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

OMB Approved No. 2900-0068
Respondent Burden: 20 minutes

APPLICATION FOR SERVICE-DISABLED VETERANS INSURANCE
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. An increase 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 serviceconnected. 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. 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:

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,
or fax to 1-888-748-5822.

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)
PRINCIPAL

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

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"

CONTINGENT
Lump Sum

Lump Sum

Or to survivors
VA FORM
DEC 2010

29-4364

Lump Sum
EXISTING STOCK OF VA FORM 29-4364, DEC 2003,
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 No.

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)
B. Plan of Insurance

A. Amount of Insurance

9B. Do you work full-time? (If "Yes," skip
to Item 10)

9A. Are you now working?
YES

C. Monthly Premium

NO

YES

9D. When did you last work full-time?

9C. If you are not working part-time, explain why (Please be specific)

NO

9E. What was your occupation?

10. Check the method showing how you wish to pay for this insurance (If you are not eligible for waiver of premiums)
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 sill 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

11. Have you had any of the following:

YES

Annually
NO

A. Lung condition?

12. If your answer to any part of Item 11 is "YES," give dates,
duration and other details. (If more space is needed, attach a
separate sheet)

B. Mental or nervous disorders?
C. Blood disorder?
D. Heart condition?
E. Cancer or tumor?
F. Diabetes?
13. Have you had any other physical defect or disease? (If "YES", explain below)

YES

NO

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.
14A. Signature of Applicant (Do NOT print, sign in ink)

14B. 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 required to obtain this benefit. Giving us your social security number is
voluntary. Refusal to provide your social security number by itself will not result in the denial of this benefit. VA will not deny an individual benefits for refusing to
provide his or her social security number unless the disclosure of the social security number is required by a Federal Statute of law in effect prior to January 1, 1975, and
still in effect.
Respondent Burden: We need this information to determine 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 information, 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.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 29-4364, DEC 2010