Document dnkRz8mb4vkQx9d5YKj6DZ0DQ

FILE NAME Manville JMA DATE 1963-1981 DOC JMA149 DOCUMENT DESCRIPTION Contract Unit Claim File - Robert O. Goans WORKERS COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 fF ROBERT O. GOANS CASE NO 65 OAK 11052 ; 5 Applicant VS. ) 7 LORENTZEN & COMPANY et al | and ARGONAUT INSURANCE COMPANY o et al CERTIFICATION Defendant 10 11 23 13 14 15 16 I hereby certify that the attached documents are true and correct copies of of this office in the the original documents entitled matter filed in the records Appeals ATTEST my hand and the Seal of the Board of the State of California Workers Compensation 17 18 282 282 Workers Compensation Workers Compensation Appeals Board 282 22 23 24 Dated at San Francisco 25 California this 37 day 26 of March 1981 27 DIA WCA FORM 115 NEW 1.78 DONT DONT DE DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS Po bog ve . INSTRUCTIONS bird Depart Depart RelationsRelations a . oe REEdical guaermdpialnoiyn eagereement 9-Accid1 ents 9 7h of r+ use this use Industrial ig 3based. . 1. Do not form in death cases Use Form 431 Do not in bird Warp 2. If the injured - 5 . employer be under beepED 21 years of age and a licem bas beepED beepED pointed a peticion for appointment of guardian ad litem and 3. The guardianguardian must sign this agreement on behalf of an injured employee der If the above the age of 14 such accompany beepED beepED minoujs minor should also sigo this agreement REEdical REEdical beretofore REEdical reports not submitted to when the and advise other WSS k k REEdical } * INBEFORE INBEFORE INBEFORE INBEFORE COMMISSION OFFICE FRANCISCO OF THE STATE CALIFORNIA fn COMPROMISE AND RELEASE ROBERT O. GOANS on Industrial Accident Commission RECEIVED - JUL 1964 4282 11052NV. CASE NO.63 11052 25th Street Off San Oakland APPLICAAPNPLTICANT Francisco California 1155 ADDRESS LORENTZEN & COMPANY : See attached list et al EMPLOYER 1155 - 5th Street Oakland California ADDRESS ARGONAUT INSURANCE COMPANY et al See attached list INSURANCS CARRIER 550 California Street San Francisco California ADDRESS The parties hereto for the purpose of compromise only hereby submit the following agreed statements of fact 1 Robert 0. Goans , employee herein born September 2 1900 claims that he was employed on the as a OCCUPATION workmen's compensation liabilitbyy 3rd _day ofApril MONTH 63 . < YEAR Oakland California EITT STATE _by_ See Industrial Commission relative to insurance carriers and STATE NAME OF OR SELF records insured then then employers insured as and the be sustained an injury arising out of and in the course of his employment as pneumonochoniosis RECEIVED JUL 30 1964 Panci IndustrialIndustrial Autiourt Commi siCnommi sin 2. The actual weekly wages of the employee at the time of injury were indispute while the average weekly wages wer $ . The employee's present disability See medical report not ISTATE PRESENT DISABILITY REBULTING FRON THE INJURY and the employee has returned to work IF SE STATE WHEN 4. ) Temporary disability indemnity has been paid to the employee in the sum of none at ing .10 The amount due and unpaid to the employee is $ per week cover b Permanent disability indemnity has been paid to the employee in the sum of _none__none_ covering period to 5. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of 6,750.00 sup in addition to any sums heretofore paid by the employer or the insurer to the employee said Lump sum to applicant less be payable as follows attorneys fees less 309 , to the Department of Employment Employment less 300.00 300.00 to Smith $ Parrish , , Paduck & Clancy for living _ expenses 500.00 500.00 Clancy living 6. Medical and hospital expenses have been paid $ 2078by the employee and none by the employer or carrier Unpaid bills amount to none Future medical and hospital expense is estimated at uncertain Unpaid an future medical and hospital expense is to be assumed as follows all unpaid and future medical bills ane to be the oblication oblication of the applicant FOR 431 PAGE t NOV 13-431 Cd 7 vA C :( Name Smith Parrish Paduck & _ 7. Name and address of employee's attorney if 315 Financial Center BuildCilngancy Oakland 8. Said attorney requests a fee of 750.00 previously Amount of attorney fce paid if any . 9. Reason for Compromise as dispute to nature duration and extent of disability disability . injuring arising out of an the in the coursecourse of the the employment Statute s Limitations lack of notice and prejudice and applicant wishes to bui his peace 10. The undersigned request that this Compromise Agreement and Release be approved employee 11. Upon approval of this Compromise Compromise Agreement Agreement by the Industrial Accident Referee and payment in accordance with the provisions hereof said Commission a panel thereof a Commissione insurance carrier from all claims and causes of action whether employee releases and forever discharges said employ as a result of said injury including any and all liability of now known or ascertained or which may hereafter arise ort said dependents heirs executors representatives administrators employer and said insurance carrier and each of them or assigns of said 7 commissio 12. It is