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Online Application Form

Hint: To understand the exact meaning of capitalized words used below, please visit the Program definitions.

"(Required)" indicates required fields

IMPORTANT! Before proceeding with your Application, please make sure that all the requirements outlined in the Application Checklist are met; otherwise, your Application may be rejected or delayed.

Once you have finished completing and submitting your Application online, you will receive a personal Application number. You will need that Application number in order to upload and submit online your Supporting Evidence Form and other supporting documents.

Please upload and submit online your Supporting Evidence Form and other documents promptly after submitting the online Application Form.

ESIS Claim Number

Soteria Unique ID

Please note that in accordance with the Program’s Protocol, Program forms must be completed and submitted to the Administrator in either English, French or Spanish, in order to be accepted and considered by the Administrator under the Program. Any forms completed and submitted in other languages will be rejected.

You are kindly requested to answer the following questions before you can complete and submit an Application online, directly on this website. Please note that an affirmative answer to each of the questions below does not automatically mean that your Application is a Receivable Claim under the Program. See the program’s Protocol for more information.

Please tell us if you are applying for compensation under the Program for yourself as the person who has sustained the claimed Injury, or as the duly authorized representative of the person of who has sustained the claimed Injury (because the person who has sustained the claimed Injury has died, is a child, or is disabled or otherwise lacks the legal capacity to submit an Application for himself).

I am applying for myself as the person who has sustained the claimed Injury

I am applying as duly authorized representative of the person who has sustained the claimed Injury

Please confirm that a power of attorney and/or statement in accordance with Section 8.b) of the Application form has been notarized by a Notary Official and is attached to the Application.

Yes

Did you, or the person you are duly authorized to represent for an Application under the Program, sustain an Injury which, in the opinion of a Registered Health Professional, is deemed to have resulted from the Vaccine or its administration?

Yes

So that we can best expedite your Application, please tell us if you are filing this Application for:

Permanent total or partial impairment; or

Congenital birth injury or illness of an unborn or new-born child of a woman who received the Vaccine and which resulted in permanent total or partial Impairment

Death

Has a waiting period of at least 30 days following the administration of the Vaccine dose deemed to have resulted in the Injury been observed, before the Application Form or the Supporting Evidence Form were completed? Please confirm that you did not complete the Application Form, and that you did not ask a Registered Health Professional to complete the Supporting Evidence Form, before the end of the 30 days waiting period.

Yes, the 30-day waiting period has been observed

No, the 30-day waiting period has not been observed

Please indicate the date on which the Vaccine was administered.

NOTE: If your Application relates to permanent total or partial impairment, or to congenital birth injury or illness of an unborn or new-born child, the calendar below will only allow you to select dates which are more than 30 days ago, consistent with the waiting period of at least 30 days following the administration of the Vaccine dose that is deemed to have resulted in the Injury. If you cannot select the date on which the Vaccine dose was administered, this means the 30 days waiting period has not yet elapsed. Please refer to question 17 of the FAQs for more information.

MM slash DD slash YYYY

Were you (or the person you represent) hospitalized for 24 consecutive hours or more in connection with the injury, illness or impairment to which this Application relates?

Yes

Please confirm that you are submitting the Application together with:

the Supporting Evidence Form, completed by one or more Registered Health Professional(s); and
the other documents required to be provided with the Application Form and the Supporting Evidence Form.

Yes

Did you, or the person you are duly authorized to represent for an Application under the Program, receive a Vaccine which is listed below? Please select your answer from the drop-down list.

Are you, or the person you are duly authorized to represent for an Application under the Program, a resident or a citizen of any of the countries below or a beneficiary of the COVAX Facility humanitarian buffer in any of the countries below? Please select your answer from the drop-down list.

Was the Vaccine administered in any of the countries listed below? Please select your answer from the drop-down list.

Please confirm that the Application Form and Supporting Evidence Form are exclusively submitted in any of the following languages: English, French, Spanish.

