----------------------------------
| SERVICE REQUEST |
----------------------------------
EXHIBIT (10)(E)
P L A T I N U M
----------------------------------
INVESTOR/SM/ SURVIVOR
----------------------------------
AMERICAN GENERAL LIFE
-----------------------------------------------------------------------------------------------------------------------------------
PLATINUM INVESTOR--FIXED DIVISION
. Division 18 - AGL Declared Fixed Interest Account
PLATINUM INVESTOR SURVIVOR--VARIABLE DIVISIONS
AIM Variable Insurance Funds Xxxxxxxxx Xxxxxx Advisers Management Trust
---------------------------- ------------------------------------------
. Division 1 - AIM V.I. International Growth . Division 36 - Mid-Cap Growth
. Division 2 - AIM V.I. Premier Equity
PIMCO Variable Insurance Trust
American Century Variable Portfolios, Inc. ------------------------------
------------------------------------------ . Division 101 - PIMCO Real Return
. Division 19 - VP Value . Division 37 - PIMCO Short-Term
. Division 102 - PIMCO Total Return
Ayco Series Trust
----------------- Xxxxxx Variable Trust
. Division 23 - Ayco Growth ---------------------
. Division 12 - Xxxxxx VT Diversified Income
Credit Suisse Trust . Division 13 - Xxxxxx VT Growth and Income
------------------- . Division 14 - Xxxxxx VT Int'l Growth and Income
. Division 105 - Small Cap Growth
SAFECO Resource Series Trust
Dreyfus Investment Portfolios ----------------------------
----------------------------- . Division 15 - Equity
. Division 24 - MidCap Stock . Division 16 - Growth Opportunities
Dreyfus Variable Investment Fund SunAmerica Series Trust
-------------------------------- -----------------------
. Division 7 - Quality Bond . Division 111 - Aggressive Growth
. Division 8 - Small Cap . Division 110 - SunAmerica Balanced
Fidelity Variable Insurance Products Fund The Universal Institutional Funds, Inc.
----------------------------------------- ---------------------------------------
. Division 28 - VIP Asset Manager . Division 10 - Equity Growth
. Division 27 - VIP Contrafund . Division 11 - High Yield
. Division 25 - VIP Equity-Income
. Division 26 - VIP Growth VALIC Company I
---------------
Franklin Xxxxxxxxx Variable Insurance Products Trust . Division 3 - International Equities
---------------------------------------------------- . Division 4 - Mid Cap Index
. Division 106 - Franklin U.S. Government . Division 5 - Money Market I
. Division 107 - Mutual Shares Securities . Division 20 - Nasdaq-100 Index
. Division 108 - Xxxxxxxxx Foreign Securities . Division 21 - Science & Technology
. Division 22 - Small Cap Index
Janus Aspen Series . Division 6 - Stock Index
------------------
. Division 31 - Aggressive Growth Vanguard Variable Insurance Fund
. Division 29 - International Growth --------------------------------
. Division 30 - Worldwide Growth . Division 103 - High Yield Bond
. Division 104 - REIT Index
X.X. Xxxxxx Series Trust II
--------------------------- Xxx Xxxxxx Life Investment Trust
. Division 32 - JPMorgan Small Company --------------------------------
. Division 17 - Growth & Income
MFS Variable Insurance Trust
----------------------------
. Division 34 - MFS Capital Opportunities
. Division 9 - MFS Emerging Growth
. Division 35 - MFS New Discovery
. Division 33 - MFS Research
AGLC0094 Rev0302
AIG AMERICAN VARIABLE UNIVERSAL LIFE
|GENERAL INSURANCE SERVICE REQUEST
COMPLETE AND RETURN THIS REQUEST TO:
Variable Universal Life Operations
AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL") PO Box 4880 Houston, TX 77210-4880
Member of American International Group, Inc. (000) 000-0000 or (000) 000-0000 . Hearing Impaired/TDD (000) 000-0000
. Fax: (000) 000-0000
------------------------------------------------------------------------------------------------------------------------------------
[_] POLICY 1. | POLICY #:________________________ CONTINGENT INSURED:_________________________________________
IDENTIFICATION | CONTINGENT INSURED:_________________________________________
| ADDRESS:________________________________________________________________ New Address (yes) (no)
