HomeMy WebLinkAboutReel_0024C (44)J EMrto YFR'S cU!Y STATE OF WASHINGTON I -
l [???))a yJS ((po?? D•pertm. E R E P O R T OF ACC I
T Clahl ND _.... ........... -
blm NumbeG Wkar and 1 ..;+
• Employ-1 Mart Complete This Raper! by Filling In and SIR Inp EmploYer•s S•dion Mlsw. Thm Mall "Part at Once 1 - - - --- - -_-
f.36g In 1 of Lab and Industries 8 Md 0 ($aid for addr•ss.l
o FI number 1 mploYO _:_ Telephone N ? 35Q
- S-W Sa It No 1 work mr
_ en IN mb•t ead9 d,by DPpe m t. l {.bo a 1 d ah)•) Y -
g turn amo .1 employer
Have this workman s he= been Included In payrolls reported to this depadme.IT------ 7?8 --------- if A0. Le ,hea ,-.?--3
___
v If not Included, give reason-------------- ---___ ____-------------------------------------------------------
--- _______________..____
mlareaa___ad maintenance _--__•--_--_ :.
W t- How long hen workman been omPtoYed by Youa __ _ _ XZ8! __ ______-Occupation when ____
WOO Busfnew of amleyerRda_PIdlIIfe_&--cgnct Fr•Loeatton of Plant or place of work where accident occurred_________ ----------------------
"
P
,?, 6 III ngaged In construction work atom Padlcular kind) -
anG Check In which department workman was employed: Construction ? Opemdon ? Rep.1, jpe On launched boat 11
M W In urad filbert J /lIIBDl9ter Has he Iinsxial - Patin R Corporate officer?
..m 1 ____._ -_ Interest i th burin Sole own r7 J
a A.M. workman Y a ___,n0
'> Will Wls wkma bake y 9
so Noma of pt on solar r dud??rv g his period of Last iae site n e tenntb Siek_loave P_ _
o• Data end ho 1 sculdent 2 ._-07162_ ]Ctl! Y worked - Z_,}Q?9 Data 1 rood to
ark 2-18-69
-------------------------
-. Y1 workm a'bngeged in thregul?r: sg of his employment h Injured? _ p68 _. - Shift hours- _8_ ijR.
DIQ ddnt occur,? Yourp Wsea L1 4,.a _ If not, Where? _____ _____._
t and ho Id t eportedcto You. 2 x-6.2_ i., To whom reported W8?.7y Brn1tg Posll:oa_rssy•____
i
y LI. y gvaal [m.e21o aaco cLdo,n17. '.Vhya:: (Attach loltar li'mcuYdary) ___.._____
e?{v?r. grvel'aff truck told rained back
hr.- old «Id
aan? happen
2 ____
-- _-__ _____ ____________________ . ___ _ ___,
1 ID Ib Iha ¢itl 1 t lly •tatinq whelh, th Jnjmed parson fall or wa struck, aI ., and all the ledon motdbullvg to the ?=Ideal. If -ceseary Ile a spppl•- '
r Illy lelt• I.,,w t• .Nv .. -
I do lire that the foregoing statamaots are true to the bast of my knowledge and ballet
S -d
thi------------ day of ____ ___.. 19 ___
--------------- C--------------
Ye 1 lld•I pwlli )
6
Adjudged non•compenrable eXcept for (TO HE USED BY DEPARTMENT ONLY)
Medical Aid Bilh allowable by law. By .......... Claim No
Allowed for antborized treatment Dl.lm• " ! t 1 _,m '
.. § Firm No
B pUA EeY9 oOK EY
and action at indicated. Y -"c1eLa. >s.min;; sa At k7?' ?
P•rv)s l.o/ lndwtrl.1 besurance
EMPLOYER'S COPY -•----•
Clarde.__.-.-
- '
R - MmICAL'AID AWARDS AmoueS7 Computed Data Notlp
- : • ?9 9.nt CODL.
