West Virginia > Workers Comp
Hearing Loss Exposure Addendum BI-1HL-a - West Virginia
| Hearing Loss Exposure Addendum Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-1HLa 09/07 Hearing Loss Exposure Addendum NON-OCCUPATIONAL NOISE EXPOSURE HISTORY Claimant's Name Claimant's Social Security Number Protection Used? Yes No Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25322-3151 Yes Hunting No How Often Type (Plugs, Muffs or Caps) Trap Shooting Firing Range Loud Music Walkman Weed Eater Lawn Mower Power Tools Chain Saw Skill Saw Band Saw Air Compressor Heavy Equipment Farm Machinery Auto Mechanic Racing Pilot Motorcycle Snow Mobile Indoor Athletics Other Other MILITARY SERVICE Do you have prior military experience? Did you have a combat assignment? What was your job in the military? Noise exposure other than basic training? Military Address / Location Service From To Job Description Type of Machinery / Equipment Used Exposure to Noise Hours / Days Hearing Protection Worn? Yes Yes No No If yes, which branch? If yes, how long? How many weeks of basic training? Comments? BrickStreet Mutual Insurance w Charleston, WV w 866.45BRICK (866.452.7425) American LegalNet, Inc. www.FormsWorkflow.com
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