29-352R Application for Reinstatement of Veterans Affairs Life I

OMB Control No. 2900-0011
Respondent Burden: 15 minutes
Expiration Date: XXXXX

APPLICATION FOR REINSTATEMENT OF VETERANS AFFAIRS LIFE INSURANCE (VALIFE)
(INSURANCE LAPSED MORE THAN 6 MONTHS)

(FOR USE BY VA INDEX)

INSTRUCTIONS
Use this form only if you are unable to apply for reinstatment through your online account and your policy has lapsed for more than 6 months but less
than 2 years. VALife can only be reinstated within 2 years of lapse as long as you are age 80 or under. After this period, you may be eligible to apply
for VALife again, if you meet certain eligibility criteria; please note that there would be another 2-year waiting period before the face amount of the
coverage would be payable as a death benefit.
Prior to completing this form, please call our toll-free number 1-800-669-8477 and we will provide the amount of payment needed to reinstate your
policy(ies) noted in block 10D (premium and interest). Interest is payable if your policy has lapsed for more than 6 months. Your payment must be
received before or with your application.
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.
When completed, this application should be submitted by Document Upload Payments and may then be submitted through Online Bill Pay.

DOCUMENT UPLOAD:

ONLINE BILL PAY:

Upload the form using our secure
website at:
https://insurance.va.gov/Home/IDU

You can log on to your bank's online bill payment
service and follow their instructions for setting up an
electronic payment. Your bank will need the
following information to set up online bill payments.

This application can also he mailed with
your payment to:

• Payee: VA Life Insurance
• Account Number: Insurance Policy Number
Some banks may also require you to enter:
• Payee Address: P.O. Box 4019
• City, State, ZIP Code: Portland, OR 97208 - 4019
• Phone Number: 800-669-8477

Department of Veterans Affairs
Insurance Center
P.O. Box 7208
Philadelphia, PA 19101

SECTION I - APPLICANT'S INFORMATION (Note: *indicates a required field)
1. FIRST NAME - MIDDLE - LAST NAME OF INSURED*

2. POLICY NUMBERS TO BE REINSTATED*

3. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and street or rural route, city or P.O., State and ZIP Code)*

4. CELL PHONE NUMBER*

(Include Area Code)

5. PHONE NUMBER*

(Include Area Code)

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

7. SOCIAL SECURITY NUMBER*

8. VA CLAIM NUMBER

9. EMAIL ADDRESS*

IMPORTANT: Insureds can access their account online and can request to have all communications sent electronically, unless incompetent by VA. If you wish to view
your account online and would like to receive electronic communications, please select the preferred method below.
By checking either box below, I consent to receive electronic communications, including text and/or email, from the Department of Veterans Affairs regarding Veterans
Life Insurance.
EMAIL

TEXT

*(If neither box is selected, all correspondence will be released via postal mail.

SECTION II - REINSTATEMENT REQUEST
10A. AMOUNT OF INSURANCE TO BE
REINSTATED*

$
VA FORM
XXXX

10B. DATE OF LAPSE

(MM/DD/YYYY)

10C. MONTHLY PREMIUM

(Mailed or Online Bill Pay)

$

29-352R

10D. AMOUNT REQUIRED TO REINSTATE
INCLUDED WITH THIS APPLICATION

$
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SECTION III - PREMIUM METHOD FOR FUTURE PREMIUMS
11. PREMIUM PAYMENT METHOD (Choose only one)*
I WANT TO PAY PREMIUMS BY A MONTHLY DEDUCTION FROM MY VA COMPENSATION OR PENSION. (We will start the deduction for you if the application

is approved.)

I WANT TO PAY PREMIUMS BY A MONTHLY ALLOTMENT FROM MY MILITARY SERVICE RETIREMENT PAY. (We will start the allotment for you if the

application is approved.)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

I WANT VA TO AUTOMATICALLY WITHDRAW THE PREMIUM EACH MONTH FROM MY CHECKING ACCOUNT.
Please provide your bank routing number and account number.
Name of Bank or Financial Institution
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. (You must select monthly or annually.)
MONTHLY

ANNUALLY

AUTHORIZATION FOR DEDUCTION FROM BENEFIT PAYMENTS OR CHECKING ACCOUNTS:
The Department of Veterans Affairs is authorized: (1) to start a deduction from your account at the financial institution stated above for the purposes of paying Government Life
Insurance premiums, or to deduct each month from benefits payable to the veteran the sum to be used in payment of premiums, and (2) TO ADJUST THE AMOUNT REQUIRED
within the limits of benefits payable, to pay premiums on the veteran's Government Life Insurance.

IMPORTANT INFORMATION AND INSTRUCTIONS FOR DEDUCTION FROM BENEFITS PAYMENTS/MILITARY SERVICE RETIREMENT PAY:
Deductions from benefit payments are established to pay premiums on a one month in advance basis, (i.e., a premium deduction made from January benefit payment will
pay a premium due in February, a February deduction will pay a March premium, and so forth). Therefore, upon reinstatement we will place a non-interest lien
against the value of your policy for the one month of premiums owed to place your account in a one month in advance status.
I UNDERSTAND THAT:
(a) If my application is approved, the last named beneficiary(ies) and selection of
optional settlement(s) on the policy(ies) reinstated, will continue in effect unless
the Department of Veterans Affairs receives a request for a change in writing using
my online account after policy activation.
(b) The amount of payment needed, as explained above, must be sent before or with this
application either through mail or online bill pay.
(c) If my application is approved, my policy(ies) will be reinstated on the premium
due date in the premium month my application is sent to the Department of
Veterans Affairs. (For example: If an insurance policy was effective July 17,
2023, a premium month would always be from the 17th of each month through
the 16th of the following month. If an application is received on January 4, 2024,
the effective date of the reinstatement would be December 17, 2023.)

(d) To prevent a lapse of my policy(ies) after applying for reinstatement, premiums
must be paid when due or within 31 days after the due date. If premiums are
paid premiums are paid monthly; the next premium will be due one the first
monthly premium due date after the date this application is sent to the
Department of Veterans Affairs.
(e) Any lien indebtedness against my policy(ies) must be paid or reinstated.
(f) Checks or money orders should be made payable to the Department of Veterans
Affairs and sent to the address shown above.
(g) Statements made on this this application are true. Any deception or false
statement either by inference, omission, or otherwise may cause cancellation of
the insurance or refusal to pay a claim. In either case, premiums may not be
returned.
(h) This form must be fully completed, signed by the applicant and submitted via
Document Upload or via postal mail as noted above.

12. DATE OF SIGNATURE

13. SIGNATURE OF INSURED (Do NOT print. This application must be signed and dated.)

PRIVACY ACT NOTICE: The 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 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 the 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 CFR 8.24 and 6.80). Title 38, United States Code, allows
us to ask for this information. We estimate you will need an average of 15 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 http://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.

QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL-FREE AT 1-800-669-8477

VA FORM 29-352R, XXXX

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