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Get VA FVRS-9930 2011

A 23218-1193 For claim information call: 1-800-441-2258 Name of employee (last, first, middle initial) m CLAIM NUMBER Address (street, city, state, zip) Date of birth (mo/day/yr) Social Security number Check the appropriate box and give your name, address, date of birth, Social Security number and daytime telephone number below: I am the surviving lawful wife or husband of the insured. I am a child or a descendant of a deceased child of the insured. The insured left no surviving lawful wi.

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