Document mmOBdm3Rkaany1VwJVjJ2YGdb

FILE NAME Insulators Workers Comp Claims IWC DATE 1967 DOC IWC063 DOCUMENT DESCRIPTION Claimant - Horsman Robert From M Archive File Name Contract Unit Claim File Robert Horsman Oct. 23/67 Amended Sept. 5/68 Scanned ? yes Source JMA NS Start Year 1967 Stop Year 1967 Contents claim Notes WORKERS ' COMPENSATION APPEALS BOARD - CALIFORNIA INDUSTRIAL ACCIDENT COMMISSION pprrioir or to 1966 APPLICANT ROBERT HORSMAN Asbestos Installer CASE # LA 316509 DATE CLAIM FILED Oct. 23 1967 Amended Sept. 5 1968 INJURY ALLEGED Inhaling foreign substances ALLEGED DATE OF INJURY 1925-1967 EMPLOYER INSURER Thorpe Insulation Co./Firemen's Fund Ins et al including M Insulation OTHER NOTES Pulmonary fibrosis secondary to asbestosis DATE OF RESOLUTION Jan. 22 1970 RESOLUTION Compromise & Release 19,000 settlement apportioned among 18 employers DOCUMENTS COPIED Compromise 1 Compromise & Release # OF PAGPAGEE 2 Application showing original defendants CLAIMANT | : Robert Horsman California Workers Compensation Appeals Board CARRIERS INVOLVED The AETNA Casualty & Surety Co. oAmerican Automobile Ins Co. American Employers Ins Co. American Motorists Ins Co. Argonaut Ins Co. oAssociated Indemnity Corp. oCalifornia Casualty Indemnity Exchange California Compensation & Fire Co. Casualty Ins Co. of California Employers Liability Assurance Corp.Ltd Employers Mutual Liability Ins Co. of Wisconsin: | oFidelity & Casualty Co. of New York Fireman's Fund Ins Co. Assurance General Accident Fire & Life Assurance Corp. Ltd. oGlobe Indemnity Co. Guarantee Insurance Co. oGreat American Ins Co. oHardware Mutual Casualty Co. Industrial Indemnity Co. Sentry oIndustrial Indemnity Exchange Insurance Co. of North America oLiberty Mutual Ins Co. Ins Co. oLumberman's Mutual Casualty Co. oMaryland Casualty Co. oMichigan Mutual Liability Co. Mission Insurance Co. oNational Automobile & Casualty Ins Co. ONew Amsterdam Casualty Co. oOcean Accident & Guarantee Corp.Ltd Corp.Ltd Pacific Employers Ins Co. Indemnity oPacific Co. Standard oReliance Ins Co. Standard Accident Ins oRoyal Indemnity Co. oSecurity Ins Co. of Hartford U.S. State Compensation Insurance Fund oTransport Indemnity Co. The Travelers Ins Co. Casualty Ins Co. oThe United Pacific Ins Co. U.S Fidelity & Guaranty Co. oZenith National Ins Co. oZurich Ins Co. Inde Accir dena t +n Indi erant ity y Co. c0e80 5/81 1 2 t WORKERS COMPENSATION APPEALS BOARD STATE OF CALIFORNIA 3 ROBERT J. HORSMAN &fi CASE No. 67 LA 316-509 5 Applicant fi VS. ) 7 THORPE INSULATION COMPANY et al FIREMAN'S FUND INSURANCE COMPANY, et al 8 10 10 Defendant CERTIFICATIO 11 I hereby certify that the attached documents are trut 12 and correct copies of the original documents filed in the recor 13 of this office in the entitled matter 14 ATTEST my hand and the Seal of the Workers Compensat 15 Appeals Board of the State of California 16 17 18 28 20 Workers CompCompeensatniConosmpaetnsiatoionn AJpupdgeeals Board 8 om, 23 Dated at San Francisco 26 California this 6 28 of April 1981 27 day DIA DIA WCAS Forv 115 NEW 1.78 @auvane DEPARTMENT OF INDUSTRIAL RELATIONS OF ACCIDENTS 1 MCLAUGHLIN EVANS DALBEY & CUMMING 1717 North Highland Avenue 2 Los Angeles California 90028 3466-3541 3466-3541 4 Attorneys for Corning 5 Fiberglass Corp. and Aetna Casualty & Surety Co. Defendants 6 Wee LF aa at ds ee OE eT Prone SOAS ae SSIES CORRECT PROCES_INSERT 8 eo 10 1111 13 14 15 WORKMEN'S COMPENSATION APPEALS BOARD . oe - STATE OF CALIFORNIA | ROBERT J. HORSMAN SSA 562-03-2606 } CASE NO Applicant 