29-4125a

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OMB Approved No. 2900-0060
Respondent Burden: 6 minutes
Expiration Date: XX/XX/20XX
1. INSURANCE POLICY NUMBER (See the
BENEFICIARY section below if you are a beneficiary
for more than one policy)

CLAIM FOR MONTHLY PAYMENTS
NATIONAL SERVICE LIFE INSURANCE

4. PAYMENT
OPTION
SELECTED BY
INSURED

3. BENEFICIARY'S SHARE (Fraction)

2. NET AMOUNT PAYABLE

IMPORTANT - Please type or print in ink when completing this form.
BENEFICIARY - This form is to be used only when monthly payments were selected by the insured, or the beneficiary is selecting
monthly payments instead of one sum. This form will be used for all policies where you are listed as a beneficiary for monthly installment unless you
specifically submit a separate form for a Lump Sum Payment on a separate policy. See the directions on page 2 if you wish to select a Lump Sum
Payment.
SIGNATURE - In order to expedite payment of this claim, Item 15 must be signed by the beneficiary. If the beneficiary is a minor or incompetent,
the person having custody of the beneficiary should complete the form and give his/her address in Item 11. We need a photocopy of the veteran's death
certificate or a statement from the attending physician showing date and cause of death. Only one certificate is required for our records.
5. FIRST, MIDDLE AND LAST NAME OF INSURED VETERAN

6. DATE OF BIRTH

7. INSURED'S PLACE OF DEATH

8. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY

9. RELATIONSHIP TO INSURED

10. BENEFICIARY'S DATE OF BIRTH

11. ADDRESS OF BENEFICIARY OR THEIR GUARDIAN 12A. BENEFICIARY'S DAYTIME TELEPHONE 12B. BENEFICIARY'S EMAIL
ADDRESS
NUMBER (Include Area Code)

13. BENEFICIARY'S SOCIAL
SECURITY NUMBER

14. SELECTION OF OPTION
Read the Instructions on page 2 and consult the tables attached before making your selection in the space below.
Check the box for the option selected, or more than one box if more than one option is selected in accordance with Instruction 2 on page 2. If selecting
Option 2, please complete all items on the line checked.
OPTION NUMBER

2

3
4

OPTION DESCRIPTION
MONTHLY INSTALLMENTS PAYABLE FOR 36 TO 240
MONTHS (In multiples of 12)

NUMBER OF EQUAL MONTHLY INSTALLMENTS

(In multiples of 12)

MONTHLY INSTALLMENTS CONTINUING THROUGHOUT THE LIFETIME OF THE BENEFICIARY WITH 120 PAYMENTS
GUARANTEED.
PROOF OF AGE REQUIRED (Driver's License or Birth Certificate)
MONTHLY INSTALLMENTS CONTINUING THROUGHOUT THE LIFETIME OF THE BENEFICIARY, WHICH WILL
GUARANTEE PAYMENT OF AN AMOUNT AT LEAST EQUAL TO THE BENEFICIARY'S SHARE OF THE FACE OR NET
AMOUNT OF THE CONTRACT.
PROOF OF AGE REQUIRED (Driver's License or Birth Certificate)

NOTE - Settlement under one of these options shall be considered full and complete settlement of all liability under this contract.
This section shall not be valid unless and until it is recorded in the Department of Veterans Affairs. If the beneficiary fails to select an
option, settlement will be based on the option selected by the insured.
IMPORTANT -This form must be signed by the beneficiary, guardian, or fiduciary, in Item 15, in order for payment to be made. If
the beneficiary cannot sign his/her name, but is competent to handle his/her own affairs, an "X", made by the beneficiary and signed
by two disinterested witnesses, is acceptable.
15. SIGNATURE OF BENEFICIARY, FIDUCIARY OR GUARDIAN

16. DATE SIGNED

TO BE COMPLETED BY BENEFICIARY IF DIRECT DEPOSIT IS DESIRED
NAME OF FINANCIAL INSTITUTION

ROUTING TRANSIT NUMBER

ADDRESS OF FINANCIAL INSTITUTION

TYPE OF DEPOSITOR ACCOUNT
CHECKING
SAVINGS

TELEPHONE NUMBER OF FINANCIAL INSTITUTION

DEPOSITOR ACCOUNT NUMBER

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM, PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477
VA FORM
XXX 20XX

29-4125a

SUPERSEDES VA FORM 29-4125a, DEC 2024,
WHICH WILL NOT BE USED.

