Group Health Claim Form Step 1 of 3 33% In re Group Health Plan Litigation United States District Court for the District of Minnesota (Case No. 23-cv-00267-JWB-DJF) CLAIM FORM GENERAL CLAIM FORM INFORMATION You may complete and submit this Claim Form online or by mail if you are a Settlement Class Member. The Settlement Class consists of all individuals who logged into healthpartners.com and virtuwell.com between January 1, 2018 and November 10, 2023 (the “Settlement Class”). If you wish to submit a Claim for a settlement cash payment, please provide the information requested below. You must submit your Claim via the Settlement Website by the Claims Deadline of April 7, 2025, or complete and mail this Claim Form to the Settlement Administrator, postmarked by April 7, 2025. Settlement Class Members who submit a timely and valid Claim Form will be eligible to receive a pro rata cash payment from the Net Settlement Fund. Each Settlement Class Member will receive, at most, one (1) payment.The Notice includes only a summary of your legal rights and options. Call (888) 833-7170 for more information.ClaimFormNoThis field is hidden when viewing the formHiddenLastName* Payment will be mailed in the form of a check to the address you provide. If you would like to receive a payment electronically (e.g., via Venmo, PayPal, or ACH), you must submit a Claim Form online. 1. Settlement Class Member InformationName:* First Name MI Last Name Mailing Address: Street Address/P.O. Box (include Apartment/Suite/Floor Number)* Mailing Address: Street Address/P.O. Box (include Apartment/Suite/Floor Number) 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 Current Email Address* Current Phone Number (Optional)Settlement Claim ID*Settlement Claim ID: Your Settlement Claim ID can be found on the Notice you received informing you about this Settlement. If you need additional help locating this ID, please contact the Settlement Administrator at (888) 833-7170. Please select one of the following payment options, which will be used should you be eligible to receive a Settlement payment: Chosen Payment Method*This field is hidden when viewing the formPayment Token*2. CertificationSignature Checkbox* I declare under penalty of perjury under the laws of the United States and the state where this Claim Form is signed that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below. I understand that all information provided on this Claim Form is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim will be considered complete and valid. Date:* MM slash DD slash YYYY Please keep a copy of your completed Claim Form for your records. It is your responsibility to notify the Settlement Administrator of any changes to your contact information after you submit your Claim. You can update your contact information by calling (888) 833-7170.Unique IDPhoneThis field is for validation purposes and should be left unchanged.