If you have any questions about the Program, an Application Form, a Supporting Evidence Form or any other Program forms, or if you need help with submitting any Program forms, then you can do the following:
- Read the How to Submit an Application instructions below;
- Read the Frequently Asked Questions (FAQs) and answers about the Program; and/or
- To the extent that your questions are not answered by the documents referenced above, you can contact the Program’s Administrator either:
- by email to firstname.lastname@example.org; or
- by writing to one of the Program’s Regional Centers or to the Administrator’s headquarters in the United States; or
- by calling the Program’s Global Telephone Hotline (which may be at-cost or toll-free, depending on which country you are calling from), or one of the Program’s direct at-cost telephone numbers of the Program’s Regional Centers.
Instructions On How To Submit An Application For Compensation Under The “COVAX No-Fault Compensation Program For AMC Eligible Economies”
APPLICATIONS CAN BE SUBMITTED AT covaxclaims.com
All COVID-19 vaccines procured or distributed through the COVAX Facility will have received regulatory approval or an emergency use authorization, allowing their general availability, including in your country. COVAX will not compromise on safety and efficacy of the COVID-19 vaccines procured or distributed by COVAX and will, in addition to all the rigorous processes that have been followed by COVAX, rely on regulatory authorities to ensure that is the case. Nevertheless, all vaccines approved for general use may, in rare cases, cause serious adverse events. Serious adverse events are possible rare reactions or problems that can occur during or after vaccination and may cause injury.
B. About the Program
If you have sustained an injury (or a person on whose behalf you are entitled to act, has sustained an injury) as a result of a COVID-19 vaccine procured or distributed through the COVAX Facility, or the administration of such a vaccine, you may be entitled to receive compensation under the COVAX No-Fault Compensation Program for AMC Eligible Economies (the “Program”).
The Program’s Administrator is ESIS Inc. (the “Administrator”), which is an independent claims administrator with over 30 years’ of relevant claims handling experience, and has regional centers around the world able to assist Program applicants in all 92 AMC Eligible Economies. You will find contact information for the Administrator below.
Please see the Program’s website, available at covaxclaims.com (note: “claims” ending with an “s”) for more information about the Program. This website includes information and resources (available in English, French and Spanish) about the Program, including:
- the Program’s Protocol (i.e., procedure), the Application Form, the Supporting Evidence Form and other Program forms;
- frequently asked questions and answers about the Program (“FAQs”); and
- contact information for the Administrator, including (a) its email address; (b) the mailing addresses and direct (at-cost) telephone numbers for the Program’s Regional Centers; and (c) the telephone numbers for the Program’s Global Telephone Hotline (which may be tollfree or at-cost, depending on which AMC Eligible Economy you are calling from).
We suggest that you carefully read the Protocol and the FAQs to obtain more information about the nature of the compensation that the Program offers, the types of injuries that are eligible for compensation, and the other conditions that apply to the Program.
Please also note that there is a fixed timeline within which the application materials (that is: the Application Form, the Supporting Evidence Form and the other documents that must be submitted with these forms) must be submitted to the Administrator. These fixed timelines are described as the “Reporting Period” in Section 2(t) of the Program’s Protocol and are illustrated in Schedule 6 (Illustrative Diagram of the Reporting Period) to the Program Protocol. You can also find more information about the Reporting Period in the FAQs.
If you have questions about Program, an Application Form or other Program forms which are not answered on the Program’s website (available at covaxclaims.com), or if you need help with submitting any Program forms, please contact the Administrator for assistance using the contact details described in Part D “Contact Information for Help/Questions”, below. Please note that the Administrator cannot complete an Application or other Program forms on your behalf.
C. How to Submit an Application for Compensation under the Program
STEP 1: OBSERVE THE 30-DAY WAITING PERIOD AFTER VACCINATION
You should wait 30 days after the COVAX-distributed COVID-19 vaccine was administered to you (or to the person on whose behalf you are submitting an Application), 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 that are required to be submitted with these forms. After this 30-day waiting period is over, you can proceed with taking these steps.
Exception: The 30-day waiting period does not apply in case that: (1) the Patient has died after a Vaccine was administered to him/her, and (2) the Patient’s death is considered by a Registered Health Professional to have been caused by that Vaccine or its administration.
The reason for this 30-day waiting period is to avoid that persons who suffer non-serious adverse events associated with a COVAX-distributed COVID-19 Vaccine, or the administration of such a Vaccine, apply for compensation under the Program. Non-serious adverse events are not covered by the Program.
