Document ykEgrg2EoZgx8O6b7zdK8gb36

*01112 01minnimu2ali!i uf Department of Industrial Accidents 1 . 600 Washington Safest Boston,. MA 02111 AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM UNDER G.L. CH. 152, SEC 43 BOARD HUMES?, 08481087 Alice L. Warren insures,cr.self-insurer ...Travelers Insurance ^4Ptrvnw, Monsanto c/o Joseph Learv Assistant Manager INSURE?.'S ADDRESS .. U- Q,,- Box Q04Q TOTAL n=mt :r-77Q-;c <35.584.00 A3.'CUNT C? LUMP SUM BostoSi9S-h8^83 NET TO CL.AI3.tANT <156,916.00 TOTAL PAYMENTS . $1.92,500.00 RcCiived or:. uMAoinusaa-*n- to5 r* an_n_d___T__ra__v_e__le__r_s___a_ _15 Thousand Five Hundrea no coLiaa ar.G. . 192C3AN33S29T INSUSSF.'S CLAIM X the LUMP SUM of One Hundred Ninety-two 192,500.00 .... (5........................... J majerr.; tvtcr. vesxiy povmer.a iireccy recurves cy roc. ns coa,l sum c;-O- n--e Hundred Ninety-two J Thousand---aFivc--e Hrsuanssadred-- flfJ esr.a(.?a-*jq,?r *-5h* n~ .,*}c>- me the i^n,surirv/ s w.a...i.v..e...r...o...f....i.t..s.....r...i.g...h....t...u...n...c..e...r G.L.Cft.l.c.is.15"*'t.ai aoncvajrisi ci.'a*,v1 .te.prvn ;i asna^in^s c sny Szic, psyrr.sr.wars riccivcu in reesmpsen or Lie ussusry ?or an wcexiy paymena now or in tne rttstire aut-mgaanrertn* wTu:^viragoirpyjsgrigir.SiL. ler iil injuries rsssivea rjv. mv husband John Warren on or icout 1948 to 1975 inclusive wm;s m Lie emoiov or Monsanto aubject to approval of the Dcparsnent or Incuitrai Accidena. -4 tv/ /?AsjsJ*. //Ir^A^r) Cltinunt leurwcea _, , c, . 40 Midway St* Indian Orcnarc, its attorney wjor&reU ___________________ iJ. i1 STFCKE CUT IF NOT APPUCAELS . I 'cndcmand -Mr from tbs LUMP SUM ii?.ounr aa;rd above, rh.e amounts listed below will be deducted sr.d paid :o the followm; "irnrs: 55.53J.OO I. s. James H. Tourtelotte 1500 Mam Street Springtield, A.i ii i Ui jlLO _TJBDS-E-PD-T-AIV-HIESaWsIO.--SNErtfO\cF--"D--KISPUUATE '' V=- ` 1 4. S -* s. ilEWS JU'.V ! SCARO ll 6. 5. 7. 5 . huiic'tcTN ~ ASdrfrmr.iimnsTtrraaii!!YV44 Lu2wW JU^== -e _ .......... !-*: S.Lc. :5? - C STRIKE OUT IF HOT APPLICABLE JPWJCsMMRSUMCWJ'JPX^CfMCrJi Ua^N&eXoiuicrI I ur.crrrar.a that afar ail of :hi above cirirrerroru. ir.rivdir.^ imm' fm nnc othrr lirru. I will rtciivrthe oer amount of5____Ut---- - t i-rinsr ansir'tsf-i'f:ac riv.s is a ccrr.-;;:; me 3crti;".:r.: ef my claim and that 1 will not be able to rcOftn mv claim or aesit further bencf:w Nrtaujc or :n:s injury. 1 am muy ri i -*rn*Purr CIaiiiuai t ifn*nift Alice L. Warren {0^4rJ UCC 086060 Pa?* 2. EMPLOYE % AGREEMENT FOR REDEEMING LIABumT 3Y LUMP SUM As*: Avea?sT* ewlj1w *$e $ **^ " Q^eess 1 fV>--7 Sacs 383.57 m- N / &________ __ Cn So~a! SeTMrr DUcHlicr' Ya N/A No r.---- rtiomiral tjnflfar 4 tfv-- a-----^________? ^' TJ 7 T7.V Nir-- liamanoiftefl7rnii|? Fli ibA tif t? I.*.---- Mnneantn Chemical Company between- 1943 and 1975 inclusive and at any other time rrinvl rhln-r-M* p vrn: ii i-A f - HO -- f V_ V v~ . fiSAiGOi --- -- -- -- - _ -- O:--- L^rr.c*LMi .......................i S.VUV.C u-----* v/--r--;* Pr----* XCorc Ci~-- Deceased 1/29/88 N/A * FLH.-.SE GIVE BRIEF H |I*j,Nt% if * % *** t * C*"* ** > i ijf.i ni'.i-' jvu-^uNo 5s i iisv3 i i T.V1 ths*t--t. ----.'/urr, r ;T. '--S:-kc_f s. r. m" reciii-tiu iuecicon or <vi rom 1543 to 7/1/74 (and perhaps into 1975) John H._Warren was exposed to vinyl ch while 'working as. a process helper,'operator, or control operator in the manure = of poly vinyl chloride at Monsanto, Although he .was not exposed .after. 1974 or /t, surficient ellular changes had been induced by his 26 year esposure to caus rare form of cancer to spread from his liver to his brain. Thishemangiosarcoma specific to vinyl chloride exposure. It was diagnosed as result of symptoms wh raw serious in May and June of 1957.- Dr; `Flatow's report of 5/3/88"is'"attached . Warren died on 1/29/88. The claim for worker's compensation benefits was deni y Travelersw- Mrs. Warren's marriage certificate is attached. She is 61 years ol nis settlement .represents the present value of the benefits she would receive ove sr life expectancy without considering the effect of 34B. In the language.of 4 ..is is an agreement to redeem liability for compensation in part. The part left nredeemed is that part to which in the future she may become entitled under 34B. la widow therefore reserves her right to receive benefits funded by the Worker's npensation Trust fund in accordance with 65(2)(a). For the purpose of adjustme ndar 343, the first date of eligibility, 6/1/87', rather than the date of injury '.all be u^ad for the^-erarpose of computine uch supplemental benef i ts IS t. 1957, c. 57. \_) C...VW TM j'ames H. Tburtelotte THIS FORM MUST BE TYPED 'OR L".0?3LY "IVTT w UCC 086061