Form 29-357 Claim for Disability Insurance Benefits

OMB Approved No. 2900-0016
Respondent Burden: I hour 45 minutes

~

CLAIM FOR DISABILITY INSURANCE BENEFITS

Department of Veterans Affairs

GOVERNIVIENT LIFE INSURANCE

PRlVACY ACT INFORMATION : 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 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records, 36VAOO, Veterans and Armed Forces
Personnel u.s. Government Life Insurance Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain this benefit.
Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. 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 I, 1975,
and still in effect.
RESPONDENT BURDEN: We need this information to determine your eligibility for VA insurance benefits. Title 38, United States Code, allows us to ask for this

information. We estimate that you will need an average of 1 hour and 45 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 OMS control numbers can be located on the OMB Internet page at

www.whitehouse.gov/omb/libraly/OMBINV.vA.EPA.htrnl#VA. If desired, you can call 1-800-827-1000 to get information on where to send your comments or

suggestions about this form.

INFORMATION AND INSTRUCTIONS

THIS APPLICAnON IS TO BE COMPLETED BY VETERANS WHO HAVE GOVERNMENT LIFE INSURANCE
AND BECOME TOTALLY DISABLED.
TOTAL DISABILITY:
1. Any impairment of mind or body which makes it impossible for the veteran to be gainfully employed.
2. Total Disability must start before the veteran's 65th birthday.

WAIVER REFUND

1. Premium Refunds limited to one year prior to date the claim is filed, unless there were circumstances beyond
the veteran's control (such as a severe mental disability). LACK OF KNOWLEDGE OF THE WAIVER
PROVISION IS NOT A CIRCUMSTANCE BEYOND THE VETERAN'S CONTROL.
2. If total disability started more than one year prior to the date of your claim, and you believe a mental disability
prevented you from filing an earlier claim, please include a statement explaining these circumstances on a separate
sheet of paper. YOU SHOULD ALSO INCLUDE ANY MEDICAL EVIDENCE WIDCH SUPPORTS YOUR
STATEMENT.
PART I should be completed by the insured veteran if able; if not, by a person acting on hislher behalf.
PART II should be completed by the insured veteran's physician or hospital official. If there will be a delay in
preparing Part II send Part I immediately.
NOTE: IF THE VETERAN HAS BEEN GRANTED DISABILITY BENEFITS FROM THE SOCIAL
SECURITY ADMINISTRATION PLEASE ATTACH A COPY OF THE AWARD LETTER.

PART I
1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)

2. INSURANCE FILE NUMBER (Include letter prefix)

3. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and street or rural route,
city or P.O., State and ZIP Code)

4. SOCIAL SECURITY NUMBER
5. DATE OF BIRTH

6. DAYTIME TELEPHONE NUMBER (Include Area Code)

7. CLAIM NUMBER

8. DATE DISABILITY PREVENTED EMPLOYMENT

9. DATE RETURNED TO GAINFUL EMPLOYMENT

10A. EDUCATION (Circle highest years completed) (If you have any other specialized training or education please complete Item 1DB)

12345678

1234

1234

(Grade School)
(High School)
10B. PLEASE PROVIDE ANY SPECIALIZED TRAINING IN THE SPACE PROVIDED BELOW

11. ARE YOU RECEIVING OR HAVE YOU APPLIED FOR ANY
DISABILITY BENEFITS AS LISTED BELOW?

D

(College)

12. DISEASE OR INJURY CAUSING TOTAL OR PERMANENT DISABILITY

VA DISABILITY
COMPENSATION

VA FORM
JUN 2008

29-357

EXISTING STOCKS OF VA FORM 29-357, APR 2005,
WILL BE USED.

IF YOU HAVE ANY QUESTIONS ABOUT DISABILITY BENEFITS OR YOUR INSURANCE, PLEASE CALL OUR
TOLL FREE NUMBER 1-800-669-8477
13. HOSPITALS WHERE YOU HAVE BEEN TREATED, INCLUDING VA HOSPITALS
NAME OF HOSPITAL

ADDRESS OF HOSPITAL

DATE OF ADMISSION

DATE OF RELEASE

14. PHYSICIANS WHO HAVE TREATED YOU FOR DISEASE OR INJURY, CAUSING TOTAL PERMANENT DISABILITY
DATE TREATMENT
DATE OF LAST
ADDRESS OF PHYSICIAN
NAME OF PHYSICIAN
BEGAN
TREATMENT

