Exhibit (10)(e)(ii) SERVICE REQUEST PLATINUM __________________________________ INVESTOR(SM) SURVIVOR __________________________________ AMERICAN GENERAL LIFE ______________________________________________________________________________ PLATINUM INVESTOR--VARIABLE DIVISIONS AIM Variable Insurance Funds, Inc. . Division 1 - AIM V.I. International Equity . Division 2 - AIM V.I. Value American General Series Portfolio Company . Division 3 - International Equities . Division 4 - MidCap Index . Division 5 - Money Market . Division 6 - Stock Index Dreyfus Variable Investment Fund . Division 7 - Quality Bond . Division 8 - Small Cap MFS Variable Insurance Trust . Division 9 - MFS Emerging Growth Morgan Stanley Dean Witter Universal Funds, Inc. . Division 10 - Equity Growth . Division 11 - High Yield Putnam Variable Trust . Division 12 - Putnam VT Diversified Income . Division 13 - Putnam VT Growth and Income . Division 14 - Putnam VT International Growth and Income SAFECO Resource Series Trust . Division 15 - Equity . Division 16 - Growth Van Kampen Life Investment Trust . Division 17 - Strategic Stock PLATINUM INVESTOR--FIXED OPTION . Division 18 - Declared Fixed Interest Account AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL") [American General Complete and return this request to: --------------------------------------------- Logo Variable Universal Life Operations A Subsidiary of American General Corporation appears here] PO Box 4880 Houston, TX 77210-4880 --------------------------------------------- (888) 325-9315 or (713) 831-3443 Houston, Texas Fax: (877) 445-3098 Hearing Impaired/TDD: (888) 436-5258 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST - ------------------------------------------------------------------------------------------------------------------------------------ [ ] POLICY 1.| POLICY #:____________________________________ CONTINGENT INSURED:_______________________________ IDENTIFICATION | CONTINGENT INSURED:_______________________________ | ADDRESS:________________________________________________________________________ New Address (yes)(no) COMPLETE THIS SECTION | FOR ALL REQUESTS. | 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) - ----------------------------------------------------------------------------------------------------------------------------------- [ ] NAME 2.| CHANGE | Change Name Of: (Circle One) Contingent Insured Owner Payor Beneficiary | Complete this section if | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last) the name of one of the | Contingent Insureds, | _________________________________________ _________________________________________________ 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) Contingent Insureds, | Owner, Payor or Beneficiary designation) | - ----------------------------------------------------------------------------------------------------------------------------------- [ ] MODE OF PREMIUM 3.| PAYMENT/BILLING | Indicate frequency and premium amount desired: $______ Annual $______ Semi-Annual $_______ Quarterly METHOD CHANGE | | $______ Monthly (Bank Draft Only) Use this section to change | the billing frequency and/ | Indicate billing method desired:_____ Direct Bill ______ Pre-Authorized Bank Draft (attach a Bank Draft or method of premium pay- | Authorization Form and "Void" Check) ment. Note, however, that | AGL will not bill you on a | Start Date: ______/______/_____ direct monthly basis. Refer| to your policy and its | related prospectus for | further information | concerning minimum premiums| and billing options. | - ----------------------------------------------------------------------------------------------------------------------------------- [ ] LOST POLICY 4.| CERTIFICATE | I/we hereby certify that the policy of insurance for the listed policy has been ____LOST_____DESTROYED | _____OTHER. Complete this section if | Unless I/we have directed cancellation of the policy, I/we request that a: applying for a Certificate | of Insurance or duplicate | _________ Certificate of Insurance at no charge policy to replace a lost or| misplaced policy. If a full| _________ Full duplicate policy at a charge of $25 duplicate policy is being | requested, a check or money| be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate order for $25 payable to | policy to AGL for cancellation. AGL must be submitted with| this request. | - ----------------------------------------------------------------------------------------------------------------------------------- [ ] DOLLAR COST 5.| Designate the day of the month for transfers:_________(choose a day from 1-28) AVERAGING | ($5,000 minimum initial | Frequency of transfers (check one): _______Monthly _______Quarterly ______Semi-Annually _____Annually accumulation value) An | amount may be deducted | I want: $___________($100 minimum) taken from the Money Market Division and transferred to the periodically from the | following Divisions: Money Market Division and | placed in one or more of | AIM Variable Insurance Funds, Inc. Morgan Stanley Dean Witter Universal Funds, Inc. the Divisions listed. The | $_________(1) AIM V.I. International Equity $________(10) Equity Growth Declared Fixed Interest | $_________(2) AIM V.I. Value $________(11) High Yield Account is not available | American General Series Portfolio Company Putnam Variable Trust for Dollar Cost Averaging.| $_________(3) International Equities $________(12) Putnam VT Diversified Income Please refer to the pros- | $_________(4) MidCap Index $________(13) Putnam VT Growth and Income pectus for more infor- | $_________(6) Stock Index $________(14) Putnam VT Int'l Growth & Income mation on the Dollar Cost | Dreyfus Variable Investment Fund SAFECO Resource Series Trust Averaging Option. | $_________(7) Quality Bond $________(15) Equity Note: Automatic | $_________(8) Small Cap $________(16) Growth Rebalancing is not | MFS Variable Insurance Trust Van Kampen Life Investment Trust available if the Dollar | $_________(9) MFS Emerging Growth $________(17) Strategic Stock Cost Averaging Option is | chosen. | ________INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION. - ----------------------------------------------------------------------------------------------------------------------------------- PAGE 2 OF 4 - ------------------------------------------------------------------------------------------------------------------------------------ [ ] TELEPHONE 6.