Document ppKo0QEazdz3Lk5ae5oE9Kwr7

FILE NAME: Contract Unit Workers Comp Claims (WCC) DATE: 1968 DOC#: WCC005 DOCUMENT DESCRIPTION: Workers Comp File - Clark, Maureen Widow Contains all documents found in the Claimant's file, with one blank page between each separate document ATTACHED SHEET PAGE ONE EMPLOY**ER A DEPENDON ROOFING CO. 3521*N. Cicero Avenue Chicago, Illinois QUARTER PERIOD OF EMPLOYMENT 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. Fort Huachuca, Arizona 3/31/41, 6/30/41 O'MALLEY PLASTICS, P.O. Box 3558 Phoenix, Arizona INC. 3/31/41, 6/30/41 A.N. BORGQUIST P.O. Box 6134 P h o e n i x ,Ar i z o n a 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 C O . , INC. 220 Nordina Street Redlands, California 6/30/ 41 C.C. MOORE & CO. Engineers Unit X-l 450 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 12/31/41 MARINE ENGINEERING & SUPPLY 941 E. 2nd Street Los Angeles, California 12/31/41, 3/31/46, 6/30/46, 3/31/47 INSURANCE CARRIER 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. 948 E.. 2nd Street =^qs 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 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 3/31/42, 12/31/42 3/31/47, 6/30/47 12/31/48, 12/31/49 STATE OF ARIZONA 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 C O . , INC. 2500 N. Alameda Street Oompton, California 3/31/49 Unknown STEARNS ROGER CORP. 660 nnnnork it-rnnt- 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 INS. CO & 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 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 9/30/56, 12/31/60 3/31/63, 6/30/63 12/31/56, 9/30/57 12/31/57, 9/30/58 12/31/56, 9/30/59, 12/31/60 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 Unknown (moved no address) CASUALTY INSURANCE CO. OF CALIFORNIA, INC. & STATE COMPENSATION INS. FUND SELF -INSURED ARGONAUT INSURANCE CO. STATE OF ARIZONA 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 12/31/59, 6/30/59 LOS ANGELES CORK CO. 4180 E. Washington Los Angeles, California 12/31/60, 9/30/C4 ARMSTRONG CONTRACTING & SUPPLY CORP. 120 N. Lime Street Lancaster, Pa. 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. L a m e s a ,C a l i f o r n i a 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 12/31/65 SENTRY INS. CO., a Corp. Unknown 12/31/65, 1/1966 LIBERTY MUTUAL INS. CO. & INS. CO. OF NO. AMERICA ''lVj.u Department of Industrial,Relations '' GOOD CAUSE APPEARING: The application herein is taken off calendar. Division of Industrial Accidents , A N C li.'- 'i Workmen's Compensation Appeals Board State of California w et* oati Please file tinned original and six copiet and print or type namet and addresses APPLICATION ?& il FOR ADJUDICATION OF ClAIM (Oeath Case) MENbAA APPLICATION 6C LA 202-043 CASE NO m /.Mrs. Maurino Clark (widow) iip ru c iN T ) " ^ ll ____Dean Clark (Deceased) _____13331 Lakowood Doulevarcl, DrlO n m it N U im m ii _____ Downey, C a l ifor n i a ____________ `______________________________ ___________ Dqan_Clark ((Dec?) SS# 327-07-944 3 ^ 'B t e u f t u i g p i O T e r n a i r r u t p t c t m l s e c u r i t y n u m b e r ) VS. See attached <C M P L O T !I sheet_____ ________________________________ EMPLOYER S AOORCSS) ________ See attached sheet <E M P L O Y E R ft I N S U R A N C E C A R R I E R OR S T A T E I f S E L P I N S U R E O OR PE RMISSIBLY U N IN S U R 1 0 ) t A D D R E S S OP I N S U R A N C E C A R R I E R , I f A N Y ) IT IS CLAIMED THAT: 1. Deceased employee born __ X ^ / 2 / 1 9 0 7 ______ t while employed as a ____ A s b e s t o s .W o rk S T _ ____________________ (BATS o r HATH I (OCCUPATIOH AT T I K I Of IHJUUT) on 1 9 4 0 - 1 9 6 6 ______ , at ( D A t lS I INJUITI V a rio u s p la c e s IC ITVI ___________________ _ by the employer sustained injury arising out I ST A T I I of and in the course of employment t o ______ i u r i q ______________ !___________________________________ !______________ I t T A T C W HA T PARTS OP BOOT W I R E IN J U R E D ) 2. The injury occurred as follows: ,, I n h a l a t i o n o f a s b e s t o s a n d o t h e r f o x e i g r L _ s u b s . t a n c . e s ____ (E X P L A IN WHAT EMPLOYEE WAS OOIN 4 AT TIM E O f INJURY AND HOW INJURY WAS REC EIV ED) -------------------------------------------------------------------------------------------------------- resulting in death on M&XLi-- -- 12H13-- . ( OAT C OP O E A T H ) 3. Actual earnings at time of injury w e re:____________________________________________________________________________ {D IVE W EEKLY OR MONTHLY SALABY OR HOURLY RATE AND NUMBER O f HOUR WORKED PER W E E K ) 4. The injury caused disability as follow s:______________________________________________________________________________ O F I C I T T LAST OAT O i l W O D U I TO TH IS IN JU U T ANO IS IH H IH O AHO [ H O IK S D A T I I Ot ALL F I A I O D t O f D U I TO TH IS IH J U D t ) J. Compensation was paid_____ _HCL $_______________ (T ill (HO) (TOTAL PAIO) $_______________ ___________________________________________ <W ( ( I V D AT ( > I OAT t O f I A T f ATW ( MT I 6. Medical treatment was received ___ y G S ____. __________________ All treatment was furnished by the employer or insurance (VCft) ( N O ) I DA TE OP LAST T R E A T M E N T ) company ____ _______other treatment was provided or paid for b y ----------------------------- ----------------------------------------------- (T ff) / NO > Doctors not provided or'paid for by employer or insurance company, who treated or examined for this injury a r e :--------------- _____________ S t . F r a n c i s H o s p i t a l , 3 6 3 0 I m p e r i a l I l i n h w a y , L y n w o o d Ca l i f o r n i a __ ( S T A T E N A M E S A N O A O O B E S S E t OP S U CH O O C T O RS A N O N A M E S OP H O S P I T A L S T O W H I C H SU CH D OC T OR S A D M I T T E O I N J U R E D ) 7. Defendants have paid burial expense. _____ _____ TOTAL P A ID ----------------------- (T ill (H O I 8. The employee left surviving him the following dependents: NAME N one DATE OF BIRTH (if under 21) RELATIONSHIP TO THE EMPLOYEE ADDRESS _________________________________ WHEREFORE, applicant requests a hearing and an award of: Death benefit----iL Burial expense----'L. Compensation accrued and unpaid___ Unpaid Medical bills_jh-- Other----------- Specify:--------------------------- ------------------------------------------------------________________________________________________ and all other appropriate benefits provided by law. Hearing requested at ----- LOS--A n g o l o s CITTI , Dated at - L K - A n q e l e S -, California, - J u n e --2-5-,-- 1 9 8 (CltTI , tO ryL < / / Number of witnesses _ - Pre-trial w anted--------------1 1 - It/*' /j 7 Estimated time of trial Set Set later on written request LAW O FFIC E S OF 381 - 3 0 1 1 154 3 W. 0 1 y m p ic '* Pfou V ovan Y IiOfj-- Anqe-les , Co l iforni a- --- l A O D R C S S ANO T I U P H O N t N U MB E R OF A f T O R N f T ) Al'rLlLiA 1 lUiN (D eath Case) FILE SIGNED ORIGINAL A ND SIX COPIES (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) 1/ __________ M A U R IN E C LA R K _lV L L cL J______ DEAN CLARK (Deceased) CASE No. - n. r y __ 1 3 3 3 E-Lakew ood -B cm le v a rdL,--B-^LO- A P P L IC A N T '* A O O R ISS -- Downey, CaXxfoxuia------------- Dean C l ark (Dec.) 88# 327-07-9443 DECEASED EM P LO YEE S NAM E AND SOCIAL S EC U R ITY NUMSCR ___________B ALDW IN E H R E T - H I L L , M P L O T II f I NC . Contracting Division, Post Office B ox number 34126___________________ EM PLO YER'S AD O RISS S an Francisco, C a lifornia_________ ___________ IN S U R A N C E C O . O F N O . A M ER IC A E M P L O Y E R 'S IN S U R A N C E C A R R IE R OR S T A T E IP S C L P .IN S U N L D OR P K R N tS S IR C r U N IN SU R ED o': l. it alleged that_JDean-C. a s d )__ NAM E OP EM PLO YEE __ 6 2 1 S outh V irgil Avenue IN SU R A N C E C A R R IE R 'S ADDRESS _Los_Angeles, California JL2/2Z12L DATE OP S IR Y H while employed as a .A flifia.tQ s_JW Q xkfir_ O C CUPATIO N A T T IM E OP IN JU R Y filili NAN E O f IM P L O T E R o n 1 9 .4 Q .. t o ^ 1 9 - 6 6 - , at VariOUS place? California, D A TE OP IN JU R Y C ITY . >. f _sustain.ed fi-njury `arissin'g o*ut'of'Va'mi in the course Of emploiym'e*nt ^ 1i to JLUNG- PARTS OP SOOT FOREIGN SUBSTANCES as follow s:___ IN H A L A T IO N O F A S B E S TOS AND O TH E R E X P LA IN HOW IN JU R Y WAS R E C E IV E D resulting in death on D A T I O r D IA T H 2. Employee's actual earnings at time of injury $__2_ -at_______ ______ _ The basis of pay was 3. Was compensation paid?_______ NO-- t il NO f ------------------ $---------------------- ------------------------------- TOTAL. rAID W it ALT IA T I D A T I o r L A IT rATM C N T . A. Was medical treatment received? . Y E S T il _______ . _____________________________ _ NO D A T I L A IT II C II V ID Was all medical treatment provided by employer or insurance company? _______ _________ _ T it NO If no, state who provided it. / Lynwood -ST^-F-RANCIS-HOSEITAL.^ 3630-Imftcrial-Highway-^.BjBMKHyx ALSO S T A T E N A M ES AMO A O D R E S S tS OP A L L DOCTORS WHO T R E A T E D OR E X A M IN E D FOR T H IS IN JU R Y I. Has burial expense been p aid ?_____ in 6. This application is hied for: ____ _ $___________ _ Who paid it? NO ... Death benefit----X -- Burial expense_________ Compensation accrued and unpaid_____________________________ Other__________ Specify:----------------------------------------------------------------- ------------.