Fillable Va Form 29-357 - Claim For Disability Insurance printable pdf download

OMB Approved No. 2900-0016

Respondent Burden: 1 hour 45 minutes

Expiration Date: 6-30-2015

CLAIM FOR DISABILITY INSURANCE

GOVERNMENT LIFE INSURANCE

PRIVACY ACT INFORMATION: 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, and published in the Federal Register. Your obligation to respond is required to obtain this benefit. 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.

RESPONDENT BURDEN: We need this information to determine your eligibility for VA insurance benefits. Title 38, United States Code, allows us to ask for this

information. We estimate that you will need an average of 1 hour and 45 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 your comments or suggestions about this form.

INFORMATION AND INSTRUCTIONS

THIS APPLICATION IS TO BE COMPLETED BY VETERANS WHO HAVE GOVERNMENT LIFE INSURANCE

AND BECOME TOTALLY DISABLED.

TOTAL DISABILITY:

1. Any impairment of mind or body which makes it impossible for the veteran to be gainfully employed.

2. Total Disability must start before the veteran's 65th birthday.

WAIVER REFUND

1. Premium Refunds limited to one year prior to date the claim is filed, unless there were circumstances beyond the

veteran's control (such as a severe mental disability). LACK OF KNOWLEDGE OF THE WAIVER PROVISION IS

NOT A CIRCUMSTANCE BEYOND THE VETERAN'S CONTROL.

2. If total disability started more than one year prior to the date of your claim, and you believe a mental disability

prevented you from filing an earlier claim, please include a statement explaining these circumstances on a separate sheet of

paper. YOU SHOULD ALSO INCLUDE ANY MEDICAL EVIDENCE WHICH SUPPORTS YOUR

STATEMENT.

PART I should be completed by the insured veteran if able; if not, by a person acting on his/her behalf.

PART II should be completed by the insured veteran's physician or hospital official. If there will be a delay in preparing

Part II send Part I immediately.

NOTE: IF THE VETERAN HAS BEEN GRANTED DISABILITY BENEFITS FROM THE SOCIAL SECURITY

ADMINISTRATION, PLEASE ATTACH A COPY OF THE AWARD LETTER.

PART I

(Type or print)

2. INSURANCE FILE NUMBER (Include letter prefix)

1. FIRST, MIDDLE, LAST NAME OF INSURED

(Number and Street or Rural

4. SOCIAL SECURITY NUMBER

3. MAILING ADDRESS FOR INSURANCE PURPOSES

Route, City or P.O., State and ZIP Code)

5. DATE OF BIRTH

6. DAYTIME TELEPHONE NUMBER (Include Area Code)

7. CLAIM NUMBER

8. DATE DISABILITY PREVENTED EMPLOYMENT

9. DATE RETURNED TO GAINFUL EMPLOYMENT

10A. EDUCATION (Check highest years completed) (If you have any other specialized training or education please complete Item 10B)

(Grade School)

(High School)

(College)

10B. PLEASE PROVIDE ANY SPECIALIZED TRAINING IN THE SPACE PROVIDED BELOW

11. ARE YOU RECEIVING OR HAVE YOU APPLIED FOR ANY

12. DISEASE OR INJURY CAUSING TOTAL OR PERMANENT DISABILITY

DISABILITY BENEFITS AS LISTED BELOW?

VA DISABILITY

SOCIAL SECURITY

VA PENSION

COMPENSATION

DISABILITY

29-357

VA FORM

EXISTING STOCKS OF VA FORM 29-357, JUN 2008,

APR 2012

WILL BE USED.

Va Form 29-357 - Claim For Disability Insurance

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