EXHIBIT (e)(4) S E R V I C E R E Q U E S T ---------------------------- P L A T I N U M ---------------------------- Investor(R) II ---------------------------- AIG AMERICAN GENERAL LIFE Platinum Investor - Fixed Option . Division 125 - AGL Declared...
EXHIBIT (e)(4)
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S E R V I C E R E Q U E S T
----------------------------
P L A T I N U M
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Investor(R) II
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AIG AMERICAN GENERAL LIFE
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Platinum Investor - Fixed Option
. Division 125 - AGL Declared Fixed Interest Account
Platinum Investor - Variable Divisions
AIM Variable Insurance Funds
. Division 126 - AIM V.I. International Growth
. Division 127 - AIM V.I. Premier Equity
The Xxxxx American Fund
. Division 259 - Xxxxx American Leveraged AllCap
. Division 258 - Xxxxx American MidCap Growth
American Century Variable Portfolios, Inc.
. Division 224 - VP Value
Credit Suisse Trust
. Division 247 - Small Cap Growth
Dreyfus Investment Portfolios
. Division 229 - MidCap Stock
Dreyfus Variable Investment Fund
. Division 133 - Developing Leaders
. Division 132 - Quality Bond
Fidelity Variable Insurance Products
. Division 233 - VIP Asset Manager
. Division 232 - VIP Contrafund
. Division 230 - VIP Equity-Income
. Division 231 - VIP Growth
. Division 254 - VIP Mid Cap
Franklin Xxxxxxxxx Variable Insurance Products Trust
. Division 250 - Franklin Xxxxxxxxx Foreign Securities
. Division 249 - Franklin Xxxxxxxxx Mutual Shares Securities
. Division 255 - Franklin Xxxxxxxxx Small Cap Value Securities
. Division 248 - Franklin Xxxxxxxxx U.S. Government
Xxxxxxx Xxxxx Variable Insurance Trust
. Division 401- Xxxxxxx Xxxxx Capital Growth
Janus Aspen Series
. Division 234 - International Growth
. Division 236 - Mid Cap Growth
. Division 235 - Worldwide Growth
X.X. Xxxxxx Series Trust II
. Division 400 - JPMorgan Mid Cap Value
. Division 237 - JPMorgan Small Company
MFS Variable Insurance Trust
. Division 239 - MFS Capital Opportunities
. Division 134 - MFS Emerging Growth
. Division 240 - MFS New Discovery
. Division 238 - MFS Research
Xxxxxxxxx Xxxxxx Advisers Management Trust
. Division 241 - Mid-Cap Growth
Xxxxxxxxxxx Variable Account Funds
. Division 256 - Xxxxxxxxxxx Balanced
. Division 257 - Xxxxxxxxxxx Global Securities
PIMCO Variable Insurance Trust
. Division 243 - PIMCO Real Return
. Division 242 - PIMCO Short-Term
. Division 244 - PIMCO Total Return
Pioneer Variable Contracts Trust
. Division 402 - Fund VCT
. Division 403 - Growth Opportunities VCT
Xxxxxx Variable Trust
. Division 137 - Xxxxxx VT Diversified Income
. Division 138 - Xxxxxx VT Growth and Income
. Division 139 - Xxxxxx VT Int'l Growth and Income
SunAmerica Series Trust
. Division 253 - Aggressive Growth
. Division 252 - SunAmerica Balanced
The Universal Institutional Funds, Inc.
. Division 135 - Equity Growth
. Division 136 - High Yield
VALIC Company I
. Division 128 - International Equities
. Division 129 - Mid Cap Index
. Division 130 - Money Market I
. Division 225 - Nasdaq-100 Index
. Division 227 - Science & Technology
. Division 226 - Small Cap Index
. Division 131 - Stock Index
Xxx Xxxxxx Life Investment Trust
. Division 251 - Growth and Income
Vanguard Variable Insurance Fund
. Division 245 - High Yield Bond
. Division 246 - REIT Index
L8993 Rev 1204
[LOGO] AIG American General
American General Life Insurance Company ("AGL")
A member company of American International Group, Inc.