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INSTRUCTIONS FOR SELECTION OF OPTIONAL SETTLEMENT
1. OPTION 1- LUMP SUM SETTLEMENT is not available when the insured selected a monthly installment option. HOWEVER, if
the insured left a will or there is other evidence, in writing, that the insured desired that the beneficiary receive a lump sum, the
beneficiary may submit a copy of such consideration. When submitting also sign Item 15 of this form and return it along with
the additional evidence. It is not necessary to complete the entire form.
2. If insured selected an option, the beneficiary may abide by the insured's selection or may request settlement in installments.
A. If insured selected Option 1 (Lump Sum Settlement), beneficiary may select Option 1, 2, 3 or 4 or may request part
payment under Option 1 and remainder under one of the other options.
B. If insured selected Option 2, beneficiary may request settlement split between two variations of Option 2.
C. If insured selected Option 2, with monthly installments in excess of 120, beneficiary may select to receive payment in a
greater number of installments under Option 2, or may elect to receive payment under Option 3 or 4 or may request
settlement split between Option 2, as herein limited, and Option 3 or 4.
D. If insured selected Option 2, with monthly installments not in excess of 120, beneficiary may select a greater number of
installments under Option 2 or may select Option 4, provided number of installments guaranteed under Option 4 is greater
than number of installments selected by insured under Option 2 or may request settlement split between Option 2 and 4, as
herein limited.
E. If insured has selected Option 3, beneficiary may select Option 4.
F. If insured has selected Option 4, and named no contingent beneficiary, beneficiary may select Option 3.
G. If beneficiary selects two methods of payment the amount payable under at least one of them must be in multiples of
$1000 and all monthly installments under such selection must be at least $10. (See instruction 5)
3. Settlement under Option 4 is not authorized when payments would be made in a shorter period than 120 months.
4. Option 3 and 4 shall not be available if the beneficiary is a firm, corporation, legal entity or trustee. Settlement to an estate is
authorized only in one sum.
5. If option selected requires payment of installments of less than $10, the amount payable shall be paid under Option 2 in such
maximum number of installments as are a multiple of 12 as will provide a monthly installment of not less than $10. If present
value at time any person initially becomes entitled to payment thereof is not sufficient to pay at least twelve monthly
installments of not less than $10 each, such amount shall be payable in one sum.
6. If the insured selected Option 1 and the beneficiary has elected payment under Option 2, 3 or 4 and dies before receiving all
installments due, the commuted (cash) value of the remaining unpaid installments guaranteed will be paid to the ESTATE OF
THE BENEFICIARY. If the insured designated Option 2, 3 or 4 and all beneficiaries die before receiving all installments due, the
commuted value of the remaining installments guaranteed will be paid to the ESTATE OF THE INSURED.
The completed form may be submitted by:

UPLOAD:
Upload the form using
our secure upload service at:
https://insurance.va.gov/home/IDU

MAIL:
Department of Veterans Affairs
Insurance Center
PO Box 5209
Janesville, WI 53547-5209

IF YOU HAVE ANY QUESTIONS CONCERNING YOUR GOVERNMENT LIFE INSURANCE, PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477.
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 2900-0060, and it expires XX/XX/20XX. Public reporting
burden for this collection of information is estimated to average 6 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. 2900-0060 in any correspondence. Do not send your completed VA Form
29-4125a to this email address.
VA FORM 29-4125a, XXX 20XX

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