PTO Form 1963 (Rev 5/2006)
`
`OMB No. 0651-0055 (Exp 12/31/2011)
`
`Combined Declaration of Use and/or Excusable Nonuse/Application for Renewal of
`Registration of a Mark under Sections 8 & 9
`
`The table below presents the data as entered.
`
`Entered
`
`Input Field
`
`REGISTRATION NUMBER
`
`REGISTRATION DATE
`
`SERIAL NUMBER
`
`MARK SECTION
`
`MARK
`
`OWNER SECTION (current)
`
`NAME
`
`STREET
`
`CITY
`
`STATE
`
`ZIP/POSTAL CODE
`
`COUNTRY
`
`ATTORNEY SECTION (current)
`
`NAME
`
`FIRM NAME
`
`STREET
`
`CITY
`
`STATE
`
`POSTAL CODE
`
`COUNTRY
`
`PHONE
`
`FAX
`
`EMAIL
`
`ATTORNEY SECTION (proposed)
`
`NAME
`
`FIRM NAME
`
`STREET
`
`CITY
`
`STATE
`
`POSTAL CODE
`
`2392584
`
`10/10/2000
`
`75500218
`
`MEDICA ELECT
`
`MEDICA HEALTH PLANS
`
`401 CARLSON PARKWAY
`
`MINNETONKA
`
`Minnesota
`
`55305
`
`United States
`
`ERIC D. PAULSRUD
`
`LEONARD STREET & DEINARD
`
`150 S 5TH ST SUITE 2300
`
`MINNEAPOLIS
`
`Minnesota
`
`55402
`
`United States
`
`(612)335-1448
`
`(612)335-1657
`
`eric.paulsrud@leonard.com
`
`ERIC D. PAULSRUD
`
`LEONARD STREET & DEINARD
`
`150 S 5TH ST SUITE 2300
`
`MINNEAPOLIS
`
`Minnesota
`
`55402
`
`

`
`COUNTRY
`
`PHONE
`
`FAX
`
`EMAIL
`
`United States
`
`(612)335-1448
`
`(612)335-1657
`
`eric.paulsrud@leonard.com
`
`AUTHORIZED TO COMMUNICATE VIA E-MAIL
`
`Yes
`
`ATTORNEY DOCKET NUMBER
`
`OTHER APPOINTED ATTORNEY
`
`54401.00124
`
`Ruth Rivard
`
`GOODS AND/OR SERVICES SECTION
`
`INTERNATIONAL CLASS
`
`GOODS OR SERVICES
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)SPECIMEN FILE NAME(S)
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)ORIGINAL PDF FILE
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)CONVERTED PDF FILE(S)
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(1 page)
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)ORIGINAL PDF FILE
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)CONVERTED PDF FILE(S)
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(1 page)
`
`SPECIMEN DESCRIPTION
`
`INTERNATIONAL CLASS
`
`GOODS OR SERVICES
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)SPECIMEN FILE NAME(S)
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)ORIGINAL PDF FILE
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)CONVERTED PDF FILE(S)
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(1 page)
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)ORIGINAL PDF FILE
`
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)CONVERTED PDF FILE(S)
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(1 page)
`
`SPECIMEN DESCRIPTION
`
`PAYMENT SECTION
`
`NUMBER OF CLASSES
`
`NUMBER OF CLASSES PAID
`
`SUBTOTAL AMOUNT
`
`TOTAL FEE PAID
`
`SIGNATURE SECTION
`
`SIGNATURE
`
`SIGNATORY'S NAME
`
`SIGNATORY'S POSITION
`
`DATE SIGNED
`
`036
`
`KEEP ALL LISTED
`
`SPN0-2041548930-195543786_._MEDICA_ELECT_web_page_-_12-
`OCT-2009.pdf
`
`\\TICRS\EXPORT8\IMAGEOUT8\755\002\75500218\xml1\S890002.JPG
`
`SPN0-2041548930-195543786_._MEDICA_ELECT_flyer_-
`_OCT-2009.pdf
`
`\\TICRS\EXPORT8\IMAGEOUT8\755\002\75500218\xml1\S890003.JPG
`
`Company web page advertising services; flyer advertising services
`
`042
`
`KEEP ALL LISTED
`
`SPN1-2041548930-195543786_._MEDICA_ELECT_web_page_-_12-
`OCT-2009.pdf
`
`\\TICRS\EXPORT8\IMAGEOUT8\755\002\75500218\xml1\S890004.JPG
`
`SPN1-2041548930-195543786_._MEDICA_ELECT_flyer_-
`_OCT-2009.pdf
`
`\\TICRS\EXPORT8\IMAGEOUT8\755\002\75500218\xml1\S890005.JPG
`
`Company web page advertising services; flyer advertising services
`
`2
`
`2
`
`1000
`
`1000
`
`/Eric D. Paulsrud/
`
`Eric D. Paulsrud
`
`Attorney of record, Minnesota bar member
`
`

