Document wrbdoGoZjOaQenjj5OOLm0LK4

MAO. NlWAftK. N. J. 0?(J^ Stat* or Nrw Jersey D Difartmint or Labor And Industry Division of Workmen's Compensation Fepa bo. 2Sc CURefill Ja) .orisATJOh R 2Tp. , _ .. EMPLOYEE'S CLAIM PETITION FOR COMPENSATION" 1 LhICHAEL ?. EARTO4________Pi,/0r, Self-insured PLAINTIFFS EXHIBIT NG108L VS. (Name of Insurance Com! NATIONAL GYPSUM CO,, HERBERT KORANSKYESQ.____________ (Attorney ior Petitioner) ___ , .., ^ ........ ........ ............ Respondent. 39 Mechanic St,, Somerville, NJ 0S (Addrese) To the Division of Workman's Compensation: Petitioner, alleging that be sustained an injury by an accident arising out of and in the course of his employment with the respondent, compensable under IL S. 34:15-7, etseq., supplements and amendments, respectfully states: 1. Name Michael P. Barta Soc. Security No. _14 4 -14.-2.138..... 2. Residence Address: (a) Street Address (b) County......Somejr.S..t. .(c) City or Town-..Basking. ..Ridge_____ (this claim #crmoN canmot mt woe*srr without tmjs information) 3. Sex--H--J- 4. Age-48____5. Marini Statu* Married 6. OccupationJXUPk.-PX^XS;c. (at time ol aeetdtat) 7. Name of employer J.?tional_Gypsmti_.Cp . (a) Address___ Division Avenue, Millington, N.J. 07946 (b) Business --,--Manufacturer.- of building--materials----------------- -- ------ --. March 1973 and 8. Did employer have notice or knowledge of injury?! On What date?--28 -years-prior $>. Place of accidental injury _ tvi-- March 1973 & 2B years prior'thereto**" 10. Describe the accident --e^P_st^e ^p....hAraful^dust.,.. Jhaaes, .*ad____ asbestos at work over the last 28 years, __ 11. Date petitioner stopped work. Date returned to work--.--TIT:. 12. Describe extent and diameter of injury. If there has been amputation or loss of usefulness of any member or impairment of any physical function, explain fully ,, chest, heart, lungs , asbestosis, emphysema. 13. Wages or earnings..^.?,QP/yk.;------- .. Compensation paid: Rate ?^/40............. Temporary disability,.."------- ----------------------------- Permanent disability___~T______ 14. Was medical aid required? .Yes. .......Was employer requested to furnish same? Yes Was it furnished?-- ^5 -- If so, between what dates?............. .... ............. ........... If not, what sum was expended?______ ---__ ___________ 3 . Give tames and addresses of physicians and hospital ;t>. vi'/.ac other vets arc there which \:u believe important.' Vour r.etWoiwr therefore prays that the Division or 'Vl'vricrr.o.rs GJ::i::en<.u.oc will determine th. nmuent c ccr,peo..':i:ion due your petitioner fr'.vn said rcjpnuuen:. under Ke*-:WG Statutes of New jersev Tide :>. Chapter :5, ami the Acts supplemental thereto and amendatory tncreot. and that your petitioner -juv be awarded his costs i:i this proceeding, and \uch other or further relief as may be proper. State or Nsv Jzssey, County or Joswrset,____ L . >/...\CL (Peti:it>ner) Si. MJCHTiSL 2AR7A _______________ of lull ape being duly sworn according to law, 00 his oath deposes and says: That he is the petitioner named in the foregoing petition; that he has read the saute and is tsteiiia? with the contacts thereof; and that the matters and things theteir. set forth are true ac cording to the best of sis' knowledge and belief. -- '/.iLik. re \/m (Pet*sonyj *? -- a Subscribed and sworn to before me thi>..........-jiztzz. of -..... -- day Herbert N;ransky, Ar. Attorney at L -------------- ---------- -------------- at --.... . (a sis affidavit may be sworn to before any person authorised to administer as oath) Meries To P.2SPON3ENT: :-*r*r-.hng .``aim petition has bean presented by die petit ;>nvr to the Division of \\c:k .;5en 1 ..