Va Form Fl 29-459 - Claim For Disability Insurance Benefits Page 2
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2OMB Approved No. 2900-0066
Respondent Burden: 10 minutes
PRIVACY ACT INFORMATION - The 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 5 Code of Federal Regulations 1.526 for routime uses indentified 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 voluntary, but your failure to provide us the information could impede processing.
RESPONDENT BURDEN - We need this information to help us make a decision on the claim for disability insurance benefits under consideration
(38 U.S.C. 1912, 1915, 1942 and 1948). We estimate that you will need an average of 10 minutes per response 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.
1. DATES OF EMPLOYMENT
2. INSURED WORKED
3. AVERAGE NO. HOURS WORKED
4. AVERAGE WAGES
FROM
TO
DAILY
WEEKLY
FULL-TIME
PART-TIME
5. LAST DAY INSURED WORKED
6. REASON
7. TYPE OF DUTIES PERFORMED
8. DATES INSURED DID NOT WORK BECAUSE OF ILLNESS
9. NATURE OF ILLNESS
10. REMARKS
11A. SIGNATURE AND TITLE
11B. DATE SIGNED
FL 29-459
AUG 2007(R)
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