COMPLETE THIS SECTION FOR | Primary Owner (if other than an insured):_______________________________
ALL REQUESTS. | Address:________________________________________________________________ New Address (yes) (no)
| Primary Owner's S.S. No.or Tax I.D. No.______________ Phone Number:( )_____-_________________
| Joint Owner (if applicable):___________________________________________________________________
| Address:________________________________________________________________ New Address (yes) (no)
-----------------------------------------------------------------------------------------------------------------------------------
[_] NAME 2. | Change Name Of: (Circle One) Contingent Insured Owner Payor Beneficiary
CHANGE |
Complete this section if the name | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
of one of the Contingent | __________________________________________________ __________________________________________
Insureds, Owner, Payor or |
Beneficiary has changed. (Please | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
note, this does not change the |
Contingent Insureds, Owner, |
Payor or Beneficiary designation.)|
------------------------------------------------------------------------------------------------------------------------------------
[_] CHANGE IN 3. | INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED %
ALLOCATION | (18) AGL Declared Fixed Interest XXXXXXXXX XXXXXX ADVISERS MANAGEMENT TRUST
PERCENTAGES | Account _____ _____ (36) Mid-Cap Growth ______ ______
Use this section to indicate |
how premiums or monthly | AIM VARIABLE INSURANCE FUNDS PIMCO VARIABLE INSURANCE TRUST
deductions are to be allocated. | (1) AIM V.I. International Growth _____ _____ (101) PIMCO Real Return ______ ______
Total allocation in each column | (2) AIM V.I. Premier Equity _____ _____ (37) PIMCO Short-Term ______ ______
must equal 100%; whole | (102) PIMCO Total Return ______ ______
numbers only. | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.
| (19) VP Value _____ _____ XXXXXX VARIABLE TRUST
| (12) Xxxxxx VT Diversified Income______ ______
| AYCO SERIES TRUST (13) Xxxxxx VT Growth and Income ______ ______
| (23) Ayco Growth _____ _____ (14) Xxxxxx VT Int'l Growth and
| Income ______ ______
| CREDIT SUISSE TRUST
| (105) Small Cap Growth _____ _____ SAFECO RESOURCE SERIES TRUST
| (15) Equity ______ ______
| DREYFUS INVESTMENT PORTFOLIOS (16) Growth Opportunities ______ ______
| (24) MidCap Stock _____ _____
| SUNAMERICA SERIES TRUST
DREYFUS VARIABLE INVESTMENT FUND (111) Aggressive Growth ______ ______
| (7) Quality Bond _____ _____ (110) SunAmerica Balanced ______ ______
| (8) Small Cap _____ _____
| THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
| FIDELITY VARIABLE INSURANCE PRODUCTS FUND (10) Equity Growth ______ ______
| (28) VIP Asset Manager _____ _____ (11) High Yield ______ ______
| (27) VIP Contrafund _____ _____
| (25) VIP Equity-Income _____ _____ VALIC COMPANY I
| (26) VIP Growth _____ _____ (3) International Equities ______ ______
| (4) Mid Cap Index ______ ______
| FRANKLIN XXXXXXXXX VARIABLE INSURANCE (5) Money Market I ______ ______
| PRODUCTS TRUST (20) Nasdaq-100 Index ______ ______
| (106) Franklin U.S. Government _____ _____ (21) Science and Technology ______ ______
| (107) Mutual Shares Securities _____ _____ (22) Small Cap Index ______ ______
| (108) Xxxxxxxxx Foreign Securities _____ _____ (6) Stock Index ______ ______
|
| JANUS ASPEN SERIES VANGUARD VARIABLE INSURANCE FUND
| (31) Aggressive Growth _____ _____ (103) High Yield Bond ______ ______
| (29) International Growth _____ _____ (104) REIT Index ______ ______
| (30) Worldwide Growth _____ _____
| XXX XXXXXX LIFE INVESTMENT TRUST
| X.X. XXXXXX SERIES TRUST II (17) Growth & Income ______ ______
| (32) JPMorgan Small Company _____ _____
| OTHER:_______________________ ______ ______
| MFS VARIABLE INSURANCE TRUST 100% 100%
| (34) MFS Capital Opportunities _____ _____
| (9) MFS Emerging Growth _____ _____
| (35) MFS New Discovery _____ _____
