Document jmzRgdLxzOez4dp3zzRojyEX2

April II, 1973 Insurance Co. of North America 167 W. Jackson Blvd. Chicago, Illinois 60604 Attni Hr. R. I, Tearney Dear Hr. Tearneyt The attached related to the tarry Thomas case was received by us on April II. This case was handled by you as rile number 911C8X837I. Please let me know If I may provide anything further and what action. If any, should be taken by us regarding this claim. Yours very truly. RKFiak R. 1C. Falter Plant Hanager i ,, . iftcoyering, the iieclfleni,!; these papers'tdyour fnstlggCe company at once. : 'ff-l-%& ',^s ^d u s t r ia `l -c q mms i<3 :<V t60 N<mh 4 SalieSir*^ Chicago. Illinois 6060 IfoORANDUM OF NAMES AND ADDRESSES' FOR SERVICE OR NOTICES Petitioner, NO. Respondent. The undersigned requests that all notices of proceedings in the above entitled matter be served personally or by#** mail upon the party whose name and address follows this memorandum. > . .;$ Name Address ;* 'Sr#. (Petitioner)-, ; \ ' l(. j* -4m f* (Respondent)^. (Carrier -- Agent) ATTORNEY'S APPEARANCE- hereby enter my appearance on behalf of . (Petitioner) . wit^put waiving my right to contest the jurisdiction. ... (Respondent)^.- Name Attorney's Name Address Address...;'.-.-; . " f1"* ' f^5rS Attorney.for iPetltioner)|Ri Phone ATTORNE^AFPIPAVIT IN COMPLIANCE WITH RULE,NO.: 2r(3)^^p|^d I hereby certify that I have not directly1 dr indirectly solicited employment by the above namedparty?snd know? soHcftatrdh of said pafty'B^'SW peraonthattiaf resulted in the employment ot myself or.any rnerTttjCEOfcnyfin *> ' Atr,llavit Subscribed and sworn to before my thte^ 1f_ _ ' rlav farm I.CJ& (42t-75M--7J) 1* ..> ' * -+A-/' t lNir.oataair.y. Publld- ~ CYWI 5-001849 N14498.01 TO EMPLOYES* XT YOU CABBY INSURANCE COVERING THIS ACCIDENT FORWARD ALL THiMr. PAPERS TO YOUB INSURANCE COMPANY AT ONCE. NOTICE OF FILING CLAIM LARRY THOMAS (vs.) MCGREGOR LEAO CO/, Petitioner, Respondent. BEFORE THE INDUSTRIAL COMMISSION OF ILLINOIS 160 N. La Salle St. Chicago, m 60601 No 73WC 1088 t a RES. MCGREGOR LEAO CO. 4500 V. ISTH ST. CHICAGO. IL. 60023 YOU ARE HEREBY NOTIFIED Gut &ppltc&ikn far adjustment at cUJm,.txL{he above entitled mattee. waa filed with wid Commission on the..................V?7P......... day o( ............ 'WJwT............... 197. J.that; paragraph (a) ol Section 19 oi the'Worlanen'a Compensation Act or Workmen's Occupational Dleeaaee Act (as amended) provide* that "II the compensation claimed Is for a partial permanent or total permeant laeapa* city or (or death." you may elect to have said matter determined by a Committee oi Arbitration by filing with said Commission your "election la writing wtthb five deyii'* oi the receipt oi this notice and by depositing with said Commission with said election the sum oi twenty dollars to be paid by said Commiesloa to the arM* traton selected by the portlet hereto ae compensation for their services as such arbitrators. And that, In case you do not make such election or fall to deposit the sum oi twenty dollars with such election; or, in case the compensation claimed la not (or "partial permanent or total penaaaeat Incapacity or tor death," an arbi trator designated by said Commission shall determine said matter. Form .33 (Memorandum oi Names and Addresses (or Service oi Notice*) .is also enclosed herewith, and should be filled out and filed with said Commission In said matter at once. Dated this............................. 9TH..........., day oi ...:................... AWIk..............................................197.2. INDUSTRIAL. COMMISSION OF ILLINOIS, By ST Secretory. NOTICE OF HEARING YOU ARE HEREBY NOTIFIED that a hearing In the above entitled matter will be held on the ....1...*.!7H..........day ol.........................W.................... 197..3., at v.?.