VA Form 29-4125a: Claim for Monthly Payments, National Service Life Insurance

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.

Enter the Insurance Policy Number in Box 1. If you are a beneficiary for more than one policy, see the BENEFICIARY section.

Enter the Net Amount Payable in Box 2 and the Beneficiary's Share (Fraction) in Box 3. Box 4 is the Payment Option Selected by Insured.

Enter the first, middle and last name of the insured veteran in Box 5, the date of birth in Box 6 and the insured's place of death in Box 7.

Enter the first, middle and last name of the beneficiary in Box 8, the relationship to insured in Box 9 and the beneficiary's date of birth in Box 10. Enter the address of the beneficiary or their guardian in Box 11, the daytime telephone number (include area code) in Box 12A, the email address in Box 12B and the Social Security Number in Box 13.

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, complete all items on the line checked.

Option 2 is monthly installments payable for 36 to 240 months; enter the number of equal monthly installments (in multiples of 12).

Option 3 is monthly installments continuing throughout the lifetime of the beneficiary with 120 payments guaranteed.

Option 4 is 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 is required (Driver's License or Birth Certificate) under Option 3 and Option 4.

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.

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 the evidence, also sign Item 15 of this form and return it along with the additional evidence. It is not necessary to complete the entire form.

If the insured selected an option, the beneficiary may abide by the insured's selection or may request settlement in installments. If the insured selected Option 1 (Lump Sum Settlement), the 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.

If the insured selected Option 2, the beneficiary may request settlement split between two variations of Option 2. With monthly installments in excess of 120, the 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. With monthly installments not in excess of 120, the beneficiary may select a greater number of installments under Option 2 or may select Option 4, provided the number of installments guaranteed under Option 4 is greater than the number of installments selected by the insured under Option 2 or may request settlement split between Option 2 and 4, as herein limited.

If the insured has selected Option 3, the beneficiary may select Option 4. If the insured has selected Option 4, and named no contingent beneficiary, the beneficiary may select Option 3.

Settlement under Option 4 is not authorized when payments would be made in a shorter period than 120 months. 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.

To be completed by the beneficiary if direct deposit is desired: the name of the financial institution, the routing transit number and the address of the financial institution.

Also enter the type of depositor account (checking or savings), the telephone number of the financial institution and the depositor account number.

Sign in Box 15 (signature of beneficiary, fiduciary or guardian) and enter the date signed in Box 16.

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. The VA needs 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 the VA records.

The completed form may be submitted by 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 the toll free number 1-800-669-8477.