29-4364c Application for Service-Disabled Veterans Insurance (Ind

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

APPLICATION FOR SERVICE-DISABLED VETERANS INSURANCE

(Individually Unemployable or Statutory)

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 serviceconnected disability. Please Note: The disability you are rated for must be a new disability, not an increase in a disability you already have. Being increased 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 service-connected. Information about any
health conditions should be included on your application.
Coverage for Statutory or Individually Unemployable Veterans
You are receiving this S-DVI application because VA has rated you individually unemployable or has rated you for certain severely disabling conditions. Because of
these ratings you are able to obtain S-DVI coverage at no cost to you. Upon receipt of this application, VA will issue you a $10,000 20 Payment Life insurance plan
under the S-DVI program at no cost to you.
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.
1. Name and Mailing Address for Insurance Purposes
A. First, Middle, Last Name

C. VA Claim Number (if any)

B. Mailing Address

D. Social Security Number

E. Date of Birth

F. Daytime Telephone Number

G. E-mail 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

Lump Sum

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.
3A. Signature of Applicant (Do NOT print, sign in ink)

3B. 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 5, Code of Federal
Regulations 1.526 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 determine, establish or verify your eligibility for VA Insurance benefits (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 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 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
DEC 2010

29-4364c