Va Form 29-4364 - Application For Service-Disabled Veterans Insurance

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OMB Approved No. 2900-0068

Respondent Burden: 20 minutes

APPLICATION FOR SERVICE-DISABLED VETERANS INSURANCE

IMPORTANT INFORMATION

Eligibility

S-DVI provides up to $10,000 of life insurance for eligible veterans. To be eligible for S-DVI, you must meet all three of the

following requirements:

1. You were released from active service in the Armed Forces on or after April 25, 1951, under other than dishonorable conditions.

2. It has been less than 2 years since VA notified you of a new service-connected disability or you are currently waiting for a

rating for your service-connected disability. Please Note: The disability you are rated for must be a new disability, not an

increase in a disability you already have. An increase to 100% or being granted individual unemployability does not automatically

entitle you to a new eligibility period.

3. You are in good health except for your service-connected disability. We will evaluate all health conditions that are not service-

connected. Information about any health conditions should be included on your application.

Cost

Before you apply for S-DVI coverage, we encourage you to compare our premium rates to commercial insurance companies. If

your disability is not serious, you may be able to find better rates from a commercial company.

When considering the cost of S-DVI coverage, remember that if you are or become totally disabled and unable to work for six

or more months you do not have to pay premiums on your Government Life Insurance policy. Most commercial life insurance

companies add an additional charge for this benefit.

Speeding Up the Application Process:

We can process your application more quickly if you send us a copy of the letter from VA that first notified that your disability was

rated service-connected within the last two years. You may also apply online by visiting our website at "

and clicking "Apply for Service-Disabled Veterans Insurance Online".

Mailing Address:

If you meet these criteria, please complete and sign the application and then send immediately to:

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

or fax to 1-888-748-5822.

Questions:

If you have questions about Government Life Insurance, you can call us toll-free at 1-800-669-8477 or visit our website at:

PLEASE BE SURE TO COMPLETE BOTH SIDES OF THIS

APPLICATION

1. Name and Mailing Address for Insurance Purposes

A. First, Middle, Last Name

B. Mailing Address

2. Beneficiary Designation and Selection of Settlement Option - The preprinted phrase "Or to survivors" means that a share of a beneficiary(ies) who dies before you will

be paid to the surviving beneficiaries. For example, if you name three principal beneficiaries and one dies before you, the share will be paid to the remaining two principal

beneficiaries.

Complete Name and Address of Each Principal and Contingent

Beneficiary's Social

Relationship of

Share to be paid to

Payment Option

(For married women, enter her own first and middle names.

the beneficiary

each beneficiary

for Each Beneficiary

Beneficiary

Security Number