EXHIBIT (10)(e)
SERVICE REQUEST
PLATINUM
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INVESTOR(SM) III
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AMERICAN GENERAL LIFE
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PLATINUM INVESTOR--FIXED OPTION Neuberger Berman Advisers Management Trust
. Division 301 - Declared Fixed Interest Account ------------------------------------------
. Division 286 - Mid-Cap Growth
PLATINUM INVESTOR--VARIABLE DIVISIONS
AIM Variable Insurance Funds North American Funds Variable Product Series I
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. Division 260 - AIM V.I. International Equity . Division 263 - International Equities
. Division 261 - AIM V.I. Value . Division 264 - MidCap Index
. Division 265 - Money Market
American Century Variable Portfolios, Inc. . Division 266 - Nasdaq-100 Index
- ------------------------------------------ . Division 269 - Science & Technology
. Division 262 - VP Value . Division 268 - Small Cap Index
. Division 267 - Stock Index
Ayco Series Trust
- ----------------- PIMCO Variable Insurance Trust
. Division 270 - Ayco Large Cap Growth Fund I ------------------------------
. Division 288 - PIMCO Real Return Bond
Dreyfus Investment Portfolios . Division 287 - PIMCO Short-Term Bond
- ----------------------------- . Division 289 - PIMCO Total Return Bond
. Division 273 - MidCap Stock
Putnam Variable Trust
Dreyfus Variable Investment Fund ---------------------
- -------------------------------- . Division 290 - Putnam VT Diversified Income
. Division 271 - Quality Bond . Division 291 - Putnam VT Growth and Income
. Division 272 - Small Cap . Division 292 - Putnam VT Int'l Growth and Income
Fidelity Variable Insurance Products Fund SAFECO Resource Series Trust
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. Division 277 - VIP Asset Manager . Division 293 - Equity
. Division 276 - VIP Contrafund . Division 294 - Growth Opportunities
. Division 274 - VIP Equity-Income
. Division 275 - VIP Growth The Universal Institutional Funds, Inc.
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Janus Aspen Series - Service Shares . Division 295 - Equity Growth
- ----------------------------------- . Division 296 - High Yield
. Division 280 - Aggressive Growth
. Division 278 - International Growth Vanguard Variable Investment Fund
. Division 279 - Worldwide Growth ---------------------------------------
. Division 297 - High Yield Bond
J.P. Morgan Series Trust II . Division 298 - REIT Index
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. Division 281- J.P. Morgan Small Company Van Kampen Life Investment Trust
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MFS Variable Insurance Trust . Division 299 - Strategic Stock
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. Division 284 - MFS Capital Opportunities Warburg Pincus Trust
. Division 282 - MFS Emerging Growth --------------------
. Division 285 - MFS New Discovery . Division 300 - Small Company Growth
. Division 283 - MFS Research
AGLC0223
Complete and return this request to: American General Life Insurance Company ("AGL") AMERICAN
Variable Universal Life Operations Member American General Financial Group GENERAL
PO Box 4880 Houston, TX 77210-4880 Houston, Texas FINANCIAL GROUP
(888) 325-9315 or (713) 831-3443
Fax: (877) 445-3098
Hearing Impaired/TDD: (888) 436-5258 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 |
| 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 Beneficiary has | Reason for Change: (Circle One) Marriage Divorce Correction Other
changed. (Please note, this does | (Attach copy of legal proof)
not change the Contingent |
Insureds, Owner, Payor or |
Beneficiary designation) |
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[_] CHANGE IN 3. | INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED %
ALLOCATION | AIM VARIABLE INSURANCE FUNDS NORTH AMERICAN FUNDS VARIABLE PRODUCT
PERCENTAGES | (260) AIM V.I. International Equity _____ _____ SERIES I
| (261) AIM V.I. Value _____ _____ (263) International Equities _____ _____
Use this section to indicate | (264) MidCap Index _____ _____
how premiums or monthly | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. (265) Money Market _____ _____
deductions are to be allocated. | (262) VP Value _____ _____ (266) Nasdaq-100 Index _____ _____
Total allocation in each column | (269) Science & Technology _____ _____
must equal 100%; whole | AYCO SERIES TRUST (268) Small Cap Index _____ _____
numbers only. | (270) Ayco Large Cap Growth Fund I _____ _____ (267) Stock Index _____ _____
|