ER 216486
INor Claim Number) f,l• 7„a.R
Nop-cont
Name .1 Injured workman _ __-Gt4dF-,e_,?_ _!__'- Soda! Security .No., _ _ _ --_ -J
.Iloa.a 177
I..aY TalePbono
--------------------------
Address (to which all mall to be addressed) ____ ___ City and b____ % d q /f
Year Job till. who. Wmad Be. Age
Dom seudenl amd o? - (Give dens el 1 • '
State hour of accident -------------------------- `
Shpt hours
GI date tut worked __ a If y h • durn•d in work give date
!. 1^ Nam, of .mpl y ?_ L.c i-___?u_------ ?,i" t'1 _ L___'_• Address
----------------------
-------------J --
7` u W you do1n9 Yo squla w •n Um f sMd•atP Y ; ?.,P ___/' 7 OoP1?("Y/?' Promlaeal___?7
O D erlba - geld Ft N 1 11?sC! rL/ tlLC'2'2e?A'[ [-G/^Y___C"?.Y(4f«'< v.?? L ___ j,.
Y s -
---------------------- ---------------------------------------------------------------------
W t h. tl your oPlnb ed b' any y by -Rere
d Pl Y by Y amp 7 tr.. ? -
-------------------------
z4 a Ma /. le } .G.Gf GGSJ YlFiI NN ... Wage Per d
.. ap
pl ?'ST N 1 w R- h d h t ron ............. ........ _........ .... INam•. tlDa) ..
T O _.... .. _._.. .
N 1 A1landle9 Php Itlvv ?
ere. G.6•??>C E:-.??Qlll. Addnes
O- Pull a_- of RU- or buabved E -'Y ci... .
n . - .. ..........
'I ne 11 dnvamtl vnd Yeu hm, minor ehadr•n submit c .. If divorced give nv deems dgle....._ _ ..
cepyol the curt ardor ah.wir, legal euatedlan el such child
rva. AL _
d : o oils prnawl add,... of such
cmlodlvn.
-, GIVE NAPES AND RIRTH PATES OF YOUR CKIIDREN UNDER In SUPPORTED BY YOU
NAME R 1 hl D.I. of Birth - --
p j•` Mo. Day Yser NAME Data of Hb h
- Rddloruhi0 MD D• Year j'
,> t
1 ' ? c
ft. 1 declare theft th laregoy I ys1 tomeab ors true to W w
e best of my knowI and 1',
Shined--- 1 ------ dosrof . f M .............
( r •• Earn-?1.. at? ?_ s_ •G___• ,
° AR.1MPC?RTANT ?. WOAKMAN SIGN HERE-• aaldn glt/ --
r R.. 2164 8 6 PHYSICIANS REPORT r---- -?
- Net Cblm NueAbw
Name W injured workmaa------ AZAteJrt,s
SNP
Add re ----------------------------
Employer. ??a?r•-pQa?LLnQt19$,Ct1Y ___.,........ Zip Code ____ Cl1m Number
? .
Employer., krO&O AYBL_O'rWMt
y---Y-Otr_____-__ Addle.._POrt
Data injured ...... 212Q,(0? -Work
------ --------Date that 1nlmmt._-2110 - ? •
History olylnluq•(Netrtnmides Loveland, .1_a glve right or I-ld __ ___ Rkml
_ -t?sltnetL.Saok-1Wttle-ohova23 Irr1Pa d ---•-
+tf/ 9raue?
---••° _
aO Physical 11.41.0k 1detail N.atr•niln« b .1'.L qiv. right or 1.11)..._...tt(71Lb0 .oQ -
....L._aLmtrr"
------------------------------------------
._' .__
s DtAgccojk..,._ .......... ?a4..e¢arni.a#rtcft>t.........
Clve Inalroeol Used ..•..,.___._......... _.__..___....._..____•_
j _____
I °nv
-•---------------- •-•••••--••-••--••••--
i1 HAR Svmkmea had pnvbun injury to area?_____________110__._.°.- I _j
;
ads[ by Pone for ________ ............................................................