Variable Universal Life
Insurance Service Request
Complete and return this request to:
Variable Universal Life Operations
PO Box 4880 . Houston, TX. 77210-4880
(000) 000-0000 or Hearing Impaired (TDD) (000) 000-0000 . Fax: (000) 000-0000
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[ ] POLICY 1. POLICY #: Insured:
IDENTIFICATION ----------------------------------------- ----------------------------------------
Address: New Address (yes) (no)
COMPLETE THIS SECTION FOR ---------------------------------------------------------------------
ALL REQUESTS. Primary Owner (If other than insured):
---------------------------------------
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)
---------------------------------------------------------------------
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[ ] NAME 2. Change Name Of: (Circle One) Insured Owner Payor Beneficiary
CHANGE
Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
Complete this section if
the name of one of the ------------------------------------------------- -------------------------------------------------
Insured, Owner, Payor or
Beneficiary has changed. Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
(Please note, this does
not change the Insured,
Owner, Payor or
Beneficiary designation).
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[ ] CHANGE IN 3. INVESTMENT DIVISION PREM % DED %
ALLOCATION ------ -----
PERCENTAGES (125) AGL Declared Fixed Interest Account % %
--- ---
Use this section to AIM Variable Insurance Funds
indicate how premiums or (126) AIM V.I. International Growth % %
monthly deductions are to --- ---
be allocated. Total (127) AIM V.I. Premier Equity % %
allocation in each column --- ---
must equal 100%; whole The Xxxxx American Fund
numbers only. (259) Xxxxx American Leveraged AllCap % %
--- ---
Xxxxxxx Xxxxx Variable (258) Xxxxx American MidCap Growth % %
Insurance Trust is not --- ---
available for any purpose American Century Variable Portfolios, Inc.
except to transfer to (224) VP Value % %
another investment --- ---
option. Credit Suisse Trust
(247) Small Cap Growth % %
Pioneer Variable --- ---
Contracts Trust is Dreyfus Investment Portfolios
available only for owners (229) MidCap Stock % %
who had Accumulation --- ---
Value invested in Pioneer Dreyfus Variable Investment Fund
on 12/10/04. (133) Developing Leaders % %
--- ---
(132) Quality Bond % %
--- ---
Fidelity Variable Insurance Products
(233) VIP Asset Manager % %
--- ---
(232) VIP Contrafund % %
--- ---
(230) VIP Equity-Income % %
--- ---
(231) VIP Growth % %
--- ---
(254) VIP Mid Cap % %
--- ---
Franklin Xxxxxxxxx Variable Insurance Products Trust
(250) FT Foreign Securities % %
--- ---
(249) FT Mutual Shares Securities % %
--- ---
(255) FT Small Cap Value Securities % %
--- ---
(248) FT U.S. Government % %
--- ---
Xxxxxxx Xxxxx Variable Insurance Trust
(401) Xxxxxxx Xxxxx Capital Growth NA %
---
Janus Aspen Series
(234) International Growth % %
--- ---
(236) Mid Cap Growth % %
--- ---
(235) Worldwide Growth % %
--- ---
X.X. Xxxxxx Series Trust II
(400) JPMorgan Mid Cap Value % %
--- ---
(237) JPMorgan Small Company % %
--- ---
MFS Variable Insurance Trust
(239) MFS Capital Opportunities % %
--- ---
(134) MFS Emerging Growth % %
--- ---
(240) MFS New Discovery % %
--- ---
(238) MFS Research % %
--- ---
Xxxxxxxxx Xxxxxx Advisers Management Trust
(241) Mid-Cap Growth % %
--- ---
Xxxxxxxxxxx Variable Account Funds
(256) Xxxxxxxxxxx Balanced % %
--- ---
(257) Xxxxxxxxxxx Global Securities % %
--- ---
PIMCO Variable Insurance Trust
(243) PIMCO Real Return % %
--- ---
(242) PIMCO Short-Term % %
--- ---
(244) PIMCO Total Return % %
--- ---
Pioneer Variable Contracts Trust
(402) Fund VCT % %
--- ---
(403) Growth Opportunities VCT % %
--- ---
Xxxxxx Variable Trust
(137) Xxxxxx VT Diversified Income % %
--- ---
(138) Xxxxxx VT Growth and Income % %
--- ---
(139) Xxxxxx VT Int'l Growth and Income % %
--- ---
SunAmerica Series Trust
(253) Aggressive Growth % %
--- ---
(252) SunAmerica Balanced % %
--- ---
The Universal Institutional Funds, Inc.
