Office of Occupational Hearing Loss 4700 MacCorkle Avenue, S. E. P.O. Box 791 Charleston, West Virginia 25322-0593 Gregory A. Burton, Executive Director Rev. 10/03 WC-3HL Employers Report of Occupational Hearing Loss Form Date Employers Name: REF: Injured workers Name: Employers Address: Social Security Number: City, State, Zip Dear Employer: The Workers Compensation Commission has eceiver d information from the above-injured worker, which leads us to conclude that you may be a proper chargeable employ in ther is claim for noise-induced hearing loss. This information is enclosed for your reference. According to WV Code 23-4-6b, employers for whom the injured worker worked at least sixty (60) days during the three (3) years immediately preceding the date of last exposure to hazardous noise MAY beco chargeame ble employers with all charges allocated proportionately among those employers. NOTICE: You have thirty (30) days from recipet of this letter to complete the following employers report and return it to the commission. If you do not file your report within thirty (30) days, the comssiomi n will base the initial ruling regarding compensability and chargeability only on the information presently contained in the file. After completing and signing the report, please return this letter to the Workers Compenonsati Commission, Occupational Hearing Loss Unit, P.O. Box 791, Charleston, WV 25322-0593. WC-3HL SECTION I TO BE COMPLETED BY THE EMPLOYER (Please type or print with a black or blue ballpoint pen.) 1. Employers Name and Address: 2. Name and Address of operation where injured worker worked: 3. County where injured 4. Employers FEIN: 5. Risk Number: 6. Telephone Number: worker worked: 7. Please provide the injured workers daily rate of pay: $ 8. Do you disagree with any of the information in Section I of the WC-1HL Ye? s No If yes, please explain specifically, including the information with which you disagree: 9. Do you have any reason to question this claim ? Yes No If yes, please explain: 10. Do you have knowledge of any previous audiograms administered to the injured wo Yesrker? No 11. Did you provide the injured worker with appropriate hearing protecti Yes on? No If yes, did the injured worker use the protective equipment that was provided? Yes No 12. Is the employee an owner, part-owner or officer of the business Ye? s No If yes, do you include his/her wages on your quarterly payroll report? Yes No I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware th law,e specifically WV Code 61-3-24e, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any information requested by the commission. I acknowledge the provisions of the aforementioned code and the severe penalties or f knowingly with fraudulent intent to aid or abet anyone in securing or attempting to secure benefits to which he or she is nontit tlede. Signature: Title: Date: / / www.wvwcc.org An equal opportunity employer.