Fillable Application & Instructions Insurance Disability Extension Servicemembers' Group (U.S. Department of Veterans Affairs)

Fill Online, Printable, Fillable, Blank Application & Instructions Insurance Disability Extension Servicemembers' Group (U.S. Department of Veterans Affairs) Form

Use Fill to complete blank online U.S. DEPARTMENT OF VETERANS AFFAIRS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application & Instructions Insurance Disability Extension Servicemembers' Group (U.S. Department of Veterans Affairs)

On average this form takes 19 minutes to complete

The Application & Instructions Insurance Disability Extension Servicemembers' Group (U.S. Department of Veterans Affairs) form is 5 pages long and contains:

  • 0 signatures
  • 5 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

BROWSE U.S. DEPARTMENT OF VETERANS AFFAIRS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
General Information
The SGLI Disability Extension provides free coverage for up to two years from your date of discharge. The SGLI
Disability Extension is available to Veterans who are totally disabled and had SGLI coverage at the time of discharge.
To be considered totally disabled, you must have a disability that prevents you from being gainfully employed OR
have one of the following conditions, regardless of employment status:
1. Permanent loss of use of any of the following:
· both hands · one foot and one eye
· both eyes · one hand and one foot
· both feet · one hand and one eye
2. Total loss of hearing in both ears
3. Organic loss of speech (lost ability to express oneself,
both by voice and whisper, through normal organs
for speech. Note: Being able to speak with an
artificial appliance is still considered a loss of speech.)
Applying on Behalf of a
Veteran?
If you are applying on
behalf of an incompetent
Veteran, please complete
all sections of the form.
Please sign your name to
the application and
indicate your relationship
to the Veteran.
Applying for the SGLI Disability Extension
How to Apply
To apply for the SGLI Disability Extension, you need to complete the following five steps:
1. Complete the attached application.
2. Sign and date the application.
3. Enclose proof of your SGLI coverage and your date of separation (e.g. your DD-214
and your last Leave and Earnings statement from the military)
4. Enclose a copy of either:
a. Your military Medical Review Board findings of disability, OR
b. Your VA rating determination.
5. Mail the application to:
VAROIC
P.O. Box 7208
Philadelphia PA 19101
If Your Application is Approved
If your application is approved, OSGLI will send you a letter providing proof of coverage. Your SGLI coverage will be
extended for a maximum of two years from your date of discharge or until you are able to work, whichever comes first.
Important Note: See the information under “After Your Extension Ends” to learn more about what will happen at the end of the free Disability
Extension.
If Your Application is Not Approved
If your application is not approved, OSGLI will automatically consider this application as an application for Veterans'
Group Life Insurance (VGLI). We encourage you to apply for the the SGLI Disability Extension within 120 days of your
discharge date. This will allow you to be automatically approved for Veterans' Group Life Insurance (VGLI) coverage if you
are not approved for the SGLI Disability Extension. If you apply after 120 days from discharge and are not eligible for the
SGLI Disability Extension, you will have to provide proof of good health to obtain VGLI.
If your VGLI coverage is approved,
it will be effective the day after your SGLI coverage terminates. You will also need to pay the first VGLI premium for your
VGLI coverage to take effect.
For more information on VGLI, go to the VA Insurance website at www.insurance.va.gov.
SGLV 8715 March 2010
Servicemembers' Group Life
Insurance Disability Extension
Application & Instructions
Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208
Philadelphia PA 19101
Toll-free phone: 1-855-390-3536
Toll-free fax: 1-888-748-5822
Page 1 of 5
After Your Extension Ends
SGLV 8715 March 2011
Page 2 of 5
At the end of the two-year extension period, OSGLI will notify you that your extension is ending and offer you the
opportunity to obtain Veterans' Group Life Insurance (VGLI). VGLI allows you to continue your SGLI coverage by
converting it to an affordable term policy that is renewable for life. You will not have to apply separately, as this
application will also be considered an application for VGLI. If you choose to convert your free SGLI coverage under
