Form VA Form 29-0812 VA Form 29-0812 Service-Disabled Veterans Insurance - Waiver of Premiums

We have good news. As a VA life insurance policyholder who is rated as qualifying for Individual
Unemployability, you may also be entitled to have the premiums on your insurance policy waived. This
letter will explain what "Waiver of Premiums" is and how it will affect your policy. It will also explain
why we think you may qualify, and give you instructions for applying.

What is Waiver of Premiums?
Waiver of Premiums simply means that, if you are totally disabled and unable to work, you will not have
to pay premiums. You will continue to have all the benefits from your policy. Rest assured that the value
of your policy will not be reduced. There is no disadvantage to having your premiums waived.

Why Do We Think You May Qualify?
You have been rated as qualifying for Individual Unemployability (IU). We use many of the same
guidelines to decide if you qualify for Waiver of Premiums as are used for IU. However, we need some
additional information to determine if we can waive your premiums.

How to Apply
On the reverse side of this letter, you will find a shortened Waiver of Premiums application. Please
follow the directions on the application and then return it to us at:

VAROIC - Insurance Waiver App
PO Box 8638
Philadelphia, PA 19101
Please make sure that you sign the application before returning it.
There is no time limit for applying. But it’s to your benefit to apply quickly. The sooner you apply, the
sooner you may be able to stop paying premiums on your insurance. If you need help completing the
application or have other questions about this letter, call us at 1-800-669-8477.

Department of Veterans Affairs

VA FORM
NOV 2006

29-0812

OMB Control No. 2900-xxxx
Respondent Burden: 20 Minutes

SERVICE DISABLED VETERANS INSURANCE - WAIVER OF PREMIUMS
NAME:

INSURANCE FILE NUMBER:

Note: Please answer Items 1-5, and return this form to the address given on the reverse side.
Address:
1. Personal
Information

Phone: (
2. Social
Security
Benefit

)

Date of Birth:

Are you receiving, or have you applied for any disability benefits from Social Security?
Yes

No

a. Date your disability prevented you from working:
3. Work
Information

b. Date you last physically went to work:
c. Have you returned to work?

If so, when?

Please tell us about your last job (Include self employment)
Dates of Work:

From

To

Occupation
4. Work
History

Reason for leaving
Hours worked weekly

Weekly Earnings

Name, address & phone number of employer

5. Signature

Your signature allows us to process your application and gives us the rights listed below
to collect information that may help us make our decision:
I consent that any physician or hospital who has treated or examined me for any purpose, or whom I have consulted
professionally and any insurance complany or organization to which I have applied for insurance or disability benefits,
may provide to the Department of Veterans Affairs any information concerning myself. A photostatic copy of this consent
shall be considered valid authorization for release of information to VA. I certify that each question has been truthfully and
completely answered to the best of my knowledge.

Don’t forget to
sign & date

Signature of Insured (Or fiduciary completing form for insured)

Date Signed

Penalty - The law provides that whoever makes any statement of a material fact, knowing it is false, shall be punished by fine or imprisonment or
both.
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 routine uses as identifed in 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 required to obtain or retain benefits.
The responses you submit are considered confidential (38 USC 5701).
RESPONDENT BURDEN: We need this information to determine whether you as a VA life insurance policyholder who is rated as qualifying for Individual
Unemployability may be entitled to have the premiums on your insurance policy waived (38 USC 1912). Title 38, USC 1912, allows us to ask for this information.
We estimate that you will need an average of 20 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 www.whitehouse.gov/library/omb/OMBINVC.html#VA. If desired you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.