~COMBINED DECLARATI"\1 OF USE & INCOMTESTABILITY '
`
`‘DER §x§» 8 & 15~ Page 1 of 3
`
`PTO Form 1583 (Rev 4/2000)
`OMB Control #0651-D009 (Exp. O8/31/2004)
`
`7
`
`"~‘C'OMBINED DECLARATION OF USE & INC0MTEsTAT3ILIT‘Y”'UNDER §§ 8 &
`15~
`
`* To the Commissioner for Trademarks *
`
`_
`<DOCUMENT INFORMATION>
`<COMBINED DECLARATION OF USE AND INCONTESTABILITY UNDER SECTIONS 8 and
`1 5>
`<VERSION 1.24>
`
`<TRADEMARK/SERVICEMARK INFORMATION>
`
`<MARK> MEDICA /
`<TYPED FORM> Yes /
`<REGISTRATION NUMBER> 21 13265 ./
`<SERIAL NUMBER> 74592862
`<REGISTRATION DATE> 1 1/18/1997 /
`<OWNER INFORMATION>
`<NAME>¢*”’I\/Iedi‘gz_1«AHea1th Plans /
`<STREET> ’
`'01 Smetana Drive
`<CITY>
` o1is
`<STATE>
`<COUNTRY> US
`<ZIP/POSTAL CODE> 5o’§'43
`
`<GOODS AND SERVICES INFORMATION>
`<ALL GOODS AND/OR SERVICES IN EXISTING REGISTRATION> Yes
`~ The owner has used the mark in comfnerce for five consecutive years after the date of
`registration, or the date of publication under Section 12(0), and is still using the mark in
`
`commerce on or in connection with all goo?/or services listed in the existing registration.
`
`<GOODS AND SERVICES INFORMATION>
`<ALL GOODS AND/OR SERVICES IN EXISTING REGISTRATION> Yes
`
`~ The owner has used the mark in commerce for five consecutive years after the date of V
`registration, or the date of publication under Section 12(c), and is still using the mark in
`commerce on or in connection with all goods and/or services listed in the existing registration.
`~
`
`<ATTORNEY INFORMATION>
`
`<NAME>‘ Eric/;lD.Pau1srud
`<STREET>
`150 South 5th Street
`<CITY> ~‘ Minneapolis
`<STATE> MN
`<COUNTRY> USA
`<ZIP/POSTAL CODE> 55402
`<E-MAIL ADDRESS> eric.pau1srud@leonard.com
`<AUTHORIZE E—MAIL COMMUNICATION> Yes
`
`81/14/2063 INITEFIS 93959279 2113265
`
`91 rc=72e5
`"2 “'7”
`
`293.33 or /
`“'°"“’ ”" «/
`
`

`
`~COMBINED DECLARATI”‘l OF USE & INCOMTESTABILITY '
`
`'DER §§ 8 & 15~ Page 2 of 3
`
`<FIRM NAME> Leonard, Street and Deinard
`<TELEPHONE NUMBER> (612)335-1448
`
`-
`«-—--—~——~.--~———-~--—————-————~——-+——»
`<ATTORNEY DOCKET NUMBER> 54401-tbo
`
`<OTHER APPOINTED ATTORNEY(S)> Doris Yock
`
`<FEE INFORMATION>
`<COMBINED SECTIONS 8 and 15 FILING FEE AMOUNT> 600
`<NUMBER OF CLASSES> 2
`<TOTAL FEES PAID> 600
`<NUMBER OF CLASSES PAID> 2
`
`<USE INFORMATION>
`<INTERNATIONAL CLASS NUMBER> O36
`<SPECIMEN> Yes
`
`<SPECIMEN DESCRIPTION> Screen capture from Registrant's Internet Web page discussing IC36
`services.
`
`<INTERNATIONAL CLASS NUMBER> 042
`<SPECIMEN> Yes
`
`<SPECIMEN DESCRIPTION> Screen capture from Registrant's Internet web page discussing former
`IC42 (now IC44) services.
`
`<LAW OFFICE INFORMATION>
`
`~ The USPTO is authorized to communicate with the applicant, attorney or representative at
`the below e—mail address ~
`
`<E-MAIL ADDRESS FOR CORRESPONDENCE> eric.pau1srud@1eonard.com
`
`<SIGNATURE AND OTHER INFORMATION>
`
`~ Declaration: The owner is using or is using through a related company the mark in commerce
`on or in connection with the goods/services identified above, as evidenced by the attached
`specimen(s) showing the mark as used in commerce. The mark has been in continuous use in
`commerce for five consecutive years after the date of registration, or the date of publication
`under Section 12(c), and is still using the mark in commerce on or in connection with all goods
`and/or services as identified above. There has been no final decision adverse to the owner's
`claim of ownership of such mark for such goods and/or services, or to the owner's right to
`register the same or to keep the same on the register; and there is no proceeding involving
`said rights pending and not disposed of either in the Patent and Trademark Office or in the
`courts. ~
`
`~ The undersigned being hereby warned that willful false statements and the like are
`punishable by fine or imprisonment, or both, under 18 U.S.C. Section 1001, and that such
`willful false statements and the like mayjeopardize the validity of this document, declares that
`he/she is properly authorized to execute this document on behalf of the Owner; and all
`statements made of his/her own knowledge are true and that all statements made on
`information and belief are believed to be true. ~
`<SIGNATURE> /Eric D. Paulsrud/
`<DATE> 01/13/2003
`<NAME> Eric D. Paulsrud
`<TITLE> Attorney for Applicant
`
`/
`
`<RAM INFORMATION>
`<RAM SALE NUMBER> 279
`
`

