5. A person claiming compensation must submit a claim in writing to the Minister indicating
(1) the name, date of birth and address of the victim, as well as the victim’s health insurance number;
(2) where the person is acting as the representative of the victim or as a person entitled to a death benefit, his or her own name, address and capacity;
(3) the name or nature of the immunizing product giving rise to the claim, the place where the vaccination was carried out, the name of the person who carried out the vaccination if known to the claimant, and the date of vaccination of the victim or of the person vaccinated from whom the victim believes the disease or infection was contracted;
(4) the date of the first manifestation of symptoms of bodily injury; and
(5) the date of death in the case of a claim for a death benefit.