This field is hidden when viewing the formHidden Claimant ID*This field is hidden when viewing the formHidden Aetna Number*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, CATEGORY C AND CATEGORY D-B CLASS MEMBERS MUST COMPLETE & RETURN THIS FORM SO IT IS RECEIVED BY AUGUST 26, 2025 TO BE ELIGIBLE FOR AN APPROXIMATELY $10,000 PAYMENT COMPLETION AND SUBMISSION OF THIS FORM IS NOT GUARANTEE OF ELIGIBILITY. YOU MUST COMPLETE AND SUBMIT THIS FORM TO BE CONSIDERED. PLEASE READ THIS ATTESTATION FORM AND THE ENCLOSED SETTLEMENT NOTICE CAREFULLY You have been identified as a potential Category B, C or D-B Class Member. According to Defendant’s records, your member files contain a precertification request or claim for one of an agreed upon set of artificial insemination or invitro fertilization (“IVF”) codes covered by this settlement that was for services received between September 1, 2017 and May 31, 2024. You may also be a potential Category C Class Member if you never submitted a precertification or claim request, but nevertheless underwent artificial insemination associated with one of an agreed-upon set of qualifying intracervical insemination (“ICI”) or intrauterine insemination (“IUI”) codes. To be eligible for an approximately $10,000 payment, you must complete and return this Attestation Form, so it is received by the Settlement Administrator on or before August 26, 2025. Aetna Member Number (W Number):*Member Name:* First Last At the time you sought coverage for or received artificial insemination services pursuant to your Aetna health benefits plan, were you in a same-sex relationship?**** Select a Choice ***YesNoSignature* 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.