24 PROCES_INSERT DIVISION PROCES_INSERT ADDRESS PROCES_INSERT 54 RECTIVA ATRIAL RECTIVA PROCES_INSERT RECTIVA ATRIAL PROCES_INSERT _ ''7700 ATRIAL SIK 67 LA 316 509 vs. COMPROMISE AND RELEASE MUNDET CORK CORPORATION et al ) y Defendants ) AGREEMENT AGREEMENT 16 - The parties hereto for the purpose of compromise only hereby submit the following agreed statements of fact 1. Robert J. Horsman born August 26 1904 claims he was employed between 1925 and June 28 1967 at various locations 2 within the State of California as an asbestos installer as a result of which he sustained an injury arising out of and occurring in the course of his employment from inhaling foreign substances or in- 24 jured self in some other manner resulting in injury to his lungs and other injuries symptoms conditions and complaints set forth 2525 in the medical reports on file NNa I ii 27. was 28 . 2. employed employed During the alleged at at various times by period of employment the applicant Coast Insulating Company The PhilipPhilip CarCeyarey Mfg Co. Corning Fiberglass Corporation Mundet , Cork Corporation Fiberglass Engineering and Supply Company Proctos Company Los Angeles Department of Water and Potter a corporation successor to California -1- a aoe 1 Los Angeles Rubber Company Los Angeles Cork Company Plant Ast 2 Company Coast Insulating Products Swift 3 Cork Company Metal Clad Packing Co. Armstron Insulation Co. Accurate Insulation 4 Inc. Shell Oil Co Company Manville Sales 5 Corporation Arms Contracting and Supply Corporation and various employers set fo 6 in the Application for Adjudication of Claim 38 3. injury are in 8 4. 10 10 5. 11 employee tir The actual weekly wages of the employee at the dispute The employee's present disability No temporary disability indemnity is in dispute has been paid to 12 12 13 13 14 14 15 16 18 6. The parties hereby agree to settle any and all cla on account of said injury by the payment of the sum of 19.000 said sum to be payable to the applicant in one lump sum after deducting of attorney fees and lien claims of record excepting t lien claim of the Department of Employment and said Dept. of Empl ment lien should be denied since the applicant's condition has be permanent and stationary since June 30 1967 Dr. Derry's report of December 8 1967 and the Department of Employment commenced payments July 5 1967 and 7. none has The been applicant's medical expense has been procu furnished by the employers or carriers 8. At employers during various times the insurance carriers the alleged period of injury were for various a b b c a e f g h i j k 1 ARGONAUT INS CO CASUALTY INS CO THE TRAVELRS INS HARTFORD ACCIDENT MISSION INS CO OF CALIF CO & INDEMNITY 1747 1747 . ha?" CO FUND STATE COMPENSATION INS UNITED STATES FIDELITY & GUARANTEE INS Co. 1:77 GUARANTY CO AMERICAN MOTORISTS INS CO SECURITY MUTUAL CAS CO INDUSTRIAL INDEMNITY CO FIREMAN'S FUND INS CO GENERAL ACCIDENT FIRE & LIFE 356 15 356 ASSUR CONTRIBUTION 1,694.00 328.00 1,259.00 41.00 91.00 1,950.00 55.00 701.00 680.00 118.00 144.00 1,780.00 275.00 -2- CONTRIBUTIC 2 m Pacific Employers Ins Co. -3/16 $ 3,009 22 n Employers Mutual Liability Ins.co. 989 3 0 Aetna Casualty & Surety Co. Gree 5,262 ++ p Proctor & Gamble Soap Co. 5 permissibly insured 25 Dm a Los angeles Departmenotf Water & Power legally insured 620.1 7 Olympic 9 9 The employee's attorney is Steven Roseman Boulevard Los Angeles California 90015 10 Attorney requests the fee of $ 1600.00 1543 West 10 10 Amount of attorney's fee previously paid if any $ None 