Revised Form

OMB Approved No. 2900-0016
Respondent Burden: 1 hour 45 minutes
Expiration Date: XX-XX-XXXX

CLAIM FOR DISABILITY INSURANCE
GOVERNMENT LIFE INSURANCE

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 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, and published in the Federal Register. Your obligation to respond is required to obtain this benefit. 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.
RESPONDENT BURDEN: We need this information to determine your eligibility for VA insurance benefits. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 1 hour and 45 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 your comments or suggestions about this form.

INFORMATION AND INSTRUCTIONS
THIS APPLICATION IS TO BE COMPLETED BY VETERANS WHO HAVE GOVERNMENT LIFE INSURANCE
AND BECOME TOTALLY DISABLED.
TOTAL DISABILITY:
1. Any impairment of mind or body which makes it impossible for the veteran to be gainfully employed.
2. Total Disability must start before the veteran's 65th birthday.
WAIVER REFUND
1. Premium Refunds limited to one year prior to date the claim is filed, unless there were circumstances beyond the
veteran's control (such as a severe mental disability). LACK OF KNOWLEDGE OF THE WAIVER PROVISION IS
NOT A CIRCUMSTANCE BEYOND THE VETERAN'S CONTROL.
2. If total disability started more than one year prior to the date of your claim, and you believe a mental disability
prevented you from filing an earlier claim, please include a statement explaining these circumstances on a separate sheet of
paper. YOU SHOULD ALSO INCLUDE ANY MEDICAL EVIDENCE WHICH SUPPORTS YOUR
STATEMENT.
PART I should be completed by the insured veteran if able; if not, by a person acting on his/her behalf.
PART II should be completed by the insured veteran's physician or hospital official. If there will be a delay in preparing
Part II send Part I immediately.
NOTE: IF THE VETERAN HAS BEEN GRANTED DISABILITY BENEFITS FROM THE SOCIAL SECURITY
ADMINISTRATION, PLEASE ATTACH A COPY OF THE AWARD LETTER.
PART I

1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)

2. INSURANCE FILE NUMBER (Include letter prefix)

3. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and Street or Rural

4. SOCIAL SECURITY NUMBER

Route, City or P.O., State and ZIP Code)

5. DATE OF BIRTH
6. DAYTIME TELEPHONE NUMBER (Include Area Code)
7. CLAIM NUMBER
8. DATE DISABILITY PREVENTED EMPLOYMENT

9. DATE RETURNED TO GAINFUL EMPLOYMENT

10A. EDUCATION (Check highest years completed) (If you have any other specialized training or education please complete Item 10B)

1

2

3

4

5

6

7

8

1

(Grade School)

2

3

4

(High School)

1

2

3

4

(College)

10B. PLEASE PROVIDE ANY SPECIALIZED TRAINING IN THE SPACE PROVIDED BELOW

11. ARE YOU RECEIVING OR HAVE YOU APPLIED FOR ANY
DISABILITY BENEFITS AS LISTED BELOW?
VA DISABILITY
COMPENSATION
VA FORM
APR 2012

29-357

VA PENSION

12. DISEASE OR INJURY CAUSING TOTAL OR PERMANENT DISABILITY

SOCIAL SECURITY
DISABILITY
EXISTING STOCKS OF VA FORM 29-357, JUN 2008,
WILL BE USED.

IF YOU HAVE ANY QUESTIONS ABOUT DISABILITY BENEFITS OR YOUR INSURANCE,
PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477
13. HOSPITALS WHERE YOU HAVE BEEN TREATED, INCLUDING VA HOSPITALS
NAME OF HOSPITAL

ADDRESS OF HOSPITAL

DATE OF ADMISSION

DATE OF RELEASE

14. PHYSICIANS WHO HAVE TREATED YOU FOR DISEASE OR INJURY, CAUSING TOTAL PERMANENT DISABILITY
NAME OF PHYSICIAN

DATE TREATMENT
BEGAN

ADDRESS OF PHYSICIAN

DATE OF LAST
TREATMENT

15. RECORD OF EMPLOYMENT FOR ONE YEAR PRIOR TO THE DATE OF TOTAL DISABILITY TO THE PRESENT
(Include self-employment)
DATES OF EMPLOYMENT
FROM

