To assist you with Industrial Deafness Compensation Entitlements and to receive your FREE digital hearing aids.  Please complete this online Application form.  The more information you can give us here, the more we can assist with your claim.

Name:*
Address:
Home or Mobile Number*
E-mail:*
Current Age:
Quote Code:
What is or was your usual Occupation?
How many years have you worked in a noisy occupation?
In which year were you last employed in a noisy job?
Have you previously made a claim for industrial deafness?
In which year did you make a claim?
Have you previously received hearing aids?
In which year did you receive hearing aids?