Document karGx7aNrqNd5QoBn4Lwde6eV

FILE NAME: Metalclad (METC) DATE: 1968 DOC#: METC005 DOCUMENT DESCRIPTION: WC Claim - Clark i i EMPLOY**ER ATTACHED SHEET PAGE ONE QUARTER PERIOD OF EMPLOYMENT ___ INSURANCE CARRIER DEPENDON ROOFING CO. 3521*N. Cicero Avenue Chicago, Illinois 3/31/40, 6/30/40 9/30/40, 12/31/40 THERM-O-PROOF INSULATION CO. 4730 Armitage Avenue Chicago, Illinois 12/31/40 DEL E. WEBB CONSTRUCTION CO. & WHITE & MILLER CONTRS., INC. Fdrt Huachuca, Arizona 3/31/41, 6/30/41 O'MALLEY PLASTICS, INC. P.O. Box 3558 Phoenix, Arizona A.N. BORGQUIST P.O. Box 6134 Phoenix,Arizona 3/31/41, 6/30/41 6/30/41, 9/30/41, 12/31/41 STANDARD ROOFING & SUPPLY CO. P.O. Box 2204 Phoenix, Arizona 6/30/41, 9/30/41 12/31/41 DEL E. WEBB P.O. Box 7588 Phoenix, Arizona 6/30/41 A .O . MILLER CO., INC. 220 Nordina Street Redlands, California 6/30/ 41 C.C. MOORE & CO. Engineers Unit X-l 45 Mission Street San Francisco, California 9/30/41 MC CONKEY, DOCKER & CO., INC. 130-32 W. Madison Street Phoenix, Arizona 9/30/ 41, 12/31/41 W.A. BECHTEL CO. 155 Sansome Street San Francisco, California 12/31/41, 3/31/41, 6/30/42 CONSOLIDATED ROOFING & SUPPLY CO. P.O. Box 614 Phoenix, Arizona MARINE ENGINEERING & SUPPLY 941 E. 2nd Street Los Angeles, California 12/31/41 12/31/41, 3/31/46, 6/30/46, 3/31/47 Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA Unknown STATE OF ARIZONA PACIFIC EMPLOYERS INS. CC INDUSTRIAL INDEMNITY CO. STATE OF ARIZONA PACIFIC EMPLOYERS INS. C< J. T. THORPE, INC. ^ 9-48 E.. 2nd Street Angeles, California MUNDET CORK CORPORATION 7101 Tonnelle Avenue North Bergen, New Jersey 12/31/41, 6/30/45, 9/30/45, 12/31/45 3/31/46, 12/31/46 3/31/49, 12/31/58 3/31/59 6/30/42, 9/30/44 12/31/44, 3/31/45 6/30/45, 6/30/46 9/30/46, 12/31/46 6/30/47, 9/30/47 6/30/48, 3/31/48 9/30/60, 12/31/47 12/31/60 PACIFIC EMPLOYERS INS. C< & AMERICAN MOTORISTS INS. COMPANY AETNA CASUALTY & SURETY INSURANCE COflPANY & PACIFIC EMPLOYERS INS. CC THE ASBESTOS & MAGNESIA MATERIALS 6/30/42, 9/30/42 119-127 N. Peoria Street Chicago, Illinois Unknown SLATTERY & COMPANY 1726 Market Street ' Denver, Colorado 12/31/42 Unknown FULLER-THOMAS CO. 118 S. 5th Avenue Tucson, Arizona - 3/31/42, 12/31/42 STATE OF ARIZONA . 3/31/47, 6/30/47 12/31/48, 12/31/49 YOUNGS SALES CORP. 1054 Central Industrial Avenue St. Louis, Missouri 9/30/45 Unknown UNITED CORK COMPANIES CORP. Ft. Central Avenue Kearny, New Jersey 3/31/46, 12/31/51 3/31/52 LIBERTY MUTUAL INS. CO. PLANT RUBBER & ASBESTOS WKS. 537 Brannon Street San Francisco, California 3/31/46, 12/31/46 SELF INSURED WARREN & BAILEY CO. , 3528 S. Garfield Avenue Los Angeles, California 12/31/46, 3/31/47 9/30/49 Unknown TECHNICAL SERVICE COMPANY 423 N. 1st Street Albuquerque, New Mexico 6/30/47 Unknown LEROW COMPANY - 5510 Sheridan Road Chicago, Illinois 6/30/48, 9/30/48 12/31/48 Unknown ASBESTOS ENGINEERING & SUPPLY CO. 12/31/48, 3/31/49 1880 W. Fillmore 6/30/49, 12/31/49 Phoenix, Arizona STATE OF ARIZONA REFINERY MAINTENANCE CO., INC. 2500 N. Alameda Street Compton, California 3/31/49 Unknown STEARNS ROGER CORP. 660 nnnnock Strnnf 6/30/49 STANDARD ACC. INS. CO. TORPE INSULATION CO. 2741 S. Yates Avenue Los Angeles, California THOMAS H. HOGAN CO. 1591 Indus Street Santa Ana, California HALL INSULATION CO. 2633 E. 3rd Street Tucson, Arizona KIRCHER, ASBESTOS & RUBBER CO. Inc. Box 6652 Phoenix, Arizona BARRETT & HOMES 6033 N. 10th Street Phoenix, Arizona 9/30/49, 12/31/49 6/30/59, 3/31/63 6/30/63, 9/30/63 12/31/63, 6/30/64 9/30/64 9/30/49 3/31/50 12/31/50, 3/31/51 6/30/51, 9/30/51 3/31/52, 6/30/52 9/30/52, 3/31/53 6/30/53, 9/30/53 3/31/54, 6/30/64 3/31/55, 6/30/55 9/30/55, 3/31/56 6/30/56, 9/30/56, 6/30/57, 9/30/57 3/31/60, 6/30/60 12/31/50 PACIFIC EMPLOYERS & FIREMAN'S FUND INS Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA ARMSTRONG CORK CO. Liberty and Charlotte Streets Lancaster, Pa. 9/30/51, 12/31/56 STANDARD ACC. INS. CO. RELIANCE INS. CO. THE TRAVELERS INS. CO. REECE INSULATION CO. 4563 Valley Boulevard Los Angeles, California ACCURATE INSULATION CO 900 S. Cypress La Habra, California JOHNS MANVILLE SALES CORP. 22 E. 40th Street New York, N.Y. COAST INSULATING PRODUCTS 2684 Lacey Street Los Angeles, California OWENS CORNING FIBERGLAS CORP P.O. Box 901 Toledo, Ohio 9/30/56, 12/31/56 Unknown (moved no address) 9/30/56, 12/31/60 3/31/63, 6/30/63 12/31/56, 9/30/57 12/31/57, 9/30/58 CASUALTY INSURANCE CO. OF CALIFORNIA, INC. & STATE COMPENSATION INS. FUND SELF -INSURED 12/31/56, 9/30/59, 12/31/60 ARGONAUT INSURANCE CO. STATE OF ARIZONA 3/31/57, 12/31/57 9/30/59, 3/31/60 9/30/60, 12/31/60 12/31/61, 3/31/62 6/30/62, 9/30/62 3/31/63, 9/30/63 3/31/64, 6/30/64 9/30/64, 12/31/64 THE AETNA CAS. & SURETY Ins Co. & THE TRAVELERS INS. CO. ATTACHED SHEET PAGE FOUR JAMAR OLMEN CONSTRUCTION c/o P.O. Box 14322 Houston, Texas 9/30/57, 9/30/58 ORIN A. WILLIAMS & JOHN S. GREEN 3775 N. 36th Avenue Box 11098 Glendale, Arizona 12/31/57 INSULATION & SPECIALTIES INC. Box 3428, Sta. A El Paso, Texas 12/31/57 METAL CLAD INSULATION CO. Box 178 Torrance, California 3/31/58, 6/30/58 BOB GRIFFIN ROOFING & * 3/31/58 INSULATION CO., INC. 151 E. 24th. Street Yuma, Arizona FIBREBOARD PAPER PRODUCTS CORP. 6/30/58, 9/30/58 1789 Montgomery Street 12/31/58 San Francisco, California WESTERN ASBESTOS CO. Box 3784 Rincon Annex San Francisco, California 3/31/59, 6/30/59 PLANT ASBESTOS CO. 1300 64th Street Emeryville, California 9/30/59, 9/30/60 3/31/61, 6/30/61 R.T. DINWIDDIE, INC. 8627 S. Atlantic South Gate, California 6/30/59, 9/30/59 INSULATION SERVICE INC. Box 4695 Tulsa, Oklahoma LOS ANGELES CORK CO. 4180 E. Washington Los Angeles, California J ARMSTRONG CONTRACTING & SUPPLY ^ CORP. 120 N. Lime Street Lancaster, Pa. 12/31/59, 6/30/59 12/31/60, 9/30/64 6/30/61, 6/30/65 9/30/65, 12/31/65 UNAFRAX CONSTRUCTION CO 1242 Abbot Dr. Pittsburgh, Pa. 9/30/61 Unknown STATE OF ARIZONA Unknown AETNA CASUALTY & SURETY INS. CO. STATE OF ARIZONA SELF INSURED STATE COMPENSATION INSURANCE FUND INDUSTRIAL