Common use of Responsibility for Distribution and Notification Requirements Clause in Contracts

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883-M0029061 Original Effective Date: January 1, 2021 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central California Alliance for Health Mr Stax Inc (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0070519-M0029061 M0024277 Original Effective Date: January 1, 2021 2020 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Plan between Central California Alliance for Health Penumbra, Inc. (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0064034-M0029061 M0024738 Original Effective Date: January 1, 2021 2017 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Savings Plan between Central California Alliance for Health Mr Stax Inc (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0070519-M0029061 M0023040 Original Effective Date: January 1, 2021 2020 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central California Alliance for Health Pres & B of Trustees, Santa Xxxxx College (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0067301-M0029061 M0025188 Original Effective Date: January 1, 2021 2019 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central Partnership Healthplan of California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0053649-M0029061 M0027196 Original Effective Date: January 1, 2021 2015 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Savings Plan between Central Partnership Healthplan of California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0053649-M0029061 M0026336 & M0026337 Original Effective Date: January 1, 2021 2015 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Savings Plan between Central California Alliance for Health Pres & B of Trustees, Santa Xxxxx College (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0067301-M0029061 M0025189, M0025190 Original Effective Date: January 1, 2021 GC-1 IMPORTANT2019 GC-1

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Savings Plan between Central California Alliance for Health Pres & B of Trustees, Santa Xxxxx College (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0067301-M0029061 M0028386 & M0028387 Original Effective Date: January 1, 2021 2019 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central California Alliance for Health Pres & B of Trustees, Santa Xxxxx College (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0067301-M0029061 M0028385 Original Effective Date: January 1, 2021 2019 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Plan between Central Partnership Healthplan of California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0053649-M0029061 M0029012 Original Effective Date: January 1, 2021 GC-1 IMPORTANT2015 GC-1

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 01-00 21 000 00xx Xxxxxx XxxxxxxOakland, XX 00000 CA 94607 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Plan between Central California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883-M0029061 M0025379 Original Effective Date: January 1, 2021 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central California Alliance for Health Superior Court of California, County of San Bernardino (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0065302-M0029061 M0028180 Original Effective Date: January 1, 2021 2018 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Savings Plan between Central California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 2022, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883-M0029061 M0026322 Original Effective Date: January 1, 2021 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Plan between Central California Alliance for Health World Class Distribution, Inc. (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January July 1, 20222021, for a term of 12 9 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0069784-M0029061 M0026707 Original Effective Date: January October 1, 2021 2019 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Plan between Central California Alliance for Health Mr Stax Inc (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0070519-M0029061 M0023808 Original Effective Date: January 1, 2021 2020 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 01-00 21 000 00xx Xxxxxx XxxxxxxOakland, XX 00000 CA 94607 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® Plan between Central California Alliance for Health (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883-M0029061 M0025378 Original Effective Date: January 1, 2021 GC-1 IMPORTANT

Responsibility for Distribution and Notification Requirements. Please see this section for important timelines for distribution of information. It is agreed that this application supersedes any previous application for this Contract. Dated at (City, State) this day of 20 (Legal Name of Contractholder) By Title PLEASE SIGN, DATE AND RETURN THE ORIGINAL APPLICATION PAGE TO BLUE SHIELD OF CALIFORNIA AT THE ABOVE ADDRESS. RETAIN THE CONTRACT. Inquiries concerning any problems that may develop in the administration of this Contract should be directed to Blue Shield of California at the address provided on page GC-1. GC-AP 0-00 000 00xx Xxxxxx Xxxxxxx, XX 00000 (000) 000-0000 GROUP HEALTH SERVICE CONTRACT Blue Shield of California Access+ HMO® PPO Savings Plan between Central California Alliance for Health Penumbra, Inc. (“Contractholder”) and California Physicians' Service dba Blue Shield of California a not-for-profit corporation In consideration of the applications and the timely payment of Dues, Blue Shield agrees to provide Benefits of this Contract to covered Employees and their covered Dependents. This Contract shall be effective as of January 1, 20222021, for a term of 12 months, subject to the provisions entitled, “Changes: Entire Contract”. Group Number: W0071883W0064034-M0029061 M0024739 Original Effective Date: January 1, 2021 2017 GC-1 IMPORTANT