Online Application Form

Beware of Fraudulent “COVID-19 Compensation Lottery Prize” scam.

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

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.

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(c) 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 (i.e., the individual (i) who is a citizen, resident, or person within the populations of concern to the COVAX Humanitarian Buffer, as defined and updated from time to time by the Inter-Agency Standing Committee (IASC) [1] in an AMC Eligible Economy; (ii) who was administered a Vaccine in an AMC Eligible Economy; and (iii) who claims or in respect of whom it is claimed that he has suffered or sustained a Serious Adverse Event which is associated with a Vaccine or its administration, and which , in turn, has resulted in an Injury).

[1] The definition of populations of concern to the COVAX Humanitarian Buffer can be found at Frequently Asked Questions- The COVAX Humanitarian Buffer.

Full name of the Patient(Required)

First Middle Last

Mailing address(Required)

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

Country of citizenship(Required)

Country of residence(Required)

Date of birth(Required)

Place of birth(Required)

Sex(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, if any

Section 2: Details of the person who has the legal power 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; or (d) does not have legal capacity for any reason to submit an Application himself, then another person who has the legal power 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 power to submit this Application for the Patient, as well the nature of that power and 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)

Place of birth(Required)

National insurance number

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

Home phone

Mobile phone

Relationship with the Patient(Required)

Nature of the person’s authority to make this Application for the Patient(Required)

If Patient has died, state the nature of person's right to make this Application for the deceased Patient and to represent all legal heirs(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? [2](Required)

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

Yes

Was the Vaccine administered to the Patient as part of:(Required)

a national immunization program, or

a humanitarian mechanism under the COVAX Facility

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? If so, please provide below the details for both the first and second doses.(Required)

Yes

If "yes", provide details:(Required)

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

Yes

If "yes", please also provide details for the additional dose(s) and/or booster dose(s) received by the Patient:(Required)

Batch or lot number(s) of each of the Vaccine dose(s) (i.e., first, second, additional and/or 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 entity/organization) who administered the Vaccine dose(s) in question [3](Required)

[3] 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 entity/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.

Name(s) of immunizer(s) (person or entity/organization) who administered the Vaccine dose(s) to Patient or in the case of birth defects, to the Patient’s mother(Required)

In case any Vaccine dose(s) was (were) supplied or administered by a Humanitarian Agency, please provide:

Name of the Humanitarian Agency that supplied or administered the Vaccine dose(s) to the Patient or, in the case of birth defects, to the Patient’s mother; and
Name(s) of the focal person(s) in that Humanitarian Agency

Exact location(s)/place(s) where the Vaccine dose(s) was/were administered to the Patient or in the case of birth defects, to the Patient’s mother(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 vaccines administered to, the Patient after the Vaccine dose(s) was/were administered to the Patient and/or during the period of 6 weeks before the administration of each Vaccine dose (Please provide this information separately for each Vaccine dose administered):(Required)

In the case of birth defects, please list any medicines taken by, and/or any other vaccines administered to, the Patient’s mother during the pregnancy and/or 6 weeks before the start of the pregnancy (Please provide this information separately for each Vaccine dose administered):(Required)

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 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. (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 state:(Required)

the nature of injury or illness suffered by the Patient to which this Application relates
the date(s) when symptoms first started
a description of the symptoms
what you believe caused the injury or illness suffered by the Patient to which this Application relates
whether 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
whether 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 ALL of the following documents may lead to the rejection of this Application and/or delays in considering this Application:

The duly 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). [4]
Invoices, receipts or other proof of payment of any medical expenses (including hospital fees) required as a consequence of the injury or illness suffered by the Patient for which this Application is made.
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, 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 pursuant to Section 2 of this Application form must also submit a power of attorney and/or statement that has been notarized by a notary public or other public official legally authorised to provide notarization or legalization services within the territory where the Vaccine was administered to the Patient or in the case of birth defects, to the Patient’s mother, confirming 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.

[4] 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 (e.g., address, telephone or mobile number, email address) of any third parties who the Applicant agrees can be contacted for further information about the injury or illness suffered by the Patient for which this Application is made. By way of example, such third parties may include any treating hospitals or medical clinics, any Registered Healthcare Professionals who administered the Vaccine dose(s) to the Patient or in the case of birth defects, to the Patient’s mother, or who otherwise treated the Patient, the Patient’s employer or school, etc.

Full Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region 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 hereby:

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 or 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/or organisations mentioned in this Application and/or in any documents attached to this Application (including, without limitation, in the Supporting Evidence form) for any information which is needed to process and evaluate the Application or any subsequent appeals; 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 hereby: (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, 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 contained or referred to in, or otherwise provided in connection with this Application and/or any documents attached to or relating to this Application and/or any subsequent appeals or other proceedings arising from or in connection with this Application (including, without limitation, in the Supporting Evidence form) 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; and
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 arising from or relating to it; or
with any other third party anticipated by ESIS, INC. Privacy Policy for COVAX No-Fault Compensation Program for AMC Eligible Economies or required by applicable laws.

The Applicant understands that consent may be withdrawn at any time, but that doing so 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 has fully read and understood, or has had read and explained to him/her, the terms and conditions of the Program Protocol and its Schedules This Application (together with any subsequent appeals or other proceeding arising from or relating to it) 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 arising from or relating to it, 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 and the Administrator shall have the right to enforce Section 10 of the Program’s Protocol.
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), then:
1. such Payment shall only be made if the Applicant timely fulfils all of the following conditions within the applicable deadline under the Protocol:
  1. returns to the Administrator a duly signed, dated, and certified Release Agreement, which will be provided by the Administrator; and
  2. returns to the Administrator a duly completed, signed and dated Payment Election Form, which will be provided by the Administrator; and
2. In the event the Applicant has received any prior payment from any other vaccine injury compensation program(s) as similar compensation for the same Injury , then the Administrator shall have the right to deduct the Other Prior Compensation Amount from the Program Amount (as defined in Section 9 of the Program’s Protocol).
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 herein below.
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 control and prevail in all respects.

Section 13: Declaration of Truth and Correctness

By signing in the space provided under Section 14 of this Application, the Applicant, hereby: (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 [5] 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.

[5] 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 certifying the Release Agreement, if any.

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)

Place(Required)

CAPTCHA

Note to Applicant

Section 1: Details of Patient

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

Section 3: Confirmations by the Applicant

Section 4: Details of the Vaccine administered to the Patient

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

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

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

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

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

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

Section 11: Personal data process consent

Section 12: Certifications and agreements

Section 13: Declaration of Truth and Correctness

Section 14: Signature, Name and Date