^ y X3 iA.AND AY.TMA* A n t n Bn vRt 0M wHY. '/? 7/ By. THE TRAVELERS INSURANCE CO. By: PARKER & DALLY By___ 'C i " <'- -N CASUALTY INSURANCE CO. OF CALIF. HARTFORD ACCIDENT &. INDEMNITY CO By VJAMES yOODS1* ' ---------- - MISSION INSURANCE COMPANY 3y / / fffT'"' (4\pj[7^_________ __ ST^jCE C O ^ S ^ T I O N 3URANCE FUN By U. S. FIDELTY & GUARANTY CO. - By: HELLlIY.HERLIHV,JONES & NELSC By_ : - - Y . . PRO CTO R & G/.M GLE SO A P C O . By: HENLEY,iEiaiHY,'ONES & NZLS -- ^ - r e j p t p 0 9-- - ( C A S E ?C0. '.5'tt j r *>. t***, . PI', 4 ,^ -iS.5 - ' . , Ir.sulat.'.cr. Cc. n! i 2741 XrfOS Firer.e.Vs Fur.:- Insurance Co., a -- '*!. * OiKtt. r| -- --------------------- . -- . i . ,, c ......., . c T ^ T ^ T " ^ - 2" _______________________ ' -T 15 CLAIMED T.-iAT: Loo .'nicies, California 1- The injured e m p i r e , born 2 / 2 . ' / ' f f l . ' , , . , '><! o. r . r . O r ___ ^--^ -O C^/w/lS-`C7 -. while employed as a v a rio u s --.^ a ...ii,, ,, <9Seu*?IC\ *r T(M(r J \ . ,, , T by the employer sustained injury s-is.n - ct and in the cc'j:ra of employment to Q C C U ^ C l t i c r . g I S i s o & S C . . s . * '*T *reri *t iWJt5, -. The injury oacurred as follows: I r - `fa- 1>~; ^OrOign su.:Star COS . ,, r tw n e r is .A , ea.Ac . , , 0. . . . . ,, ^ - 3. Actual cammy a; time of injury were: .'a x itU r. ......... ..................... . ~ ta ...= ...... ' A A A . T I i r A1ATI AA. At > < * 1 _1 C > 0 - I . n ' v ^7 . . t .OlVw-t i-.*o. thm4ci*<.rj-miftuunT(cm; 4. ir.c injury aaused disability as follows: eUr.O 2o , I S . , 7 t o f l a t f ! <*ceirv u j t et p o f f wo*- s J t t o t* i % i i i u * > o lh9 *****o* * u r x * i o r c . - 3<,t .. .,4 J. Compensation wa> paid . ^0 5 ,T"' *" ' ( Medical treatr.-.e-ii seat received l ' e s item me iw{iikt t*Tc, . ,, iOATJ or U*T 0T*f.7 , . " ,7 ^ 7 T r u 7 r^ ." . ~ Al` treatment was lurr.ishad by ti:r emy Cf-*npan\ ----HO other ,,ttrrecaj:tment was provided or paid for by D u.tor, not pr.-....';J 0r paid for by employer or insurance contpjm . who treated or examined for this injur-.- are _ -------------- UI : .AM - g r r F ancT S r . R e n i r a l e ' c ~ - , r t >:.<:ssfse>>.:. i' - . s . a. t t , . . .-77.71 . : ,','lrV r7~ 7F ------------ - L r.m y ^ m e m I-..rrn e e o r Un.mplw ment Coi,Vei: rtwn DisaHlit;. ben.fi:: has-e been r.cei-ed sinee ,!,e Jareof injury. s. O- ..r A.i-.s ;.. '.*0r.. filed for industrial injurl.. by this einpknee a. follov s: _________ _____ T Cal* !' e , . . . . . . .... 1,1 : ^ Tcmyicar. J,. - t s indsnii::.. Pcr,... Meu'.-.'l tM in i n Cn-.r . ' r r s 'i . i :> r 1 . ( c -- - - --- ... r*- rr't' Irsulation Co. 27 ;i Z . Yates Av Los V r.go) ?, California ."conic?n Insulation Co. Corra noo , C* ?ifo.rnia c:-.o railr cn.-uy ::fg. co. 532 ?. Monterey I-'ass Ad. Monter" ?n.r);, California. 0175-': ' Western Asbestos Co. 240 Valley Drive -isMane, California, 04005 *1 of r- " <-; . 1 1 1 *> / rir r ^ Fireman's Fund r.'v.-'-erc 1 -> *> / - - Co-'vrnv 3223 fth Street - Les Ar.re'e?, Calif ; - /.'rii, l rf? Partford 1rs.- 'rouv ; 542 S. Coring rtreat* Los 'nvoles, ca.lifer-- 'a c'..-'.n/ it r? General .Accident 1rs! c 3535 7). 6th Street Los Aroelcs, California 6/12/65 V 1/2/66 ' Insulations Ir.o. (sole1 to) ilio Carey Mfg. Co. . 