29-0190 Application Invitation to Apply for Supplemental Insuran

IN REPLY REFER TO:

FILE NUMBER:

Congress has approved new legislation which allows the Department of Veterans Affairs (VA) to offer an additional
$20,000 of Supplemental Service Disabled (RH) insurance to totally disabled RH policyholders. This new
insurance is similiar to the RH insurance you have today and may be added to your existing coverage. This
Supplemental insurance does not provide for waiver of premiums due to total disability.
You may select from any of the nine plans of RH insurance. The premiums for the Supplemental RH insurance are
determined by your age and plan of insurance you select. Rates are based on the standard RH premium rate
schedules. The enclosed VA pamphlet (29-9) contains a description of the available plans and premium rates. To be
eligible for this insurance you must be under 65 years of age and be totally disabled. If you meet these requirements
and wish to apply, please complete this application and return it to: Department of Veterans Affairs, Regional
Office and Insurance Center - SRH, P.O. Box 7208, Philadelphia, PA 19101. This application must be submitted
before November 1, 1993, or before your 65th birthday whichever occurs first.
If you have any additional questions concerning your Government Life Insurance, just call our toll-free number,
1-(800)-669-8477.
Sincerely yours,

OMB Approved No. 2900-0539
Respondent Burden: 20 Minutes

APPLICATION FOR SUPPLEMENTAL SERVICE DISABLED
VETERANS (RH) LIFE INSURANCE
NOTE: Please type or print in ink and complete both sides of this form. Sign and date on reverse.
1. ARE YOU NOW WORKING?

YES

NO

2. ARE YOU TOTALLY DISABLED?

YES

NO

3. DATE DISABILITY PREVENTED EMPLOYMENT
4. ENTER THE AMOUNT, PLAN AND PREMIUM OF THE INSURANCE FOR WHICH YOU ARE APPLYING (See VA Pamphlet 29-9)
AMOUNT OF INSURANCE REQUESTED
PLAN OF INSURANCE
MONTHLY PREMIUM AMOUNT

5. CHECK THE METHOD SHOWING HOW YOU WISH TO PAY THE PREMIUMS FOR THIS INSURANCE (Check one)

BY A MONTHLY DEDUCTION FROM VA COMPENSATION OR PENSION (We will start the deduction for you if the insurance is approved)
BY A MONTHLY ALLOTMENT FROM MY MILITARY SERVICE/RETIREMENT PAY (We will start this allotment for you if the insur
BY AUTOMATIC MONTHLY WITHDRAWALS FROM MY BANK ACCOUNT (VA MATIC)
(SEND YOUR FRIST PAYMENT WITH THIS APPLICATION)(We will contact you for the additional information needed to start the withdrawal)
I WILL SEND PREMIUMS DIRECTLY TO VA AS FOLLOWS:
(SEND YOUR FIRST PAYMENT WITH THIS APPLICATION)
VA FORM
JUL 2004

29-0190

MONTHLY

QUARTERLY

SEMI-ANNUALLY

ANNUALLY

PRIVACY ACT INFORMATION: No insurance may be granted unless a completed application has been received (38 U.S.C. 1922). The information, provided on a
voluntary basis, will be used by VA employees and your authorized representatives in the maintenance of Government insurance programs. Responses may be disclosed
outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 36VA00, Veterans and Armed
Forces Personnel U.S. Government Life Insurance Records-VA, published in the Federal Register.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments regarding
this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send comments.
6. BENEFICIARY DESIGNATION
SHOW FULL NAME AND ADDRESS OF EACH PRINCIPAL
AND CONTINGENT BENEFICIARY

BENEFICIARY’S
SOCIAL SECURITY NO.
(If Known)

RELATIONSHIP
TO INSURED

SHARE TO EACH
(Use fractions such as
1/2,2/3 or all)

OPTION
FOR EACH
1,2,3 OR 4

PRINCIPAL

1
1
1
1
1

OR TO SURVIVOR(S)
CONTINGENT
(Person(s) who receives proceeds if all of the Principal Beneficiaries die
before the insured.) (If none, write "NONE")

1
1
1
1
1

OR TO SURVIVOR(S)
7. REMARKS (Include any additional information which will clarify your
intent regarding the payment of your insurance. Also, list the policy
number of any policy on which the beneficiary is not to be changed)

8. YOUR SOCIAL SECURITY NUMBER

9. DAYTIME TELEPHONE NUMBER (INCLUDE AREA CODE)

I understand that this change cancels all prior Beneficiary and Option selections; and unless indicated in item 7, Remarks, this change applies to
all Government Life Insurance policies under the above file number.
10. SIGNATURE OF INSURED (Do not print)

11. DATE

IMPORTANT INFORMATION
Your designation is still valid even if you do not know the Social Security Number, so send this application right away.
Having the beneficiary’s Social Security Number will help us locate the beneficiary.
If you have any questions concerning designating a beneficiary, call us toll free at 1-800-669-8477

DO NOT WRITE IN THE SPACE BELOW - FOR VA USE ONLY
ENTERED BY VA

SIGNATURE OF VA INSURANCE OFFICIAL

DATE RECORDED

POLICY NUMBER ASSIGNED

RH-