{.nuHnisation for ~.caring and determination. i.nle^ un answer in dtiniicate is filed with ti; *nry of the Division, Labor and Industry Building, fin:-: V.*. Treucon. N\ j. 08625, WITHIN 2i Til?. WILL PUGO&D WITH PKOOr OF CLAIM ACCORDING* TC i-A v AND MAY OBTAIN JUDGMENT AGAINST YOU. Division ui Workmen's Compensation aUT-stati owe* sumv. - :4 0N HACL MWAU. M. 4. ettoi It I *1 Stats of Nnr Jstssr 5*V piPAxncxNT or Lasox and Inpusrt DmUOK Of WOKSMXK*S COMTBNUTZOK pCo. 20c 41 to Pi EMPLOYEE'S CLAIM PETITION EOR COMPENSATION / MICHAEL F. BARTxJI VS. NATIONAL GSPSDK CO., Petitioner, 8*l-inurd (Nwt of Zsmnact Company) HERBERT KORAKSST, ESQ. (Attarsr far Pntieae} Respondent., SQ Maghawlfl r (AddrtM) 1Ta J To thi Division or Womcmin's Commnsation: Petitioner, alleging that he sustained an injury by an accident arising out of and in die course of his employment with the respondeat, compensable under R. S. 34:15*7. ec seq* supplemeno and amendments, respectfully state: KICSASL ft, BARTA 1. Name Soc. Security No. 144-14-2138 2. Residence Address: (a) Street Address,..3.9--LftfcluftPftd. (b) County. Sooarnnt .(c) City or Town-JB-Mkiag.-Ridgft. ithis claim ocrmoN cannot ac ntoecssro wrmour this information) 3, Sr*M _ 4. Age-Aft-- 5. Marital Stams Jiarrind A Occupation-- (attime of techett) 7. Name of employer ^ATXOMATi Co-- _ -- .. . , . .,, Division Avenoe, Millington, Mow Jersey 07846 (a) Address - .n. ..... -- (b) Business -Ksnafifttcmg, of Building Matnrlali Proa beginning of 8. Did employer hare notice or knowledge of injury?. On what date?^.lt3X3.t . t. 19 9. Place of accidental injury________________________ -- T**** ._____ 10. Describe the accident JggOftPrfr to hAgaftaQLVfrfci^ work ora the lan* 3ft ysTo.1 11. Date petitioner stopped work. Date returned to wrk_ ------ 12. Describe exmat tad character of injury. If there has been amputation or loss of usefulness of any member or impairment of any physical function, explain fully - onbostosis, oaphynoaa. heart lnng , 13. Wages or 8200.00 Compensation paid: Rate Temporary dimahtlt<y_ ***" 14. Was medical aid required?. Tt Permaaeat disability Was employes requested to furnisa same? Was it furnished?Jfftft-------- If so, between what dates? If not, what sum was expended? . _____ Tan 15. Give ****** and addresses of physicians and hospital Id. What ocher faces are there which you believe important? Your petitioner therefore prays chat the Division of Workmen's Compensation will determine the amounr of compensation due your petitioner from said respondent, under Revised Statutes of New Jersey, Title 54, rhapear 15, the Acs supplemental thereto and amendatory thereof, and that your petitioner may be awarded his coss in this proceeding, and such ocher or further relief as may be proper. State or Nsv Jrasiv, County or SOMERSET. MICHAEL ? BARSfctitioner) ss. MICHAEL ?, BARTA .of full age being duly sworn according to law, on his oath deposes and says: That he is die petitioner named in die foregoing petition; that he has read the same and is familiar with the contents thereof; and chat the matters and things therein set forth are sue ac cording to the best of his knowledge and belief. yJZllcLA P wesaa ?. Subscribed and sworn to before me this. of 7. // - - -- i day at. "S *Hgcfaaatf-S.tgget, Somerville yM J, HERBERT .to .attorney, (This affidavit may be sworn to before any person authorized to administer an oath) Notice To The Respondent: The foregoing claim petition has been presented by the 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. 08(52$, WITHIN 20 DAYS, THE PETITIONER WILL PROCEED WITH PROOF OF CLAIM ACCORDING TO *. L&yW* AND MAY OBTAIN JUDGMENT AGAINST YOU. * -~7 Division of Wojucme j Compensation V