INDEMNITY CO. Unknown Unknown ZURICH INSURANCE CO. FIREMAN'S FUND INS. CO. THE TRAVELERS INS. CO. LIBERTY MUTUAL INS. CO ATTACHED SHEET PAGE FIVE UNAFRAX CONSTRUCTION CO. 1242 Abbot Dr. Pittsburgh, Pa. 9/30/61 INDUSTRIAL SERVICE & ENGINEERING CO. OF CALIFORNIA Box 16138 Long Beach, California 3/31/63 LIBERTY MUTUAL INS. CO. LIBERTY MUTUAL INS. CO. KITZMANS PLUMBING & HEATING 6940 Alvarado Rd. Lamesa,California THE ISOTHERM CO. 605 Williams Bakersfield, California THERMAL ENGINEERING INC. . Hoffman & So. 10th Street Richmond, California BALDWIN, EHRET, HILL, INC. 500 Brevnig Avenue Trenton, New Jersey 6/30/63 INS. CO. OF NO. AMERICA 6/30/64, 12/31/64 SENTRY INS. CO., a . Corp. 12/31/65 Unknown 12/31/65, 1/1966 LIBERTY MUTUAL INS. CO. & INS. CO. OF NO. AMERICA 7 D epartm ent of Industrial .Relation* GOOD CAUSE APPEARING: The application herein is taken off calendar. Division of Industrial Accidents Workmen's Compensation Appeals Board State of California APPLICATION oiH ,il. ' 'o AMei?d A a p p l i c a t i o n RifIRII. WCAt *TC FOR ADJUDICATION OF CLAIM (Death Case) 66 LA 202-043 Piente file signed original and tix copiet . CASE N O ------------- ------------- and print or type names and addresses m/. Mrs. M L Maurino Clark (widow) (APPLICANTI ' Dean Clark (Deceased) 13331 Lakewood Boulevard, DtlO (APPLICANT S AODRttftl Downey, California___________ Dea n_CJLark [_(Dec~?l SS# 327-07-944 3 ~TBrgnttDTteirrT7)tirIBUtITlsicmiTTWIMIII vs. See attached sheet <CHPLOYIR) See attached sheet (IMPIOTI*ftINftURPACNRCMtIftCfAt!RIRlIY!*UNOIRNSfUtTRAETDl)IfILflNftURCOOR (IMPIOTAR ft AOORtftft) (ADORISIOfINSURANCCCARRIIR.IfANY) IT IS CLAIMED TH A T: 1. Deceased employee born -- 1 2 / 2 / 1 9 _ 0 7 --------- , while employed as a ------- A s b e s t o s W o r k e r ----- (i Da As TeC Om fi fi tiliRfTuHil (OCCUPATION AT T I N I < 1940-1966 at Various places , by the employer sustained injury arising out ( DATI Of INJURY) of and in the course of employment to ,lUDSL ISTATl WHAT PAATA OF OOT WIt INJUNIBI 2. The injury occurred a. follows: ' ' I n h a l a t i o n , _ o f _ a s b e s t o s _ a n _ d _ g t h e r , f o x e i g n _ s u b s . t a n c . e s ------ ( I S F I A I M WHAT I M M . O T A I WAA O O IH AT TIM A O f IH J U A T AKO HOW IH JU A T WAA M C t l V A D I resulting in death on -- U L -- 4--- L 2 H 6 -- . (DATI OF OIATHI 3. Actual earnings at time of injury were: (4IVC WIIRLY OR MONTHLY ftALARY OR HOURLY RATI AND NUNRIR Of HOUR* WORKED PI* Will) 4. The injury caused disability as follows IfFICITTLASTOATOFFWOOUITOTHISIHJUTAHOISIHMIHOAHO[NOIHOBATIAOFAUFIPODSOFFOUITOTHISINJUTI J. Compensation was paid (FIA--I --ITHIOQI. 6. Medical treatment was received --I-T-I-SI ------------------------ ` )----------------- ITOTALFAID) <W11ITAT11 IOATI OF LAST FATHIHTI ____ . All treatment was furnished by the employer or insurance INOI IDATIOFLASTHIATHCHTI company ITISI other treatment was provided or paid for by INOI Doctors not provided or'paid for by employer or insurance company, who treated or examined for this injury are: ------------ St. Francis Hospital. 3630 Imperial Highway.,_LynWQ-OdA_CsJLilQXnicL-- --IftTATIRAMIANOAOORCftftKtOfSUCHDOCTORANONANI____O__f__H_O__f_t__P.IT. A.LtTOWHICHAIIFUUCHHDAOFCTHTOR SlAAUDMI TITT TmIOI tIlNl lJlUl fRIDOl ) 7. Defendants have paid burial expense. --I-T-I-S-I- --I-N-O-I-- TOTAL PAID g. The employee left surviving him the following dependents: NAME None DATE OF BIRTH (if u n d er 2 1 ) RELATIONSHIP TO TH E EMPLOYEE ADDRESS WHEREFORE, applicant request* a hearing and an award of: Death benefit----iL Burial expense- J L . Compensation accrued and unpaid___ Unpaid Medical bills-*-- Other------- Specify: ------------------ --- ------------------------- and all other appropriate benefits provided by law. Hearing requested at -----L O S - A n g o l a S --------- Dated at - L K - A n q e l e S -- California, - J u 1) 0- 415^--1 - - c i t y i (C itii y ^ S 7y / Number of witnesses -- __Pre-trial w anted--------------- 7 Estimated time of trial- ........... J LAW " OFFICES /\/ '['tU' - OF ` Set n o w ____ ; Set later on written request ,, ,, *_ . -- , uriursH ii ATioiNtLi 1543 W. Olympic Boulevard IiOfr--Anqe-le3 , California .A n k a ra AMO I I I I f uiiH f mo HR<> I At t n a u r i I AJt'i'A-JH-r 1 1 VJ IN (D eath Case) FILE SIGNED ORIGINAL AND SIX COPIES (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) ________ MAURLNE-C1ARK--trticLj--------- -*' appiicant DEAN CLARK (Deceased) CASE No. /v -r ._L333L-Lakewood Pou1e.va rd,-BXQ- APPLICANT* ADORE* .-- Downey, Califoxuia- Dean Clark (Dec.) 88# 327-07-9443 D IC IA SI O l u n o t t i NANI ANO OCIAL l l C U A I t t N U l BALDWIN EHRET-HILL, INC. m rL orn f Contracting Division, Post Office Box number 34126_________________ m r i O Y i n a d o n i* San Francisco, California INSURANCE CO. OF NO. AMERICA m r i o i i r t in u a n c c c a i i a on t a t i i r i i L r . i n i u m o 0 r i a t u t i L r u ninu io . 621 South Virgil Avenue INtUAANCt CAHKIIK' AOOKIH ...hQS_Angeles, California 1. It is alleged that_10*33X1_C. -- ---- -- ^ Kj . l K .r . ( B ^ ^ . 5 fifld)---- NAME OF EMPLOYEE*" , -- \2*J 2/X9Q? DAT OP I IR T H , while employed as a _Afhfa.ts_JWQxker OCCUPATION AT TIME OP INJURY NAME OP EMPLOY In c _ on __ 1 9 4 0 t o . . ._19 6 6 , at _ y .a r i .Q.US__p 3 .9 .$ ? California, OATK OP I N. J U. .R. Y. C IT Y V i/ . !'< WWv.. (. , . * K' . sustained injury arising out of and in the course or employment to JLUNG- PA IT Of SOOT as follow s:___ IN H A L A T IO N . t ll - L A I N HOW INJU Nt WAS l I C t l V l D FOREIGN SUBSTANCES. resulting in death on DATI Or DIATH 2. Employee's actual earnings at time of injury $-- 2_ The basis of pay was 3. Was compensation paid?-----NO-- tl| NO $--------3-- -------- TOTAL rAID (SIL T (ATI , 4. Was medical treatment received? . YES ,. ----------- ------------------------------------ TI NO DATI LAIT C l i v i D Was all medical treatment provided by employer or insurance company? --------- TO DA TI o r LAIT rAVMCHT NO If no, state who provided it. / Lynwood ST FprvMrTS nn.9pttat.