Form 29-357 Claim for Disability Insurance Benefits, Government Life

OMB Approved No. 2900-0016
Respondent Burden: 1 hour 45 minutes
Expiration Date: XX/XX/20XX

CLAIM FOR DISABILITY INSURANCE BENEFITS
GOVERNMENT LIFE INSURANCE

PRIVACY ACT INFORMATION: 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, 36VA29, Veterans and Uniformed Services Personnel
Programs of U.S. Government Life Insurance Records - VA, published in the Federal Register. Your response is required to obtain or retain this benefit. Giving us your
SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. 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.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0016, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 1 hour 45 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at vapra@va.gov. Please refer to OMB Control No.
2900-0016 in any correspondence. Do not send your completed VA Form 29-357 to this email address.

INFORMATION AND INSTRUCTIONS
THIS APPLICATION IS TO BE COMPLETED BY VETERANS WHO HAVE GOVERNMENT LIFE INSURANCE
AND BECOME TOTALLY DISABLED.
TOTAL DISABILITY:
1. Any impairment of mind or body which makes it impossible for the veteran to be gainfully employed.
2. Total Disability must start before the veteran's 65th birthday.
WAIVER REFUND
1. Premium Refunds limited to one year prior to date the claim is filed, unless there were circumstances beyond the
veteran's control (such as a severe mental disability). LACK OF KNOWLEDGE OF THE WAIVER PROVISION IS
NOT A CIRCUMSTANCE BEYOND THE VETERAN'S CONTROL.
2. If total disability started more than one year prior to the date of your claim, and you believe a mental disability
prevented you from filing an earlier claim, please include a statement explaining these circumstances on a separate sheet of
paper. YOU SHOULD ALSO INCLUDE ANY MEDICAL EVIDENCE WHICH SUPPORTS YOUR
STATEMENT.
PART I should be completed by the insured veteran if able; if not, by a person acting on his/her behalf.
PART II should be completed by the insured veteran's licensed practitioner of the healing arts acting within the scope of
their practice or hospital official. If there will be a delay in preparing Part II send Part I immediately.
NOTE: IF THE VETERAN HAS BEEN GRANTED DISABILITY BENEFITS FROM THE SOCIAL SECURITY
ADMINISTRATION, PLEASE ATTACH A COPY OF THE AWARD LETTER.
PART I

1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)

2. INSURANCE POLICY NUMBER (If more than one policy,
please complete a separate form for each policy number)

3. MAILING ADDRESS FOR INSURANCE PURPOSES (Number and Street or Rural

4. SOCIAL SECURITY NUMBER

Route, City or P.O., State and ZIP Code)

5. DATE OF BIRTH
6. DAYTIME TELEPHONE NUMBER (Include Area Code)
7. CLAIM NUMBER
8. DATE DISABILITY PREVENTED EMPLOYMENT

9. DATE RETURNED TO GAINFUL EMPLOYMENT

10A. EDUCATION (Check highest years completed) (If you have any other specialized training or education please complete Item 10B)

1

2

3

4

5

6

7

8

1

(Grade School)

2

3

4

(High School)

1

2

3

4

(College)

10B. PLEASE PROVIDE ANY SPECIALIZED TRAINING IN THE SPACE PROVIDED BELOW

11. ARE YOU RECEIVING OR HAVE YOU APPLIED FOR ANY
DISABILITY BENEFITS AS LISTED BELOW?
VA DISABILITY
COMPENSATION
VA FORM
XXX 20XX

29-357

VA PENSION

12. DISEASE OR INJURY CAUSING TOTAL OR PERMANENT DISABILITY

SOCIAL SECURITY
DISABILITY
SUPERSEDES VA FORM 29-357, AUG 2022,
WHICH WILL NOT BE USED.

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IF YOU HAVE ANY QUESTIONS ABOUT DISABILITY BENEFITS OR YOUR INSURANCE,
PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477
13. HOSPITALS WHERE YOU HAVE BEEN TREATED, INCLUDING VA HOSPITALS
NAME OF HOSPITAL

ADDRESS OF HOSPITAL

DATE OF ADMISSION

DATE OF RELEASE

14. LICENSED PRACTITIONERS WHO HAVE TREATED YOU FOR DISEASE OR INJURY, CAUSING TOTAL PERMANENT DISABILITY
NAME OF LICENSED
PRACTITIONER OF THE HEALING
ARTS ACTING WITHIN THE SCOPE
OF THEIR PRACTICE

ADDRESS OF LICENSED PRACTITIONER OF THE HEALING
ARTS ACTING WITHIN THE SCOPE OF THEIR PRACTICE

DATE TREATMENT
BEGAN

DATE OF LAST
TREATMENT

15. RECORD OF EMPLOYMENT FOR ONE YEAR PRIOR TO THE DATE OF TOTAL DISABILITY TO THE PRESENT
(Include self-employment)
DATES OF EMPLOYMENT
FROM

