Transcript of 166-12c-1_serial_1_section_3_56-la-156_la_report_6.9.68-part_3_of_6.pdf

================================================== Page 1 ================================================== ARGONAUT INSURANCE omYC_~ DATE_ NJuRED_ L Policy #_ ANSURED_ PoLIcY Term CONVERSATION with CLAIM #_ 2203y L ChL 1 0 0 [e 85_ 8s" Z7_ZAg LuL L4Z e 718 CLM 547 R-1 Fc UAA ================================================== Page 2 ================================================== EARL KLAFFOON Orjnetzrm INVESTIGATIONS 37857 TT7A +7;, 24*02 1033 WEST,CTX STREET SUITE 210 68723172771Z77_ Los ANGELES, CALIFORNIA 0o057 (rrnat-033076747774x202" KUBBARD 3.0943 February 7 , 1968 Argonaut Insurance Company 443 Shatto Place Los Angeles 9 California 90005 Attention: Mrs J, Stiner RE: SIRHAN B SIRHAN VS . Altfillish Const Co 0 2X-20344 5 L-3191 WORKMEN S COMPENSATION APPEALS BOARD HEARING AirC February_ 7 1968 9 : 00 a0 M 0 An investigator of this agency reported to the Workmen 5 Compensation Appeals Board in the California Stete Building: 2 Los Angeles California, where he waited to testify and to project motion pictures at this hearing_ Later in the he was advised by Mr e Evans , the attorney handling this case, that his testinony 2nd motion pictures would not be; needed this date. He was then excused for the Thanking you for this assignment 9 I remain, 634/ // falsen Earl He Laffoon EHL:sft 713 day: day _ ================================================== Page 3 ================================================== EARL K,LAFFOON {menoDrptez INVESTIGATIONS 070o/X77xc tztz 1e33 WEST GTK STREET SUITE 210 8 R-Dtrhiroo,SfpzF LJs ANCELES, CALIFORNIA 90o57 Lanan-3ote33472 3-7452 KUBBARD 3-6943 February 2, 1968 Argonaut Insurance Company 443 Shatto Place Los Angeles , California Attention: Mrs _ Jean Stiner RE SIRHAN B SIRHAN VS Altfillish Construction Co . 2x 203445 L-3191 SURTEILLANCE REPORT January_ 25,1968 MR SIRHAN was spot checked from 1.30 p . m , to 4:30 p . m on this date Including travel time three ana one- half hours were spent on this a8signment this date The following 1s a brief summary of this date '8 spot check _ 1.30 p . m , Upon arriving at MR _ SIRHAN 8 res idence in Pasadena we attempted 3 direct contact The door was answered by MR SIRHAN S mother who proved friendly and related the following Information MR - SIRHAN is currently employed , but his hours are quite irregular at this tine _ His mother had no idea where he worked since he had told her it was none of her bus iness She went on to say that he had attempted to return to work as an exercise boy , but was unsuccessful > due to lack of seniority_ After learning the above information, the contact was ended Since MR SIRHAN S mother haa stated that his hours were quite Lrregular we took up a position of surveillance, assuming he might return at any time 4.30 p . m . Since MR StRHAN had not returned, and furtcher surveillance seemed unwarranted , we discontinued 720 '3s66 ================================================== Page 4 ================================================== RE : SIRHAN B SIRHAN February 2, 1968 Page 2 on thia assignment for the day _ This informatlon Ias telephoned to you We will place MR SIRHAN under early morning surveillance January 26 1968 MR _ SIRHAN was placed under surveillance from 4:30 2 . m to 11.30 :this date Including travel time, elght hours were spent on this a8signment this date_ The following i8 a brief summary of this date'8 surveillance 4.30 a.m _ Surveilzance commenced _ 8:52 a .m A man, fitting MR SIRHAN S description_ 9 departed the residence driving a Volkgwagon &_ We followed him to the United Picture Frame_Company where he parked and entezed the building, going ou t of view As he was welking towards the building, we exposed 30 of 16 Inm color film of this activity_ After ne had entered the bullding, we made a Department of Motor Vehicles check of his vehicle It proved to be registered Adel_ B Sirhan We then made an employment verification at The frame company , and it was learned that Adel Sirhan did Work_there; We shen placed a phone caTl to MR SIRHAN 8 residence 3 and verified his presence at home It Wa8 a180 learned that the man the investi- gator followed and photographed wa8 MR SIRHAN 'S brother They are apparently very similiar in appearance We then returned to MR _ 0 SIRHAN ' S residence and resumed surveillance . 9:50 2 .m , MR . SIRHAN wa8 first observed , as he was running dOwn the sidewalk As he ran; we exposed 15' of color film} MR _ 5 SIRHAN appeaxed 10 move in a free 2nd easy unreatricted maner 721 ================================================== Page 5 ================================================== RE: SIRHAN B SIRHAN February 2, 1968 Page 3 10:00 a.m MR _ SIRIAN arrived at the Organic_Pasadena This proved to be a health foods store, located at 1380North Lake Pasadena,_California MR _ 0 SIRHAN Then entered the store, going out of view 10:30 a.m, Since MR_ SIRHAN was still in the store 9 we placed a phone call and verified his employment at the health food store_ A short time later, we entered the store and observed MR 0 SIRHAN in the back room , 8 tamping small bottles , to be put on the shelf 11.30 a.m . Since it appearea that MR SIRHAN would remain in the building the res t of the we discontinued _ A total of 15'. color wa8 taken this date This information has been telephoned to you We have suspended activity on this case until We receive further instructions from you Thanking you for this a88ignment , I remain, [1seh Yh ~ Earl H_ Laffoon EHL 1s CC McLaughlin 0 Evans , Dalbey 8 Cumming Mr , B , Evans 722 day , ================================================== Page 6 ================================================== ARGONAUTAINSURANCE FRO) DATE_ INJURED_ Policy # INSURED_ POLicy TERM CONVERSATION WitX Fa;7e KAh CLAIM # YLaU aly Z 89 723, ClM 547 R-1 DAA Av ================================================== Page 7 ================================================== cnpmneasck Iasahamce JBonfvv 443, SHATTO PLACE LOS ANGELES, CALIFORNIA 90005 January 17, 1968 Aitfillisch Construccion Company Inc Route 4F1, Box 159-B Corona, California Attention: Laura Kraus Claim No: 02X 203445 Claimane: SLrhan Sirhan Emp loyer: Altfillisch Conbcructicu Co0 Inj Date: 9/25/66 Centlenen: He have your letter of 21, 1967 9 betting forth the veek8 thaz Mr Sirhan worked for you after hie date of injury on9/25/66 . In vlew of the fact thez Mr Sirhan wi11 probably contend chat he d1d not return to his regular duties follovlng the Injury of September 25 ,; 1966 , and that he terminated becauge of his linitacions , Ve would appreciate youz advising us 88 Eo Whether Mr Sirhan did return to his regular duties including exerciaing horse8 , &d whether hts terulnatfon of employment was related to linitation caused in turn by hf8 injury o€ Septenber 25 , 1966 _ Thank you for your cocperatLon - Very truly your8 , H0zezwi D_ Seiner Claimg Exaniner cc: McLaughlir, Evans Dalbey & Cuming Attention: Barry Evans Answsr: Jirlun Siriiwn dic return to his rerular 0'16:2s Riter ji8 ijury &nd iiis tornination ~was due Eo ti I;ct tx t Quit volunterii) #e moz}e: Jron lo/1 * 11/15 at M rals2 im Pav; `t 8'% } :tf'we | 1. wup! (} 1/2 io 12/10 #law h8 t p#r7!:11 4< 724 July Ie qwi ================================================== Page 8 ================================================== ARGONAUT INSURANCE To KRom DATE #NJURED POLICY NSURED_ CCZ POLICY TERM ZONVERSATION with CLAIM 2K-2ozYsf 5b54H Zx-23125324 TUG ZZUCOC 7277 Yyz Uis7i4e2 Ezza Wzzui, ~jc'en L 7 MU7 tu?01Z LL X 725 F2Y7 L ================================================== Page 9 ================================================== cAngoncik Saecentate