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 by VA as qualifying for
Individual Unemployability, you may also be entitled to a waiver of your premiums. 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 if you are totally disabled and unable to work, you will not have to
pay premiums. You will continue to have all the benefits and full coverage from your policy.

Why Do We Think You May Qualify?
The VA has rated you as qualifying for Individual Unemployability. The rules to qualify for Individual
Unemployability and waiver of premiums are very similar. However, we need some additional
information to determine if we can waive your premiums.

How to Apply
On the reverse side of this letter is a 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 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
APR 2008

29-0812

OMB Control No. 2900-0700
Respondent Burden: 20 Minutes

SERVICE DISABLED VETERANS INSURANCE - WAIVER OF PREMIUMS
Note: Please answer Items 1-5, and return this form to the address given on the reverse side.
NAME:

INSURANCE FILE NUMBER:

Address:
1. Personal
Information

Phone: (
2. Social
Security
Benefit

3. Work
Information

)

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:
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
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:
5. Signature
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 company 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: 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 1.576 for routine uses identified in 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 mandatory.
RESPONDENT BURDEN: We need this information to determine your eligibility for a waiver of premiums on your government life insurance. Title 38, United States
Code, 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/OMBINV.VA.EPA.html#VA. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions
about this form.