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

OMB Control No. 2900-0179
Respondent Burden: 30 Mins.
Expiration Date: XXXXXXXX

(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 routine uses identified in VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of
U.S. Government Life Insurance - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The responses 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.reginfo.gov/public/do/PRAMain. 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

2. INSURANCE FILE NUMBER (Include letter prefix)

1. FIRST NAME - MIDDLE NAME - LAST NAME OF INSURED

3. MAILING ADDRESS

5. VA FILE NUMBER (If any)

4. SOCIAL SECURITY NUMBER

7. POLICY NUMBER

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
XXXX

29-1549

EXISTING STOCKS OF VA FORM 29-1549, MAR 2008,
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.
1 A. ARE YOU NOW WORKING?
YES

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

NO

1 B. DO YOU WORK FULL TIME?
YES

NO

HAVE YOU EVER HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING: (Check all that apply)
2. DISEASE OF THE HEART OR ARTERIES;
CHEST PAIN?
3. HIGH BLOOD PRESSURE?
4. CANCER, TUMOR OR POLYP?
5. LUNG DISEASE?

YES

NO

14. ANY DISEASE OF THE PROSTATE OR
TESTES IF A MALE; UTERUS, OVARIES OR
BREAST IF A FEMALE?

16. WITHIN THE PAST 5 YEARS, HAVE YOU
BEEN TREATED BY A PHYSICIAN?
17. ARE YOU NOW OR HAVE YOU EVER BEEN
HOSPITALIZED FOR ILLNESS, DISEASE OR
INJURY?

7. EMOTIONAL OR MENTAL DISORDER?

18. DO YOU HAVE ANY SERVICE
CONNECTED DISABILITIES?

8. DISEASE OF THE BLOOD?

19. HAVE YOU EVER APPLIED FOR DISABILITY
COMPENSATION OR PENSION?

10. DIABETES?
11. ARTHRITIS, PARALYSIS, OR DISEASE,
OR DEFORMITY OF THE BONES,
MUSCLES, OR JOINTS?
12. DISEASE OR ULCER OF STOMACH,
INTESTINES OR RECTUM?
13. ANY DISEASE OF THE URINARY TRACT,
SUGAR, ALBUMIN, OR BLOOD IN URINE?

NO

15. DO YOU USE OR HAVE YOU BEEN
TREATED FOR THE USE OF ALCOHOL OR
ANY HABIT FORMING DRUG?

6. EPILEPSY, UNCONSCIOUSNESS,
DIZZINESS OR IMPAIRMENT OF
NERVOUS SYSTEM?

9. TUBERCULOSIS, PLEURISY, OR
BRONCHITIS?

YES

20. HAS ANY APPLICATION YOU HAVE MADE
FOR PRIVATE OR GOVERNMENT LIFE,
HEALTH, DISABILITY OR ACCIDENT
INSURANCE BEEN REFUSED, POSTPONED
APPROVED AT SUB-STANDARD RATES
OR ON A DIFFERENT BASIS THAN
APPLIED FOR?
21. HEIGHT:

FEET

22. WEIGHT:

POUNDS

INCHES

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

VA FORM 29-1549, XXXX

24B. DATE

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