TO

OCCUPATION

HOURS WORKED
WEEKLY

NAME AND ADDRESS OF EMPLOYER

DATES OF EMPLOYMENT
FROM

LAST DAY INSURED WORKED
DATE

TO

LAST DAY INSURED WORKED
DATE

REASON FOR TERMINATION OF EMPLOYMENT

HOURS WORKED
WEEKLY

OCCUPATION

NAME AND ADDRESS OF EMPLOYER

DATES OF EMPLOYMENT
FROM
TO

LAST DAY INSURED WORKED
DATE

OCCUPATION

NAME AND ADDRESS OF EMPLOYER

EARNINGS
WEEKLY

EARNINGS
WEEKLY

REASON FOR TERMINATION OF EMPLOYMENT

HOURS WORKED
WEEKLY

EARNINGS
WEEKLY

REASON FOR TERMINATION OF EMPLOYMENT

I consent that any licensed practitioner of the healing arts acting within the scope of their practice or hospital who has treated or examined me for any purpose, or who I
have consulted professionally, any insurance company or organization to which I have applied for insurance, or any person, persons, firm or corporation to whom, or to
which I have applied for employment or disability benefits, may provide to the Department of Veterans Affairs or testify as to, or produce in court, any information
obtained concerning myself by reason of the foregoing, and waive any privileges which render such information confidential. A photostatic copy of this consent shall be
considered valid authorization for release of information to VA. I certify that each question has been truthfully and completely answered to the best of my knowledge.
16. DATE OF SIGNATURE

17. SIGNATURE OF INSURED (Or official or fiduciary completing form for insured)

PENALTY - The law provides that whomever makes any statement of a material fact, knowing it to be false, shall be punished by fine or imprisonment or both.
VA FORM 29-357, XXX 20XX

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REPORT FOR DISABILITY INSURANCE PURPOSES OF
TREATMENT IN A HOSPITAL FROM AN ATTENDING LICENSED
PRACTITIONER OF THE HEALING ARTS

PART II

Part II of this application should be completed by the appropriate hospital official or by the veteran's attending licensed practitioner of
the healing arts acting within the scope of their practice. If appropriate hospital summaries are available, please forward with application.
1. FIRST, MIDDLE, LAST NAME OF INSURED (Type or print)

2. INSURANCE POLICY NUMBER (Include letter prefix)

3. HOME ADDRESS (Number and Street or Rural Route, City or P.O., State and ZIP Code)

6. HISTORY (Conditions causing disability)
B. DATE INSURED STOPPED WORKING BECAUSE OF DISABILITY

A. WHEN DID INJURY OR ILLNESS BEGIN?
C. DATE OF FIRST TREATMENT

FOR VA USE ONLY
5. SOCIAL SECURITY NUMBER
4. CLAIM NUMBER

D. FREQUENCY AND NATURE OF TREATMENT

E. OBJECTIVE SYMPTOMS AND FINDINGS WHEN FIRST SEEN

F. DIAGNOSIS, INCLUDE RESULTS OF SPECIAL STUDIES

7. HOSPITALIZATION
FROM

DATE

NAME AND ADDRESS OF HOSPITAL

TO

CONDITION AT DISCHARGE

8. PROGNOSIS
A. DATE OF LAST EXAM OR TREATMENT

B. OBJECTIVE FINDINGS

C. DIAGNOSIS - CONDITIONS CAUSING DISABILITY

D. IS VETERAN CAPABLE OF DOING
ALL OF HIS/HER WORK?
YES

NO

E. IS VETERAN CAPABLE OF DOING
ANY OTHER WORK?
YES

NO

F. CARDIAC FUNCTION (Check if applicable)
AHA FUNCTIONAL CAPACITY - CL 1 (NO LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 3 (MARKED LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 2 (SLIGHT LIMITATION)

AHA FUNCTIONAL CAPACITY - CL 4 (COMPLETE LIMITATION)

G. MENTAL/NERVOUS IMPAIRMENT (Ability to function in stressful situations and engage in
interpersonal relations) (Check if applicable)
NO
SLIGHT
MODERATE
MARKED
SEVERE
LIMITATION
LIMITATION
LIMITATION
LIMITATION
LIMITATION

H. SINCE FIRST TREATMENT HAS VETERAN
IMPROVED

WORSENED

REMAINED
THE SAME

9. NAME AND ADDRESS OF ATTENDING LICENSED PRACTITIONER OF THE HEALING ARTS ACTING WITHIN THE SCOPE OF THEIR PRACTICE OR
HOSPITAL

10. DATE OF REPORT

11. SIGNATURE AND TITLE OF PERSON PREPARING REPORT

When completed and signed, send this claim form IMMEDIATELY to the office of the Department of Veterans Affairs where the Insurance Records are
maintained. The address of the Department of Veterans Affairs office that maintains these records is:
Department of Veterans Affairs
The fastest and most secure way to send documents to VA
Regional Office and Insurance Center (WP)
Insurance is to use our document upload service at
P.O. Box 7208
https://insurance.va.gov/home/IDU.
Philadelphia, PA 19101
VA FORM 29-357, XXX 20XX

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