Form 29-8485 APPLICATION FOR ORDINARY LIFE INSURANCE REPLACEMENT INSU

OMB Control No. 2900-0166
Respondent Burden: 5 minutes
Expiration Date: XXXXXXX

1. INSURANCE FILE NUMBER (Include letter
prefix)

APPLICATION FOR ORDINARY LIFE INSURANCE

2. EMAIL ADDRESS

REPLACEMENT INSURANCE FOR MODIFIED LIFE REDUCED
AT AGE 65
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 5, Code of Federal Regulations 1.526 for routine uses identified in VA system of records, 36VA29, Veterans and
Uniformed Services Personnel Programs of U.S. Government Life Insurance - VA, and published in the Federal Register. Your obligation to respond is
required to obtain or retain benefits. The responses you submit are considered confidential (38 USC 5701).
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 65th birthday.
3. FIRST NAME - MIDDLE NAME - LAST NAME OF INSURED

4A. MAILING ADDRESS 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 65th 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 SUBMIT THIS APPLICATION WITH YOUR FIRST PREMIUM PAYMENT TO VA USING THE OPTIONS BELOW.

The fastest and most secure way to send your
application to VA Insurance is to use our document
upload service at
https://insurance.va.gov/home/IDU.

VA FORM
XXXX

29-8485

MAIL THE COMPLETED FORM TO:
VAROIC
P.O. BOX 7787
PHILADELPHIA, PA 19101

SUPERSEDES VA FORM 29-8485, MAY 2018,
WHICH WILL NOT BE USED.

You may submit payments to VA Life Insurance through your
preferred banking institution online Bill Pay feature. Select
"VA Life Insurance" as the Payee and enter your Insurance
File Number as the Account Number.
• VA Collections Address:
PO Box 4019
Portland, OR 97208-4019