Document emzGmwpNqqn5Rr3gmmM7D90Q4

PAUL A. DAVIS, M.D. INDUSTRIAL SURGEON 5034 WEST ROOSEVELT ROAD CHICAGO SO. ILLINOIS PHONES: AUSTIN 7-0738 8 7*0739 nATF. August II, 19u9 name of fmpl qyff_ 3 oiiA .Blalio________________________ name of company___Yictor-Dana| ACCEPTED REMARKS REJECTEDO jvLil,e to return to work us per instructions of Dr. Vevertca until further notice. Paul A. Davis, M.D. DANA-287 VPD-189-0002408 D i CAS' JALt Y Group Hcrulh Insurance Benefits ~~T o A A> NAME First Name HOME ADDRESS No. ER l/tc7~o EMPLOY TO BE COMPLETED BY THE EMPLOYEE (Be sure to complete each item to avoid a delay in the payment of your claim.) Middle Initial l3 I ~7 3 &ft k o__________ _____________DATE OF BIRTH ~ ~>9 SEX Last Name * M fQ Street CrA<k'?~T 0AAK Aur City l),ut S/a^1 ' Slate to*'/ 0 A- TELEPHONE */W~ & S~f ? Zip Code m >xi*ri A sYOUR OCCUPATION h s T* s gp?, ,rn. a EMPLOYER'S ADDRESS 5^-7-J-^L Street IS THIS CLAIM FOR A DEPENDENT? If Yes, Give Name _-- JJLg L/ft 0L City /AJU/ S YES . Relationship. NO gj' Date of Birth . State . Married YES Q NO Q HAVE YOU COMPLETED A STATEMENT OF CLAIM PREVIOUSLY FOR THIS ILLNESS? YES 0 If Yes, Do Not Complete Remainder of Form Except for Signature. . NO J5cf' DO YOU HAVE MORE THAN ONE EMPLOYER? If Yes. Give His Name * No. Street ?, DO YOU HAVE OTHER FAMILY MEMBERS EMPLOY En?_ If Yes, Give Name__/> . Name and Address of Employers''-*.*! C/t >.\>r , 'O. . i. NATURE OF ILLNESS D 1 F T1 C i, / Ty A r <zAT/ iAj^ .YES0 No . City mKYES-ii? . . . State _ DATE OF FIRST TREATMENT___ & -/ ' (* 9__ 9. (S THIS CLAIM BASED ON AN ACCIDENT? _ . If Yes, Give Date!JDand Time0 A.M. 0 P.M, Where Did Accident Occur? _____ _______ . How Did Accident Happen?____________________________________ _. YES 0 NO Jf _ .... __ 0. ARE ANY OF THE ILLNESSES OR INJURIES FOR WHICH CLAIM IS BEING MADE RELATED TO EMPLOYMENT? YES 0 Nog" 1. ARE YOU OR ANY OF YOUR FAMILY MEMBERS COVERED THROUGH ANY OTHER PLAN WHICH PROVIDES MEDICAL BENEFITS OR SERVICES? If Yes, Give Name and Address of Organization Providing Service YES 0 NO hereby authorise any insurance company, prep^ymenf organisation. employer, hospital, or physician, to release aft information with respect to myself or any of my lependents which may have a Onarinj ur the benefits payable under this or any other plan providing benefits or services. UGNATURE or OTHER FAMILY MLt.lfJEtt WHOSE INSURANCE COVERS THIS INDIVIDUAL . f hereby authorize any insurance company, prepayment organisation. employer, hotpilef, or physician, to release aff information with respect to myself or any of my dependents which may have a bc.ti**.*; -r- the bent-fits payable under this or any other plan providing benefits or services, t certify that the information by me in support of this claim is true and correct. ' JATE ___ ^ / A- j A ^ ^SIGNATURE Or EMPLOYEE C-21-t) 5-GB PRINTED IN U.SA. VPD-1 89-0002409 1