29-352 Application for Reinstatement and or Total Disability In

OMB Control No. 2900-0011
Respondent Burden: 30 minutes
Expiration Date: 11/30/2023

(FOR USE BY VA INDEX)

APPLICATION FOR REINSTATEMENT (INSURANCE LAPSED MORE THAN 6 MONTHS)
GOVERNMENT LIFE INSURANCE AND/OR TOTAL DISABILITY INCOME PROVISION
INSTRUCTIONS

Use this form for reinstatement of your Government Life Insurance and/or Total Disability Income Provision when application is made more than 6
months after the date of lapse regardless of age.
Amount of payment needed for reinstatement:
TERM POLICIES - Two premiums; One for the premium month of lapse and one for the premium month in which the application is sent to
the Department of Veterans Affairs.
LIFE AND ENDOWMENT POLICIES - All unpaid premiums with interest on the amount of insurance to be reinstated. Please call our tollfree number (1-800-669-8477) for instructions to calculate the amount of payment (premium and interest) needed to reinstate your policy(ies).
When completed and signed by you, send this application with payment needed to:
Department of Veterans Affairs
Regional Office and Insurance Center (REIN)
P.O. Box 7208
Philadelphia, PA 19101
NOTE: Additional correspondence may also be submitted by Document Upload. Payments may also be submitted on line through Online Bill pay.

UPLOAD:
Upload the form using our secure website at:
www.insurance.va.gov

ONLINE BILL PAY:
You can log on to your bank's online bill payment service and follow their
instructions for setting up an electronic payment.
Your bank will need the following information to set up online bill payments.
• Payee: VA Life Insurance
• Account Number: Insurance Policy Number
Some banks may also require you to enter:
• Payee Address: P.O. Box 4019
• City, State, ZIP Code: Portland, OR 97208 - 4019
• Phone Number: 800-669-8477

SECTION I - APPLICANT'S INFORMATION
1A. FIRST - MIDDLE - LAST NAME OF INSURED

1B. INSURANCE POLICY NUMBER (If more than one policy, please

complete a separate form for each policy number)

2. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and street or rural route, city or P.O., State and ZIP Code)
3. SOCIAL SECURITY NUMBER

4. VA CLAIM NUMBER (If any)

5. DAYTIME TELEPHONE NUMBER (Include Area Code)

6. POLICY NUMBER(S) TO BE REINSTATED
7A. AMOUNT OF INSURANCE TO
BE REINSTATED

7B. PLAN OF INSURANCE

7C. DATE OF LAPSE

(MM/DD/YYYY)

$

7D. MONTHLY PREMIUM

$

7F. AMOUNT OF TOTAL DISABILITY INCOME
PROVISION TO BE REINSTATED

7G. DATE OF LAPSE

(MM/DD/YYYY)

$

7H. MONTHLY PREMIUM

$
8. TOTAL AMOUNT SENT

7E. AMOUNT SENT WITH THIS
APPLICATION (INS)

$
7I. AMOUNT SENT WITH THIS
APPLICATION (TDIP)

$
$

I UNDERSTAND THAT:
1. The amount of payment needed must be sent before or with this application. Checks and money orders should be made payable to the Department of Veterans Affairs.
2. The Department of Veterans Affairs will, if necessary, ask for a physical examination report in connection with this application.

VA FORM
NOV 2020

29-352

SUPERSEDES VA FORM 29-352, APR 2017,
WHICH WILL NOT BE USED.

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SECTION II - STATEMENT OF APPLICANT (Please answer every question, date and sign this statement)
INFORMATION: The purpose of questions contained in STATEMENT OF APPLICANT is to secure complete information regarding the condition of the applicant's
health. All diseases, injuries, abnormalities, deformities, or infirmities must be stated and fully described. Statements made by the applicant in this application are relied
upon in granting insurance. Consequently, any deception or knowingly false statement either by inference, omission, or otherwise may result in cancellation of the
insurance or in refusal to pay a claim on the policy.
9A. ARE YOU NOW WORKING?
YES

9B. DO YOU WORK FULL-TIME?