RESER VE COVPUTATION SHEET Claim No_ Name 8f Injured_ Date of Injury Age _ Occupation Cx2-ee Group Letter Comp: Rate (Temp: ) (P.D_ Babed: or Wage of Estimated P_ D_ Rating_ 0 %, O; Wke. Temp: Comp: Paid Wk . $ Further Est. Temp: WX_ Total femp; Comp: Total Comp: Est: $ .2072 Med. Paid Future Est; Med; sat4ys Total Med, Est Estimated Date Rating Factors; Objective 64 Subjective 262 ZLLE Eeexq Rating Forrnula '.7 (0 8730-3 "S0 6bz 5 ' 363 03S0 Reviewed Datc 726 By_ By 713}/ ) ================================================== Page 10 ================================================== TO hxe L84 AT RiEc I X /`# DATE [32x-6X X2ozyys 44e_ZL 624102 3 2_2 7S, 1A2 La 1zz-2_ ~LAiLx abeoNAUT INSURANCE PlEASE REPlY 70 Azze SICXED _ ' Wse Rcvcrse 0690 You Rerly T 6C '[l ================================================== Page 11 ================================================== DEPARTXENT Of INDUSTRIAL RELATIONS D'soNOF INDUSTRMAL ACCIDENTs WORKMEN'S COMPENSATION APPEALS BOARD STATE OF CALWORNIA Case No. 67 1-312 144 {JINAW 30 31aX0% Notice of Time and Place of Applicant_ VS. Further Hearing G433 TISZA DEL: %CO ARCoNAVE IISUIANZE COMZArr; 0 #crpor8clo Defendant-D NOTICE TO ALL PARTIES You are hereby notifjed that further hearing be held in the above-entitled accion 2t 4107, LOS ANGELES STATFE OFFICE BUJLDING, 107 SOUTH: BROADWAY LOS ANGELES, CALIFORNIA FEErIARY 7$ 2983 9.02 AaNlc VOR KMEN'S COMPENSA TION APPEALS BOARD By RErExEPNOZCF Daced 3R0: Los Angeles, California NOTE: CONTINUANCES AND FUR THER HEARINGS ARE NOT 'FA VORED. A}sk SERVED BT MAIL O PERSONS SHOWA ON TiiE OFFICIAL ADDRESS RECORD D'e: Bv: 1-01-3 T"' 1*35h 728 "1f wviiT | 0{A 'Xt (714 41 70 3 will ================================================== Page 12 ================================================== McLAUGHLIN, EvANS, DALBEY CUMMING ATToRNEYS AT LAW John MC LAUGALIN AREA Code 213 BARRY EVANS 1717 nORtH HIGdLAND AVENUE, Suite 7i0 TELEPAONE WM_ BLA /R DALBEY Los 466-0541 RAY B cumming ANGELES, CALIFORNIA 90028 HAROLD BENNETT NED L: GAYLORD Jenuery 15 , 1968 JOAN BARTOS GEORGE R. AASWELL ALLAN R.SCHUMMER RobERT H, GiLLhAA Az_ Ingurance Company 473oB848 Shatto Place Los Angeles California Attention : J 0 Do Stiner Claimg Examiner Re : Your Claim No 0 02X-203445 Sirhan Sirhan V8 0 AlCEilliach Cofstruccion Company , Inc 0 Date 0f Injury 9-25-66 Gentlemen : The above matter {8 now scheduled {or furcher_hearing before the Appeals Board a: Los Angeles 0n February 7 Fe refer you to our eerlier letter of January 3, regerding trlel preparation& If youz further {rvestigation does disclose that applicent did retlrt to his reguls dueies and ccntinued perfort chem foz 8oue peziod of Gime poat injury , then an inaividual Who could 80 testify should be aveilable 8t the hear= 0 In adaition, L8 sub ro8a 18 effeccive once 8signed _ :hen we should be 80 edvised 80 that arrengement8 car be @@ade €o view the motion Picture film &nd artange for the ePpearance Oi the necessary investigator ac the hear Your8 very McLAUGHLIN , EVANS 8 DALBEY & CUMMLNG 050n4.2 ' Yw By : Barry F . Evas BFE:cj z 729 ming ing ing0 tzuly,. Jukuu Ok. Ut !lx|7 ================================================== Page 13 ================================================== Ixise cvs Bnrl K. LAFFOcN ' Gx 22429 &z INVESTIGATIONS -2-6 & 4 1633 WEST 8THSTREET SUiTE 210 Los ANGELES, CALIFORNIA 90057 G0 L.A_ HUbbard 3-6943 H Srans SS WAME Of INSURANCE compiny 2/2 3-/9 CLAiM NUMBER 11iuu L2ss AX223/4 ASSIGNED BY DATE ASSIgNED 2 4 hfes_ h2z 6s MNSURED ADDREsS City 4LLLsk Ionsdzu Lss Klzce-hin)Esleu Ctzle Nor co CLAiMANT ADDRESS City 2han 2Suehaz LSlbuaed Sz Ecashaa 2 AGE Weight HEiGKT MARRIED OR SINGLE 7 { 2 3 'l Smz2E RACE WEAR GLASSES MUSTACHE ColOR Of HAiR OCCUPATiON DATE Of [NJURY LocATion MALE OR FEMALE SKfROS 22k-/1 J ACCIDENT 042fn Jeoe_ bpesz hss_Mus2Zu)_[oz SbLL RenytEy_sbef 4LS LlEek 5L_b2x Lcl Evf_Ld Uhul bems: batk_fL LAZ_hand ClaimaNT'S ATTORNEY ADDRESS city Zhf LepmfR_ K maeEn Esacu= DOCTOR ADDRESS city Zo TEL X city WheRE Keafing HELD HEARinG DATE Time Of HeaRING MEstal_ZpL2EL-6 012?IE REMARKS Lan 1_baLk L2en 1 OnEQoscao L_~Ljln}__szs Huz - bsadud-_lp2 4 ~sleuchlineif 21 LLEE 22 Aelssh {NVESTIGATiON REQUIRED SerEiLanch 2cs 2Lzbad LEES ELAeebul AUthorization To USE Mope THAX OnE OPERAtor XukbeR Of Dats ALLOTTED If MoRE SPACE is REQUIRED; USE REVERSE %ide 730 Zne24 Hleaens, Baeev Lompl LmL2 X Dnp- tellc S %2/36 ba Lul MS fmen b1z bndvg Lo =EEY _ EefX LELvy Iec ================================================== Page 14 ================================================== Rc eParsarhovnce 1Aer%9 443 SHATTO PLACE LOS ANGELES, CALIFORNIA 90005 January 17 _ 2 1968 Altfillioeh Constructton aRy , Inc . Route #1, Box 159-B Corona, Californie Attention: Laura Krea Claim No: 02X 203445 Clainant: Szrhan Sizhan loyer: Alcfillfsch Ccnstruction Co. Inj Date: 9/25/66 Gentlemen; He have ycur lekter of July 21, 1967 2 setting forth the Mecks Enet Mr 0 Sirhan wozked for Jou afcer his dea of iejury cw] 9/25/66. Io vIcw of tha fec: tnec Nr Sirhan #ill probably coneard that ha a18 not return Eo his rogular dutieg following tbe Lajury of Septenbar 25 , 1966 , and Ebec be torrinated baceese of hf8 1%altaezon: , we world appreciete your adviaing (3 83 Lo whcthar Fr Sirhan d:d Zeturn co hic reguler duties Includ:ag azezcloing horaes, E3 Mheghar hss teriraescn of eIp Loyiuenc Ma8 Eolatad to Limitacion ceuaed 112 tura by hig Injury of Sepcember 25, 1966 & Thank: you {or yoxr Cooperetion . Eruily yout? , J , D. Se1tez Clalocs Exaniaer cc: Nclenghlin, Evzns Dalbey & Cuming Atcercion: Barry Evang 731 Com?= Emp Vezy ================================================== Page 15 ================================================== McLAUGHLIN, EvANS, DALBEY & CUMMING AtTORnEYs AT LAW JOMN F, MCLAUGHLIN AREA CODE 213 BARRY EVANS 17I7 NORTH HIGHLAND AVENUE, SUITE 710 TELEPHONE WM. BLAIR DALBEY Los ANGELES, CALIFORNIA 90020 466 8541 RAY B.CUMMING HAROLD J. BENNETT Ntd GAYLORD January 3 , 1968 John BARTOS GEORGE R. HASWELL ALLAM R SCHUMmER AobERT H, GiLLAAM fx bogbuttonzizance Company 44_ Shatto Place Los Angeles , California Attention: J 0 Da Stiner Ctains Examiner Re : Your Claim No . 02X 203445 Sirhan 6irhan VS Alcfillisch Cons truction Coipany , Inc. Date 0f Injury;--9-25263 Gentleten : We ar2 proceeding to file and serve the report of Dr Martin Albori of Deccmber 20, 1967 whieh establishes 2 rather substantial medical conflict hen consideration is given to the repor t of Dr Yamshon of November previously served upon this office the attorneys for 'appiicane- We noie from reviewing Dr Albori' 8 report that the applicant apparently Will contend that ine never did return to his regular cuties following the injury of September 25 1966 and finally in December of that year he was terminated 'because of his liniiations Tle leiter from your assured dated July 21, 1967 by inference would seem Lo take issue with these clains However 9 we do believe that some further contact should be made With your assured and a determination made 8S to whether epplicant ever did iri fact return to his regular duties including exercising horses and wheiher applicant S termination 0f euployment Tvas related to linitations caused in turn by his injury Further , S OIc effort at sub rosa might be warranted in viem of applicant's elaboration upon the extent of his disabi Youis very McLAUGHL IN , EVANS 8 DALBEY & CUIING By : 0wp43 Barry Qau^ BFZ:cjz fk 6 732 ~mu-L 1"^ by. lity truly, ================================================== Page 16 ================================================== Employer'ST Ldaatiliatiil Number: MARTIN ALBORI, M.D_ PII 739 NORTK HIGHLAND AVENUE HOLLYWOOD , CALIFORNIA 90038 TELEPHONE 937-1176 DATE December 2lst 1962 Argonaut Insurance Company 4k3 Shatto Place Los Angeles_ California 90005 FOR PROfEDciONAL SeRVICEA RENDERED Re : Sirhan Sirhan Altfillish Corrstructfbn Company Claim 02X-2034k5 12/18/67 Code 0002 Special Examination 3 Review of Submitted records , and report 882.50 42 l0} 733 Ailie' Eans 'JuA ================================================== Page 17 ================================================== sfeside jumies 463 Sharzo Place, Lo: Angeles, Celffeznia Deccnber 6, 1967 S4rhan 8irhen 696 Rocz Hoszd Pegadena, Cal;Eornie The: Xereys for this patient 02x 203465 are not in Our offices. Altfilliceb Copctzuction CommEny , Zoc 0 8i2n7n $Zsh18a Dr . R, Ae Nelson 9/25/66 Mcpday , Becrb? 