Yes

Please select the language in which you will be submitting the Application Form and the Supporting Evidence Form:

English

French

Spanish

Note to Applicant

In order for your Application to be considered, you need to submit, at the same time as your Application, a power of attorney or statement notarized by a Notary Official confirming that you are the duly authorized legal representative of the person on whose behalf you are submitting this Application. You may try again after you have obtained that power of attorney or notarized statement.

For more information about the requirements that apply to this power of attorney or notarized statement, please see Section 8(b) of the Application Form (Schedule 2).

You should wait 30 days after the administration of the Vaccine dose that is deemed to have resulted in the Injury before taking any steps towards: (a) the completion or submission of the Application Form and the Supporting Evidence Form, and (b) obtaining any of the documents required to be provided with these forms.

Please wait until this 30-day waiting period is over before proceeding to take any of these steps.

In order for your Application to be considered, all application materials (including the Supporting Evidence Form and the other documents required under the terms of the Application Form and the Supporting Evidence Form) should be submitted at the same time as your Application.

Please try again after you have obtained these other application materials.

Please note that the Application form, the Supporting Evidence form and all other Program forms must be completed and submitted in English, French or Spanish only; no other languages can be accepted by the Administrator.

Please try again after the Application Form and the Supporting Evidence Form have been completed in either English, French or Spanish.

Based on your answer, it appears that you (or the person you represent) was not administered a Vaccine procured or distributed under the COVAX Facility, as listed in Schedule 1 of the Program’s Protocol. Please note that the Program only applies to these Vaccines, and does not cover other vaccines.

Based on your answer, it appears that you are not eligible to apply for compensation under the Program, because you are not (or the person you represent is not) a citizen, a resident, or a beneficiary of the COVAX Facility humanitarian buffer in any of the countries designated as “AMC Eligible Economies”. Please note that the Program only applies to Vaccines procured or distributed under the COVAX Facility in any of the AMC Eligible Economies, but not in other countries.

Based on your answer, it appears that you are not eligible to apply for compensation under the Program, because you (or the person you represent) were not administered a vaccine in one of the countries designated as “AMC Eligible Economies”. Please note that the Program only applies to Vaccines procured or distributed under the COVAX Facility in any of the AMC Eligible Economies, but not in other countries.

Because the Vaccine was administered too recently, it appears that you are not eligible to submit an Application for compensation under the Program.

Based on the information you have provided, you Application cannot be accepted because a Registered Health Professional has not deemed your injury to have arisen out of a COVAX-distributed COVID-19 vaccine or its administration. You may try again after obtaining an opinion from a Registered Health Professional that your injury arose out of a COVAX-distributed COVID-19 vaccine or its administration.

Should you have any questions, please contact the Program’s Administrator at covaxclaims@esis.com.

Section 1: Details of Patient

Please provide the following information about the Patient.

Full name of the Patient(Required)

First Middle Last

Mailing address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Country of citizenship(Required)

Country of residence(Required)

Country where Vaccine was administered(Required)

Date of birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

National insurance number

(or other social security or similar identification number), if any

Home phone, if any

Mobile phone, if any

Email address, if any

Section 2: Details of the person who has the legal authority to submit this Application for the Patient

If the Patient: (a) has died; or (b) is disabled to the extent that the Patient cannot submit an Application himself; or (c) is a child (minor); or (d) does not have legal capacity for any reason to submit an Application himself, then another person who has the legal authority to submit this Application for the Patient must do so.

In the above cases, please provide below the details of the person with the legal authority to submit this Application for the Patient, and the details of that person’s relationship with the Patient.