__363 Q_Imparial ..Highway.-,--fijawHKyx -California ALSO STA TE NAMES ANO A0 D R E M I S OP ALL DOCTOR* WHO TREATED OR EXAMINED FOR THIS INJURY J. Has burial expense been p aid ?----------- TO 6. This application is led for: . / Death benefit__ X------ Burial expense. Who paid it? Compensation accrued and unpaid Other__________ Specify:------------------ . 7. The employee left surviving him the following dependents: AGE A,* NAME ( I r D u o l i, 21 ) NONE ,(0uA.^Jlv t'L RELATIONSHIP TO THE EMPLOYEE A --' v- '. t ADDRESS IM PO R TA N T-- If any applicant is under 21 years of age, it will he necessary to file Petition for Appointment of Guardian ad Litem. Forms for this pur|x>sc may be obtained at the ofliec oi the Indusiri.il Accident Commission. WHEREFORE, applicant requests a bearing and an award for J l appropriate benefits be is entitled to by law. Hearing request.e.dI at .----L---o--s-----A--n- aq-e---l--e--s---------------- Dated at___ AngelS_ _f California/'.*.---C h ............... 21 . - J-, T , - C1TT . * ^ ' D* T` ------- Estimated time of trial ^ 4 Pita set now____ ; set later on written request. -/ ? / .... LAW_ O F F IC E S OF STEV E n APPLICANT % A T .O kN C Y OR R t P h ll^ N T A T IV E ROSEM AN_____ L621 W. 9th St., (Du 5-3071) f.% H ' T1 ' Mf ' i n n i M 1 * * tr r * f t | fc|T TJ Vf >'. ( APPLICATION FILE SIGNED ORIGINAL AND SIX COPIES (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) Dean Clark A PP LIC A N T Social Security N . 3 2 7 - 0 7 - 9 4 4 3 . Baldwin -Ehret Hill, Inc. Unknown CM PLOVCN' S IN S U tA N C I C A R R IfR OR STA TC If S tL f-IN S U R L O OR P C R N IS S IB L T U N IN S U arO i,GLA 9 2 0 4 3 - CASE No. 13331 Lakewood Boulevard A P P L IC A N T 'S AOONCSft Downey, Cal.ifornia Telephone No.. Contracting Div., P.O. Box 34126 A N P LO V C R 'S AOORCSS San Francisco, California IN SU RAN C A C A R R I& R 't A O O R Cbt l. It U alleged that--D a _ a n _ _ l rk ^ ,_ NAME o r t M r l O U t l j ^ / 2 ^ 1 ^ 0 l____ ( while employed on___ 19.. DAT T OP 1 IR TM D A TS OF IN JU R T as a__akqs.tg^WorkejL O C CU PA TIO N A T T IM E OP IN JU R T by__EaJLdw.ia=Elirs at. . - various places, including San t California. C fT T . TOWN OR P L A C t WMCRK IN JU R T O CCURRKO F T 3 HC 1 S C O " .*A. . *`l{ 1, sustained Injury arising out of and occurring in the coursie of thr employment. N A N I OP (M PLO VC R _____ Lung-- S TA TC W HAT PA R TS OP BOOT W CRS IM JU R tO ANO A U 6 H 0 U IN T R ES U LT S T n h a 1 . a t i . n n o r a s b e s t o s . - f l n d --Q-fcllfiX- j.u b s ta n g e s . C 1P LA 1 N W H A T I N R I O T I L W AS D O IN A T T I N I O P IN J U R T ANO MOW IN JU R T W AS R L C C IV C D 2. Actual earnings at time of injury $. -Pr------ The basis of pay was: W i s t 0 MONTH TA TS PAT riN lO O 0 * H O URLY RAT K , HOUN1 A DAT AND D AT* A W i l l 3. Periods disabled for work: P C C IF T lia iN N IN S AND CNDINO D A T S ! O r A L L P tN IO O J O FF W O O * DU S TO TH I> IN JU R Y .. Date returned to work----------- 4. Was compensation p a i d ? ------- _LO--- > $-- TO TA L PAID $- (S K IT NAT* OAFS OF LAST PATNCNT Have you received unemployment or unemployment compensation disability benefits since the date of injury? 5. Was medical treatment received? -- Y f i 5 _ ----------- State date last received: ----? YKR NO f t Y --------- Was all treatment provided by the employer or insurance c o m p a n y ? ----------- H 2 ------------- T (t NO If not, state who provided i t . ----------------------------------------------------------------------------------------------------------- Alio state names and addresses of all doctors who treated or examined for this injury. - 6. This application is bled because of disagreement regarding liability lor: Temporary disability_y e - Permanent disability----- y e s l 'ropcr Compensation Rate . .y O S Self-procured medical costs__y e a - Litigation costs y t^ s _ Medical treatment yQ5 . Other________ y c c Spec.fy:___ j m m ti d i j L t r . m o u .L c i l l - t x c a tm c . U .. a n d ..u .u ry o r y 7. Have you ever had a case for another injury before the California Commission?----------- ------- WHEREFORE, tr>titeant requests a Acarig ami award for all afifinifinate benefits firoiided by law. Los Angeles Hearing requested a t ---------------------- Dated at LoS .-AllyC LO S . I cut. California, ^ __i n J .<; .t iV'Ij.i' ` A I* f*I I C A N f f c b l k ^ T U R L l.'.:?-1*_L? u n ii . i 0 1 (t r<[ Estimated time of trial------------------Please set now____ ; set later on written request- .L A W - F E lC liS . OIL.ST E V E N 11QS EMAN. A P P L I C A N T k At I O R N I Y OH M f R U I N t A T N C --U-)-- Jl-- .Loa Anaalc.S-A._SaLiLorni A D O R O S ANO T I L C P H C N C N ' J M I I H OI A f i OR N i T OR R t P R L M N A T I V l CU 'tVyCyH. dfo.rft . _..._ . _ __ ___ : ~Xk;4<c^ C (m^ ____ ___ :...... ....... .............. ... . -------------Jdvo.V- Ehret r-itl______ ______________ x l i s l U Ccr ^ __ _______ / f f h S V o ^ ...C j3 f ----- -,____ - A o A t - M d A v .t j U ._ _ _ _ ;...... ..,._ w S <Co cni*\5-_______ F l ^ U q c c I A p < r ftodU c'tL. Pl<xvs4 A s t> s -f QS _____________________ u - : 'i-*'.!' U V; ` Pt 'S VT' I: i WORKMEN'S COMPENSATION APPEALS BOARD 2 STATE OF CALIFORNIA 3 CASE NO. 66 L.A. 292-0*0 4 MAURINE CLARK (Widow), DEAN CLARK (Deceased), Appljj^ertit, 7 VS. 8 BALDWIN EHRET-HILL, INC., et al, 9 ORDER APPROVING COMPROMISE AND RELEASE 10 Defendants. ) 11 12 The parties to the above-entitled action having filed a Com- ~ 13 promise and Release herein, on June 13, 1969, settling this case 14 for 1 5 ,*+10 .5 0 in addition to all sums which may have been paid prev 15 iously, and requesting that it be approved; and this Board having 16 considered the entire record, including said Compromise and Release, 17 now finds that it should be approved; and 18 IT IS ORDERED that said Compromise and Release is approved. 