-------------------------------------------- 7. The employee left surviving him the following dependents: NAME AGE ( Ip U n o ln 21 ) NOM ii.Unu.1.. < l`L RELATIONSHIP TO THE EMPLOYEE NONE M - v.i ADDRESS IM PO R TA N T-- If any applicant is under 2! years of age, it will be necessary to file JVtiiion lor Appointment of Guardian ad Litem, l orms for this pur|>osc may be obtained at the office oi the lndusiri.il Accident Commission. WHEREFORE, applicant requests a bearing and an award for <// appropriate benefits be is entitled to by law. Hearing requested at -- Dated at .L o s. A n g e l o s ( .... ,,Kmrch 2 2 , 1 9 6 6 "i CITY M ----- Eitimated time of trial .---------------------------------- 4 Pltaie set now____ ; set later on written request. LAW O FFICES OF STEVEn T^OSEMAN *on* f A P f . l C A M f ' L AT . O L M I OR R t ' k C l ' N T A T l V l L621 W. 9th St., (Du 5 - 3 0 7 1 ) h* 11 ' in iNf N'iwni M r * s 9 f r f 1 1 MT I T J V f APPLICATION ft FILE SIGNED ORIGINAL AND SIX CORIES (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) Dean Clark , APPLICANT Soci.il Security No. 3 2 7 - 0 7 - 9 4 4 3 Baldwin -Ehret Hill, Inc. EMPLOYER Unknown________________________ E M P L O Y E R IN 1 U A A N C I C A R R IER OA ATATC I f tlf - U U U R L O OR P t R N I I t lI L f U N IN A U arO !GLA 292 003' CASE No. 13331 Lakewood Boulevard A P P LIC A N T 'S AOONCSS Downey, California Telephone No______________________________________ Contracting Div., P.O. Boic 34126 XNPLO VCR'b ADORE Sein Francisco, California_______ IM S U R A N C i C A R R IE R 'S A O O R fb t 1. It ij alleged that - O tk^,. name orturioni V / 2 / 1 V 0 7 ____ while employed on DAT P o r 1 IRTN 1940T U)fa6_ 19_ DATE OP INJURY as a_aske^.to3_worker. O C CUPATIO N A T T IN E OP IN iU R T . at. various places, including S a n __t California. o il , town oa n t e t w iicat tN iuat o ccu a ato F r S n C i S C O by__ aaJLdwi.ii=Eiir t-HilJL-- Inc..... employment. NANI or IN riO T ta l . . , ' I { 1, ''' sustained Injury arising out of und occurring in the course of thr ______Lung__ S TA TE W HAT AAATS O r SOOT W EAE IH J U tlO ANO SUBSEQ UENT A E S U IT S inhalation.of asbestos and other,lore!g n .substances E X P L A IN W HAT EM PLO YEE WAS DO INR AT T I N I OP IN iU R T ANO MOW IN JU R Y WAS R iC E IV E D 2. Actual earnings at time of injury $. OB MOUSIY BATE. HOUBS A DAT AND OAT* A WEEK 3. Periods disabled for work: 4. Was compensation p a i d ? ____ NO per------- The basis of pay was: WEES OB MONTH STATEFAT riBtOO srCCIFTBIOINNINOANDENOINODATESOrA ll rtBIODSOrrWOO DUETOTHIS INJUBT Date returned to work_______ $ ------ $- Have you received unemployment or unemployment compensation disability benefits since the date of injury? 5. Was medical treatment re c e iv e d ? _________________ State date last received:_______________________ YES NO Was all treatment provided by the employer or insurance c o m p a n y ? ----------- H 2 ------------ - YES NO If not, state who provided i t . _______________________________________________________________________ Also state names and addresses of all doctors who treated or examined for this injury. .. _llSffiP . . --2 . 6. This application is filed because of disagreement regarding liability lor: Temporary disability_y e S --Permanent disability----. y e s l 'ropcr Compensation Kate . . yCS Self-procured medical costs__y e s - Litigation costs y t^ s _ Medical treatment yGC . Other___ ye^Spcc.fy: ifnmr - .d la tur. m a d Leal., trea tmeut a n d u.urgory ______ 7. Have you ever had a case for another injury before the California Commission?_______ ____________ ___ W IIU R L .IO R I-, rjtplieant requests a hearing and award for all appropriate benefits provided b y Ijiv. Los Angeles Hearing requested a t ------------------------ . . . - CUT Dated at Los.-Aiigc l o s . , C a l . f , Fe b r u ar y 15, 19 DATE J ' '. 6 ' O ' A l T l l C A M f k blOWm TU l U r 1" 0 Estimated time of trial------------------- - ....... Please set now____ ; set later on written request--------- LAW-JDFlillCliS. QE_.SIJEVRN U.QSBiAAN_____________ APPLI CANT k A I I O R N I Y ON C P f t l l l N T A f W C --U-Lh-- JL.-,-- .Lo g A nq a le s . .-- a l i f . ornia A 0 R LA S ANO T E L E P H O N E H ' J H I H I 01 A n O M I T O f R E P R E S E N T A T IV E C k >Wcy H-4 Dec^-v dfarft _ ... : C 0J 1-& f n 1'^ -..Cf^iw______ __ _ _____ _______ _______ __ B * i d * i * ' - . E h r + t i i / l _______ ___________________x l i s l U ft KHt + c o f f e ________________ _______ ___ ______n __ / i r m s i r o ^ ...d o r _____ _______ ______ _________________ __ __ . A c te5LlciAM.i [Ic_____ . -. ..: ..