29-4125K Claim for Monthly Payments - United States Government Li

OMB Approved No. 2900-0060
Respondent Burden: 15 Minutes
1. INSURANCE FILE NUMBER

CLAIM FOR MONTHLY PAYMENTS
UNITED STATES GOVERNMENT LIFE INSURANCE
(USGLI)
3. NET AMOUNT PAYABLE

F2. INSURANCE POLICY NUMBER

5. PAYMENT OPTION
SELECTED BY
INSURED

4. BENEFICIARY’S SHARE (Fraction)

IMPORTANT - Use this form for K prefix policies ONLY. PLEASE TYPE OR PRINT IN INK WHEN COMPLETING THIS
FORM.
BENEFICIARY - This form is to be used only when monthly payments were selected by the insured, or the beneficiary is select
monthly payments instead of one sum. See the directions on the reverse side if you wish select a Lump Sum Payment.
SIGNATURE - In order to expedite payment of this claim Item 16 must be signed by the beneficiary. If the beneficiary is a minor or
incompetent, the person having custody of the beneficiary should complete the form and give his/her address in Item 12.
DIRECT DEPOSIT - If direct deposit is desired, please fill out the direct deposit box on the reverse side.
We need a photocopy of the veteran’s death certificate or a statement from the attending physician showing date and cause of
death. Only one certificate or statement is required for our records.
6. FIRST, MIDDLE AND LAST NAME OF INSURED VETERAN

7. DATE OF BIRTH

8. INSURED’S PLACE OF DEATH

9. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY

10. RELATIONSHIP TO INSURED

11. BENEFICIARY’S DATE OF BIRTH

12. ADDRESS OF BENEFICIARY OR THEIR GUARDIAN

13. BENEFICIARY’S DAYTIME
TELEPHONE NUMBER (Include Area Code)

14. BENEFICIARY’S SOCIAL SECURITY NUMBER

(

)

15. Read the instructions on the reverse side and consult the tables attached before making your selection in
the space below. Check ( ) the box for the option selected, or more than one box if more than one
option is selected in accordance with Instruction 2 on the reverse side. If selecting Option 2, please
complete all items on the line checked.
OPTION NUMBER

OPTION DESCRIPTION
NUMBER OF EQUAL MONTHLY INSTALLMENTS
(In multiples of 12)

2

MONTHLY INSTALLMENTS PAYABLE FOR 36 TO 240

3

MONTHLY INSTALLMENTS CONTINUING THROUGHOUT THE LIFETIME OF THE BENEFICIARY WITH 120
PAYMENTS GUARANTEED.

MONTHS (In multiples of 12)

PROOF OF AGE REQUIRED

MONTHLY INSTALLMENTS CONTINUING THROUGHOUT THE LIFETIME OF THE BENEFICIARY, WHICH

4

WILL GUARANTEE PAYMENT OF AN AMOUNT AT LEAST EQUAL TO THE BENEFICIARY’S SHARE OF THE
FACE OR NET AMOUNT OF THE CONTRACT.
PROOF OF AGE REQUIRED
THIS OPTION IS AVAILABLE TO THE BENEFICIARY ONLY WHEN THE INSURED DIES WHILE RECEIVING TOTAL

5

PERMANENT DISABILITY PAYMENTS. THE BENEFICIARY MAY ELECT TO RECEIVE THE REMAINING MONTHLY
INSTALLMENTS.

NOTE - Settlement under one of these options shall be considered full and complete settlement of all liability
under this contract. This section shall not be valid unless and until it is recorded in the Department of Veterans
Affairs. If the beneficiary fails to select an option, settlement will be based on the option selected by the
insured.
IMPORTANT -This form must be signed by the beneficiary, guardian, or fiduciary, in Item 16, in order for
payment to be made. If the beneficiary cannot sign his/her name, but is competent to handle his/her own
affairs, an "X", made by the beneficiary and signed by two disinterested witnesses, is acceptable.
16. SIGNATURE OF BENEFICIARY, FIDUCIARY OR GUARDIAN

17. DATE SIGNED

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM, PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477
VA FORM
AUG 2002

29-4125K

EXISTING STOCKS OF VA FORM 29-4125K, SEP 1996,
WILL BE USED.

INSTRUCTIONS FOR SELECTION OF OPTIONAL SETTLEMENT
1. A LUMP SUM SETTLEMENT is not available when the insured selected a monthly installment option.
HOWEVER, if the insured left a will or there is other evidence, in writing, that the insured desired that the
beneficiary receive a lump sum, the beneficiary may submit a copy of such consideration. When submitting also
sign Item 16 of this form and return it along with the additional evidence. It is not necessary to complete the
entire form.
2. If the insured selected Option 2, with monthly installments in excess of 120, beneficiary may elect to
receive payment in a greater number of installments under Option 2, or may elect to receive payment under
Option 3 or 4.
3. If the insured selected Option 2, with monthly installments in excess of 120, beneficiary may elect to
receive payment in a greater number of installments under Option 2 or may elect to receive payment under
Option 3.
4. If the insured has selected Option 2, and named no contingent beneficiary, beneficiary may elect to receive
payment under Option 4.
5. If insured has selected Option 4, the beneficiary may elect to receive payment under Option 5.
6. The tables attached indicate what you will receive monthly on the monthly installments plan (Option 2) and
on the continuous monthly installment plan (Option 3 or Option 4). The amount represent the value per
thousand of insurance. If you entitled to more than $1000 under the policy, the value should be increased
proportionately. (i.e., $3000 policy will pay on the 36 monthly installment system, three times $29.19 or
$87.57 monthly).
TO BE COMPLETED BY BENEFICIARY IF DIRECT DEPOSIT IS DESIRED
NAME OF FINANCIAL INSTITUTION

ROUTING TRANSIT NUMBER

ADDRESS OF FINANCIAL INSTITUTION

TYPE OF DEPOSITOR ACCOUNT
CHECKING
SAVINGS

TELEPHONE NUMBER OF FINANCIAL INSTITUTION

DEPOSITOR ACCOUNT NUMBER

SEND COMPLETED FORM TO:
DEPARTMENT OF VETERANS AFFAIRS
REGIONAL OFFICE AND INSURANCE CENTER
P.O. BOX 7208
PHILADELPHIA, PA 19101
PRIVACY ACT NOTICE: No proceeds may be paid unless a completed claim form has been received (38
U.S.C. 1917). The information provided on a voluntary basis will be used by VA employees and your
authorized representatives in the maintenance of Government Insurance programs. Responses may be disclosed
outside the VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in
the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance
Records - VA, published in the Federal Register.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this
collection of information unless it displays a valid OMB Control Number. Public reporting burden for this
collection of information is estimated to average 6 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. If you have comments regarding this burden estimate or any other
aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.