1211 11. Reason for Compromise A bona fide dispute exists 12 as to whether or not the applicant sustained injury which arose 13 13 out of and occurred in the course of his employment through ex- 14 posure to any deleterious substances while working for the named 1515 employers The nature of the applicant's illness and the extent 16 of his disability is set forth in the medical reports on file 117 7 There is a dispute as to whether or not any portion of the appli18 cant's disability is due to causes other than industrial exposure 18 The applicant has expressed the desire of resolving the litigation 201201 by obtaining a lump sum amount and controlling his own medical 22 2222 2323 treatment in the future All parties desire to resolve the dis- puted issues by this settlement and expense of litigation thereby avoiding protracted delay 24 24 2525 26 27 27 28 28 2929 12. The undersigned request Release Agreement be approved that this Compromise and 13. Upon approval of this Compromise Compromise AgremenAt greement by the Workmen's Compensation Appeals Board or a Referee and payment in accordance with the provisions hereof said employee releases and forever discharges said employer and insurance carrier from all 3030 3131 claims and causes of action whether now in oe ascertained or which may hereafter arise or develop as a result of said 3232 including any and all liability of said employer 2 carriers and each of them to the dependents heirs executors representatives administrators or assigns of said employee 3 SF WITNESS this Aday of Cos. os , 1970 at Los Angeles California 5 mH 7 8 g STEVEN ROSEMAN Applicant's Aplicant's att ARGONAUT INSURANCE COMPANY 11 CO 10 SECURITY MUTUAL By HANNA AND CASUALTY BROPHY 11 tf By ue 12 THE TRAVELERS INSURANCE CO 1413 14 By PARKER & DALLY . By ee 15 CASUALTY INSURANCE CO OF CALIF 15 ~ 37 37 By y, 18 HARTFORD ACCIDENT & INDEMNITY CO 19 19 WOODS MISSION 2020 INSURANCE COMPANY 21 21 2322 By FW Harrington Harrington 23 STATE STATE COMPENSATION COMPENSATION INSURANCE FUN 225425 By INSURANCE S. FIDELTY & GUARANTY CO 26 HERLIHY By HERLINY JONES & NELS 7.0 By 7.0 7.0 ry LOS ANGELES DEPARTMENT OF WATER & POWER . 29 pini is we Tele mA Sewers Sesate 30 By pee sete 8. 31 PROCTOR & GANDLE SOAP CO By MERLINY ERLIHY MONES & 32 by Gj || ( ( H GUARANTEE INSURANCE COMPANY 3 By 4 4 .; AMERICAN MOTORISTS CO 10 LUMBERMEN'S MUTUAL INSURANCE CO H 24 20 6 20 ; ? 7 ^ NDUSTRIAL INDEMNITY COMPANY By Jean C > feneal 9 FIREMAN'S INSURANCE By WEINGFAUNNDD KENDIG & COMPSTAOCNKWYELL Lk 11 By 6 #Z #Z f FIRE 12 - GENERAL ACCIDENT LIFE 23 ASSURANCE COMPANY By HERB GARABEDIAN 14 15 16 17 18 19 20 AETNA SURETY & CASUALTY CO 21 By MCLAUGHLIN , EVANS DALBEY & CUMMIN 22 23 24 STATE OF CALIFORNIA ) 25 COUNTY OF LOS ANGELES ) SS - 26 Fanu he 27 | 28 I 29 On 22 this 22 22 day of Fanu A.D. A.D. 1970 before before me the undersigned a Notary Public in and for the said County and State residing therein duly commissioned and sworn personally appeared ROBERT J. HORSMAN known to me to be the person whose name is subscribed to the within Instrument and acknowledged that executed the same 30 i. my IN official official WITHISS WHERSOF seal the day and I have hercunto set my hand year first first above written and affine 32 } SEAL SEAL SEAL - ni On oot ; ee Notary CO Notary Public in and for ~ County State said ~ .a -- -- .. yo - _ . : ee - meee Ce oe > wen . See MAINST MAINST . MAINST MAINS MAINST T MAINST MAINST . . a Row we ~. e, _ . 28 = ee ony ees edie = oe Seep rate - re oe rer, whet wet wet and denjua CASNOE ST nt tutte Mr. 1 es rn e ft Gomme = rt ote. 9 .