-. : _____ :_________ -_____ i!....____ -,0<fcL**5.__,<C$ m *\5-______ .....:_:__ ,_____!______ : _ ___ _ ;_ f t o d U c'fe__ ...... ___________ _________ ___- _PJ<**dL_ _ \o<tsrf.ss______ ___________ ____!______ : _ -- -- :' H M ' F r :-|-U M'isV. ' " f V; . **' 'V ' v 'Vf. `|v-. ** 'y Jt vr- WORKMEN'S COMPENSATION APPEALS BOARD STATE OF CALIFORNIA CASE NO. 66 L.A. 292-0lO MAURINE CLARK (Widow), DEAN CLARK (Deceased), Appljj>afit, 7 VS. 8 BALDWIN 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, settling this case 14 for 15,^10.50 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 i 20 AGAINST: HARDV/ARE 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 -- U__HiIm iM!wttnrdt.altrtAaatlHdiMlattsiMi Am -- I l A u rd bd* Atatm . X PAYABLE AG FOLLOWS: 2 By: FIREMAN'S FUND INSURANCE COMPANY 3 To: Applicant #> 1+8.53 Dr. Cohn Field 200.00 4 Attorney Steven Roseman, for conts 86.b? Attorney Steven Roseman, for fees 700.00 5 51,035.00 6 HARDWARE MUTUAL CASUALTY COKI'ANY 235.00 7 INDUSTRIAL INDEMNITY EXCHANGE 333-00 8 INDUSTRIAL INDEMNITY COMPANY l+ll+.OO 9 INSURANCE COMPANY OF NORTH AMERICA 180.00 10 PACIFIC EMPLOYERS INSURANCE COMPANY 8H6.00 11 RELI/J'ICE INSURANCE COMPANY 67 .50' 12 THE TRAVELERS INSURANCE COMPANY 621. 00J 13 FIBRKROARD CORPORATION AND PLANT RUBBER ASBESTOS WORKS 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 1+50.00 18 STATE COMPENSATION INSURANCE FUND 585.00 19 LIBERTY MUTUAL INSURANCE COMPANY __ 2.7Q.QS- TOTAL ` 55,^10.50 Referee V/ORKMEN'S COMPENSATION APPEALS BOARD .T LOS ANGELES, CALIFORNIA August 28, 1969. 27 28 29 'All parties served by null a:; ahovri c>ri OffLelnl Address Record. 30 7/7- ________ ./r?/69 66 LA 292-C^j/ tw rUMitofladmtrii Relation O i m i a i 4 | n 4 M tn | Accidents StateofCteiterwte A#j(i fcmd Hmhb Upteltev m *6A*frfcft (ft.S-6> r* 1 2 3 4 5 MAURINE CLARK (Widow), ) DEAN CLARK (Deceased),-* 6 Applicant, 7 VS. ) 8 BALDWIN EHRET-HILL, INC., ) et al, 9 ) 10 Defendants. ) ... ORDER AtPROVING 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 settling this case 14 for #5,*fl0.50 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 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- f Im CInmw<l far* it'-sai rom fttiatiwif Aliuli Star* %S4> * >' v A* *.. 1 PAYABLE AS FOLLOWS: 2 By: FIREMAN'S FUND INSURANCE COMPANY 3 To: Applicant I *+8.53 Lr. John Field 200.00 4 Attorney Steven Rosenan, for costs 86.*+7 Attorney Steven Roseman, for fees 700.00 5 $1 ,035.00 6 HARDWARE MUTUAL CASUALTY COMPANY 235.00 7 INDUSTRIAL INDEICJITY EXCHANGE 333.00 8 INDUSTRIAL INDEMNITY COMPANY *fl*+.00 9 INSURANCE COMPANY OF NORTH AMERICA 180.00 10 PACIFIC EMPLOYERS INSURANCE COMl'ANY 8*+6.00 11 RELIANCE INSURANCE COMPANY 67 .50 12 THE TRAVELERS INSURANCE COMPANY 621.00 13 FIBREBOARD CORPORATION AND PLANT RUBBER ASBESTOS WORKS 180.00 14 CASUALTY INSURANCE COMPANY CF CALIFORNIA 39.00 15 ARGONAUT INSURANCE COIIPAILY 65.00 16 ZURICH INSURANCE COMPANY 90.00 17 AMERICAN MOTORISTS INSURANCE COMl'ANY *+5o.oo 18 STATE COMPENSATION INSURANCE FUND 585.00 19 LIBERTY MUTUAL INSURANCE COMPANY __ .2 7 Qu.QQ TOTAL $5,^10.50 Roflferee 1 WORKMEN'S COMPENSATION A1PEALS BOARD $AU)i80 AT LOS ANGELES, CALIFORNIA August 28, 1969. All parties served by r'-ail a:; :;h.>wr> on Official Address Record. '/t/f * // '' . /. . --- ;--- 1-- P /2 ?/',0 La P P P .-C k "/ tmiioi H nal MmUm CMHwm* AttuiitiMfd 9hmm flitiUww AHMy f < DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INUIJSIRIAI ACCIDENTS WORKMEN'S COMPENSATION APPEALS STATE OF CALIFORNIA BOARD MAURINE CLARK (WIDOW) DEAN CLARK (DECEASED) A [>pin an/ vs. BALDWIN E1IRETHIILL, INC.; et al Case N o . COLA 'yil 0^13 N o tice of Tim e and Place of Further H earing ALL ISSUES Dfinjan t n o t i c i : t o a i .i. p a r t ie s You arc hereby notified that further hearing will be held in the above-entitled action at 4107 LOS ANGLLLS STATE OM ICL BUILDING, 107 SOUTH BROADWAY LOS ANGLLLS, CALIFORNIA Aucuat '7, TJC9 9 A.M. ALL DAY Dated at: Los Angeles, California WORKMEN'S COMPENSATION APPEALS BOARD Ii i. ' I i By r i-I m i l. NOTE: CONTINUANCES AND FURTHER HEARINGS ARE NOT FAVORED. SERVED BY MAIL ON PERSONS SHOWN ON THE OFFICIAL ADDRESS RECORD Date: .. By: Copy of application filed 3/.-j /l 6 .-e /'/;.6/C3 served Parker, McGee, Peckham & Roberto and Baldwin, Tiioiaas & Taker. D I A W C A 8 FORM 2 3 L A iRCV FORMCRLV F o r m 4 0 0 L 12 6 ( D r o %p DEPARTM ENT O F INDUSTRIAL. RELATIONS DIVISION O F INDUSTRIAL. ACCIDENT'S WORKMENS COMPENSATION APPEALS STATE OF CALIFORNIA BARCT^ MAURINE CLARK (WIDOW) DEAN CLARK (DECEASED) Case No. 66LA 292 043 N otice o f H earing \ Applicant.. \ vs. / BALDWIN EHRET-HILL, INC.; AND OTHER DEFENDANTS AS SET FORTH ON PAGES 1, 2, 3. 