Workers’ Compensation

Workers’ Compensation Administration

The City of Oxnard is self-insured for workers’ compensation claims up to $1 million per claim. Above that level, the City purchases excess workers’ compensation insurance to statutory limits through the CSAC Excess Insurance Authority.
Employees should use the following forms and documents related to the filing of a workers’ compensation claim.

0 – WORKERS-COMPENSATION-INJURY-PACKET-INSTRUCTIONS.pdf

1 – CorVel INJURY PACKET INSTRUCTIONS

2– Employee’s Claim for Workers’ Compensation Benefits (CA Form DWC-1)

3-Report-of-Occupational-Injury-or-Illness-CA-Form-5020.pdf

4 – Supervisors-Incident-Investigation-Report

5 – Body Diagram

6 – Physician’s Notice of Return to Work-Temporary Medical Restrictions – COO

7a – Temporary Modified Duty Agreement (Fire)

7b – Temporary Modified Duty Agreement

8 – CorVel Medical Provider Notice

9 – Voluntary Predesignation Form

10 – Time of Hire Workers’ Compensation Pamphlet.pdf

11 – Employee Fact Sheet –  Workers’ Compensation

Mileage Sheet

REPORTING ONLY-DECLINATION OF MEDICAL TREATMENT.docx

For questions regarding workers’ compensation claims, please contact the Human Resources Representative listed below:

Alex Juarez-Pina, Human Resources Analyst

alex.juarez-pina@oxnard.org
300 W Third Street | Oxnard, CA 93030
O: 805-385-7458 | F: 805-385-8352