Download:
pdf |
pdfOMB Approved No. 2900-NEW
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX
OSGLI
PO Box 41618
Philadelphia, PA 19176-1618
Phone: 800-419-1473
Fax: 800-236-6142
Veterans’ Group Life Insurance VGLI
VGLI is term life insurance that offers coverage which is renewed every five years and does not terminate if premium payments are paid on time.
Premium amounts will adjust at five-year age brackets. Term life insurance coverage does not build cash value over time. For more information
about VGLI, please visit https://www.va.gov/life-insurance/options-eligibility/vgli/ or call 800-419-1473 (Monday to Friday, 8 a.m. to 5 p.m. ET.).
Important to know: You may be able to keep your SGLI coverage for up to two years after your separation if you
separated with a disability and meet the legislative requirements. Visit va.gov/life-insurance/options-eligibility/
sgli/ to download an application and apply today.
Veterans’ Group Life Insurance Application Instructions
You have one year and 120 days from your date of separation to apply for Veterans’ Group Life Insurance (VGLI). You can easily apply online
by visiting myvgli.prudential.com. Simply complete the application, upload your official separation documentation and most recent leave and
earnings statement, and remit your first premium. You can also complete the attached application and return it to the above address.
To complete the attached application, follow these easy steps:
1. Veteran Information. Complete all fields under “Veteran.” You do not have to fill out fields under “My Correct Address Information Is” if
you’ve provided your correct address in the fields above. Complete all fields under “Additional Contact Information.”
2. Coverage Election and Payment Method. Choose your coverage amount and billing preferences. The chart below shows the most
frequently requested coverage amounts and the monthly premium. Coverage is available in $10,000 increments. For coverage amounts
not shown below, please see the rate chart at Veterans’ https://www.va.gov/life-insurance/options-eligibility/vgli/ insurance.va.gov or
call 800-419-1473. Your initial VGLI coverage cannot exceed the amount of Servicemembers’ Group Life Insurance you had at the time
of discharge. However, if you had less than $500,000 of SGLI at discharge and you get VGLI coverage, you will have the
opportunity to increase your VGLI coverage by $25,000 on your one-year anniversary and every five-year anniversary
thereafter, up to the maximum of $500,000, until age 60.
Amount Age 29 & Age
of
Coverage Under 30–34
Age
35–39
Age
40–44
Age
45–49
Age
50–54
Age
55–59
Age
60–64
Age
65–69
Age
70–74
Age Age 80 &
75–79
Over
$500,000 $35.00
$45.00
$60.00
$80.00
$105.00
$165.00
$300.00
$495.00
$735.00 $1,130.00 $2,140.00 $2,250.00
$450,000 $31.50
$40.50
$54.00
$72.00
$94.50
$148.50
$270.00
$445.50
$661.50 $1,017.00 $1,926.00 $2,025.00
$400,000 $28.00
$36.00
$48.00
$64.00
$84.00
$132.00
$240.00
$396.00
$588.00
$904.00 $1,712.00 $1,800.00
$350,000 $24.50
$31.50
$42.00
$56.00
$73.50
$115.50
$210.00
$346.50
$514.50
$791.00 $1,498.00 $1,575.00
$300,000 $21.00
$27.00
$36.00
$48.00
$63.00
$99.00
$180.00
$297.00
$441.00
$678.00 $1,284.00 $1,350.00
$250,000 $17.50
$22.50
$30.00
$40.00
$52.50
$82.50
$150.00
$247.50
$367.50
$565.00 $1,070.00 $1,125.00
$200,000 $14.00
$18.00
$24.00
$32.00
$42.00
$66.00
$120.00
$198.00
$294.00
$452.00
$856.00
$900.00
$150,000 $10.50
$13.50
$18.00
$24.00
$31.50
$49.50
$90.00
$148.50
$220.50
$339.00
$642.00
$675.00
$100,000
$7.00
$9.00
$12.00
$16.00
$21.00
$33.00
$60.00
$99.00
$147.00
$226.00
$428.00
$450.00
$50,000
$3.50
$4.50
$6.00
$8.00
$10.50
$16.50
$30.00
$49.50
$73.50
$113.00
$214.00
$225.00
$10,000
$0.70
$0.90
$1.20
$1.60
$2.10
$3.30
$6.00
$9.90
$14.70
$22.60
$42.80
$45.00
3. Health Statement. If your date of separation was less than 240 days ago, then you do not need to complete this section. If your date of
separation was more than 240 days ago, then please be sure to complete this section.
