VA Form 29-0152 Application for Conversion Government Life Insurance

OMB Control No. 2900-0149
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX

APPLICATION FOR CONVERSION
GOVERNMENT LIFE INSURANCE
PRIVACY ACT INFORMATION: No insurance may be converted unless a completed application form has been received (38 U.S.C. 1904 and 1942). The 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 as identified in VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life Insurance - VA,
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: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently
valid OMB control Number. The OMB control number for this project is 2900-0149, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to
OMB Control No. 2900-0149 in any correspondence. Do not send your completed VA Form 29-0152 to this email address.
1. INSURANCE POLICY NUMBER TO BE CONVERTED (Include letter prefix)
IMPORTANT
(If more than one policy, please complete a separate form for each policy
(Answer all items. (See VA Pamphlet 29-73-1)
number)
Do not return policy with this form.)
2. FIRST, MIDDLE, LAST NAME OF INSURED AND MAILING ADDRESS FOR
INSURANCE PURPOSES (Include number and street or rural route, P.O.

3. VA CLAIM NUMBER (If any)

Box, city, state, ZIP Code and country)

4. SOCIAL SECURITY NUMBER

5. DAYTIME TELEPHONE NUMBER (Include Area Code)

6B. AMOUNT OF INSURANCE TO BE CONVERTED

6A. PERMANENT PLAN(S) APPLIED FOR
ORDINARY LIFE

ENDOWMENT AT AGE 60

20 PAYMENT LIFE

ENDOWMENT AT AGE 65

30 PAYMENT LIFE

MODIFIED LIFE 65

20 YEAR ENDOWMENT

MODIFIED LIFE 70

$

6C. IF YOU ARE NOT CONVERTING THE ENTIRE POLICY, DO YOU WISH TO
CONTINUE ANY TERM INSURANCE?
YES

NO

(If "YES" enter amount $

7. METHOD OF PREMIUM PAYMENT
A. DESIRED METHOD OF PAYMENT (Check one)

B. DESIRED METHOD FOR DIRECT PAYMENT OF FUTURE PREMIUMS

(Check one)

DIRECT PAYMENT TO VA (If checked, complete Item 7B)

MONTHLY

MONTHLY DEDUCTION FROM VA PENSION OR COMPENSATION

ANNUAL

MONTHLY ALLOTMENT FROM RETIREMENT/ACTIVE SERVICE PAY
VA MATIC (Automatic Checking Account deduction)

8. PAYMENT AMOUNT
AMOUNT OF FIRST PREMIUM

$

9A. ARE YOU NOW DISABLED?
YES

NO

(If "YES," give name of disability below and complete
Items 9B and 9C) (If "No," go to Item 10)

9B. DATE LAST TREATED BY PHYSICAN OR HOSPITAL

(Include VA Physician or hospital)

9C. DOES YOUR DISABILITY PREVENT YOU FROM WORKING?
YES

NO

(If "YES," explain fully below)

UPLOAD:
The fastest and most secure way to send your application to VA Insurance is to use
the document upload service at https://insurance.va.gov/home/IDU.

OR MAIL THE COMPLETED FORM TO:
VAROIC
P.O. BOX 42954
PHILADELPHIA, PA 19101
10B. DATE OF APPLICATION

10A. SIGNATURE OF APPLICANT

IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, CALL US TOLL-FREE AT 1-800-669-8477.
VA FORM
XXX XXXX

29-0152

EXISTING STOCK OF VA FORM 29-0152, JUL 2021,
WILL BE USED.

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