19 AWARD IS MADE in favor of: MAURINE CLARK 20 AGAINST: HARDWARE MUTUAL CASUALTY COMPANY; INDUSTRIAL INDEMNITY 21 EXCHANGE; INDUSTRIAL INDEMNITY COMPANY; INSURANCE | 22 COMPANY OF NORTH AMERICA; PACIFIC EMPLOYERS INSURANCE 23 - * COMPANY; RELIANCE INSURANCE COMPANY; THE TRAVELERS 24 . - . - -INSURANCE COMPANY; FIBREBOARD CORPORATION AND PLANT 25 RUBBER ASBESTOS WORKS; FIREMAN'S FUND INSURANCE COMP 26 ANY; ARGONAUT INSURANCE COMPANY; ZURICH INSURANCE COMP 27 ANY; CASUALTY INSURANCE COMPANY OF CALIFORNIA; AMERICA! 28 * MOTORISTS INSURANCE COMPANY; STATE COMPENSATION INSUR 29 ANCE FUND; LIBERTY MUTUAL INSURANCE COMPANY. 30 -1- i al ti ItMW ail ferr tat nr fonr ttmti turd X PAYABLE AG FOLLOV.'G: 2 By: FIREMAN G FUND INSURANCE COMPANY 3 To: Applicant Dr. -ohn Field # ^on*oo "r a 'l ? 4 Attorney Steven Roseman, for coats n nn Attorney Gteven Roseman, for fees -- W 5 51,03 J00 6 HARDWARE MUTUAL CASUALTY COMPANY 235.00 7 INDUSTRIAL INDEMNITY EXCHANGE 333.00 8 INDUSTRIAL INDEMNITY COMPANY blh-.OO 9 INSURANCE COMPANY OF NORTH AMERICA 180.00 10 PACIFIC EMPLOYERS INCURAUCE COMPANY 8U6.00 11 RELIANCE INSURANCE COMPANY 67 .50" 12 THE TRAVELERS INSURANCE COMPANY 621.00/ 13 FIRBURBEBREORARDASCBOERSPTOORSATWIOORNKSAND PLANT 1 8 0 .0 0 14 CASUALTY INSURANCE COMPANY OF CALIFORNIA 39.00 15 ARGONAUT INSURANCE COMPANY 65.00 18 ZURICH INSURANCE COMPANY 90.00 17 AMERICAN MOTORISTS INSURANCE COMPANY 1+5 0 .0 0 18 STATE COMPENSATION INSURANCE FUND 585.00 19 LIBERTY MUTUAL INSURANCE COMPANY __ 27QJ2Q. . TOTAL ' 35,^10.50 Referee . WORKMEN'S COMPENSATION APPEALS BOARD T LOS ANGELES, CALIFORNIA August 28, 1969. 27 28 29 -All parties served by null us shown ori Official Address Record. 30 J 2 j L L '-i_______ V O 0/ ^ 66 LA 292-C1^ BwrUNtt of latfuttni Relation OitKiaB 4 tnAMtri! Acctdtels WvlMn't ftMrd MS t a t t of C ifato w U 04 4 f t ( ftn . i - 6 6 )  * o IVJ 1 W O R KMEN^ COMPENSATION Al PEALS BOARD // 2 ST?E OF CALIFORNIA 3 CASE NO. 66 L.A. 292-0^3 4 5 MAURINE CLARK (Widow), ) DEAN CLARK (Deceased),-" 6 ) Applicant, 7 VS. ) 8 BALDW IN EHRET-HILL, INC., ) et al 9 ' ' ) 10 Defendants. ) ORDER APPROVING COMPROMISE AND RELEASE 11 12 . The parties to the above-entitled action having filed a Com 13 promise and Release herein, on June 13* 1969 settlin^Jbhis^case 14 for $ 5 ,U1 0 . 5 0 in addition to all sums which may have been paid prev- 15 iously7"and requesting that it be approved; and this Board having 16 considered the entire record, including said Compromise and Release, 17 now finds that it should be approved; and 18 IT IS ORDERED that said Compromise and Release is approved. 19 AWARD IS MADE in favor of: MAURINE CLARK - 20 AGAINST; HARDWARE MUTUAL CASUALTY COMPANY; INDUSTRIAL INDEMNITY' 21 EXCHANGE; INDUSTRIAL INDEMNITY COMPANY; INSURANCE 22 COMPANY OF NORTH AMERICA; PACIFIC EMPLOYERS INSURANCE 23 COMPANY; RELIANCE INSURANCE COMPANY; THE TRAVELERS 24 INSURANCE COMPANY; FIBREBOARD CORPORATION AND PLANT 28 RUBBER ASBESTOS WORKS; FIREMAN'S FUND INSURANCE COMP 26 ANY; ARGONAUT INSURANCE COMPANY; ZURICH INSURANCE COMP 27 ANY; CASUALTY INSURANCE COMPANY OF CALIFORNIA; AMERICA 28 * MOTORISTS INSURANCE COPT ANY; STATE COMPENSATION INSUR 29 ANCE FUND; LIBERTY MUTUAL INSURANCE COMPANY. 30 - 1- ti ii i imm I Comi ltiifatr fttiatiwtt MtilS Ittrtf 5-*i) vM A I 1 PAYABLE AS FOLLOWS; 2 By: FIREMAN *S FUNE INSURANCE COMPANY 3 To: Appileant $ W.53 200.00 Lr. John Field Attorney Steven Rosenan, for costs 86.V7 4 Attorney Steven Roseman, for foes ^ 700.OQ 51,035.00 5 HARDWARE MUTUAL CASUALTY COMPANY 235.00 6 INDUSTRIAL INDEICJITY EXCHANGE 333.00 7 8 INDUSTRIAL INDEMNITY COMPM Y Hl^-.OO INSURAN CE COMPANY OF NORTH AMERICA 180.00 9 10 PACIFIC EMPLOYERS INSURANCE COMI'ANY 8^ 6.00 11 RELIANCE INSURANCE COMPANY 67 .50 12 THE TRAVELERS INSURANCE COMPANY 621.00 13 FIRBURBEBBEORARDASCBOERSTPOGSRATVJICORNKSAND PLANT 180.00 14 CASUALTY INSURANCE COMPANY OF CALIFORNIA 39.00 15 ARGONAUT INSURANCE COMPANY 65.00 16 ZURICH INSURANCE COMPANY 90.00 17 AMERICAN MOTORISTS INSURANCE COMPANY V 50.00 18 STATE COMPENSATION INSURANCE FUND 585.00 19 LIBERTY MUTUAL INSURANCE COMPANY __ 270.00. TOTAL $5,^10.50 AT LOS AliSELES, CALIFORNIA August 28, 1909. Rflfcroe QjLa ------- l _ _ All inrtles served by -aLl os *. \/]A -/\ ` a/2?/r,n 66 La 202-0^3-,/ _ ')_ D iN rla M t ( M u il r ii Rtlationt WOaioiiinee-t ti tt.daiMNtwit.Il AwcCttSwwuUliBojrJ w m fMltteW *H M ) UA*(*?<*# :*'<> * iilufWi' O f f i c i Address Keoord. r < DEPARTM ENT OF INDUSTRIAL RELATIO N S DIVISION OF INDUSTRIAL A C C ID EN TS WORKMEN'S COMPENSATION APPEALS STATE OF CALIFORNIA BOARD MAURINE CLARK (WIDOW) DEAN CLARK (DECEASED) A [>pin ant vs. BALDWIN EliRETMlILL, INC.; et al Case N o. COLA ' Xio 0^13 Notice of Time and Place of Further Hearing ALL I S S U E O kJ Deje mlant 0 NOTICE TO AI.I. PARTIES You arc hereby notified that further hearing will be held in the above-entitled action at 4107 LOS ANGELES STATE OIMCE BUILDING, 107 SOUTH BROADWAY LOS ANGELES, CALI LORN IA Auust ''l, TjC9 9 A.M. ALL DAY WORKMEN'S COMPENSATION APPEALS BOARD i/ l. * \Ii - By Kl IhKI I. Dated at: Los Angeles, California NOTE: CONTINUANCES AND FURTHER HEARINGS ARE NOT FAVORED. SERVED BY MAIL ON PERSONS SHOWN ON THE OFFICIAL ADDRESS RECORD Date: I 4 A 4.\..* Hy: Copy of application filed /.-j/l C <-c i / . - G/ C served larlcer, McGee, Peckham & Roberts and Baldwin, TEoiaas & Taker. DIA WCAB FOAM 23 LA iCV 12* FOffMfttivFORM 400 L 0 T o*P D EPA RTM EN T O F INDUSTRIAL. RELA TIO N S DIVISION OF IN D U S T R IA L . ACCIDENTS WORKMEN'S COMPENSATION APPEALS b a S f ,r STATE OF CALIFORNIA MAURINE CLARK (WIDOW) DEAN CLARK (DECEASED) Qa%e No# 66LA 292 043 N otice of H earing * \ Applicant.... K- IO BALDWIN EHHET-HILL, INc'.; AND Jlf * DEFENDANT AS SET FORTH ON PAGES 1, 2, 3 a 4 AND 5 OF \ ATTACHED AMENDED APPLICATION INSURANCE COMPANY OF NORTH AMERICA, a corpora tion* AND OTHER DEFENDANTS AS SET FORTH ON PAGES K T * AND 5 OF ATTACHED A m APPLICATION ____________ D,)"*11*1 'i . . , W n filed with the Workmen's Compensation Appeals s r r S - w - - 4107 LOS ANGELES STATE OFFICE BUILDING, 107 SOUTH BROADWAY LOS ANGELES, CALIFORNIA .Tftnuarv 22 & 23a 1969 9:00 A.M. 2 days Appeals Board will proceed to hear and dispose of the said and that at said time and place the Workmen's Compensat.on application in the manner prescribed by law. WORKMEN'S COMPENSATION APPEALS BOARD Dated at: Los Angeles, California By 'Mil 1.. 