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
146.21 KB PDF | Updated 06/03/24
1 – CorVel Injury Packet Instructions
1.01 MB PDF | Updated 06/03/24
2 – Employee’s Claim for Workers’ Compensation Benefits (CA Form DWC-1)
309.66 KB PDF | Updated 06/03/24
3 – Report of Occupational Injury or Illness (CA Form 5020)
214.37 KB PDF | Updated 06/03/24
4 – Supervisors Incident Investigation Report
46.65 KB PDF | Updated 06/03/24
5 – Body Diagram
173.37 KB PDF | Updated 06/03/24
6 – Physician’s Notice of Return to Work-Temporary Medical Restrictions – COO
310.02 KB PDF | Updated 06/03/24
7a – Temporary Modified Duty Agreement
23.33 KB DOCX | Updated 06/03/24
7b – Temporary Modified Duty Agreement (Fire)
23.27 KB DOCX | Updated 06/03/24
8 – CorVel Medical Provider Notice
427.04 KB PDF | Updated 06/03/24
9 – Voluntary Predesignation Form
1.72 MB PDF | Updated 06/03/24
10 – Time of Hire Workers’ Compensation Pamphlet
69.07 KB PDF | Updated 06/03/24
11 – Employee Fact Sheet – Workers’ Compensation
266.14 KB PDF | Updated 06/03/24
12 – Mileage Sheet
55.09 KB PDF | Updated 06/03/24
Reporting Only – Declination of Medical Treatment
158.81 KB PDF | Updated 06/03/24
For questions regarding workers’ compensation claims, please contact the Human Resources Representative listed below:
Alex Juarez-Pina, Human Resources Analyst
[email protected]
300 W Third Street | Oxnard, CA 93030
O: 805-385-7458 | F: 805-385-8352