If you haven’t yet downloaded a paper copy of the Application Form, you can do so on Schedules and Other Documents.

"(Required)" indicates required fields

Please upload a scan of your duly completed and signed “Application Form”. Ensure that the scan is clear and that it is possible to read every page of the form.
Drop files here or
Max. file size: 2 MB, Max. files: 1.

    Submit Other Documents

    After you submit your printed Application, the Administrator will contact you and provide you with your application number and instructions on how to submit the other documents required for your Application.


    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.


    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.