On this page, you can upload and submit:
- Supporting Evidence Form;
- Invoices for medical expenses;
- If applicable, power of attorney or notarized statement confirming that you are the legally authorized parent, guardian, heir or legal representative of the Patient;
- If applicable, other documents in support of you Application Form and/or Supporting Evidence Form;
- Forms relating to an appeal of a Rejection of your Application or an appeal of a Denial of your Receivable Claim, and your notice of Appeal of Rejected Application form (Schedule 4).
Please remember that your application will only be considered complete once the Supporting Evidence Form and other required documents are submitted in addition to the submission of the Application Form.
As a first step, please upload all attachments under the various sections of this page. Once you have finished uploading all attachments, then click “SUBMIT” at the bottom of this page in order to submit all attachments at the same time.
Where can I find my Application number?
- If you submitted an Application Form online, then your Application number was displayed on the confirmation page after the online submission and was also sent to the Applicant’s email address, if any, as provided in the Application.
- If you: (1) submitted an Application Form via email; (2) uploaded and submitted a manually completed Application Form via the Upload Printed Application page; or (3) sent your Application Form by regular mail, then your Application number was sent by the Program’s Administrator to the Applicant’s email address, if any, or mailing address as provided in the Application.
- If you need help in obtaining your number, please contact the Program’s Administrator at [email protected] for assistance.
The supporting evidence, using the form in Schedule 3 to the Program's Protocol, required to evaluate an Application and that shall include:
- detailed medical documentation from a Registered Health Professional describing the Injury and medical treatment required as a result of the Injury, together with details of any Hospitalization or prolonged Hospitalization, including but not limited to admission and discharge records;
- a description of the nature, extent, functional impact and prognosis of the Injury, as assessed by the Registered Health Professional.
- a statement from the Registered Health Professional that the Injury was, in the Registered Health Professional’s opinion, the result of the Vaccine or its administration;
- certification from a Registered Health Professional of when, where and which Vaccine was administered;
- in the case of death, a death certificate and any other documentation available from a Registered Health Professional of the cause and manner of death; and
- any further evidence that the Administrator may deem necessary to adjudicate the Application, and/or Receivable Claim, as applicable, guided, as appropriate, by the Scientific Advisory Committee, the Review Panel, and/or the Appeals Panel.
A resident, a citizen or person within the population of a Participating Member State who claims or in respect of whom it is claimed that he or she 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.
A written claim for compensation completed by an Applicant on the application form approved by and provided by the Administrator, as set forth in Schedule 2 to the Program's Protocol, which must be accompanied by all Supporting Evidence, using the prescribed form in Schedule 3 to the Program’s Protocol.
Any duly completed Application for compensation (i) that is accompanied by all Supporting Evidence, (ii) that is filed/submitted by an Applicant prior to the end of the Reporting Period with the Administrator, and (iii) that is found by the Administrator, and/or by the Administrator’s Vice President of Risk Consulting to be receivable as provided in Section 4 or Section 7 of the Program's Protocol.
Either (as the context requires):
- The Patient who directly submits an Application for compensation under the Program for himself; or
- In the event the Patient has died, is a child, or is disabled or otherwise lacks the legal capacity to submit an Application for himself, then the Applicant must be a person who is a duly authorized legal heir (in the case of death), parent, legal guardian, or other legal representative of the Patient.
The AVAT No Fault Compensation Scheme, as detailed in the Protocol and its Schedules.
ESIS, Inc., the claims Administrator appointed to manage and administer the Program, including, but not limited to, the receipt and registration of Applications, distributing acknowledgements of receipt of Applications, setting financial reserves for Receivable Claims, review of Applications, Supporting Evidence, and other documents to assess receivability, assessing Receivable Claims, and approve or deny, as the case may be, Payment for compensation, in accordance with the terms of the Program's Protocol.
Any healthcare professional, including physicians, surgeons, nurses, midwives, nurse practitioners, physicians’ assistants, psychiatrists, psychiatrists, physical therapists, occupational therapists, dentists, and pharmacists, who is duly licensed or legally authorized to practice the profession in the Participating Member State 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.
A public or private institution which: (1) is licensed or otherwise formally recognized as a hospital, clinic or other healthcare facility by the Government of the Participating Member State where it is located; (2) provides 24-hour medical, surgical, and/or nursing care, or treatment under the supervision of licensed physicians, surgeons, nurses,, and/or other healthcare professionals; and (3) has the capacity to provide room and board to patients resident overnight.
Serious bodily injury or illness suffered or sustained by a Patient that:
- requires Hospitalization or prolongs an existing Hospitalization; and
- results in permanent total or partial Impairment; or
- is a congenital birth injury or illness in an unborn or new-born child of a woman who received a Vaccine and results in permanent total or partial Impairment; or
- results in death.
A notary public or other public official legally authorized to provide notarization, and/or legalization services within the Participating Member State in which the Applicant or Claimant, as the case may be, resides.
An appeal filed by an Applicant, following the denial of receivability of his Application by the Administrator, in accordance with the procedure described in Section 7 of the Program's Protocol and using the form in Schedule 4 to the Program's Protocol.
A three-member panel that:
- Is comprised of 2 duly licensed physicians and 1 duly licensed nurse, who shall be appointed by the Administrator from a roster of 6 such physicians and nurses and
- Will review all Notices of Appeal of Denied Receivable Claims filed by Claimants and determine – in accordance with the terms of the Program's Protocol — whether the Review Panel’s denial of the relevant Receivable Claim should be upheld or reversed.
An appeal filed by a Claimant, following the denial of his Receivable Claim by the Review Panel, in accordance with the procedure described in Section 8 of the Program's Protocol and using the form in Schedule 5 of the Program's Protocol.