Form 29-10279 Veterans Affairs Life Insurance (VALife) Policy Maintena

OMB Approved No. 2900-0918
Respondent Burden: 10 minutes
Expiration Date: XX/XX/20XX

VETERANS AFFAIRS LIFE INSURANCE (VALife)
POLICY MAINTENANCE APPLICATION

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.
(Note: * indicates a required field)

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

2. POLICY NUMBER* (Include Letter Prefix)

3. SOCIAL SECURITY NUMBER*

4. DATE OF BIRTH* (MM/DD/YYYY)

5. VA CLAIM NUMBER

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

8A. CELL PHONE NUMBER
(Include Area Code)

7. EMAIL ADDRESS*

8B. HOME PHONE NUMBER
(Include Area Code)

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

Text

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

SECTION II: AGENT ACTING ON BEHALF OF INSURED

(Guardian, Attorney-in-Fact, VA Fiduciary - You must attach proof of authority if this is your first time acting on behalf of the veteran)
9. NAME OF AGENT ACTING ON BEHALF OF INSURED*

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

11. EMAIL ADDRESS OF AGENT ACTING ON BEHALF OF INSURED*

12. PHONE NUMBER OF AGENT ACTING ON BEHALF OF INSURED*

(Include Area Code)

SECTION III: SELECTION OF CHANGES
13. YOU MUST CHECK ONE:*
Update contact information of insured - The mailing address, email address, and phone number supplied in Section I will be used
as the updated information for the insured. Please note that updating this information here will not change the insured's information
for other VA benefits of healthcare.
Update contact information of agent acting on behalf of insured - The mailing address, email address, and phone number supplied
in Section II will be used as the updated information for the agent acting on behalf of the insured. Please note that updating this
information here will not change this information for other VA benefits or healthcare.
Update beneficiary information - Go to Section IV
Apply to decrease, cancel, or surrender coverage - Go to Section V
Apply to reinstate lapsed policy - Go to Section VI
Update premium payment method - Go to Section VII

INSTRUCTIONS: Once you have completed applicable sections based on your selection(s), go to Section VIII to certify and sign this form.
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SECTION IV: UPDATES TO 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 to submission.)
1. ATTACH COURT ORDER HERE, IF ANY

SECTION V: APPLICATION TO DECREASE, CANCEL, OR CASH SURRENDER COVERAGE
Use this section for decreasing, canceling, or cash surrendering the veteran's VALife policy.

IMPORTANT INFORMATION: You may decrease or cancel the veteran's coverage during the initial 2-year enrollment period, but you cannot cash surrender the
coverage until after this time.
If you decrease or cancel / cash surrender the veteran's coverage, you will need to re-apply on behalf of the veteran if you would like to obtain VALife coverage or
increase coverage in the future. In this event, 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.
INSTRUCTIONS: Prior to completing this section, please call our toll-free number (1-800-669-8477) and we will provide the amount of the policy's cash value and/or
reduced paid-up insurance value.
1. YOU MUST CHECK ONE (Choose only one. Then proceed to Question 2.)
Decrease Coverage (During initial 2-year enrollment period)
New Amount of Coverage $
Decrease Coverage (After initial 2-year enrollment period)
Cash Surrender of Part of Coverage, Retaining Reduced Amount of Coverage of $
Cancel / Cash Surrender on All Coverage
(Cash surrender only available after initial 2-year enrollment period because the policy has no cash value before this time period elapses.)
2. HOW WOULD YOU LIKE TO RECEIVE THIS PAYMENT? (Chose only one. You will only receive a payment if you elected to cash surrender part
of or all coverage after the initial 2-year enrollment period.)
By direct deposit (You may attach a voided check to help ensure the information is clear.)
(NOTE: The account must be in the name of the veteran. Direct Deposit will continue with all future payments to this account. You must notify us of any changes.
If the veteran does not have an active bank account, please contact us using the number at the top of this form to discuss payment options.)
Name of Bank or Financial Institution ___________________________________

Bank Routing Number ____________________________

Bank Account Number __________________________________

Bank Account Type

Checking

Savings

Apply to pay premiums in advance on remaining coverage or other policy(ies)
(You may only select this option if you elected to cash surrender part of or all coverage in the previous question. Any residual cash value
resulting from the surrender will be applied towards paying future premiums.)
Use cash value to buy Reduced Paid-Up (RPU) insurance

SECTION VI: APPLICATION FOR REINSTATEMENT

Use this section for reinstatement of VALife when application is made after the date of lapse. You must also complete Section VII.
IMPORTANT INFORMATION: VALife can only be reinstated within two years of lapse. After this period, you may be eligible to apply for VALife again on behalf
of the veteran, if the veteran is age 80 or under; 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.
INSTRUCTIONS: Prior to completing this section, please call our toll-free number (1-800-669-8477) and we will provide the amount of payment (premium and
interest, if applicable) (1D) needed to reinstate the veteran's policy(ies). We will notify you with instructions on how to make this payment if the application is
approved.
1A. AMOUNT OF COVERAGE
TO BE REINSTATED
$
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1B. DATE OF LAPSE

1C. MONTHLY PREMIUM

1D. AMOUNT OF PAYMENT
NEEDED FOR REINSTATEMENT

$

$

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SECTION VII: UPDATES TO PREMIUM PAYMENT METHOD

Use this section to make updates to the premium payment method for the VALife policy.
1. PREMIUM PAYMENT METHOD (Choose only one.)
I want to pay premiums by a monthly deduction from the veteran's 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 the veteran's 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 the veteran's checking account.
Please provide the veteran's 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 ACCOUNT:
The Department of Veterans Affairs is authorized: (1) to start a deduction from the veteran's 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:
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, TO PREVENT LAPSE OF INSURANCE, CONTINUE TO PAY PREMIUMS UNTIL YOU HAVE BEEN NOTIFIED THAT THE
AUTHORIZATION HAS BEEN ACCEPTED AND THAT THE DEDUCTIONS FROM BENEFIT PAYMENTS ARE BEING MADE. ANY
OVERPAYMENT OF PREMIUMS WILL BE REFUNDED.

SECTION VIII: 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 83 FR 44407, August 30, 2018. Your obligation to respond 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0918, and it expires XX/XX/20XX. Public reporting burden for this
collection of information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate
and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please
refer to OMB Control No. 2900-0918 in any correspondence. Do not send your completed VA Form 29-10279 to this email address.
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