Full Name of the person submitting the Application for the Patient(Required)

First Middle Last

Mailing address(Required)

Street Address Address Line 2 City State / Province / Region Postal Code Country

Date of birth(Required)

MM slash DD slash YYYY

National insurance number

(or other social security or similar identification number, if any)

Home phone

Mobile phone

Email address

Relationship with the Patient(Required)

For example: Are you the parent or legal guardian of the Patient who is a child (minor)? Or did the Patient die and are you the duly-authorized and legally recognized representative of all legal heirs of the Patient?

Section 3: Confirmations by the Applicant

The Applicant (i.e., the Patient directly submitting this Application for himself, or the person submitting this Application for the Patient) should please respond to all of the following questions and, if necessary, provide relevant details:

A. Have you waited at least 30 days after the administration of the Vaccine dose that you believed has resulted in the Injury, before completing this Application and before asking a Registered Healthcare Professional(s) to complete the Supporting Evidence Form?(Required)

NOTE: The 30-day waiting period described above does not apply in the event the Patient has died following the administration of a Vaccine.

Yes

If "no," provide details:(Required)

B. Have you, or has any other person, submitted any previous application for compensation under the Program for the Injury described in this Application?(Required)

Yes

If "yes," provide details:(Required)

C. Has any payment already been received from any other source as compensation for the Injury described in this Application? This could for example include an award from a court or arbitral tribunal, or settlements payments)(Required)

Yes

If “yes”, please provide the amount and (to the best of your ability) details of all such prior payments:(Required)

D. Is the Applicant/Patient eligible to receive payment from any other vaccine injury compensation program as compensation for the Injury described in this Application?(Required)

Yes

If “yes”, please provide (to the best of your ability) of all such other vaccine injury compensation program(s):(Required)

E. Has the Applicant/Patient previously applied for compensation for the Injury from any other vaccine injury compensation program(s)?(Required)

Yes

If "yes", please provide the following:(Required)

A copy of the final decision(s) of other vaccine injury compensation program(s); and
If compensation has been awarded by the other vaccine injury compensation program(s), then please provide: (a) the compensation amount(s) awarded, (b) a description of the nature of the compensation (for example: was the amount provided as lump-sum compensation for the Injury, and/or as a compensation for lost revenue, and/or as compensation for medical expenses, etc.), and (c) an indication how the compensation amount has been or will be paid (for example, has or will the compensation amount be provided as a single payment or in instalments?). If you are unable to provide all this information, please provide the name of, and contact details for, the other vaccine injury compensation program(s) in question

F. Are there any pending legal proceedings, demands or claims for compensation for the Injury described in this Application (including any pending claims for the Injury before any other vaccine injury compensation program)?(Required)

Yes

If “yes”, provide details of all such pending legal proceedings, demands or claims (including of all pending claims before any other vaccine injury compensation program(s)):(Required)

Section 4: Details of the Vaccine administered to the Patient

Did the Patient (or in the case of birth defects, the Patient’s mother) receive a Vaccine that is listed in Schedule 1 of the Protocol? [1](Required)

[1] Please see the list of Vaccines listed in Schedule 1 to the Protocol, available on the Program’s website at covaxclaims.com

Yes

What is the name of the Vaccine?(Required)

If the Vaccine is a two dose schedule vaccine, did the Patient receive both doses of the Vaccine?(Required)

Yes

Did the Patient receive any additional dose(s) and/or booster dose(s) in addition to the original one or two doses of the Vaccine?

Yes

Batch or lot number(s) of each of the Vaccine dose(s) (i.e., first, second, additional booster dose(s), as applicable) administered to the Patient or, in case of birth defects, to the Patient’s mother. Such batch or lot number(s) are provided by the immunizer(s) (person or organization) who administered the Vaccine dose(s) in question [2](Required)

[2] NOTE:The batch or lot number(s) of the Vaccine dose(s) administered to the Patient, or, in case of birth defects, to the Patient’s mother, is critical information that is needed in order to verify whether such Vaccine dose(s) is (are) covered by the Program. This information must therefore be provided. In general, you can find this information on the vaccination card or any other paper or electronic document that the Patient may have received when the Vaccine dose(s) was (were) administered to the Patient. If you do not know the batch or lot number(s) of the Vaccine dose(s), please contact the vaccination centre or the immunizer(s) (person or organization) who administered the Vaccine dose(s) to the Patient or in the case of birth defects, to the Patient’s mother, in order to obtain this information.

