Submit a claim for work related, noise-induced hearing loss

Start a new claim

Confirm this is the correct claim form for your hearing loss.

Was your hearing loss gradual or sudden?

• Gradual, over a period of a few years
• Sudden, like an explosion

You have indicated that your hearing loss was sudden. You do not qualify for a noise-induced hearing loss claim, but you may still be eligible for benefits. Please submit a Report of injury or illness to start a claim.

Please provide your email address, and we will send you a reference number. You can use this reference number to resume a partially completed form within 30 days.

If you are under the age of 16, you will need your parent or guardian’s signature to release your medical information. You cannot submit your claim online. Please download the Report occupational noise-induced hearing loss form and send us a paper submission by fax or mail.

Gathering necessary information before starting your claim

This form will take you approximately 45 minutes to complete and will require the following information:

• Basic personal information
• Dates and locations of your hearing-loss-related health care appointments, including audiologists and ear, nose and throat (ENT) specialists.
• Name(s), address(es) and amount of time spent at your current and previous employers that contributed to your hearing loss
• List of tools and/or equipment used at each employer that contributed to your hearing loss
• Audiogram
• Proof of employment documents for each relevant employer. More about proof of employment

What if I don't have all the information?

• If you don’t have all the required information, you can start filling out the online form with the information you have. You will have 30 days from the date you initially start the form to gather the rest of your documents.
• You can also download and complete the Workers’ Report of Occupational Noise-Induced Hearing Loss and fax or mail in your claim, or call us at 1-800-387-0750.