Fillable Printable VA Form 4107INS

VA Form 4107INS

YOUR RIGHTS TO APPEAL OUR DECISION

VA FORM

MAY 2017

4107INS

We have reached a decision on your application or claim. This form will tell you what to do if you disagree with

our decision.

IF YOU DISAGREE WITH OUR DECISION

If you disagree with our decision, you can:

1. Submit New Evidence to Support Your Claim

You can send any additional evidence you have to support your application or claim to the address at the

top of our letter. We will consider any new evidence as long as it is evidence we have not already seen and

it relates to your claim. We will then let you know whether it changes our decision.

2. Appeal

If you want to begin an appeal of our decision, you must:

a. Write us a letter telling us you disagree with our decision. This letter is called your "Notice of

Disagreement." If we denied applications or claims for different insurance policies, please tell us in

your letter which insurance policy or policies your disagreement concerns. You can also send us

additional evidence with your Notice of Disagreement.

b. Send your Notice of Disagreement and any additional evidence to support your application or claim

to the address at the top of our letter.

We will review your Notice of Disagreement and any new evidence together with the evidence we already have

and let you know whether it changes our decision. If we cannot approve your application or claim, we will send

you a letter notifying you of our decision and asking if you want to continue your appeal or withdraw it. If you

choose to continue your appeal, we will send you a Statement of the Case that describes the facts, laws,

regulations, and reasons we used to make our decision and a VA Form 9, "Appeal to Board of Veterans' Appeals"

to complete.

3. Challenge VA's Decision at a Federal Court

You may also challenge VA's decision on your application or claim by filing a complaint with a United

States district court in the District of Columbia or in the district in which you reside within six years from

when the right of action first accrues. To find a district court, use the map on this website:

http://www.uscourts.gov/court_locator.aspx.

HOW LONG DO I HAVE TO APPEAL THE DECISION?

You have:

• One year to appeal to the Board of Veterans' Appeals (Board) by submitting a Notice of Disagreement; or

• Six years to challenge VA's decision at a federal district court.

If you do not start your appeal on time, our decision will become final. Once our decision is final, you cannot get

the VA benefit we denied unless you either show that we were clearly wrong to deny the benefit or send us new

evidence that relates to the reason we denied your claim.

YOUR RIGHT TO REPRESENTATION

You can have someone represent you, if you wish. You can find a list of Veterans Service Organizations that will

represent you for free at http://www.va.gov/vso. An attorney or agent can also represent you but may require you

to pay for their services. VA cannot pay any attorney or agent fees.