VA Form 29-8701 Application for Ordinary Life Insurance (Age 70)

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

APPLICATION FOR ORDINARY LIFE INSURANCE

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

REPLACEMENT INSURANCE FOR MODIFIED LIFE REDUCED
AT AGE 70 NATIONAL SERVICE LIFE INSURANCE
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 bases will be used by VA employees and your authorized representatives in the maintenance of Governments 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 1-800-821-1000 for mailing 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 70th birthday.
2. FIRST NAME, MIDDLE NAME AND LAST NAME OF INSURED

3. DAYTIME TELEPHONE NUMBER

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

(COMPLETE ONLY IF DIFFERENT THAN THAT SHOWN OF REVERSE)

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
70th birthday.

5. AMOUNT OF INSURANCE APPLIED FOR

$

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

29-8701

SUPERSEDES VA FORM 29-8701, JUN 2000,
WHICH WILL NOT BE USED.