Document nk11zaBbd5Zw7EDMm3y178gzX

'Ifj OF WOMOCMrt COMPENSATION Sl-VSSSsr. e PLAINTIFFS i EXHIBIT l NG108F ' JOHN KOCISKO r=& Pt&somer, n. i NATIONAL GTPSTJM COMPANY RgSpo*d**L Hartford (Him bunaei Coapigy) 0 * Bricn, Devlin & Shaw (Ammr ter Pctmoqtr) 1015 Park Avenue, P.0. Box 827 (Addnn) To 7hs Division or Wowcmsn's Compensation: - Pecmooer, alleging that he sustained an injury by an accident arising out of and in the course of his employment with the respondent, compensable under R.S.34:15-7, et seq* supplements and amendments, respectfully states: # 1. Name John Kocisko Soc. S__e_c_u_r--ity No. 146-01-8293 2. Residence Address: (a) Street Address. 32 Northyiew Road (b> County.. Morris ,,(c) City or Ttr-r*. MilliTigfnn, w_ .t rrwts euuM pcttt*on cannot se pmcusid without Tma Mramunew 3. M 4, Agt--^X__ 5. Marital Status. --M .-- 6. Occupation. Machinist (atHam ofacridott) 7. Name of employer (a) Address . National Gypsum Company Division Avenue, Millington, N.J. (b) Business ____ Asbestos aiding products ~ on arid berore 8. Old employer bate notice or knowledge of injury?. On what de> May 15,'1971 9* Place of accidental injury -despondent PTCTliftftft___ Dam. 8gvaYib;g9Te 10. Describe die accident -dust and reined e wi^fu*gSs silicates and dusts for'44 years caused oeenpflcirmai 11. Dace petitioner stopped work__5/17/71 _ ------ Date returned to Tmrir ,tT?aHlg 12. Describe extent and character of injury. If there has been amputation or loo of usefulness of any of impairment of any physical function, --fully Chronic exposure to industrial dusta _caused asbest'osis.^imeuinocopiosis^^tQt^llv traumatic neurosis. $3.91 per hr. - 40 hrs.r--plus 8 hrs. 13. Wages or earning* Sat^pgsrtiaeL- Compensation paid: Rate______ Temporary disability. Permanent disability maximum due 14. Was medical aid required?--YCS, _ _ employer requested to furxusii Was it famished? If IQ,. bereea whet Am> _ * If not, what sum was expended? .yes.  i **> I* names tad addresses of physicians tad hospital ^r. jpilla& H. .Cox, 211South Finley Avenue, Basking Ridge, N. J. Dr. J. Chrobok, 1390 Valley Road, Stirling, N.J., company doctor. Dr. Enrico Funaro, Morristown Medical Group, 290 or 26 Madison A\e Morristown, N.J., takes company x-rays. Dr. Wright, Cleveland, Ohio Morris County Chest Clinic, Morris Plains - x-rays every year. 16. What other facts are there which you believe important? Your petitioner therefore prays that the Division of Workmen's Compensation will determine the .mntiWf of compensation due your petitioner from said respondent, under Revised Statutes of New Jersey, Title 34, Chapter 15, aad the Acts supplemental thereto and amendatory thereof, and that your petitioner may be awarded his costs in this proceeding, and such other or further relief as may be proper. Statz or Niw Jmszy, County or------- P1*^00----------------------- T ty (Ttaticncr) ... fofaP Kocisko nf age being duly sworn according to law, on his <**h deposes and says: That he is the petitioner named in the foregoing pernios; that he has read the same and is with the contents thereof; and that the matters and things therein set forth are true ac cording to the beat of his knowledge aad belief. Subscribed and sworn to before me this. 18th of Mssl # to 71 , / Plainfield. New Jersey y JANELLE HOUK S NOTARY WftllCJO.BL.lRSY My Commission Expires May20.1974 (This affidavit may be sworn to before any person authorized to administer an oath) day Nones To The Respondent: The foregoing claim petition has been presented by die petitioner to the Division of Work men's Compensation for hearing and determination. Unless an answer in duplicate is filed with the \ Secretary of the Division. Labor and Industry Building, Box W, Trenton, N. J. 08625, WITHIN 20 DAYS, THE PETITIONER WILL PROCEED WITH PROOF OF CLAIM ACCORDING TO LAW AND MAY OBTAIN JUDGMENT AGAINST YOU. Division of Wokkmkn's Oimpknmtion