(135) Equity Growth % %
--- ---
(136) High Yield % %
--- ---
VALIC Company I
(128) International Equities % %
--- ---
(129) Mid Cap Index % %
--- ---
(130) Money Market I % %
--- ---
(225) Nasdaq-100 Index % %
--- ---
(227) Science & Technology % %
--- ---
(226) Small Cap Index % %
--- ---
(131) Stock Index % %
--- ---
Xxx Xxxxxx Life Investment Trust
(251) Growth and Income % %
--- ---
Vanguard Variable Insurance Fund
(245) High Yield Bond % %
--- ---
(246) REIT Index % %
--- ---
Other: % %
--- ---
100% 100%
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L8993 Rev1204 PAGE 2 OF 5
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[ ] MODE OF PREMIUM 4. Indicate frequency and premium amount $ Annual $ Semi-Annual $ Quarterly
PAYMENT/BILLING desired: ----- ----- -----
METHOD CHANGE $ Monthly (Bank Draft Only)
-----
Use this section to
change the billing Indicate billing method desired: Direct Bill Pre-Authorized Bank Draft
frequency and/or method ------- ------- (attach a Bank Draft Authorization Form
of premium payment. Note, and "Void" Check)
however, that AGL will
not bill you on a direct Start Date: / /
monthly basis. Refer to ------ ------ ------
your policy and its
related prospectus for
further information
concerning minimum
premiums and billing
options.
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[ ] LOST POLICY 5. I/we hereby certify that the policy of insurance for the listed policy has been LOST
CERTIFICATE DESTROYED OTHER. ----- ------
----
Complete this section if
applying for a Unless I/we have directed cancellation of the policy, I/we request that a:
Certificate of Insurance
or duplicate policy to Certificate of Insurance at no charge
replace a lost or -------
misplaced policy. If a
full duplicate policy is Full duplicate policy at a charge of $25
being requested, a check -------
or money order for $25
payable to AGL must be be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate
submitted with this policy to AGL for cancellation.
request.
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[ ] DOLLAR COST 6. Day of the month for transfers (Chose a day of the month between 1-28)
AVERAGING (DCA) ------
($5,000 MINIMUM Frequency of transfers: Monthly Quarterly Semi-Annually Annually
BEGINNING ---- ------- ------- -------
ACCUMULATION VALUE)
DCA to be made from the following investment option:
An amount can be -----------------------------------------
systematically Transfer: $ ($100 minimum, whole dollars only)
transferred from any one --------------------------
investment option and
directed to one or more AIM Variable Insurance Funds
of the investment options (126) AIM V.I. International Growth $
below. The AGL Declared ---------
Fixed Interest Account is (127) AIM V.I. Premier Equity $
not available for DCA. ---------
Please refer to the The Xxxxx American Fund
prospectus for more (259) Xxxxx American Leveraged AllCap $
information on the DCA ---------
option. (258) Xxxxx American MidCap Growth $
---------
NOTE: DCA is not American Century Variable Portfolios, Inc.