| (33) MFS Research _____ _____
------------------------------------------------------------------------------------------------------------------------------------
AGLC0094 Rev0302 PAGE 2 OF 5
------------------------------------------------------------------------------------------------------------------------------------
[_] MODE OF 4. | Indicate frequency and premium amount desired: $______ Annual $_____ Semi-Annual $____ Quarterly
PREMIUM | $_____ Monthly (Bank Draft Only)
PAYMENT/BILLING |
METHOD CHANGE | Indicate billing method desired: _____Direct Bill _____Pre-Authorized Bank Draft (attach a
Use this section to change the | Bank Draft Authorization Form and
billing frequency and/or method | "Void" Check)
of premium payment. Note, |
however, that AGL will not bill | Start Date: ________/ _______/ _________
you on a direct monthly basis. |
Refer to your policy and its |
related prospectus for further |
information concerning minimum |
premiums and billing options. |
-----------------------------------------------------------------------------------------------------------------------------------
[_] LOST POLICY 5. | I/we hereby certify that the policy of insurance for the listed policy has been
CERTIFICATE | ______LOST ______DESTROYED ______OTHER.
Complete this section if applying |
for a Certificate of Insurance or | Unless I/we have directed cancellation of the policy, I/we request that a:
duplicate policy to replace a |
lost or misplaced policy. If a | _______Certificate of Insurance at no charge
full duplicate policy is being |
requested, a check or money order | _______Full duplicate policy at a charge of $25
for $25 payable to AGL must be |
submitted with this request. | be issued to me/us. If the original policy is located, I/we will return the Certificate
| or duplicate policy to AGL for cancellation.
------------------------------------------------------------------------------------------------------------------------------------
[_] DOLLAR COST 6. | Designate the day of the month for transfers: _______(choose a day from 1-28)
AVERAGING | Frequency of transfers (check one): _____Monthly _____Quarterly _____Semi-Annually _____Annually
($5,000 minimum initial | I want: $________________ ($100 minimum, whole dollars only) taken from the Money Market I
accumulation value) An amount may | Division and transferred to the following Divisions:
be deducted periodically from the |
Money Market I Division and | AIM VARIABLE INSURANCE FUNDS XXXXXXXXX XXXXXX ADVISERS MANAGEMENT TRUST
placed in one or more of the | (1) AIM V.I. International Growth $_______ (36) Mid-Cap Growth $_______
Divisions listed. | (2) AIM V.I. Premier Equity $_______
The AGL Declared Fixed | PIMCO VARIABLE INSURANCE TRUST
Interest Account is not available | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. (101) PIMCO Real Return $_______
for Dollar Cost Averaging. | (19) VP Value $_______ (37) PIMCO Short-Term $_______
Please refer to the prospectus | (102) PIMCO Total Return $_______
for more information on the | AYCO SERIES TRUST
Dollar Cost Averaging Option. | (23) Ayco Growth $_______ XXXXXX VARIABLE TRUST
Averaging Option. | (12) Xxxxxx VT Diversified Income $_______
Note: Automatic Rebalancing is | CREDIT SUISSE TRUST (13) Xxxxxx VT Growth and Income $_______
not available if the Dollar Cost | (105) Small Cap Growth $_______ (14) Xxxxxx VT Int'l Growth and Income $_______
Averaging Option is chosen. |
| DREYFUS INVESTMENT PORTFOLIOS SAFECO RESOURCE SERIES TRUST
| (24) MidCap Stock $_______ (15) Equity $_______
| (16) Growth Opportunities $_______
| DREYFUS VARIABLE INVESTMENT FUND
| (7) Quality Bond $_______ SUNAMERICA SERIES TRUST
| (8) Small Cap $_______ (111) Aggressive Growth $_______
| (110) SunAmerica Balanced $_______
| FIDELITY VARIABLE INSURANCE PRODUCTS FUND
| (28) VIP Asset Manager $_______ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
| (27) VIP Contrafund $_______ (10) Equity Growth $_______
| (25) VIP Equity-Income $_______ (11) High Yield $_______
| (26) VIP Growth $_______
| VALIC Company I