`
`DATE SIGNED
`
`PAYMENT METHOD
`
`SUBMIT DATE
`
`TEAS STAMP
`
`10/12/2009
`
`CC
`
`FILING INFORMATION
`
`Mon Oct 12 20:01:12 EDT 2009
`
`USPTO/S08N09-XXX.XXX.XX.X
`X-20091012200112876054-23
`92584-46095c561dbda818ce3
`3bb6de32826ee6-CC-12333-2
`0091012195543786657
`
`

`
`PTO Form 1963 (Rev 5/2006)
`
`OMB No. 0651-0055 (Exp 12/31/2011)
`
`Combined Declaration of Use and/or Excusable Nonuse/Application for Renewal of Registration of a Mark under
`Sections 8 & 9
`
`To the Commissioner for Trademarks:
`
`REGISTRATION NUMBER:(cid:160)2392584
`REGISTRATION DATE:(cid:160)10/10/2000
`
`MARK: (cid:160)MEDICA ELECT
`
`The owner, MEDICA HEALTH PLANS, having an address of
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)401 CARLSON PARKWAY
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)MINNETONKA, Minnesota 55305
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)United States
`is filing a Combined Declaration of Use and/or Excusable Nonuse/Application for Renewal of Registration of a Mark under Sections 8 & 9.
`
`For International Class 036, the mark is in use in commerce on or in connection with all goods or services listed in the existing registration for
`this specific class; or, the owner is making the listed excusable nonuse claim.
`
`The owner is submitting one specimen showing the mark as used in commerce on or in connection with any item in this class, consisting of a(n)
`Company web page advertising services; flyer advertising services.
`
`Original PDF file:
`SPN0-2041548930-195543786_._MEDICA_ELECT_web_page_-_12-OCT-2009.pdf
`Converted PDF file(s) (1 page)
`Specimen File1
`Original PDF file:
`SPN0-2041548930-195543786_._MEDICA_ELECT_flyer_-_OCT-2009.pdf
`Converted PDF file(s) (1 page)
`Specimen File1
`
`For International Class 042, the mark is in use in commerce on or in connection with all goods or services listed in the existing registration for
`this specific class; or, the owner is making the listed excusable nonuse claim.
`
`The owner is submitting one specimen showing the mark as used in commerce on or in connection with any item in this class, consisting of a(n)
`Company web page advertising services; flyer advertising services.
`
`Original PDF file:
`SPN1-2041548930-195543786_._MEDICA_ELECT_web_page_-_12-OCT-2009.pdf
`Converted PDF file(s) (1 page)
`Specimen File1
`Original PDF file:
`SPN1-2041548930-195543786_._MEDICA_ELECT_flyer_-_OCT-2009.pdf
`Converted PDF file(s) (1 page)
`Specimen File1
`
`The registrant hereby appoints ERIC D. PAULSRUD and Ruth Rivard of (cid:160)LEONARD STREET & DEINARD
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)150 S 5TH ST SUITE 2300
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)MINNEAPOLIS, Minnesota 55402
`(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160) United States
`to file this Combined Declaration of Use and/or Excusable Nonuse/Application for Renewal of Registration of a Mark under Sections 8 & 9 on
`behalf of the registrant. (cid:160)The attorney docket/reference number is 54401.00124.
`
`A fee payment in the amount of $1000 will be submitted with the form, representing payment for 2 class(es), plus any additional grace period
`fee, if necessary.
`
`Declaration
`
`

