Free Microsoft Word - BI-1HLa - West Virginia


File Size: 323.1 kB
Pages: 1
Date: January 31, 2008
File Format: PDF
State: West Virginia
Category: Workers Compensation
Author: krichard
Word Count: 148 Words, 968 Characters
Page Size: 595 x 842 pts (A4)
URL

http://www.wvinsurance.gov/wc/pdf/forms/Hearing_Loss_Exposure_Addendum.pdf

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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: American Mining Claims Service P.O. Box 660988 Birmingham, AL 35266-0988

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?

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