*3.............. o'clock.............. .A,It, at .!......................... I H.. MMUft.fk............................. In the City oi......................... $WC#................. Dlinols, before the Arbitrator designated by the Industrial Commission of Illinois. Dated this......................... $TH.............. day oi....................... AW! k................................................... 197.3... LS m Ct*l S'00150 N14498.02 iiSC ' tavf 3 MW" ' STATI OF ILLINOIS RICHARD B. OOILVtE, Governor INDUSTRIAL COMMISSION ICO N. LA SALLE ST.. CHICAGO. ILLINOIS COCCI APPLICATION FOR ADJUSTMENT OF CLAIM NOTICI OF DISFGTCO CLAIM AND MIMOAANDUM OF NAMIS AND ADDRISHS LARRT THOMAS, (This form lo Ijo AM la triplicate) CONFIDENTIAL INFORMATION REDACTED M#:oaSGOR LEAS CO. RESPONDENT. 73C 1085 The petition of the undersigned respectful!]' shows to Dili Honorable Commiulon the following, to-wit: .... 197.. LARR'i TK0MA3 -wu injured by reason of on Occident arising out of ond In {Nome of person injured) _ __ _ the course of h-il-employment by the abore named ffLASEgOH LEAD CO... that your petitioner ia the person injured. (Nome of Employer) 2. That a dispute has arisen with respect to the compensation to be paid'for the disability resulting if . from such injury, acid the general nature ol the dispute Is: ^. The employer denies liability for the compensation provided for In the Workmen's Compel)-' 1 <b) A dispute existsafeefniog the amount and duration of the compensation payable. ' 3. The following psxticu^Krolative to thli application are herewith given: (a) Name of injurode^e^ THOMAS.^ : 763- South-Kowetn, Chicago, (b) Name of employer- MK.OREOOR LEAD CO. Place of business and addresa *.** <c) Piece of accident_____L_ * 15th, CMWg* <d> Nature of work upon which injured was engaged at time of accident and how caimeH-C. Injured during tile couree' end scope of.hi* employ. . ; <e) State whether medical, surgical and hospital treatment were furnished by employer and, aleo to what extent: amount expended for above purposes ind periodtreated--_____________________________ ______ To be shotm ____ _____ (f) Earnings of employee during year preceding injury, if employed by the same employer; if not so employed, give earnings of such employees ill the same elaaa or grtde-1 (Over) CYWI 5-001* N14498.03 -- mo k s mim amount () l---------------- .per week lor. undr paragraph () of section 8.' <i) *.. ..pr week for complete end permanent disability, including pension provided for under jmragraph If) of section 8. 5. (a) Date of service on employer of notice of accident ........J5S?.diM_______________________ (t>) If notice not served within forty-five days, did any agent of employer have knowledge of the facts and eimnastsnces of accident?. 8. Petitioner wee..21-------- -years of age and was at the time of the injury. Names, ayes snd addresses of all children under eighteen years of age st tbs time of injury. st -- LARRY THOMAS, JR. SAME ' * ,;v/' A*p.. . *.?'** - **' *> v.. ." j-r ' 'SV 2V >--t- ffl ------ (: 7. Your petitioner prays thst the Industrial Commission appoint as arbitrator to make such inquiries '. ' d investigations as he shsll deem necessary, snd thst a day be appointed by said Industrial Cotonds...' sion sod the time and place thereof thud, where said arbitrator may hear such . parties hereto may submit, and that an award and 'decision may bemade, iirconfo: in such case made and provided. The undersigned requests that all notices of proceedings in the above entitled matter be served per-- f t- }{< sonally, or by registered mail upon-the party whoso name, aadaddrese follows as attorney for the netWlpv -fr-ZLi tloner; if no attorney's name appears, then to the name and address of th* undersigned. . , TT- ;i 3 ys e. A A 'Dated this ...............-............ ........ - day of ...................... ...........____________________19T.._?S" . ! RICHARD 3. Attoroeyfor Address Li!25* ' City..... Telephone____ Clt* Street (Signed/ CbdsJSfiOl Address & } :J$[ ssvtUAMt a m ansenf os eourueeei arm RICHARD S. CORE; ____________________________ " . - LARR* THOMAS 't'vi. V mm** MlH V U ^W|W MTt* M4 JIM <1 * * MM *W : z ;m :rrvrrrri: rirnr' t tJWMar- ------*- -t : -s-:-- lfO * Ptmtm W 4i N 0*4 * ******* >ww * mww W ***** * n!** * Mn* * f** * * fc* w,`"" KO EXCEPTIONS CYWI 5-0016SZ