29-8485a Application For Ordinary Life Insurance

OMB Control No. 2900-0166
Respondent Burden: 5 minutes
Expiration Date: 10/31/2017

1. INSURANCE FILE NUMBER (Include letter
prefix)

APPLICATION FOR ORDINARY LIFE INSURANCE

2. POLICY NUMBER ON NEW INSURANCE
(To be assigned by VA)

REPLACEMENT INSURANCE FOR MODIFIED LIFE REDUCED
AT AGE 70
NATIONAL SERVICE LIFE INSURANCE

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 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S.
Government Life Insurance Records - VA and published in the Federal Register. Information provided on a voluntary basis will be used by VA employees and your
authorized representatives in the maintenance of Government Insurance programs.
RESPONDENT BURDEN: We need this information from you to purchase additional government life insurance. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 5 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 comments or suggestions about this form.
IMPORTANT: This application and the initial premium must be submitted to the Department of Veterans Affairs before your 70th birthday.
3. FIRST NAME - MIDDLE NAME - LAST NAME OF INSURED
4A. MAILING ADRESS FOR INSURANCE PURPOSES (Number and street or rural route, city or P.O., State and ZIP Code)

4B. IS THIS A CHANGE OF ADDRESS FOR YOUR INSURANCE RECORDS? (Check one)
YES

5. DAYTIME TELEPHONE NUMBER (Include Area Code)

NO

I wish to apply for the amount of insurance shown in Item 6, the block to the right, as replacement for the
insurance that will end on the day before my 70th birthday.

6. AMOUNT OF INSURANCE APPLIED FOR

I understand that the beneficiary designation and optional settlement under this new policy will remain the same as that on my Modified Life policy and will remain so
until I submit a change in writing to the Department of Veterans Affairs.
7. SIGNATURE OF INSURED (Do not print) (Sign in ink)

8. DATE OF APPLICATION

9. PLEASE MAIL THIS APPLICATION TO THE VA OFFICE BELOW.

Department of Veterans Affairs
Regional Office and Insurance Center
P.O Box 7787
Philadelphia, PA 19101
VA FORM
OCT 2014

29-8485a

SUPERSEDES VA FORM 29-8485a, MAR 2008,
WHICH WILL NOT BE USED.