BI-1HLa 09/07 Return completed form to: Hearing Loss Exposure Addendum BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25322-3151 NON-OCCUPATIONAL NOISE EXPOSURE HISTORY Claimant’s Name Claimant’s Social Security Number Yes No Protection Used? Yes No How Often Type (Plugs, Muffs or Caps) Hunting 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? Yes No If yes, which branch? Did you have a combat assignment? Yes No If yes, how long? What was your job in the military? How many weeks of basic training? 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? Comments? BrickStreet Mutual Insurance w Charleston, WV w 866.45BRICK (866.452.7425) American LegalNet, Inc. www.FormsWorkflow.com