4. Beneficiary Designation. Use this section to name your beneficiaries. If you would like to name more beneficiaries than the application
allows, please list those additional beneficiaries on a separate sheet of paper along with your name, Social Security number, signature,
and date. Your beneficiary designation is not valid unless it is signed, dated, and received by OSGLI prior to your death.
5. Authorization/Signature. Please sign and date the application and send it to OSGLI at the address above. Include your first VGLI
premium payment and a copy of your DD-214 or most recent Leave and Earnings Statement with your application. Your VGLI application
is not considered complete unless we receive these items with your application.
GL.2009.153
Ed. 06/2024
SGLV 8714
Page 1 of 6
Application For Veterans’ Group Life Insurance
OSGLI use only
IMPORTANT: No insurance may be granted unless a completed application has been
received (38 U.S.C. 1977). Please complete all fields and correct any inaccurate information.
1
VETERAN INFORMATION (INFORMATION ON FILE)
First Name:
MI:
Last Name:
Social Security
Number:
DOD ID Number also
know as EDI-PI:
Address 1:
Address 2:
City:
State:
Country:
ZIP Code:
Date of
Birth:
Branch of
Service:
Gender:
Male Female
Date of Separation:
Age
MM
DD
YYYY
MY CORRECT ADDRESS INFORMATION IS (check this box for changes )
First Name:
MI:
Last Name:
Address 1:
Address 2:
City:
State:
Country:
ZIP Code:
ADDITIONAL CONTACT INFORMATION
Email:
Please send me general information and newsletters by email
Please send me notices related to my bill or policy by email
Daytime
Phone:
Evening
Phone:
*8714A001*
GL.2009.153
Ed. 06/2024
*
8
7
1
4
A
0
0
1
*
SGLV 8714
Page 2 of 6
OSGLI use only
2
COVERAGE ELECTION AND PAYMENT METHOD
I am applying for the following amount of coverage: $
,
Amount must be in multiples of $10,000 and cannot exceed $500,000 or the amount on date of discharge (whichever is less).
Your SGLI amount on the date of your discharge was: $
I would like my payment cycle to be:
(You will find this amount on your separation document).
,
Monthly Quarterly Semiannually Annually
I have enclosed my first premium payment of: $
,
Automatic Monthly Deductions from military retirement pay. (Payment cycle must be monthly. You must submit your premium until the
automatic deduction starts.)
Automatic Monthly Deductions from VA Compensation. (Payment cycle must be monthly. You must submit your premium until the
automatic deduction starts.)
My VA claim file number is:
Yes No
Have you been able to work since leaving the service?
Yes No
If no, is this due to a disability incurred while in the service?
3
HEALTH STATEMENT (Please attach a separate sheet with details for any question answered “yes”)
Have you had or been treated for or had known indications of:
Y
N
A. Heart trouble or abnormal pulse?
B. High blood pressure?
C. Diabetes or sugar in urine?
D. Cancer or tumors?
E. Lung or respiratory disorders?
Y
F.
G.
H.
I.
Disorders of kidney, bladder, or urinary system?
Liver or gall bladder disorder?
Stomach or intestinal disorder?
Arthritis?
N
Y
N
In the past five years have you:
J. Been declined or postponed for any form of life
or health insurance or offered a policy with a
higher premium because of health reasons only?
K. Been absent from work for more than five
continuous days because of sickness or injury?
L. Been advised to have a surgical procedure?
M. Been a patient or been advised to enter a
hospital or health care facility?
N. Consulted, been attended, or examined by a
doctor or other practitioner other than annual
or periodic physicals?
Y
N
O. Used barbiturates, heroin, opiates, or other
narcotics or been treated for alcoholism?
P. Been diagnosed as having Acquired
Immunodeficiency Syndrome (AIDS) or
AIDS-related complex (ARC)?
Q. Do you have any known physical impairments,
deformities, or ill-health not covered above?
R. Do you have a service-connected disability?
If yes, please provide your VA claim number
and include a copy of your VA Rating Decision Letter.
Veteran’s Signature:
X
Date:
MM
DD
YYYY
*8714A002*
GL.2009.153 Ed. 06/2024
*
8
7
1
4
A
0
0
2
*
SGLV 8714
Page 3 of 6
OSGLI use only
4
BENEFICIARY DESIGNATION
Beneficiary(ies) and Benefit Payment Options
I designate the following beneficiary(ies) to receive my insurance proceeds. I understand that the primary beneficiary(ies) will
receive payment upon my death. The share of any primary beneficiary who dies before me will be distributed equally among the
remaining primary beneficiaries. If all primary beneficiary(ies) die before me, the insurance will be paid to the secondary beneficiaries.
I understand that unless I have named a beneficiary(ies) below, my insurance will be paid under the provisions of the law (38 U.S.C.