4 AND 5 OF \ ATTACHED AMENDED APPLICATION ' INSURANCE COMPANY OF NORTH AMERICA, a corpora tion; AND OTHER DEFENDANTS AS SET FORTH ON PAGES 1, 2, 3, 4 AND 5 OF ATTACHED AMENDED APPLICATION Defendant.. 8 You ire hereby notified that an application for compensation has been filed with the Workmen's Compensation Appeals Board of the State of California. You are further notified that said application has been set for hearing at 4107 LOS ANGELES STATE OFFICE BUILDING, 107 SOUTH BROADWAY LOS ANGELES, CALIFORNIA January 22 & 23, 1969 9:00 A.M. 2 days and that at said time and place the Workmen's Compensation Appeals Board will proceed to hear and dispose of the said application in the manner prescribed by law. WORKMEN'S COMPENSATION APPEALS BOARD Dated at: Los Angeles, California By 'Hi! !.. o : i:i .;i REFEREE NOTE: The parties are expected to lubmic all ditputed issues lor decision at this hearing. All witnesses, evidence, medical reports, payrolls and other proof must be available at the hearing. CONTINUANCES WILL BE GRANTED ONLY UPON A CLEAR SHOWING OF GOOD CAUSE. Requests for continuances are tn be made within 1 days of the date of tlm notice. NOTE TO INSURED EMPLOYERS: Your attendance at thia hearing may not be neccisary. Aik your insurance company. SERVED BY MAIL ON PERSONS SHOWN ON THE OFFICIAL ADDRESS RECORD D`":12/4/68 Br . Copy of application filed 2/17/66, 6/26/68 and 9/4/68 served all amended applications parties. filed 3/23/66, O IA W C A B f o a m 2 0 L A <*CV ! * F O * M fALV FOAM 3 5 L.I <7)t .s D ip tn m at of lad sitm l M tw Division of Industriel Accidents W orkm en's Compensation Appeals Board Scote of Coliforaio 1353 flesse pie signed originel end six copies end print or type ns-mes end eddresses APPLICATION FOR ADJUDICATION OP CLAIM (Death Case) AMENDED APPLICATION 66 LA 292-043 CASE NO. /pfMn. ijg/-- Maur.ine Clark (Widow} (A P P L IC A N T ) 13331 LAk owood Boulevard f -B- l-Q(AP PLIC A N T! A M M I I ) Downey^ California------------- Dean ,,teas J f --------- Baldwin- Ehxpt>Hill,l ac. (ID P LO T t*) (SEE ATTACHED SHEET FOR _________ ADDITIONAL EMPLOYERS)___ i t a p t o t t r t m tu D A D C i c a n d ic d o t t a t c ip f K L r > iN W it on PCSNI$!1BLT UNINSUDID) (SEE ATTACHED SHEET FOR P . 0 . DO X 3* * 2%f i a; n e r s s ' t a s a > 9an Franc isco r California-- <a s i s s o r l a s u i A s e s M i n i . , i r n v i T IS C LA affiS DM i ?NA1 C M " 1" S > 1. Deceased employee born -- 1 2 / 2 / 1 9 J 0 2 ---------- - while employed as a Da t i d p n i n t h ) Asbestos Worker. (OCCUPATION AT T I N ! OP IN JUDT) 19AD to 1966 ( D A T ! OP INJUDT) at various places (C lIT ) by the employer tuftatned injury anting out of and in the course of employment t o ------------ L u n g ( T A T I WHAT PADT9 0P DOST W i l l IN J U D IO ) 2. The injury occurred as follow s:____Inhalat ion o f Asbestos and-other .foreign -subst ances-- i u r l a i what n o t was m i At t i i or i j u y a r b now in ju r y was r s c i i v i b ) - resulting in death on -- u ^ r-J --A J 1 Q-&-6-- ( M T S OF BSATH I J. Actual earnings at time of injury w ere:_____, , ---------- ------------- --------- ................ - ---- ----------------------------- IO N S W EEKLY OK M M Y N L Y SALARY O KOUKLY RATS 0 K U C R OF HOUR# W ORKS F S W S SK) 4. The injury caused disability as follow s:---------------------------------------------------------------- ------------- ........................................................ ( SRRC1FY LAST AY OFF WORR B U I YO T H IS INJURY A SS R IR R IR R ARR I R t I R R A T I OF ALL R f IO t OFF U S TO TH I> INJURY I 5. Compensation was paid-------- - ^ q -- $------------------------ )................................ (Y tt) (R O ) (TOTAL F A II IW SSKLY BAYS) ............................. .............. - (DATS OF LAST R A V R S R T I - --- 6. Medical treatment was received y g g --------------------------------------- All treatment was furnished by the employer or insurance m > ( M l ( M T S o r LAST Y *S A Y R T I com pany_____ _____ other treatment waa provided or paid for by ---------------------------------------------- -- ------------ -- ------- (Y S *I (M l Doctors not provided or paid for by employer or insurance company, who treated or examined for this injury are: ---------------- 7. Defendant hawe oaid burial expense. ____ _____ TOTAL P A ID _______________ WHEREFORE, applicant requests a hearing and an award of: Death benefit X ... Burial expense-_X-_ Compensation accrued and unpaid-X-- Unpaid Medical hillaX . Other_X__ Specify: * 1 1 htarw af i -ha____________________________________ ----------------------------------------------------- ---------------------- and all other appropriate benefits provided by law. Hearing .t Angeles___ _^ JtLOS Angeles atformi Aug. 26, 1968 < *** Number of witnesses_____ Pre-trial wanted__________ ( tri (BATS I Estimated time of trial One f u l l day_______ Set now -XX.; Set later on written request------- ______________________ __________________________________________ (A R R LIC A S r'S S I A t U R II LAM O F F IC E S OF STErVDN ROSEMAN A PPLIC AN T * A T T O N N tV ) ____ 154-3.