EXHIBIT (e)(4)
----------------------------
S E R V I C E R E Q U E S T
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P L A T I N U M
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Investor(R) Survivor II
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AIG AMERICAN GENERAL LIFE
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Platinum Investor Survivor II--Fixed Option
. Division 18 - AGL Declared Fixed Interest Account
Platinum Investor Survivor II--Variable Divisions
AIM Variable Insurance Funds
. Division 130 - AIM V.I. International Growth
. Division 131 - AIM V.I. Premier Equity
The Xxxxx American Fund
. Division 186 - Xxxxx American Leveraged AllCap
. Division 185 - Xxxxx American MidCap Growth
American Century Variable Portfolios, Inc.
. Division 153 - VP Value
Credit Suisse Trust
. Division 173 - Small Cap Growth
Dreyfus Investment Portfolios
. Division 155 - MidCap Stock
Dreyfus Variable Investment Fund
. Division 140 - Developing Leaders
. Division 139 - Quality Bond
Fidelity Variable Insurance Products
. Division 159 - VIP Asset Manager
. Division 158 - VIP Contrafund
. Division 156 - VIP Equity-Income
. Division 157 - VIP Growth
. Division 180 - VIP Mid Cap
Franklin Xxxxxxxxx Variable Insurance Products Trust
. Division 176 - Franklin Xxxxxxxxx Foreign Securities
. Division 175 - Franklin Xxxxxxxxx Mutual Shares Securities
. Division 181 - Franklin Xxxxxxxxx Small Cap Value Securities
. Division 174 - Franklin Xxxxxxxxx U.S. Government
Xxxxxxx Xxxxx Variable Insurance Trust
. Division 187 - Xxxxxxx Xxxxx Capital Growth
Janus Aspen Series
. Division 160 - International Growth
. Division 162 - Mid Cap Growth
. Division 161 - Worldwide Growth
X.X. Xxxxxx Series Trust II
. Division 184 - JPMorgan Mid Cap Value
. Division 163 - JPMorgan Small Company
MFS Variable Insurance Trust
. Division 165 - MFS Capital Opportunities
. Division 141 - MFS Emerging Growth
. Division 166 - MFS New Discovery
. Division 164 - MFS Research
Xxxxxxxxx Xxxxxx Advisers Management Trust
. Division 167 - Mid-Cap Growth
Xxxxxxxxxxx Variable Account Funds
. Division 182 - Xxxxxxxxxxx Balanced
. Division 183 - Xxxxxxxxxxx Global Securities
PIMCO Variable Insurance Trust
. Division 169 - PIMCO Real Return
. Division 168 - PIMCO Short-Term
. Division 170 - PIMCO Total Return
Pioneer Variable Contracts Trust
. Division 188 - Fund VCT
. Division 189 - Growth Opportunities VCT
Xxxxxx Variable Trust
. Division 144 - Xxxxxx VT Diversified Income
. Division 145 - Xxxxxx VT Growth and Income
. Division 146 - Xxxxxx VT Int'l Growth and Income
SunAmerica Series Trust
. Division 179 - Aggressive Growth
. Division 178 - SunAmerica Balanced
The Universal Institutional Funds, Inc.
. Division 142 - Equity Growth
. Division 143 - High Yield
VALIC Company I
. Division 132 - International Equities
. Division 133 - Mid Cap Index
. Division 134 - Money Market I
. Division 136 - Nasdaq-100 Index
. Division 137 - Science & Technology
. Division 138 - Small Cap Index
. Division 135 - Stock Index
Xxx Xxxxxx Life Investment Trust
. Division 177 - Growth and Income
Vanguard Variable Insurance Fund
. Division 171 - High Yield Bond
. Division 172 - REIT Index
AGLC0463 Rev1204
[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 #: CONTINGENT INSURED:
IDENTIFICATION -------------------------------------- --------------------------------
CONTINGENT INSURED:
COMPLETE THIS SECTION FOR --------------------------------
ALL REQUESTS. Address: New Address (yes) (no)
---------------------------------------------------------------------
Primary Owner (If other than an 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) Contingent 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 ------------------------------------------------- -------------------------------------------------
Contingent Insureds,
Owner, Payor or Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
Beneficiary has changed.
(Please note, this does
not change the Contingent
Insureds, Owner, Payor or
Beneficiary designation).