| FRANKLIN XXXXXXXXX VARIABLE INSURANCE (3) International Equities $_______
| PRODUCTS TRUST (4) Mid Cap Index $_______
| (106) Franklin U.S. Government $_______ (20) Nasdaq-100 Index $_______
| (107) Mutual Shares Securities $_______ (21) Science & Technology $_______
| (108) Xxxxxxxxx Foreign Securities $_______ (22) Small Cap Index $_______
| (6) Stock Index $_______
| JANUS ASPEN SERIES
| (31) Aggressive Growth $_______ VANGUARD VARIABLE INSURANCE FUND
| (29) International Growth $_______ (103) High Yield Bond $_______
| (30) Worldwide Growth $_______ (104) REIT Index $_______
|
| X.X. XXXXXX SERIES TRUST II XXX XXXXXX LIFE INVESTMENT TRUST
| (32) JPMorgan Small Company $_______ (17) Growth & Income $_______
|
| MFS VARIABLE INSURANCE TRUST OTHER:_____________________________ $_______
| (34) MFS Capital Opportunities $_______
| (9) MFS Emerging Growth $_______
| (35) MFS New Discovery $_______
| (33) MFS Research $_______
| ______ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
------------------------------------------------------------------------------------------------------------------------------------
AGLC0094 Rev0302 PAGE 3 OF 5
------------------------------------------------------------------------------------------------------------------------------------
[_] AUTOMATIC 7. |
REBALANCING | Indicate frequency: ________Quarterly ________Semi-Annually ________Annually
($5,000 minimum accumulation |
value) Use this section to apply | (DIVISION NAME OR NUMBER) (DIVISION NAME OR NUMBER)
for or make changes to |
Automatic Rebalancing of the | _________%:___________________________________ ________%:________________________________
variable divisions. Please refer |
to the prospectus for more | _________%:___________________________________ ________%:________________________________
information on the Automatic |
Rebalancing Option. | _________%:___________________________________ ________%:________________________________
Note: Dollar Cost Averaging is |
not available if the Automatic | _________%:___________________________________ ________%:________________________________
Rebalancing Options is chosen. |
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
|
| ________ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
------------------------------------------------------------------------------------------------------------------------------------
[_] TELEPHONE 8. | I (/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer
PRIVILEGE | values among the Variable Divisions and Declared Fixed Interest Account and to change
AUTHORIZATION | allocations for future purchase payments and monthly deductions.
|
Complete this section if you | Initial the designation you prefer:
are applying for or revoking |
current telephone privileges. | _________Policy Owner(s) ONLY -- If Joint Owners, either one acting independently.
| _________Policy Owner(s) OR Agent/Registered Representative who is appointed to represent AGL
| and the firm authorized to service my policy.
|
| AGL and any non-owner designated by this authorization will not be responsible for any claim,
| loss or expense based upon telephone transfer or allocation instructions received and acted
| upon in good faith, including losses due to telephone instruction communication errors. AGL's
| liability for erroneous transfers or allocations, unless clearly contrary to instructions
| received, will be limited to correction of the allocations on a current basis. If an error,
| objection or other claim arises due to a telephone transaction, I will notify AGL in writing
| within five working days from the receipt of the confirmation of the transaction from AGL. I
| understand that this authorization is subject to the terms and provisions of my variable
| universal life insurance policy and its related prospectus. This authorization will remain in
| effect until my written notice of its revocation is received by AGL at the address printed on
| the top of this service request form.
|
| ________ INITIAL HERE TO REVOKE TELEPHONE PRIVILEGE AUTHORIZATION.
