VA Form 29-357, Claim for Disability Insurance Benefits (Government Life Insurance) Instructions

Enter the VA claim number for this disability insurance benefits claim exactly as it appears on your VA correspondence or award letter.

Enter the date when the veteran's disability began or prevented the veteran from being gainfully employed.

Enter the insured veteran's date of birth.

Enter the date when the veteran returned to gainful employment.

Enter the veteran's daytime telephone number including the area code (use standard local formatting such as (###) ###-#### or include country code if applicable).

Enter the name and brief description of the disease or injury that caused the total or permanent disability (e.g., diagnosis, affected body part, onset or relevant details) as a text string.

Check this box if the veteran’s highest level of college completed is 1 year.

Check this box if the veteran’s highest level of college completed is 2 years.

Check this box if the veteran’s highest level of college completed is 3 years.

Check this box if your highest completed grade school education is 1 year.

Check this box if your highest completed grade school education is 2 years.

Check this box if your highest completed grade school education is 3 years.

Check this box if your highest completed grade school education is 4 years.

Check this box if your highest completed grade school education is 5 years.

Check this box if your highest completed grade school education is 6 years.

Check this box if your highest completed grade school education is 7 years.

Check this box if your highest completed grade school education is 8 years.

Check this box if the highest level of education you completed was 1 year of high school.

Check this box if the highest level of education you completed was 2 years of high school.

Check this box if the highest level of education you completed was 3 years of high school.

Check this box if the highest level of education you completed was 4 years of high school (high school graduate).

Enter the date you last worked for this employer.

Enter the average number of hours you worked per week for this employment.

Enter the weekly earnings you received from this employment.

Enter the job title or occupation you held with this employer.

Provide the full name and mailing address of the employer for this job.

State the reason your employment ended with this employer (for example, layoff, resignation, discharge).

Enter the date you began working for this employer.

Enter the date your employment with this employer ended or indicate if you are still employed.

Enter the full official name of the first hospital where you received treatment.

Enter the complete street address of the first hospital, including city, state, and ZIP code.

Enter the date you were admitted to the first hospital.

Enter the date you were discharged or released from the first hospital.

Enter the full name of the first licensed practitioner who treated you, including any professional credentials or suffixes if applicable.

Enter the full mailing address of that practitioner, including street address, city, state, and ZIP code.

Enter the date when treatment by this practitioner began.

Enter the date of the most recent treatment you received from this practitioner.

Enter the full government life insurance policy number for this policy exactly as shown on your policy (include any letters, dashes, or other characters).

Enter the insured veteran's full name (first, middle, last) as typed or printed exactly as you want it to appear on the record.

Enter the date when the insured signed this form.

Provide the insured's handwritten signature (the person completing or authorizing the form should sign here).

Enter the insured person's complete mailing address for insurance purposes, including number and street or rural route, city or P.O. box, state, and ZIP code.

Check this box if you are receiving or have applied for VA disability compensation benefits.

Check this box if you are receiving or have applied for a VA pension.

Check this box if you are receiving or have applied for Social Security disability benefits.

Enter the last date you were insured and actually worked for this employer.

Enter the amount you were paid per week for this employment.

Enter the typical number of hours you worked per week for this employment.

Provide the reason your employment with this employer ended (for example, resignation, layoff, termination, retirement).

Enter the employer's full name and mailing address for this period of employment.

Enter the job title or occupation you performed for this employer.

Enter the start date when you began this period of employment.

Enter the end date when this period of employment finished.

Enter the full name of the second hospital or medical facility where you received treatment.

Enter the street address, city, and state of the second hospital or facility where you were treated.

Enter the date you were admitted to this hospital for the treatment or stay.

Enter the date you were discharged or released from this hospital after that treatment or stay.

Enter the full name of the second licensed practitioner who treated you for the disease or injury.

Enter the complete address of that second licensed practitioner’s practice, including street, city, state, and ZIP code.

Enter the date when treatment by this second licensed practitioner began.

Enter the date of the last treatment provided by this second licensed practitioner.

Enter the insured veteran's Social Security Number as a nine-digit identifier (include all digits, typically formatted without spaces or dashes).

Enter any specialized training you have received related to your employment or disability claim, including the training title, institution or provider, and relevant dates or qualifications; provide additional details as needed to describe the training. Fill only if 'Part I - Item 10A: Grade School - 3 years' 10A. EDUCATION indicates other specialized training or education.

Enter the average number of hours you worked per week for this employer.

Enter the date of your last day insured worked for this employer.

Enter your weekly earnings from this employer.

Provide the reason your employment ended with this employer (for example: layoff, resignation, discharge, or illness).

Enter the employer's full name and mailing address where you were employed.

Enter the job title or occupation you performed for this employer.

Enter the date you began working for this employer.

Enter the date you stopped working for this employer.

Enter the full name of the third hospital where you were treated, including any facility or campus designation.

Enter the full street address of the third hospital where you were treated, including city, state and ZIP code.

Enter the date you were admitted to the third hospital.

Enter the date you were discharged or released from the third hospital.

Enter the full name of the third licensed practitioner who treated you, including any credentials (for example, MD, DO, RN) if known.

Enter the full mailing address of the third licensed practitioner or their practice, including street, city, and state.

Enter the date when the third licensed practitioner began treating you.

Enter the date of the last treatment you received from the third licensed practitioner.