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 COMP INJURY PACKET INSTRUCTIONS

1 – Report of Occupational Injury or Illness (CA Form 5020)

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

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

3 – Body Diagram

4 – Supervisor’s Incident Investigation Report

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

6 – Temporary Modified Duty Agreement

6 – Temporary Modified Duty Agreement (Fire)

7 – AIMS Medical Provider Notice

8 – Prescription Drug Program Instant Access Card English

8 – Prescription Drug Program Instant Access Card Spanish.pdf

9 – Voluntary Predesignation Form

10 – Employee Fact Sheet – Workers’ Compensation

11 – Time of Hire Workers’ Compensation Pamphlet

Mileage Sheet

REPORTING ONLY – FIRST AID FORM

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

Alex Juarez-Pina, Senior Human Resources Coordinator

alex.juarez-pina@oxnard.org

300 W Third Street | Oxnard, CA 93030

O: 805-385-7458 | F: 805-385-8352