189 1967 1430 P . Mo Mazein Albozz, M @0 739 Borch Figalard Avatuzo Lc8 Awgoles0 Calezorala 933-1176 68 M 0 U Ja Da Sezasr 6 CC2 Palmaz 6 Toownr C22 Mclenghlin 4 30023 See: Richard 4 _ Xel3l; Ei, Do 37 5 "(P .S , Please forward all X-rays ce; Yorrvs: Jontso} to Dr . Albori ec] Marein Alboziy X, 9a NH? 73b aXlsck_ 2+-_9 7< LnLs ================================================== Page 18 ================================================== 'X: Wtl?:v {v, 90,} TE: Mr 97-76 Decewber 20, 1967 48P 8a2t Ingurance Compsny Shatto Flaco Los Angelec , Calefornia 90005 Re: 8irhan Sirhan 696 Eabt Koward Poaadena , Cai iforuia Dlr: 9/25/66 E; Alcfillibh Conbtruction Co . Cip # 02X-203445 Gentlemen: The ace was ezamined at thia offlee on Deccugez 18 , 1967 0 Te findings Er e 88 follcw3} He 10 8 male, eZogle, age 23_ 0 Hz8 occupatioa 13 cat Of erercise UU HIETORZ: #Tcey Drrt Ie pocLent_<elacea tbac oD Septcnber 25, 1966, whzle ezezc_eing E horae, he Ea8 tbzowr frcn tbe hozae . He fell &d sus Eined Injurles , Ba waa taken tQ the Corona Cornenlty Hocpical He hud @ Jaceration 0f the left eyelid, 8 Laceration of &ha chin Codv tugion 02 the Ppine und 0f Che left hand D Zba Leceration were swtured. Je Btates thac a: the tica 0f the fall be WoS briefly unconbcloug Re Va8 ender the care of Doctor Nelbor, He Mas djacharged che nezt end remaioed udoz furtker care bj Doctor Nelaon a4 bewad subcequently referred to Doctor Miller 808 then 60 Doctor Klengo He bt8te3 he 88i21 18 under tbe cre 02 Doctor Kiehn Wich treatents to tbe lezt e7e: he 18 gived bome eyedrop3 0 During thia time be 8core8 be V38 8een by Beverel 8peclaliot8 . He 128 tenporary dlobbled 'Eoc Morlc for 8 iod of about two weok3 be chenreturned 60 wozk for che 8ame cmploycr but "not 0zl @V full cepacitsh I Mas not exercibipg the horsesa , 1 Just worked 88 helper &nd stable Zn December 4 I w88 Cereinated because Of my [iuitationg Whick were due to the icjwry wich 1 received Norking {8 88 that place' 1 trfed Co find cthez work bu€ 1 ecill;had handicawp3 Fith %y eye and low back @xd 88 8oQ3 28 I medclored thege lerdicap8 I would noc gec & jcbe I did noc &0 on Ungrployzent becaaze I (Mw 735 1 boy, day pex 286881e221_ boy- #8 DEC 33, 0 8 #Q v? ================================================== Page 19 ================================================== 7 -7 Zin Ho: Re; Sdrnan Sishen Decenbar 20, 1967 didn' t kenord 1f % M35 covercd by Uncrployent- I rettrned t0 Tps about' three reeks ag0 when I found 8 job 23 grocery clerk, in 0 goall Gwore? the wori L9 Iighc &4 [' @ gtill this worb" COMIAINIE ? #Zhe patient 8t8te3 that he OIu*I C4tC10 iu~ still ha8 om8idergble discoufort in the epine, pargicularly 1x7 the Low beck but 8012 diecoufort 0}20 along the upper Bpinca He states tbat &his dlsonmfort occur? Wbenaver he moven , hends Scoo38 r acands for a Long time_ He does not %now if the disconfozt i3 iocreabed by cpuzhing Gr sneaziag because be ocates he never cougos O% 8neeze3, Dieconfort 18 grebter in the morning but &. Lim28 Or {n cola reothez 813o a6 nighco Fe hes DQ radlated *o che Lower e7trenie_e8 , Ec complaine BZoUEozb the left eje Wnere he 8 Zaxed thet the skin OD che ionar @1d8 0f the eye 18 tlghc &d anconfortable eopecially in colder veatber 0 Ee stare8 that thse Opa Ecy fec0 92 balance"_ Ee indieeres cac tie scar on thechin region 10 Lnduated and glve8 him 8 fcelicg of pressure 0 Ee 8talc thac a€ thl3 tima he hg8 00 impaired: 0f viezon_ 0 PASTRZORY : Wich Above eaployer for @bouc eetr-6tOt Lnoaco P udr 8i% Ionth: He 8tace8 chae Rever P in the dld he n%va QGy lndueErlal clgim, aLg16 flcant {ofury, 8izgery Oz' s1g0if1C808 8icknC88. EXAMZNAZTON: riD_ Age 23 beighe 5 44"' walght; 115 Gecupglion Gzerczze On exaninatiow 0f the ekull, thc patlent bag no Points Qf cendezne38 , tbere arc 8o 8car3 0 ro 81808 Of reg_duala of ijjury. Eyea : Only Fich hiB &80l3tanc8, Cab Q very mlnimal Sca3 be noticed Or the medial end 02 &e lefc eyelid_ Theze i5 Do indication that ehls @C0% YBrar Painful 02: tedder L8 18 coszetically noc moticaablee Iotion8 Of bis eyelid aze not aEfected, %e leer t8 diletco by eyodcopa .which thg pallenc Bt8688 were applied th_9 Goznzng ro hlo eye Doctor Riean, Face And chin; With tle paczenc'8 Os8ictonce 4 9 @caz cen be norieed Qn} 2h8 uader 8ide 0 his righ2" chin. #: 736 Tei AT_ 7ur7M Qaly doing {rhrc pe3e boy. Pupil py ================================================== Page 20 ================================================== MAR:: 738 Tio"h : Mum0. :0 3c32 Ticiondcor 937 Re: Sirian 3irhno December %0 , 2967 Zhe cosmotic begrigg 19 obvlougly nil &d &no Grea 18 min:rcally indurated, 'Tbeze ere no reecticna ef pain Ox tendertess, 3D Vugbegtion Of regional dloabllicy from thfs Veaz' Wper extren_ties ; Re states thaz he-kad 4 concuxcLon to ths left hAzd but be gtate8 that ajupEouag have Buba 8fded en Lirely Cn regional ezauinaticn there are Na painful reaction3 , 0 linitationg 0f EoGionse no 8ign8 of @fter efsectd 92 Enjuryo Evldence of 8lgnificau8 nallbicing 18 ootcedo Spine 9 Pelvis Gnc Owjer @rcremitie3} Zhe patlenc'8 19 nocwal 9 he Qe8r28 Do 8uppore, be walles On hzo coes end beelt and be_cpote Mlthcut &0y Gifficulty His feet ae {lot. Trere 18 Increased gwayback 01 po8tuzd Dacure, rnere 03 DO 8pagm ac &ny time duzing ezaninacion, no defozmitieC, no Vislble 88e18 6 Ke statc? chae di8o comfcrt L9 a: tbe Zambogacral Jewel tere 8rq [70 Polnes 6 tendernc g and tbere 18 abgence Qf pointg of trlgger Pain, Reflezes ezc &l} noztal, tbore 8re Bo 8em3ory changee 9 girche re Rozual &nd '82 testa Bre entizoly pegative, Minnual Lnitotion anterloz Elexion {3 displayed the palienc bue Ozz sicting Elezion tegt hi8 range 10 grcatez than overage. MeagurenentB Grd t3028: Spinal notizo/nornal; Anterzor Elezion 20[95 Zinsozt1p3 0ims Eloor by 1 inch Eztension 40/35 Botation righz 6 left 35/35 Lateral bending #Jght & left 401bQ Siccing flezion teat (icBride '0} 100/9 LOWER EXTREIETZES (RIGi (LEFE) : Thigh girtha 164/264 Calf girths 1250144 Lorgth Qf lower eztrenitieg 33/33 Straight leg *aising 85/85 FlLp ce8*8 Negotive @ 90/90 8 Ln8egue 8 te3t: Negetive Patrici" 8 te8t: Megaelve Ely' 8 tesc; Nagative E 737 gait py 8 :Q ================================================== Page 21 ================================================== MARNA: 7:n_ 736 Ncll:#'-JJ, U: {c?? Tele?koml 7.1176 Re : Sirnan Sirben ebe Decenber 20, 1967 XeRAYS: Subnitted Eilms : Thebe ur @ Ioreja from the Cood SamarLtan Hospitel and are fllms of he Skull dnd 02 the lunbar spine. Tae finding? Gre cntirely normal and negative. Theze ere no eIgns Df Zeccdt or old Lnjurieg nD abnormalities of the disc 8pac88 , no Jighfficanc orchritic chenges 0 There 13 postural sweybecke SURMTED_EILZS These ere records of Dcccor NelBon, KEsridttp {r0nt6+o Doctor Kiehn, Doccor Teahma 2 Doctor Pattersor, Doctor Johnsor Doceor Nugent an Doctor Yamahon Tha records refer CQ the Patient'8 copplaincs_ and Snjurfe8 incident to &he accident 0f Septembez 25 4 19660 Exenination by aeveral eye specialist? 