-&L-..O lympic Roti,1evard^-.Los-Ange le s r . California ot*ttoyi gooi5 ATTACHED SHEET PAGE ONE EMPLOYER QUARTER PERIOD OF EMPLOYMENT DEPENDON ROOFING CO. 3521 N. Cicero Avenue Chicago, Illinois THERM-O-PROOF INSULATION CO. 4730 Armitage Avenue Chicago, Illinois 3/31/40, 6/30/40 9/30/40, 12/31/40 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 6/30/41 A .O . MILLER C O ., INC. 220 Nordina Street Redlands, California 6/30/ 41 C.C. MOORE & CO. Engineers Unit X-l 450 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 12/31/41 MARINE ENGINEERING & SUPPLY 941 E. 2nd Street Los Angeles, California 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 J.T. THORPE, INC. 748 E. 2nd Street ds Angeles, California MNDET 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 3/31/42, 12/31/42 3/31/47, 6/30/47 12/31/48, 12/31/49 STATE OF ARIZONA 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 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 Unknown ORIN A. WILLIAMS & JOHN S. GREEN 3775 N. 36th Avenue Box 11098 Glendale, Arizona 12/31/57 _STATE OF ARIZONA INSULATION & SPECIALTIES INC. Box 3428, Sta. A El Paso, Texas 12/31/57 Unknown METAL CLAD INSULATION CO. Box 178 Torrance, California 3/31/58, 6/30/58 AETNA CASUALTY & SURETY INS. CO. BOB GRIFFIN ROOFING & . 3/31/58 INSULATION CO., INC. 151 E. 24th Street Yuma, Arizona STATE OF ARIZONA FIBREBOARD PAPER PRODUCTS CORP. 6/30/58, 9/30/58 1789 Montgomery Street 12/31/58 San Francisco, California SELF INSURED WESTERN ASBESTOS CO. Box 3784 Rincon Annex San Francisco, California 3/31/59, 6/30/59 STATE COMPENSATION INSURANCE FUND PLANT ASBESTOS CO. 1300 64th Street Emeryville, California 9/30/59, 9/30/60 3/31/61, 6/30/61 INDUSTRIAL INDEMNITY CO R.T. DINWIDDIE, INC. 8627 S. Atlantic South Gate, California 6/30/59, 9/30/59 * Unknown INSULATION SERVICE INC. Box 4695 Tulsa, Oklahoma LOS ANGELES CORK CO. 4180 E. Washington Los Angeles, California ARMSTRONG CONTRACTING & SUPPLY CORP. 120 N. Lime Street Lancaster, Pa. 12/31/59, 6/30/59 12/31/60, 9/30/G4 6/30/61, 6/30/65 9/30/65, 12/31/65 Unknown ZURICH INSURANCE CO. FIREMAN'S FUND INS. CO. THE TRAVELERS INS. CO. UNAFRAX CONSTRUCTION CO. 1242 Abbot Dr. Pittsburgh, Pa. 9/30/61 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 6 HEATING 6940 Alvarado Rd. L a m e s a ,C a l i f o r n i a 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. fi INS. CO. OF NO. AMERICA '.t* '-IV ED Departm 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 e r titi, w e t d ati Please file signed original and six copies and print or type names and addresses APPLICATION gQ jf FOR ADJUDICATION OF CLAIM (Death Case) # MEfol!) APPLICATION 66 LA 292-043 CASE NO M Mrs. iU L Maurino Clark (wxdow) (A PPLIC A N T ) Dean Clark (Deceased) 13331 Lakewood Boulevard, BrlO (A P P LIC A N T 'S A D O N tS S l Downey, C a l i f o r n i a _________ Dea n Clark tDecT) SS# 327-07-9443 nrxiffTnrirfomrsicuRiTv nuwncni vs. See attached sheet 4t a i i o i i > .. 1: w . ` See attached sheet (E M P L O Y E R 'S IN SU R A N C E C AR R IE R OR S T A T E Ip S C L M N S U R C O OR PE RM IS S IB LY U N IN S U R E D ) IT IS CLAIMED THAT: I A D D R E S S OP IN S U R A N C E C A R R IE R . IP A N Y ) `V , - s! , ' 1. Deceased employee b o m i W . . ^ . P 7 ______ , while employed as a . (B IT S B IIT H I Asbestos Worker (OC CU PA YIO N A t T IM E OP IN JU R Y ) on 1940-1966____ at Various places < D * T I r I.J U IT ) IC IT T 1 of and in the course of employment t o ______ i.Vhf ___________ by the employer sustained injury arising out / (S T A T E W HAT PAR TS OP BOOT W IR E IN J U R E S ) 2. The injury occurred as follows: Inhalation of asbestos and other foreign substances. (E X P L A IN W NAT E M P L O Y S ! W AS S O IN S AY T I M ! OP IN JU R Y A N S NOW IN JU R Y WAS R E C E IV E S ) resulting in death on . MflX. 4 $ 1 9 6 6 - (B A T S OP O IA T N ) 3* Actual earnings at time of injury were: ___________________________________________________________ ------------------------------- IO IV S W E IIL Y OR NONTNLY S A U R Y OR HOURLY RATE ANO NUMBER OP HOURS WORKED PER W EEK) 4. The injury caused disability as fo llo w s:__________________ ;_______________________________________________________________* (SPC C IP Y U S T SAY OPP W ORK SU E TO T H IS IN JU R Y ANO B IO IN N IN O ANO IN D IN O S A TE S OP A LL PERIODS OPP SUE TO T H IS IN JU R Y ) 5. Compensation was paicLJ-- L HQ $ !