available if the (224) VP Value $
Automatic Rebalancing ---------
option has been chosen. Credit Suisse Trust
(247) Small Cap Growth $
See restrictions for ---------
Xxxxxxx Xxxxx Variable Dreyfus Investment Portfolios
Trust and Pioneer (229) MidCap Stock $
Variable Contracts Trust ---------
in Box 3 above. Dreyfus Variable Investment Fund
(133) Developing Leaders $
---------
(132) Quality Bond $
---------
Fidelity Variable Insurance Products
---------
(233) VIP Asset Manager $
---------
(232) VIP Contrafund $
---------
(230) VIP Equity-Income $
---------
(231) VIP Growth $
---------
(254) VIP Mid Cap $
---------
Franklin Xxxxxxxxx Variable Insurance Products
Trust
(250) FT Foreign Securities $
---------
(249) FT Mutual Shares Securities $
---------
(255) FT Small Cap Value Securities $
---------
(248) FT U.S. Government $
---------
Janus Aspen Series
(234) International Growth $
---------
(236) Mid Cap Growth $
---------
(235) Worldwide Growth $
---------
X.X. Xxxxxx Series Trust II
(400) JPMorgan Mid Cap Value $
---------
(237) JPMorgan Small Company $
---------
MFS Variable Insurance Trust
(239) MFS Capital Opportunities $
---------
(134) MFS Emerging Growth $
---------
(240) MFS New Discovery $
---------
(238) MFS Research $
---------
Xxxxxxxxx Xxxxxx Advisers Management Trust
(241) Mid-Cap Growth $
---------
Xxxxxxxxxxx Variable Account Funds
(256) Xxxxxxxxxxx Balanced $
---------
(257) Xxxxxxxxxxx Global Securities $
---------
PIMCO Variable Insurance Trust
(243) PIMCO Real Return $
---------
(242) PIMCO Short-Term $
---------
(244) PIMCO Total Return $
---------
Pioneer Variable Contracts Trust
(402) Fund VCT $
---------
(403) Growth Opportunities VCT $
---------
Xxxxxx Variable Trust
(137) Xxxxxx VT Diversified Income $
---------
(138) Xxxxxx VT Growth and Income $
---------
(139) Xxxxxx VT Int'l Growth and Income $
---------
SunAmerica Series Trust
(253) Aggressive Growth $
---------
(252) SunAmerica Balanced $
---------
The Universal Institutional Funds, Inc.
(135) Equity Growth $
---------
(136) High Yield $
---------
VALIC Company I
(128) International Equities $
---------
(129) Mid Cap Index $
---------
(130) Money Market I $
---------
(225) Nasdaq-100 Index $
---------
(227) Science & Technology $
---------
(226) Small Cap Index $
---------
(131) Stock Index $
---------
Xxx Xxxxxx Life Investment Trust
(251) Growth and Income $
---------
Vanguard Variable Insurance Fund
(245) High Yield Bond $
---------
(246) REIT Index $
---------
Other: $
--------------------------------------- ---------
INITIAL HERE TO REVOKE DCA ELECTION.
-----------
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L8993 Rev1204 PAGE 3 OF 5
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[ ] AUTOMATIC REBALANCING 7. Indicate frequency: Quarterly Semi-Annually Annually
----- ----- -----
($5,000 minimum (Division Name or Number) (Division Name or Number)
accumulation value) Use %: %:
this section to apply 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: Automatic ---------- ---------------------------------- ---------- ----------------------------------
Rebalancing is not %: %:
available if the Dollar ---------- ---------------------------------- ---------- ----------------------------------
Cost Averaging option has %: %:
been chosen. ---------- ---------------------------------- ---------- ----------------------------------
%: %:
See restrictions for ---------- ---------------------------------- ---------- ----------------------------------
Xxxxxxx Xxxxx Variable %: %:
Trust and Pioneer ---------- ---------------------------------- ---------- ----------------------------------
Variable Contracts Trust
in Box 3 above. INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
----------
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[ ] AUTHORIZATION FOR 8. I (or we, if Joint Owners) hereby authorize AGL to act on telephone instructions or e-service
TRANSACTIONS instructions, if elected, to transfer values among the Variable Divisions and AGL Declared Fixed
Interest Account and to change allocations for future premium payments and monthly deductions.