18 degative for Any 8148 of 80 Injury to the left eye CZ for eny 81g08 or disabllicy attributable %o &he winoz Gcar rsar tbe left eye. Examination by neuroburgeons 18 reporced to be negative with rGferenee to neur OJurgical findinge . A report by Doctor Yaughon referg to aubjective Esctors' cf pormanent disabilzty involving the Low bsck &nd to gcarring And disfigurcient incldent to the Ecar8 0 I thozoughly dlbagrec,with these Cons clusiong 0 CONCZUSzON: Wieh1 raferenca to &he 8c878 @nd 08io to the parient 8 1ow becs, Zt,18 Div opinion_ that thj8 patient 8 Bubjecclve complelnts are en tirely amcupporced by resional evalualion Df Che %indinge 6 Wizbout hls 833i8canc20 I rolld Rot have notieed che gcarg ,&nd their cosmetie defect cherefore, ail9 I al30 Go nc belye thac thege 8a*8 8CC0Rnr for any 8ubjeetive digconfort of peir rr tendert0880 Tharo Ma& an ePparert ninor injury co the lefr band frcnrhich the patlenc haa Subjec-ively &d oojectiyely recovered, He claim3 pereistent 8yrntor3 iuvolving the 1ow back wbere regioual ezamination I8 Doc Bupdorcirs? Q7@3 to a minimal ertert, thece ccmplaints. J_eqpeluie tbat in 0y ppinlon he 433 fully_recovered; Som 3 8u68 Tective and objecfive pojne 02 Vicw, Em &e &bove Uries Ilth objeceive reciduals concloedng Qf minor Bcers Wnich d0 not Accotrt foz AnY a8fackiccy Or cogmetic defect. Based On the subicted records there Wga temporary disabilicy for aboue tio Neak8 Jy,Vw' S5 2 & 02 Tcc %8 Veeux: "738 bony 18 , inj CZ; ================================================== Page 22 ================================================== MaRtm ALECX 1 Nostm M{oa m {U2 ILLY 3OC, " &l:d :33 TelepitRt 837. 70 Re: Sirhan irhr ~5 December 1962 hbouz which %lue d8 potlent resumed lighter Iork &d two Meels Jacez , ha redumed hia prevlou8 regulaz wori . If thera are jnJ dleabllities irvolving che lefc eye , these W2l bc roported eve 8pacialuete. wich reference cotho Other Ereae, I Eeal that recovery has bean complete Without a07 after @ffec tzuly Jour Martin Albozi, Mo MA;ka 2061; V 8 FQ Kwt? 20 , by :82 MenYMce739 ================================================== Page 23 ================================================== 637rto 7i2c0, 102 [ozel08. Callfozn'a Mosbr 9 19,2 8ran SarnaR 626 Ees: Rovcl Peneders, CalAfozt # 0z 2034$ Aleflllieth Corstrecttca (0730} + Icc . S00 $rhin 4/2,/66 "osdnye 3cerier 18, 3857 1.3 ? < Nartea Alorl D 739 Rnt" 2 slacd Avcaua ic0 Angalas, Calfferle 927-127$ J.B: 81n30 Cc: Paler Tcr8= C: Xeleulie 3742 EC: Eicbarf {. NJ (P.Sa Pleasa forvard 0ll %-2473 CC? Tosreci Jol? Co DI- Mbori Cc4 #arrke Aleort, Actached 13 a copy of our gedleal a3 vell 2; epplicart 8 . Plezse forvard four of your repozta Thank You 740 a copie: ================================================== Page 24 ================================================== ARGONAUT_INSURANCE_COMPANY FROM McLaucalin, Evans; Dalbey & Cumming Attomneys at Law Attn: Richard Ishhina Glaima 8717 NORTH HIGHLAND AVENUE, SUITE 71d Exeminer LOS ANGELES, CALIFORNIA 9C028 HOllywood 6-8541 'SUBJECT: GIAZMMO 02Xs203444,5 DATR: 11/16l6z FolD STRHAN SIRHAN V8e AZEILLISCL_GONSTRUCTION_GOMPANY E aalz Yalaua Asy hz Stumy ddiabuBzz Eie Qid_Ytuuualpiu Ala iodunlz = Auutl b1l Su}gaEuyibob_Oxhebeds ~~oAou4 - yec Llbae 22 DeeesutIz4 PLEA $ E REPRY To SiCNED AM I9ULZ E& &) M 0 01 DATE SIGNED aRAYARC Co_INC" BRooxlyn, N. Y. '222 Txis COpY FOR PERSON APDRESSED Opp (sa4e QAal 2S2Z8ru441 LlyaLab ================================================== Page 25 ================================================== DSrAnTMEPITO% [vDUcthiAlRELATONS Dwsico? inDUSTFML ACCIDENTS WORXMEN'S COMPENSATION APPEALS BOARD stTE CF CRLFC?NA Nocic? er2 fequest ic2 Allovvance of Lien CASE NO. Zcraz] , Eerancn E, D,) 234 Morc E37ror? Apcre? Eo3 Bez2lcs 22:06 LicY Clkirait KcanESS Elzbo Bo f.rh3 C23 Ins Eonazd 86r28 9 Pezndez3 {8ployfr RSFES; sedja 723*0 2el 010 cxplosc? 4253295 {X~Miycz CarRKE? 707{79 The edersigned hcrcby requests the Workmen'$ Conpensatio Appeals Board to determir? and 2llow aS 7 E tke sun: cf 2zr12f 7 22423/22 Dollars 02 ajins: 25y amount nor dac 0r Tlich may hcreaftcr ~-come payablc a5 compenstion to_ Airhan_Ex_Jizh: [xplcyc= 0= 33c3m:0f ijury susthincd by hin2 on__ @erre 35, :s Date Tyo regest #nd cloimn Sor Jicn is for: (Cross cut parts not appliczble) (1) Thc rg1sonable expcuse incurrcd by ( 0 belialf of said erployce for n:edical trcatmect to cure Or rclieye frosn : 2 efsets &f gid icjuy; 0: crecic? cooin20i03 C6t (2)THAAMASAhleEelic?lcIRcnc.inc"Trad %0 prove A coutested clzim; o 2 () ThaFnr 2 bksluecf lijng ;FAnC.p; mid employee or of his dcpendents, subsequent to thc inju-y; e ( Thc_{exconable liing SICeVTAs_f_,he_jfc Or minor childrcr, cr both, of saiul cmnployce, sbcequcn: to thc date cf 25)-Xkisibn jr e#ecring his {nlily; cr 314 wedlersicned dcclrcs thac he &rlivzer' o: mailcl 1 cozy 0f this Jimn clxin to czch cf the #bove-named Partic; 0: Foycrt?? 4837 #ttcrmry{oX " aiAmT 40pfzs? 0/ AttoaIy Fot Zlainant LcX c am EMPIOIEZS CONSENT TO AULOWANCE QF LEN r:n!o:&2nne' dlcwerre 0f € W^ ["Tind my fr"hestic" Kcycc {PP: 742 D;AWCAnTum" G (Riv_ Y.7',} ForilelyTcit?)) 83216-301 2-07 :0o" f J~ (82 bez ~/ { G+ ================================================== Page 26 ================================================== LEONARD J, YAMSHON, MD DISABIUTY EALUATION DIPLOMATZ, AMERican DOxRD Pmycical Kcdicime AND REHABILITATION BY apbointNZnt '224 Nonth SeRRANO AvENUE Los ARGILEO, Califormia Soode NORHARDX I.ifcD Bovcmbex 6 2987 To REOMi : IT KAY CCXCERN : E0 : Slcbax;&_ 8i2bad Ip: Granja Vlete Dei Rfo Bato 92 Injuzy ; 9-28-36 Fhls @AD p 81xian $. Sirben Mas Bee1 Ard Eanidex ob tbl8 0te MRTORY je @t€e8 he 16 en ezerc2se 6oy _ Tnlo 'Rork requzzes zot Cz bepdlcg , 142+1080 C81I0E 0 eec Qn 8-35-66 he F2 8 exerclo= boraes a04 be 538 tbzoww' Irom 0 borse _ ne 5aS @eed by Dr . nezadm . %e 028 2oui2 t0 bave 8 Zaceraticd 0f hi8 2est 21d Tbere wa8 . 8630 Babd In blo eye, Ee bad 3 2accre:402 02 n18 c8l1 a2d 8 . Zarg? cotusicn 8w0r 6i0 baek 084 cobte8 {on 0f blg Jezz taba 204 @0202p2e 8b2982033 Ae @t8*68 tbaz ver bg wa3 tbpowt cz% 02 tbe borae be aCeBe" e € know @zQatly bow po Janded 0 Be wa? beplgali.64 , Xo288 mere Eade 828 wezo reporced to b? negatsve. He W20 e@eo Been by D? N1o3on and Dr & RZeen He wab ee0m by: Dx . Tebhga bod py Dr . Jcbiaon Dz Johnboa Zele *bewe were 80 be{pos Logicax Dzoblors Be F5? Beew by Nejgen€ Fe 82atem be wa8 ozf vor% Zcr two neek9 48 tb82 tX@e be Gedt back to %ght Fcrk Ar tbe DrcBQb€ t153 be.#* loekLEg {Or mork _ PAEz nISTORY Nonconcr LbetO3y . (Ohunthsiin 2 70-7 i0g upper Cr . 743 ================================================== Page 27 ================================================== LEONARD J. YAMSHON, M.d DisABILITY EVALUATON DIPLOMaTE, Axf ican BocbD Pkysical B(EDICinE AnD REKABILiTATiOH CyAPPOintMENT 224 NCRTK SERRAHO RVENUE Los Alcrlis, CALIPORNIA Sooo: NoRMANDY 1,1169 ~Z- Re : Slrban B 3irban Novewboz C , 1057 FTSEZ CO"PL AIITZ Fa ccrplaibg cz Ciin Jp hig beci: fe {ind3 be b93 ps ko j h19g tack 82 t? trico to be 10 cna poait icp foz eby pP?Jed] 02 t'c?. T2 94023 tbet Rben be bends 0ng 1ift] 63 b3 rA2n Il2 24033 chat 22 be olta cr 0ta023 Dr tricj t0 be in 7 bo2r pc3fti02 be bcs back pazn ,- De ~1r-j tLst mb?s he turr3 ovex Lo bed 0 €.nigbe he 17212 &nk? (2 mith backnsn Fe find3 tbs % pbon be getB in 7 rrtlally tent Fc3ition be 633 difficulty i@) ntra catcning {29 . EAZIC Zhese 18 0 beaicd Bca? undez the %ight mandiblo awd cv?? the rfGht iLCbzr Orca cter? J8 tondernezs in the Zeeboeacral grea . fe ba3 rain C' ncrerent cz rhe trenk _ Truok wot Long- Rre complete . 07 #Zczicn witb cg2crt ke touceed Ebe flccr I? hzz bypegthc34a c?er tbe esterIor 2ater82 aspectc Oz rofh +hich3, zte reficzc3 ar2 bilatcrally eguel F? (3 po :n reforsc: to *ie back on knee chest raos ira Gtzaiont raoing ara Peffcroing. Fatrick '0 .tcot Circlrzozcrz?: Right Lezi 75h G" obor? rstolla 27 ! 