Document emzM0jBLgz42gZNxX0MNYn9OM
FILE NAME Manville JMA
DATE 1966 DOC JMA144
DOCUMENT DESCRIPTION Contract Unit Claim File Lawrence J.
Taylor Sr.
. el_a- EMPLOYER'S EMPLOYER'S
WORKMEN'S COMPENSATION URFARI MEIN LANSING MICHIGAN
BASIC REPORT OF COMPENSABLE INJURY
COPY SHALL BE GIVEN IMMEDIATELY TO INJURED EMPLOYEE AND INSURANCE CARRIER
immediately to the Department on Form 100 all injuries mcluding diseases which
Employers must report
and cause 1. An aggregate of seven ^ or more
atise out of and in the ourse of the employment disability not including Sundays or the day of injury
2. Death
3. Specific Losses
days ofla cone of DEATH also file immediately an additional report on Form 106
See Additional Instructions un Reverse Side The Travelers Insurance Company
EMPLOYER anville Sales Corporation =. ome if |
, eee
Ma 6.8 C. Wember
LEAVE BLANT
832 FisheBr lig
Detroit
2
Michigan
States
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BUSINES Number Industrial Industrial Insulation Industrial TYPE OF BUSINESS CCN. Industrial Insulation
COMPANY Griswold MISURANCE CARRIER TRAVELERS TRAVELERS INSURANCE
Insulation
719
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eenmevsey
csnsneneseseses
Street Detroit26 Mich
374-01-6553 EMPLOYEE INJURED
Lawrence J. Taylor Sr.
(Om eome)
Taylor Taylor
Soc Sec No.
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Detroit Schigan Maritei Address 16854 Beaverland NOT COLUMN er. 60
( and sumber
Ckg
If under 18 Occupational Approval
(eter No. Wkng
Permit
DO
M THIS Ses.
CASE NO
empol f io njuy redeeme plo' yees 's children under age 16 inj wiu th r injeurd ed
ME injured is married man is wife living with him Yea
injured other family members 6-10-66 relatives at 50 supported injured
. Describe injury or disease Collapsed Lung
cae
ese
ee
cc
cetaes
EMPLOYER
UBURANCE
DATE OF Elimit
$f specific loss give date of loss
moving material Bow did injury or disease happen
6-13-66 After moving
a load of
thismanhad
WP _.
WP
NATURE
WhereCity Romulus
ee
Foreman Laurence Taylor
Phyecien..
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(Styent mad oumnber)
State
Witnesses
Hospital
Michigan
ees
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tne cecentucenttinsgsivese gums
New Grace Hospital
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(Cave
{(Otaers
Straight Time Earnings
Hourly rate
Overtime Earnings
Hourly rate
If board room furnished give value
Hours per week Hours per week .
Total $0 1. Total $
Total $
Combined weekly earnings $
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Boon piece work or commission explain fully
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Estimated length of disability
AwardAward MAS A COPY OF THIS
BEEN
TO EMPLOYEE 38 Yes
EMPLOYER Signature in ink
or Representative
Not
No
Insurance
.
Carrier
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OCCUPATI
DEPENDENTS
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WEEKLY WAGS
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AGENCY
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INJURY TYP
COORD ST
@O613 REY 7-48 printed la U.5 4 Sa ee
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SUPERVISOR'S INVESTIGATION REPORT
The unsafe acts of persons and the unsate conditions that cause accidents can be corrected only
when they are known specifically It is your responsibility to And them and same them and to state the
remedy for them in this report
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Camper:
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___ Johns- anville cales emoratiun emoratiun
ACCTOFTACI CTTN IN anville anville w aumber of bviding, Wore. dat.
MetroAirport
One OP Laurence Laurence
Laurence J. Taylor sr
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PAN
ANE >
ACCOM
Honigan
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' JOB OR PORTION
ence We AcceeR Cinete what the trigred ows duing ant the dremeunen tending to Ge euttdent}
After moving a load of insulating material this man was struggling to gt his breath
about that time I happened on th job and saw in in I asked what was wrong and he told we he was having trouble getting is breath this was on Friday he worked the following
Monday still having a little trouble nut on Tuesday morning he came in and had to go back nom He went to the docter and the loctor put him in the hospital
GREEN Surin @ aly Geer, pew Sgit, int of guts @ tats ond gum, Wakes ngs, he}
Sone
TS
UNSAFE SRASE ALT. UNSAFE WORK
FOOCEDUNE (eurbad o renered quard edad moving austin, w ' @etilic Ram of seste pressdere lack of plated evloty, oc.)
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NEW NEW 2900 7 Y
Use reverse sketch miditional
6-20-66
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7 1 106856/866
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REOPENED REOPENED FINAL APPROVAL APPROVAL
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OFFICE
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UND SERVICE
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