Va Form 29-4364 - Application For Service-Disabled Veterans Insurance Page 2

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EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN ON THIS SIDE

3. VA Claim Number (If any)

4. Social Security No.

5. Date of Birth

6. Daytime Telephone Number

7. Email address

(Month, Day,Year)

(Include Area Code)

8. ENTER THE AMOUNT, PLAN, AND PREMIUM OF THE INSURANCE FOR WHICH YOU ARE APPLYING

(See Pamphlet 29-9 - Service-Disabled Veterans Insurance Information and Premium Rates)

A. Amount of Insurance

B. Plan of Insurance

C. Monthly Premium

9B. Do you work full-time? (If "Yes," skip

9C. If you are not working part-time, explain why (Please be specific)

9A. Are you now working?

to Item 10)

YES

9D. When did you last work full-time?

9E. What was your occupation?

10. Check the method showing how you wish to pay for this insurance (If you are not eligible for waiver of premiums)

A. I want to pay premiums by a monthly deduction from my VA Compensation or Pension. (We will start the deduction for you if the insurance is approved)

B. I want to pay premiums by a monthly allotment from my military service/retirement pay. (We sill start the allotment for you if the insurance is approved)

C. I want VA to automatically withdraw the premium each month from my bank account (VA MATIC) (Send your first payment with this application)

D. I will send premiums directly to VA as follows (Send your first payment with this application)

Monthly

Quarterly

Semi-Annually

Annually

11. Have you had any of the following:

12. If your answer to any part of Item 11 is "YES," give dates,

YES

duration and other details. (If more space is needed, attach a

A. Lung condition?

separate sheet)

B. Mental or nervous disorders?

C. Blood disorder?

D. Heart condition?

E. Cancer or tumor?

F. Diabetes?

13. Have you had any other physical defect or disease? (If "YES", explain below)

YES

CERTIFICATION: I have reviewed all of my answers above and certify that they are true and correct to the best of my knowledge and belief.

14A. Signature of Applicant (Do NOT print, sign in ink)

14B. Date

Privacy Act Notice: 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, published in the Federal Register. Your obligation to respond is required to obtain this benefit. Giving us your social security number is

voluntary. Refusal to provide your social security number by itself will not result in the denial of this benefit. VA will not deny an individual benefits for refusing to

provide his or her social security number unless the disclosure of the social security number 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 (38 U.S.C. 1922). Title 38, United States Code, allows us to ask

for this information. We estimate that you will need an average of 20 minutes to review the information, 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 If desired, you can call 1-800-827-1000

to get information on where to send comments or suggestions about this form.

VA FORM 29-4364, DEC 2010