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.
Speeding Up the Application Process:
We can process your application more quickly if you send us a copy of the letter from VA that first notified that your disability was
rated service-connected within the last two years. You may also apply online by visiting our website at "www.insurance.va.gov"
and clicking "Apply for Service-Disabled Veterans Insurance Online".
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.
APPLICATION FOR SERVICE-DISABLED VETERANS INSURANCE
IMPORTANT INFORMATION
PLEASE BE SURE TO COMPLETE BOTH SIDES OF THIS
APPLICATION
1. Name and Mailing Address for Insurance Purposes
A. First, Middle, Last Name
29-4364
VA FORM
JUL 2014
SUPERSEDES VA FORM 29-4364, DEC 2010,
WHICH WILL NOT BE USED.
Continued on Reverse
OMB Approved No. 2900-0068
Respondent Burden: 20 minutes
Expiration Date: 07/31/2017
B. Mailing Address
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.
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.
Mailing Address:
If you meet these criteria, please complete and sign the application and then send immediately to:
Department of Veterans Affairs Regional Office and Insurance Center (RH), P.O. Box 7208, Philadelphia, PA 19101,
or fax to 1-888-748-5822.
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
(For married women, enter her own first and middle names.
For example, Mary Rose Smith, not Mrs. John Smith)
Relationship of
the beneficiary
to you
Share to be paid to
each beneficiary
(Use $ amounts,
%, or fractions)
Payment Option
for Each Beneficiary
(See pamphlet for
more information)
Or to survivors
Or to survivors
Contingent (Person(s) who get the proceeds if the principal
beneficiary(ies) die before the insured.) If none, write "NONE"
Lump Sum
Lump Sum
Lump Sum
Lump Sum
Lump Sum
Lump Sum
PRINCIPAL
CONTINGENT
Beneficiary's Social
Security Number
(If known. This is
not required for
this designation
to be valid)
