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Statement of Claim for Members and Dependents 2026

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Click ‘Get Form’ to open the Statement of Claim for Members and Dependents in the editor.
Begin by filling out the Member Information section. Enter your name, date of birth, ID number, marital status, and member status. Ensure all fields are completed accurately.
Provide your mailing address and check if it is a new address. Include your preferred method of contact—either email or telephone.
In the Dependent Information section, list each dependent's name, relationship to you, date of birth, and employment status. If applicable, provide their address and other relevant details.
Complete the Other Coverage Information section if you or your dependents have additional health care benefits. Fill in policyholder details and coverage specifics.
Review all entries for accuracy before signing the form at the bottom. Ensure that you authorize any necessary disclosures regarding insurance coverage.

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Versions	Form popularity	Fillable & printable
2019	4.3 Satisfied (59 Votes)
2016	4.4 Satisfied (59 Votes)

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Can I sign my Statement of Claim for Members and Dependents in electronic format?

Based on eSignature regulations, forms approved digitally have the same validity as those approved with pen and paper. You can electronically sign almost any business and private documentation. Four types of documents still demand wet signatures only - wills and testamentary trusts, court orders and other court forms, state statutes regulating divorce, adoption, or other family law, and notice of cancellation of utility services. If you adhere to the regulations and utilize a reliable and compliant software solution, like DocHub, you can eSign your Statement of Claim for Members and Dependents without printing it.

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How to file a VA claim for dependents?

A dependent may be a spouse, domestic partner, or child (some plans refer to spouse and dependents meaning that they differentiate between the spouse and the children). You can cover your biological, adopted, and stepchildren.

How do I claim dependents on VA disability?

Fill out an Application Request to Add and/or Remove Dependents (VA Form 21-686c). Note: If your dependent is a child whos between 18 and 23 years old and attending school full time, youll also need to fill out and mail us a Request for Approval of School Attendance (VA Form 21-674) with your application.