3M Earplugs Claim Application Form

Myself On behalf of a family member

First Name

Last Name

Phone Number

Date of Birth

Best time to contact

Address

City

State

Zip

Did you serve in the military from 2003 - 2015?

Yes No

Have you ever used 3M’s/Aaero Technologies Dual-ended Combat ArmsTM earplugs (Version 2 CAEv.2) while in the military?

Yes No

Did you ever purchase any 3M earplugs?

Yes No

Did you suffer from hearing loss prior to deployment?

Yes No

Where were your pre and post-deployment hearing screenings performed?
Pre: Post:

Do you suffer from or been diagnosed with hearing loss (partial or full) and/or tinnitus?

Yes No

When were you diagnosed with hearing loss?

Where were you treated/diagnosed with partial/full hearing loss?

Do you receive disability benefits from the government for hearing loss?

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