0 ! KI I referee z z z z z z ^ Req ,, ,, for continuances are tn be made w i.hin I day. of the date of tlm not.ee. N O T E T O IN SU R ED E M P LO Y E R S: Your attendance at ihia hearing m ay nut be neee.tary. A.k your .m u rin c e P causf SERVED BY MAIL ON PERSONS SHOWN ON THE OFFICIAL ADDRESS RECORD By* 12/4/68 4-1on*fiied 2/1 7 /66, Copy f i / o l ^ ^ a n d l / V e a ^ e r v e d all amended applications parties. filed 3/23/66, OIA W C AB F O A M * 0 LA . M V l l - a a . . FO*LV FOAM 3S L > T ear .. of la d a itr itl Rotation Division of Industrial A cddonts W orkm en's Com pensation Appeals Board V Scste of C alifo n u s ' Ceffi 4 1933 PltsM fUo tignod oritinsi **d six copitt mud print or typo moms ond mddrtutt APPLICATION FOR adjudication op claim (Doath Case) amended a p p l ic a t io n 66 LA 292-043 CASE NO. >W Mr*. MLU.__ M auri ne C la rk ..(WadonO ' <applicarti 13 331 T.fVnwwn^nnn 1nvniM . D 10- Dovm ey-y Califognift ' Dean 9S5lS *Ja .3.2Jcui0.7cy.3rV}rfi. , f. B a lflv r'n (IRPLOTIR) Tnru (SEE ATTACHED SHEET FOR A D D I T I O N . ^ , EMPLOYERS ! P.0. Dox 3 4 1 2 ^ - a d o r im i San Pranciaco, CallJCurniar I I I P I S T I I ' I IDftWRARCI CARRICR OR ITATI II f t l t f IRRORt0 OR PCiaiftftllLT URINIURIO) (SEE ATTACHED SHEET FOR ADDITIONAL CARRIERS) IT IS CLAIMED `THAT: h u h o i u e i c a b i i i * . I1 a * ) Deceased employe bom 1 2 / 2 / 1 9 & Z --------- - while employed a --------- f tB h ftfftlM W g r k e ^ ^ i>jw) (DATI OP RIRTR 19AD to U& ----- - varions plaas..,--- by the employer suttained injury arising out C S A tlO f m ju s tl ( TTI of and in the course of employment to ----------- LUIICJ (iTttt m , , , my ijutoi 2. The injury occurred as follows: ---- I n h a l a t i o n ^ o f t o, ? . I *otm X s * a n Q ~ ----------------------------------------------- _______ ____________ resulting in death on -- M a r / A / ---1 9 6 6 ----- ------------------------------------------ ------ --------------------------- (l(T Or OIATM) J. Actual earnings at time of injury were: ISIVS ( S I L T OS eSTNLT SAIA* OUSS OS 4. The injury caused disability at follows:U n LAST SAT OS, . O ' . . . . TO THIS ..A O St A.. AB . . . . . . S * T . Of A U . .. O S . 0" TO TN I. '> J . C o m p e n s a t i o n w a s p a i d ---------- *------- ._. _. ._._. _'. 1_E_T___ $- (W 't'L Y SATS) it isi (not m m m id " l . A T i O r U . T ' A T . T , 6. Medical treatment was received XS>S All treatment was furnished by the employer or insurance (01 fOATSOrUASTTS'ATBA.T com pany------- ------ (ITTS(S*)) (iMm il other treatment was provided or paid for by not prom M , pdJ (o. b , .p lo y o' ~ n tP>y. I f" ^ " *' 7 DIMeTfePnfldnanTt* hnawver owauiud buuuriimal evx*pe.*n.s.e. --------- -1------ TOTAL PAID -- " WHEREFORE, applicant request* a hearing and an award of: Death benefitE ----- Burial expense--X-- Compensation accrued and unpaidJL -- Unpaid Medical bilkX-----Other X, Specify: f ll 1 b e n e f i t s --------------------------------------------- ____________________________________ andJ a^ll11oAth. leirs e aopspairaosifptHriVaiatePmbKeno eflf#iUtsf ( provided by law. Los Anaeles _ Hearing requested a t ------------------- 1----------------- ^ m i . Los Angeles r . Aug. 26, 1968 ------------ -- -------------CaLf rnia------------------- ^ -------itti Number of witnesses------- Pre-trial w anted-------------- ITISI IM I Estimated time of trial----2Di=-- ------- (A t.U C A 'T I SItHA TUId Set now , XX. ; Set later on written request------- T.AM fYFFTPBR OP STEVEN. BOSEMAN 3fil=i3511- (APPLICANT ATTORNIVI U 4 1 W. Ol ympi n ttrml fvarri r T.nfl Angeles,. California `om-'*'imattoii 90015 ATTACHED SHEET PAGE ONE EMPLOYER QUARTER PERIOD OF EMPLOYMENT DEPENDON ROOFING CO. 3521 N. Cicero Avenue Chicago, Illinois 3/31/40, 6/30/40 9/30/40, 12/31/40 THERM-O-PROOF i n s u l a t i o n CO. 4730 Armitage Avenue Chicago, Illinois 12/31/40 DEL E. WEBB CONSTRUCTION CO. & WHITE & MILLER CONTRS., INC. Fort Huachuca, Arizona 3/31/41, 6/30/41 O'MALLEY PLASTICS, INC. P.O. Box 3558 Phoenix, Arizona 3/31/41, 6/30/41 A.N. BORGQUIST P.O. Box 6134 Phoenix Arizona 6/30/41, 9/30/41, 12/31/41 STANDARD ROOFING & SUPPLY CO. P.O. Box 2204 Phoenix, Arizona 6/30/41, 9/30/41 12/31/41 DEL E. WEBB P.O. Box 7588 Phoenix, Arizona A .O . MILLER CO., INC. 220 Nordina Street Redlands, California C.C. MOORE & CO. Engineers Unit X-l 450 Mission Street San Francisco, California MC CONKEY, DOCKER & CO., INC. 130-32 W. Madison Street Phoenix, Arizona W.A. BECHTEL CO. 155 Sansome Street San Francisco, California CONSOLIDATED ROOFING & SUPPLY CO. P.O. BOX 614 Phoenix, Arizona MARINE ENGINEERING & SUPPLY 941 E. 2nd Street Los Angeles, California 6/30/41 6/30/ 41 9/30/41 9/30/ 41, 12/31/41 12/31/41, 3/31/41, 6/30/42 12/31/41 12/31/41, 3/31/46, 6/30/46, 3/31/47 INSURANCE CARRIER Unknovm Unknown STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA STATE OF ARIZONA * STATE OF ARIZONA STATE OF ARIZONA Unknown STATE OF ARIZONA PACIFIC EMPLOYERS INS. CO INDUSTRIAL INDEMNITY CO. STATE OF ARIZONA PACIFIC EMPLOYERS INS. CC v J T . THORPE, INC. 748 E. 2nd Street ds Angeles, California MUNDET CORK CORPORATION 7101 Tonnelle Avenue North Bergen, New Jersey 12/31/41, 6/30/45, 9/30/45, 12/31/45 3/31/46, 12/31/46 3/31/49, 12/31/58 3/31/59 6/30/42, 9/30/44 12/31/44, 3/31/45 6/30/45, 6/30/46 9/30/46, 12/31/46 6/30/47, 9/30/47 6/30/48, 3/31/48 9/30/60, 12/31/47 12/31/60 PACIFIC EMPLOYERS INS. CO & AMERICAN MOTORISTS INS. COMPANY AETNA CASUALTY & SURETY