the Disability Extension to VGLI, the effective date of VGLI will be the day after your SGLI coverage ends. You will also
need to pay the first VGLI premium for your VGLI coverage to take effect.
1. Personal Information
2. Insurance Amount
3. Eligibility
Application for SGLI Disability Extension
Please complete Sections 1-5 of this application.
Return your completed application to:
VAROIC
P.O. Box 7208
Philadelphia PA 19101
Important: Please read the instructions for applying for the SGLI Disability Extension on pages 1 and 2 before completing this form.
Please include a photocopy of either your military Medical Review Board findings of disability or your VA rating determination.
*lost ability to express oneself, both by voice and whisper, through normal organs for speech. Being able to speak with an
artificial appliance is still considered a loss of speech.
Permanent loss of use of both hands Yes
No
VA Rating Yes No
Home Phone Number
Street Address or PO Box
City
State
Zip Code
Date of Separation
Branch of Service
Social Security Number
Date of Birth
Last Name
First Name
Middle Name
Other Phone Number
Male
Female
Email Address
A. Your Current Ratings and Statutory Conditions
1. Has VA rated you Individually Unemployable?*
Yes
No
2. Do you have any of the following conditions:
Organic loss of speech*
Yes
No
Permanent loss of use of both feet
Permanent loss of use of both eyes
Permanent loss of use of one hand and one foot
Permanent loss of use of one foot and one eye
Permanent loss of use of one hand and one eye
Total loss of hearing in both ears
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
*This means VA has determined that you are incapable of maintaining gainful employment due to your service-connected conditions.
Your life insurance coverage under the Disability Extension is free. The amount of your life insurance coverage under the Disability
Extension is the same amount that you had on your date of separation which is $_______________.
The following questions will help determine your eligibility for the SGLI Disability Extension. If you need more room for your answers,
please use the continuation sheet in section 4 of this application.
3. Do you have a disability rating?
Yes NoMilitary rating
%
Rating
%
SGLV 8715 March 2011
Page 3 of 5
Choose one of the five work statuses below and answer the applicable questions.
B. Your Work Status
Page 4 of 5
SGLV 8715 March 2011
3. Eligibility (cont'd)
a. Are you attending school to be trained for a new career because you are no longer able to work in your former career due
to disabilities caused by your military service?
I am working full time (more than 20 hours per week)
I am working part time (20 hours or less per week).
I have not worked since I was discharged due to my service related disabilities.
I am not working currently but have worked since discharge.
I am currently in school.
No
Yes. ( Please attach medical evidence that confirms your medical provider's and/or doctor's recommendation.)
a. Has your medical provider advised you to stop working or reduce work hours due to a worsening service-connected
disability?
a. Please provide the following information about your service related disabilities since you were discharged from
service. (If you need more space, use the Continuation Sheet in Section 4.
b. Please provide the following information about your work history since you were discharged from service.
1.
2.
3.
4.
5.
a. Please explain when and why you stopped working
Date
SIGNATURE OF APPLICANT (Do not print; sign in ink)
PENALTY: The law provides that whoever makes any statement of a material fact knowing it to be false shall be punished by fine or imprisonment or both
Name or Nature of Your Disabilities Date Your Disabilities Began
Date your disabilities prevented you from working
full time (more than 20 hours per week)
Yes (please complete the chart below)
No
Name and Address of Employers
(include self employment)
Type of Work
(occasional or seasonal)
Dates of Employment
From (MM/DD/YY) to (MM/DD/YY)
Previous Occupation New Degree/Certification Sought
Desired Future
Occupation
Date Training
Began
4. Continuation Sheet
Use this page to provide any additional information regarding your eligibility that does not fit on the prior pages.
SGLV 8715 March 2011
Page 5 of 5
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application & Instructions Insurance Disability Extension Servicemembers' Group (U.S. Department of Veterans Affairs)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document