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EMPlOYER'S COPY STATED1 OF WASHINGTON REP O DT OF 1 A I D T o
{II . 1-m! of
t{Yf r `1 1
.y Filing lu (111 claim N b rl l b and I d _ I Claim N
Employer Must C pl le This - tt and Signing Employer,'t an a h Mail Re--- ---
Port of On'. to
. 10 O p rf t f l barl>andIndustries, District Office. (See ravens .iris for add,.,,.)
43GO i
N 3a5 3505 ..`
tye FjUmboraael?nod bpi ?•or-_ Tolaphonn No.
S? y p rtmont v1 Lobar .ntl Induelrloal Social Socurily No. of workman -----
------------
--
! um name of employer JO CQunt 1)O Of I'I$. F -
--------------- Aadross____._0 _____0._?c_?___i__n9 ri Ori
------
V Have this workman a hours boon Included In Payrolls repelled to this montl.____B-----------
11 eo, In what close?_
It not Inducted, glvo reason-----------------------------------------------------
How
F- long hasworkman been employed by you?__ .12 a-eara__._ --Occupation when Injurod?__RAad_GSl'IS}.TL1C'ria'•OIl_-________
Business ah emPtoY _ ._I'L7iAt 11A COYf:i -r '
,y0
_ __ ___ ___i of plant or place of work whom accident occurred _. _
w6 (il 9 9 d I. c a t clean work atom particular ular kind)
-----
Check in which department workman wan employed: Construction M Op...H.. I] Repair -
-------------------------
N o of Has he say financial Oa launched boat
_ mBc injured work- a •6 Te BIIChino __-_ __ _•Interest In the business? -n0____.Part, r? Corrpora? --le T
't ^• Wlll.thle work be kept on salary during his period of disability?--------------- 11 so, attach an scitf.l]_ W,?pr)dn,S t,
I ?O M ospianatlon___
»a Data and hour of accident ----------within past ye M. Last day worked ----------------------- Data .t.-d to work ---
z --- --
ow Was workman engaged. in the regular course - of his employment when Inlurod?__ _ __ _______________ ___ShHI h m 8_!!,.Ifa_P__.iA
a.: IDid accident eccur_on. your promises?____ ____ ___ _ If not, whore? ___
i awe Date and hour accident reported to you---------------------------------- P.M. To whom reported----_--------------------- Pettit ------ -)
D• Name and address of mtnnding physician -------------- 1?ri_Ittr-9A__-G-mon---------
'.y Do you question allowance of claim? Why? (Attach loll- if noco er,ty)--------- Il0
--------------
Ima• ale accident happen?___UP o;c:r3i,cttion right hprn3a..llan been rib ,,
tiaz'Pdsi?ti- ------------------ _
ID W ih "Md 1 t fly rating whether the Injured P a fall ar, was truck. 1 --- --" """` - -_-_-
and 11 the 1 oars contributing to the Itl.nL if -- -
1 Y I tlar.l ry writ - pple-
f doctors lhatapeJ r gohrg at te?l_ t;,}r tru to the best t y knowledge db Ilof.
,
Ignad -- --__?ay ol ----------------- ----. Is
l - (PmPleye(l ___((AA``: p (Ofit;- lP-_;;F7 . - k
Q.:
it ptdged 11011 cofrspenta to except Of (TO BE USED BY DEPARTMENT ONLY)
"a, ?:i'w-'r'" ?.'l ?• -
1 Afedrea! Ard IIr![J a[l0wabla by law. By iClaim No
/ Claim. Eaaminer !<
>i!lowed ? 0rfarr?icatetborrzed, d treatment BY ------ ------- - ------ '
i and aetl0llo fl Claims Examiner B
upon i I dust I nco
EMPLOYER'S COPY MEDICAL AID AWARDS A t { C p lol Dam Nollce
+ .^ a Boot
Cont.-...--_.
