PCS Potash - Cory
Please find enclosed a Short Term Disability application and a PotashCorp Fitness to Return to Work
Assessment Form. Complete the steps below to insure your claim is received and processed by
Great West Life in a timely manner:
1. Fully read and complete the Employee’s Statement – Be sure to sign and date pages 3, 4, and
5. Please note, if your claim is approved, payment will be made to you by PCS Cory, so there is no
need to complete the direct deposit authorization section.
2. Have the Attending Physician’s Initial Statement completed – Please note, this statement must be
completed by your Physician (not a Physiotherapist, Surgeon, Massage Therapist, etc).
3. Mail, fax, or email both the Employee’s Statement and Attending Physician’s Initial Statement
directly to Great West Life:
Great West Life (Regina DMSO)
1901 Scarth Street
Regina, SK S4P 4L4
Fax: 306-751-6800
Email: Regina.DMSO@greatwestlife.com
Have the Fitness to Return to Work Assessment Form completed by your Physician once you are
deemed fit to return to work.
Please note:

You must have medical clearance to return to work to full duties at least one week in advance of
return to work (not the day you return).

If there are any medical restrictions, a return to work meeting is mandatory. The return to
work meeting must take place at least 1 week prior to return to work. Included at the return to work
meeting will be yourself, Human Resources Representative, Occupational Health Nurse,
Department Supervisor, Department General Foreman and/or Superintendent, Safety
Representative, Union President (or designate), and the OHC Employee Co-Chair.

The Fitness to Return to Work Assessment Form must be received by the Occupational
Health Nurse prior to your return to work meeting.

It is important to maintain contact with the Occupational Health Nurse and your Supervisor during
your period of disability.

Please contact Jenn Selkirk at (306) 657-5118 or jenn.selkirk@potashcorp.com should you require
assistance.