Form VA Form 29-0152 VA Form 29-0152 Application for Conversion

OMB Approved No. 2900-0149
Respondent Burden: 15 minutes

APPLICATION FOR CONVERSION
GOVERNMENT LIFE INSURANCE
PRIVACY ACT INFORMATION: No insurance may be converted unless a completed application form has been received (38 U.S.C. 1904 and 1942). The VA will not disclose information
collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses as identified in VA
system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA, published in the Federal Register. Your obligation to respond is required to
obtain or retain benefits. The responses you submit are considered confidential (38 USC 5701).
RESPONDENT BURDEN: This form is used by the insured to convert to a permanent plan of insurance. We need this information to determine what permanent plan of insurance the insured
requested. We estimate that you will need an average of 15 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB Control Number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB Control Numbers can
be located on the OMB Internet Page at: www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send your
comments about this form.
1. INSURANCE FILE NUMBER (Include letter prefix)

IMPORTANT
Answer all items. (See VA Pamphlet 29-73-1)
Do not return policy with this form

2. FIRST, MIDDLE, LAST NAME OF INSURED AND MAILING ADDRESS FOR
INSURANCE PURPOSES (Include number and street or rural route, city or
P.O., State and ZIP Code)

3. POLICY NUMBER TO BE CONVERTED (Include letter prefix)

4. VA CLAIM NUMBER (If any)

5. SOCIAL SECURITY NUMBER

6. DAYTIME TELEPHONE NUMBER (Include Area Code)

7A. PERMANENT PLAN(S) APPLIED FOR
ORDINARY LIFE
20 PAYMENT LIFE

7B. AMOUNT OF INSURANCE TO BE CONVERTED
ENDOWMENT AT AGE 60
ENDOWMENT AT AGE 65

30 PAYMENT LIFE

MODIFIED LIFE 65

20 YEAR ENDOWMENT

MODIFIED LIFE 70

$
7C. IF YOU ARE NOT CONVERTING THE ENTIRE POLICY, DO YOU
WISH TO CONTINUE ANY TERM INSURANCE?

YES

NO

(If "YES" enter amount $

)

8. METHOD OF PREMIUM PAYMENT
A. DESIRED METHOD OF PAYMENT (Check one)

B. DESIRED METHOD FOR DIRECT PAYMENT OF FUTURE PREMIUMS
(Check one)

DIRECT PAYMENT TO VA (If checked, complete Item 8B)
MONTHLY

SEMI-ANNUAL

QUARTERLY

ANNUAL

MONTHLY DEDUCTION FROM VA PENSION OR COMPENSATION
MONTHLY ALLOTMENT FROM RETIREMENT/ACTIVE SERVICE PAY
VA MATIC (Automatic Checking Account deduction)

9. PAYMENT AMOUNT
AMOUNT OF FIRST PREMIUM

$

10A. ARE YOU NOW DISABLED?
YES

NO

If "Yes", give name of disability below and complete Items
10B and 10C) (If "No", go to Item 11)

10B. DATE LAST TREATED BY PHYSICIAN OR HOSPITAL (Include VA physician
or hospital)

10C. DOES YOUR DISABILITY PREVENT YOU FROM WORKING?
YES

NO

If "Yes", explain fully)

MAIL THE COMPLETED FORM TO:
VAROIC
P.O. BOX 42954
PHILADELPHIA, PA 19101
11A. SIGNATURE OF APPLICANT (Application MUST be signed and dated in ink) (Do not print)

11B. DATE OF APPLICATION

IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, CALL US TOLL-FREE AT 1-800-669-8477.
VA FORM
JAN 2007

29-0152

EXISTING STOCK OF VA FORM 29-0152, MAY 2000,
WILL BE USED.