VA Form 29-0151 Application for Service Disabled Veterans Insurance

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

APPLICATION FOR SERVICE-DISABLED
VETERANS INSURANCE
IMPORTANT INFORMATION
S-DVI provides up to $10,000 of life insurance for eligible veterans. To apply for this coverage, read the instructions
below and complete both sides of the application. Make sure you sign and date the form.
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 S-DVI 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 you that
your disability was rated service-connected within the last two years. You may also apply online by visiting our
website at: "www.insurance.va.gov" and clicking "Apply for Service-Disabled Veterans Insurance Online".
Mailing Address
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. 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

2. 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)
B. I want to pay premiums by a monthly allotment from my military service/retirement pay. (We will start the allotment for you)
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

3A. ARE YOU NOW WORKING?
YES
VA FORM
APR 2005

NO

29-0151

SEMI-ANNUALLY

3B. DO YOU WORK FULL-TIME?
YES

NO

ANNUALLY

3C. IF YOU ARE NOT WORKING OR WORKING PART-TIME, EXPLAIN WHY.
PLEASE BE SPECIFIC.

EXISTING STOCK OF VA FORM 29-0151, DEC 2003,
WILL BE USED.

Continued on Reverse

EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN AT THE BOTTOM OF THIS SIDE
4A. Are you now hospitalized? (If "YES", for what condition(s)? Please list below.)

4B. Name and Address of Hospital

5. 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

6. Have you had any of the following:

YES

A. Lung condition?
B. Mental or nervous disorders?
C. Blood disorder?
D. Heart condition?
E. High blood pressure?
F. Paralysis?
G. Cancer or tumor?
H. Stomach condition?
I. Diabetes?
J. Seizure disorder?
9A. Height
Feet

Inches

9B. Weight
10. Date of Birth

NO

7. If your answer to any part of Item 6 is "YES", give
dates, duration and other details (If more space is
needed, attach a separate sheet)

8. Have you had any other physical defect or
disease? (If "YES", explain below)
YES

NO

9C. Has your weight changed more than 10 pounds during the past two
years? (If "YES", give complete details below including amount gained
or lost and length of time present weight maintained)

Lbs.
YES
NO
11. Daytime Telephone No. (Include Area Code)

12. E-Mail Address

13. Beneficiary Designation and Selection of Settlement Option - The preprinted phrase "Or to Survivors" means that the 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)

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

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

Lump Sum
Lump Sum
Or to survivors
14A. Signature of Applicant (Do NOT print, sign in ink)

14B. Date

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.
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/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.