CONTRACT 3145 Vender Agreement3 ?4,S.
PIU V, TE MEDICAL -CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924 -8311 (800) 8017105
APPLICATION FOR DeltaCare GROUP DENTAL SERVICE CONTRACT
The undersigned group ( "Applicant ") hereby applies for a DeltaCare GROUP DENTAL SERVICE
CONTRACT with PRIVATE MEDICAL- CARE, INC, ( "PNII ") on the following terms
I. Applicant hereby authorizes PMI to furnish the dental Benefits described in the attached Contract,
subject to all of the terms and conditions of the Contract.
II Applicant or Enrollees agree to pay to PNU, in advance, the Premiums specified in Schedule D to the
Contract.
III. Upon acceptance of this Application by PMI, and payment of the initial Premiums, the Contract shall
be effective at 12.01 a.m. on the Effective Date shown on Schedule D and the Contract shall continue
until terminated as provided.
TV, Applicant agrees to make available to Eligible Employees or Enrollees any notices concerning Benefits
required to be furnished by PMI.
V. PNTI will provide directly to each Eligible Person or Enrollee a combined Evidence of Coverage
and Disclosure Form (EOC). PMI's Enrollment materials advise Eligible Persons that an EOC
is also available upon request, prior to enrollment by contacting PMI's Customer Relations
department. A matrix which, describes the program's major Benefits and coverage is included
at the beginning of the EOC and as Schedule F withih this Contract. The EOC will disclose
the terms and conditions of coverage, but will constitute only a summary of the program. As
required by the California Health & Safety Code, the Contract must be consulted to determine
the exact terms and conditions of the coverage provided. A copy of the Contract will be
furnished upon request. Enrollees should read the EOC carefully. Persons with special
healthcare needs should read the section entitled "Special Needs ". Pursuant to California
Health and Safety Code, the EOC provides Enrollees with information regarding the societal
benefits of organ donation and the method whereby an Enrollee may elect to be an organ or
tissue donor. Enrollees may also obtain information about Benefits by calling PMI's Customer
Relations department at (800) 422 -4234.
VI, Applicant agrees to receive, on behalf of Enrollees, all applicable notices concerning Benefits under
this Contract.
VII, THE PRV -MrU vIS PAYABLE UNDER THIS CONTRACT ARE SUBJECT TO INCREASE UPON
RENEWAL AFTER TAE END OF THE DI ITIAL CONTRACT TERM OR ANY StMSEQUENT
CONTRACT TEAM.
VIII. THIS CONTRACT IS SUBJECT TO ARBITRATION IN ACCORDANCE WITH ARTTCI E 6.
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02012 -0017
(Group Number)
Segundo
Applicant)
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