(Net Claim Honshu)
Non-0ont.__--'
n Name of injured wo km T? ,r -
a 5------- 7'-------- p E_?1! / D' _ Soda, Bacurity J I
,,,vssa .^T Y -,.,? Telephone No. - --------
Address ??a.e/.'aver/oa rr. y- _ _ ___
(- Addr (to which an m II and Stato
to _
a dd ed)__//_________!?L'[ All, /- ---
T?-?j -0 ____ / Sh
___ 975 L,
7 ______
' v
Place of bl Ut/"O ht -Ago _ Hefght_ n L E -Weight
Dvle saddest oew d. wit1-13___ State he [ G Id ?. (CI data 1 Irth? !?D
- --------------- 7 Ship hours-- >A --- 30`?
Give data last worked ____ 1 y?.. h w r.nmsil l 4 DIv d Te. I y - ^
Te eta- T
No of
.mpEvY.e f C L/ -
H Wo a you doing your regular wo at time of accident? ___ -- e --------- -------
rY - 7 yC ,t, On' mPloyars pramisos?----------- O Daa ib cddo t I. full: ------- P./. 7i! l/ /t C? 444`/6. ! -l i /y
------------------------
-- .
m -_ ____- _____ _ _____ ___
?Z Wm the amddent l your 'opido caused In any way by someone at employed by your employer?____ 214_-------
6 How log have you worked for this employer? ------ / l IYos or not -age or '
£ a. -------------- __S_
e5 ?-
Date you ropoda
o accident toemployer rrtt__ on -_-E h ? f O Y' day
v oO Name of Attending Physician 1!_L]1-?'_' ____________Addroea_?
3 lf?t"??NTG 9lh5r=n? .
h a lT ---
f Full name of rvlle or hueband____.___. _I------
divorced give final decree data ------------------- •'
._____ -
aF 71 ?dlvoreod and you have m1 or iidien?gobmlt copy of the court order showing legal custodian of such children. c. a 1 <Q r Afdoigwo pp,? nl address of each cuelodlan.
R --- r -_- -GIVE NAMES AND BIRTH DATET.'OF YOUR CHILDREN UNDER IB SUPPORTED BY YOU :
NAME R.I. t (Binh
? y Year NAMC - B-Imlo.-P Dale of Blr Dar
tg ! declare that the foregoing atelomoalsylro/ft o 1 the beat of my knowledge and belief
h
x -- sI-nag _' --J---. day ut_--- NQ vG ,) rCi_ Y 19_ 1c5, at-_ /' y /olu?lS e ?It? wa N n
9
1 PORTANT 171?woxlauN SIGN HERE ?•.':`"?_TC"` - rr __ - --
PHYSICIAN'S REPORT - - - ---------------•
T Bug
Uoa. fie.. No. ?_ _.-. ._ i _ __
Y ) r Name of in ursd wo kmaa (
G -
Info Claim Number
Adare.. ForT--'ToVt7eciid--'
€ Employer ` JefSeraaaRiffhlroy Dspt Add...... Port Tovnaendl Waah.
EbEtict date not Imalrn &VI 1 --------------
Data lunad
__ _.
_____.Dal. first traalmonl-_____..___ --._3_?. .Wmkm,n'sA a
History of inlury:-_ I.- m1. of nTnni..
-Rlgtlt ingtEi>mh hernia _ .... -- ----- -- ' ------------------------------•--
q ?Ayskel rtedMgs Es Mail
i a
In R1ght ingandl he
- rnln . ...... .. ....... ._.--------------------------------------------------
.agrosi :.__,-_... .. ....... ... .....__-.__._____-.. _
Ms. Irealmonl used..- _Ma ir
,. pis-
pa Right- inguina1,hornie- autharizad_by.Dept-pC-Inbor and I---Rq riea
U not
"r
x-Tay xaaiags ----- - royad ...... _.._._-
?i ------_- -------
'. •? It., workman had p-lou. Injury to area?... no-_ e? .
Nu wor4ma arsr been heatad by any... I., present or condill..? no
zr _ ...._ " Y enYono for present or almliar canJ111onT no... .__._Al Yes. ..Plate ... .-------------- I__.____.