INSURANCE COMPANY & PACIFIC EMPLOYERS INS. CO THE ASBESTOS & MAGNESIA MATERIALS CO 119-127 N. Peoria Street Chicago, Illinois 6/30/42, 9/30/42 Unknown SLATTEP.Y & COMPANY 1726 Market Street Denver, Colorado 12/31/42 Unknown FLLER-THOMAS CO. 118 S. 5th Avenue Tucson, Arizona YOUNGS SALES CORP. 1054 Central Industrial Avenue St. Louis, Missouri 3/31/42, 12/31/42 3/31/47, 6/30/47 12/31/48, 12/31/49 9/30/45 STATE OF ARIZONA Unknown UNITED CORK COMPANIES CORP. Ft. Central Avenue Kearny, New Jersey 3/31/46, 12/31/51 3/31/52 LIBERTY MUTUAL INS. CO. PLANT RUBBER & ASBESTOS WKS 537 Brannon Street San Francisco, California 3/31/46, 12/31/46 SELF INSURED WARREN & BAILEY CO. , 3528 S. Garfield Avenue Los Angeles, California 12/31/46, 3/31/47 9/30/49 Unknown TECHNICAL SERVICE COMPANY 423 N. 1st Street Albuquerque, New Mexico 6/30/47 Unknown LEROW COMPANY 5510 Sheridan Road Chicago, Illinois 6/30/48, 9/30/48 12/31/48 Unknown ASBESTOS ENGINEERING & SUPPLY CO. 12/31/48, 3/31/49 1880 W. Fillmore 6/30/49, 12/31/49 Phoenix, Arizona STATE OF ARIZONA REFINERY MAINTENANCE CO., INC. 2500 N. Alameda Street Oompton, California 3/31/49 Unknown STEARNS ROGER CORP. 660 Bannock Street Denver, Colorado 6/30/49 STANDARD ACC. INS. CO. RELIANCE INS. CO. THORPE INSULATION CO. 2741 S. Yates Avenue Los Angeles, California \ THOMAS H. HOGAN CO. 1591 Indus Street Santa Ana, California HALL INSULATION CO. 2633 E. 3rd Street Tucson, Arizona KIRCHER, ASBESTOS & RUBBER CO. Inc. Box 6652 Phoenix, Arizona BARRETT & HOMES 6033 N. 10th,Street Phoenix, Arizona 9/30/49, 12/31/49 6/30/59, 3/31/63 6/30/63, 9/30/63 12/31/63, 6/30/64 9/30/64 9/30/49 3/31/50 12/31/50, 3/31/51 6/30/51, 9/30/51 3/31/52, 6/30/52 9/30/52, 3/31/53 6/30/53, 9/30/53 3/31/54, 6/30/64 3/31/55, 6/30/55 9/30/55, 3/31/56 6/30/56, 9/30/56, 6/30/57, 9/30/57 3/31/60, 6/30/60 12/31/50 PACIFIC EMPLOYERS INS. & FIREMAN'S FUND INS . CO. Unknown Unknown STATE OF ARIZONA STATE OF ARIZONA ARMSTRONG CORK CO. Liberty and Charlotte Streets Lancaster, Pa. 9/30/51, 12/31/56 STANDARD ACC. INS. CO. RELIANCE INS. CO. THE TRAVELERS INS. CO. REECE INSULATION CO. 4563 Valley Boulevard Los Angeles, California ACCURATE INSULATION CO. 900 S. Cypress La Habra, California 9/30/56, 12/31/56 9/30/56, 12/31/60 3/31/63, 6/30/63 JOHNS MANVILLE SALES CORP. 22 E. 40th Street New York, N.Y. COAST INSULATING PRODUCTS 2684 Lacey Street Los Angeles, California 12/31/56, 9/30/57 12/31/57, 9/30/58 12/31/56, 9/30/59, 12/31/60 OWENS CORNING FIBERGLAS CORP. P.O. Box 901 Toledo, Ohio 3/31/57, 12/31/57 9/30/59, 3/31/60 9/30/60, 12/31/60 12/31/61, 3/31/62 6/30/62, 9/30/62 3/31/63, 9/30/63 3/31/64, 6/30/64 9/30/64, 12/31/64 S fT Y INf?HftAYT0N 0 9 * I TNP* Unknown (moved no address) CASUALTY INSURANCE CO. I CALIFORNIA, INC. & STATE COMPENSATION INS. FUND SELF -INSURED ARGONAUT INSURANCE CO. STATE OF ARIZONA THE A|2TNA CAS. & SURETY Ins Co. & THE TRAVELERS INS. CO. Unknown ATTACHED SHEET PAGE FOUR JAMAR OLMEN CONSTRUCTION c/o P.O. Box 14322 Houston, Texas 9/30/57, 9/30/58 ORIN A. WILLIAMS & JOHN S. GREEN 3775 N. 36th Avenue Box 11098 Glendale, Arizona 12/31/57 INSULATION & SPECIALTIES INC. Box 3428, Sta. A El Paso, Texas 12/31/57 METAL CLAD INSULATION CO. Box 178 Torrance, California 3/31/58, 6/30/58 BOB GRIFFIN ROOFING & 3/31/58 INSULATION CO., INC. 151 E. 24th Street Yuma, Arizona FIBREBOARD PAPER PRODUCTS CORP. 6/30/58, 9/30/58 1789 Montgomery Street 12/31/58 San Francisco, California WESTERN ASBESTOS CO. Box 3784 Rincon Annex San Francisco, California 3/31/59, 6/30/59 PLANT ASBESTOS CO. 1300 64th Street Emeryville, California 9/30/59, 9/30/60 3/31/61, 6/30/61 R.T. DINWIDDIE, INC. 8627 S. Atlantic South Gate, California 6/30/59, 9/30/59 INSULATION SERVICE INC. Box 4695 Tulsa, Oklahoma 12/31/59, 6/30/59 LOS ANGELES CORK CO. 4180 E. Washington Los Angeles, California J ARMSTRONG CONTRACTING & SUPPLY CORP. 120 N. Lime Street Lancaster, Pa. 12/31/60, 9/30/G4 6/30/61, 6/30/65 9/30/65, 12/31/65 UNAFRAX CONSTRUCTION CO. 1242 Abbot Dr. Pittsburgh, Pa. 9/30/61 Unknown STATE OF ARIZONA Unknown AETNA CASUALTY & SURETY INS. CO. STATE OF ARIZONA SELF INSURED STATE COMPENSATION INSURANCE FUND INDUSTRIAL INDEMNITY CO. Unknown Unknown ZURICH INSURANCE CO. FIREMAN'S FUND INS. CO. THE TRAVELERS INS. CO. LIBERTY MUTUAL INS. CO. ATTACHED SHEET PAGE FIVE UNAFRAX CONSTRUCTION CO. 1242 Abbot Dr. Pittsburgh, Pa. ^ 9/30/61 INDUSTRIAL SERVICE & ENGINEERING CO. OF CALIFORNIA Box 16138 Long Beach, California 3/31/63 KITZMANS PLUMBING & HEATING 6940 Alvarado Rd. Lamesa,California THE ISOTHERM CO. 605 Williams Bakersfield, California THERMAL ENGINEERING INC. . Hoffman & So. 10th Street Richmond, California BALDWIN, EHRET, HILL, INC. 500 Brevnig Avenue Trenton, New Jersey 6/30/63 6/30/64, 12/31/64 12/31/65 12/31/65, 1/1966 LIBERTY MUTUAL INS. CO. LIBERTY MUTUAL INS. CO. INS. CO. OF NO. AMERICA SENTRY INS. CO., a Corp. Unknown LIBERTY MUTUAL INS. CO. & INS. CO. OF NO. AMERICA '-IVED t D epartm ent of Industrial ^Relations . *1' - GOOD CAUSE APPEARING: The application herein is taken off calendar. Division of Industrial Accidents , , Workmen's Compensation Appeals Board State of California it r iiK B . w e it Please file signed original and six copies and print or type names and addresses APPLICATION oQ FOR ADJUDICATION OF CLAIM (Death Case) . i ; NEl^DA APPLICATION 66 LA 292-043 ' CASE NO.-------------- y j u,, M ./ Maurino Clark (widow) (APPLICANT ) - Dean Clark (Deceased) 13331 Lakewood Boulevard, BrlO (APPLICANT'S ADONtSSl . Downey, California _________ Dean Clark tDec?) SS# 327-07-9443 ! 