`
`Section 8: Declaration of Use in Commerce
`Unless the owner has specifically claimed excusable nonuse, the mark is in use in commerce on or in connection with the goods and/or services
`identified above, as evidenced by the attached specimen(s) showing the mark as used in commerce.
`
`Section 9: Application for Renewal
`The registrant requests that the registration be renewed for the goods and/or services identified above.
`
`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 may jeopardize 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/(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)(cid:160)Date: 10/12/2009
`Signatory's Name: Eric D. Paulsrud
`Signatory's Position: Attorney of record, Minnesota bar member
`
`Mailing Address (current):
`(cid:160)(cid:160)(cid:160)LEONARD STREET & DEINARD
`(cid:160)(cid:160)(cid:160)150 S 5TH ST SUITE 2300
`(cid:160)(cid:160)(cid:160)MINNEAPOLIS, Minnesota 55402
`
`Mailing Address (proposed):
`(cid:160)(cid:160)(cid:160)LEONARD STREET & DEINARD
`(cid:160)(cid:160)(cid:160)150 S 5TH ST SUITE 2300
`(cid:160)(cid:160)(cid:160)MINNEAPOLIS, Minnesota 55402
`
`Serial Number: 75500218
`Internet Transmission Date: Mon Oct 12 20:01:12 EDT 2009
`TEAS Stamp: USPTO/S08N09-XXX.XXX.XX.XX-2009101220011
`2876054-2392584-46095c561dbda818ce33bb6d
`e32826ee6-CC-12333-20091012195543786657
`
`

`
`Visitor Resources - Medica Elect
`
`http://wwW.n1edica.com/C1/McdicaE1cct/dcfilultaspx
`
`MEDICA
`Everyone Benefits.”
`
`Home
`
`Considering Medica
`
`Members ;.
`
`Employers 8. Payers ;.
`
`Providers 4
`
`Brokers & Agents ;
`
`About Medica ;
`
`Medica Elect
`
`What Is Medica E|ec:t®?
`Medica Elect is a primary care system health plan that works closely with these respected Care Systems:
`
`Allina
`Aspen Medical Group
`CareNorth Health S stem Duluth
`Ct1ildren’s Physician Network
`Hennepin Faculg Associates
`Minnesota Healthcare Network
`Park Nicol let Health Services/Methodist
`Rlverway Clinics
`Stillwater Medical Group
`
`For Care System specific information, click on the Care System name above.
`
`When you enroll you’ll choose a primary care clinic (PCC) from one of these care systems to be your medical
`"home." Your PCC will work with you to coordinate your care including, when appropriate, referrals to
`specialists.
`Coordinated care is important. The respected Institute of Medicine says care coordination is one of the priority
`areas for heath care quality improvement.
`Medica Elect includes a comprehensive network of physicians, specialists and other types of care providers,
`and clinics and hospitals.
`You are encouraged (but not required) to get care at the hospitals and clinics in the Medica Elect Preferred
`Network. That way your out-of-pocket costs will be lowest, your coverage highest.
`
`PAPERWORK FREE at Medica Elect network facilities. Just show your Medica ID card.
`EMERGENCY CARE is covered anywhere; keep your Medica ID card with you when you
`travel.
`its easy to get the highest coverage for PRESCRIPTIONS. Use Medica’s online mai|—order
`pharmacy or fill prescriptions at Medica Elect network pharmacies. Several national retail and
`drugstore chains are network pharmacies so you can get convenient "copay only" coverage
`even when you’re away from home.
`Awide range of PREVENTIVE SERVICES (including physicals, mammograms, annual eye
`exams, immunizations and allergy shots) are covered when directed by your primary care clinic
`or physician.
`To get the highest level of coverage, you may need a REFERRAL from your primary care clinic
`or provider to see a specialist. No referral is needed for Urgent Care or Emergency Room
`service, OB/GYN doctors, Mental health/substance abuse providers, and optometrists or
`ophthalmologists (for a once a year preventive eye exam)
`Great CUSTOMER SERVICE. Year after year, in review after review, Medica’s senrice ranks
`#1.
`
`10/12/2009 6:53 PM
`
`