If known, name(s) of immunizer(s) (person or organization) who administered the Vaccine dose(s) to Patient or in the case of birth defects, to the Patient’s mother(Required)

Location(s)/place(s) (for example, health facility) where the Vaccine dose(s) was/were administered to the Patient or in the case of birth defects, to the Patient’s mother. If the Vaccine was administered at a mobile vaccination unit, please state “mobile vaccination unit in …..”[include name of the town or village].(Required)

Date(s) (Day/Month/Year) when the Vaccine dose(s) was/were administered to the Patient or in the case of birth defects, to the Patient’s mother (please specify the date for each Vaccine dose administered)(Required)

Section 5: Details of other medication/vaccination, to the extent known

Please list any medicines taken by, and/or any other (non-COVID-19) vaccines administered to, the Patient after the Vaccine dose(s) was/were administered to the Patient (Please provide this information separately for each Vaccine dose administered):(Required)

Please list any medicines taken by, and/or any other (non-COVID-19) vaccines administered to, the Patient during the period of 6 weeks before the administration of each Vaccine dose to the Patient (Please provide this information separately for each Vaccine dose administered):

In the case of birth defects, please list any medicines taken by, and/or any other (non COVID-19) vaccines administered to, the Patient’s mother during the pregnancy:(Required)

In the case of birth defects, please list any medicines taken by, and/or any other (non COVID-19) vaccines administered to, the Patient’s mother 6 weeks before the start of the pregnancy:

Section 6: Details of previous long-term medication, to the extent known

Please list any medicines not described above that were taken by the Patient (or in the case of birth defects, the Patient’s mother) for a consecutive period of more than 3 weeks, during the 24 months before each of the Vaccine dose(s) was/were administered to the Patient, or in the case of birth defects, the Patient’s mother (Please provide this information separately for each Vaccine dose administered):(Required)

Section 7: Describe what happened after the Vaccine dose(s) was/were administered to the Patient or in the case of birth defects, to the Patient’s mother. Please be as precise and complete as possible

In the space provided below, please describe in your own words what happened after the Vaccine dose(s) was/were administered to the Patient or in the case of birth defects, to the Patient’s mother. Please:(Required)

describe the injury or illness suffered by the Patient
state the date(s) when symptoms first started
describe the symptoms of the injury
indicate what you believe has caused the injury or illness suffered by the Patient
indicate if the Patient ever had the same injury or illness in the past (or in the case of birth defects, whether the Patient’s mother had another unborn or new-born child with a congenital birth injury or illness) and, if yes, provide further explanation, including dates
indicate if you know of a close family member of the Patient, such as brother, sister, parent, child, aunt, uncle, or 1st cousin, who suffered any similar injury or illness before, and if yes, please indicate which close family member and describe the similar injury or illness.

Section 8: Additional documents required to be submitted with this Application

The following documents must be submitted by the Applicant together with this Application form, in order for this Application to be considered complete. Please note that failure or delay in submitting any of the following documents may lead to the rejection of, or delays in considering, this Application:

The completed and signed Supporting Evidence form attached as Schedule 3 to the Program’s Protocol. The Supporting Evidence form must be completed and signed by one or more Registered Health Professional(s). [3]
If the Patient (1) has died, or (2) is disabled to the extent that the Patient cannot submit this Application himself, or (3) is a child (minor), or (4) does not have legal capacity for any other reason to submit this Application for himself, then the person submitting this Application for the Patient (as indicated in Section 2 of this Application form) must also submit a power of attorney or statement that has been notarized by a Notary Official within the territory of residence of the Patient or the Applicant, or within the territory of administration of the Vaccine. This notarized power of attorney or statement must confirm that:
1. the person submitting the Application for the Patient is the legally recognized parent, guardian, heir or legal representative, as the case may be, of the Patient; and
2. in the event the Patient has died, the person submitting this Application on behalf of the Patient: (A) is the duly-authorized and legally recognized representative of all legal heirs of the Patient, as listed in the power of attorney or statement; and (B) has all necessary rights, powers and authority to represent, act for and bind all of such legal heirs; and (C) there are no other legal heirs of the Patient other than those legal heirs who are listed in the power of attorney or statement.

[3] The term Registered Health Professional means any health professional, including physicians, surgeons, nurses, midwives, nurse practitioners, physicians’ assistants, psychiatrists, physical therapists, occupational therapists, dentists and pharmacists, who is duly licensed or legally authorized to practice the profession in the AMC Eligible Economy in which the Patient resides and received the Vaccine or in the case of birth defects, where the Patient’s mother resides and received the Vaccine.

Section 9: Contact details of hospitals, Registered Healthcare Professionals and others who can provide additional information about the injury or illness suffered by the Patient

In the space provided below, please provide the names and contact details (address, telephone or mobile number, email address) of any third parties who can be contacted for further information about the injury or illness suffered by the Patient. This includes for example any treating hospitals or medical clinics, any person or organization who administered the Vaccine dose(s) to the Patient or in the case of birth defects, to the Patient’s mother, any Registered Healthcare Professionals who treated the Patient, etc.

Full Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Additional Contact Information

If you wish to include additional contact information that was not possible to input in the fields above, please indicate it below.

Section 10: Consent for the sharing of medical information and release of medical and/or professional secrecy

By signing in the space provided under Section 14 of this Application, the Applicant :

consents to the Administrator, the Administrator’s Senior Vice President of Risk Consulting, the members of the Review Panel, the members of the Appeals Panel and/or any other persons representing and/or advising any of them to have access to, and examine the Patient’s medical and other relevant records in connection with this Application for the purposes of determining whether a compensation payment under the Program is due; and
agrees that the Administrator, the Administrator’s Senior Vice President of Risk Consulting, the members of the Review Panel, the members of the Appeals Panel and/or any other persons representing and/or advising any them may ask any of the persons and organisations mentioned in this Application and/or in any documents attached to this Application (including the Supporting Evidence form) for any information which is needed to process and evaluate the Application, any subsequent appeals and/or other proceedings relating to this Application; and
releases any and all of the aforesaid the persons and organisations from any applicable medical and/or professional secrecy under any applicable law.

Section 11: Personal data process consent

By signing in the space provided under Section 14 of this Application, the Applicant: (i) consents to all necessary processing of Patient’s (and in the case of birth defects, the Patient’s mother’s) personal and medical data for the purposes of the Application and any related matters, as detailed in the ESIS, INC. Privacy Policy for COVAX No-Fault Compensation Program for AMC Eligible Economies; and (ii) agrees that any such data, as well as any other information and documentation provided in connection with this Application (including, without limitation, in the Supporting Evidence form) and/or any subsequent appeals or other proceedings relating to this Application may be shared with:

the members of the Review Panel, the members of the Appeals Panel and/or any other persons representing and/or advising any them;
any local health services and/or any local law enforcement or other government agencies, any intergovernmental organizations and any international institutions as may be required from time to time for the purposes of law enforcement, the detection of criminal activity, risk profiling of vaccines or any other reasonably proportionate activity which may from time to time be required in connection with the Application or any appeals or other proceedings relating to this Application ; or
with any other third party anticipated by the ESIS, INC. Privacy Policy for COVAX No-Fault Compensation Program for AMC Eligible Economies or required by applicable laws.

Consent may be withdrawn at any time. Withdrawing consent however means that it may not be possible to continue processing the Application under the Program.

