BI-3 HL 09/07 Employer’s Report of Occupational Hearing Loss Return completed form to: BrickStreet Mutual Insurance Office of Occupational Hearing Loss P.O. Box 791 Charleston, WV 25332-0791 Date: Employers’ name: REF: Claimant’s name: Employer’s address: Social Security Number: City, State, Zip Dear Employer: BrickStreet Mutual Insurance has received information from the above-claimant, which leads us to conclude that you may be a proper chargeable employer in this claim for noise-induced hearing loss. This information is enclosed for your reference. According to WV Code § 23-4-6b, employers for whom the claimant worked at least 60 days during the three years immediately preceding the date of last exposure to hazardous noise MAY become chargeable employers with all charges allocated proportionately among those employers. NOTICE: You have 30 days from receipt of this letter to complete the following employer’s report and return it to BrickStreet Insurance. If you do not file your report within 30 days, BrickStreet 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 BrickStreet Mutual Insurance, Occupational Hearing Loss Unit, P.O. Box 791, Charleston, WV 25332-0791. P L E A S E T Y P E O R P R I N T W I T H A B L A C K O R B L U E B A L L P O IN T P E N . SECTI ON I – TO BE COMPLE TED BY THE E MP LOYE R. 1. Employer’s Name and Address: 3. County where claimant worked: 2. Name and Address of operation where claimant worked: 4. Employer’s FEIN: 5. Policy Number: 6. Telephone Number: 7. Please provide the claimant worker’s daily rate of pay: $ 8. Do you disagree with any of the information in Section I of the BI-1 HL? with which you disagree: 9. Do you have any reason to question this claim? Yes Yes No If yes, please explain specifically, including the information No If yes, please explain: 10. Do you have knowledge of any previous audiograms administered to the claimant? Yes No 11. Did you provide the claimant with appropriate hearing protection? provided? Yes No Yes No If yes, did the claimant use the protective equipment that was 12. Is the claimant an owner, part owner or officer of the business? report? Yes No Yes No If yes, do you include his/her wages on your quarterly payroll I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, 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 BrickStreet Insurance. I acknowledge the provisions of the aforementioned code and the severe penalties for knowingly with fraudulent intent to aid or abet anyone in securing or attempting to secure benefits to which he or she is not entitled. Signature: Title : BrickStreet Mutual Insurance  P.O. Box 791  Charleston, WV    www.brickstreet.com  Date: / /  25332  American LegalNet, Inc. www.FormsWorkflow.com