Va Form 29-353 - Application For Reinstatement (Non Medical - Comparative Health Statement)
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2OMB 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 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 as identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA, and published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in
the denial of benefits. 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. The responses you submit are considered confidential (38 U.S.C. 5701).
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 If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about
this form.
(Include letter prefix)
1. INSURANCE FILE NO.
Use this form if you apply for reinstatement within 6 months from date of lapse. Before completing this form,
All numbered
please read the the IMPORTANT INFORMATION AND INSTRUCTIONS on back. Type or use ink.
items must be completed.
F
(Type or print)
3. POLICY NO(S) TO BE REINSTATED
2. FIRST NAME-MIDDLE NAME-LAST NAME OF INSURED
(Number and street or rural route, city or P.O., State and
5. SOCIAL SECURITY NUMBER
4. MAILING ADDRESS FOR INSURANCE PURPOSES
ZIP Code)
6. VA CLAIM NUMBER
C
7A. AMOUNT OF INSURANCE TO BE
7B. PLAN OF INSURANCE
7C. DATE OF LAPSE
7D. MONTHLY PREMIUM
7E. AMOUNT SENT WITH
REINSTATED
THIS APPLICATION
$
$
$
8. METHOD AND MODE OF PAYMENT FOR FUTURE PREMIUMS
A. METHOD
B. AMOUNT OF MONTHLY PENSION
C. MODE FOR DIRECT REMITTANCE
OR COMPENSATION RECEIVED
MONTHLY DEDUCTION FROM VA
DIRECT REMITTANCE TO THE
MONTHLY
PENSION OR COMPENSATION
DEPARTMENT OF VETERANS
AFFAIRS
QUARTERLY
ALLOTMENT FROM ACTIVE SERVICE
SEMI-ANNUALLY
PAY OR SERVICE DEPARTMENT
RETIREMENT PAY
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
(Do NOT print. This application must be signed and dated)
10. DATE OF SIGNATURE
12. TELEPHONE NUMBER
11. SIGNATURE OF INSURED
(Include Area Code)
VA FORM
EXISTING STOCKS OF VA FORM 29-353, MAY 2007,
29-353
OCT 2010
WILL BE USED.
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