Section 12: Certifications and agreements

By signing in the space provided under Section 14 of this Application, the Applicant acknowledges and agrees as follows:

He/she accepts, and agrees that this Application (together with any subsequent appeals or other proceeding relating to this Application) will be subject to and dealt in accordance with, the terms and conditions of the Program’s Protocol and its Schedules;
For the entire duration of the assessment process of this Application and any subsequent appeals or other proceedings relating to this Application, the Applicant (which includes the Patient and the individual, if any, submitting this Application for the Patient), shall not initiate, or cause or allow to be initiated, any other application, legal proceeding, demand or claim for compensation or damages against any other person or legal entity (including any application or claim before any other vaccine injury compensation program), in relation to the Injury for which this Application is made. In the event that any such other application, legal proceeding, demand or claim comes to the attention of the Administrator, this Application shall automatically be rejected.
If any compensation under the Program is approved for payment to the Applicant (which includes the Patient and the individual, if any, submitting this Application for the Patient), thensuch Payment shall only be made if the Applicant returns to the Administrator the following documents within the applicable deadline described in the Protocol:
1. a duly signed, dated, and certified Release Agreement, which will be provided by the Administrator; and
2. a duly completed, signed and dated Payment Election Form, which will be provided by the Administrator.
All complaints and disputes arising out of or relating to this Application and/or the Protocol (including, but not limited to, the interpretation or application thereof) shall be submitted in writing to the Administrator. The Administrator will acknowledge the complaint and/or dispute in writing, and the Administrator’s Vice President of Claims will conduct an investigation into the complaint or dispute within 30 days of receipt. Following the investigation, the Vice President of Claims will provide a written response to the Applicant or Claimant, as the case may be. If the Applicant or Claimant is dissatisfied with the decision, the Applicant or Claimant has the option to submit the matter to binding arbitration as provided hereinbelow.
Any dispute arising out of or relating to this Application and/or the Protocol (including, but not limited to, their interpretation or application) shall, unless amicably resolved, be settled by arbitration. The arbitration shall be conducted in accordance with the rules of arbitration of the International Chamber of Commerce. The parties shall accept the arbitral award as final and binding on them.
If there is any conflict or inconsistency between the English language version of this Application form and any translations, the English language version shall prevail.

Section 13: Declaration of Truth and Correctness

By signing in the space provided under Section 14 of this Application, the Applicant: (i) certifies that the statements, facts and answers contained in this Application and/or any documents submitted with this Application, are true, complete and correct to the best of his/her knowledge and belief; and (ii) understands and agrees that:

If, whether fraudulently or otherwise, any person [4] falsifies or misrepresents any material information or fails to disclose any material fact and, in consequence of the falsification, misrepresentation or failure, a Payment is made, then the person to whom the Payment was made shall be liable to repay that Payment amount to the Administrator; and
Any person who, for the purpose of obtaining any Payment under the Program, whether for himself or some other person: (1) knowingly makes any false statement or representation, or (2) produces or furnishes, or causes or knowingly allows to be produced or furnished, any document or information which he knows to be false in a material particular, shall have committed an offence punishable to the extent the law permits within the relevant country.

[4] For purposes of this Section 13, the term “person” includes, but is not limited to: (i) the Applicant or the individual submitting the Application on behalf of the Applicant; (ii) the author of any evidence in support of this Application, any Supporting Evidence or any notice of appeal under this Application, and/or (iii) any Notary Official as required by the Protocol.

IMPORTANT! Before submitting with your Application, please make sure that all the requirements outlined in the Application Checklist are met; otherwise, your Application may be rejected or delayed.

Section 14: Signature, Name and Date

The Applicant (i.e., the Patient or the individual submitting this Application for the Patient, as applicable), has signed this Application form as of the date set forth below:

Full Name(Required)

Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Place(Required)

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Comments

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