' to there an re, D of a.....
e se of the rns 1.1- 0 ... AO .... -.. / -
.' Win this or say other p'-stellaq condition compllcals treatment ar r.tsrd r o.ely7 probably, not ;
1
t Is condition cilagnosed the result of accident described? Yes a Probably ? Po .Ibly ? 11.0
?-
u no.plt.1 rMion requlr.ct, name hwpHal__,Wlll, be- 2Laapitalized at_ St.. Aware.. .... Port Townsend. Waah4>,1crE
?
Frdm.Iad IimeIva des to InlurrL John ra Roapitol
? A6+ad1 gPay Ik
RI. br'}aoe TSDrrfaon eix?T Yevronce troo § YPort T., '
Hama. L _.. __._ .Address.. ._.. • ..... .......... .. .... I
II?.tuu .?-.. ... ... a.,,, _.? .4•,-.?.... e _ 12-14-65,. ...Fauna Aceounl No.. ,_k30Ci _
y -
IUr. 0", V- All ...I
fl mh.r SlamP) +Kfy}.,fA
1.FM101IR-1EMOVE '"I" TWO-I1", COPY-THIS II TOUR Co"
April 27
1966 " r
,
Department of Labor & Industries
?s Suite h13.
lst Federal Savings & Loan Building
5th and Pacific
Bremerton, Washington
' Accident Report
. Att'ns Mr. Robinson Res Louis T. Buchillo
claim R530138
Dear Sirs
This slain is not the result of a recorded industrial accident. 5
and was apparently discovered by the physician while he was making a
routine examination. In as much as this could be the result of an
industrial event, the result of activities off the job or the result of
malformation existing since birth and no record of an accident exists,
I do not believe the claim merits an award for damages.
Sincerely, ro
E VIN A. BECKER
County Engineer
i
Men"
.•. uur?S?."7tsaf"G?i4_,.i?- :?a•?,.w.`sL.??°?4:.
'
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.:
EMPLOYER
r
.
I IN AND BEFORE THE
ER
VI
SUPS
OR OF INDUSTRIAL INSURANCE, DEPARTMENT OF LABOR AND INDUSTRIES yy
® STATE OF WASHINGTON
ORDER ALL OWING„ CL AIM FOR MEDICAL TREATMEN T ONLY
?•
e C
.
BREM
2-7-58
468403
4360
8-3
t1-20-57
2-7-58
®
L
Firm
'IQame Pursuant to Rem. Rev. Stat. Sec. 7679 (K), which provides
- that no compensation shall be paid for the data of injury ® Y
F
Cn' or the three days following and based on information
JEFFERSON CO DEPT OF H IWAYS included in the files of the above claim Indicating tnat -
'
L_ 7
C®
Order PORT TOWNSEND, WN an injury wuhm the provisions and jurisdiction of the
Workma
's Co
t has o
urred but that a
e
satio
A
.
and n
mp
n
n
c
cc
result of said injury no time lass of over three days or -
Notice permanent partial disability resulted, now: -
. PF IT IS HEREBY ORDERED THAT:
- ® 1. THE ABOVE CLAIM BE ALLOWED AND CLOSED FOR
Claimant MEDICAL TREATMENT. -
LOUIS BUCH I LLO 2. THAT NO TIME LOSS COMPENSATION BE PAID.
19TH & HOLCOMB
® PORT TOWNSEND, WN
3. THAT NO PERMANENT PARTIAL DISABILITY AWARD
C BE MADE.
® Attending
Physician
Nolan B. Turner
yt
® C M SCHAILL, MD SUPERVISOR OF INDUSTRIAL INSURANCE
MED BLDG
PORT TOWNSEND, WN
NO PROTEST RELATIVE TO THS ORDER OR APPEAL THEREFROM CAN BE RECOGNIZED UNLESS MADE WITHIN 60
DAYS FROM THE DATE OF CLAIMANT'S RECEIPT OF THIS ORDER. ALL APPEALS MUST BE FILED WITH THE BOARD
OF INDUSTRI AL INSURANCE APPEALS,OLYMPIA,WASHINGTONWITH COPY TOTHEDIRECTOR OF THIS DEPARTMENT.
u
?a t
We are in receipt of your bill for services rendered to the above
named workman. No claim has been received from this workman and in
the absence of such a claim we have no authority to pay for the medical
services rendered.
