Submit the completed form to the VA office that maintains your insurance records. You can upload documents securely at https://insurance.va.gov/home/IDU or send them by mail to: Department of Veterans Affairs, Regional Office and Insurance Center (WP), P.O. Box 7208, Philadelphia, PA 19101. Make sure all information is accurate and attach any required supporting documents.

The form expires on 8/31/2025. Ensure to submit your claim and supporting documents prior to this date.

The purpose of this form is to allow veterans with government life insurance policies to claim disability benefits due to total disability. It ensures that the necessary information is collected to determine eligibility for benefits, including waiver of premiums and premium refunds. By providing detailed personal, insurance, and medical information, the VA can process the claim and provide the required benefits to the veteran.

• 1. First, Middle, Last Name of Insured: The full name of the insured veteran.
• 2. Insurance Policy Number: The policy number for the government life insurance.
• 3. Mailing Address for Insurance Purposes: The mailing address where insurance-related correspondence should be sent.
• 4. Social Security Number: The SSN of the insured veteran.
• 5. Date of Birth: The birth date of the insured veteran.
• 6. Daytime Telephone Number: The phone number for contact during daytime hours.
• 7. Claim Number: The number assigned to the disability claim.
• 8. Date Disability Prevented Employment: The date when the disability prevented the veteran from working.
• 9. Date Returned to Gainful Employment: The date when the veteran resumed working, if applicable.
• 10. Education: The highest level of education completed by the veteran.
• 11. Specialized Training: Any specialized training or education received by the veteran.
• 12. Receiving or Applied for Disability Benefits: Indicates whether the veteran is receiving or has applied for other disability benefits.
• 13. Disease or Injury Causing Total or Permanent Disability: Description of the condition causing the veteran's disability.
• 14. Hospitals Where Treated: Details of hospitals where the veteran has been treated for the disability.
• 15. Practitioners Who Treated: Information about licensed practitioners who treated the veteran for the disability.
• 16. Record of Employment Prior to Disability: Employment details one year prior to the disability to the present, including self-employment.
• 17. Signature of Insured: The insured veteran's signature or that of an official completing the form.
• 18. Date of Signature: The date the form was signed by the insured or their representative.

Failure to submit this form may result in denial of disability insurance benefits.

• Loss of Benefits: Not submitting the form can lead to a loss of insurance benefits.
• Delay in Processing: Submitting incomplete or incorrect information can cause delays in processing the claim.

• 1. Total Disability: When you become totally disabled and are unable to work.
• 2. Waiver of Premiums: To request a waiver of insurance premiums due to disability.
• 3. Premium Refund: To claim a refund for premiums paid while being totally disabled.
• 4. Medical Certification: When medical practitioners need to certify the disability.
• 5. Insurance Record Update: To update insurance records with current disability status and information.