`
`~COMBINED DECLARATI" 1 OF USE & INCOMTESTABILITY ' DER §§ 8 & 15~ Page 3 of 3
`
`<RAM ACCOUNTING DATE> 01/14/2003
`<INTERNET TRANSMISSION DATE> Mon Jan 13 19:01:11 EST 2003
`
`200889c5a7375d916dd3481b6d1e4d32-RAM-279-20030113185816960120
`<E—MAIL ADDRESS FOR ACKNOWLEDGMENT> eric.pau1srud@le0nard.com
`
`The information collected on this form allows the USPTO to determine whethera mark may be registered on the Principal or Supplemental register, and
`providesnotice of an applicant's claim of ownership of the mark. Responses to the requestfor information are required to obtain the benefit oi’ a
`registration on the Principal or Supplemental register. 15 U.S.C. §§1051 et seq. and 37 CFR. Part 2. Allinformation collected will be made public.
`Gathering and providing the information willrequire an estimated 18 minutes (depending if the application is based on an intentto use the mark in
`commerce, use of the mark in commerce, or a foreign application or registration).Please direct comments on the time needed to complete this form,
`and/or suggestions for
`reducing this burden to the Chief
`information Officer, U.S. Patent and Trademark Office, U.S. Department of
`Commerce,Washington DC. 20231. Please note that the PTO may not conduct or sponsor a collection of information using a form that does not
`display a valid OMB control number.
`
`

`
`~COMBINED DECLARATI” I OF USE & INCOMTESTABILITY I DER §§ 8 &15~ Page 1 of3
`
`~COMBINED DECLARATION OF US
`
`E & INCOMTESTABILITY UNDER §§ 8 &
`__1.5___ ____,._.____________.________.__._,.__..__.____.___.-
`
`The table below presents the data as entered.
`
`Input Field
`
`MARK
`
`TYPED FORM
`
`REGISTRATION NUMBER
`
`SERIAL NUMBER
`
`REGISTRATION DATE
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`COUNTRY
`
`ZIP/POSTAL CODE
`
`ALL GOODS AND/OR
`SERVICES IN EXISTING
`REGISTRATION
`
`ALL GOODS AND/OR
`SERVICES IN EXISTING
`
`A REGISTRATION
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`COUNTRY
`
`ZIP/POSTAL CODE
`
`E-MAIL ADDRESS
`
`Entered
`
`MEDICA
`
`Yes
`
`21 13265
`
`74592862
`
`1 1/18/1997
`
`Medica Health Plans
`
`5601 Smetana Drive
`
`Minneapolis
`
`MN
`
`US
`
`Yes
`
`Eric D. Paulsrud
`
`150 South 5th.Street
`
`Minneapolis
`
`MN
`
`USA
`
`S5402
`
`eric.pau1Srud@Ieonard.com
`
`AUTHORIZE E-MAIL
`COMMUNICATION
`
`Yes
`
`FIRM NAME
`
`Leonard, Street and Deinard
`
`

`
`SPECIMEN
`
`Internet "fransmiesion ]5_a‘te:-_
`01132003
`
`in
`
`A ? Registration Number:
`2113265
`
`Class Number:
`036
`
`'
`
`Serial Number:
`745 92862
`
`*74592862*
`
`3Medi(a 5el|‘—Insured — Mitrnsnft Internet Enpiura
`File
`View
`Favorites
`Help
`
`{Em}; ésnizcis Login Q]Vahoo!Se:a;h0ptioT1e igjrrro QTTAB-i-"sting
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`
`Medica Self-Insured
`
`Awhnlly maimed subsidiary on/Iedicacl Medica Self-Insured
`covers more than 230,000 members in Minnesota‘ Nunh
`Dakota and Wisconsin Medina Selfiinsured helps clients
`with 100 or more employees maximize theirhealih care
`dollars wiih:
`
`- Flexibiity. Clients benefit from full administrative
`services. in-house siop—ioss carrier, managed care
`networks, industry-ieading rlsk management and
`custnmized health plan designs In meettheir unique
`needs,
`a Seniice excellence. Medica SeI1—|nsured provides
`
`

