If you wish to download a paper copy of the Claim Form, you can do so at Schedules and Other Documents.

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

    Submit other documents

    Once your printed Claim Form is submitted, the Administrator will be in contact to provide you with your Claim number and instruct you on how to submit the remaining documents required for your Claim to be considered complete.

    Claim

    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.

    Administrator

    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.