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| SERVICE REQUEST |
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EXHIBIT 10(c)
P L A T I N U M
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INVESTOR/SM/
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THE UNITED STATES LIFE
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PLATINUM INVESTOR--FIXED OPTION Xxxxxxxxx Xxxxxx Advisers Management Trust
. Division 148 - USL Declared Fixed Interest Account ------------------------------------------
. Division 184 - Mid-Cap Growth
PLATINUM INVESTOR--VARIABLE DIVISIONS
AIM Variable Insurance Funds PIMCO Variable Insurance Trust
---------------------------- ------------------------------
. Division 150 - AIM V.I. International Growth . Division 186 - PIMCO Real Return
. Division 151 - AIM V.I. Premier Equity . Division 185 - PIMCO Short-Term
. Division 187 - PIMCO Total Return
American Century Variable Portfolios, Inc.
------------------------------------------ Xxxxxx Variable Trust
. Division 166 - VP Value ---------------------
. Division 161 - Xxxxxx VT Diversified Income
Ayco Series Trust . Division 162 - Xxxxxx VT Growth and Income
----------------- . Division 163 - Xxxxxx VT Int'l Growth and Income
. Division 250 - Ayco Growth
SAFECO Resource Series Trust
Credit Suisse Trust ----------------------------
------------------- . Division 164 - Equity
. Division 190 - Small Cap Growth . Division 165 - Growth Opportunities
Dreyfus Investment Portfolios The Universal Institutional Funds, Inc.
----------------------------- ---------------------------------------
. Division 251 - MidCap Stock . Division 159 - Equity Growth
. Division 160 - High Yield
Dreyfus Variable Investment Fund
-------------------------------- VALIC Company I
. Division 156 - Quality Bond ---------------
. Division 155 - Small Cap . Division 152 - International Equities
. Division 153 - MidCap Index
Fidelity Variable Insurance Products Fund . Division 149 - Money Market I
----------------------------------------- . Division 167- Nasdaq-100 Index
. Division 255 - VIP Asset Manager . Division 168 - Science & Technology
. Division 254 - VIP Contrafund . Division 169 - Small Cap Index
. Division 252 - VIP Equity-Income . Division 154 - Stock Index
. Division 253 - VIP Growth
Vanguard Variable Insurance Fund
Xxxxxxxx Xxxxxxxxx Variable Insurance Products Trust --------------------------------
---------------------------------------------------- . Division 188 - High Yield Bond
. Division 191 - Franklin U.S. Government . Division 189 - REIT Index
. Division 192 - Mutual Shares Securities
. Division 193 - Xxxxxxxxx Foreign Securities Xxx Xxxxxx Life Investment Trust
--------------------------------
Xxxxx Xxxxx Series . Division 158 - Growth & Income
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. Division 258 - Aggressive Growth
. Division 256 - International Growth
. Division 257 - Worldwide Growth
X.X. Xxxxxx Series Trust II
---------------------------
. Division 179 - JPMorgan Small Company
MFS Variable Insurance Trust
----------------------------
. Division 181 - MFS Capital Opportunities
. Division 157 - MFS Emerging Growth
. Division 182 - MFS New Discovery
. Division 180 - MFS Research
USL 8993 REV 0302
COMPLETE AND RETURN THIS REQUEST TO: THE UNITED STATES LIFE INSURANCE COMPANY
Administrative Center IN THE CITY OF NEW YORK ("USL")
PO Box 4880 Houston, TX 77210-4880 Administrative Center: Houston, TX
(000) 000-0000
Hearing Impaired (TDD): (000) 000-0000
Toll-Free Fax: (000) 000-0000 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST
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[_] POLICY 1. | POLICY #:_________________________________ INSURED:_____________________________________________
