Document gLvD6zrRkg3E46oz3ryj4OYG

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1967 DOC#: WCC061 DOCUMENT DESCRIPTION: Workers Comp File - Gilbert, Oscar L File Name C o n tra c t U n it C la im File: O s c a r L. G ilb e rt A p r. 1 9 /6 7 Scanned ? yes Source JMA: N S-JM Start Year 1967 Stop Year 1967 Contents claim Notes WORKERS COMPENSATION APPEALS BOARD - CALIFORNIA (INDI'SI .IAL ACCIDENT COMMISSION, prior to 1966) APPLICANT OSCAR L. GILBERT _______________ ___ CASE *ANA 19219 Asbestos Worker/Insulator________ DATE CLAIM FILED INJURY ALLEGED April 19, 1967______________________________________ Inhalation of asbestos/injury to lungs ALLEGED DATE OF INJURY 1942-Nov. 28, 1966_______________ __ EMPLOYER/INSURER Fiberglass Engineering & Supply/AETNA Casualty et. a ________________ i n c l u d i n g - 3 - t f n C a r p ________________ _________________________________ _ OTHER NOTES " generalized infiltration of what is apparently fiberglass." Med Rpt to applicant's attorney: "... believe his major problems are secondary to his exposures [to asbestos, fiber glass, and the dust surrounding them]." DATE OF RESOLUTION RESOLUTION Jan. 19, 1968 Compromise & Release $15j000 settlement DOCUMENTS COPIED 1) Compromise & Release # OF PAGE 4 CLAIMANT ___________ O s c a w G r 'i l b j ^ r i - ___________________ ' _______________ California Workers' Compensation Appeals Board CARRIERS INVOLVED: The AETNA Casualty & Surety Co. oAmerican Automobile Ins. Co. oAmerican Employers Ins. Co. American Motorists Ins. Co. oArgonaut Ins. Co. oAssociated Indemnity Corp. California Casualty Indemnity Exchange oCalifornia Compensation & Fire Co. oCasualty Ins. Co. of California oEmployers Liability Assurance Corp.Ltd. oEmployers Mutual Liability Ins. Co. of Wisconsin oFidelity & Casualty Co. of New York Fireman's Fund Ins. Co. oGeneral Accident, Fire & Life Assurance Corp. Ltd. oGlobe Indemnity Co. oGuarantee Insurance Co. oGreat American Ins. Co. oHardware Mutual Casualty Co. (Sentry Ins. Co.) olndustrial Indemnity Co. olndustrial Indemnity Exchange Insurance Co. of North America oLiberty Mutual Ins. Co. oLumberman*s Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co. oMission Insurance 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. oState Compensation Insurance Fund oTransport Indemnity Co. The Travelers Ins. Co. oThe United Pacific Ins. Co. oU.S. Fidelity & Guaranty Co. oZenith National Ins. Co. oZurich Ins. Co. Co.) o ______________________________________________________________________________________________________ o _______________________________________________________________________________________________________ o ______________________________________________________________________________________________________ o ______________________________________________________________________________________________________ o 5 /8 1 rm f 1 WORKERS' COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 OSCAR L . GILBERT, Case No. 6 7 ANA 1 9 2 1 9 5 Applicant 6 vs. 7 PABCO CORPORATION, EMPLOYEES MUTUAL INSURANCE COMPANY OP 8 WISCONSIN 9 D efendant 10 CERTIFICATION 11 I hereby c e r t if y th a t th e a tta ch ed docum ents ere tru e 12 and c o r r e c t c o p i e s o f t h e o r i g i n a l d o c u m e n ts f i l e d i n t h e r e c o r d s ^ 13 o f t h i s o f f i c e i n t h e a b o v e - e n t i t l e d m a t t e r . 14 ATTEST my h a n d a n d t h e S e a l o f t h e W o r k e r s 1 C o m p e n sa tio n ' IS A ppeals Board o f th e S ta te o f C a lifo r n ia . 16 17 18 19 20 21 22 23 24 B a te d a t San F r a n c is c o , 25 C a l i f o r n i a , t h i s y \ d a y 26 o f M a r c h , 1 9 8 1 27 OIA WCAB FORM 1 1 (MCW 1 .7 6 ) M FAR TM SM T o f IMOURTWAL M LA TiO M a ftlV IH O N O F IN M IT I U L ACdORMTR - INSTRUCTIONS V' ' 1. Oo net m tits form In. dentil cues. Use Form 16. Oo not use in third-party eases. Use 17. 2. If the injure.d imployee he under 21 yean of age and a guardian ad litem has not been previously appointed, a petition tor appointment ot guardian ad litem and trustee must accompany this agreement X The guardian must sign this agreement on behalf of an injured employee who is under 21 years of age. If the minor is above the ate of such miner should also sign this agreement v. Attach all medical reports not heretofore submitted to the Workmen's Compensation Appeals Board and advise when other reports were fr W ORKM EN'S COM PENSATION APPEALS BOARD DIVISION OF INDUSTRIAL ACCIDENTS DEFARTMENT O F INDUSTRIAL RELATIONS COMPROMISE A N D RELEASE STATE OF CALIFORNIA CASE TCri 67 AHA 1921 SOCIAL SECURITY N O . 