Form VA Form 29-4364 VA Form 29-4364 Application for Service-Disabled Veterans Insurance

OMB Approved No. 2900-0068
Respondent Burden: 40 minutes

APPLICATION FOR SERVICE-DISABLED VETERANS
IMPORTANT INFORMATION
Eligibility
S-DVI provides up to $10,000 of life insurance for eligible veterans. To be eligible for S-DVI, you must meet all three of the
following requirements:
1. you were released from active service in the Armed Forces on or after April 25, 1951, under other than dishonorable conditions.
2. it has been less than 2 years since VA notified you of a new service-connected disability or you are currently waiting for a
rating for your service-connected disability. Please Note: The disability you are rated for must be a new disability, not an
increase in a disability you already have. Being increased to 100% or being granted individual unemployability does not
automatically entitle you to a new eligibility period.
3. you are in good health except for your service-connected disability. We will evaluate all health conditions that are not
service-connected. Information about any health conditions should be included on your application.

Cost Before you apply for S-DVI coverage, we encourage you to compare our premium rates to commercial insurance companies.
If your disability is not serious, you may be able to find better rates from a commercial company.
When considering the cost of S-DVI coverage, remember that if you are or become totally disabled and unable to work for six
or more months you do not have to pay premiums on your Government Life Insurance policy. Most commercial life insurance
companies add an additional charge for this benefit.

Speeding Up the Application Process We can process your application more quickly if you send us a copy of the letter from
VA that first notified that your disability was rated service-connected within the last two years.

Mailing Address If you meet these criteria, please complete and sign the application and then send immediately to:
Department of Veterans Affairs Regional Office and Insurance Center (RH), P.O. Box 7208, Philadelphia, PA 19101.

Questions If you have questions about Government Life Insurance, you can call us toll-free at 1-800-669-8477 or visit our website
at: www.insurance.va.gov.
PLEASE BE SURE TO COMPLETE BOTH SIDES OF THIS APPLICATION

1. Name and Mailing Address for Insurance Purposes
A. First, Middle, Last Name

B. Mailing Address

2. Beneficiary Designation and Selection of Settlement Option - The preprinted phrase "Or to survivors" means that a share of a
beneficiary(ies) who dies before you will be paid to the surviving beneficiaries. For example, if you name three principal beneficiaries and one
dies before you, the share will be paid to the remaining two principal beneficiaries.
Complete Name and Address of Each Principal and Contingent
Beneficiary (For married women, enter her own first and middle names.
For example, Mary Rose Smith, not Mrs. John Smith)

Beneficiary’s Social
Security Number (If known.
This is not required for this
designation to be valid)

Relationship of
the beneficiary
to you

Share to be paid to
each beneficiary
(Use $ amounts,
%, or fractions)

Payment Option
for Each
Beneficiary (See
pamphlet for
more information)

Lump Sum
Lump Sum
Lump Sum
Or to survivors

Lump Sum

Contingent (Person(s) who get the proceeds if the principal
beneficiary(ies) die before the insured. If none, write "NONE"

Lump Sum
Lump Sum
Lump Sum
Or to survivors
VA FORM
DEC 2003

29-4364

Lump Sum
EXISTING STOCK OF VA FORM 29-4364, MAY 1999,
WILL BE USED.

Continued on Reverse

EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN ON THIS SIDE
3. VA Claim Number (If any)

4. Social Security
Number

5. Date of Birth
(Month, Day,Year)

6. Daytime Telephone Number
(Include Area Code)

(

7. Email address

)

8. Enter the amount, plan, and premium of the insurance for which you are applying. (See Pamphlet 29-9 - Service-Disabled Veterans Insurance
Information and Premium Rates)
A. Amount of Insurance

B. Plan of Insurance

C. Monthly Premium

9. Check the method showing how you wish to pay for this insurance
A. I want to pay premiums by a monthly deduction from my VA Compensation or Pension. (We will start the deduction for you if the
insurance is approved)
B. I want to pay premiums by a monthly allotment from my military service/retirement pay. (We will start the allotment for you if the
insurance is approved)
C. I want VA to automatically withdraw the premium each month from my bank account (VA MATIC) (Send your first payment with this
application)
D. I will send premiums directly to VA as follows: (Send your first payment with this application)
Monthly

Quarterly

10A. Are you now working?
Yes
No

Semi-Annually

Annually

10B. Do you work full-time?
Yes
No

10C. If you are not working or working part-time, explain why

11A. Are you now hospitalized? (If "YES", for what condition(s)? (List below)
Yes
No

11B. Name and Address of Hospital

12. Have you ever been treated for the use of alcohol or drugs, including marijuana, sedatives, stimulants, etc.? (If "YES", give date(s) and
type of treatment(s)
Yes
No
13. Have you had any of the following:
A. Lung condition?

YES

NO 14. If your answer to any part of Item 13 is "YES", give dates,
duration and other details (If more space is needed, attach
separate sheet)

B. Mental or nervous disorders?
C. Blood disorder?
D. Heart condition?
E. High blood pressure?
15. Have you had any other physical defect or disease? (If "YES",
explain below)

F. Paralysis?
G. Cancer or tumor?

Yes

No

H. Stomach condition?
I. Diabetes?
J. Seizure disorder?

16A. Height
Feet

Inches

16B. Weight

16C. Has your weight changed more than 10 pounds during the past two years?
(If "YES", give complete details including amount gained or lost and length
of time present weight maintained)
Yes
No

Lbs.
CERTIFICATION: I have reviewed all of my answers above and certify that they are true and correct to the best of my knowledge and belief.
17A. Signature of Applicant (Do NOT print, sign in ink)

17B. Date

PRIVACY ACT NOTICE: 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 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. Your obligation to respond is voluntary, but your failure to provide us the information
could impede processing Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA
will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to
January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information to determine, establish or verify your eligibility for VA Insurance benefits (38 U.S.C. 722). Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 40 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/library/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or
suggestions about this form.