DEPARTMENT OF VETERANS AFFAIRS Insurance Center P O Box 42954 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the full name of the deceased Service Member or Veteran in Item 1, followed by their Social Security Number in Item 2 and date of death in Item 3.
3. For Items 4, 5, and 6, provide details about the branch of service, duty status on the date of death, and discharge date if applicable.
4. In Items 7 through 10, fill out your full name, relationship to the deceased, your date of birth, and your Social Security Number.
5. If you were married to the deceased but not named as a beneficiary, complete Items 11A through 14C. If not married or not named as a beneficiary, proceed to Part II.
6. Complete Parts IV and V for payment method selection and certification. Ensure all information is accurate before submission.

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