Va Form 29 4364 PDF Details

Life insurance stands as a critical component of financial planning, especially for those who have served their country and may face unique challenges due to service-connected disabilities. The VA 29 4364 form, sanctioned by the Office of Management and Budget with an expiration date of September 30, 2024, offers a lifeline in the form of Service-Disabled Veterans Insurance (S-DVI), providing up to $10,000 of life insurance coverage to veterans who qualify. Eligibility criteria are stringent, requiring the veteran to have been released from active service under conditions other than dishonorable after April 25, 1951, to have received notification of a new service-connected disability within the past two years or be currently awaiting a disability rating, and to be in good health with the exception of service-connected disabilities. The form further emphasizes the importance of evaluating S-DVI costs against commercial insurance rates, taking into account the unique benefit that waives premium payments for those who are totally disabled and unable to work for six or more months—a benefit oftentimes not matched by private insurers. With detailed instructions on how to expedite the application process, whether via online submission or traditional mail, and comprehensive guidance on designating beneficiaries, the VA 29 4364 form encapsulates a vital resource for disabled veterans navigating the complexities of life insurance during post-service life. It underscores the VA's commitment to transparency and support, offering various payment options and addressing potential health concerns with sensitivity and respect, making it an instrumental part in safeguarding the financial stability of veterans and their families.

QuestionAnswer
Form NameVa Form 29 4364
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesapplication veterans lump online, va form 29 4364, va form 29 357 fillable, form 29 4364

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OMB Approved No. 2900-0068

Respondent Burden: 20 minutes

Expiration Date: 9/30/2024

APPLICATION FOR SERVICE-DISABLED VETERANS INSURANCE

IMPORTANT INFORMATION

Eligibility

S-DVI provides up to $10,000 of life insurance for eligible veterans. To be eligible for S-DVI, you must meet all three of the following requirements:

1.You were released from active service in the Armed Forces on or after April 25, 1951, under other than dishonorable conditions.

2.It has been less than 2 years since VA notified you of a new service-connected disability or you are currently waiting for a rating for your service-connected disability. Please Note: The disability you are rated for must be a new disability, not an increase in a disability you already have. An increase to 100% or being granted individual unemployability does not automatically entitle you to a new eligibility period.

3.You are in good health except for your service-connected disability. We will evaluate all health conditions that are not service-connected. Information about any health conditions should be included on your application.

Cost

Before you apply for S-DVI coverage, we encourage you to compare our premium rates to commercial insurance companies. If your disability is not serious, you may be able to find better rates from a commercial company.

When considering the cost of S-DVI coverage, remember that if you are or become totally disabled and unable to work for six or more months you do not have to pay premiums on your Government Life Insurance policy. Most commercial life insurance companies add an additional charge for this benefit.

Speeding Up the Application Process

You may apply online by visiting our website at "www.insurance.va.gov" and clicking "Apply for Service-Disabled Veterans Insurance Online".

The fastest and most secure way for insureds and beneficiaries to send the application to VA Insurance is to use the document upload service at https://insurance.va.gov/home/IDU.

OR MAIL THE COMPLETED FORM TO:

VAROIC

P.O. BOX 7208

PHILDELPHIA, PA 19101

Questions

If you have questions about Government Life Insurance, you can call us toll-free at 1-800-669-8477 or visit our website at: www.insurance.va.gov.

PLEASE BE SURE TO COMPLETE BOTH SIDES OF THIS

APPLICATION

1. Name and Mailing Address for Insurance Purposes

A. First, Middle, Last Name

B. Mailing Address

2.Beneficiary Designation and Selection of Settlement Option - The preprinted phrase "Or to survivors" means that a share of a beneficiary(ies) who dies before you will be paid to the surviving beneficiaries. For example, if you name three principal beneficiaries and one dies before you, the share will be paid to the remaining two principal beneficiaries.

Complete Name and Address of Each Principal and Contingent

Beneficiary's Social

 

Share to be paid to

 

Security Number

 

Payment Option

Beneficiary (For married women, enter her own first and middle names.