------------------------------------------------------------------------------------------------------------------------------------
[_] CORRECT AGE 9. | Name of Contingent Insured for whom this correction is submitted:_______________________________
Use this section to correct the |
age of any person covered under |
this policy. Proof of the correct | Correct DOB: _________/____________ /_____________
date of birth must accompany this |
request. |
------------------------------------------------------------------------------------------------------------------------------------
[_] TRANSFER OF 10. | (DIVISION NAME OR NUMBER) (DIVISION NAME OR NUMBER)
ACCUMULATED |
VALUES | Transfer $_______ or _______% from ____________________________ to _____________________________
Use this section if you want to |
move money between divisions. | Transfer $_______ or _______% from ____________________________ to _____________________________
The minimum amount for transfers |
is $500.00 | Transfer $_______ or _______% from ____________________________ to _____________________________
Withdrawals from the AGL |
Declared Fixed Interest Account | Transfer $_______ or _______% from ____________________________ to _____________________________
to a Variable Division may |
only be made within the 60 days | Transfer $_______ or _______% from ____________________________ to _____________________________
after a contract anniversary. |
See transfer limitations outlined | Transfer $_______ or _______% from ____________________________ to _____________________________
in prospectus. If a transfer |
causes the balance in any | Transfer $_______ or _______% from ____________________________ to _____________________________
division to drop below $500, AGL |
reserves the right to transfer | Transfer $_______ or _______% from ____________________________ to _____________________________
the remaining balance. Amounts |
to be transferred should be | Transfer $_______ or _______% from ____________________________ to _____________________________
indicated in dollar or percentage |
amounts, maintaining | Transfer $_______ or _______% from ____________________________ to _____________________________
consistency throughout. |
-----------------------------------------------------------------------------------------------------------------------------------
AGLC0094 Rev0302 PAGE 4 OF 5
------------------------------------------------------------------------------------------------------------------------------------
[_] REQUEST FOR 11. |
PARTIAL | ______I request a partial surrender of $_____ or _____% of the net cash surrender value.
SURRENDER/ | ______I request a loan in the amount of $_____.
POLICY LOAN | ______I request the maximum loan amount available from my policy.
Use this section to apply for a |
partial surrender from or policy |
loan against policy values. For | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
detailed information concerning | percentages in effect, if available; otherwise they are taken pro-rata from the AGL Declared
these two options please refer to | Fixed Interest Account and Variable Divisions in use.
your policy and its related |
prospectus. If applying for a | ________________________________________________________________________________________________
partial surrender be sure to |
complete the Notice of Withholding| ________________________________________________________________________________________________
section of this Service Request |
in addition to this section. | ________________________________________________________________________________________________
|
| ________________________________________________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
[_] NOTICE OF 12. | The taxable portion of the distribution you receive from your variable universal life insurance
WITHHOLDING | policy is subject to federal income tax withholding unless you elect not to have withholding
Complete this section it you have | apply. Withholding of state income tax may also be required by your state of residence. You may
applied for a partial surrender | elect not to have withholding apply by checking the appropriate box below. If you elect not to
in Section 11. | have withholding apply to your distribution or if you do not have enough income tax withheld,
| you may be responsible for payment of estimated tax. You may incur penalties under the
| estimated tax rules, if your withholding and estimated tax are not sufficient.
|
| Check one: ________I DO want income tax withheld from this distribution.
|
| ________I DO NOT want income tax withheld from this distribution.
|
------------------------------------------------------------------------------------------------------------------------------------
[_] AFFIRMATION/ 10. | CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY: (1) THAT THE NUMBER SHOWN ON THIS FORM IS
SIGNATURE | MY CORRECT TAXPAYER IDENTIFICATION NUMBER AND; (2) THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING
Complete this section for | UNDER SECTION 3406(a)(1)(C) OF THE INTERNAL REVENUE CODE.
ALL requests. | THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT
| OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING.
|
|
|
| Dated at__________________________this___________day of___________________________,__________
| CITY, STATE
|
|
| X______________________________________________ X__________________________________________
| SIGNATURE OF OWNER SIGNATURE OF WITNESS
|
| X______________________________________________ X__________________________________________
| SIGNATURE OF JOINT OWNER SIGNATURE OF WITNESS
|
| X______________________________________________ X__________________________________________
| SIGNATURE OF ASSIGNEE SIGNATURE OF WITNESS
|
------------------------------------------------------------------------------------------------------------------------------------
AGLC0094 Rev0302 PAGE 5 OF 5