`
`Welcome to Medica E|ect®
`
`We're pleased that you selected Medica Elect
`
`Getting Started:
`
`this year. Medica Elect is a good value, and we
`
`are able to keep it a good value by asking you to
`
`make some decisions up front, such as selecting
`
`a care system. The information below will help
`
`you better understand your health plan so you
`
`have the best possible experience.
`
`Medica Elect checklist
`
`\/ First select a Medica Elect care system.
`
`\/ Next choose a primary care clinic.
`
`‘/ Check with your primary care clinic if you
`need a referral to a specialist.
`
`First select a Medica Elect care system
`To get started you need to choose a Medica Elect care
`system. A care system is simply a group of primary care
`clinics, specialists and hospitals that have agreed to work
`together to provide you care.
`
`Each family member may select a different Medica Elect
`care system and may change care systems each month,
`if desired.
`
`To find a care system, use the search tool Find a Doctor
`on Medica.com or call Customer Service at the number
`
`listed on the back of your Medica ID card.
`
`Next choose a primaw care clinic
`Your next step is to choose a primary care clinic which
`participates in the care system you have selected.
`
`When you need care, you will always start at your primary
`care clinic. Your primary care provider will get to know
`your health risks and overall care needs and is in the
`best position to direct you to a specialist, if needed.
`
`Like the care system, each family member may select a
`different primary care clinic within the care system and may
`change clinics every month, if desired.
`
`Check with your primary care clinic if you
`need a referral to see a specialist
`To see a specialist within your care system-
`Check with your primary care clinic. Some care systems
`allow you to see a specialist within the care system without
`a referral. Others do not.
`
`To see a specialist outside your care system-
`All Medica Elect care systems require that you get a
`referral from your primary care clinic to see a specialist
`who is not part of the care system you selected.
`
`Generally, you will be able to receive care from a health
`care provider within your care system. However, if the
`right care is not available within your care system, your
`primary care provider will refer you to a specialist outside
`the care system.
`
`QUESTIONS?
`We’re here to help. Call Customer Service at the
`number on the back of your Medica ID card.
`
`7:00 a.m. — 6:00 p.m.
`Monday through Friday:
`(Wednesdays: Closed 8:00 a.m. — 9:00 a.m.)
`
`COM5381-10309
`
`

`
`Visitor Resources - Medica Elect
`
`http://wwW.n1edica.com/C1/McdicaE1cct/dcfilultaspx
`
`MEDICA
`Everyone Benefits.”
`
`Home
`
`Considering Medica
`
`Members ;.
`
`Employers 8. Payers ;.
`
`Providers 4
`
`Brokers & Agents ;
`
`About Medica ;
`
`Medica Elect
`
`What Is Medica E|ec:t®?
`Medica Elect is a primary care system health plan that works closely with these respected Care Systems:
`
`Allina
`Aspen Medical Group
`CareNorth Health S stem Duluth
`Ct1ildren’s Physician Network
`Hennepin Faculg Associates
`Minnesota Healthcare Network
`Park Nicol let Health Services/Methodist
`Rlverway Clinics
`Stillwater Medical Group
`
`For Care System specific information, click on the Care System name above.
`
`When you enroll you’ll choose a primary care clinic (PCC) from one of these care systems to be your medical
`"home." Your PCC will work with you to coordinate your care including, when appropriate, referrals to
`specialists.
`Coordinated care is important. The respected Institute of Medicine says care coordination is one of the priority
`areas for heath care quality improvement.
`Medica Elect includes a comprehensive network of physicians, specialists and other types of care providers,
`and clinics and hospitals.
`You are encouraged (but not required) to get care at the hospitals and clinics in the Medica Elect Preferred
`Network. That way your out-of-pocket costs will be lowest, your coverage highest.
`
`PAPERWORK FREE at Medica Elect network facilities. Just show your Medica ID card.
`EMERGENCY CARE is covered anywhere; keep your Medica ID card with you when you
`travel.
`its easy to get the highest coverage for PRESCRIPTIONS. Use Medica’s online mai|—order
`pharmacy or fill prescriptions at Medica Elect network pharmacies. Several national retail and
`drugstore chains are network pharmacies so you can get convenient "copay only" coverage
`even when you’re away from home.
`Awide range of PREVENTIVE SERVICES (including physicals, mammograms, annual eye
`exams, immunizations and allergy shots) are covered when directed by your primary care clinic
`or physician.
`To get the highest level of coverage, you may need a REFERRAL from your primary care clinic
`or provider to see a specialist. No referral is needed for Urgent Care or Emergency Room
`service, OB/GYN doctors, Mental health/substance abuse providers, and optometrists or
`ophthalmologists (for a once a year preventive eye exam)
`Great CUSTOMER SERVICE. Year after year, in review after review, Medica’s senrice ranks
`#1.
`
`10/12/2009 6:53 PM
`
`