Has wgkmaa ever been bested h an E .
pneanl rn atmllu 11 ea, • _. h then any disease N the eau Inland)
preuL _ ...........
,
ring . ...................... _....._?.- _...•...._
Will Win or nay other pre+vlstfng candltloR complicate treatment or 191Ard r•revery! - .__...• ...............................
Is condldm diagnosed the nwlt a accident d•acsib.rll ........ ---------
e
11 FarWtelluUon r u d, more hnyluh_.. Q Probeb1Y,? Possibly ? No 13
e ?_? w._
liumated it.. Ice, does to InjuryP ................., ................. Yes Addrw._..___. ( -
. f P, I IY9• Y tae M iSmau. -_ ..
+ N• • Jab eT y. :r:ar Wx:; :r.,c:asi r,.;:.z:E•-ma.
Y/
Hlgn t y OR /m/? -Aster-atE..f'brt 35?Dattteyrt;-•Acoa ,
;? y'f „_tMPSOYIR.-RfMOV[ SNtrr two PIN. COPY -1111% IS YOUR COPY ".,.PnY••Acmunl Ho..,__17RyAC.... .....
(U,• Net. Pay. Arnunl NB k S1 Inp) r,I'E;R-a l
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IN AND BEFORE THE '
' EMPLOYER
SUPERVISOR OF
INDUST L INSURANCE, DEPARTMENT LABOR AND INDUSTRIES
n STATE OF WASHINGTON
GENERAL ORDER
ssANCn oPriee
C Are Ar GLVMri cuiM nuMSes PmM nuMaen cues GATe Ix,uxe
s
xa,
rce.axv.MPLOra.
.t - Bram. 7-26-65 F-258454 4360-1 8.3 I
12-14-64 7-26-65
"' .!'.. • Firm Jefferson County Dept, of Highways
- ANY APPEAL FROM THIS ORDER
r
c Name' Port of Townsend. Wash. MUST BE MADE TO THE BOARD OF
INDUSTRIAL INSURANCE APPEALS,
OLYMPIA, WITHIN SIXTY DAYS
Order FROM THE DATE THIS ORDER IS
COMMUNICATED
and
Notice TO THE PARTIES
AFFECTED, OR THE SAME SHALL
BECOME FINAL. COPY OF THE
PF APPEAL MUST BE SENT TO THE
DIRECTOR OF THE DEPARTMENT.
Albert J. Ammeter
? ANY REQUEST FOR DEPARTMENTAL
.
Claimant
Chimaetao
61eeh RECONSIDERATION OF THIS ORDER
.
. MUST BE MADE WITHIN SIXTY
f DAYS. A FURTHER APPEALABLE
ORDER WILL FOLLOW SUCH
REQUEST.
t4N5Y.
3 _ C
.' Attending
Physician
Brace H. B"dgas. H.D.
u Medical. Bldg.
Port Townsend, LTash.
q
I It Is Hereby Ordered That: PERMADISRT PARTIAL DISABILITY
° 35% of maximum allowed for unspecified disabilities ---------.
-----$3062.50
$1000.00 cash award paid at this time- --------------------------------- -$1000.00
Balance Of permanent partial disability of $2062.50
to be paid at the rate of $270.00 per month
plus 5% interest per seem on unpaid balance
pursuant to R.C.W. 31.32.080
)5) (Cbspter 274. Laws of 1961)
TIME LASS AS PAID
CLAIM IS HEREBY CLOSED..
NO FURTHER ORDER WILL BE ISSUED RELATIVE TO THE DETMCDIATIOH OF
PERMAH6 r PARTIAL DISABII.ITY.
DEPT. OF LAUOR Z lt:OUSI'XIC
OLYMPIA
WA]I
.
IINOTGN
?41 APJ
JUL 26
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