--------------------- ; $________________ ___________________________________________ (Y E S ) (M O ) (TO T A L P A IS ) ( WECRLV R A TE) I DATE O f LAST PAYMENT > t 6. Medical treatment was received___ y e s ________________________ All treatment was furnished by the employer or insurance imi mot <dat*orur company _____ -____ other treatment was provided or paid for b y ___________________________________________________ mti mol 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.California__ (S T A T E N A M ES AMO A O O R E tfE S OP SUCM DOCTORS AMO NAM ES OP H O SPITA LS TO W HICH SUCH DOCTORS A S M IT T E S IN JU R E D ) 7. Defendants have paid burial expense* ____ _____ TOTAL PAID (TER ) (M O ) I. The employee left surviving him the following dependents: NAME None DATE OF BIRTH {it undar 21) RELATIONSHIP TO THE EMPLOYEE ADDRESS WHEREFORE, applicant requests a hearing and an award of: Death benefit___ii_ Burial expense-- Compensation accrued and unpaid___ 5 Unpaid Medical bills. ^ -- Other--------Specify:---------------------------------------------------------------------------------------- -- _____________________________________________ . and all other appropriate benefits provided by law. Hearing requested at -- Number of witnesses -- Los- An^oXoS--------, Dated at -LOK-Ancj46--- . California, - J u f t e (-C--I T-Y--) Pre-trial wanted i c i 'r t i ,, / ? l TES I (M O ) 25-,-- 4 9f-8- f S A jj^ ^ ' Estimated time of trial. Set now ; Set later on written request LAtf OFFICES OF 3311 1543 W. Olympic^ftouicv'r' rrzy i GtI-1-iFoifiTrct-------- l i o b a i ANO T IL IP H U N C N UN O f ATTONNCT) <ff, "te ; - - * APPLICATION (D eath C ase) FILE SIGNED ORIGINAL AND SIX COPIES (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) CASE No. .i<0.-id. -IAt LHu0j _______ MA URINE CLARK (Wid . i ---APP LIC AN T " _______ DEAN CLARK (Deceased) .1333]-- Lakewood Roulevard,-- BIQ___ A P P LIC A N T' A O O R -Downey , C a l i-forn ia----------------- Dean Clark (Dec.) 8# 327-07-9443 D C C S A IK O C M P LQ Y f t * N AM E AN D SO C IAL S E C U R ITY N U H 1 K R BALDWIN EHRET-HILL, INC. larioTsa Jf Contracting Division, Post Office Box number 34126___________________ K N P lO T ir i A D D R til San Francisco. California_________ J ________INSURANCE CO, OF NO. AMERICA ,, T -i-c f I IMPIOTI' INSURANCE CARNUR ON TATI I f SELP-IN9UNC0 ON FBNNIMINLT UNIN*ORIO ^ '*i* * ~ i. it is alleged thatJDftan. Clark (Decgag.edl. PLOT! __ A s b e s t o s Wo r k e r . . on i c#,i OCCUPATION AT T IM E OP IN JUR Y ,I .V'f/*-.- by- Baldwin-Ehret-Hill. Inc. RANK T I P IO V I 621 South Virgil Avenue___________ IN S U IA N C K C A R N IIN '9 ADO RE Los Angeles. California___________ / / L .Q . 1 2 2 3 9 7 OATK OP NINTH _, while employed as a 194 Q t Q . . . OATK OP INJURY 19 6 6 , at v a r i o u a p l a .0 ? California, C IT Y .f> // sustainedinjury arising out of and m the cours of employment 1J \ . CO a LUNG PART OP ROOT as follows: INHALATION QF .A S aS S T O S -A N P - O m gR - fS P U M N NOW IN JU R Y W A R KC KIVKO ..r O B E I O N .-S U B S T A N C E S i V' '-3. 2* Employee' actuel earning at time of injury )-- 2 - i`A- resulting in death on MXCL 4 __ 1 9 6 6 - DATK OP OKATH _at-- WCIR OR MONTH The basts of pay was______ ,v* 3. Was compensation paid? NO- $- TOTAL AI (SALT ATI DATE Of LAST ATMENT *1 -M 4, Was medical treatment received? Y E S I , - ri" ' w . TM M DATE U S j . -.y-. V a s a{( medical treatment provided by employer or insurance company? If no, state who provided it. / Lynwood .-ST.- FRANCIS-HOSE1TAL, 3630 Imperial Highway, Bawnays-California. ALSO T A T I R A M I A N D A O O N C M tS D P A U . D O CTO R WHO T R IA T * D 0 K X A M iN f D POR T H U IN JU R Y S. Has burial expense been paid?_______ ______ _ $------------------ - Who paid it? _ TEE SO , / . This application ia filed for: i ../ Death benefit__X -- _ Burial expense,,_______ Compensation accrued and unpaid O t h e r _ _ _ _ _ _ _ Specify:_____________________________________________________ 7. The employee left surviving him the following dependents: N A Mjfi_E *Q m <li>UAnGo eEr ai) l.t !`l ----------- R ELA TIO N SH IP TO TH E EM PLOYEE NONE -U- ADDRESS : IM PO R T A N T --If any applicant is under 21 years o f age, it will Ik necessary to file Petition for Appointment of Guardian ad ; Litem. Forms for this purpose may be obtained at the office of the Industrial Accident Commission. 