VA Form 29-0151 Application for Service Disabled Veterans Insurance

OMB Approved No. 2900-0068
Respondent Burden: 20 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-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,
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. 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 Payment

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 sill start the allotment for you)
C. I want VA to automatically withdraw the premium each month from my bank account (VA MATIC) (Please send your first payment with
this application)
D. I will send premiums directly to VA as follows: (Please send your first payment with this application)
Monthly
VA FORM
DEC 2010

Quarterly

29-0151

Semi-Annually

Annually

SUPERSEDES VA FORM 29-0151, APR 2005,
WHICH WILL NOT BE USED.

Continued on Reverse

EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN AT THE BOTTOM OF THIS SIDE
3A. Are you now working?
YES

3B. Do your work full-time?

NO

YES

3C. If you are not working or working part-time, explain why. Please be specific.

NO

3D. When did you last work full-time?

4. Have you had any of the following:

3E. What was your occupation?

YES

NO

A. Lung condition?

5. If your answer to any part of Item 4 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?
6. Have you had any other physical defect or disease? (If "YES", explain below)

7. Social Security Number

8. Date of Birth

YES

NO

9. Daytime Telephone Number

10. E-mail Address

11. 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)

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)

PRINCIPAL

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"
CONTINGENT

Lump Sum
Lump Sum
Lump Sum

Or to survivors
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.
12A. Signature of Applicant (Do NOT print, sign in ink)

12B. 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 29-0151, DEC 2010