`
`Internet TrarE_rrFs>s'i0nADate:
`01132003
`
`‘
`
`2
`
`'
`
`_
`
`_
`
`Registration Nlitnber:
`2113265
`
`Class Number:
`042
`
`Serial Number:
`74592862
`
`*74592862*
`
`:3 About Medica — Mrcrusort Internet Euuorer
`File
`Edit
`View
`Favorites
`Tools
`Help
`Links §_]SAEGISLogin
`?_]Yahoo!Search0ptions QJPTO gTTA8—Filing
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`gfistory
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`_Address
`httoszflwwwrmedlca.com/medicalabommed.nsflAbout+Medica?0pen\llew
`
`About Nledica
`
`Medina serves employers, individuals and communities in
`Minnesota and adlacentcountles in Wisconsin and North
`Dakota. Approximately one million people and more than
`10,000 employers are Medica members and customers.
`Medica members have convenient access to care
`throughout our coverage area in Minnesota and adjacent
`counties in Wisconsin,Nor1h Dakota and South Dakota. The
`Medica network includes eight major health s3rslems.159
`hospitals and more than 16,300 physicians and other health
`care prDCeSS|nl'la|S
`
`Medlcatll ls Minnesota‘s second largest provider othealth
`maintenance organization (HMO) options and other health
`plans. in addition to HMO options, Medina offers preferred
`provider organization (PPO) plans, primary care physician
`(PCP) and dental plans, and indemnity insurance.
`
`Medlca, first as the pioneering physlcamled HMO Physicians
`Health Plan (PHP) and now as the provider ofa broad
`portfolio orhealth plan choices, has helped to inspire health
`care reform and continuous improvementwlth core values
`
`that are now widely emulated:
`
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`5\F §m=,®© 5:43PM
`
`

`
`~COMBINED DECLARATI”‘I OF USE & INCOMTESTABILITY '
`
`‘DER §§ 8 & 15~ Page 2 of 3
`
`TELEPHONE NUMBER
`
`(612)33 5-1448
`
`FAX,.NUMBER-. .. .
`
`(6J.2)33.5=1657
`
`..-_- I
`
`.1
`
`ATTORNEY DOCKET
`NUMBER
`
`OTHER APPOINTED
`
`ATTORNEY(S)
`
`54401 —tbo
`
`Doris Yock
`
`COMBINED SECTIONS 8 and 15
`FILING FEE AMOUNT
`
`600
`
`NUMBER OF CLASSES
`
`TOTAL FEES PAID
`
`NUMBER OF CLASSES PAID
`
`INTERNATIONAL CLASS
`NUMBER
`
`SPECIMEN
`
`2
`
`2
`
`036
`
`Yes
`
`SPECIMEN DESCRIPTION
`
`Screen capture from Registrant's Internet web page discussing
`.
`IC36 services.
`
`INTERNATIONAL CLASS
`NUMBER
`
`SPECIMEN
`
`042
`
`Yes
`
`SPECIMEN DESCRIPTION
`
`E-MAIL ADDRESS FOR
`CORRESPONDENCE
`
`Screen capture from Registrant's Internet web page discussing
`former IC42 (now IC44) services.
`
`eric.paulsrud@1e0nard.com
`
`SIGNATURE
`
`/Eric D. Pau1srud/
`
`DATE
`
`NAME
`
`TITLE
`
`01/13/2003
`
`Eric D. Paulsrud
`
`Attorney for Applicant
`
`RAM SALE NUMBER
`
`279
`
`RAM ACCOUNTING DATE
`
`01/14/2003
`
`INTERNET TRANSMISSION
`DATE
`
`Mon Jan 13 19:01:11 EST 2003
`
`TEAS STAMP
`
`E—MAIL ADDRESS FOR
`
`USPTO/SO8N15-2099820712-20030113190111808039-
`21 13265-200889c5a7375d916dd3481b6d1e4d32—RAM—279—
`200301 13185816960120
`
`

`
`~COMBINED DECLARAT‘ ‘‘ ‘T OF USE & INCOMTESTABILITY '
`
`‘DER §§ 8 & 15~ Page 3 of 3
`
`ACKNOWLEDGMENT
`
`eric.pau1srud@leonard.com
`
`Go "Back
`
`

`
`Registration Number:
`
`2113265
`
`_ Serial Number: 74592862_.
`
`*74592862*
`
`RAM Sale Number: 279
`
`Total Fees:
`
`$600
`
`RAM Accounting Date: 01/14/2003
`
`Transaction
`
`§8 affidavit
`§15 affidavit
`
`.
`
`Trans action
`Date
`
`01/13/2003
`01/13/2003
`
`Number
`of Classes
`
`Total
`F_e£:_
`
`$200
`$400