Homak Intake
Employee Information About Accident
Store 34994
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Your name *
Please describe your accident and injury *
Check the boxes that best match your accident *
Slip & Fall
Trip Over
Fall from Ladder / Table / Chair / Rack
Struck by
Lifting
Pulling or Pushing
Carrying Product / Boxes / Materials
Cut
Other
Check the boxes that best match your injury *
Burn
Cut
Strain or Sprain
Foreign Body in Eye
Bruise / Contusion
Fracture
Other
Body part(s) affected *
Head
Neck
Shoulder — Left
Shoulder — Right
Arm — Left
Arm — Right
Hand — Left
Hand — Right
Chest
Back
Abdomen
Hip
Leg — Left
Leg — Right
Knee — Left
Knee — Right
Foot — Left
Foot — Right
Other
I was given an Employee Claim Form (DWC-1) *
Select…
Yes
No
Print name (serves as your signature) *
Date completed *
Submit
