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Get F262-013-111 Continuation Emp History Hearing Loss Continuation - Lni Wa

Ame Claim Number Start date of first employment Employer s Business Name From (Month/Year) Employer s Address City Job Title State Employer s Phone No. To (Month/Year) ZIP + 4 Indicate time exposed to noise in hours per week Describe job duties, type of machinery, tools, material, equipment used, and percentage of time at duties: Were you exposed to loud noise on this job? Yes If yes, please describe the noise source: No Would you describe the noise as continuous? Yes No.

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