Document wrgZx0mQOMKEXLgXzjwvD2dKd
OF CLAIM
GROUP POLICY 17300-G
ACCIDENT AND SICKNESS WEEKLY
A
DISABILITY .-.BENEFITS
... Employe
Mr.
. Mrs.
Miss.
Initial*
*3- f j
-> i No
1. Last day worked.
^'rC;*ivty. "
TO BE COMPLETED BY WESTINGHOUSE
Check Monthly
# TSt
'X9&P'
Dept. No.
Empl. No.
/<?-/)?<?>
^ Soc. Sec. No! /
' . Streey'V ! ' . .
______ Ta . _______ /
ft*$
*
S~tate - - -
--
Weekly Benefits $.
2./Effective date'of coverage: r ' Emplo
Benefit Due Date.
-APPROVED BYi
.19.
MAILING ADDRESS 7 = >
WESTINGHOUSE ELECTRIC CORPORATION
LESTER BRANCH P.O. BOX175 :
..
PHILADELPHIA. PENNA. 19113
ATT. IND.-REL.-DISABILITY BENEFITS
ISSUED B "Tr
TO BE COMMPPZLLtEE.'TT*EEL DD' *--*BBmYYi THE ^MPLOYE
4. Date you were first disabled by this sickness or injury.
S'-<2 S'
f - lT*. >. ?. .* . -*.. c. - r . 2. If you were Hospitalized, as a bed patient, answer the following:
i.7 7
(a) flame and Address of Hospital
, Jyr
/
<bI)Date Admitted 0 f
19
.10-
3. Was this disability due to an accident? Yes
.. J <CI '
(c) Date Discharged
f/3 J71 at.
Hour
No
If "Yes," answer the following:
(a) When did the accident happen? Date_ i9--------------- (; Hour w
(b) Give a brief description of the accident and where it happened.
4. Vacation days still due this year_______________
3 . "" ^
s ' ,oA
5. Give any information which might assist the Company in the consideration of this claim_________________ ;_______________
3. Dept. No. f'J? p JD
Empl. No.2 Cr ^ ^ Age ^3
Home Phone No.
1 certify that in applying for accident and sickness insurance I am totally disabled and unable to work for either myself or any company and
vill return to work as soon as possible.
.
further understand that falsificaii&n of: information could result in termination or recovery of all money paid or termination of my
snployment.
1*
* Employ
WESTINGHOUSE FORM 30682 PGO
Produced 3/93
28006469 ) *
v^
y (* d fO~BE COMPLETED BY THE PHYSICIAN ATTENDING
^
Thomas J. Mitchell
me ot patient.
Age S3
> Oat^of first treatment for this sickness or injury.
8/22
19 J2_
) Date of last treatment______ ___ i__________ __
9/19
19 77
Silicosis (Abestoels). rlriit lung; possible carcinoma of right upper lobe
surgery was performed or is contemplated, give the nature and date .
E. Friedman
Bronchoscopy 011 8/31/77 by Dr. Steven
ie patient was physically unable to work from _
RJ22
.19__ML
tswer (a) or (b) whichever applies --
(a) The patient was able to return to work (b) The patient may be able to resume work.
10/15.
this disability,is-Jhe.result of the patient's occupation, explain^dfly__ Questionable If x-ray changes are Hue
(Tasbestos exposure
&rt
LEASE COMPLETE, SIGN, DATE AND MAIL IMMEDIATELY!
Signature ^ -
Attending Physician
Name (please print) Robert G. Trout. M. D.
. The Glover Clinic
Address
Suite 202 .
3910 Powelton Avenue
Phlia., Pa. 19104
Data
Office Phone No.. 387-5950
AYMENTS TO OUR EMPLOYE CANNOT BE MADE
/ITHOUT THIS FORM.. VZ&'ZZZ. :
MEDICAL DEPARTMENT REVIEW
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is>s:
\ Date:
:
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y
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RETURN INTERVIEW SCHEDULED:
Date: ' ' '
________________
Time: --
a.m.p.m.
Notice Mailed.
Date
if *. *. .V.v
Produced 3/93
~ > #4 t
28006468