Fillable Va Form 29-1549 - Application For Change Of Permanent Plan (Medical) (Page 2 of 2) in pdf

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?

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

YES

1 B. DO YOU WORK FULL TIME?

YES

HAVE YOU EVER HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING:

(Check all that apply)

YES

14. ANY DISEASE OF THE PROSTATE OR

2. DISEASE OF THE HEART OR ARTERIES;

TESTES IF A MALE; UTERUS, OVARIES OR

CHEST PAIN?

BREAST IF A FEMALE?

15. DO YOU USE OR HAVE YOU BEEN

3. HIGH BLOOD PRESSURE?

TREATED FOR THE USE OF ALCOHOL OR

ANY HABIT FORMING DRUG?

4. CANCER, TUMOR OR POLYP?

16. WITHIN THE PAST 5 YEARS, HAVE YOU

BEEN TREATED BY A PHYSICIAN?

5. LUNG DISEASE?

17. ARE YOU NOW OR HAVE YOU EVER BEEN

6. EPILEPSY, UNCONSCIOUSNESS,

HOSPITALIZED FOR ILLNESS, DISEASE OR

DIZZINESS OR IMPAIRMENT OF

INJURY?

NERVOUS SYSTEM?

18. DO YOU HAVE ANY SERVICE

7. EMOTIONAL OR MENTAL DISORDER?

CONNECTED DISABILITIES?

19. HAVE YOU EVER APPLIED FOR DISABILITY

8. DISEASE OF THE BLOOD?

COMPENSATION OR PENSION?

9. TUBERCULOSIS, PLEURISY, OR

20. HAS ANY APPLICATION YOU HAVE MADE

BRONCHITIS?

FOR PRIVATE OR GOVERNMENT LIFE,

HEALTH, DISABILITY OR ACCIDENT

10. DIABETES?

INSURANCE BEEN REFUSED, POSTPONED

APPROVED AT SUB-STANDARD RATES

11. ARTHRITIS, PARALYSIS, OR DISEASE,

OR ON A DIFFERENT BASIS THAN

OR DEFORMITY OF THE BONES,

APPLIED FOR?

MUSCLES, OR JOINTS?

21. HEIGHT:

FEET

INCHES

12. DISEASE OR ULCER OF STOMACH,

INTESTINES OR RECTUM?

13. ANY DISEASE OF THE URINARY TRACT,

22. WEIGHT:

POUNDS

SUGAR, ALBUMIN, OR BLOOD IN URINE?

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

24B. DATE

VA FORM 29-1549, MAR 2008

Va Form 29-1549 - Application For Change Of Permanent Plan (Medical) Page 2

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