Fillable VBA 29 357 ARE (U.S. Department of Veterans Affairs)

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VBA 29 357 ARE (U.S. Department of Veterans Affairs)

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CLAIM FOR DISABILITY INSURANCE
GOVERNMENT LIFE INSURANCE
RESPONDENT BURDEN: We need this information to determine your eligibility for VA insurance benefits. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 1 hour and 45 minutes to review the instructions, 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 your comments or suggestions about this form.
INFORMATION AND INSTRUCTIONS
THIS APPLICATION IS TO BE COMPLETED BY VETERANS WHO HAVE GOVERNMENT LIFE INSURANCE
AND BECOME TOTALLY DISABLED.
TOTAL DISABILITY:
1. Any impairment of mind or body which makes it impossible for the veteran to be gainfully employed.
2. Total Disability must start before the veteran's 65th birthday.
WAIVER REFUND
1. Premium Refunds limited to one year prior to date the claim is filed, unless there were circumstances beyond the
veteran's control (such as a severe mental disability). LACK OF KNOWLEDGE OF THE WAIVER PROVISION IS
NOT A CIRCUMSTANCE BEYOND THE VETERAN'S CONTROL.
2. If total disability started more than one year prior to the date of your claim, and you believe a mental disability
prevented you from filing an earlier claim, please include a statement explaining these circumstances on a separate sheet of
paper. YOU SHOULD ALSO INCLUDE ANY MEDICAL EVIDENCE WHICH SUPPORTS YOUR
STATEMENT.
PART I should be completed by the insured veteran if able; if not, by a person acting on his/her behalf.
PART II should be completed by the insured veteran's physician or hospital official. If there will be a delay in preparing
Part II send Part I immediately.
NOTE: IF THE VETERAN HAS BEEN GRANTED DISABILITY BENEFITS FROM THE SOCIAL SECURITY
ADMINISTRATION, PLEASE ATTACH A COPY OF THE AWARD LETTER.
1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)
PART I
2. INSURANCE FILE NUMBER (Include letter prefix)
3. MAILING ADDRESS FOR INSURANCE PURPOSES
(Number and Street or Rural
Route, City or P.O., State and ZIP Code)
4. SOCIAL SECURITY NUMBER
5. DATE OF BIRTH
6. DAYTIME TELEPHONE NUMBER (Include Area Code)
7. CLAIM NUMBER
8. DATE DISABILITY PREVENTED EMPLOYMENT
9. DATE RETURNED TO GAINFUL EMPLOYMENT
10A. EDUCATION (Check highest years completed) (If you have any other specialized training or education please complete Item 10B)
(Grade School)
(High School) (College)
10B. PLEASE PROVIDE ANY SPECIALIZED TRAINING IN THE SPACE PROVIDED BELOW
11. ARE YOU RECEIVING OR HAVE YOU APPLIED FOR ANY
DISABILITY BENEFITS AS LISTED BELOW?
12. DISEASE OR INJURY CAUSING TOTAL OR PERMANENT DISABILITY
VA DISABILITY
COMPENSATION
VA PENSION
SOCIAL SECURITY
DISABILITY
OMB Approved No. 2900-0016
Respondent Burden: 1 hour 45 minutes
Expiration Date: 06/30/2022
PRIVACY ACT INFORMATION: 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 and Uniformed Services Personnel
Programs of U.S. Government Life Insurance Records - VA, published in the Federal Register. Your obligation to respond is required to obtain this benefit. Giving us
your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
1 2 3 4 5 6 7 8 41 2 3 41 2 3
29-357
VA FORM
JUN 2019
SUPERSEDES VA FORM 29-357, APR 2012,
WHICH WILL NOT BE USED.
PAGE 1
IF YOU HAVE ANY QUESTIONS ABOUT DISABILITY BENEFITS OR YOUR INSURANCE,
PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477
13. HOSPITALS WHERE YOU HAVE BEEN TREATED, INCLUDING VA HOSPITALS
NAME OF HOSPITAL ADDRESS OF HOSPITAL DATE OF ADMISSION DATE OF RELEASE
14. PHYSICIANS WHO HAVE TREATED YOU FOR DISEASE OR INJURY, CAUSING TOTAL PERMANENT DISABILITY
NAME OF PHYSICIAN ADDRESS OF PHYSICIAN
DATE TREATMENT
BEGAN
DATE OF LAST
TREATMENT
15. RECORD OF EMPLOYMENT FOR ONE YEAR PRIOR TO THE DATE OF TOTAL DISABILITY TO THE PRESENT
(Include self-employment)
TO
