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EMPLOYEE'S CLAIM PETITION FOR COMPENSATE UNDER THE
PENNSYLVANIA WORKMEN'S COMPENSATION ACT OF 191$, AS REENACTED AND AMENDED
' (TYPE OR PRINT CLEARLY)
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. SOCtAU SCCCRITV.NO.
.182-05-0186
OATS OY 6IRTH
10/1/07
TtLEPHONt *
356-1468
|5 PLAINTIFFS I
|| ,; EXHIBIT
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OSiL HONORABLE BrrEREE:
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sbocenaocd diiMH-yiiMlyiJUpa dit following (actX'-r^T--XV
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rarebrines* -- Manufacturing steam turbines " ''
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ly OCSCRIO* YOUR WORK INCLUDINQ Tin.t,!F AMV:rt.:>y
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igjjjfMy-injury occurred otr <-apIover*s premises S> . ; - .-.... ..If not, state exact location, including county or state:'
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injury or diseaseocwni^a At followingnMn * inhalation *ingestion of;.. insulating^
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OCCmK mn.LT THK SyeHTt WHtCH mSUCTCD <M,-YOUfr*N>tf*Y OR OOCAIK
^l^wu^tgroifevbbsi^cclve pul^c?iiary disease heagt:;
ofay lajty.er Asense is
a<|' anvpXvdngtvty aaligPflnt tiMiT. left ^S-
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OESCMiaC FULLY, MCUUDIN4 PARTS OR BOOT ARRCCTCO
r;ijf cld:ii foeOCCUPATrONAL OlSEASE andirr Section 108, camplta the foilowing odditionol information:
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-^a: I kecame'(tota21y> {partially) disaUed as a result of tie above occupational disease :
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j^b.jMjrla$i exposure arts; Jnne30. T973,'todielMzard of die above occupational disease was
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employed by
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7s>c; Prior to June 30, 1973, I was exposed to die hazard of the above occupational disease while employed by:
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f*r6duced 3/93
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/j. v/us treated by the fallowing doctors aad/or hospitals: ^
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__ 9. a. I ad..i/.f. rtsattt sit employeras furnish the above medics! sad bospies! services*
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5d:yyfl ?~faaiA awrjee services.
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if ae_ for aTor port oT these, services vu.
ews^fajs^riscase from fXfiCT VI& iMJJwtT*
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ijifinMeldi iw uooc sit my previous occipatioa sad at my.former wages, which were""*- *+i /n
ed upon ny; employer on
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STVrCTO WHOM AND MOW MOTICK WA iVKN
jn the following maonervv'^
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fasects to be important:
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I ask I i of the Peonsyl
-hminUe Referee Issue an award of cxMspeasauoa to ae. io accordaoce .with tbe prpyi>? iVCtNapcasation Act.
iASE ESTER MY APPEARANCE FOR PETITIONER
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!CE This s*iion should be filed a anginal and five exact copies either typed or printed, It is only necessary to .
meke'effieavfr to the errginol petition.
2B006484 ) ' :V
Produced 3/93