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[ ] CHANGE IN 3. INVESTMENT DIVISION PREM % DED %
ALLOCATION ------ -----
PERCENTAGES (18) AGL Declared Fixed Interest Account
---- ----
Use this section to AIM Variable Insurance Funds
indicate how premiums or (130) AIM V.I. International Growth
monthly deductions are to ---- ----
be allocated. Total (131) AIM V.I. Premier Equity
allocation in each column ---- ----
must equal 100%; whole The Xxxxx American Fund
numbers only. (186) Xxxxx American Leveraged AllCap
---- ----
Xxxxxxx Xxxxx Variable (185) Xxxxx American MidCap Growth
Insurance Trust is not ---- ----
available for any purpose American Century Variable Portfolios, Inc.
except to transfer to (153) VP Value
another investment ---- ----
option. Credit Suisse Trust
(173) Small Cap Growth
Pioneer Variable ---- ----
Contracts Trust is Dreyfus Investment Portfolios
available only for owners (155) MidCap Stock
who had Accumulation ---- ----
Value invested in Pioneer Dreyfus Variable Investment Fund
on 12/10/04. (140) Developing Leaders
---- ----
(139) Quality Bond
---- ----
Fidelity Variable Insurance Products
(159) VIP Asset Manager
---- ----
(158) VIP Contrafund
---- ----
(156) VIP Equity-Income
---- ----
(157) VIP Growth
---- ----
(180) VIP Mid Cap
---- ----
Franklin Xxxxxxxxx Variable Insurance Products Trust
(176) FT Foreign Securities
---- ----
(175) FT Mutual Shares Securities
---- ----
(181) FT Small Cap Value Securities
---- ----
(174) FT U.S. Government
---- ----
Xxxxxxx Xxxxx Variable Insurance Trust
(187)Xxxxxxx Xxxxx Capital Growth NA
----
Janus Aspen Series
(160) International Growth
---- ----
(162) Mid Cap Growth
---- ----
(161) Worldwide Growth
---- ----
X.X. Xxxxxx Series Trust II
(184) JPMorgan Mid Cap Value
---- ----
(163) JPMorgan Small Company
---- ----
MFS Variable Insurance Trust
(165) MFS Capital Opportunities
---- ----
(141) MFS Emerging Growth
---- ----
(166) MFS New Discovery
---- ----
(164) MFS Research
---- ----
Xxxxxxxxx Xxxxxx Advisers Management Trust
(167) Mid-Cap Growth
---- ----
Xxxxxxxxxxx Variable Account Funds
(182) Xxxxxxxxxxx Balanced
---- ----
(183) Xxxxxxxxxxx Global Securities
---- ----
PIMCO Variable Insurance Trust
(169) PIMCO Real Return
---- ----
(168) PIMCO Short-Term
---- ----
(170) PIMCO Total Return
---- ----
Pioneer Variable Contracts Trust
(188) Fund VCT
---- ----
(189) Growth Opportunities VCT
---- ----
Xxxxxx Variable Trust
(144) Xxxxxx VT Diversified Income
---- ----
(145) Xxxxxx VT Growth and Income
---- ----
(146) Xxxxxx VT Int'l Growth and Income
---- ----
SunAmerica Series Trust
(179) Aggressive Growth
---- ----
(178) SunAmerica Balanced
---- ----
The Universal Institutional Funds, Inc.
(142) Equity Growth
---- ----
(143) High Yield
---- ----
VALIC Company I
(132) International Equities
---- ----
(133) Mid Cap Index
---- ----
(134) Money Market I
---- ----
(136) Nasdaq-100 Index
---- ----
(137) Science & Technology
---- ----
(138) Small Cap Index
---- ----
(135) Stock Index
---- ----
Xxx Xxxxxx Life Investment Trust
(177) Growth and Income
---- ----
Vanguard Variable Insurance Fund
(171) High Yield Bond
---- ----
(172) REIT Index
---- ----
Other:
--------------------------------------------- ---- ----
100% 100%
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AGLC0463 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 AVERAGING 6. Day of the month for transfers (Chose a day of the month between 1-28)
(DCA) ($5,000 MINIMUM ------
BEGINNING Frequency of transfers: Monthly Quarterly Semi-Annually Annually
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 (130) AIM V.I. International Growth $
below. The AGL Declared ------------
Fixed Interest Account is (131) AIM V.I. Premier Equity $
not available for DCA. ------------
Please refer to the The Xxxxx American Fund
prospectus for more (186) Xxxxx American Leveraged AllCap $
information on the DCA ------------
option. (185) Xxxxx American MidCap Growth $
------------
NOTE: DCA is not American Century Variable Portfolios
available if the (153) VP Value $
Automatic Rebalancing ------------
option has been chosen. Credit Suisse Trust
(173) Small Cap Growth $
See restrictions for ------------
Xxxxxxx Xxxxx Variable Dreyfus Investment Portfolios
Trust and Pioneer (155) MidCap Stock $
Variable Contracts Trust ------------
in Box 3 above. Dreyfus Variable Investment Fund
(140) Developing Leaders $
------------
(139) Quality Bond $
------------
Fidelity Variable Insurance Products
(159) VIP Asset Manager $
------------
(158) VIP Contrafund $
------------
(156) VIP Equity-Income $
------------
(157) VIP Growth $
------------
(180) VIP Mid Cap $
------------
Franklin Xxxxxxxxx Variable Insurance Products Trust
(176) FT Foreign Securities $
------------
(175) FT Mutual Shares Securities $
------------
(181) FT Small Cap Value Securities $
------------
(174) FT U.S. Government $
------------
Janus Aspen Series
(160) International Growth $
------------
(162) Mid Cap Growth $
------------
(161) Worldwide Growth $
------------
X.X. Xxxxxx Series Trust II