I consent that any physician or hospital who has treated or examined me for any purpose, or who I have consulted professionally, any insurance company or organization
to which I have applied for insurance, or any person, persons, firm or corporation to whom, or to which I have applied for employment or disability benefits, may provide
to the Department of Veterans Affairs or testify as to, or produce in court, any information obtained concerning myself by reason of the foregoing, and waive any
privileges which render such information confidential. A photostatic copy of this consent shall be considered valid authorization for release of information to VA.
I certify that each question has been truthfully and completely answered to the best of my knowledge.
PENALTY - The law provides that whomever makes any statement of a material fact, knowing it to be false, shall be punished by fine or imprisonment or both.
17. SIGNATURE OF INSURED (Or official or fiduciary completing form for insured)
DATES OF EMPLOYMENT LAST DAY INSURED WORKED HOURS WORKED EARNINGS
REASON FOR TERMINATION OF EMPLOYMENT
DATE
OCCUPATION
WEEKLY WEEKLY
NAME AND ADDRESS OF EMPLOYER
16. DATE OF SIGNATURE
FROM
TO
DATES OF EMPLOYMENT LAST DAY INSURED WORKED HOURS WORKED EARNINGS
DATE
OCCUPATION
WEEKLY WEEKLY
NAME AND ADDRESS OF EMPLOYER
FROM
TO
DATES OF EMPLOYMENT LAST DAY INSURED WORKED HOURS WORKED EARNINGS
DATE
OCCUPATION
WEEKLY WEEKLY
NAME AND ADDRESS OF EMPLOYER
FROM
REASON FOR TERMINATION OF EMPLOYMENT
REASON FOR TERMINATION OF EMPLOYMENT
VA FORM 29-357, JUN 2019
PAGE 2
REPORT FOR DISABILITY INSURANCE PURPOSES OF TREATMENT IN A
HOSPITAL OR FROM AN ATTENDING PHYSICIAN
H. SINCE FIRST TREATMENT HAS VETERAN
PART II
Part II of this application should be completed by the appropriate hospital official or by the veteran's attending physician. If appropriate
hospital summaries are available, please forward with application.
3. HOME ADDRESS (Number and Street or Rural Route, City or P.O., State and ZIP Code)
1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print) 2. INSURANCE FILE NUMBER (Include letter prefix)
9. NAME AND ADDRESS OF ATTENDING PHYSICIAN OR HOSPITAL
A. WHEN DID INJURY OR ILLNESS BEGIN?
B. DATE INSURED STOPPED WORKING BECAUSE OF DISABILITY
6. HISTORY (Conditions causing disability)
C. DATE OF FIRST TREATMENT
D. FREQUENCY AND NATURE OF TREATMENT
E. OBJECTIVE SYMPTOMS AND FINDINGS WHEN FIRST SEEN F. DIAGNOSIS, INCLUDE RESULTS OF SPECIAL STUDIES
8. PROGNOSIS
DATE
TO
NAME AND ADDRESS OF HOSPITAL CONDITION AT DISCHARGE
E. IS VETERAN CAPABLE OF DOING
ANY OTHER WORK?
7. HOSPITALIZATION
D. IS VETERAN CAPABLE OF DOING
ALL OF HIS/HER WORK?
A. DATE OF LAST EXAM OR TREATMENT
B. OBJECTIVE FINDINGS
F. CARDIAC FUNCTION (Check if applicable)
C. DIAGNOSIS - CONDITIONS CAUSING DISABILITY
IMPROVED
REMAINED
THE SAME
WORSENED
G. MENTAL/NERVOUS IMPAIRMENT (Ability to function in stressful situations and engage in
interpersonal relations) (Check if applicable)
NO
LIMITATION
SLIGHT
LIMITATION
MODERATE
LIMITATION
MARKED
LIMITATION
SEVERE
LIMITATION
10. DATE OF REPORT 11. SIGNATURE AND TITLE OF PERSON PREPARING REPORT
When completed and signed, send this claim form IMMEDIATELY to the office of the Department of Veterans Affairs where the Insurance Records are
maintained. The address of the Department of Veterans Affairs office that maintains these records is:
5. SOCIAL SECURITY NUMBER
4. CLAIM NUMBER
FROM
FOR VA USE ONLY
Department of Veterans Affairs
Regional Office and Insurance Center (WP)
P.O. Box 7208
Philadelphia, PA 19101
YES NO
NOYES
AHA FUNCTIONAL CAPACITY - CL 1 (NO LIMITATION)
AHA FUNCTIONAL CAPACITY - CL 2 (SLIGHT LIMITATION)
AHA FUNCTIONAL CAPACITY - CL 3 (MARKED LIMITATION)
AHA FUNCTIONAL CAPACITY - CL 4 (COMPLETE LIMITATION)
VA FORM 29-357, JUN 2019
PAGE 3
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Completed 21 July 2020

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