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Contact Us

(218) 335-3698 Phone
(800) 631-5528 Toll-free
(218) 335-3697 Fax

Mailing Address
190 Sailstar Drive NW
Cass Lake, MN 56633

Physical Address
16126 John Moose Drive
Cass Lake, MN 56633

Office Hours

Monday - Friday
8:00 a.m. - 4:30 p.m.

Information

2023 LLBO Benefits Guide

2022 Benefits at a Glance

QCCBL Machine Readable File Table of Contents link

2023 Annual Fee Disclosure

401(k) & 403(b)

Online Distribution Request Info

401(k) Designation of Beneficiary Form

403(b) Designation of Beneficiary Form

401(k) Hardship Distribution Guidelines

401(k) Hardship Distribution Request Form

403(b) Hardship Distribution Request Form

401(k) In-Service Distribution Request Form

403(b) In-Service Distribution Request Form

401(k) Loan Payment/ Payoff Transmittal Form

403(b) Loan Payment/ Payoff Transmittal Form

401(k) Separation From Service Distribution Request Form

403(b) Severance From Employment Distribution Request Form

403(b) In-Kind Direct Rollover Request Form

401(k) Loan Request Form

403(b) Loan Request Form

LLBO Salary Deferral Form

Medical & Dental Insurance

Delta Dental Reimbursement Request

HIPAA Form

Medicare Part D 2023 Credible Coverage Notice

Member/Group Medical Enrollment Form

Member/Group Medical Change Form

Delta Dental Member Portal

Vision Claim Form

Purchased/Referred Care Info

ClearScript/Pharmacy Benefit

8 Ways to Save

2024 Clearscript Formulary

2024 Pharmacy Benefits Update

2024 Preventative Care Medications

Life Insurance

Beneficiary Designation Form and Instructions

LLBO Basic Life and AD&D Insurance Info

Supplemental Life Insurance Info

Personal Health Application

Estate Guidance- Will Preparation

Leave of Absences

Short Term Disability Information

Telephonic Short Term Instructions

Attending Physicians Statement - Initial Report

Attending Physicians Statement - Progress Report

Important Insurance Information: Leave of Absence

Return to Work Form

Mental Health Attending Physician's Statement

Unum

Unum Accident Insurance

Unum Critical Illness

Unum Hospital Insurance

Unum Long Term Disability

Unum Whole Life Insurance

Employee Benefits

Ascensus Customer Service- Employees
888-652-8086
Ascensus website: Ascensus - Retirement Login
Ascensus Representatives at First National Bank Bemidji
David Blamer & Ryan Welle
(218) 751-2430
[email protected]

NOTICE:

Medical & Dental Coverage Change Forms can be picked up at Human Resources or downloaded above. If you will be declining coverage, a HIPAA form will also need to be signed. Remember changes to your policies can only be made during “Open Enrollment” or throughout the year with a “qualifying event”.