4 3 2 - 1 0 t44,23 (Mt.1 (Mrs.) OSQAR X,. - 6532 B e ste l A ve.. W estminster, Cali -EIBERGLASS -ENGINEERIHG CO.. ET AL -SEE..ATTACHED. SHEET. Mtrr Acts iteMwateCAWn The partsea hereto, for the purpose of compromise only, hereby submit the fallowing agreed ttatcmeats of fact: *. ---------- S S C ftR , . I r a . J ? n f l 5 S T _______________________ , employee herein, bora n from 1942 to 1967 May 23, 1911,________ claim! that he was employed on t h e / __ _____ --day af . . to e v a r io u s c i t i e s i n C a lif. OWNTNP rVKA> MMTVp (C tA V C v a a-- a a t o g g t o s w p y .H ; hf the em ployers named h e r e in (hunt 99 UMtmvamt -- then insured as : workmen's compensseion liability Ky Scfi a t t a c h e d sh o o t * C A M i m Oft W MeTNftO S k ft.lH f tU f tM , -and du he sustained an injury anting out of and in the course of his employment as follows:______ TO th e lu n g s Arid more p a rticu la rly as s e t forth in a l l o f the m edical reports file d herein. 2. The actual weekly wages of the employee at the time of injury were % m a x im u m , , while the average weekly wages wer er J____ tO X m U EI______ JJ i. Tbc employee's present disability is. in dispute irrA T V M IM W M T 1A tl.lV V ULTI** PWOM T H tN M V } *7 ^ _--. and the employee--llilS --JSIlAturaed to work- U P f to . ftTATC W H tM l 4. (a) Temporary disability indemnity has been paid to the employee in the sum of I -- HQUr? t\ - a t i1S _ 4 beginning____________ to and including------------------ The amount due and unpaid to the ettploye i $_ <5** (b) Permanent disability indemnity has been paid to the employee in the sum of J -- 50*1-..covering period. J. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of j- H iP P .P z f ifi- in addition to any sums heretofore paid bv the employer or the insurer to the employee, said sum to be payable as follows: x z a a x a K x g x x x a t^ , ,, .......... ..... S e e A d d e n d um t o P a r a g r a p h 5 . i. Medical and hospital expenses have been paid C _J-_..L L ?^SL -by the employee and t -----OSES--------- by the employer or carrier. Unpaid bills amount to s_J?.9P..-..Q3_______ Future mtdical and hospital expense Is estimated at C-5jJB.0 f ij . QS ------- Unpaid and future mediial and hospital expense Is to be assumed as follows:__ A.X.X--.Py--&p.P.Xi.CRX1t-- ..... . -------------------- OiA WCAB rents is <f*qc l.**l (FO*tLY FOAm K51) c C - R o se, K lein and M arias 7. Name and 'address of employee's attorney, if anv - Q .Q -lL U & S a d w a y ^ an t a Ana. C alifornia Said attorney requests a fee of .. . , .. Amount of attorney fee previously paid, if any, -fl- 9. Reuoa for CamProm;._.A-dispttte e x i s t s in t h i s., c a s e , r e g a r d in g th e Q u estio n o f wh, or n o t th e a p p lic a n t has s u s ta in e d any in d u s t r ia l in ju r y or in j u r ie s and i.f s a , -W hethgr-_the.V--W.ere .p rod uc t i v e to anv e x t e n t o f a p p l i c a n t ' s p r e s e n t a l l e g e d d i s a b i l i t y . . The d e fe n d a n ts a s s e r t th e a f f ir m a t iv e d e fe n s e o f th< Statute o f lim it a t io n s and co n seq u en tly th e hazards o f l i t i g a t i o n are fo r m id a b le on b o th s i d e s . T h e r e fo r e , i t i s a g reed t h a t t h i s Compromise . a d e q u a t e ..____________________________________ _________________ _______________________________ 10. T lx undersigned request th at this Compromise Agreement and Release be approved. 11. Upon approval o f this Compromise Agreement by the Workmen's Compensation Appeals Board or a Referee, and payment; i accordance w ith the provino hereof, said employee releaxs and forever discharges said employer and insurance carrier fro n ra claims and causa of action, whether now known or ascertained, or which may hereafter arise or develop ax a result of said injur) including any and all liability of said employer end said insurance carrier and each of them to the dependents, heirs, executor representatives, sdministraton or assigns of said employee. 