NO

YES

NO

9C. IF NOT WORKING OR WORKING PART-TIME, EXPLAIN WHY
10. HAVE YOU EVER HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING?
YES

A. DISEASE OF THE HEART OR ARTERIES, CHEST PAIN?

NO

YES

H. TUBERCULOSIS, PLEURISY, OR BRONCHITIS?

B. HIGH BLOOD PRESSURE?

I. DIABETES?

C. CANCER, TUMOR OR POLYP?

J. ARTHRITIS, PARALYSIS, OR DISEASE OR DEFORMITY OF
THE BONES, MUSCLES OR JOINTS?

D. LUNG DISEASE?

K. DISEASE OR ULCER OF STOMACH, INTESTINES, OR
RECTUM?

E. EPILEPSY, UNCONSCIOUSNESS, DIZZINESS OR
IMPAIRMENT OF NERVOUS SYSTEM?

L. DISEASE OF THE URINARY TRACT, SUGAR, ALBUMIN, OR
BLOOD IN URINE?

F. EMOTIONAL OR MENTAL DISORDER?

M. ANY DISEASE OF THE PROSTATE OR TESTES IF A MALE,
UTERUS, OVARIES OR BREASTS IF A FEMALE?

G. DISEASE OF THE BLOOD?

N. DO YOU USE OR HAVE YOU BEEN TREATED FOR USE OF
ALCOHOL OR ANY HABIT FORMING DRUG?

11. WITHIN THE PAST 5 YEARS, HAVE YOU
BEEN TREATED BY A PHYSICIAN?
YES

NO

12. ARE YOU NOW OR HAVE YOU EVER
BEEN HOSPITALIZED FOR ILLNESS,
DISEASE OR INJURY?
YES

15. HAS ANY APPLICATION YOU HAVE MADE FOR PRIVATE OR GOVERNMENT LIFE, HEALTH,
DISABILITY OR ACCIDENT INSURANCE BEEN REFUSED, POSTPONED, APPROVED AT
SUBSTANDARD RATES OR ON A DIFFERENT BASIS THAN APPLIED FOR?
YES

NO

14. HAVE YOU EVER APPLIED FOR
DISABILITY COMPENSATION OR
PENSION?

13. DO YOU HAVE ANY
SERVICE-CONNECTED
DISABILITIES?

NO

YES

NO

NO

YES

NO

16A. YOUR HEIGHT

FEET

INCHES

16B. YOUR WEIGHT

POUNDS

17. REMARKS (Give complete details to YES answers. Include dates, diagnosis, physicians or hospitals, and names and addresses. Indicate after each disability whether

service-connected or non service-connected. If additional space is needed, attach a separate sheet of paper)

I consent that any hospital, physician or surgeon who has treated or examined me for any purpose, or whom I have consulted professionally, may divulge to the
Department of Veterans Affairs any information obtained by them, or it, concerning myself. I understand that the Government will rely on the truth of those answers. I
HAVE READ THE ABOVE ANSWERS AND TO THE BEST OF MY KNOWLEDGE, THEY ARE TRUE. I am obliged to advise the Department of Veterans Affairs
of any change of health condition arising after the signing and prior to the delivery of this form to the Department of Veterans Affairs.
18A. SIGNATURE

18B. DATE SIGNED (MM/DD/YYYY)

PRIVACY ACT NOTICE: The 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 5, Code of
Federal Regulations 1.526 for routine uses identified in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U. S. Government Life Insurance -VA,
published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. Giving us your SSN account information is
voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The 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. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information to determine, establish or verify your eligibility for VA insurance benefits (38 CFR 8.24 and 6.80). Title 38, United States Code, allows
us to ask for this information. We estimate you will need an average of 30 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 http://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.

IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, CALL TOLL-FREE 1-800-669-8477
VA FORM 29-352, NOV 2020

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