Complete this section if
you are applying for or Initial the designation you prefer:
revoking current
telephone or e-service Policy Owner(s) only -- If Joint Owners, either one acting independently.
privileges. --------
Policy Owner(s) or Agent/Registered Representative who is appointed to represent AGL
--------
and the firm authorized to service my policy.
AGL and any persons designated by this authorization will not be responsible for any claim, loss or
expense based upon telephone instructions or e-service instructions received and acted on in good
faith, including losses due to telephone instructions or e-service communication errors. AGL's
liability for erroneous transfers and 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 instruction or e-service instruction, I will notify AGL in writing
within five working days from receipt of 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 in its home office.
INITIAL HERE TO REVOKE TELEPHONE PRIVILEGE AUTHORIZATION.
-------
INITIAL HERE TO REVOKE E-SERVICE PRIVILEGE AUTHORIZATION.
-------
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[ ] CORRECT AGE 9. Name of 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 DOB: / /
correct date of birth ------ ----- ------
must accompany this
request.
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[ ] TRANSFER OF 10. (Division Name or Number) (Division Name or Number)
ACCUMULATED VALUES
Use this section if you Transfer $ or % from to .
want to move money ------- --------- ----------------------------- ----------------------------
between divisions. Transfer $ or % from to .
Withdrawals from the AGL ------- --------- ----------------------------- ----------------------------
Declared Fixed Interest Transfer $ or % from to .
Account are limited to 60 ------- --------- ----------------------------- ----------------------------
days after the policy Transfer $ or % from to .
anniversary and to no ------- --------- ----------------------------- ----------------------------
more than 25% of the Transfer $ or % from to .
total unloaned value of ------- --------- ----------------------------- ----------------------------
the AGL Declared Fixed Transfer $ or % from to .
Interest Account on the ------- --------- ----------------------------- ----------------------------
policy anniversary. If a Transfer $ or % from to .
transfer causes the ------- --------- ----------------------------- ----------------------------
balance in any division Transfer $ or % from to .
to drop below $500, AGL ------- --------- ----------------------------- ----------------------------
reserves the right to Transfer $ or % from to .
transfer the remaining ------- --------- ----------------------------- ----------------------------
balance. Amounts to be
transferred should be
indicated in dollar or
percentage amounts,
maintaining consistency
throughout.
See restrictions for
Xxxxxxx Xxxxx Variable
Trust and Pioneer
Variable Contracts Trust
in Box 3 above.
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L8993 Rev1204 PAGE 4 OF 5
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[ ] REQUEST FOR PARTIAL 11. Transfer $ or % from to .
SURRENDER/POLICY LOAN ------- ------- --------------------- ------------------
Use this section to apply I request a partial surrender of $ or % of the net cash surrender value.
for a partial surrender -------- ------- -----
from or policy loan I request a loan in the amount of $ .
against policy values. -------- --------
For detailed information I request the maximum loan amount available from my policy.
concerning these two --------
options please refer to
your policy and its Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
related prospectus. If percentages in effect, if available; otherwise they are taken pro-rata from the AGL Declared Fixed
applying for a partial Interest Account and Variable Divisions in use.
surrender, be sure to
complete the Notice of ----------------------------------------------------------------------------------------------------
Withholding section of
this Service Request in ----------------------------------------------------------------------------------------------------
addition to this section.
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[ ] NOTICE OF WITHHOLDING 12.
Complete this section if The taxable portion of the distribution you receive from your variable universal life insurance
you have applied for a policy is subject to federal income tax withholding unless you elect not to have withholding
partial surrender in apply. Withholding of state income tax may also be required by your state of residence. You may
Section 11. elect not to have withholding apply by checking the appropriate box below. If you elect not to 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.
---------
If no election is made, we are required to withhold Federal Income Tax (if applicable).
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[ ] AFFIRMATION/SIGNATURE 13. CERTIFICATION: Under penalties of perjury, I certify: (1) that the number shown on this form is my
correct taxpayer identification number and; (2) that I am not subject to backup withholding under
Complete this section for 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.
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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
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L8993 Rev1204 PAGE 5 OF 5
