Step 1 of 6 16% FacebookThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formhidden claimant id*This field is hidden when viewing the formhidden identifier*This field is hidden when viewing the formhidden LastName*This field is hidden when viewing the formhidden Category*This field is hidden when viewing the formhidden payment choice*This field is hidden when viewing the formHIDDEN Aetna Number* CLAIM FORM Mara Berton v. Aetna Inc. & Aetna Life Insurance Company U.S. District Court, Northern District of California Case No. 4:23-cv-01849 (HSG) CATEGORY A CLASS MEMBERS ONLY NEED TO COMPLETE THIS FORM IF SEEKING MORE THAN THE DEFAULT PAYMENTS. THIS FORM MUST BE POSTMARKED OR SUBMITTED ONLINE BY JUNE 29, 2026 CATEGORY B CLASS MEMBERS MUST COMPLETE AND RETURN THIS FORM SO IT IS POSTMARKED OR SUBMITTED ONLINE BY THE DEADLINE TO BE PART OF THE CLASS AND BE ELIGIBLE FOR ANY PAYMENT FROM THIS SETTLEMENT CATEGORY C AND D-B CLASS MEMBERS MUST COMPLETE AND RETURN THIS FORM SO IT IS POSTMARKED OR SUBMITTED ONLINE BY JUNE 29, 2026 TO BE PART OF THE CLASS AND BE ELIGIBLE FOR ANY PAYMENT FROM THIS SETTLEMENT CATEGORY D-A CLASS MEMBERS MUST COMPLETE AND RETURN THIS FORM SO IT IS POSTMARKED OR SUBMITTED ONLINE BY THE DEADLINE TO BE PART OF THE CLASS AND BE ELIGIBLE FOR ANY PAYMENT FROM THIS SETTLEMENT COMPLETION AND SUBMISSION OF THIS FORM DOES NOT GUARANTEE PAYMENT. GENERAL CLAIM SUBMISSION FORM INFORMATION ➢ Failure to fully complete a claim may result in an ineligible claim. After you submit your claim, if additional information is required to complete your claim, you will be notified by mail and/or email. ➢ To get the documentation you need, you may need to request your medical records and billing records from your fertility treatment provider(s). ➢ Any documents submitted as supporting evidence will not be returned. Please retain copies of your documents for your own records. ➢ This form will be maintained as highly confidential until the case has concluded, and then it will be destroyed. COMPLETION AND SUBMISSION OF THIS FORM IS NOT GUARANTEE OF ELIGIBILITY. GENERAL CLAIM SUBMISSION FORM INFORMATION ➢ Failure to fully complete a claim may result in an ineligible claim. After you submit your claim, if additional information is required to complete your claim, you will be notified by mail and/or email. ➢ To get the documentation you need, you may need to request your medical records and billing records from your fertility treatment provider(s). ➢ Any documents submitted as supporting evidence will not be returned. Please retain copies of your documents for your own records. ➢ This form will be maintained as confidential until the case has concluded, and then it will be destroyed. YOU ARE HIGHLY ENCOURAGED TO SUBMIT THIS FORM ONLINE The platform is safe and secure for submitting health-related information. PLEASE READ THIS CLAIM SUBMISSION FORM AND YOUR SETTLEMENT NOTICE CAREFULLY Are you seeking more than the default payments?* Yes No Class Member Information – REQUIREDNAME:* Class Member First Name M.I. Class Member Last Name Aetna Member Number (W Number):*Aetna Member Number (W Number):*Social Security Number:*Employer/ Plan Sponsor:*Date of Birth:* MM slash DD slash YYYY Mailing Address* Class Member Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code This field is hidden when viewing the formCheck if address is non-US Please check if this is a non-U.S. address Class Member Email Address:* By providing Atticus your email, you are agreeing that Atticus can contact you via email.Class Member Telephone:*Pick One:* Mobile Home Are you acting on behalf of a deceased or incapacitated Class Member? Yes No If you are acting on behalf of a deceased Class Member or a Class Member who does not have the capacity to act on their own behalf, documentation supporting your authority to act on their behalf will be required to validate your claim. To proceed, please complete the representative portion of the claim below and submit documentation substantiating your authority to act on behalf of the above Class Member.FOR SURVIVORS/REPRESENTATIVES OF CLASS MEMBERS ONLYName* Representative First Name M.I. Representative Last Name Address* Representative Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Representative Email Address: By providing Atticus your email, you are agreeing that Atticus can contact you via email.Representative Telephone:*Pick One:* Mobile Home Upload supporting documentation which substantiates your authority to act on behalf of the above Class Member* Drop files here or Select files Max. file size: 24 MB, Max. files: 5. ATTESTATION – REQUIREDAt the time you sought coverage for or received artificial insemination services while you were on an Aetna plan, were you in an Eligible LGBTQ+ Relationship as defined in the Notice?