17" Cil1 4" Lelcj pctcllo 23" 13" DI7CZI3Q T3ed on tb? blsforz thfo 248 R3g In}ured &€ work 9 8-35-C5 Ec nd 8 opraln 02 big back He Gparcntly 0390 taa en Lojury *0 l1g Zcft eyc but I do rot Yecl C6334f4c8 {0 cczIcnt (pc" tbat RDj tbss nboula re dcne, 3n crhtbalcolcsio:_ '4u Jcg ================================================== Page 28 ================================================== LEONARD J. YAMSHON; MD: Disaeiliny EVALUAiiON Diplokatr BERICAN noaro PHYO'CAL KEOiciNE AN? REhaDiLiTATION UY APPOiktneiiT 23 .crth GERRAiO AvEMUE Los A"SELJ, CLIPORRia DoOoa NcnMandy 1 G0 ~3- E2 : Sirban D Sirban 1c7ccbez C , 1cC7 DTEZUCI (cc3:irwcd) {? 827} C030 Rcc?ratfong 0z hjs Xac8 R rd h2 Qoeg bave 8c? ccrzlng c") 02 Wr ?? eur?ace cf Eb? chin 0n tn? "c** n:] 7 :91* ccar 10 this oren Tbere 20 8Zs0 TCz? brale:} c};zanic-3 83023 cver tbe riclt pcstcrio: 21sbn? 0;"'03 cr] 12.c2a1 Jeatar ac? T? 673 ccmplafntg rofarred t0 the b?ek cop3 I9t20g of FJin I2 {ie23 tka: h2 hcs PO 40 sk?? be C2*8 ip 8 razt4n317 bon: Do3itec? foz any przod 0f t ine . Be 3130] tbat t? cncio: tolcrate rcreioir In & bfo positio?_ Io 3382 240r3 *ho? 42 b2 ataudg e: oit8 For 3 prozcnged [77i03 o2 rin? 0? i1?3 besk Fain, Fhen h1e Lerds c2 tries t0 3#: bo 803 tzc Fn:b: I2 c-3 not Povc OrJ Jcf ccmplaioto lut on th13 cate be {oc.J :0 b2r? sr?? n7re3rbcsi? to pin Ff'ick over the ?38034c3 Zctcr z car33: C boch tbiets The oiGbificarce c? #nis 1M cot 2uil7 clorenalpe:i 0 4. 47 rczn'bic *bnt &e cculd baFe 8032 cantusion 02 tb? CI;:c-Jc? {cEozn? r?r7c3 {n tha {912 5i? Snetorj c? @cnhiilty or?: 5r? cubestiv? ccaolaints, 03l6h2 €q rodcrate 1 4 h czennta 2c= [2403 Ln rhc Fartiolly nr:) bqu3tt103 reciticz? 2c nn} } Frolcnzed [3ic] 0f tire _ 3 @2nr?ing ar] 4*2icurescnt_ 3 J ?rofhiai3wn . 745 ================================================== Page 29 ================================================== LEONARD J: YAMSKON; MD. DISABILITY EVAluATiON DisLOmATr , wrdicay BOARD PYSical nedicime ARd Rexianilitation dY APPoNTMEMiT 22/ Nonth J[RRAN? AVcNUc Los / NGILE?, caLifornik Doooa Nonxardy 1.1109 -47' Fc: 8rben B. Birban Mcvcmbcr 0 , 1587 DIEZIC (ccn:anuea) > (}5 sc% fc2l Cual4fcd 80 cc_zcne Gith rccera t0 bz9 07?. Fcz 0 31 prac:ical Fl?rojc: bfg condgezon can: be ceeake?rcd t0 1? F2zzancot ar3 otatiorary 84nccrely v cur8 0 EI:rg Ico-ara Aaeshon , 2I . Ds 746 ================================================== Page 30 ================================================== KHAUIZ FORREST L. JOHNSON, M:D. 1052 WEST SIXTK STRZET Los ANGELES 17 HUNTLEY 2-8242 Argonaut Insurance Company 443 South Shatto Place Los Angeles _ Calif 90005 Attn: Miss Stiner PrqfesSional SERvicEs RemderED Re 8IRHAN SirHar B _ No: 02Y 2 03445 Er: Altfillisch_Constr Co d/a: 9/2 5766 OFFICE VISIT: 10/9/67 S16 . 50 FORREST L JOHNSON MD 747 ================================================== Page 31 ================================================== Good BAMARITAN RADIOLOGICAL #zbichz GRoup HOSPITAL Of THE GoOP SAMARITAN Joxn D Ci;P, M,D. PAUL Ri. fEnfOws. M.D DEPARTMENT OF RADlOLoBy RPMnTic?TRERAPY Ard NuclEim {ZociSt Ro3ERT E. RICKENJERC M,D; DUANS 1. Gillus, Ma.D: 1212 OrsYto OTREET MICIAEL G MeREDITH RAduTiCN #*iYsiciSt JOKN D CAMP_ JR:.M.D Lo3 ANGELES, CALIFORNIA Sco87 RorERT E.LEI6, M.D. REPORT ON RADIOLOGICAL EXAMINATION: Op Mr Sirhan Sirhan 45800 Mt THE REQUEST OF DATE Dr. F Joknaon 9/6/67 STVLZL,; Routine vlews show the bone tables of normal density Wichoue evidence Of injuzy 0r disease. The pineal Xs not calclfied. No abnormal intracranfal calcificatforz are seena The selZa turcica Ls_ inkac: mith Do evidence of enlargerent Or erosion , Visualized porcions of the pettous bone ere 2ls0 norral_ LiMBAR SP INE : Anteroposterior 9 Jeteraland coned lateral viewg sbox Dormal' pogterior vertebral alignuent . Vertebzel acight and dloc spece8 are maintained_ CONCLUSION: Noral skull Nozmal Juwbar RLIo Lex+ Robert Ec Leyis, MaDde 748 L. body epine 2 ================================================== Page 32 ================================================== McLAUJGHLIN, EvANS, DALBEY & CUMMING ATTORNEYS AT LAW JOAN F MCLAUGHLIN AREA COdE 213 BARRY F . EVANS 1717 nORTH HIGhLAND AVENUE, SUIE 710 TELEPHONE WM 0LA/R DALBEY 466-8541 Los ANGELES; CALIFORNIA 90028 RAY 8 CUMMinG HAROLO J. BENNETT NED LGAyLoad October 26, 1967 JOAN F. BARTOS GEORGE R_ HASVIELL ALLAN R.SCHUMMER ROBERT M.GILLHAM Argonaut Ingurance Company 443 Shatto Place Los Angeles , California 90005 Attention: Richard J Fobbinsg baminer Re : Your Clafmi Wo . 02X-203445 Sirhan Slrn 4rtrirlisch Construction Co. Date 0r Injury: 9-25-66 Gentlemen: Tnis will confirm our relephone conversation On the afcernoon of October 24, with Mz Robbing at Which time we advised him of the 8ervice by applicant 8 attorney of the report Of a doccor in the field of eye, Maurice W Nugent, daed October 10, 1967_ 9 thar contains the concluding opinions that applicanc has no permanent disability wi th regard to hi8 eye As 2 conse- quence, the examination scheduled Nitn Dr Kiehn should be canceled forthwith We attach a copy of' Dr Nugent 8 8 report for your file There may be need oc an orthopedic evaluation but for the moment, we suggest you hold 0ff any further exeninations The case 18 off celendar and we antclpate that we Will be served with further medical reports the attorneys for applicant_ At that we shall submit Otix appropriate recommendations Yours very truly, McLAUCHLIN , EVANS , DALBEY & `CUMMING By : Barry aGseur BFE:ka Enclosure CS lys_: 573 Lukczl Ye ~est Uy&xlge 771750 by time,; (euEvans Kak ================================================== Page 33 ================================================== MAURICE W_ NUGENT, M.D-FACS_F.l.CS: WilsirE MET"OPOLItan MICDICAL CENTER 1127 WilShiRe @OULEVARD UitE S05 Los ANGELES, CALIFORNIA 90017 PMONE: 481-2462 Gctober 10 , 1967 x{lrar and Toomer 9 aclor eys n &; :itizons Enk lc 1{ Mortl : 4reu"0 Kaca2 :elife) 91101 nttention: Anae 'iooror ittorney Re: irten 3 3irian - ;renja !istul -ei i.i0 C290 Woo : 67 Li 312 144 ;e r _irg: 0 Jesober 10 , 1961 I exbmlned the aiove naied 8i1c tic folloiing 13 2 oplithelmolo_ic %l consultarion rerort. %18 #elmolo_lcgl 6xemination }ei 9 cona Bt your 270- ques t u.d iAth p-risuicn ul' tl.e above. na: .ede Flcave :e inforned tbat I havc #t band 0 eopy 0f }is #B.icel 11i0 ar tbig vaw verused_ prior ic tno ophthel~ molugicel exa:inat;on enri aein rolloving. Ihis vcry plcagunt 0 :l cooperative Jobni: Ien eve Ki0 Yo sl ificart eneral history , 1uat history 01' 16mfly bis- tory. j;g vroscnt ptory st:tes t:t 'e 1i89 n6ver La 'lu9808 ord tiat ii.e sccide:& In que:tion' r'G8ultcd Iroi biing tbrc n frum 1 orse september 25,.1966 &6 orona 0 60 tbiuke i.c K8? t1rci: into @ fciee, cit it 1.85 curi g E erd Xe Grid 0 tior? wer & n3t cortein vf wt 10 nito Ir eny event 9 hc ctotec tl:et ko No2 unconscivu: {6r 8 short tice E!& bc. Dn ta Cofio to :en he R6a 1n t;8 orona Om cnlty Iobpitelo L.0 s tatoc: trez 2.0 CBze t0 cile t:ey 0820 s1turing nfs facial laceratione Ar9 Sirhan statcd h0 w 03 12 fc87ftel over nig.t W5;c reloc?dc 0:): tker one #vck lutcr rcturnee to tho coctor J Or ,%mbl 61' $ tiie & ;c: J:utec tl.ut {C 1 2 J bge to worx X10 #ocis lator #fd t .Gn noted ivor @UV Qr Fucnt it] ti.e Joft cyc vith t feolin: of tenslon cnd painc_ 751 18#P ve . 