HIGHER LEVEL REVIEW

Social Security Number

VA FileNumber

DOB

VA INSURANCE POLICY NUMBER (If applicable)

Current Mailing Address Number and Street

Current Mailing Address Apartment Or UnitNumber

Current Mailing Address City

Current Mailing Address State Or Province

Current Mailing Address Country

Current Mailing Address ZIP Or PostalCode

Phone Number

International Telephone Number If Applicable

Email

Social Security Number

DOB

Current Mailing Address Number And Street

Current Mailing Address Apartment Or Unit Number

Current Mailing Address Address State Or Province

Current Mailing Address City

Current Mailing Address Country

Current Mailing Address ZIP Or PostalCode

Phone Number

International Telephone Number If Applicable

Email

WOULD LIKE AN INFORMAL CONFERENCE. I understand electing an informal conference is optional and may delay a decision.

Benefit Type
NATIONAL CEMETERY ADMINISTRATION
COMPENSATION
PENSION/DIC/SURVIVORS BENEFITS
FIDUCIARY
EDUCATION
VETERANS HEALTH ADMINISTRATION
VETERAN READINESS AND EMPLOYMENT
LOAN GUARANTY
LIFE INSURANCE

VA will make two attempts to contact you OR your representative to schedule the informal conference. Contact attempts will be between the hours of 8:00 a.m. and 4:30 p.m. Eastern Time. INDICATE ONE PREFERENCE:
Call me between 8:00 a.m. - 12:00 p.m. ET
Call me between 12:00 p.m. - 4:30 p.m. ET
Call my representative between 8:00 a.m. - 12:00 p.m. ET
Call my representative between 12:00 p.m. - 4:30 p.m. ET

NAME OF REPRESENTATIVE'S (Last)

REPRESENTATIVE'S TELEPHONE NUMBER (Include Area Code)

REPRESENTATIVE'S E-MAIL ADDRESS

SIGNATURE OF VETERAN OR CLAIMANT (Sign in ink)
Clear
DATE SIGNED OF VETERAN OR CLAIMANT (Sign in ink)

NAME OF VA AUTHORIZED REPRESENTATIVE (First)

NAME OF VA AUTHORIZED REPRESENTATIVE (Last)

SIGNATURE OF VA AUTHORIZED REPRESENTATIVE (Sign in ink)
Clear
DATE SIGNED OF VA AUTHORIZED REPRESENTATIVE (Sign in ink)