29-0189 Application for Supplemental Service Disabled Veteran (S

IN REPLY REFER TO:

DATE:

FILE NUMBER:

ADDRESS:

Your approval for waiver of premiums on your Service-Disabled Veterans Insurance (RH) coverage makes you eligible
for up to $30,000 of Supplemental Service-Disabled Veterans Insurance (SRH). The information below provides
information about the coverage and instructions on how to apply for the coverage.
Plans and Premiums
You may select from any of the nine plans of RH insurance for your SRH coverage. The premiums for your SRH
insurance are determined by your age and the plan of insurance and amount of coverage you select. You can select any
amount of coverage you desire up to $30,000. If you choose less than $30,000 initially, you can request additional
coverage within one year of receiving this notice.
Please review the enclosed VA pamphlet (Service-Disabled Veterans Insurance Information and Premium Rates 29-9), for a
detailed description of the available plans and premium rates.
No Waiver of Premiums
Unlike your basic coverage, the supplemental coverage does not provide for a waiver of premiums if you are totally
disabled. If you desire this coverage, you must pay the premiums for it.
Deadline To Apply
If you are interested in SRH Insurance, you must apply before
whichever comes first.
How To Apply
Simply complete the application and return it to:
Department of Veterans Affairs
Regional Office and Insurance Center (SRH)
P.O. Box 7208
Philadelphia, PA 19101

or before your 65th birthday,

Questions
If you have questions about Government Life Insurance, you can call us toll-free at 1-800-669-8477. Insurance Specialists
are available from Monday through Friday, 8:30 a.m. to 6:00 p.m., Eastern time. We recommend that you call on
Wednesdays, Thursdays, or Fridays when you can reach us more quickly. You can also visit our website at
www.insurance.va.gov. The website provides detailed information on a range of topics, including applying for insurance
and filing death claims.
Sincerely yours,
Joe Tomaselli
Chief, Insurance Claims
VA FORM
JAN 2011

29-0189

OMB Approved No. 2900-0539
Respondent Burden: 20 minutes

APPLICATION FOR SUPPLEMENTAL SERVICE-DISABLED
VETERANS (SRH) LIFE INSURANCE
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 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

Semi-Annually

3. Beneficiary Designation and Optional Settlement
Complete Name and Address of Each Principal and Contingent
Beneficiary's Social
Beneficiary (For married women, enter her own first and middle names. Security Number (If
For example, Mary Rose Smith, not Mrs. John Smith)
known. This is not
required for this
designation be valid)

Annually

Payment Option for
Relationship of the Share to be paid to each
beneficiary to you beneficiary (Use $ amounts, Each
%, or fractions)
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

Lump Sum
4. This beneficiary change cancels all prior Beneficiary and Option selections and will apply to all my Government Life Insurance
policies under my file number unless the box is checked.
I would like this change to apply only to my Supplemental Service-Disabled Insurance policy. Please keep the existing
beneficiary designation on all other insurance policies under my file number.
5. Your Social Security Number

6. Day Time Telephone Number (Include Area Code)

8. Signature of Applicant (Do NOT print, sign in ink)

7. Email Address
9. Date

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 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. 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 establish your eligibility for VA Insurance benefits (38 U.S.C. 1922). Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 20 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 http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000
to get information on where to send comments or suggestions about this form.
VA FORM
JAN 2011

29-0189

EXISTING STOCKS OF VA FORM 29-0189, AUG 2005,
WILL BE USED.