`
`Welcome to Medica E|ect®
`
`We're pleased that you selected Medica Elect
`
`Getting Started:
`
`this year. Medica Elect is a good value, and we
`
`are able to keep it a good value by asking you to
`
`make some decisions up front, such as selecting
`
`a care system. The information below will help
`
`you better understand your health plan so you
`
`have the best possible experience.
`
`Medica Elect checklist
`
`\/ First select a Medica Elect care system.
`
`\/ Next choose a primary care clinic.
`
`‘/ Check with your primary care clinic if you
`need a referral to a specialist.
`
`First select a Medica Elect care system
`To get started you need to choose a Medica Elect care
`system. A care system is simply a group of primary care
`clinics, specialists and hospitals that have agreed to work
`together to provide you care.
`
`Each family member may select a different Medica Elect
`care system and may change care systems each month,
`if desired.
`
`To find a care system, use the search tool Find a Doctor
`on Medica.com or call Customer Service at the number
`
`listed on the back of your Medica ID card.
`
`Next choose a primaw care clinic
`Your next step is to choose a primary care clinic which
`participates in the care system you have selected.
`
`When you need care, you will always start at your primary
`care clinic. Your primary care provider will get to know
`your health risks and overall care needs and is in the
`best position to direct you to a specialist, if needed.
`
`Like the care system, each family member may select a
`different primary care clinic within the care system and may
`change clinics every month, if desired.
`
`Check with your primary care clinic if you
`need a referral to see a specialist
`To see a specialist within your care system-
`Check with your primary care clinic. Some care systems
`allow you to see a specialist within the care system without
`a referral. Others do not.
`
`To see a specialist outside your care system-
`All Medica Elect care systems require that you get a
`referral from your primary care clinic to see a specialist
`who is not part of the care system you selected.
`
`Generally, you will be able to receive care from a health
`care provider within your care system. However, if the
`right care is not available within your care system, your
`primary care provider will refer you to a specialist outside
`the care system.
`
`QUESTIONS?
`We’re here to help. Call Customer Service at the
`number on the back of your Medica ID card.
`
`7:00 a.m. — 6:00 p.m.
`Monday through Friday:
`(Wednesdays: Closed 8:00 a.m. — 9:00 a.m.)
`
`COM5381-10309
`
`

`
`ROUTING SHEET TO POST REGISTRATION (PRU)
`
`Registration Number?
`
`2392534
`
`RAM Sale Number: 12333
`
`Serial Number:
`
`75500218
`
`l
`
`|
`
`RAM Accounting Date: 20091013
`
`Total Fees:
`
`$1000
`
`Note: Process in accordance with Post Registration Standard Operating Procedure (SOP)
`
`Transaction
`
`Transaction
`Date
`
`Fee per
`Class
`
`Number
`of Classes
`
`Number of
`Classes Paid
`
`§8 affidavit
`Application for Renewal (§9)
`
`20091012
`20091012
`
`$100
`$400
`
`Physical Location: 900 - FILE REPOSITORY (FRANCONIA)
`
`Lost Case Flag: False
`
`In TICRS (AM—FLG—IN—TICRS): True
`
`Transaction Date:
`
`20091012