9 en3,, v8 0 $ opl:- foj: only ================================================== Page 34 ================================================== ~2-: 1l-l0-67 Xe 8 Sirhari sizhan r AlIcr & Toorer attorney 9 at 1,ew j10 eppare tly fe0ls that ti030 0yIptou8 are st,ill pro8onto ie Gid 5ot mertion sny tkitcling 01 t_0 lld Ez' 02 or t20 leit oy € , although 1t 19 -ontioned in 219 n0d1cal file0 ~xaiinutior; MT' 0 Sfrhen Xe? very cooperetive end very Ploagante Hig symptOmg x0re sOrovc.at va200 sRd varibble, bat pleasant co-peraticn 6&9 estacliekea and W0 croceedod J # &h hls @xdningtlon bitb rull cooperltion, }is vigion iithoud _lesae: W8 5 2 bertor tran norel 20/15 in 6acxi 6y Ce 4 rofraction w 8 $ dore & sd 8 most minlual refractive orror wiis 1ourc , ne ely 8 +0025 cylindler in ttie riu:t eye 2t 165 Bx18 wnd: 0 +0026 cylinder et 8318 60 iu tr0 1e t" oje 0 Neelles: Lo 8 ay tri8 Insi,nificant r6froctive error 19 of 20 consequencu tnd it 19 essontiallj bflaterelly syametrie c&1 0 'e intreocular presguro W4S Wezsurcd end it Nc3 fouind *C be 8 norwl 17 Willintors Gf %ercury in 62ch eye 0 '2.0 oculor Wuwclg bulunc0 1.83 mcesusoc anci folra to be completely Il6 'cftivo in cvory dotuilo Ine excuraiona #or'0 ckocked a1;c #10 Qyes wor6 found to be - rully mobile in) 0l1 carclinol rositicns of Eaz0 and Xlo peresl? or parolyslg were Prewent ~rutwoever 0 "er0 *83 ezcellent convel'_oec& 0 ii_6 {ci8 ard fani Ticre 8 tucie "Erc: measured wit 2 retinogeoco , 312} thulmoscopo #* 8 biosicrosco;e end pokh 6 es wur :'ounci tu bo oxcollor: Ir} 0vo>y c0 01l0 #:0 pupils kere rounc E xc oGue] u3C nsfungod rarzblly to ligt J :: acco;oC 0ticnla kis neer Poirt #ithout a1y correctio Iatzoovor :22 8 {ull mormial Jae. er I in @dch 6yG anc? thig 18 4s 1t should be in tkis 4,0 srouj 6 'i:0 lidg ona Ednexae Fera All iaspected erd 0 amincd co1'6 fully Erd 6 ec02* uncer tc leit brow 'cra in tiza Ar6s bo:arda t 0 Yos0 0f tho 10] + up:er eyelid shoked { ver] cell Sc{x' ~cont 8;& Ono t:et ag "caled ex-eptioneliy xell 0 752 30 Oph ================================================== Page 35 ================================================== -3- : iO-lO-67 ; GImer & l0o3er ite : Sirhan Eo Sirtan Attornej8 4t Law "his 8c8r t tc.e nosel eni 6r' tne loft upper ejelid lg tte rosult oz nis lacoration 03d tlie 8urgieal procedure of repair . It Xiel {I healec voli and ha8 no t erden sFotg in but ir} tkis locebion X0 16 cuite customery to Hava 0 swall miount 0f ceep 8 C Sir? tissue bcneath tke skirg bat this 1d elvAyB lont olono and no ottempt 1S made %0 iriprovo on 10 circumgtence 0 { did not esi Ior nel: %ereys 09 hig. filo show8 tizat these :ove ieei} tuor) Qu4 t:sr0 96r0 2lo iinding8 for any forelE1 bocy Jp bnly iractur@0 'ine fields wor6 studied on tko tanzent 8croon Gnd the rinht 6y 0 w 09 fully ncrmal both quentitetively arc (uali- te tively 6ftb vericus 81zed test obje:ta and t difforont Idifferu ces frorn tu0 scro8r} 0 "i1.8 left 0: € i.owever & & first gave 8 seller field thar norzal9 but #kO] n'0 Siri-An wa? invited to eeke 8 ood losicel effort,. ho did 36 :ed tbe v{suel fiel8 in 8 left by& elso sbcwed 8 fuli noreal peripheral isopter arci matched tbose of nis right 0y &0 4..0 blino Byots ie1*8 noraal &..a equal: in 08ch G88 0 'itero X43 nj conpluint of twvi tening 01 thie lids 0z urcas obout t::0 eft 0y8 , 201 was trery &ny sign 0f eny mubcue lar twitchingo I c@x only stato tet thig yourg %anl les 8 moat exceliont poir oi eye3 8 `c 2 Ioost excollent 3a72 '#ical rejult of ire repair of nig 1 ceretion a & tne nao4l end or t:-6 l0it upper eyelid erd t:er8 19 no indicatfon Hetsoever of furthex treateent; Or' com licebions or re ultub 8is8bilftie80 In #ddltlon #0 #ke abov6 9 tre eyc uxemiration sbow? no defoc t 01 t_e Intoricr 0 f' eucl: eyc ror 8?y localizetion of `any ceritrel nlervoug 8y8ter: eefecte #1naeroly ycurs) J27cw34 1c0 Jugoto (ioD0 MX:i it, Vary 753 ================================================== Page 36 ================================================== MAURICE W. NUGENT. M,D_ F.A,cs F.C.S. Wilshine METROFOLTAN MEDICAI. CENTER 1;27 WIlshiMneMOULLVAMD SUTE 505 Los AticLEs, CaifOXMIA '10u!7 Phoni I01.24w: #oluer 2 Tvomes Atturney:: a t I,:W 16 No Marengo Ave Yusedene , Calif 9;101, Z Re_ S_rhan 1}_ 5-1*w+121 rok Pmc 'ihs. 3: cL" Rerusal 0f file E: t 1Oth Colsulttion eye examinntior ad report 850.0) 754 L5 ================================================== Page 37 ================================================== GEORCE H. PATTERSON, MD. FORREST L. JOHNSON, M.D 1052 WEsT' SIXTH 'STREET Los ANGELES 17 NEUROLOCICAL SURGERY HUNTLEY 2-8242 10 October 1967 Argonaut Insurance Company 443 South Shatto Place Los Hngeles California 90005 Re: SRHAN Sirhan B No: 02X 2 03445 Attention: Miss Stiner Er: Altfillisch Con str Co d/a: 9/25/66 Dear Sir: Mr Sirhan Sirhan was seen again in my office on October 9 _ 1967 _ At this time he stated that he ha s not been working and that his symptoms are essentially the same He states he has pain in his low back and a feeling of tightness around the left eye . He states that the sensation around the left eye seems to be increased with weather EXAMINATION: Pupils are equal and react to light Funduscopic examina tion is within normal limits Extra-ocular movements are intact There is no nystagmus Patient wa lks well on his heels &nd toes Tendon reflexes are active and equal bilaterzlly throughout I found no pathological toe Signs Patient reports tenderness on palpation over the upper sacrum Back movements are carried through 4 normal range Forward bending is accomplished to & point at which the fingertips touch the toes . Straight leg raising is accomplished to 85 degrees bilaterally COMMENT : Lfindno_evidence of any neurological problem Relative to thc back problem I believe the patient S conditlon should be considered permnent ond stationary disability factors being subjective complaints of low back pain that I assess as minimal in degree The patient!s eye problem should probably be evaluated by Dr Kiehn :. No retun 2opcint - ment was made to sec this patient If I may be of any further help in his Care please let me know Yours very truly , ~ M/xf ^ FORREST L TOHNSON M. D.` TJfusk 755 cold would ================================================== Page 38 ================================================== DEPARTNENT OF INDUSTRIAL RELATIONS DIYiS;ON OF INDUSTRIA_ ACCIDENTS WORXMEN'S COMPENSATION APPEALS BOARD STATE OF CALIFORNIA CASE No. 67 LA 312 144 SIREAN B_ STRFfN Apblicant VS. ORDER TAKING GRASJA VISiA DEL RIO OFF CALENDAR ARGUSIUY' INSURANCE COMPANY , ' corporztion Defenanls Pursuent to Stipulation of tle parcies , and GOOD CAUSE APPEARING: Ir Is IEREBY ORDERED Thzt :he above-enticled matter be and the same hereby is taken off calendar, and all further action herein suspendcd, subjcct to being resct upOn request of iny_ of the partics hereco: BINGEQZ? Rcferee, WORKMEN'S COMPENts {0 APPEALS BOARD CIR/ cr PARTIES SER TED As CHECKED DASED Arl Filed At LOS AmCEles ON OFFICIAL ADDRESS RECORD CheIfORWIa Dste: Bss SatE) &X 13431 @} ESRRcn, CCT } & 1S57 Y_ 03 8 20+? x {XFxwj KsSS W o 758 = WC/?Fofv 50 Rv 7-65) Fct"tirfc y %0 Ttoh 74 ================================================== Page 39 ================================================== Froa? thE Office Of Jokh D CAKP X D SyAdiOLoGy ROBERT € RIcrE?BEPG 4.D. Good SAMARITAH RADKOLOGICKL MEDICAL GROUP (ADiaTiON THERAPY PaUL KEADOWS 4 0 BILLING DATE 1212 Shatto Sircet NUCLEAR MEDICINE DUANE |. GILLUK; H 0 Angelos, California 90017 John CAMP JR. M 0 09 2 1 STATEMENT OF MEDICAL SERVICES ROBERT E. levis M D PATIENT: S1RHAN SIkHAN DOCTOR: F JOHNSON 56 057k4 CLiIM NUMBER ACCOUNT NUMBER OATEOf iNJURY ALTFIlLIsCt CONSTR C( PIEASE MAKE CXECKS PAYABLE To: BILL TO: AkGUNAUT INS CO 1 0 0 ] wi ILSHIRE BLVD GOOD SAhARITaN RADiOLOGICal Kedical GroW? P 0. Box 60035 Terminal Annex LuS ANGFLES CAL Los Angeles, Californio 90054 MONTA DAY TR_ CODE CHARGES PAYMENTS 7027, FTVE VTEw S 2319 30 025 {7] () ThAFe VIt:s 4223 2240 ALL BILLS PAYABLE UPON PRESENTATION PLEASE