Fillable Va Form 29-4125a - Claim For Monthly Payments National Service Life Insurance printable pdf download

OMB Approved No. 2900-0060

Respondent Burden: 6 Minutes

1. INSURANCE FILE NUMBER

F -

CLAIM FOR MONTHLY PAYMENTS

2. INSURANCE POLICY NUMBER

NATIONAL SERVICE LIFE INSURANCE

Fraction)

3. NET AMOUNT PAYABLE

5. PAYMENT

4. BENEFICIARY'S SHARE (

OPTION

SELECTED BY

INSURED

IMPORTANT - Use this form for all policy prefixes except K. Please type or print in ink when completing this form.

BENEFICIARY - This form is to be used only when monthly payments were selected by the insured, or the beneficiary is selecting

monthly payments instead of one sum. See the directions on the reverse side if you wish to select a Lump Sum Payment.

SIGNATURE - In order to expedite payment of this claim Item 16 must be signed by the beneficiary. If the beneficiary is a minor or

incompetent, the person having custody of the beneficiary should complete the form and give his/her address in Item 12.

We need a photocopy of the veteran's death certificate or a statement from the attending physician showing date and cause of death.

Only one certificate is required for our records.

6. FIRST, MIDDLE AND LAST NAME OF INSURED VETERAN

7. DATE OF BIRTH

8. INSURED'S PLACE OF DEATH

9. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY

10. RELATIONSHIP TO INSURED

11. BENEFICIARY'S DATE OF BIRTH

12. ADDRESS OF BENEFICIARY OR THEIR GUARDIAN

14. BENEFICIARY'S SOCIAL SECURITY NUMBER

13. BENEFICIARY'S DAYTIME

(Include Area Code)

TELEPHONE NUMBER

15. SELECTION OF OPTION

Read the instructions on the reverse side and consult the tables attached before making your selection in the space below.

Check the box for the option selected, or more than one box if more than one option is selected in accordance with Instruction 2 on the reverse side.

If selecting Option 2, please complete all items on the line checked.

OPTION NUMBER

OPTION DESCRIPTION

NUMBER OF EQUAL MONTHLY INSTALLMENTS

(In multiples of 12)

MONTHLY INSTALLMENTS PAYABLE FOR 36 TO 240

MONTHS (In multiples of 12)

MONTHLY INSTALLMENTS CONTINUING THROUGHOUT THE LIFETIME OF THE BENEFICIARY WITH 120

PAYMENTS GUARANTEED.

PROOF OF AGE REQUIRED

MONTHLY INSTALLMENTS CONTINUING THROUGHOUT THE LIFETIME OF THE BENEFICIARY, WHICH WILL

GUARANTEE PAYMENT OF AN AMOUNT AT LEAST EQUAL TO THE BENEFICIARY'S SHARE OF THE FACE

OR NET AMOUNT OF THE CONTRACT.

PROOF OF AGE REQUIRED

NOTE - Settlement under one of these options shall be considered full and complete settlement of all liability under this contract.

This section shall not be valid unless and until it is recorded in the Department of Veterans Affairs. If the beneficiary fails to select an

option, settlement will be based on the option selected by the insured.

IMPORTANT -This form must be signed by the beneficiary, guardian, or fiduciary, in Item 16, in order for payment to be made. If

the beneficiary cannot sign his/her name, but is competent to handle his/her own affairs, an "X", made by the beneficiary and signed

by two disinterested witnesses, is acceptable.

16. SIGNATURE OF BENEFICIARY, FIDUCIARY OR GUARDIAN

17. DATE SIGNED

TO BE COMPLETED BY BENEFICIARY IF DIRECT DEPOSIT IS DESIRED

NAME OF FINANCIAL INSTITUTION

ROUTING TRANSIT NUMBER

ADDRESS OF FINANCIAL INSTITUTION

TYPE OF DEPOSITOR ACCOUNT

CHECKING

SAVINGS

TELEPHONE NUMBER OF FINANCIAL INSTITUTION

DEPOSITOR ACCOUNT NUMBER

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM, PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477

29-4125a

VA FORM

EXISTING STOCKS OF VA FORM 29-4125a, AUG 2002,

NOV 2010

WILL BE USED.

Va Form 29-4125a - Claim For Monthly Payments National Service Life Insurance

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