 

Relationship of

each beneficiary

(If known. This is

for Each Beneficiary

For example, Mary Rose Smith, not Mrs. John Smith)

the beneficiary

(Use $ amounts,

not required for

(See pamphlet for

 

 

to you

%, or fractions)

 

this designation

more information)

 

 

 

PRINCIPAL

to be valid)

 

 

 

 

 

 

 

 

 

 

 

 

Lump Sum

 

 

 

 

 

 

 

 

 

Lump Sum

 

 

 

 

 

Or to survivors

 

 

 

Lump Sum

 

 

 

 

 

Contingent (Person(s) who get the proceeds if the principal

 

 

 

 

beneficiary(ies) die before the insured.) If none, write "NONE"

 

 

 

 

CONTINGENT

 

 

 

 

 

 

 

 

Lump Sum

 

 

 

 

 

 

 

 

 

Lump Sum

Or to survivors

Lump Sum

VA FORM

29-4364

SUPERSEDES VA FORM 29-4364, JUN 2018,

Page 1

SEP 2021

WHICH WILL NOT BE USED.

EVERY QUESTION MUST BE ANSWERED, BE SURE TO SIGN ON THIS SIDE

3. VA Claim Number (If any)

4. Social Security No. 5. Date of Birth

(MM/DD/YYYY)

6. Daytime Telephone Number

7. Email address

(Include Area Code)

8.ENTER THE AMOUNT, PLAN, AND PREMIUM OF THE INSURANCE FOR WHICH YOU ARE APPLYING

(See Pamphlet 29-9 - Service-Disabled Veterans Insurance Information and Premium Rates)

 

A. Amount of Insurance

B. Plan of Insurance

 

C. Monthly Premium

 

 

 

 

 

 

 

 

 

 

 

 

9A. Are you now working?

9B. Do you work full-time?

9C. If you are not working part-time, explain why (Please be specific)

 

 

 

 

 

 

 

(If "Yes," skip to Item 10)

 

 

 

 

YES

 

NO

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9D. When did you last work full-time?

 

 

9E. What was your occupation?

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Check the method showing how you wish to pay for this insurance (If you are not eligible for waiver of premiums)

A. I want to pay premiums by a monthly deduction from my VA Compensation or Pension. (We will start the deduction for you if the insurance is approved)

B. I want to pay premiums by a monthly allotment from my military service/retirement pay. (We will start the allotment for you if the insurance is approved)

C. I want VA to automatically withdraw the premium each month from my bank account (VA MATIC) (Send your first payment with this application)

D. I will send premiums directly to VA as follows (Send your first payment with this application)

 

Monthly

 

Annually

11. Have you had any of the following: YES NO 12. If your answer to any part of Item 11 is "YES," give dates, duration and other details.

(If more space is needed, attach a separate sheet)

A. Lung condition?

B. Mental or nervous disorders?

C. Blood disorder?

D. Heart condition?

E. Cancer or tumor?

F. Diabetes?

13. Have you had any other physical defect or disease? (If "YES", explain below)

 

YES

 

NO

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.

14A. Signature of Applicant (Do NOT print, sign in ink)

14B. 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 of Uniforned Services Personnell Programs of U.S. Government", published in the Federal Register. 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: We need this information to determine your eligibility for VA Insurance benefits (38 U.S.C. 1922). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 20 minutes to review the information, 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 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.

VA FORM 29-4364, SEP 2021

Page 2

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Guidelines on how to fill out va form 29 4364 printable portion 1

2. The next part would be to fill in all of the following blanks: Or to survivors, Lump Sum, VA FORM SEP, SUPERSEDES VA FORM JUN WHICH, and Page.

Part no. 2 for submitting va form 29 4364 printable

When it comes to VA FORM SEP and Page, ensure you review things here. Both of these are viewed as the most important ones in the page.

3. The next part will be straightforward - complete all the empty fields in VA Claim Number If any, Social Security No, Date of Birth, Daytime Telephone Number, Email address, MMDDYYYY, Include Area Code, ENTER THE AMOUNT PLAN AND PREMIUM, See Pamphlet ServiceDisabled, A Amount of Insurance, B Plan of Insurance, C Monthly Premium, A Are you now working, B Do you work fulltime, and C If you are not working parttime to complete the current step.

Completing part 3 in va form 29 4364 printable

4. Filling out B Mental or nervous disorders, C Blood disorder, D Heart condition, E Cancer or tumor, F Diabetes, Have you had any other physical, YES, CERTIFICATION I have reviewed all, A Signature of Applicant Do NOT, B Date MMDDYYYY, and VA will not disclose information is key in this form section - make sure you spend some time and be mindful with every single field!

Stage no. 4 in filling out va form 29 4364 printable

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