It is possible that this injury was reported to us under a different
spelling than shown on your bill. The workman may have signed his name
differently, or the name may have been misspelled on your bill. If the
claim has already been filed, will you please return this sheet to us giv-
ing the following information:
(1) Claimant's full name as shown on the accident report
(2) Claim number (if known)
(3) Date of accident
(4) Employer
1
1
`r
t
If a claim has not been filed, will you please have the necessary
accident report completed and mailed to us at the earliest possible time
so that action may be taken on your bill.
Your prompt cooperation will be appreciated.
Louis BoohMo
19th & Landes
Port Townsend, Washington
Joffdmm Co. Dapt of NUM"
Port Toensard, 1rcxc1Ar4rtw
Very truly yours,
Supervisor of Industrial Insurance
Rata W. Ylagol
Claim Division
Y M6} d{ ?, {.i r l°l!
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S?.t,,. __,..W..+i•erg...-..??ilfia?r-d1}.c?ti}?....r+a'?y,??-
P
e neviae IN AND BEFORE THE EMPLOYER
rSUPERVISOR OF INDUS INSURANCE, DEPARTMENT LABOR AND INDUSTRIES
® STATE OF WASHINGTON
ORDER ALL OWING CL AIM FOR MEDICAL
u TREATMEN
ewe T ONLY
oere inruneo
nr?oren
-
® enencx ornce
I
C
aREM
oere Aro1rnne
5_22..6
aA,e......
r
31a663-
nn. n
nen
436o
1-1
3 20-56
5 22-56
_
Firs
Name Pursuant to Rem. Rev. Stat. Sea. 7679(K) which provides
®
tha t no compensation shalt be paid for the dais of injury
. OF HIGHWAYS or or the three oe day daya following and based on lnformalton
. COUNTY DEPT
JEFF
Yl?
L?
PORT TOWNSEND, WN Included in the files of the above claim indicating that -
® an injury within the provisions and jurisdiction of the
d b
h
t
'
ut t
a
as
a Compensation Act has occurre
Order Workman
and a result of said Injury no time loss of over three days or
Notice permanent partial disability resulted, now: -
8
- ® ® . .
PF IT IS HEREBY ORDERED THAT; ? ?.
® 1. THE ABOVE CLAIM BE ALLOWED AND CLOSED FOR ®F
Claimant MEDICAL TREATMENT.
® LOUIS SUCH I LLO
19TH & LANDES 2 THAT NO TIME LOSS COMPENSATION HE PAID.
_
END
N
PO
T TO
® e
® R
WNS
, W
3. THAT NO PERMANENT PARTIAL DISABILITY AWARD
- - ® BE MADE.
C
®
Att.ading
Physician Nolan H. Tumor
R S CR I ST MD SUPERVISOR OF INDUSTRIAL INSURANCE
MED. BLDG
-, PORT TOOaEND, WN
® By
NO PROTEST RELATIVE TO THIS ORDER OR APPEAL THEREFROM CAN BE RECOGNIZED UNLESS MADE WITHIN 60
DAYS FROM THE DATE OF CLAIMANT'S RECEIPT OF THIS ORDER. ALL APPEALS MUST BE FILED WITH THE BOARD OF
® INDUSTRIAL INSURANCE APPEALS, OLYMPIA, WASHINGTON WITH COPY TO THE DIRECTOR OF THIS DEPARTMENT.
•' ?.? _. ' ,. =?"...,..,';. yr ?Jr"r'u?u ?i«?P??S?'"1?fa?'d?t??t; ?ar,.,,?.ak'?`w?,.,r7?r9?"""•, ...
