VA Form 29-0151 Application For Service-Disabled Veterans Insurance

OMB Control No. 2900-0068
Respondent Burden: 40 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR SERVICE-DISABLED
VETERANS INSURANCE

IMPORTANT INFORMATION
• S-DVI provides up to $10,000 of life insurance for eligible veterans. To apply for this coverage, read the instructions below and
complete both sides of the application. Make sure you sign and date the form.
• Cost
Before you apply for S-DVI coverage, we encourage you to compare our premium rates to commercial insurance companies. If your
disability is not serious, you may be able to find better rates from a commercial company.
When considering the cost of S-DVI coverage, remember that if you are or become totally disabled and unable to work for six or
more months you do not have to pay premiums on your S-DVI policy. Most commercial life insurance companies add an additional
charge for this benefit.
• Speeding Up the Application Process
We can process your application more quickly if you send us a copy of the letter from VA that first notified you that your disability
was rated service-connected within the last two years. You may also apply online by visiting our website at : "www.insurance.va.gov"
and clicking "Apply for Service-Disabled Veterans Insurance Online".
• Mailing Address
Please complete and sign the application and then send immediately to:
Department of Veterans Affairs Regional Office and Insurance Center (RH)
P.O. Box 7208, Philadelphia, PA 19101
• Questions
If you have questions about Government Life Insurance, you can contact us toll-free at 1-800-669-8477 or at www.insurance.va.gov.

Please be sure to complete both sides of this application.
1. Enter the amount, plan, and premium of the insurance for which you are applying. (See Pamphlet 29-9, Service-Disabled Veterans Insurance
Information and Premium Rates).
B. PLAN OF INSURANCE
A. AMOUNT OF INSURANCE
C. MONTHLY PREMIUM
2. CHECK THE METHOD SHOWING HOW YOU WISH TO PAY FOR THIS INSURANCE:
A. I WANT TO PAY PREMIUMS BY A MONTHLY DEDUCTION FROM MY VA COMPENSATION OR PENSION. (VA will start the deduction for you)
B. I WANT TO PAY PREMIUMS BY A MONTHLY ALLOTMENT FROM MY MILITARY SERVICE/RETIREMENT PAY. (VA will start the allotment for you)
C. I WANT VA TO AUTOMATICALLY WITHDRAW THE PREMIUM EACH MONTH FROM MY BANK ACCOUNT (VA MATIC). (Send first payment with this form)
D. I WILL SEND PREMIUMS DIRECTLY TO VA AS FOLLOWS: (Send first payment with this form)

QUARTERLY

MONTHLY

3A. ARE YOU NOW WORKING?
YES
VA FORM
XXX XXXX

NO

29-0151

ANNUALLY
SEMI-ANNUALLY
3B. DO YOU WORK FULL-TIME? 3C. IF YOU ARE NOT WORKING OR WORKING PART-TIME EXPLAIN WHY
(Please be specific)
YES
NO

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EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN AT THE BOTTOM OF THIS PAGE.
4A. ARE YOU NOW HOSPITALIZED? (If "Yes," for what condition(s)? Please list below)

4B. NAME AND ADDRESS OF HOSPITAL

5. HAVE YOU EVER BEEN TREATED FOR THE USE OF ALCOHOL OR DRUGS, INCLUDING MARIJUANA, SEDATIVES, STIMULANTS, ETC.?
(If "YES", give date(s) and type of treatment(s))
YES

NO
YES

6. HAVE YOU HAD ANY OF THE FOLLOWING:
A. LUNG CONDITION?

NO

7. IF YOUR ANSWER TO ANY PART OF ITEM 6 IS
"YES," GIVE DATES, DURATION AND OTHER
DETAILS (If more space is needed, attach a separate
sheet)

B. MENTAL OR NERVOUS DISORDERS?
C. BLOOD DISORDER?
D. HEART CONDITION?
E. HIGH BLOOD PRESSURE?
8. HAVE YOU HAD ANY OTHER PHYSICAL DEFECT OR
DISEASE? (If "Yes," explain below)

F. PARALYSIS?
G. CANCER OR TUMOR?

YES

H. STOMACH CONDITION?

NO

I. DIABETES?
J. SEIZURE DISORDER?
9A. HEIGHT
Feet

Inches

9B. WEIGHT

9C. HAS YOUR WEIGHT CHANGED MORE THAN 10 POUNDS DURING THE
PAST TWO YEARS? (If "Yes," give complete details below including amount
gained or lost and length of time present weight maintained)
YES

10. DATE OF BIRTH

Lbs.
NO
11. DAYTIME TELEPHONE NO. (Include Area Code)

12. EMAIL ADDRESS (If applicable)

13. Beneficiary Designation and Selection of Settlement Option - The preprinted phrase "Or to Survivors" means that the share
of a beneficiary(ies) who dies before you will be paid to the surviving beneficiaries. For example, if you name three principal
beneficiaries and one dies before you, the share will be paid to the remaining two principal beneficiaries.
Complete Name and Address of Each Principal
and Contingent Beneficiary (For married women, enter
her own first and middle names For example, Mary Rose Smith, not Mrs. John Smith)

Beneficiary's Social
Security Number (If known) Relationship of the
beneficiary to you
(This is not required for
this designation to be
valid)

Share to be paid to
each beneficiary
(Use $ amounts,
%, or fractions

Payment Option for Each
Beneficiary (See
pamphlet for more
information)

Or to survivors
Contingent Person(s) who get the proceeds if the
principal beneficiary(ies) die before the insured. If none,
write "NONE"

Or to survivors
14A. SIGNATURE OF APPLICANT (Do NOT print, sign in ink)

14B. DATE SIGNED

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 1.526 for routine uses as 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. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. Giving us your SSN account information is voluntary. Refusal to
provide your SSN by itself will not result in denial of benefits. The 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. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN - We need this information to determine, establish or verify your eligibility for VA Insurance benefits (38 U.S.C. 722). Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 40 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send your comments about this form.

VA FORM 29-0151, XXX XXXX

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