STEP 2: ENSURE THAT ALL APPLICATION MATERIALS ARE DULY COMPLETED, SIGNED AND DATED
After the 30-day waiting period described above is over, you can proceed to apply for compensation under the Program. To apply for compensation, you should: (1) complete the Application form; (2) ask relevant Registered Health Professional(s) to complete the Supporting Evidence form; (3) obtain the other documents required to be submitted with these forms; and then (4) submit them to the Administrator.
The Application form, the Supporting Evidence form and other Program forms are available for download in English, French and Spanish on the Program’s website at covaxclaims.com.
To complete the Application Form (Schedule 2), you have the following two options: (1) complete the Application directly online on the Program’s website (covaxclaims.com); or (2) download, print and complete the Application form on paper.
For completion of the Supporting Evidence Form or any other Program forms, please download the form from the Program’s website (covaxclaims.com), print it, and complete it on paper (or, in the case of the Supporting Evidence Form, have it completed on paper by one or more Registered Health Professional(s)). Except for the Application form, the other Program forms (including the Supporting Evidence form) cannot be completed online on the Program’s website.
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. However, the other documents that are required to be provided with the Application form and the Supporting Evidence form (as described in these forms) can be obtained and submitted in other languages. Please see Step 3 below for more details about how to submit the Program’s forms, once completed.
STEP 3: SUBMIT ALL APPLICATION MATERIALS (TOGETHER AND AT THE SAME TIME) TO THE ADMINISTRATOR USING ONE OF THE MEANS BELOW
Once all your application materials have been duly completed, signed, dated and obtained, you can submit them to the Administrator. Please note that all application materials should all be submitted together and at the same time through one of the means described below. Please also remember that you should do this before the end of the Reporting Period described in Part B above.
You can submit the Application Form and other application materials either online through the Program’s website, or by email or by regular mail. Please see below for more information.
- To Apply Online: To submit the Program application materials online, then please:
- complete and submit the Application Form directly online (or if you have completed the Application Form on paper, then upload and submit the Application Form online) on the Program’s website [“ONLINE SUBMISSION OF APPLICATION FORM”]; and
- upload and submit the Supporting Evidence Form and the other documents that you should submit with the Application Form and the Supporting Evidence Form on Application Attachments.
- To Apply by Email: To submit the Program application materials by email, please: (a) scan the printed and completed Application form, Supporting Evidence form and the other documents that you should submit with these forms; and (b) email these scanned forms and documents (as one or more email attachments) to email@example.com.
- To Apply by Regular Mail: To submit the Program application materials by regular mail, please send the printed and completed Application form, Supporting Evidence form and the other documents that you should submit with these forms, by regular mail to one of the Program’s Regional Centers.
All Application forms will be time and date stamped by the Administrator upon their receipt. Within 24 hours of receipt by the Administrator, the Administrator will send you an acknowledgement (by email or mail) of the receipt of your application materials. This Acknowledgement will include your Application number, the name of the assigned claim representative of the Administrator and his/her direct contact information.
D. Contact Information for Help/Questions
If you have general inquiries about the Program or the application process, you can contact the Administrator through any of the following means:
- By Email: You can email your questions to the Administrator at: firstname.lastname@example.org
- By Regular Mail: You can send your questions to the Administrator by regular mail:
- to one of the Program’s Regional Centers whose addresses are listed in Annex 1 to these Instructions (Contact Information for Regional Centers) and are also available on the Program’s website (covaxclaims.com); or
- to the ESIS headquarters in the United States, whose address is shown below:ESIS
New Claims Reporting
Attention: Covax Team
P.O. Box 5129
Scranton, PA 18505-0568
United States of America
- By Calling one of the Regional Hotlines: You can call any of the telephone numbers below and a representative of the Administrator will assist you. Please note that you will not be able to complete or submit any Program forms by telephone. The telephone numbers for the Program’s Regional Centers are at-cost. The telephone number for the Global Telephone Hotline may be toll-free or at-cost, depending on which AMC Eligible Economy you are calling from. You should verify whether or not any calling charges apply before calling any of the telephone numbers below:
Global Telephone Hotline 1-833-276-8262 Africa +27 (0)11 463 5900 Asia Pacific +61 7 3223 3100
+65 6632 8639
+852 2526 5137
Europe +49 211 95456250
+32 2 257 03 52
India +91 (020) - 26612524 Latin America +52 55 5093 6467
Middle East and North Africa +971 4 345 9541
+972 35 628 811