RETURN COpY TOTAL DUE 52 23 Witk REMITTANCE 757 Los ================================================== Page 40 ================================================== {mc-r 04987 Etraan Sirncn 638 Buj? @FWni Co1+3 PeJac-cZea Olineo 80385 AESISILZIAAE Cufs SZZ2 *7309 9/25/66 @ctores 276 1S8F 9.00 A4a Cc Gxsion #lebsSlalla 68 %e %1 Molra: 37071783 Poaeesuo Csllc 6 Bezz_ 08031 ; Pelxs 03302 #i Meleiioo 37ar En3 cpplican: fallad his sco ayrcintu Wigm TS 6 Elk ce9 So (rwn %03y Mod& ~PoS e Dxe gubpoqcaz; t0 Y3it" OR1jatio 624103200 2lens? IcorIe a11 Ibzyr 39 ulth Jcin' Oplpit andlcoclugiona_ 758 22csza ctluoia ey &uojactive 0orplgs0rsu Ae tkcy Cozongunte Wita #a injuzy7 PZ2i8B ZDZAE0 FOVB COPIZS & ZGuR D5XT2 < 0 0 ================================================== Page 41 ================================================== # Sc 7' McLAUGHLIN, EvANS, DALBEY & CUMMING ATTORNEYS AT LAW JohN MCLAUGALiN AREA COdE 213 BARRY F. EVANS 1717 NORTh HIGhLAND AVENUE, Suite 7i0 TELEPHONE WM. BLAIR DALBEY 466-8541 Los ANGELESE CALIFORNIA 90028 RAY 8. CUMMING HAROLD J.BENNETT NED L. GAYLORD Septerrber 23 , 1967 John BARTOs GEORGE R.HASWELL ALLAN R. SCHUMMER RoBERT A.GILLAAM Ar Insurance Company Aeyo5nat18 Place Los Angeles , California Re: Sirhan Sirhan VS Altfilliach Construction Cowpany Case No _ 67 LA.3121 Your Clain No 2Xo303 Gentleien: The above~captioned case .set for trial on October 2nd is being continued as the applicant S attorney has still not received his medical evidence and has been advised that he probably will not until the middle of October So that al1 evidence will be available at the time of trial, We have agreed to this continuance to avoid the necessity 0f possibly two hear ings Since the only issue is that of permanent disability , the de is noi prejedicial Very truly you:s , McLAUGHLIN EVANS , DALBZY & CUMMMING stnri~ By ; P Cumming RBC: cjz 752 lay 14 Ray " ================================================== Page 42 ================================================== STATEMENT TELEPHONE 666-+ , ,5 ALBERT TASHMAS M. D 6753 HOLLYWOOD BLVD Los ANGELES; CALIFORNIA 90028 August 18 19.62 Argonaut Ingurance Coupany 1001 Wilshire Boulevard Los_Angeles 9 California FOR PROFESSIONAL SERVICES: Re: Sirhan Sirhan Claim: QZX 203445 8/15/67 Code 0002-Consultation 0f' unusual complexity , 875.00 [ 0-3-6 1 760 5ona- ================================================== Page 43 ================================================== FORREST L. JOHNSON, MD I052 MEST SIXTK STREET Los ANGZLES 17 HUNTLEY 2-8242 Argonaut Insurance Company 443 South Shatto Place Los Angeles , California 90005 Attention: Miss Stiner PROFESSIJMAL SERVICES REMDERED Re: SBKAN Sirhan No: b2X 2 03445 Er: Altfillisch Constr Co 0 , d/a: 9/2 5/66 Neurological Examination & Report 5 September 1967 83 8 . 50 /9 3 FORREST L JOHNSON MD 761 ================================================== Page 44 ================================================== GEORCE H. PAZTERSON, M.D. FORREST L:JOHNSON, M.D: 1052 WEST S*TH STREET Los ANCELES IT NEUROLOGICAL SURCERY HUNner 2-8242 10 October 1967 Argonaut Insurance Company 443 South Shatto Place Los Hngeles_ California 90005 Re: SIHAN Sirhan B _ No: 02X 203445 Attention: Miss Stiner Er: Altfillisch Constr Co . d/a: 9/25/66 Dear Sir: Mr Sirhan Sirhan was seen again in my office on October 9 , 1967 . At this time he stated that he has not been working and that his symptoms are essentia the same He states he has pain in his low back and & feeling of tightness around the left eye He states that the sensation around the left eve seems to be increased with cold weather EXAMINATION: Pupils are equal and react to light Funduscopic examina - tion is within normal limits Extra-ocular movements are intact There is no nystagnus Patient walks well on his heels and toes Tendon reflexes are active and equal bilaterally throughout I found no pathological toe signs Patient reports tenderness on palpation over the upper sacrum Back movcinents are canied through'& normal range Forward bending is accomplished to & point at which the fingertips touch the toes Straight raising is accomplished to 85 degrees bilaterally COMMENT : I find no evidence of any ne urological problem _ Relative to the back problem_ I believe the patient 's condition should be considered pernanent &nd stationary_ disability factors being subjective complaints of low back pain that I would assess as minimal in degree The patient's eye problem should probably be evaluated by Dr Kiehn No return aoecint- ment wa s made to see this patient_ If I may be Of any further hel? in hiz Care please let me know Yours truly 5A- 2r~ FORREST L. JOHNSON_ M. Da J/wsk 762" lly leg very ================================================== Page 45 ================================================== GEORCE H: PATTERSON, M.D: FORREST L. JOHNSON, M.D_ I052 Vizst StxTH STREET Los ANCELES [7 HUNTLEY 2-8242 NEUROLOGICAL SURcERY 6 September 1967 Argonaut Insurance Company 443 South Shatto Place Los Angeles _ Calliorta 90005 Re: SRBAN _ 81chan B= Attention: ilss Stiner No: O2X 2 03445 Er: Altflllsch Const Co . d/a: 9/25/66 Dear Sir: Thls s a report concerning Nr _ Sirhan Slrhan , 8 23-year-ald _ 6 right-handed male seen in my office on September 5, 1967 . CHEF COMPLAINT: Discomzort of chizl , left eye and low back FRESENT ILLNESS: On September 25, 1966 . while &t work 6 the patlentf wa 8 thrown from & horge The patient reports he wa8 unconsclous for ar uknow ~period of tlme He reports tkat he wa8 taken t0 a hospltal by ambulance and started regainlng consciousnes8 whlle hle wouunds were belng stltched The patlent wa s hogpltalized overnlght He statee that they wanted him to stay longer but he did not lke the idea The patlent retuned to the doctor about a week later tc have the sutures removed and wa8 told that he should stay off work for ten to fourteen days _ When the patient rerurned tQ mork , be worked aroud the bar ior about two week8 and then resumed hls work 28 an exerclae He states that On re 8uming ?hl8 wcrk 8 he noted increased discomfort particularly around the Jest &ye ard also lex back dezomiort He Wa $ subsequently seen by the doctor who had origina treated him aud then was referred to [wo oher doctors Because the patient had gubsequantly moved to hls home In Pasadena 0 he was then gefered to Dr Ket in Pzsdeg2 Sometime In November 1966 _ the patlen? was dlgcharged fon hls job because he felt that he wa8 unable to phyglcally work tfe hour8 on tke job that Ivere regulred of hlm _ The patient reports that he hag not been wozking eince hig dlscharge from that employment_ The patlent atate8 ha has noted no particular change &s? hi8 symptons &n tha last few months He describes ehe left eye complalats as balng waves of pain In the eye Itself 8 tlcht sensation In the skin around the left eye . 