12. It is agreed by all p a m a hereto that the fling of this document is the filing of an application on behalf of die employee, and the the W .CA.B. may in its discretion set the m atter for h a rin g as a regular application, reserving to the parta the right to put issue any of the facts admitted herein, and that if hearing is held with this document used as an application the defendants shal have available to them all defensa that were available as of the date of filing of this document, and that the W .CA.B. mas thereafter either approve a id Compromise Agreement and Release or disapprove the same end issue Findings and Award afro hearing has been held end the m atter regularly submitted for decision. 13. For the purpose of determining the lien claim filed herein for the unemployment compensation diability benefits which have beer paid under or pursuant to the California Unemployment Inrurance Code, the p artia propose the following division o f the turn agreed upon for settlement and release of this cast: $________________ for temporary disability covering the period____________________________ $________________ for accrued medical expense paid or incurred by the employee. $________________ for future medical care. f tr permanent disability. (The above segregation must be fair and reasonable and must be based on the real facts o f the case. There should be no attempt made to deprive the lien claimant of a reasonable recovery consistent with all the amounts involved.) Witness the signature hereof tint________ day of. \ wimiMU T M I IH J U R tk ARMbtCADT'f IO N A V V M MU9T ATT I f VCD S T TWO O lflM T f A C f T r* T M I M O R M K H 0 W L I M M ITO M I A MOTAMT M O b lf t. P lan t Rubber & A sb estos Works STATE OF CALIFORNIA %L rs. R A M J L ____--County of.JLi jjjl ^ Its'A tto r n e y s On this } `f __ day *f J A / W f A l t \ / A.n l i J i S - before m e ,__ *ft / ? 4 I P ft,SL/$A k /r t _________ t Votary Public in and for the saidC ounty and State, residing therein, duly commissioned and sworn, personally appeared ....... 7-"------- knoun to me to be the person-- whose name-- - -$ -- ---- ----- ... ......... -- ............. ................ ---- bscnbeS to the within Instrument, and acknowledged to me that -- he----executed the Jflffif- W uEnssi, I have hereunto set my fund and affixed f?i^ official Sttfi ttyt day and year tn thu Certificate first eboxf w ritten. JOHNS-MANVILLE CORPORATION T r a v e le r s /I n s u r a n c e Company + /1 in iL L David Taylor*' T jK /.sr J . T . THORPE & COMPANY A m erica n M o to r is e s I n s u r a n c e Company < g ^ i m ir/ PLANT ASBESTOS COMPANY BALDWIN-EHRET-RILL. IN C. INSULATION, INC. P a c i f i c E m p lo y ers Company In s u r a n c e Company o f N o r th A m erica By: PLANT RUBBER AND ASBESTOS WORKS, p erm issib ly se lf-in s u r e d By: A SYDNEY LOUIS CARPENTER THORPE INSULATION COMPANY PLANT INSULATION COMPANY F irem a n 's Fund-A m erican In su r a n c e Company By:. !/ FIBERGLASS ENGINEERING COMPANY A etn a C a su a lty and S u r e ty Company W eingand/rvK en d ig & S t o c k w e ll / 3 RE: OSCAR L. GILBERT ADDENDUM TO COMPROMISE AND RELEASE LINE 5 The Compromise and R elea se i s to b e p aid as fo llo w s : Aetna c a s u a lty and Surety Company, 2404 W ils h ir e B oulevard, Los Angeles (F ib erglass. Engineering Co.) $ 6 ,7 7 1 .4 9 . F irem en 's Fund-American Insurance Compa'ny, S ix th S tr e e t, Los A n geles, C a lifo r n ia (Sydney Louis Carpenter, Thorpe In su la tio n Company, P la n t I n s u la tio n Con^any) $ 5 ,5 0 2 .9 9 , Works P la n t Rubber and A sb esto s penpany-, 537 Brannon S t r e e t , San Francisco, C aliforn ia, (perm issibly self-in su red ) $1,8 1 1 .8 8 ). P a c i f i c Employers company (In sra n ee Company o f North American) (P lan t A sbestos com pany)B aldw in-E hret-H ill, I n c ., In su la tio n , In c.) $161.06 American M o to rists Insurance company (J . T. Thorpe & Co.) $ 8 7 .6 0 . T ra v ele rs Insurance Conpany (Joh n s-M an ville C orporation) $ 6 6 4 .9 8 . TOTAL: $15,000.00 I t i s in ten d ed by t h i s Compromise to r e le a s e and fo r ev er s e t t l e any and a l l l i a b i l i t y o f each and a l l o f th e named in su ran ce c a r r ie r s h e r e in for any p e r io d s o f in su red employment w hether now known or unknown. A l l p a y a b le i n a lum p sum l e s s t h e f o l lo w in g sum s t o b e p a id by A etn a C a s u a lt y & S u r e ty Com pany: $ 2 6 9 .0 0 t o M o rto n R r i t z e r , M.D. ; $ 2 2 6 .0 0 to Dr. Sm art; $ 2 0 .0 0 to D r. W e in ste in ; $ 1 0 0 .0 0 to D r. S ch u b in ; $ 5 0 4 .8 9 to O c c id e n ta l L if e In su ra n ce Company; and $ 5 0 0 .0 0 t o th e D epartm ent o f E m ploym ent, a l l i n f u l l s a t i s f a c t i o n o f th e ir r e s p e c tiv e L ie n s; and le s s a tto r n e y s' f e e s .