21-0151 Application for Service-Disabled Veterans Insurance

OMB Control No. 2900-0068
Respondent Burden: 40 minutes
Expiration Date: XXXXXXX

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.
• Submitting your Application Online
The fastest and most secure way to submit your application to VA Insurance is to use the document upload service at:
https://insurance.va.gov/home/IDU.
• If you prefer to Mail the Application
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 VA 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).
A. AMOUNT OF INSURANCE

B. PLAN OF INSURANCE

C. MONTHLY PAYMENT

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)

MONTHLY
VA FORM
XXXX

29-0151

ANNUALLY

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EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN AND DATE AT THE BOTTOM OF THIS PAGE.
3A. ARE YOU NOW WORKING?
YES

3B. DO YOU WORK FULL-TIME?

NO

YES

3C. IF YOU ARE NOT WORKING OR WORKING PART-TIME EXPLAIN
WHY (Please be specific)

NO
3E. WHAT WAS YOUR OCCUPATION?

3D. WHEN DID YOU LAST WORK FULL TIME?

4. HAVE YOU HAD ANY OF THE FOLLOWING:

YES

A. LUNG CONDITION?

NO

5. IF YOUR ANSWER TO ANY PART OF ITEM 4 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. CANCER OR TUMOR?
F. DIABETES?
6. HAVE YOU HAD ANY OTHER PHYSICAL DEFECT OR
DISEASE? (If "Yes," explain below)
YES

NO

7. SOCIAL SECURITY NUMBER

8. DATE OF BIRTH

9. DAYTIME TELEPHONE NO. (Include Area Code)

10. EMAIL ADDRESS (If applicable)

11. 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
(This is not required for
beneficiary to you
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)

PRINCIPAL
LUMP SUM

LUMP SUM
Or to survivors
Contingent Person(s) who get the proceeds if the
principal beneficiary(ies) die before the insured. If none,
write "NONE"
CONTINGENT
LUMP SUM
LUMP SUM
Or to survivors
Certification: I have reviewed all of my answers above and certify that they are true and correct to the best of my knowledge and belief.
12A. SIGNATURE OF APPLICANT (Do NOT print, sign in ink)

12B. 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, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life Insurance -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, XXXX

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