IDENTIFICATION | 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)
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[_] NAME 2. | Change Name Of: (Circle One) Insured Owner Payor Beneficiary
CHANGE |
Complete this section if the name | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
of the Insured, Owner, Payor or | __________________________________________________ __________________________________________
Beneficiary has changed. (Please |
note, this does not change the | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
Insured, Owner, Payor or |
Beneficiary designation). |
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[_] CHANGE IN 3. | INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED %
ALLOCATION | (148) USL Declared Fixed Interest XXXXXXXXX XXXXXX ADVISERS MANAGEMENT TRUST
PERCENTAGES | Account _____ _____ (184) 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. | (150) AIM V.I. International Growth _____ _____ (186) PIMCO Real Return ______ ______
Total allocation in each column | (151) AIM V.I. Premier Equity _____ _____ (185) PIMCO Short-Term ______ ______
must equal 100%; whole | (187) PIMCO Total Return ______ ______
numbers only. | AMERICAN CENTURY VARIABLE
| PORTFOLIOS, INC. XXXXXX VARIABLE TRUST
| (166) VP Value _____ _____ (161) Xxxxxx VT Diversified Income_____ ______
| (162) Xxxxxx VT Growth and Income______ ______
| AYCO SERIES TRUST (163) Xxxxxx VT Int'l Growth and
| (250) Ayco Growth _____ _____ Income ______ ______
|
| CREDIT SUISSE TRUST SAFECO RESOURCE SERIES TRUST
| (190) Small Cap Growth _____ _____ (164) Equity ______ ______
| (165) Growth Opportunities ______ ______
| DREYFUS INVESTMENT PORTFOLIOS
| (251) MidCap Stock _____ _____ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
| (159) Equity Growth ______ ______
| DREYFUS VARIABLE INVESTMENT FUND (160) High Yield ______ ______
| (156) Quality Bond _____ _____
| (155) Small Cap _____ _____ VALIC COMPANY I
| (152) International Equities ______ ______
| FIDELITY VARIABLE INSURANCE (153) Mid Cap Index ______ ______
| PRODUCTS FUND (149) Money Market I ______ ______
| (255) VIP Asset Manager _____ _____ (167) Nasdaq-100 Index ______ ______
| (254) VIP Contrafund _____ _____ (168) Science & Technology ______ ______
| (252) VIP Equity-Income _____ _____ (169) Small Cap Index ______ ______
| (253) VIP Growth _____ _____ (154) Stock Index ______ ______
|
| FRANKLIN XXXXXXXXX VARIABLE _____ _____ VANGUARD VARIABLE INSURANCE FUND
| INSURANCE PRODUCTS TRUST (188) High Yield Bond ______ _______
| (191) Xxxxxxxx U.S. Government _____ _____ (189) REIT Index ______ _______
| (192) Mutual Shares Securities _____ _____
| (193) Xxxxxxxxx Foreign Securities _____ _____ XXX XXXXXX LIFE INVESTMENT TRUST
| (158) Growth & Income ______ ______
| JANUS ASPEN SERIES
| (258) Aggressive Growth _____ _____ Other:_______________________ ______ ______
| (256) International Growth _____ _____ 100% 100%
| (257) Worldwide Growth _____ _____
|
| X.X XXXXXX SERIES TRUST II
| (179) JPMorgan Small Company _____ _____
|
| MFS VARIABLE INSURANCE TRUST
| (181) MFS Capital Opportunities _____ _____
| (157) MFS Emerging Growth _____ _____
| (182) MFS New Discovery _____ _____
| (180) MFS Research _____ _____
|
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USL 8993 REV 0302 PAGE 2 OF 5
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[_] 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 USL 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. |
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[_] 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 USL 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 USL for cancellation.
