Form VA Form 29-1549 VA Form 29-1549 Application for Change of Permanent Plan (Medical)

OMB Control No. 2900-0179
Respondent Burden: 30 minutes
(For Use of VA Index)

APPLICATION FOR CHANGE OF PERMANENT PLAN
(MEDICAL)
(CHANGE TO A POLICY WITH A LOWER RESERVE VALUE)
PRIVACY ACT INFORMATION: 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 rountine uses identified in 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. The repsonses
you submit are considered confidential (38 USC 5701).
RESPONDENT BURDEN: We need this information to verify your eligibility to change your permanent plan (38 U.S.C. 5902). Title 38, United States Code, allows
us to ask for this information. We estimate that you will need an average of 30 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/library/omb/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send your suggestions or
comments about this form.

INSTRUCTIONS
This form is used to change a permanent plan of Insurance to another permanent plan with a lower reserve value.
The difference between the reserve of the two plans may be applied to a policy loan, applied to future premiums, or refunded to you
in cash.
REQUIREMENT: You must be in good health to change to a plan with a lower reserve value. Please complete all the health
questions on the back of this form.
The beneficiary and/or optional settlement under the new policy will remain the same as under the old policy. If a change is desired,
submit VA Form 29-336, Designation of Beneficiary - Government Life Insurance.
It is not possible to change from a permanent plan to Term Insurance. Call our toll-free number for information on the available
plans.
Complete and return this form to the following address:

Department of Veterans Affairs
Regional Office and Insurance Center (COP)
P. O. Box 7208
Philadelphia, PA 19101

PART I - STATEMENT OF APPLICATION
1. FIRST NAME - MIDDLE NAME - LAST NAME OF INSURED

2. INSURANCE FILE NUMBER (Include letter prefix)

3. MAILING ADDRESS

4. SOCIAL SECURITY NUMBER

7. POLICY NUMBER

5. VA FILE NUMBER (If any)

8. AMOUNT OF INSURANCE
APPLIED FOR

6. DAYTIME TELEPHONE NUMBER

9. PLAN OF INSURANCE
APPLIED FOR

$

10. DO YOU WISH TO CONTINUE OR ADD THE
TOTAL DISABILITY INCOME PROVISION
YES

NO

11. DISPOSITION OF RESERVE CREDIT
PAY FUTURE PREMIUMS

APPLY TO INDEBTEDNESS

PAY IN CASH

12. METHOD OF PREMIUM PAYMENT
DIRECT PAYMENT TO VA (Complete Item 13)

MONTHLY ALLOTMENT FROM SERVICE PAY

MONTHLY DEDUCTION FROM VA BENEFIT CHECK

MONTHLY DEDUCTION FROM YOUR CHECKING ACCOUNT

13. MODE OF PREMIUM PAYMENT
MONTHLY

QUARTERLY

SEMI-ANNUALLY

ANNUALLY

IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE CALL TOLL FREE 1-800-669-8477.
VA FORM
MAR 2008

29-1549

EXISTING STOCKS OF VA FORM 29-1549, JUL 2001,
WILL BE USED.

PART II - EMPLOYMENT AND HEALTH INFORMATION
The purpose of questions listed below is to secure complete information regarding the condition of the applicant’s health. All
diseases, injuries, abnormalities, deformities, or infirmities must be stated and fully described. Statements made by the applicant in
this application are relied upon in granting insurance. Consequently, any deception or knowingly false statement either by inference,
omission, or otherwise may result in cancellation of the insurance or in the refusal to pay a claim on the policy.
It may be necessary to ask for a physical examination in connection with this application.
Please answer every question, date and sign this application.
NOTE: Complete the following employment questions. If additional space is needed, attach a separate sheet of paper.
1A. ARE YOU NOW WORKING?
YES
NO

1C. IF NOT WORKING OR WORKING PART-TIME, EXPLAIN WHY

1B. DO YOU WORK FULL TIME?
YES

NO

HAVE YOU EVER HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING: (Check all that apply)
YES NO 14. ANY DISEASE OF THE PROSTATE OR
2. DISEASE OF THE HEART OR ARTERIES;
TESTES IF A MALE; UTERUS, OVARIES
CHEST PAIN?
OR BREAST IF A FEMALE?
15. DO YOU USE OR HAVE YOU BEEN
3. HIGH BLOOD PRESSURE?
TREATED FOR THE USE OF ALCOHOL OR
ANY HABIT FORMING DRUG?
4. CANCER, TUMOR OR POLYP?
16. WITHIN THE PAST 5 YEARS, HAVE YOU
BEEN TREATED BY A PHYSICIAN?
5. LUNG DISEASE?
17. ARE YOU NOW OR HAVE YOU EVER BEEN
6. EPILEPSY, UNCONSCIOUSNESS, DIZZIHOSPITALIZED FOR ILLNESS, DISEASE OR
NESS OR IMPAIRMENT OF NERVOUS
INJURY?
SYSTEM?
18. DO YOU HAVE ANY SERVICE 7. EMOTIONAL OR MENTAL DISORDER?
CONNECTED DISABILITIES?
19. HAVE YOU EVER APPLIED FOR DISABIL8. DISEASE OF THE BLOOD?
ITY COMPENSATION OR PENSION?
20. HAS ANY APPLICATION YOU HAVE MADE
9. TUBERCULOSIS, PLEURISY, OR
FOR PRIVATE OR GOVERNMENT LIFE,
BRONCHITIS?
HEALTH, DISABILITY OR ACCIDENT
10. DIABETES?
INSURANCE BEEN REFUSED,
POSTPONED
11. ARTHRITIS, PARALYSIS, OR DISEASE,
APPROVED AT SUB-STANDARD RATES
OR DEFORMITY OF THE BONES,
OR ON A DIFFERENT BASIS THAN
MUSCLES, OR JOINTS?
21. HEIGHT:
FEET
INCHES
12. DISEASE OR ULCER OF STOMACH,
INTESTINES OR RECTUM?
13. ANY DISEASE OF THE URINARY TRACT,
22: WEIGHT:
POUNDS
SUGAR, ALBUMIN, OR BLOOD IN URINE?

YES NO

23. REMARKS (Give complete details to "YES" answers. Include dates, diagnosis, physicians or hospitals, and names and addresses. Indicate
after each disability whether service-connected or nonservice-connected. If additional space is needed, attach a separate sheet of paper)

I consent that any hospital, physician or surgeon who has treated or examined me for any purpose, or whom I have consulted professionally may
divulge to VA any information obtained by them, or it, concerning myself. I understand that the Government will rely on the truth of these answers.
I HAVE READ THE ABOVE ANSWERS AND TO THE BEST OF MY KNOWLEDGE, THEY ARE TRUE.
I am obliged to advise VA of any change of health condition arising after the signing and prior to delivery of this form to VA.
24A. SIGNATURE

24B. DATE