4 WHEREFORE, applicant requests a bearing and an award fo r all appropriate benefits be is entitled to by law. Dated at Loa Angeles CjUfornia,^ r c ,h_ 2,l . V966 u iu u jv iia i iiv v m u u ^uiiuiiiasiuii * t APPLICATION V v/ FILE SIGNED ORIGINAL AND SIX COPIES (PLEASE PRINT OR TYPE NAMES AND ADDRESSES) Dean Clark /_______ &MUCAN Social Security Nn. 3 2 7 - 0 7 - 9 4 4 3 i)6LA 9 2 0 4 5 - c a se No. 13331 Lakewood Boulevard A PP LIC A N T' t AOO RCSt Downey, California Baldwin -Ehret Hill, Inc. CHPL6VI1 Unknown________________________ (PLOTCR'S INRU RANCI CARRIER 01 ftTATC IP lU P .IH IU IID 01 P C lN ltf lB L f UNINRURTR Telephone N o-------------------------------------------------------------- Contracting Div, P0. Box ( P IO V U T A A Q O R tR t San Francisco, California 34126 INAURARCI C A R R ItR 'l AOORCSt 1. It it alleged that . D e a n . C j a g k y _____________________ ^ Q l while employed nn w as or carton t oat or n r* 1 9 4 0 --1 9 6 6 j j _______________ . OATt o r i*4u t aao ' asbestos W o r k e r __________ i __________ a t ______ various places, includlnq_San t California, OCCUPATION AT VtMt OP INJURT C IT T , TOWN OR PLA C ( W M (R ( IN JU R Y OCCURRED C T a ilC lS C O b y ...... B a X d w i h r E h r e t . H i l l , -- I n s ... J 1 . 4 ' . ( T* L ( j T J i4.* sustained in ju r/arising out o f and occurring in the course o f thr employment. **"' 19 _______ LUI _____________________ STA TS WHAT PART OP SOOT W IR I INJURED AMD SUSSIQUKMT RESULTS Tnhalafcirm of asbestos and other foreign substances S X P U IN WMAT ( H P t O V t i WAS O O lM AT T IM S OP INJURY AND HOW INJURY WAS R K C K IVtD 2. Actual earnings at time o f injury $_ _per- The basis of pay was: B HOBBIT M T S . BOUM BAT ABB BATS A V ISA 3.Periods disabled for work: -- Inter-taj.t-fcently--aml since January,-- L9L.6_______ . S P IC IF T K S IN N IM A B B IB B IB S D A T IS OF A IL P tatO O S O f f W O O U t TO TH IS IN JU B T Date returned to work-- 4. Was compensation paid? No TTS BO TOTAL PAID W it LT B ATI OATC OP LAST PATB E BT Have you received unemployment or unemployment compensation disability benefits since the date of injury?_____ 5. Was medical treatment received? __ Y S.fi- State date last received: currently Wat all treatment provided by the employer or insurance company? no If not, state who provided i t . . Alto state names and addresses of all doctors who treated or examined for this injury. - S t . Francis Ho s p i tal 6. This application is filed because of disagreement regarding liability for: Temporary disability--y e s - Permanent disability----- y e s Proper Compensation R a ic -...y fiS Self-procured medical-costs-- y e a Litigation costs -ye a - Mciiic.il treatment - y S . Othcr-- y e fiS p c c ify :___ i mmc.diatf- medical--treatment..a n d _suryory._____ 7. Have you ever had a case for another injury before the California Commission? __. _______________________ WHEREFORE, applicant requests a bearing and award fur all appropriate benefits provided by law. Los Angeles Hearing requested at--------------------------------------- c it t Dated at. J L o a - A n y e l Q S . A e iT t _TCalifornia, F e b r u a r y 1 5 , 1 9 OATI u fJ fi.iMl ,Mt :,., \\ r{ * t^\ APPI IC A N T'b 6 I0 T U R E Estimated time of trial------------------------------ --- Please set now_____ ; set later on written request. LAM O F P T flliiS OF S T E V E N ROSE MAN____________________ APPLICANT* b A T TORNA f OR R IP P E i t NT AT1VC 6 . 2 J -- i-- a n i - i t - - - r , n i R n r r n i e s . C a l i f o r n i a ____ A P O R L ANO U U P H O N C N U M lL R O f A m OR N IT OR REPRESEN IA T 1 V I * * I U f L ____ J k tiM I J A .l / i i - i ___ ~ frur S (* 7 f7 p JSZ____ J^a/ejUSM r*/S. ,<2 o__ J___KJf ucY /brf- 9?/T/S Wbruary 23, l$6j AI MASI le* Offices S te te n Bo h m b 1& 3.West Hiath Street Los Aaetles, California 9OC0L5 OWtXWMI Subjects ID-- a C^orly(Decedent) Tleurine Clark (Widow) Case 66JA 29&&3 2a reply to your letters of Wbruary 16 addressed to us sad our svfosldlary# Ar-- trong Contracting sad Supply Corporation, we wish to advise that our workaon1! compensation insurance carrier was Standard Accident Insurance Company ia I95I and Stas Travelers Iaaurance Ccepaay la I956 sad 1961. Wsry truly yours# Wallace B. Hofffcrtfc ? l STEVEN ROSEMAN ANTHONY J. BRADISSE HERMAN FEUERSTEIN JAMES J .WALSH 1621 Law Offices STEVEN ROSEMAN A TTORNEY* AND CO U N SELO R* AT LAW WEST NINTH STREET LOS ANGELES S001S February 16, 1967 TCUKPHONCi D U N K IR K 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 ? * u i STEVEN ROSEMAN ANTHONY J. BRAOISSE HERMAN FEUER8TEJN j a m e s j .w a l s h 1021 Low Offices STEVEN ROSEMAN ATTORNEYS AMO CO UNSELORS A T LAW WEST NINTH STREET LOS ANOELES 9001 S February 16, 1967 TKLKPHONKt D U N K IR K 0 -3 0 7 1 v s* 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 mi 1