To submit this form, send it to OSGLI at PO Box 41618, Philadelphia, PA 19176-1618. You can also fax it to 800-236-6142 or email it to OSGLI using the contact information provided in the form. Make sure to include your first premium payment and a copy of your DD-214 or most recent Leave and Earnings Statement. Submit within one year and 120 days from your date of separation.

You have one year and 120 days from your date of separation to apply for VGLI. Ensure to mark your calendar and submit within this window.

The purpose of this form is to enable veterans to apply for Veterans' Group Life Insurance (VGLI), providing them with the opportunity to continue their life insurance coverage after separation from service. This form collects vital information about the veteran, including personal details, coverage preferences, health statements, and beneficiary designations. By completing and submitting this form, veterans ensure they receive the life insurance benefits they are entitled to, safeguarding their financial security. This form also ensures that veterans can update their beneficiary information as needed, maintaining accurate records of their life insurance policy.

• 1. Veteran Information: Includes fields for personal details like name, social security number, address, birth date, and branch of service.
• 2. Coverage Election and Payment Method: Allows selection of coverage amount and billing preferences, including payment cycle and first premium payment options.
• 3. Health Statement: Requires information about any past or current health conditions and medical history.
• 4. Beneficiary Designation: Enables the designation of beneficiaries for the life insurance policy.
• 5. Authorization/Signature: Includes the signature of the applicant along with the date to validate the form.

Failure to submit this form can result in the loss of life insurance coverage.

• Loss of Coverage: Veterans may not receive life insurance benefits, affecting their financial security.
• Ineligibility for Future Coverage: Missing the submission deadline could make the veteran ineligible for future VGLI coverage.

• 1. Veterans Applying for Coverage: Use this form to apply within one year and 120 days of separation from service.
• 2. Servicemembers Transitioning to Civilian Life: Complete this form to maintain life insurance after separating from the military.
• 3. Updating Beneficiary Information: Use this form to update or change beneficiary details for your life insurance policy.
• 4. Applying for Increased Coverage: Submit this form if you wish to increase your VGLI coverage at your one-year and five-year anniversaries.
• 5. Providing Health Statements: Complete relevant health statement sections if more than 240 days have passed since your separation.