HiddenHidden Claimant ID* HiddenHidden Last Name* ATTESTATION FORM Goidel et al. v Aetna Life Insurance Company U.S. District Court, Southern District of New YorkCase No. 1:21-cv-07619(VSB)CATEGORY B AND CATEGORY C CLASS MEMBERS MUST SUBMIT THIS FORM SO IT IS RECEIVED BY BAR DATE TO BE ELIGIBLE FOR AN APPROXIMATELY $10,000 PAYMENT For members receiving form directly:Litigation Number: Member Name: First Last For all members:At the time you sought or could have sought coverage for artificial insemination services, did you have a uterus?**** Select a Choice ***YesNoAt the time you sought or could have sought coverage for artificial insemination services, did you have a partner?**** Select a Choice ***YesNoIf yes, at the time you sought or could have sought coverage for artificial insemination services, was your partner incapable of producing sperm due to having been assigned the female sex at birth, being intersex, or being assigned the male sex at birth and having transitioned or having been in the process of transitioning to the opposite gender?**** Select a Choice ***YesNoFull Name* Signature* I certify under penalty of perjury that this Out-of-Pocket Expense Submission and the documents provided to substantiate my expense submission are true and correct to the best of my knowledge. ClaimFormNoUnique IDPhoneThis field is for validation purposes and should be left unchanged.
