If (1) Aetna denied your request for precertification or your claim for one of an agreed-upon set of qualifying artificial insemination (intracervical insemination (“ICI”) or intrauterine insemination (“IUI”)) or in vitro fertilization (“IVF”) procedures, or if Aetna would have denied your request for coverage for artificial insemination that you underwent, between September 1, 2017 and Execution date and you were in an Eligible LBGTQ+ Relationship as described in the Settlement Notice, (2) you have not requested exclusion from the settlement, and (3) you incurred out-of-pocket expenses arising from Defendant’s denial or anticipated denial of your infertility coverage request that exceed your Default Dollars for Benefits amount or your Proof of Greater Covered Care award, you may be eligible for additional compensation and should complete this Out-of-Pocket Expense Submission.