1970). The designation below cancels any prior SGLI or VGLI beneficiary designation or payment instruction.
A. Primary Beneficiaries
The total for all primary beneficiaries must equal 100%.
1. Type
(Select One)
Gender:
Child Parent Spouse Other Family Other Estate Charitable Institution
Male Female
MI:
First Name:
Last Name:
Other:
Address:
Phone:
Payment:
2. Type
(Select One)
Gender:
Social Security Number:
Lump Sum* 36 Installments
%
Share:
Child Parent Spouse Other Family Other Estate Charitable Institution
Male Female
MI:
First Name:
Last Name:
Other:
Address:
Phone:
Payment:
Social Security Number:
Lump Sum* 36 Installments
Share:
To list more beneficiary(ies) please copy and attach additional pages.
%
(must equal 100%) TOTAL
* If you elect a lump-sum payment, the beneficiary(ies) will be given the option of receiving the lump-sum payment through the Prudential
Alliance Account by check or Electronic Funds Transfer (EFT). Alliance is not available for payments less than $5,000, payments to
individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.
The funds in an Alliance Account begin earning interest immediately and will continue to earn interest until all funds are withdrawn. Interest
is accrued daily, compounded daily, and credited every month. The interest rate may change and will vary over time subject to a minimum
rate that will not change more than once every 90 days. You will be advised in advance of any change to the minimum interest rate via your
quarterly Alliance Account statement or by calling Customer Support at 877 255-4262.
The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential
Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The
Bank of New York Mellon. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). The Bank
of New York Mellon is not a Prudential Financial company.
*8714A003*
GL.2009.153
Ed. 06/2024
*
8
7
1
4
A
0
0
3
*
SGLV 8714
Page 4 of 6
OSGLI use only
B. Secondary Beneficiaries
The total for all secondary beneficiaries must equal 100%.
1. Type
(Select One)
Gender:
Child Parent Spouse Other Family Other Estate Charitable Institution
Male Female
MI:
First Name:
Last Name:
Other:
Address:
Phone:
Payment:
2. Type
(Select One)
Gender:
Social Security Number:
Lump Sum* 36 Installments
%
Share:
Child Parent Spouse Other Family Other Estate Charitable Institution
Male Female
MI:
First Name:
Last Name:
Other:
Address:
Phone:
Payment:
Social Security Number:
Lump Sum* 36 Installments
Share:
To list more beneficiary(ies) please copy and attach additional pages.
5
%
(must equal 100%) TOTAL
AUTHORIZATION/SIGNATURE
I authorize OSGLI to record and consider the individuals/institutions that I have named on this form as beneficiaries for VGLI benefits,
specifically those names I have entered in section A (“Primary Beneficiaries”) and also section B (“Secondary Beneficiaries”).
I understand that I cannot have combined SGLI and VGLI coverage for more than $500,000. I understand that unless I have named a
beneficiary(ies) above, my insurance will be paid under provisions of Federal Law.
Veteran’s Signature:
X
Date:
MM
The Veteran must sign and date this form.
The signature date must be the date this form is actually signed.
DD
YYYY
Submit the completed form by fax to 800-236-6142 or mail to: OSGLI, PO BOX 41618, Philadelphia, PA 19176-1618
Please remember to: 1) Sign and date your application, include your official separation documentation (DD214, NGB22 or other),
include your initial premium and keep a copy of this completed application for your records.
The Office of Servicemembers’ Group Life Insurance (OSGLI) administers Servicemembers’ Group Life Insurance and Veterans’ Group
Life Insurance under the supervision of the Department of Veterans Affairs. OSGLI is a division of The Prudential Insurance Company
of America.
*8714A004*
GL.2009.153
Ed. 06/2024
*
8
7
1
4
A
0
0
4
*
SGLV 8714
23520856
Page 5 of 6
OSGLI use only
PRIVACY ACT INFORMATION: No insurance may be converted unless a completed application form has been received (38 U.S.C. 1904 and 1942). 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 as identified in 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 required to obtain or retain benefits. The responses you submit are considered
confidential (38 USC 5701).
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-NEW, and it expires XX/XX/20XX. Public reporting burden for this
collection of information is estimated to average 30 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-NEW in any correspondence. Do not send your completed VA Form SGLV 8714 to this email address.
*8714A004*
GL.2009.153
Ed. 06/2024
*
8
7
1
4
A
0
0
5
*
SGLV 8714
Page 6 of 6
| File Type | application/pdf |
| File Title | Veterans’ Group Life Insurance VGLI |
| Author | Prudential |
| File Modified | 2024-12-09 |
| File Created | 2024-07-03 |