| DREYFUS INVESTMENT PORTFOLIOS PIMCO VARIABLE INSURANCE TRUST
| (273) MidCap Stock _____ _____ (288) PIMCO Real Return Bond _____ _____
| (287) PIMCO Short-Term Bond _____ _____
| DREYFUS VARIABLE INVESTMENT FUND (289) PIMCO Total Return Bond _____ _____
| (271) Quality Bond _____ _____
| (272) Small Cap _____ _____ PUTNAM VARIABLE TRUST
| (290) Putnam VT Diversified Income _____ _____
| FIDELITY VARIABLE INSURANCE PRODUCTS FUND (291) Putnam VT Growth and Income _____ _____
| (277) VIP Asset Manager _____ _____ (292) Putnam VT Int'l Growth and
| (276) VIP Contrafund _____ _____ Income _____ _____
| (274) VIP Equity-Income _____ _____
| (275) VIP Growth _____ _____ SAFECO RESOURCE SERIES TRUST
| (293) Equity _____ _____
| JANUS ASPEN SERIES - SERVICE SHARES (294) Growth Opportunities _____ _____
| (280) Aggressive Growth _____ _____
| (278) International Growth _____ _____ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
| (279) Worldwide Growth _____ _____ (295) Equity Growth _____ _____
| (296) High Yield _____ _____
| J.P MORGAN SERIES TRUST II
| (281) J.P Morgan Small Company _____ _____ VANGUARD VARIABLE INVESTMENT FUND
| (297) High Yield Bond _____ _____
| MFS VARIABLE INSURANCE TRUST (298) REIT Index _____ _____
| (284) MFS Capital Opportunities _____ _____
| (282) MFS Emerging Growth _____ _____ VAN KAMPEN LIFE INVESTMENT TRUST
| (285) MFS New Discovery _____ _____ (299) Strategic Stock _____ _____
| (283) MFS Research _____ _____
| WARBURG PINCUS TRUST
| NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST (300) Small Company Growth _____ _____
| (286) Mid-Cap Growth _____ _____
| Other:_______________________ _____ _____
| (301) Declared Fixed Interest
| Account _____ _____
100% 100%
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AGLCO223 PAGE 2 OF 5
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[_] MODE OF 4. | Indicate frequency and premium amount desired: $______ Annual $_____ Semi-Annual $____ Quarterly
PREMIUM |
PAYMENT/BILLING | $_____ Monthly (Bank Draft Only)
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 "Void" Check)
billing frequency and/or method |
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. |
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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 | Unless I/we have directed cancellation of the policy, I/we request that a:
for a Certificate of Insurance or |
duplicate policy to replace a | _______Certificate of Insurance at no charge
lost or misplaced policy. If a |
full duplicate policy is being | _______Full duplicate policy at a charge of $25
requested, a check or money order |
for S25 payable to AGL must be | be issued to me/us. If the original policy is located, I/we will return the Certificate
submitted with this request. | or duplicate policy to AGL 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
| I want: $________________ ($100 minimum) taken from the Money Market Division and transferred to
($5,000 minimum initial | the following Divisions:
accumulation value) An amount may |
be deducted periodically from the | AIM VARIABLE INSURANCE FUNDS NORTH AMERICAN FUNDS VARIABLE PRODUCT
Money Market Division and placed | (260) AIM V.I. International Equity $______ SERIES I
in one or more of the Divisions | (261) AIM V.I. Value $______ (263) International Equities $______
listed. The Declared Fixed | (264) MidCap Index $______
Interest Account is not available | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. (266) Nasdaq-100 Index $______
for Dollar Cost Averaging. Please | (262) VP Value $______ (269) Science & Technology $______
refer to the prospectus for more | (268) Small Cap Index $______
information on the Dollar Cost | AYCO SERIES TRUST (267) Stock Index $______
Averaging Option. Note: Automatic | (270) Ayco Large Cap Growth Fund I $______
Rebalancing is not available if | PIMCO VARIABLE INSURANCE TRUST
the Dollar Cost Averaging Option | DREYFUS INVESTMENT PORTFOLIOS (288) PIMCO Real Return Bond $______
is chosen. | (273) MidCap Stock $______ (287) PIMCO Short-Term Bond $______
| (289) PIMCO Total Return Bond $______
| DREYFUS VARIABLE INVESTMENT FUND
| (271) Quality Bond $______ PUTNAM VARIABLE TRUST
| (272) Small Cap $______ (290) Putnam VT Diversified Income $______
| (291) Putnam VT Growth and Income $______
| FIDELITY VARIABLE INSURANCE PRODUCTS FUND (292) Putnam VT Int'l Growth and
| (277) VIP Asset Manager $______ Income $______
| (276) VIP Contrafund $______
| (274) VIP Equity-Income $______ SAFECO RESOURCE SERIES TRUST
| (275) VIP Growth $______ (293) Equity $______
| (294) Growth Opportunities $______
