VA Form 29-8701 Application for Ordinary Life Insurance (Age 70)

OMB Approved No. 2900-0166
Respondent Burden: 5 minutes

1A. INSURANCE FILE NUMBER

APPLICATION FOR ORDINARY LIFE INSURANCE
REPLACEMENT INSURANCE FOR MODIFIED LIFE REDUCED
AT AGE 70
NATIONAL SERVICE LIFE INSURANCE

1B. NEW POLICY NO.(Assigned by VA)

PRIVACY ACT NOTICE - 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, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records-VA, and published in the
Federal Register. Your obligation to respond is required to obtain this benefit.
RESPONDENT BURDEN - We need this information to determine your eligibility for an insurance benefit. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find
the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB Control
Number is displayed. Valid OMB Control Numbers can be located on the OMB Internet Page at:
www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA . If desired, you can call 1-800-827-1000 for mailing information on
where to send your comments.

IMPORTANT - This application and the first premium must be submitted to the
Department of Veterans Affairs BEFORE your 70th birthday.
2. FIRST - MIDDLE -LAST NAME OF INSURED

3. DAYTIME TELEPHONE NUMBER

(

)

4. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and street or rural route, city or post office, STATE and Zip
Code) (COMPLETE ONLY IF DIFFERENT THAN THAT SHOWN ON REVERSE)

I wish to apply for the amount of insurance shown in the block to the
right as replacement for the insurance coverage that will end on the day
before my 70th birthday.

5. AMOUNT OF INSURANCE
APPLIED FOR

$

I UNDERSTAND that the beneficiary designation and optional settlement under this new policy will be the same as on my Modified
Life policy and will remain the same until I submit a change in writing to the Department of Veterans Affairs.
6. SIGNATURE OF INSURED (Do not print. Sign in ink)

7. DATE OF APPLICATION

When completed, mail this application and the first premium to the Department of Veterans Affairs at the address shown on the
reverse.
VA FORM
JUN 2008

29-8701

SUPERSEDES VA FORM 29-8701, JUN 2000,
WHICH WILL NOT BE USED.