VA Form 29-353 Application for Reinstatement (Non Medical - Comparative

OMB Control No. 2900-0011
Respondent Burden: 15 Minutes

APPLICATION FOR REINSTATEMENT

(For Use of VA Index)

(NON MEDICAL - COMPARATIVE HEALTH STATEMENT)
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, 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 voluntary. VA uses your SSN to identify your insurance file. Providing your SSN will help ensure that your records are
properly associated with your insurance file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The 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, establish or verify your eligibility for VA insurance benefits (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 15 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 http://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.
Use this form if you apply for reinstatement within 6 months from date of lapse. Before completing this form,
please read the the IMPORTANT INFORMATION AND INSTRUCTIONS on back. Type or use ink. All numbered

1. INSURANCE FILE NO. (Include letter prefix)

items must be completed.

F

2. FIRST NAME-MIDDLE NAME-LAST NAME OF INSURED (Type or print)

3. POLICY NO(S) TO BE REINSTATED

4. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and street or rural route, city or P.O., State and

5. SOCIAL SECURITY NUMBER

ZIP Code)

6. VA CLAIM NUMBER

C
7A. AMOUNT OF INSURANCE TO BE
REINSTATED

7B. PLAN OF INSURANCE

7C. DATE OF LAPSE

$

7D. MONTHLY PREMIUM

7E. AMOUNT SENT WITH
THIS APPLICATION

$

$

8. METHOD AND MODE OF PAYMENT FOR FUTURE PREMIUMS
A. METHOD
MONTHLY DEDUCTION FROM VA
PENSION OR COMPENSATION

DIRECT REMITTANCE TO THE
DEPARTMENT OF VETERANS
AFFAIRS

B. AMOUNT OF MONTHLY PENSION
OR COMPENSATION RECEIVED

C. MODE FOR DIRECT REMITTANCE

MONTHLY
QUARTERLY

ALLOTMENT FROM ACTIVE SERVICE
PAY OR SERVICE DEPARTMENT
RETIREMENT PAY

SEMI-ANNUALLY

$

ANNUALLY

CERTIFICATION OF HEALTH

I am applying for reinstatement of my insurance in the amount shown above. As a condition to the reinstatement of this insurance, I
certify that to the best of my knowledge and belief, I am now in as good health as I was on the last day of the grace period (31 days after
the date of lapse.)
SINCE THAT DATE, I have not been ill or suffered or contracted any disease, infirmity, or injury, nor have I been prevented by reason
thereof from attending to my usual occupation, nor have I consulted a physician, surgeon, or other practitioner for medical advice or
treatment at home, hospital, or elsewhere in regard to my health, except as shown below. This statement includes any treatment or
examination by a VA physician acting on behalf of VA, a medical officer in the active service of the Army, Navy, Air Force, Marine
Corps, Coast Guard, or a physician of the Public Health Service. This statement refers to all disabilities, including any service
disabilities.
EXCEPTION: Describe any illness, disease, injury or medical treatment, with dates. Also, give the names and addresses of any and all
doctors, other practitioners and/or hospitals concerned. Use Item 9 , "REMARKS".
9. REMARKS

10. DATE OF SIGNATURE

VA FORM
OCT 2010

29-353

11. SIGNATURE OF INSURED (Do NOT print. This application must be signed and dated)

EXISTING STOCKS OF VA FORM 29-353, MAY 2007,
WILL BE USED.

12. TELEPHONE NUMBER

(Include Area Code)

IMPORTANT INFORMATION AND INSTRUCTIONS
1. PURPOSE
This form may be used for reinstatement of Government Life Insurance when application is sent within 6
months from date of lapse.
2. PREMIUMS NEEDED FOR REINSTATEMENT
a. TERM POLICIES - Two premiums: One for the premium month of lapse and one for the premium month in
which the application is sent to the Department of Veterans Affairs.
b. LIFE AND ENDOWMENT POLICIES - All unpaid premiums (without interest) on the amount of insurance to
be reinstated.
3. DISPOSITION OF APPLICATION
When completed and signed by you, send the application with payment (needed IMMEDIATELY) to:
Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208
Philadelphia, PA 19101
Additional correspondence may also be submitted by Document Upload and fax. Payments may also be submitted by Online Bill Pay.
UPLOAD:
Upload the form using
our secure website at
www.insurance.va.gov

FAX:
1-888-748-5828

ONLINE BILL PAY:

Log into your bank's online bill payment service and follow their instructions for setting up electronic payments. Your bank will need the following
information to set up online bill payments:
• Payee: VA Life Insurance
• Account number: Insurance File number (do not include “F” in your file number)
Some banks may also require you to enter -• Payee Address: PO Box 4019
• City, State, Zip: Portland, OR 97208-4019
• Phone number: 800-669-8477

I UNDERSTAND THAT:
(a) If my application is approved, the last named beneficiary(ies) and
selection of optional settlement(s) on the policy(ies) reinstated, will
continue in effect unless the Department of Veteran Affairs receives a
request for a change in writing over my signature. (VA Form 29-336
should be used to make any change).
(b) The amount of payment needed, as explained above, must be sent
before or with this application.
(c) If my application is acceptable, my policy(ies) will be reinstated on the
premium due date in the premium month my application is sent to the
Department of Veterans Affairs. (For example: If an insurance policy was
effective July 17, 1956, a premium month would always be from the 17th
of each month through the 16th of the following month. If an application
for reinstatement was sent January 4, the effective date of reinstatement
would be December 17.) If an acceptable application is sent on a premium
due date, reinstatement will be effective on that date.
(d) To prevent a lapse of my policy(ies) after applying for reinstatement
premiums must be paid when due or within 31 days after the due date. If
premiums are paid monthly, the next premium will be due on the first
monthly premium due date after the date this application is sent to the
Department of Veterans Affairs.

(e) Any indebtedness against my policy(ies) must be paid or reinstated.
(f) Checks or money orders should be made payable to the Department of
Veterans Affairs and sent to the address shown above.
(g) The Department of Veterans Affairs will, if necessary, ask for a
physical examination report in connection with this application.
(h) Statements made by me in this application are relied upon, any
deception or false statement either by inference, omission, or otherwise
may cause cancellation of the insurance or refusal to pay a claim. In either
case, premiums may not be returned.
(i) I must let the Department of Veterans Affairs know of any change in
my health beginning after the date I sign and before the date I send this
form to the Department of Veterans Affairs.
(j) This form must be fully completed, signed by me and sent immediately
to the address above.

QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL-FREE AT 1-800-669-8477
VA FORM 29-353, OCT 2010