Document bagDg40ebenr9vmG1aNVvm3V1

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1966 DOC#: WCC057 DOCUMENT DESCRIPTION: Workers Comp File - Taylor, Lawrence J File Name Contract Unit Claim File: Lawrence J. Taylor Sr. Scanned ? yes Source JMA: NS-JM Start Year 1966 Stop Year 1966 Contents claim Notes WORKMEN'S COMftNiAlivw vcr** tmtn i LANSING, MICHIGAN EMPLOYER'S BASIC REPOkT OF COMPENSABLE INJURY (COPY SMALL I I OIVEN IMMIDIATELY TO INJURIA EMPLOY! ANA INSURANCE CARRIER) Employers must report immediately to the D epartm ent on Form 10R all injnrics. including diseases, which itise out of and in the ourse '( the friploym ent and cause: 1 An aggregate of seven ( ) or mate days o/ disabrhty not including Sundays or the day ot injury. 2. Death. 3. Specific Losses In cnae of AIAYM also hi immediately an additional report an Form IOb additional instruct ion* >n tevarse Side, Lh* travetara insurance f ran. i n n rw Johns-vtunrille Sales Corporation -- a * 832 Fishnr Bldg. D ntroit 2, >*>! RilMt tmi Nm Nt iCNti TTPI OP lUSIMSS in d u s tria l Insulation IflLcaigan 24 ML a C. (lA* EIWtftMCl CARRHRT>" ' "rttLRS lasuaasce cones* 719 Griswold Sir--t, Datrod 26, Mich. OftAVC BLANK1 /. UURCD IMPtOYIl..1^ "* ??* . J. \ TaZ 1_.3.r -.................... . . . t o Sec. . (Mmmawi rMMMrMtul) flw nmi Address lW X BpRYVland num * >> > t r o i t * ileM jpw....... Marital statm.......H............... rcnvi 'tMn> Ace. .... If under IL Occupational Approval No. ...._ Wkng. Permit No.......... Sea. ^ .... m00tmmotrowu*nwrrMt Pumhrr of ta^arad employee's children under age 16. living with injured.. .......................... V inpared is a married man. ta rife living with him' ........... ................. Number of other family members or relatives at least 59% supported by MpmaA.......... R ..... BATE OP INJURY ... .......................... Last day rorked Dmcribe injury 0 damme CollapWid W ........................................ - 1 1 3 * CARS NO RNFLOYBR N<) wwarAivcs KLACft OKmnv " nan or mnmr z :: ::::. . V ^rctftc teas, give date of lorn ..... &-13-66 .................: . ........ z z s c i s ' ............................................................ -.... - Ns* did injury or d-*~c Happen? *** a load.of ____t o f i t down b fc s o M he was a l l a i t o f w in d . ........................................................... . ..... LOCATION lNle*v7Cty to m a n I* '*n0* Ta7lo r Wkfmcwm... ........... SUte Witnesses Hospitat . 'leW *0 .. .. *9** ................................ . ................................... Bswiiamr tim OCCUVSTIOW ~ " (|uort W a--brr> Occupation of injured employee ...... Mrwgfit Time Earntags: Hourly rale.. Overtime Eanungs. Hourly rate If board, room furnished give value (Cftr) (Wt+Ti ......................................... Hours per week Total S.............................. Hours per week .. Total $ ................... Total $ Combined weekly earnings S W an piece work or commission, explain fully - Estim ated length of disability . NAS A COPY Of THIS R(PART'SEEN GIVEN TO EMPLOYEE? " " Yes ...................... No cowjuo cowi) a idT OmNORNTI WKtKLT AM aoswev mjuav rrr* m o NT Signature (in ink) EMPLOYER or Representative (Not Insurance Carrier) X M r af Report................... - ..... .............................. s s n ) agv*y~** 1 1. u .1. 1. .a r a r ^ nr c l,: f v y nu Um Y*, I . T. OUCrMM S U | M A M 1477004 7-1aM |4 V 4 4 f i S p -------- r n ------- 4ALtUfl tCfefe*.feO*/ t" !* isnsr 4 14 |i8Z45svnsir^,. r. I J B B w *1 4 f . IBB IWaII w m m kkjm M lrn , 3l M . M n U , Si JQM LJ*L9a_J742^ Cm . J*_tUBQQQ________ ----JfiwwBKETi ranas arei load cf ast ci l. >UHSI MAL mal i TBT.iJftlTnBf 1 - ! J44ikM 7-85-44 IoccM0^3BS. owmffTtov I M COY. A M M V. 1 4Dl X -J~ . ii~<fnffM|8 UdmO fmF*tfWe*.4'AfaftpMi.MifBP.J.*#a*tJLAH M il AMOUMT M *.HNA|.A*fOVAl O tM t(M M 4l'APP90VM INhmOM<4ffn*XiriiMM>i vc-u | . Offtc i ACCM O a C C y i f O l v t o r n e e ' ** T f BfTtO U N COV. W ic ir. WAOt C O O I*_J CUSS _____ 1- i l COY TVFItOSl CXANOf M H G UAMM< C4V A H CHAMOIS Ul I.U - >7/7*J r - r 2 >r L ^ . /_