DECLARATION Samuel Ayala 13562 Glacier Cir Hesperia Ca. 92345 email: samayala01@hotmail tel: (760) 244-8721 Claim.# 3708100-00 Wcab.# NOR0174277 Case.# ADJ3050524 I Samuel Ayala, born 5/6/1970, while employed within the state of California as a Carpenter on 5/23/91, by Lee Bolin & Associates & Mkay Lumber & Assoc, Whose Workers Compensation Insurance carrier is TheZenith, Zenith insurance co. Where I Samuel Ayala, sustained an Industrial Hight Impact Injury to Body, Mayor complains and injured areas are neck and Back, shoulders, Hips, Left Knee & Left anckle all injured on 5/23/1991. When a wall was pulled with a forklift braking the top & bottom plates causing the wall to collapse and striking me and pinning unconsciously against the concrete. The injury caused 100% total disability for the period 5/23/91 through 8/7/91. Which resulted in permanent disability of 31.2%. with future medical was agreed pending proposal for future payments temporarily and Permanent Disability on future reoccurrences and added disability. Unearn lost wages, Lost gainful employment & earning due to impairments form disability. There has been reason for medical treatment to relieve mental and physical aggravated injuries from 5/23/1991. Initial Injuries from accident from 05/23/91 1. Headaches – Hematoma to the frontal lobe (bleeding from the brain) 2. Neck pain –4 herniated disks (caused by wall hitting my head downwards crushing me to concrete.) 3. Shoulders pain – (shifting of the shoulders to the right when the wall crushed me onto the concrete) 4. Lower back pain – caused by (1) slipped disk and Herniated disks 5. Left hip pain – caused by shifting of the hips to the right when the wall crushed me onto the concrete 6. Left knee pain – caused pressure of the wall that crushed me onto the concrete 7.Left ankle – caused by pressure of the wall that crushed me onto the concrete I Samuel Ayala was trapped down under the 1 ton plus church wall for several minutes. Antelope Valley Hospital initial findings in exams showing neck and back injuries and pain with any attempt of movement of any body part. Head injury was hematoma on the frontal lobe. (bleeding from the brain). I Samuel Ayala, was unable to go back to work to Lee Bolin & Associates as a framer so I looked for work in Architectural field Drafting of Construction plans for permits, as an Architectural Computer Aided Drafter. With my 2 years of Architecural Drafting School, I was able to find employment as a Computer Aided Drafter with Cadd Conversion / Commercial Graphics. While employed at Cadd Conversion / Commercial Graphics, 3014 w 7th st. Los Angeles, Ca. 90005 I was trained in Autocad Setups and Document Conversion Services, while relocating the Cadd Conversion office to a larger office my back & neck pain increased so time off was needed. I Samuel Ayala, moved on to RKZ Inc in 1998. Previously known as Rierson & Duff located now 3002 Dow #118 Tustin Ca. 92780. By 2000 My headaches and neck pain increased and radiates to shoulders and left hand w/ my fingers cramping and numbing also my back was now always in pain. I Samuel Ayala, seeked medical treatment thru my current employers insurance. Dr. Randall G Shue, D.O. located at 13939 San Antonio dr. Norwalk Ca. 90650. Dr. Randall G Shue took me off work for a few weeks, but when RKZ received the information regarding my disability from Dr. Randall office RkZ Inc. terminated me immediately and refused to assign WCAB or Disability case. I Samuel Ayala, tried contacting Zenith Insurance for medical treatment from my WCAB case #NOR0174277 and was denied, they claimed it was not industrial related and that my case had closed back in 1994. I was forced to go back to work without proper medication or medical treatment. In 2004 Dr. Benavidez General Medicine located at 2600 Pacific Coast Hwy. Ste. A Longbeach Ca. 90804 took me of work and put me on disability, but state disability and S.S.I. refused to approve benefits once again, knowing of the 31:2% permanent cumulative disabilities from the 1991 construction accident. I Samuel Ayala, in 2008 I aggravated my neck, back & knee injuries. The pain was so sever, I had to go to the emergency room. I informed Zenith Insurance of my medical needs, and again denied me treatment until I got copies of Wcab Stipulations of 1994. It took 2 month for Zenith Insurance to issue the authorization to Kiaser Permanente Hospital in Riverside where Kiaser Permanente & Zenith Insurance claimed that It was not industrial related to the point of billing me for the doctor’s visit, and emergency room treatment and medication. Those bills are still unpaid (Attached Kaiser visit approval) In june of 2009, I Samuel Ayala, after not being able to receive Unemployment, Disability,Workers Compensation or Social Security disability benefits. I decided to help my girlfriend move to Pittsburgh Pennsylvania. Where within 2 weeks I was offered a position as a roof gutter helmet assistant installer with Gutter Helmet. I Samuel Ayala, aggravated my injuries with the constant climbing up and down ladders pain causing me to slipped on a roof top (some overnight rain) sliding from the ridge to the roof drain gutter. I avoided falling off the roof by grabbing onto a tree branch. The supervisor acknowledge me falling and ask if i was ok, when we got back to the warehouse, I Samuel Ayala, was told it was my last day of work. The reason for my termination was not having a valid driver’s license due to child support arrears. I disclosed my driver license situation to my employer on my 1st day. Not having employment or money for a place to live I Samuel Ayala, immediately took a flight to Los Angeles. Upon arrival I filled for medical & food stamps, within a month I Samuel Ayala, was referred to Dr Albano who referred me to MRI’s, EEG’s, EGR and Physical Therapy and other test needed. I Samuel Ayala, find myself with no Unemployment, Disability, W.C., or S.S.I. I have worked 19 out of 23 year with a permanent disability of 31:2%. Now not being able to work in the industrial and the office as an Architectural Drafting due to my constant chronic neck and back pain due to my disability that is worsening by any repetitive motion and know my age is a negative factor. I Samuel Ayala, strongly believe I was and still am discriminated from receiving any of my benefits or loss wages. Under (code section 1237) (labor code section 96(k)(labor code section 230c. Uncompensated wage loss for injured workers with permanent disabilities 1991-1996 I Samuel Ayala was not at fault for the construction accident of 5/23/1991. The accident was caused by Thomas Steno from Steno Design Studio, 11774 Hespria Rd. Ste B2 Heperia Ca. 92345. a General Contractor at that time for Mckay Lumber & Lee Bolin & Associates. Thomas Steeno decieded he could use a grendel forklift to lift a framed church wall which weigh 1 ton plus. I Samuel Ayala, and 4 to 5 co-workers were securing the wall with supports when Thomas Steeno moved the forklift in reverse pulling and breaking the top-plate together with all supports crushing me against the concrete. Trapping me down under the 1 ton plus church wall for several minutes. 3 days later I wake up from unconsciousness in the Antelope Valley hospital. I Samuel Ayala, declare, under penalty of perjury under the laws of the state of California that the foregoing is true and correct. Sincerely Samuel Ayala WORKERS COMPENSATION 091411.DOC
Posted on: Wed, 20 Nov 2013 05:18:27 +0000
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