2 S. Monterey Pass D. Monterey Park, California 0vcr.s Cornino Fiberglns Corn. P.0. Bo:: 01* * Toledo, Ohio Los Angeles Cor): Co. ~.T. Thorpe, Inc. 9 4 C B. 2nd Street Los.Angeles, California, 012 3,4/65 a ne) Feb'. , 1266 1 0 ,11/1252 11,12/1253 1-7/1954 1-12/1257 3-12/1250 1955,1261,1962, 2,3,4,5,6/1963 3-12/1964 and 8-10/12CC 12/1964 and 1,2/1965 1961, 1963 6 1964 Pacific Bainlover s Ir.s. Co. * 405^ tfilshire Boulevard Los Angeles, California The Aetna Casualty t Surety Ins. Co., 2404 filshire Boulevard Los Angeles, California and Fr-.ployers Mutuals cf Ma 3540 'ilshire Boulevard Los Areles, California Fireman's Fund Ins. Co. 3223 !f. 6th Street Los Angeles, California American Motorists Ins. 3545 Wilshire Plvd. Los A.r.oles, California Armstrong Contracting 6 Supply 120 1!. Lir.e Street * ** Lancaster, Pa. Commercial Contracting Coro. 32217 Stephenson Fr.'y. Madison "eights, Michigan 1961, 1962, 1963 6 1964 1962 The Travelers Ins. Co. 3600 Kilshire Boulevard Los Angeles, California The Isotherm Co. 05 Milliar.s Street Bah cr f c.Id , Ca li fornia 1962 Munet Cor): C: recration 710: enrol le Avenue Vo. Serge:., M.I. 1932,1952,155? 19 Cl The Aetna Car,ur.lt:' : Su Ir.s. Co. ` 2404 Milshiro r 1":1. ( _ . . \Z Ci ........ 7 Co." -; . - - o *1 d . Chico ' . y.o ta, Califorr.ia ?1 rr. _ r.cl.ostcc Co. I S - . ' - . * J l \ Zj --* Long Dutch, Calif. ' Accv.rale Insulation Co., Inc. 3:23 Dottier St. LCS an a ion, California _M r Conditioning Inc. --?noi Kectr.er Boulevard ;n Dicgc, California Coast.Insulating Products i o longer in business) V .34 Lacy St. Los Angeles, California Department of "ator i Pcxer of the City of Los Angeles 207 S. Broadv:ay Los Angeles, California Armstrong Cor': Co. 120 Li:.;o St. Lancaster, California rovr. a P.oot Construction Co. >'..'ston, Texas Johns Danville Insulation Co. South Carolina ( (v xas City, Texas Houston, Texas Korth brothers Atlanta, Ga. Pittsburg, ?a. Denver, Colorado Stern Brothers Denvnv, Colorado i>rt'.T. r n i v y. "o-.i* 0 , T e x t - ( - -r - ' ---------- *~ 1 * - --- 1391 ? t f\ / 1 o * 11,12/100'"' * .*r, 7 2,3,4/1900 5 ''3 C o . "'ir-.il Los Anvclc-*-, r.-. 1 <- r -- Casualty Ins. C c . c~ Cc ? . C . rox 3103 Ana "'.si:-., California er.c St? to Cor.rcr.satier. Ir.?. r.C. Sox 2134 Los Angeles, California; 12/1954, 1-12/1955 1-12/195G 19 5 S ant! 5-10/196$ S-10/1954 Argonaut Insurance Co. 443 Shatto PI. Los Angeles, California and Guarantee Ins. Co. 1671 V.'ilshire Live!. Los Angeles, California (LEGALLY UDIDSIT.CD) 11,12/1954 The Travelers Ins. Co. 3600 V.'ilshire boulevard Los /'ngeles, Calif. 1951, 1-4/1952 1942,1947,1945 1949, 6-9/1952 (Self Insured) 1951 1943, 1-3/1950 1940,1941 6 1950 6-5/195^ 9-11/1950 ` 104 9 - 1046, 1947 c s -csrs L'arc. lites Hour Ee::cr Pce ripa ar/i AoatimT Co. KorCarclir.:. * Paulsborough, Kov: Jersey r.ic:*j.c:v;w Virginia lis.iC- Ir.sulaticr. Co. Al tant?., Gsa. ' ` Marine Engir.eerir.es Co. Los Angeles, California - Badyor Construction Co. ! chite, Kansas V Plant IluL'ber S Asbestos Co. Sar. Francisco, California ,537 Brannon Street)/ S'.-.-ift Packing Co. Los Angeles,'california barrer, s Baiioy Insulation Co Los Angeles, California General Petroleum Co. Tos .-.ngelos, California 'S Angeles rubber Co. us Angeles, California Proctor and Garble Sca-> Co. 160)'::cst 7th Street ` ' Long Loach,California enaco Oil Co., Inc. (main office) 3350 Uilohiro Los Ar.flon , Gali forni?. Thor: hr verb/ Plumbin', Co. Lf" -'-"'roles, California (::o z:::\ i:; '';r.:c Arp -..-tor Co. Lor. Angeles, Californie r' ' H Co. Cn! i.r cock Co . ( VC'-.i: > :?i5 1941 1 93 O', 2,r v.", 19--C l CO 1938, If-3? 153) Pacific Employers 1rs. 4050 " ilshire*Eclcvr'" Los Angeles, California 1938 1937 1937 ' 1934, 1935 s 1936 1933 1931 and 1932 (Self Insurer.) Security Mutual Cas. Cc c/o Beeves Bay Adjust: 113? b\ cth St. Los Angeles, Calif. r State Compensation Ins. P.O.Bern 2134 Los Angelos-, Californio Occidental Indennif(address unknown) ' State Compensation. ire. P.O. Bon 2134 Los Angelos, Californio and Lumberman's "utual Ir.s". 3545 Kilchire Bculevc*-d Los Angeles, California (Self Insured) 1930 1927,19?8,Iff? California Cr.o. Indnmnit Enc'-rn-e 417 3.'hill street Los Angeles, California 1925 a:-.': l??r, 3 92C State Co.T'-mrr'o" I-- ' P.O. r:e:: 2 1 3 / ........ '