| I (/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values among PRIVILEGE | the Variable Divisions and Declared Fixed Interest Account and to change allocations for future AUTHORIZATION | purchase payments and monthly deductions. | Complete this section if | Initial the designation you prefer: you are applying for or | revoking current telephone| __________Policy Owner(s) only--If Joint Owners, either one acting independently. privileges. | __________Policy Owner(s) and 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 7.| | Name of Contingent Insured for whom this correction is submitted:___________________________________ | Use this section to correct| Correct DOB: ________/________/________ the age of any person | covered under this policy. | Proof of the correct date | of birth must accompany | this request. | - ----------------------------------------------------------------------------------------------------------------------------------- [ ] 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 | Transfer $________ or ______% from_______________________________to__________________________________ divisions. The minimum | amount for transfers is | Transfer $________ or ______% from_______________________________to__________________________________ $500.00. Withdrawals | from the Declared Fixed | Transfer $________ or ______% from_______________________________to__________________________________ Interest Account to a | Variable Division may only | Transfer $________ or ______% from_______________________________to__________________________________ be made within 60 days | after a contract anniver- | Transfer $________ or ______% from_______________________________to__________________________________ sary. See transfer limit- | ations outlined in pros- | Transfer $________ or ______% from_______________________________to__________________________________ pectus. If a transfer | causes the balance in any | Transfer $________ or ______% from_______________________________to__________________________________ division to drop below | $500, AGL reserves the | Transfer $________ or ______% from_______________________________to__________________________________ right to transfer the | remaining balance. | Transfer $________ or ______% from_______________________________to__________________________________ Amounts to be transferred | should be indicated in | dollar or percentage | amounts, maintaining | consistency throughout. | - ----------------------------------------------------------------------------------------------------------------------------------- [ ] CHANGE IN 9.| INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED % ALLOCATION | PERCENTAGES | AIM Variable Insurance Funds, Inc. Morgan Stanley Dean Witter | (1) AIM V.I. Int'l Equity ______ ______ Universal Funds, Inc. Use this section to | (2) AIM V.I. Value ______ ______ (10) Equity Growth ______ ______ indicate how premiums or | (11) High Yield ______ ______ monthly deductions are to | American General Series Portfolio Co. be allocated. Total | (3) International Equities ______ ______ Putnam Variable Trust allocation in each | (4) MidCap Index ______ ______ (12) Putnam VT Diversified column must equal 100%; | (5) Money Market ______ ______ Income ______ ______ whole numbers only | (6) Stock Index ______ ______ (13) Putnam VT Growth | and Income ______ ______ | Dreyfus Variable Investment Fund (14) Putnam VT Int'l | (7) Quality Bond ______ ______ Growth and Income ______ ______ | (8) Small Cap ______ ______ | SAFECO Resources Series Trust | MFS Variable Insurance Trust (15) Equity ______ ______ | (9) MFS Emerging Growth ______ ______ (16) Growth ______ ______ | | Van Kampen Life Investment | Trust | (17) Strategic Stock ______ ______ | (18) Declared Fixed ______ ______ | Interest Account ______ ______ - ----------------------------------------------------------------------------------------------------------------------------------- PAGE 3 OF 4 - ------------------------------------------------------------------------------------------------------------------------------------ | [ ] AUTOMATIC 10.| Indicate frequency: _______ Quarterly ______ Semi-Annually ______ Annually REBALANCING | | (Division Name or Number) (Division Name or Number) ($5,000 minimum | %_________:________________________________________ %_________:____________________________________ 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: Dollar Cost | %_________:________________________________________ %_________:____________________________________ Averaging is not available | if the Automatic | Rebalancing Option is | _________INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION. chosen. | - ----------------------------------------------------------------------------------------------------------------------------------- [ ] REQUEST FOR 11.| _________I request a partial surrender of $_________ or _________% of the net cash surrender value. PARTIAL | 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 | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation from or policy loan against| percentages in effect, if available; otherwise they are taken pro-rata from the Declared Fixed Interest policy values. For detailed| Account and Variable Divisions in use. information concerning | these two 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. | - ------------------------------------------------------------------------------------------------------------------------------------ [ ] NOTICE OF 12.| The taxable portion of the distribution you receive from your variable universal life insurance policy WITHHOLDING | 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 elect not to Complete this section if | have withholding apply by checking the appropriate box below. If you elect not to have withholding you have applied for a | apply to your distribution or if you do not have enough income tax withheld, you may be responsible for partial surrender in | payment of estimated tax. You may incur penalties under the estimated tax rules, if your withholding Section 11. | 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/ 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. | | The Internal Revenue Service does not require your consent to any provision of this document other Complete this section for | than the certification required to avoid backup withholding. ALL requests. | | | Dated at __________________________________ this _________ day of ________________________, ________. | | | 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 1099 PAGE 4 OF 4