763 boy lly and ================================================== Page 46 ================================================== Argonaut Insurance Company 6 Scptember 1967 5r Page 2 Re: SRHAN . Sirhan B . He reports 8 persistent paln under ht8 chin &nd a feeling of tlghtesg of the skln under hls-chin thzt Interferes wlth his shaving The patlent reports that he has back all the tlme buz thl8 Lg Increabed wlth bending move~ ments or wlth fting even mnlmal weight8 _ Patlent hag noted no accentua - tion of back with coughing or sneezing _ He reports no lower extremity in PAST HISTORY: No operations _ No prevtous bospltallzations _ No serioug Illnesses No other accldents Or injurleg . No allergens known PHYSICAL EXAMWATION: The patlent 18 8 small, thin male not Ja ecute dlstress _ Blood Pressure: 120/70 RAS _ 120/70 JAS Head: There is 8 smal} , well-healed ecar near eje inner canthug Of tke leit eye and gome sllght proninence In the mediu] 88p7ct Of th3 Jeft eupraozbital ridge The patlent reports tenderness on palpatton-in thls reglon Of the supra ~ orbftal ridge Neckz ' Supple Cheet: Clear t0 percusalon and auacukatlon Heart: Regular sinus rhythm Na murmurs heara _ Extremitiee: No gross defornities _ NETROLOC ICAL EXAMINATION: Sensortum; Patlent is alert , oriented and coopezative _ Cranlal Nerves; Essence of peppermint percelved blaterally II Patlent reports & general congtrictlon Of the left Vlsual Elelds tkot 1s not conslstent to the confrontatlon testing . The optic dlscs appearea normal bllaterally III , IV, VI ` Extza-ocular movement 8 weze {ntect . [ {cud no nystegu8 _ Petlent variably reported hyperestheeia ovez the right chin VII Facial mcvement8 were unimpa red _ Corneal reflex waB pregent blatera_ VIII Faint watch tick wae heard bflaterally I,X Palate elevated Jn midline There waa RQ Impetrment 0? phonation Or swa llowing Xi No deficlt noted XII Tongue protruded In mldllne Sensory Exanination: Pin wheel, ootton wisp and wibratzon were percetved throughout Metor_Examlnatlon: No specifc wcakness wa s found 764 paln pain pa lly ================================================== Page 47 ================================================== Argonaut Insurance Company 6 Sertember 1967 I Page 3 Re: SRHAN Strhan 8 Cerebellar Examination: There is no nystagmus There I6 no ataxla [andem walk Is well Ferformed Reflexes: Tendon superEiclal reflexe8 were active and equal bllateially _ I found no patholodcal toe sign8_ Back_Exam-nationi Patlent report8 tendemegg on palpatlon over the low thrc ? lumbar gpines _ There appears to be 6lgiac paragplnous muscle spi8m In the Yuzbar reglon _ Back movements were carried out through an essetlally notra ] range the patiert reporting Low back 88 cbe extremes Of these movements Forward bending I8 aocompllahed to a POlnt at whlch zhe {nger- tips touch the toes Ettalgh: leg ralslng I8 aCCOmplighed to 85 degrees bllaterally _ the patlent at thls tlme reporting low back paln IMPRRSSION AND COMMENT: The patlert reporte thaz he Wa8 unconscous at the tlme of hlB Injury_ although the modlcal reporta that I had avalleble for revlew did not verify this _ At any rate I found noevidence Qr a neurdoglcal problemat thts time The patient reports dlecomiort In the region Of tle facla} scars _ Ibelieve_theze Jg_@ 9-glfloent_fucttozal overlay_tbat_tends_to magtfy these_Compl nTB The patlent roportcaly Buszained & Contu8uxa Qf hs back at the tJme of hls Injury and currently h38 complaints Qf paln Ln hie low back Arrangements were made for lumbar splne lilms,_ I have &sked the patient to return In about one month fcr re-examination I belleve the patlent should be seen again by Dr Kleh for hi8 re~evaluation relatve t0 the scars and the complaints InvolvIng the lef @ye Ibelleve the patlent 1g 'capable of returning to wcrk as 8 stable boy at this tlie Your8 very truly . FORREST La JQENBON _ M. D. FL/nsk 765 and pain and ================================================== Page 48 ================================================== COOD SAMARIFAN RADIOLOGICAL #BZDIcAL C7QUp KOSPITAL OF THE Good SAMARITAR: JoxM D. CRKP, M.D. Paul :l MeADOivs_ M.- DPPARTENT OF' RaDiolory Rarutiow Tnurt RIDD MueLcd {ALiDE ROBERT E. RICiENBERT , M.D. DUANE !. GILLUM. M.D. 1212 Cratto 5TRtz7' Mickiez GMEDrh TWDuto; PtsiCIST JOHN D. CAMp. JR: M.D_ Log RNGELE3, CalifoRNIA 00oJt RobeRt E. LEYIS, M.D. REPORT ON RADIOLOGICAL EXAMINATIOAF Mr _ Sirhgn Sirhan 45800 At THE RZQubT Of DATT Dr . F I,o Jokngon 9/6/67 SKMLL; Roucine vfews show the bone cables of normal densicy vchcue evidence of Infuy 0; disease. Tre Pineal Is not celcifled. No abnormal increeranial calcificacions" are s?er Tne selle turcica is {ntect with no evidence of enlargenent or erobion. visualized portiong of the petrous bone are alg0 normal LUYBAR SP INE : Anteroposterior lateralend coned leteral vier;b Bhow; norziaf posterior ~vrlebral body al1gnment Vertebrel height and 81gc spacee axe metntained, COvCLUSION: Ncrwal skulJ Normal lubar epine RL/n ULewz Eoberc Ea Levs , M.B , 768 ================================================== Page 49 ================================================== SEuRQEURGERY 6FmONE 542-7409 Samuel QW. Weaver, _MD. 1125 EA9T 17th St,,SUITE 114 SANTA ANA, CALIF. 92701 2O; June_2ls .19_ 62 AArgonaut Insuuance__Conpany 443Shatto_ELace Los Angeles ,_CaLifornla 90005 FOr PROFESSIONAL SERVICES 7o RE : Sirhan; Sfrhan 6/16/67 2 hr appointment he 1d for neurologica l eva luation and e lectroencepha logran: 877 00 Appointments we re' scheduled for thrs may Ori 5/23/67 and 6/16/67 . Ke' did nog` keep the appointment on either date 0 767_ 772 ro: ================================================== Page 50 ================================================== Dcpart nt of Ja {usrial Rclmiione GO()I) CAUSE APPEARING: DivisOu of Inaustsial Accidents The APplication kerein Compeuaation ^ppeals B is tken of calendar. Statc of Calilernia ApPiicATION R{(EF{ [ #cA 9 DaTi For AdjudicaTior Of CLAIN 1i} 31214: CASE NO. Blease filc signed original cnd six copics #d prist or type names Gnd ad:resscs 17 E MAviks_ SIRHAN_Ba_SIRHAN 696 East Howard LLI DX 'ld Kni7' Du"i >} PII Scial Sccurity No Pasadena . 3 Ca Lifornia Applicaht _ Ir oTh{ TmaX injuied [AplcYee 'ppli:amt 'L:P{3$ Vs_ GRANJA VISTA_DEL_RIQ Box 1591 , Rcute M?Lotli 4pi9i 4e: 0 ( $ $ Corona J California ARGONAUT INSURANCE COMPANY 1001 Wilshire Boulexard [#ploten ISuRARCE Carrilr on Sta{ i SlL! INSUPEd 0# 'DoR[sg Jr (R TIE4issh?l " UmihJuaed Los Ange les , Ca lifornia IT IS CLAIMED THAT: PII LJ The injured emnployee, born while cmployed Js 1 exercise (Datl @f BWTm orcp' {Ct M"l J' on 9-25-66 a[ Corona CaliEornia_ by the cmploycr ustained injury jr:~ing 0atl 0f imJury icity StiT [ 0f and in the course of cmploymcnt [0 eye_ lower back Stati #ma] Pa P ;> €/ Bc C1 6{0 ( 'Jc{C 2 The injury cccurred 2s follows: thron_ off_filly_while exercising heri_breezing he: [IpliIR #Ma1 #P[OT[[ #1$ Ocing '4{ Jr 4) 790 at_full_speed Actual carnings 2t time o{ injury wcrc: 8315_ per month 6ivf mcETT 0r YorTi Y Sa ! Juparatllt State #alue {56 W[ek Or Kohtm 0f Tips 41 ; Wdsinc Op WTA[p X0/4mTAs0 Thc injury caused disability a5 follows: Va rious_periods Sp{cify As1 O4 0i #op Du{ TD T4is ihjnt ARD 6[e'nhing Mi 'Kg 0, 5 _ Compcnsation WRS S (TES ) hq Totai Paid, #({K[TMa( 04: 0' 145 { J#f" 6. Medical {rej ment was rcceived 4-6-62_ A/I (re'auni 4 /6 turnishcd bx the cmplwer {)f {-M; YeS "0 D4T{ 9/ (A9| 7acAfuLnt. company other {rcatmeni wRs proridcd OI for by res #o} 4i#l '5bSom cr i81a8' Pr? 'o " Doctors nor provided or for by cmploycr or insurance compnv_ 4' ho (reted Vr cnncd ior chis Inju:, J?t 9tatc KA#[S Anc KodaESS[S Of Suck doctors Anq #ihes 0} Moscital $ {0 #iicm ~Wr4 Doc i0#$ Dhittf 0 7_ Uncmploymen[ Insurancc or Unemployment Compensation Disbilirv bxnelirs have lwcn receivel since the dre of erju % 8_ Orher cascs have been filed for industrial injuries by this emplxres 01$ Spcci, "Y 91"01P 4M;' 9_ This 2Pplic?tion is fed bccause of 3 disagrecrnent regarding lixbility for: Tcmporjri: disability indemnity X Petinncr:; ability indcmnity_ X Reimbursement for medical expemse Meddual [re)nieni X .(ompenSJit Jf 7r( Other_ Specify: and applicant requests 2 hearing and #ward of thc samc, Jnc for xll other xrpropriMe lwneli: ` pruviledl:kvy Ji Hearing requested 30 Los Angeles_ IJated J[ Pasadena_ Jlifornul_ 10_ (CiTT ! > " Numkr o witnesscs Pre-trial wantcc (>, J:srimatcd :imc of trial SIRHA R _ SikHAT S"r nom' X Si latcr on wri{te"1 rec}ue: FALR Ti 16 th Vnre!; 746-2086 64. -1){( 771 boy left 19 M{ paid pi Paid followQone prepi+ July

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