(184) JPMorgan Mid Cap Value $
------------
(163) JPMorgan Small Company $
------------
MFS Variable Insurance Trust
(165) MFS Capital Opportunities $
------------
(141) MFS Emerging Growth $
------------
(166) MFS New Discovery $
------------
(164) MFS Research $
------------
Xxxxxxxxx Xxxxxx Advisers Management Trust
(167) Mid-Cap Growth $
------------
Xxxxxxxxxxx Variable Account Funds
(182) Xxxxxxxxxxx Balanced $
------------
(183) Xxxxxxxxxxx Global Securities $
------------
PIMCO Variable Insurance Trust
(169) PIMCO Real Return $
------------
(168) PIMCO Short-Term $
------------
(170) PIMCO Total Return $
------------
Pioneer Variable Contracts Trust
(188) Fund VCT $
------------
(189) Growth Opportunities VCT $
------------
Xxxxxx Variable Trust
(144) Xxxxxx VT Diversified Income $
------------
(145) Xxxxxx VT Growth and Income $
------------
(146) Xxxxxx VT Int'l Growth and Income $
------------
SunAmerica Series Trust
(179) Aggressive Growth $
------------
(178) SunAmerica Balanced $
------------
The Universal Institutional Funds, Inc.
(142) Equity Growth $
------------
(143) High Yield $
------------
VALIC Company I
(132) International Equities $
------------
(133) Mid Cap Index $
------------
(134) Money Market I $
------------
(136) Nasdaq-100 Index $
------------
(137) Science & Technology $
------------
(138) Small Cap Index $
------------
(135) Stock Index $
------------
Xxx Xxxxxx Life Investment Trust
(177) Growth and Income $
------------
Vanguard Variable Insurance Fund
(171) High Yield Bond $
------------
(172) REIT Index $
------------
Other: $
--------------------------------------------- ------------
INITIAL HERE TO REVOKE DCA ELECTION.
-------------
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AGLC0463 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 Contingent Insured for whom this correction is submitted:
-------------------------------
Use this section to
correct the age of any Correct DOB: / /
person covered under this -------- -------- --------
policy. Proof of the
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 Transfer $ or % from to .
------- --------- ----------------------------- ----------------------------
Use this section if you Transfer $ or % from to .
want to move money ------- --------- ----------------------------- ----------------------------
between divisions. The Transfer $ or % from to .
minimum amount for ------- --------- ----------------------------- ----------------------------
transfers is $500.00. Transfer $ or % from to .
Withdrawals from the AGL ------- --------- ----------------------------- ----------------------------
Declared Fixed Interest Transfer $ or % from to .
Account to a Variable ------- --------- ----------------------------- ----------------------------
Division may only be made Transfer $ or % from to .
within the 60 days after ------- --------- ----------------------------- ----------------------------
a contract anniversary. Transfer $ or % from to .
See transfer limitations ------- --------- ----------------------------- ----------------------------
outlined in prospectus. Transfer $ or % from to .
If a 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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AGLC0463 Rev1204 PAGE 4 OF 5
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[ ] REQUEST FOR 11. I request a partial surrender of $ or % of the net cash surrender value.
PARTIAL SURRENDER/ -------- ------- -----
POLICY LOAN I request a loan in the amount of $ .
-------- --------
Use this section to apply I request the maximum loan amount available from my policy.
for a partial surrender --------
from or policy loan
against policy values. Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
For detailed information percentages in effect, if available; otherwise they are taken pro-rata from the AGL Declared Fixed
concerning these two Interest Account and Variable Divisions in use.
options please refer to
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 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
apply. Withholding of state income tax may also be required by your state of residence. You may
Complete this section if elect not to have withholding apply by checking the appropriate box below. If you elect not to have
you have applied for a withholding apply to your distribution or if you do not have enough income tax withheld, you may be
partial surrender in responsible for payment of estimated tax. You may incur penalties under the estimated tax rules, if
Section 11. 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/ 13. CERTIFICATION: Under penalties of perjury, I certify: (1) that the number shown on this form is my
SIGNATURE correct taxpayer identification number and; (2) that I am not subject to backup withholding under
Section 3406(a)(1)(c) of the Internal Revenue Code.
Complete this section for
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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AGLC0463 Rev1204 PAGE 5 OF 5
