On this page, you can upload and submit:
- A Supporting Evidence Form;
- If applicable, other documents in support of your Claim Form and/or the Supporting Evidence Form;
- Invoices for medical expenses;
- If applicable, power of attorney or notarised statement confirming that you are the legally authorised parent, guardian, heir or legal representative of the Patient;
- Forms relating to an appeal of your rejected Claim or an appeal of a denial of your Receivable Claim, and your Notice of Appeal of Rejected Claim Form (Schedule 4)..
In order to be considered a complete Claim, your Claim will need the Supporting Evidence Form and other required documents to be submitted in addition to the Claim Form.
First, please upload all attachments through the relevant sections of this page. Once you have finished uploading all your attachments, click “SUBMIT” at the bottom of this page. This will submit all the attachments that you have provided at the same time.
Where can I find my Claim number?
- If you submitted a Claim Form online, your Claim number was displayed on the confirmation page after the online submission. It will have also been sent to your email address provided in your Claim (if an email address was provided).
- If you: (1) submitted a Claim Form via email; (2) uploaded and submitted a manually completed Claim Form via the Upload printed Claim Form; or (3) sent your Claim Form by regular mail, then the Scheme’s Administrator will have sent the Claim number to the Claimant’s email address or mailing address given in their Claim.
- If you need help in obtaining your Claim number, please contact the Scheme’s Administrator at [email protected] for assistance.
The supporting evidence, using the form in Schedule 3 of the Scheme’s Protocol, required to evaluate a Claim and that shall include:
- detailed medical documentation from a Registered Healthcare Professional describing the Injury and medical treatment required as a result of the Injury, together with details of any Hospitalisation or prolonged Hospitalisation, 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 Healthcare Professional.
- a statement from the Registered Healthcare Professional that the Injury was, in the Registered Healthcare Professional’s opinion, the result of the Vaccine or its administration;
- certification from a Registered Healthcare 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 Healthcare Professional of the cause and manner of death; and
- any further evidence that the Administrator may deem necessary to adjudicate the Claim and/or Receivable Claim, as applicable, guided, as appropriate, by the Scientific Advisory Committee, the Review Panel, and/or the Appeals Panel.
A written claim for compensation completed by a Claimant, using the Claim Form approved by and provided by the Administrator, as set forth in Schedule 2 of the Scheme’s Protocol, which must be accompanied by all Supporting Evidence.
A beneficiary of a Vaccine (i) procured and/or delivered by UNICEF on a Participating Country’s behalf; (ii) donated to a Participating Country through UNICEF; or (iii) formally included into the Scheme (but otherwise procured and/or delivered but not by or through UNICEF) 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.
Any duly completed Claim for compensation (i) that is accompanied by all Supporting Evidence, (ii) that is filed/submitted by a Claimant 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 Scheme's Protocol.
An appeal filed by a Claimant, following the denial of receivability of his or her Claim by the Administrator, in accordance with the procedure described in Section 7 of the Scheme’s Protocol and using the form in Schedule 4 of the Scheme’s Protocol.
The Covid-19 Vaccine Facility No-Fault Compensation Scheme, established to provide fair compensation to eligible vaccine recipients who suffer a Serious Adverse Event related to a COVID-19 vaccination that has been either:
- procured and/or delivered by UNICEF on a Participating Country’s behalf;
- donated to a Participating Country through UNICEF; or
- formally included into the Scheme (but otherwise procured and/or delivered but not by or through UNICEF),
as detailed in the Scheme 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 individual, who meets all of the following requirements:
- is a Patient who was administered a Vaccine (or in the event the Patient has died, is a child, or is disabled or otherwise lacks the legal capacity to submit a Claim for himself or herself, is an individual who is a duly authorised heir (in the case of death), parent, legal guardian or other legal representative of the Patient); and
- is, or is duly authorised to represent, a Patient who has sustained an Injury which, in the opinion of a Registered Healthcare Professional, is deemed to have resulted from a Vaccine or its administration; and
- the Vaccine was administered before its Scope of Coverage Endpoint (as indicated in Schedule 1 of the Scheme’s Protocol); and
- has submitted a Claim for compensation, using the prescribed form in Schedule 2 of the Scheme’s Protocol, together with all Supporting Evidence, using the prescribed form in Schedule 3 of the Scheme’s Protocol to the Administrator, following the procedures described in the Scheme’s Protocol, and provided that this Claim is submitted: (a) in full observance of the waiting period of 30 days referred to in Section 1(c) and in Schedules 2 and 3 of the Scheme’s Protocol; (b) before the end of the Reporting Period; and (c) otherwise within the time limits set forth in Section 4 of the Scheme’s Protocol; and
- has not received any prior payment from any other public source, including from any governmental or publically funded no-fault compensation scheme, as compensation for the Injury; and
- is not eligible to receive compensation from any other source for the Injury, or if eligible for such compensation, discloses the nature and full extent of such eligibility; and
- has no pending lawsuits or claims for compensation for the Injury; and
- agrees not to seek or make any claims for compensation from any other public source, including from any governmental or publically funded no-fault compensation scheme, for the Injury for as long as the Claim, and/or Receivable Claim, as applicable, is pending with the Scheme; and
- is not and does not represent a Patient in respect of whom the Administrator is by any applicable sanctions regime, including any UN Security Council sanctions regime, precluded from accepting a Claim and/or paying compensation under the Scheme.
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 authorised to practice the profession in the country 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 recognised as a hospital, clinic or other healthcare facility by the government of the relevant country 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 Hospitalisation or prolongs an existing Hospitalisation; 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 authorised to provide notarisation, and/or legalisation services within the country in which the Claimant resides.
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 Scheme's Protocol and using the form in Schedule 5 of the Scheme’s Protocol.