agreed by all parties hereco that the filing of this document is the the commission may in its discretion set the matter for hearing filing of an application on behalf of the employee az issue any of the facts admitted herein and that if hearing is healsd awirtehgutlhairsapplication reserving to the parties the right to have available to them all defenses that were available as of the date of document used as an application the defendant thereafter either approve said Compromise Agreement and Release filing of this document and that the hearing has been held and the matter regularly submitted for or decision disapprove the same and issue Findings and Aware 13. For the purpose of determining the lien claim filed herein for the paid under or pursuant to the Californis Unemployment Insurance unemployment compensation disability benefits which hav upon for settlement and release of this case Code the parties propose the following division of the sum $ _for temporary disability covering the period to $ for accrued medical expense paid or incurred by the employee 175.250.0 future medical care 1.000.00 for $ for 14 permanentpermanent disability See below consistent The above segregation must be fair and reasonable and must be based on the real facts of the to deprive the lien claimant of a reasonable recovery case There should be no with all the amounts involved attempt l Werness the Signature hereof this 23 day of : . WITNESSEE T i . DISINTERESTED PERSONS APLICANT'S ACKNOWLEGGES ACKNOWLEGGES BEFORE NOTARY NOTARY PUBLIC See Yu attached list for signatures | STATE OF CALIFORNIA _County of 14 Applicant hereby releases any claims known or un- known against the above On this woe employer and insurance County and companies for a pneumono- chonicsis disability employers and insurance companies SS attornies y Rb 2k July July July AD 1964 befo Notary Public in and for th State residing therein duly commissioned and sworn personally appea Robert Goans and Joseph E. Smith known to me to be the person tubose name S. Instrument and acknowledged to me that be subscribed to the u executed the seme In Witness Whereof I have hereunto set mymy hand and affixed official seal the da year in this Certificate first shove written Notary Public in and for waid Conery and Stolt of Califo Foow 431. PAGE 2 REV 12.03 11218 13.4 or I I csec csec . nn car) . ~ ' : rs + + toe - wa ly The attorneys and insurance hereto and agree to pay the share of the Compromise and companies hereunder sign their name following sums as their proportionate Release settlement . SEDGWICK DETERT MORAN & ARNOLD on behalf of Mundet Cork Company Fiberglass Engineering and Supply Company Illinois Fiberglass - , Fiberglass Company ee ecereeeeaseeees 5 T 800.00 By__ 3 J. Patrick Goodwin on behalf of ~~ x National InsurancCompeany 25.00 A|Preel, \ Employers Liability Assurance . Company Ltd. insurance carrier VAA, for National Insulation Inc 75.00 & RS Meclisin Meclisin Meclisin Hanna and Brophy on behalf of 4s . United States Fidelity and - Guaranty eee eee eee eees $ 75.00 By Bradlock Bradlock Bradlock Royal Indemnity 50.00 By California Casualty Indemnity Exchange ... T 125.00 By Argonaut Insurance Company By Travelers Insurance Company 350.00 By Industrial Indemnity Company By State Compensation Insurance Fund ... $ acer 2,850. 2,850.00 0 2,850 0.00 Employers Fornsurance Mullen &Fillipi Fillipi Fornsurance Pacific Company ... eee cece sence nee By 1,700.00 W. Ww, Lowndes R. FP Zt Ce and ' WORKERS COMPENSATION APPEALS BOARD - CALIFORNIA INDUSTRIAL ACCIDENT COMMISSION prior to 1966 APPLICANT ROBERT 0. GOANS Asbestos Insulation Mover CASE # OAK 11052 DATE CLAIM FILED INJURY ALLEGED May 16 1963 Amended Aug. 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 DOCUMENTS COPIED Compromise 1 Compromise & Release # # OF PAGE PAGE Compensation CLAIMANT Robert Jeans California Workers | 16 Appeals Board CARRIERS INVOLVED oThe AETNA Casualty & Surety Co. American Automobile Ins Co. oAmerican Employers Ins Co. oAmerican Motorists Ins Co. Argonaut Ins Co. OAssociated Indemnity Corp. California Casualty Indemnity Exchange oCalifornia Compensation & Fire Co. oCasualty Ins Co. of California Employers Liability Assurance Corp. Employers Mutual Liability Ins Co. of Wisconsin - oFidelity & Casualty Co. of New York _ oFireman's Fund Ins Co. oGeneral Accident Fire & oGlobe Indemnity Co. . Assurance Life Assurance Corp. Corp. Ltd. oGuarantee Insurance Co. oGreat American Ins Co. Co. oHardware Mutual Casualty Co. Industrial Indemnity Sentry oIndustrial Indemnity Exchange oInsurance Co. of North America oLiberty Mutual Ins Co. OLumberman's Mutual Casualty Co. oMaryland Casualty Co. Michigan Mutual Liability Co. oMission Insurance Co. Ins Co. Co. oNational Automobile & Casualty Ins ONew Amsterdam Casualty Co. Co. oOcean Accident & Guarantee Corp. Ltd. Pacific Employers Ins Co. oPacific Indemnity Co. oReliance Ins Co. Royal Indemnity Standard Accident Ins Co. Co. U.S. oSecurity Ins Co. of Hartford State Compensation Insurance Fund oTransport Indemnity Co. The Travelers Ins Co. oThe United Pacific Ins Co. U.S Fidelity & Guaranty Co. Zenith National Ins Co. oZurich Ins Co. Casualty Ins Co. ) o0 0 5/81 mmf