TO

OCCUPATION

HOURS WORKED
WEEKLY

NAME AND ADDRESS OF EMPLOYER

DATES OF EMPLOYMENT
FROM

LAST DAY INSURED WORKED
DATE

TO

LAST DAY INSURED WORKED
DATE

REASON FOR TERMINATION OF EMPLOYMENT

HOURS WORKED
WEEKLY

OCCUPATION

NAME AND ADDRESS OF EMPLOYER

DATES OF EMPLOYMENT
FROM
TO

LAST DAY INSURED WORKED
DATE

OCCUPATION

NAME AND ADDRESS OF EMPLOYER

EARNINGS
WEEKLY

EARNINGS
WEEKLY

REASON FOR TERMINATION OF EMPLOYMENT

HOURS WORKED
WEEKLY

EARNINGS
WEEKLY

REASON FOR TERMINATION OF EMPLOYMENT

I consent that any physician or hospital who has treated or examined me for any purpose, or who I have consulted professionally, any insurance company or organization
to which I have applied for insurance, or any person, persons, firm or corporation to whom, or to which I have applied for employment or disability benefits, may provide
to the Department of Veterans Affairs or testify as to, or produce in court, any information obtained concerning myself by reason of the foregoing, and waive any
privileges which render such information confidential. A photostatic copy of this consent shall be considered valid authorization for release of information to VA.
I certify that each question has been truthfully and completely answered to the best of my knowledge.
16. DATE OF SIGNATURE

17. SIGNATURE OF INSURED (Or official or fiduciary completing form for insured)

PENALTY - The law provides that whomever makes any statement of a material fact, knowing it to be false, shall be punished by fine or imprisonment or both.
VA FORM 29-357, APR 2012

REPORT FOR DISABILITY INSURANCE PURPOSES OF TREATMENT IN A
HOSPITAL OR FROM AN ATTENDING PHYSICIAN

PART II

Part II of this application should be completed by the appropriate hospital official or by the veteran's attending physician. If appropriate
hospital summaries are available, please forward with application.
1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)

2. INSURANCE FILE NUMBER (Include letter prefix)

3. HOME ADDRESS (Number and Street or Rural Route, City or P.O., State and ZIP Code)

6. HISTORY (Conditions causing disability)
B. DATE INSURED STOPPED WORKING BECAUSE OF DISABILITY

A. WHEN DID INJURY OR ILLNESS BEGIN?
C. DATE OF FIRST TREATMENT

FOR VA USE ONLY
5. SOCIAL SECURITY NUMBER
4. CLAIM NUMBER

D. FREQUENCY AND NATURE OF TREATMENT

E. OBJECTIVE SYMPTOMS AND FINDINGS WHEN FIRST SEEN

F. DIAGNOSIS, INCLUDE RESULTS OF SPECIAL STUDIES

7. HOSPITALIZATION
DATE
FROM

NAME AND ADDRESS OF HOSPITAL

TO

CONDITION AT DISCHARGE

8. PROGNOSIS
A. DATE OF LAST EXAM OR TREATMENT

B. OBJECTIVE FINDINGS

C. DIAGNOSIS - CONDITIONS CAUSING DISABILITY

D. IS VETERAN CAPABLE OF DOING
ALL OF HIS/HER WORK?
YES

NO

E. IS VETERAN CAPABLE OF DOING
ANY OTHER WORK?
YES

NO

F. CARDIAC FUNCTION (Check if applicable)
AHA FUNCTIONAL CAPACITY - CL 1 (NO LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 3 (MARKED LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 2 (SLIGHT LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 4 (COMPLETE LIMITATION)

G. MENTAL/NERVOUS IMPAIRMENT (Ability to function in stressful situations and engage in
interpersonal relations) (Check if applicable)
NO
SLIGHT
MODERATE
MARKED
SEVERE
LIMITATION
LIMITATION
LIMITATION
LIMITATION
LIMITATION

H. SINCE FIRST TREATMENT HAS VETERAN
IMPROVED

WORSENED

REMAINED
THE SAME

9. NAME AND ADDRESS OF ATTENDING PHYSICIAN OR HOSPITAL

10. DATE OF REPORT

11. SIGNATURE AND TITLE OF PERSON PREPARING REPORT

When completed and signed, send this claim form IMMEDIATELY to the office of the Department of Veterans Affairs where the Insurance Records are
maintained. The address of the Department of Veterans Affairs office that maintains these records is:
Department of Veterans Affairs
Regional Office and Insurance Center (WP)
P.O. Box 7208
Philadelphia, PA 19101
VA FORM 29-357, APR 2012