Veterans Burial Allowance Insurance Claim Form
Veteran Information
Full Name
Social Security Number
Date of Birth
Date of Death
Address
Branch of Service
Service Number
Claimant Information
Full Name
Relation to Veteran
Address
Phone Number
Email
Burial Information
Place of Burial
Date of Burial
Funeral Home Name
Funeral Home Address
Insurance Details
Policy Number
Insurance Company
Amount Claimed
Certification & Signature
Certification Statement
Signature
Date