1N 9 f U l T t i ACCURITV NUMRCR) . VS. See attached sheet 1: ' ` ____ See attached sheet ( S H P L O T K I'S INSURANCE CA R R IER OR ST A T T IP S C L M N S U R C O OR PCRM ISSISLT UNINSURED) IT IS CLAIMED TH A T: (A D D RESS OP INSURANTS CA R R IER . IP ANY) a- '`V , - .1 l,' 1. Deceased employee bom 12/2/1907______ f while employed as a ------ Asbestos Worker; (O CCUPATION AT T IM I OP IN JU R ?) on 1940-1966 I D A TI P INJURTJ at Various places . (C IT T of and in the course of employment t o --------- .VD9L (STA TO by the employer sustained injury arising out : f I ST A T E WHAT M A T S O f SOOT W I R I IN JU R IO ) 2. The injury occurred as follows: * ' Inhalation of asbestos and other foreign substances I ( I ALAIN WHAT I N f L O T R I WAS OOINA AT TIM S O f INJU RT ANO NOW INJURT W AI I I C I I V I O I resulting in death on -- MaX_>-- 4-,-- 1 9 6 6 .. (OATS O f OSATHI 3. Actual earnings at time of injury were: (O IV K W C ERLY OR NONTNLT SALARY OR HOURLY RAYS ANO NWNR1R OP HOURS W O RKIO P ER W E E D 4. The injury caused disability a follows:( S f S C If T LAST OAT O f f WO O U I TO TH IS INJURT ANO O IS IN H IN . ANO INDINO D A T S! or ALL r illO D S orr O U I TO THIS IN JURT) I. Compensation was paid---- L !_H Q . (V IS ) (NO) 6. Medical treatment was received (V tS) $ --------:------------------ : $ ------------------------------------ -------------------- (T O T A L PAIO) ILT A T I > I DAT! o r LAST RATHINT I (N O ) (OATS OP U S T TREATM ENT) All treatment was furnished by the employer or insurance company (T IS I other treatment was provided or paid for by (H O I Doctors not provided or paid for by employer or insurance company, who treated or examined for this injury are: St. Francis Hospital. 3630 Imperial Highway, Lynwood A-California-- ( T A T N A N * AHO A S O M t S I l O f SUCH D O C T O AHO N A H O f H O A flT A L t TO WHICH SUCH DOCTORS A O N IT T tS IN JU R IO ) 7. Defendants have paid burial expense. ------- ------- TOTAL PAID IT II) (H O I I. The employee left surviving him the following dependents: NAME None DATE OF BIRTH (iiund 21) RELATIONSHIP T O T H E EMPLOYEE ADDRESS WHEREFORE, applicant requests a hearing and an award of: Death benefit---- iL Burial expense---- X - Compensation accrued and unpaid___ _ Unpaid Medical bills ^ -- Other--------Specify: and all other appropriate benefits provided by law. Hearing requested a t ----- LOS--An g &Xo S - (C IT Y ) , Dated at _ L o _ Anrj46 ,e,'m ' Number of witnesses------- Pre-trial wanted . IT IS I IN O) . California, -- . s7 2 5 -,-- 1-9 8- ... ' Estimated time of trial------------------------------ LA\f OFFICES OF 'CT^W^'^oA^ 381-33l 1 Set now ____Set later on written request 1543 W. Olympic Boulevard , _ . _ , , . lAFitLICAMT, A TTO R N ITI Oa-l-t For n i a- I A O D R C E S ANO T E L E P H O N E N U M R C R OF A T T O R N E Y ) % n -?' ' i APPLICATION (D eath Case) e:..'1 : ^ > fOi (t f. *1 /4l L* L' j ^ file sig ned original a n d six copies (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) CASE No. _______MAURINE CLARK fWid^ L --- APPLICANT DEAN CLARK (Deceased) l e i ' l l T.aVAutnnri Rnn la v a rrt 0- APPLICANT'S A00REAI _Downey y-Xaliforn i.a- Dean Clark (Dec.) 8# 327-07-9443 DECEASEDEMPLOYEE'NANSANDSOCIALECURITYNUNNKR -WX 4 <#* * BALDWIN EHRET-HILL, INC. uriorii I '* ' ' . .'#'& * - ' - / - - -* INSU RANCE CO. OP NO, AMERICA EMPLOYER'INSURAPNCCREMCISASRISPLUTSUONNINSSTUARTEIDIPSSIF-INSMREDO/R Contracting Division, Post Office Box number 3 4 1 2 6 ____________ KMPLOTirS A0DRI9S San Francisco. California, 621 South Virgil Avenue INSUBANCSCABBIIB'SAODSSSS Los Angeles. California 'W - ' ' ` L* j.U u allegedTun. Dn Clark (Deceased) . -AL;` * ~-*W!iBllsgtfLoss,mrLOTNiBc"*" i -- , 12/2/19.QX (*TIw ,I,TM while employed as a RbftSt*nH Worker_____ :___ _ on -- 124.0-- tQ.-- 19-66.,at VflfiOUS-- plPC.CflCalifornia, CCUfATION AT TINS OS INiUST * OATt OM NJUST ^ ( v I L` '^ b / C J i by. B alH u ln -B h rflf-H i 1 1 , I n c . PLOYER _ sustainetf'wjuryarising out^of^and in the c o u rse employment J to . LUNG PARTI OP ROOT asfollows: INHALATION OF .ASBESTOS AMP QTH1B- IIFLAINHOWINJUNYWASRSCIIVSD FOREIGN SUBSTANCES resulting in death on H a r C l l --4 j -- 1 ,9 6 .6 OATSor OSATH 2. Employee's actual earnings at time of injury $-- 2--------- at-- - The basis of pay was. 3, Was compensation paid? , NO_ WCSSLYSAYS -Si*4. Was medical treatment received? . YES , BATS LAST S IC IIV IO Was 11 medical treatment provided by employer or insurance company? DAYSor LASTrAYHCNT . . S`k ` If no, state who provided i t . --------- -- ------------------------------ ---- --- --------------------- -- ------------~ / Lynwood ________ c m pp& w rT S h o s p i t a l . .16 1 0 I mo e r i a l H i g h w a y , B a w n a y g - C a l l f o r n x a * ALSOSTATSNAMESANDA. DD_ RESSESOf ALL_D_O__C__T_O.R.SWH. .O,, .TuSsEaATmEOb 0T1u lEaXiAtsMs uINa tEf0 POSTHISINJURY }. Has burial expense been paid? us 6. This application is filed for: Who paid it? '>i,;. V'. Death benefit-- X . Burial expenae- Compensation accrued and unpaid Other--------------- Specify: .----------------- 4 . 7 , The employee left surviving him the following dependents: i ! , ' 1 NAME AGE . . Ilr Uhosn a i) RELATIONSHIP _ TO THE EMPLOYEE ? NONff ^ NONE U-- .t ADDRESS IM PO R TA N T-- If any applicant is under 21 years of age, it will be necessary to file Petition for Appointment of Guardian ad Litem. Forms for this purpose may be obtained at the office o: the Industrial Accident Commission. WHEREFORE, applicant requests a bearing and an award for uII appropriate benefits he is entitled to by aw. Hearing requested at -- ^ P s ------- Estimated time of tr ia l------------ ---------------------4 Please set now____ ; set later on written request. Dated a, >v. Los Angeles CITT California,^-jlr c h 2 2 ' V96 nA tf `InjsnjTIiff -- LAW O F F IC E S 'oF s4VEPHSEM AN A P f . l C A N r , AT OKNCY OS S I YACS'.N YATIVS 1621 w. 9th St. ,____ (Du 5-3071) o d r %% < n n i n r m o N t H ' i M f i r f f i t ' i f o r r . f e r * n v f uiuwaviiai iivviUKlU ^UlUUliMlUII * % APPLICATION <Z <* FILE SIGNED ORIGINAL AND SIX COPIES (PLEASE PRINT OR TYPE NAHES AND ADDRESSES) Dean Clark / APPLICANT Social Security No, 327-07-9443________ Baldwin -Ehret Hill, Inc.