VA Form 29-8700 Application For Ordinary Life Insurance (Age 65)

OMB Approved No. 2900-0166
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX
1A. INSURANCE FILE NUMBER

APPLICATION FOR ORDINARY LIFE INSURANCE
REPLACEMENT INSURANCE FOR MODIFIED LIFE REDUCED
AT AGE 65 NATIONAL SERVICE LIFE INSURANCE

1B. NEW POLICY NO. (Assigned by VA)

PRIVACY ACT - No insurance may be granted unless a completed application has been received (38 U.S.C. 1904). The information provided on a voluntary basis will
be used by VA employees and your authorized representatives in the maintenance of Government insurance programs. Responses may be disclosed outside VA only if
the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel
U.S. Government Life Insurance Records - VA, published in the Federal Register.
RESPONDENT BURDEN - VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid
OMB Control Number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.

IMPORTANT - This application and the first premium must be submitted to the Department of Veterans Affairs BEFORE your 65th birthday.
3. DAYTIME TELEPHONE NUMBER (Include Area Code)

2. FIRST - MIDDLE - LAST NAME OF INSURED

4. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and street or rural route, city or post office, STATE and Zip Code)

5. AMOUNT OF INSURANCE APPLIED FOR

I wish to apply for the amount of insurance shown in the block to the right as
replacement for the insurance coverage that will end on the day before my
65th birthday.
I UNDERSTAND that the beneficiary designation and optional settlement under this new policy will be the same as on my Modified Life policy and will remain the
same until I submit a change in writing to the Department of Veterans Affairs.
6. SIGNATURE OF INSURED (Do not print. Sign in ink)

7. DATE OF APPLICATION

When completed, mail this application and the first premium to the Department of Veterans Affairs at the address shown on the reverse.
VA FORM
MAR 2014

29-8700

SUPERSEDES VA FORM 29-8700, JUN 2000,
WHICH WILL NOT BE USED.