WASHINGTON STATE EMPLOYEES'
_ RETIREMENT SYSTEM
EMPLOYEE'S PERMANENT RECORD
?,. To Be Completed During the First 30 days of Employment by
All Employees in All Eligible Positions
All
TO THE RETIREMENT BOARD: P
As a condition of my employment under the requirements of the State Employees' Retirement
Act I submit. the following information:
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Cosh Maintenance
Allowance
Total Agency From Whose Funds
Compensation 1. Paid
$ 250,00 $ § 250.00 Je f ad Finds
§ $ § -
When service Was nendered PERIOD OF SERVICE
N ma of Department,
commission or Agency Title of Position Hold Doglnning
Mo. Day Yr.
y Yr.
Entling
Ma. Da Length of
Ptried
(Months) Saltily POid
Jefferson 0olmt Trunk Driver 11-1-' 48' 12-31- 148 §606.97
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1-1- 149
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.....__.:__.._._.
7. Social Security No,_.__536.12aa4738-
8. Check by (X)-Marital status: Single-._._ Married_._ Widowed...__... Divorced
0. Check by (X)-Sex: MaleX__ Female..-.___
10. Date of Place of birth__,port- 'pgrneend---4l#pravn-C#
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} r' I HEREBY CERTIEY;That-all of the statements
r which I have entered is this Employee's Permanent
Record are true and complete to the best of my knowl-
edge and belief.
(Signature)......----_T_:.:___? _
tSBAL] Subscribed and sworn to before me this
_ y
_._
_____
day of.-_
Notary Pubitc.________._._.____._
Residing
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GENERAL INFORMATION REGARDING THE EMPLOYEE
S
g;• PERMANENT RECORD FORM
All
te
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thi
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P
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d F
tit
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4 tt
s
a
men
s
n
s
e
manen
ecor
orm cons
e a recor
u
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'
the State Employees
Retirement System and will be used in determining
the percentage of all State employees eligible or ineligible for member- yy
r
ship and in establishing the rights, privileges and benefits of employees "
participating in the system. Information supplied by the employee is to
be considered strictl
confidential and is for the use of the Retirement
f
C
y
'
'
Board only. Questions should be answered to the best of the employee
s
l
kn
d
i
f
i d
ow
e
ge,
n
ormat
on and belief and in respect to Section 41, Chapter i
lg s 274, Laws of 1947:
"Any person who shall knowingly make any false state-
ts
o
h
ll f
l
if
i
f
l
ifi
d t _ s
''
men
,
r s
a
a
s
y or perm
a
ed any recor
or
t to be
s ,
records of this. Retirement System in any attempt to defraud
the Retirement System as a result of such act
shall' bb' guilty
`
,
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s
i
d
e
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o
a gro
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s
em
anor. x
A Further: The attention of all employers and employees is called to 't
i . Section 14, Chapter 274, Laws of 1947, as amended by Section 8, Chapter 240,
Laws of 1949, which reads as follows: 4
s
a• Y " 1 "Within thirty (30) days after his employment or his accep-
tance into membership by action of the Retirement Board each
employee, appointive or elective official shall submit to the
Retirement Board a statement of his name, sex, title, compensa-
tion, duties, date of birth, and length of service as an employee
y
and such other information
ffi
i
l
ppoi
ti
e or
l
ti k*
,
or a
n
e
ec
ve o
c
a
v
as the Retirement Board shall require. Each employee becom- y
s ing an original member shall file a detailed statement of all his
h
h
h
f
t
m ac
s
suc
ot
er
prior service as an employee and shall furnis
as the Retirement Board may require for the proper operation
f k 'ttr.
' of the Retirement System. Compliance with the provisions set
forth in this section shall be considered to be a condition of
8 ,.. .F f employment, and failure by an employee to comply may result
' in separation from service."
a This form should be filled out in ink or on a typewriter. Because it
`• is possible to supply but one blank to each employee, it is important that
the printed instructions furnished you for completing this form be care-
fully studied and that work sheets be used for compiling information be-
fore making any entries.
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