- metry dee SsJ,IG Ee re Fe ate Sr:1 Sea Beet Nas YY RTD tt eee Sorermeinniemtin eee ee oe Mee tee CA TENS 8 S9 Ake Tht NIE Le tee ewe NARE omer SE NARE NARE we me te EM _SEE EM _SEE $ 9X o ee mew nneree= See feemwe = eee SPP 64249716 64249716 4359881 soe ee Therpe Therpe TherpeTherpe VS. Insulation Insulation Co. Averum Sat attached_abeat attached_abeat attached_abeat EMPLOYEI EMPLOYEI 2741 _s Katos Averum EMPLOYER 3 450ESS . Fireman's Fireman's Fireman's Fund Insurance Ingalas California attached shoat 3323__ Corn Son ******* SIN PARARE Se R ev * * SENSURED SENSURED ON i 840 5948637 5948637 5948637 : ith Street Street 1633ES OF INSUPORTE PIRK on 44 N^ CTLAIMED THAT Los Angeles California 1. The injured employeempleoyee born 3/26/1 3/26/1 F 2t 0/25/1967 while emploeymedployed as employed ... Ashecton Installer Installer or 1925 to 0/25/1967 various LOCCUPATION AT TIME OF ,, ar 1947E OF alles of and in the course course of employment to CITY Occupational Occupational STATE Disease Disease by the employer sustained injury , arising 2. 2. The injury occurred as follows Inhaling Inhaling STATE ++ T PARTOSF BODY WERE INJURE T foreign foreign cubstances rgaPLAIN WHAT EMPLOYEL MAS BRING AT THE THE OF INJURY INJURY AND 450 UPY 3. 3. Actual earnings at time of injury were Haximum GINE WELL OA HO4 ST GALKET GA KRUBLY DATE AND NUMEZ^ GF 2043 600622 720 15 4. The injury caused SEPARATELY SEPARATELY STATE VALAR PER WEEK OF MOST OF TIPS MEAL disability as follows JJuun ne e 2 200 1907 LOBINS OF OTHER ADVANTAGES REGULARLY RESESTES RESESTES to date SPECIFY LAST ELY OFF Way US TO TRIS INJURY AND BEGINKING AND ENDING DATES OF ALL PIGIOUS 5. Compensation was paid ( ETES NO ; QTAL PAID AWSBELY RATE ves \ ves 6. Medical treatment was received furnished _ en ~ Alle treatment was by employer 1983 1401 TATE OF LAST TREATWEST TOATE OF LAST PATMENT PATMENT the employer en insura company company IYES IYES other ----other treatment was provided or paid for by Ductors not provided or paid for by employer or Regirald - Dr. Scorna Scorna II II Derry Derry and and Dr. mtr on en . Derry ae 657678 ** AND ADUR ht << >> 0279 53 NAME 6 22865 IRANE PER50 za d~ tkerP3AGING P3AGING OF PAY 5 0 * 1024 1024 this injury are Smart Uzungleyment Insurance Insurance or mplay ment Coieper bour filed for industrial injuries by benifits Disabilty men Disability Disability benifits have been received the received since date since injury rage injury 1721 ca employee as follow st em cee eee +576 +576 CA 4,488 *** - **** yy * 4 aan od 7 3 T aa!e te . at S.. . : so : ws a Ao . . . H sey 4 post edt, r . Sa ay a TL re] ' ot ae an : oo _ a . for Temporar Modigal traitu est , approjai aprojai . . Aa RY ev o Smee oo .e rs re ome . owe 1 * 7 7 m tat oa tou. a ro ee ee me eee mse Western Asbestos Co. * 240 Valley Drive "T risbane California 04005 Insulations Inc. sold to ilip Carey fg Co. \ 2 S. Honterey Pass Rd Monterey Park California Owens Corning Fiberglas Corp. P.O. Box 901 Toledo Ohio Los Angeles Cork Co. w.T. Thorpe Inc. 94 E. 2nd Street Los_Angeles Los_Angeles California 012 i Armstrong Contracting & Supply 120 N. Lime Street Lancaster Pa . Commercial Contracting Corp. By 32217 Stephenson Madison Heights Michigan Co. Strect California 6/12/65 1/2/66 Fireman's Fund Insurano Cormeny . 3323 NL 6th Street - Los Angeles Calif v : Hartford Ins rout 542 S. Spring Strect Los Angeles Californie General Accident In t 3535 . 