environmental litigation group, p.c.
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3M Earplugs Claim Application
Myself
On behalf of a family member
First Name
Last Name
First Name
Last Name
Phone Number
Email
Date of Birth
Best time to contact
Address
City
State
Zip
Did you serve in the military from 2003 - 2015?
Yes
No
Dates of service, including discharge date
Have you ever used 3M’s/Aaero Technologies Dual-ended Combat ArmsTM earplugs (Version 2 CAEv.2) while in the military?
Yes
No
When?
Where?
Yellow/Olive?
Are the earplugs still in your possession? Or any related packaging/documents?
Did you ever purchase any 3M earplugs?
Yes
No
Where and where did you use them?
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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