* Yes No Artificial Insemination HistoryArtificial Insemination History Between 4/17/19 and 12/31/24 – REQUIREDArtificial Insemination – payment choice* I am seeking the Default Payments I am seeking a higher payment A. ARTIFICAL INSEMINATION HISTORY: ELIGIBILITYProvide the requested information and documentation for at least one IUI or ICI cycle you paid for out-of-pocket and have not been reimbursed for by insurance between 4/17/19 and 12/31/24.B. ARTIFICAL INSEMINATION HISTORY: SEEKING HIGHER PAYMENT Provide the requested information and documentation for all IUI or ICI cycles you paid for out-of-pocket between 4/17/19 and 12/31/24 and have not been reimbursed for by insurance. Artificial Insemination History Chart – Required Date of Service Services Received (check all that apply) Provider Name Provider Address Upload Documentation of Service Actions Edit Delete There are no Artificial Insemination Records. Add Artificial Insemination History Maximum number of artificial insemination records reached. Fill out this chart if you believe your plan should have paid your medical provider more than $11,408 for fertility treatment you underwent between 4/17/19 and 12/31/24. If not, click “Next”. B. ARTIFICAL INSEMINATION HISTORY: SEEKING HIGHER PAYMENT Provide the requested information and documentation for all IUI or ICI cycles you paid for out-of-pocket between 4/17/19 and 12/31/24 and have not been reimbursed for by insurance. Artificial Insemination History Chart – Optional Date of Service Services Received (check all that apply) Provider Name Provider Address Upload Documentation of Service Actions Edit Delete There are no Artificial Insemination Records. Add Artificial Insemination History Maximum number of artificial insemination records reached. SPECIAL HARMS SUBMISSION – OPTIONAL Fill out this section if you are seeking additional money because you paid over $11,408 out-of-pocket or suffered other harm. If you are not seeking additional money, skip to the bottom and click “Next”. A. OUT-OF-POCKET EXPENSES/ECONOMIC LOSSThe Special Harms Fund is available to compensate people for expenses and losses that exceed their Default or Pro Rata Payment plus their Dollars for Benefits Payment. To get compensation, the expenses/losses must be because of Aetna’s allegedly discriminatory policy. Examples of potentially eligible expenses include: ➢ Costs or economic losses that you incurred because you underwent IUI cycles to meet Aetna’s requirements to be considered infertile that you would not have otherwise undergone, including costs associated with associated medications, monitoring visits, purchases of donor sperm, and delivery and storage of donor sperm; ➢ Wages lost because you went to fertility treatment appointments you would not have gone to if you weren’t trying to meet Aetna’s requirements to be considered infertile; ➢ Interest on debts you could not pay down because you needed to pay for fertility procedures out-of-pocket; and ➢ IVF costs if your plan covered IVF but you were denied coverage because of Aetna’s allegedly discriminatory policy.Are you applying for compensation for out-of-pocket costs or economic losses in excess of $11,408? No Yes If you are not seeking additional money, change your previous answer to “No”. Special Harms Chart – Optional Expense Amount Expense Date Description of Expense and Support Documents Upload Documentation of Service Actions Edit Delete There are no Expenses. Add Out-Of-Pocket Expenses/Economic Loss Maximum number of expenses reached. B. SPECIAL HARMSThe Special Harms Fund is available to compensate Class Members who suffered harms that did not affect all Class Members. Examples of special harms you may be able to get compensation for include: ➢ Circumstances such as a history of sexual assault, abuse, or pregnancy loss rendering fertility procedures especially difficult or traumatic; ➢ Extreme delay or total loss of the ability to parent due to Aetna’s challenged policy; ➢ Pain and suffering, medical complications, and/or miscarriage associated with having to undergo fertility procedures you underwent to meet Aetna’s requirements to be considered infertile that you otherwise would not have undergone. If you are seeking additional compensation for harms that did not affect all Class Members, please answer the questions below.Are you seeking additional compensation for harms that did not affect all Class Members? No Yes 1. Did you undergo any medical procedures to try to meet Aetna’s Definition of Infertility that you would not have otherwise undergone? If so, please describe the procedures and any pain, suffering, or medical complications that you experienced as a result.*2. Did you experience extreme delay in receiving fertility treatment as a result of Aetna’s denial of coverage or anticipated denial of coverage? Please explain why and explain any negative effects you believe the delay had on you medically, including with respect to your ability to become pregnant or carry a pregnancy to term.*3. Is there anything else you would like to share about what happened to you following the denial or anticipated denial of infertility coverage?PROVIDE AS MUCH DOCUMENTATION AS YOU CAN TO SUPPORT YOUR CLAIM. Any supporting documentation provided will not be returned. Please retain copies of your documents for your own records. You will be notified by mail and/or email if anything additional is needed for your Special Harm Submission. Please make sure the Settlement Administrator has your current mail and email addresses.Documentation* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 24 MB. CERTIFICATIONSignature checkbox* I declare under penalty of perjury under the laws of the State of California and the United States that the medical procedure history and financial information included in this form and the accompanying supporting evidence are true and correct to the best of my knowledge. 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