29-10277 Application for Veterans Affairs Life Insurance (VALife)

OMB Approved No. 2900-NEW
Respondent Burden: 10 minutes
Expiration Date: XXXXXXX

APPLICATION FOR VETERANS AFFAIRS LIFE INSURANCE (VALife)
IMPORTANT: For use only by authorized agents acting on behalf of a veteran.
This is an electronic form only. Do not print or mail this form. Printed versions of this form will not be accepted.
If you have questions about Government Life Insurance, you can visit our website at: www.benefits.va.gov/insurance or call us toll-free at 1-800-669-8477.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
1. NAME (First, Middle, Last Name)

2. SOCIAL SECURITY NUMBER

3. DATE OF BIRTH (MM/DD/YYYY)

4. VA CLAIM NUMBER

5. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

6. EMAIL ADDRESS

7. PHONE NUMBER (Include Area Code)

SECTION II: AGENT ACTING ON BEHALF OF VETERAN
8. NAME OF AGENT ACTING ON BEHALF OF VETERAN (Guardian, Attorney-in-Fact, VA Fiduciary - You must attach proof of authority.)

9. MAILING ADDRESS OF AGENT ACTING ON BEHALF OF VETERAN (Street Address, Unit/Apt. Number, City, State, ZIP Code)

10. EMAIL ADDRESS OF AGENT ACTING ON BEHALF OF VETERAN
(Guardian, Attorney-in-Fact, VA Fiduciary)

11. PHONE NUMBER OF AGENT ACTING ON BEHALF OF VETERAN
(Include Area Code)

SECTION III: BENEFICIARY DESIGNATION

Insurance will be paid based on the order of precedence prescribed in 38 USC 1922B(e)(2) unless a court order is provided
specifying the beneficiary(ies) of the policy. (A copy of the court order must be attached to this form prior submission.)

IMPORTANT: Please attach proof of authority and other supporting documentation by selecting the icon to the right.
SECTION IV: AMOUNT OF INSURANCE, PREMIUM AND PAYMENT METHOD
12. AMOUNT OF INSURANCE
$40,000

$30,000

$20,000

$10,000

13. AMOUNT OF MONTHLY PREMIUM (Go to Veteran Affairs Life Insurance (VALI) Premium Rates - Life Insurance for premium rates. You must
submit first premium within 30 days of application.)

14. PREMIUM PAYMENT METHOD (Choose only one. We will contact you about paying the initial premium to complete/validate your application.
I want to pay premiums by a monthly deduction from the veteran's Compensation or Pension.
(We will start the deduction for you if the insurance is approved.
I want to pay premiums by a monthly allotment from the veteran's military service retirement pay.
(We will start the allotment for you if the insurance is approved.
I want VA to automatically withdraw the premium each month from the veteran's checking account.
Please provide the veteran's bank routing number and account number.
Bank Routing Number

Checking Account Number

I will pay premiums directly through EBilling. We will notify you by email with instructions on how to pay the premiums electronically.
Monthly
VA FORM
XXXX

29-10277

Annually
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SECTION V: 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.
15. ELECTRONIC SIGNATURE OF AGENT ACTING ON BEHALF OF VETERAN

16. Date (MM/DD/YYYY)

PRIVACY ACT NOTICE: 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, 36VA29, "Veterans and Uniformed Services Personnel
Programs of U.S. Government Life Insurance - VA” (36VA29), published at 75 FR 65405-02, October 22, 2010. Your response is required to obtain this benefit.
Giving us your social security number is voluntary. Refusal to provide your social security number by itself will not result in the denial of this benefit. VA will not
deny an individual benefits for refusing to provide his or her social security number unless the disclosure of the social security number is required by a Federal Statute
of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: We need this information to determine your eligibility for VA Insurance benefits (38 U.S.C. 1922). Title 38, United States Code, allows
us to ask for this information. We estimate that you will need an average of 10 minutes to review the information, 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.
VA FORM 29-10277, XXXX

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