| JANUS ASPEN SERIES - SERVICE SHARES
| (280) Aggressive Growth $______ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
| (278) International Growth $______ (295) Equity Growth $______
| (279) Worldwide Growth $______ (296) High Yield $______
|
| J.P. MORGAN SERIES TRUST II VANGUARD VARIABLE INVESTMENT FUND
| (281) J.P. Morgan Small Company $______ (297) High Yield Bond $______
| (298) REIT Index $______
| MFS VARIABLE INSURANCE TRUST
| (284) MFS Capital Opportunities $______ VAN KAMPEN LIFE INVESTMENT TRUST
| (282) MFS Emerging Growth $______ (299) Strategic Stock $______
| (285) MFS New Discovery $______
| (283) MFS Research $______ WARBURG PINCUS TRUST
| (300) Small Company Growth $______
| NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
| (286) Mid-Cap Growth $______ Other___________________________ $______
|
| _____ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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AGLC0223 PAGE 3 OF 5
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[_] AUTOMATIC 7. |
REBALANCING | Indicate frequency: ________Quarterly ________Semi-Annually ________Annually
|
($5,000 minimum accumulation | (Division Name or Number) (Division Name or Number)
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 chosen. | _______% : ___________________________________ _______% : ________________________________
| _______% : ___________________________________ _______% : ________________________________
| _______% : ___________________________________ _______% : ________________________________
|
| ________ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
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[_] TELEPHONE 8. | I(/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values
PRIVILEGE | among the Variable Divisions and Declared Fixed Interest Account and to change allocations for
AUTHORIZATION | future purchase payments and monthly deductions.
|
Complete this section if you are | Initial the designation you prefer:
applying for or revoking current | _________Policy Owner(s) ONLY - If Joint Owners, either one acting independently.
telephone 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 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.
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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 person covered under | Correct DOB: _________/____________ /_____________
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 want to | Transfer $_______ or _______% from ____________________________ to _____________________________
move money between divisions. |
The minimum amount for transfers | Transfer $_______ or _______% from ____________________________ to _____________________________
is $500.00. Withdrawals from the |
Declared Fixed Interest Account to| Transfer $_______ or _______% from ____________________________ to _____________________________
a Variable Division may only be |
made within the 60 days after a | Transfer $_______ or _______% from ____________________________ to _____________________________
contract anniversary. See transfer|
limitations outlined in | Transfer $_______ or _______% from ____________________________ to _____________________________
prospectus. If a transfer causes |
the balance in any division to | Transfer $_______ or _______% from ____________________________ 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.
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AGLC0223 PAGE 4 OF 5
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[_] 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 | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
loan against policy values. For | percentages in effect, if available; otherwise they are taken pro-rata from the Declared Fixed
detailed information concerning | Interest Account and Variable Divisions in use.
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. |
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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 you have | elect not to have withholding apply by checking the appropriate box below. If you elect not to
applied for a partial surrender | have withholding apply to your distribution or if you do not have enough income tax withheld,
in Section 11. | 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.
|
| It 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
SIGNATURE | my 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.
|
| 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
|
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AGLCO223 PAGE 5 OF 5