6th Street Los Angeles California 3,4 and 10,111952 11,12 1953 1954 1957 1957 1959,1961,1962 1959,1961,1962 2,3,4,5,6 1964 and 8-10 1906 12/1964 and 1905 1961 1963 & 1964 Pacific Employers Ins Co. 4050 Wilshire Boulevard Los Angeles California The Aetna Casualty { Surety Ins Co. California California 2404 Wilshire Los Angeles Boulevard Boulevard CCalaiflorinifa ornia and Employers Mutuals of Cal 3540 Wilshire Boulevard Los Argeles California Fireman's Fund Ins Co. 3223 W. 6th Street Los Angeles California American Motorists Ins 3545 Wilshire Blvd. Los Angeles California 1961 1962 1963 & 1964 1962 The Travelers Ins Co. 3600 Wilshire Roulevard Los Angeles California California 1962 1939,1050,1950 193,05190 193,105,1950 193,105,1950 6.19016.1901 1939,1050,1950 1939,1050,1950 1939,1050,1950 193,105,1950 1939,1050,1950 The Aetna Casualty I Sur Ins Co. 2400 Wilshire Blvd. LosLos Angeles Angeles CaClaili ffoorrnniiaa en + C eye we te et e = Ree ee = as ee years ae ermm Ce SOA wete loe Se eeemen times Se ee wie oe Contaction Contaction Contaction Contaction Contaction Natal Natal Natal Works 24. 24. 24. Chic Chic ao Hont Hont Hont California California Plant Plant shots shots Co. Co. 15h 15h 15h 15h 15h 15h St. St. Beach Beach Calif : Long Beach Calif Accurate Accurate Insulation Insulation 32322233 Hottler Hottler St. St. Co. Angeles Los Angeles California California California California Inc. 1,10 0953 12/1960 2341 wee oo - Industriel Industriel Industriel Industriel Industriel Incecric s wee eam 4 305 305 80 80 2fg5a sg -s* on Ot. 2 ou Los Los Angeles Angeles Angeles Californi Californi Californi ' Air Conditioning Inc. --7001 --7001 Kettner Boulevard in Diego California Department of Mater Mater Mater & Power the of City of Los Los Los Angeles Angeles Angeles 207 S. Broadway Los Angeles California Armstrong Cork 120 3. EiEine ne SSt.t. California Lancaster California Co. Manvil e Manvile Manville Carolina Insulation Insulation Insulation Insulation Insulation Insulation Insulation Insulation Insulation Co. Co. Co. State Los 1960 12/1954 1-12 1-12 1959 and 1960 8-10 Argonaut Insurance Co. 443 Shatto Shatto 71 Los Angeles California and Guarantee Ins Co. 1671 Wilshire Elvd Los Angeles California LEGALLY UNINSURED UNINSURED 11,12 1951 1-4 1942,19471,1928 9149492,119497,519228 1951 Travelers The Travelers Ins Co. 3600Wilshire Boulevard Boulevard Los ingeles Calif Self Insured 10 S S we kk wCe, % 2745 - My i ee _- E ares E tues Sle s SSIS ryPit eses SSIS : Paulsborough Paulsborough New Jerse Richmond Virginia Brooks Fisher Insulation Co. Altants Ga Plant Rubber & Asbestos Co. SanFrancisco Francisco California Swift Brannon Street Swift Packing Co. Los Angeles California Warren & Dailer Dailer Insulation Co. Los Angeles Californic General Petroleum Co. Tos Angeles California Rubber Rubber Rubber Rubber California Co. 1930 1010 1040 1040 1940 car ed . i . ~ 1939 . Pacific Employers Irs 4050 HilshireHilshire Boulevard Los Angeles California California 1938 1937 1937 1934 1935 & 1936 1933 1931 and 1932 Self Insured Security Mutual Cas o Reeves & Bay St. 1139 N. 6th Co Adjusto Los Angeles Calif State Compensation P.O.Row 2134 Los Angeles Ins Occidental Indemnity address unknown State Compensation Compensation Compensation CompensCoamtpeinsoatnion Ino Ino Ino . P.O. Box 2134 Los Angeles California and Lunkerman's Mutual Ins 3545 3545 Wilshire BoulevardBoulevard LosAngeles California Self Insure 1930 1927,1970,1028 California Cas Indornit Exchange 417 S. Hill Street Los Angeles California 1925 aired 1926 1926 Statc Consation P.O. Box 213 : ay mone Inc.