Form 29-389 Notice of Lapse & Application for Reinstatement

OMB Control No. 2900-0128
Respondent Burden: 12 minutes

NOTICE OF LAPSE
GOVERNMENT LIFE INSURANCE
1. INSURANCE FILE NUMBER 2. POLICY NO. (Including letter prefix)

3. DATE OF LAPSE
MONTH

F

DAY

4. DATE MAILED BY VA

YEAR

5. AMOUNT OF INSURANCE

ADDRESS OF INSURED

$

.

.

6. DATE OF LAST TIMELY PAYMENT
7. AMOUNT OF LAST TIMELY PAYMENT

$
8. AMOUNT NEEDED TO REINSTATE
A

PREMIUMS
DUE

$

B

LESS
OVERAGE

-

C

PLUS
SHORTAGE

+

D

TOTAL
AMOUNT DUE

$

Your insurance lapsed on the date shown. You may reinstate your protection now by following the instructions in the
paragraphs checked below.
Complete the application on the back of this form and return it at once with a payment for the total amount due.
Return this form at once with a payment for the total amount due. You do not have to complete the application.
If you submit your application on or after ________________ , add to the total amount due one additional
premium of $_________ for each month of delay. If you delay reinstatement more than six months from the date
of lapse, interest will be charged on all premiums from date of lapse.
The current term period of your policy ends _________________________. If you reinstate after that date, the
amount required to reinstate is $ ____________ based on the renewal premium of $ ____________________
monthly.
If you reinstate on or before ___________________, evidence that your health is as good on the date of the
application as it was at the end of the grace period is acceptable. Otherwise, a VA Form 29-352, Application For
Reinstatement, will be required.
Unless you meet reinstatement requirements on or before __________________ you will have lost all rights to
reinstate this insurance.
The payment sent on ___________________ could not be used to prevent lapse. This payment is included in
Item 8B.

IF YOU HAVE QUESTIONS ABOUT YOUR INSURANCE, CALL TOLL-FREE AT 1-800-669-8477.

FROM
VA FORM
NOV 2005

29-389

Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 8079
Philadelphia, PA 19101

OMB Control No. 2900-0128
Respondent Burden: 12 minutes

APPLICATION FOR REINSTATEMENT
Privacy Act Notice: 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 (i.e., to reinstate lapsed government life insurance) as identified in the VA system of records, 36VA00, 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 or
retain benefits. 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 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 your eligibility for reinstatement (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 12 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.

BE SURE TO INSERT ALL INFORMATION - DATE - SIGN AND MAIL IMMEDIATELY WITH THE TOTAL AMOUNT.
1. AMOUNT OF INSURANCE TO
BE REINSTATED

2. AMOUNT OF TOTAL DISABILITY INCOME
PROVISION TO BE REINSTATED

3. AMOUNT SENT WITH
THIS APPLICATION

4. SOCIAL SECURITY
NUMBER

CERTIFICATION OF HEALTH

5A. I am applying for reinstatement of my insurance in the amount shown above. As a condition to the reinstatement of this
insurance, I certify that to the best of my knowledge and belief, I am in as good health now as I was on the last day of the grace
period (31 days after the date of lapse).
YES

NO (If "No," please complete Item 5B)

5B. Please describe any illness, disease, injury or medical treatment with dates, which have occurred since the date of lapse.

I UNDERSTAND THAT:
A. If my application is approved, the last named beneficiary(ies) and selection of optional settlement(s) on policy(ies) reinstated, will
continue in effect unless the Department of Veterans Affairs receives a request for a change in writing over my signature. (VA Form
29-336 should be used to make any changes.)
B. STATEMENTS MADE BY ME IN THIS APPLICATION ARE RELIED UPON. ANY DECEPTION OR FALSE STATEMENT
EITHER BY INFERENCE, OMISSION, OR OTHERWISE, MAY CAUSE CANCELLATION OF THE INSURANCE OR
REFUSAL TO PAY A CLAIM. IN EITHER CASE, PREMIUMS MAY NOT BE RETURNED.
C. I must let the Department of Veterans Affairs know of any change in my health beginning after the date I sign and before the date
I send this form to the Department of Veterans Affairs.
IMPORTANT: This form must be fully COMPLETED, SIGNED and sent IMMEDIATELY to the Department of Veterans Affairs.
Checks and money orders should be made payable to the Department of Veterans Affairs.
Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208
Philadelphia, PA 19101
6. MAILING ADDRESS (Please complete only if your address shown on the front is not correct)

7. TELEPHONE NUMBER

8. SIGNATURE OF POLICYHOLDER (Do not print. This certification must be signed and dated)

9. DATE OF SIGNATURE

PENALTY - The law provides whoever makes any statement of material fact knowing it to be false shall be punished by fine or imprisonment or both.
VA FORM 29-389, NOV 2005