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[_] 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 (149) 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 | (150) AIM V.I. International Growth $_______ (184) Mid-Cap Growth $_______
Divisions listed. | (151) AIM V.I. Premier Equity $_______
The USL Declared Fixed | PIMCO VARIABLE INSURANCE TRUST
Interest Account is not available | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. (186) PIMCO Real Return $_______
for Dollar Cost Averaging. | (166) VP Value $_______ (185) PIMCO Short-Term $_______
Please refer to the prospectus | (187) PIMCO Total Return $_______
for more information on the | AYCO SERIES TRUST
Dollar Cost Averaging Option. | (250) Ayco Growth $_______ XXXXXX VARIABLE TRUST
| (161) Xxxxxx VT Diversified Income $_______
| CREDIT SUISSE TRUST (162) Xxxxxx VT Growth and Income $_______
| (190) Small Cap Growth $_______ (163) Xxxxxx VT Int'l Growth and Income $_______
|
| DREYFUS INVESTMENT PORTFOLIOS SAFECO RESOURCE SERIES TRUST
| (251) Midcap Stock $_______ (164) Equity $_______
| (165) Growth Opportunities $_______
| DREYFUS VARIABLE INVESTMENT FUND
| (156) Quality Bond $_______ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
| (155) Small Cap $_______ (159) Equity Growth $_______
| (160) High Yield $_______
| FIDELITY VARIABLE INSURANCE PRODUCTS FUND
| (255) VIP Asset Manager $_______ VALIC COMPANY I
| (254) VIP Contrafund $_______ (152) International Equities $_______
| (252) VIP Equity-Income $_______ (153) Mid Cap Index $_______
| (253) VIP Growth $_______ (167) Nasdaq-100 Index $_______
| (168) Science & Technology $_______
| FRANKLIN XXXXXXXXX VARIABLE INSURANCE (169) Small Cap Index $_______
| PRODUCTS TRUST (154) Stock Index $_______
| (191) Xxxxxxxx U.S. Government $_______
| (192) Mutual Shares Securities $_______ VANGUARD VARIABLE INSURANCE FUND
| (193) Xxxxxxxxx Foreign Securities $_______ (188) High Yield Bond $_______
| (189) REIT Index $_______
| JANUS ASPEN SERIES
| (258) Aggressive Growth $_______ XXX XXXXXX LIFE INVESTMENT TRUST
| (256) International Growth $_______ (158) Growth & Income $_______
| (257) Worldwide Growth $_______
| OTHER:_____________________________ $_______
| X.X. XXXXXX SERIES TRUST II
| (179) JPMorgan Small Company $_______
|
| MFS VARIABLE INSURANCE TRUST
| (181) MFS Capital Opportunities $_______
| (157) MFS Emerging Growth $_______
| (182) MFS New Discovery $_______
| (180) MFS Research $_______
|
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USL 8993 REV 0302 PAGE 3 OF 5
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[_] CORRECT AGE 7. | 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 | Correct DOB: _________/____________ /_____________
date of birth must accompany this |
request. |
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[_] TRANSFER OF 8. | (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 _____________________________
Withdrawals from the USL Declared |
Fixed Interest Account are | Transfer $_______ or _______% from ____________________________ to _____________________________
limited to 60 days after the |
policy anniversary and to no | Transfer $_______ or _______% from ____________________________ to _____________________________
more than 25% of the total |
unloaned value of the USL | Transfer $_______ or _______% from ____________________________ to _____________________________
Declared Fixed Interest Account |
on the policy anniversary. If a | Transfer $_______ or _______% from ____________________________ to _____________________________
transfer causes the balance in |
any division to drop below | Transfer $_______ or _______% from ____________________________ to _____________________________
$500 USL reserves the right |
to transfer the remaining balance.| Transfer $_______ or _______% from ____________________________ to _____________________________
Amounts to be transferred should |
be indicated in dollar or | Transfer $_______ or _______% from ____________________________ to _____________________________
percentage amounts, maintaining |
consistency throughout. | Transfer $_______ or _______% from ____________________________ to _____________________________
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[_] AUTOMATIC 9. |
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. | _________%:___________________________________ ________%:________________________________
This option is not available |
while the Dollar Cost | _________%:___________________________________ ________%:________________________________
Averaging Option is in use. |
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
|
| ________ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
|
|
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USL 8993 REV 0302 PAGE 4 OF 5
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[_] REQUEST FOR 10. |
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 USL 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. | ________________________________________________________________________________________________
|
| ________________________________________________________________________________________________
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[_] NOTICE OF 11. | 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 if 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 10. | 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.
|
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[_] AFFIRMATION/ 12. | 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
|
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USL 8993 REV 0302 PAGE 5 OF 5