____ ' uruui Unknown______________________ P i o v e r IM SU M N CS CANNI ON T A T I IP S L /< IN U M 0 ON PC N N ItIBU UNINVUtr i>6LA 9 2 0 0 c a se No. 13331 Lakewood Boulevard APPLICANT' t ADORO* Downey, California________ Telephone No__________ ____________________________ Contacting Div., P . O . Box 34126 P L O V f N ' k AOONCNf San Francisco, California INAURANO CANNI' A00NC l. It is alleged t W D e a n C l a r k ^ _________ NAH OP P L O T -------^ 0 l______________ , while employed nn D T* O f 1IRTN 1940--1966 jj____ . OATS O f INJ U K I M il-asbestos Worker______i__ OCCUPATION AT T IN OP INJUNT , various places, including San California, * m . TOWN OR PLACS W H IR I INJURY OCCURRIO F r a n d S C O by__ Baldwin-Ehret Hill, Inc. employment. **"1 I"n0Tf ------------ sustained injur/arising out of and occurring in the course of thr ______ Lung__________ STATS HAT M i l l O f SORT W H S IN JU RID NO SUSStOUSN T R IS U L T I inhalation of asbestos and other foreign substances I X P U i N N A T CM P lO V C t A 0 0 INN AT T IN E OP INJURY ANO HOW INJURY WA> NKCKIVCO 2. Actual earnings at time of injury $____________ per The basis of pay was: _____ __________________________ . S S I OR MONTH RT A T S RAT M A IO D R MOUALT R A T I. HOURA A SAT ANB OATR A I R K -- . -- -------------------------------------------------------------------- J. Periods disabled for w ork:---3toterHvifc-fcantly.-and since. Jannary,_L9&6________________ . srscir r k s in n im o ano in d in r d a t ir o f a ll p ir io o r o n w ork out to t h is in ju r y -.......... . - ... ................ ........... .............. ......................... . Date returned to work_____________________ 4. Was compensation p a i d ? ____NO . Tt NO $____________ $_____________________________________________________ TOTAL PAID W IIK IY RATI OATC OP LAST PA TN IN T Have you received unemployment or unemployment compensation disability benefits since the date of injury?______ _____ T IS NO I. Was medical treatment received? __YS.fi. _______ . State date last received: T IS NO. currently____________________ Was all treatment provided by the employer or insurance c o m p a n y ? _______ T it NO If not, state who provided *- _______ ____________________________________ _ Also state names and addresses of all doctors who treated or examined for this injury. St. Francis Hospital 6. This application is filed because of disagreement regarding liability for: Temporary disability--ye& - Permanent disability-----y e s P ro p c r Compensation Raie.....y S S Self-procured medical-costs-- y e a - Litigation costs ~ y a U- Medical treatment. yBi3 . Other___ y e e S p c c ify :___ i t n n x a d l a . t r , m e d i c a l - t r e a t m e n t a n d _ s u r y e r y 7. Have you ever had a case for another injury before the California Commission?_________________ WHEREFORE, applicant requals a bearing and award fur all appropriate benefits provided by law. Los Angele Hearing requested at-------------------- eiTT Estimated time of trial---------------------------- --- _ Please set now_____; set later on written request. Dated at. J L o a _ A n y e I c s . . California, F e b r u a r y 1 5 , 1 9 OATI . APPI ICANT' b t i a T U N C LAW O F P T C M S O F S T E V E N ROSRMAM___________________ APPLICANT* b ATTONNLV OR A( PR C1C N TAT IV C J12J-- i-- at-h :n-. . T .n n ; angles. California AP UR A IS ANO T l l I P H O N t N U M I I R Of A f T O R R I Y OR R t P R I S I R IA T I V I < t> W bruary 23, l$6j AI KAIL Lev O ffices , : StCVCU B o t a n 1621 West K loth S tre e t Los A ngeles, C klifoarale ' 90Q15 '* . OWtXWMI . . Svtojecti lDwmOLAEl/(Decedent) T isuria* C lark (Widow) Ca m 66 IA S9& & 3 - 2a rep ly to your le tte r s o f W bruary 16 addressed to us and our svfosldlary, A m strong C o n tractin g and Supply C o rp o ratio n , we w ish to ad v ise th a t our u o rk aen 's ccnpensatioa in su ran ce c a r r ie r was Standard A ccident Insurance Cceany in I 95I and The T rav elers Insurance Ccsgpaay l a I 956 sad 1961. W ry tr u ly yours, W allace B. Hofffcrth DBS ; % STEVEN ROSEMAN ANTHONY J. BRADISSE HERMAN FEUERSTEIN JAMES J .WALSH 1621 Law Offices STEVEN ROSEM AN ATTO RN EY* AND C O U N SELO R * AT LAW WEST NINTH STREET LOS ANGELES S001S February 16, 1967 TCUKPHONCi DUNKIRK 8 * 3 0 7 1 i y Armstrong Contracting & Supply Corporation 120 North Lime Street Lancaster, Pennsylvania Re: Dean Clark (Decedent); Maurine Clark (Widow) 66 LA 292-043 Gentlemen: We are the attorneys for the widow of Dean Clark. We are representing Mrs. Clark before the Workmen's Compen sation Appeals Board in connection with a claim which alleges exposure to foreign substances, such as asbestos, during the period of 1940 through 1965. Social Security records indicate that Mr. Dean Clark was employed by your company during the following period or periods: The second quarter of 1961. Would you kindly furnish us with the name of your Workmen's Compensation insurance carrier for the above-noted period or periods? Thank you. SR:lm ? STEVEN ROSEMAN * u ' ' i STEVEN ROSEMAN ANTHONY J. BRAOISSE HERMAN FEUER8TEJN j a m e s j .w a l s h 1021 Low Offices STEV EN ROSEM AN A T TO R N EY S AMO C O U N S E L O R S A T LAW WEST NINTH STREET LOS ANOELES 9001 S February 16, 1967 TKLKRHONKt DUNKIRK 0 * 3 0 7 1 vs* Armstrong Cork Company Liberty and Charlotte Streets Lancaster, Pennsylvania Re: Dean Clark (Decedent); Maurine Clark (Widow) 66 LA 292-043_______________________________ Gentlemen: We are the attorneys for the widow of Dean Clark. We are representing Mrs. Clark before the Workmen's Compen sation Appeals Board in connection with a claim which alleges exposure to foreign substances, such as asbestos, during the period of 1940 through 1965. Social Security records indicate that Mr. Dean Clark was employed by your company during the following period or periods: The second and third quarters of 1951, the last quarter of 1956. Would you kindly furnish us with the name of your Workmen's Compensation insurance carrier for the above-noted period or periods? Thank you. SR: lm 1