15. RECORD OF EMPLOYMENT FOR ONE YEAR PRIOR TO THE DATE OF TOTAL DISABILITY TO THE PRESENT
(Include self-emDlovmentJ

DA TES OF EMPLOYMENT
FROM

TO

LAST DAY INSURED WORKED
DATE

lr

NAME AND ADDRESS OF EMPLOYER

,IIUN

DATES OF EMPLOYMENT
FROM

TO

LAST DAY INSURED WORKED
DATE

OCCUPATION

NAME AND ADDRESS OF EMPLOYER

DATES OF EMPLOYMENT
TO
FROM

LAST DAY INSURED WORKED
DATE

OCCUPATION

NAME AND ADDRESS OF EMPLOYER

HOURS WORKED
WEEKLY

EARNINGS

WEEKLY

REASON FOR TERMINATION OF
EMPLOYMENT

HOURS WORKED
WEEKLY

EARNINGS

WEEKLY

REASON FOR TERMINATION OF
EMPLOYMENT

HOLIRS
WEEKLY

WEEKLY

EARNINGS

REASON FOR TERMINATION OF
EMPLOYMENT

I consent that any physician or hospital who has treated or examined me for any purpose, or who I have consulted professionally, any insurance
company or organization to which I have applied for insurance, or any person, persons, firm or corporation to whom, or to which I have applied for
employment or disability benefits, may provide to the Department of Veterans Affairs or testify as to, or produce in court, any information obtained
concerning myself by reason of the foregoing, and waive any privileges which render such information confidential. A photostatic copy of this
consent shall be considered valid authorization for release of infonnation to VA. I certify that each question has been truthfully and completely
answered to the best of my knowledge.

16. DATE OF SIGNATURE

17. SIGNATURE OF INSURED (Or official or fiduciary completing form for insured)

PENALTY - The law provides that whomever makes any statement of a material fact, knowing it to be false, shall be punished by

fine or imprisonment or both.

VA FORM 29-357, JUN2008

REPORT FOR DISABILITY INSURANCE PURPOSES OF TREATMENT IN A
HOSPITAL OR FROM AN ATTENDING PHYSICIAN

PART II

Part II of this application should be completed by the appropriate hospital official or by the veteran's attending physician.
If appropriate hospital summaries are available, please forward with application.
1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)
12. INSL!RANCE FILE NUMtstti (Include
prefix)

3. HOME ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

FOR VA USE ONLY
4. CLAIM NUMBER

A. WHEN DID INJURY OR ILLNESS BEGIN?

C. DATE OF FIRST TREATMENT

letter

\5. SOCIAL SECURITY NUMBER

6. HISTORY (Conditions causing disability)
B. DATE INSURED STOPPED WORKING BECAUSE OF DISABILITY

D. FREQUENCY AND NATURE OF TREATMENT

E. OBJECTIVE SYMPTOMS AND FINDINGS WHEN FIRST SEEN

F. DIAGNOSIS, INCLUDE RESULTS OF SPECIAL STUDIES

7. HOSPITALIZATION
A. DATE
FROM

B. NAME AND ADDRESS OF HOSPITAL

TO

C. CONDITION AT DISCHARGE

8. PROGNOSIS
A. DATE OF LAST EXAM OR
TREATMENT

B. OBJECTIVE FINDINGS

C. DIAGNOSIS - CONDITIONS CAUSING DISABILITY

D. IS VETERAN CAPABLE OF DOING
ALL OF HIS/HER WORK?

n

DYES
NO
E. IS VETERAN CAPABLE OF DOING
ANY OTHER WORK?
DYES
F. CARDIAC FUNCTION (Check if applicable)

o
o

AHA FUNCTIONAL CAPACITY - CL 1 (NO LIMITATION)

o
o

n

NO

AHA FUNCTIONAL CAPACITY - CL 3 (MARKED LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 2 (SLIGHT LIMITATION)
AHA FUNCTIONAL CAPACITY - CL 4 (COMPLETE LIMITATION)
G. MENTAL/NERVOUS IMPAIRMENT (Ability to function in stressful situations,
H. SINCE FIRST TREATMENT-HAS VETERAN
and engage in interpersonal relations) (Check if applicable)
NO
o ~1~~~TH}TlnI\l n M2~Ef~A~ o ~~rllgON
n
LIMITATION
9. NAME AND ADDRESS OF ATTENDING PHYSICIAN OR HOSPITAL

10. DATE OF REPORT

D

~I~~~~I()M n IMPR()VFD

n

WORSEMFn

n

REMAINED
HIF C:l\MF

11. SIGNATURE AND TITLE OF PERSON PREPARING REPORT

When completed and s~ned, send this claim form IMMEDIATELY to the office of the Department of Veterans Affairs where the Insurance Records
are maintained. The ad ress of the Department of Veterans Affairs office that maintains these records is:
Department of Veterans Affairs
Re8ional Office and Insurance Center (WP)
P. . Box 7208
Philadelphia, PA 19101
VA FORM 29-357, JUN 2008