EXHIBIT (10)(d)
SERVICE REQUEST
PLATINUM
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INVESTOR(SM) SURVIVOR II
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AMERICAN GENERAL LIFE
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PLATINUM INVESTOR--FIXED OPTION Neuberger Berman Advisers Management Trust
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. Division 18 - Declared Fixed Interest Account
. Division 167 - Mid-Cap Growth
PLATINUM INVESTOR--VARIABLE DIVISIONS
North American Funds Variable Product Series I
AIM Variable Insurance Funds ----------------------------------------------
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. Division 132 - International Equities
. Division 130 - AIM V.I. International Equity
. Division 133 - MidCap Index
. Division 131 - AIM V.I. Value
. Division 134 - Money Market
American Century Variable Portfolios, Inc.
------------------------------------------ . Division 135 - Stock Index
. Division 153 - VP Value . Division 136 - Nasdaq-100 Index
Ayco Series Trust . Division 137 - Science and Technology
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. Division 138 - Small Cap Index
. Division 154 - Ayco Growth Fund
PIMCO Variable Insurance Trust
Credit Suisse Warburg Pincus Trust ------------------------------
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. Division 168 - PIMCO Short-Term Bond
. Division 173 - Small Company Growth
. Division 169 - PIMCO Real Return Bond
Dreyfus Investment Portfolios
----------------------------- . Division 170 - PIMCO Total Return Bond
. Division 155 - MidCap Stock Putnam Variable Trust
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Dreyfus Variable Investment Fund
-------------------------------- . Division 144 - Putnam VT Diversified Income
. Division 139 - Quality Bond . Division 145 - Putnam VT Growth and Income
. Division 140 - Small Cap . Division 146 - Putnam VT International Growth and Income
Fidelity Variable Insurance Products Fund SAFECO Resource Series Trust
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. Division 156 - VIP Equity-Income . Division 147 - Equity
. Division 157 - VIP Growth . Division 148 - Growth Opportunities
. Division 158 - VIP Contrafund The Universal Institutional Funds, Inc.
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. Division 159 - VIP Asset Manager
. Division 142 - Equity Growth
Janus Aspen Series - Service Shares
----------------------------------- . Division 143 - High Yield
. Division 160 - International Growth Vanguard Variable Insurance Fund
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. Division 161 - Worldwide Growth
. Division 171 - High Yield Bond
. Division 162 - Aggressive Growth
. Division 172 - REIT Index
J.P. Morgan Series Trust II
--------------------------- Van Kampen Life Investment Trust
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. Division 163 - J.P. Morgan Small Company
. Division 149 - Strategic Stock
MFS Variable Insurance Trust
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. Division 141 - MFS Emerging Growth
. Division 164 - MFS Research
. Division 165 - MFS Capital Opportunities
. Division 166 - MFS New Discovery
AGLC0463
AMERICAN American General Life Insurance Company ("AGL") Complete and return this request to:
GENERAL Member American General Financial Group Variable Universal Life Operations
FINANCIAL GROUP Houston, Texas PO Box 4880 Houston, TX 77210-4880
(888) 325-9315 or (713) 831-3443
Fax: (877) 445-3098
VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST Hearing Impaired/TDD: (888) 436-5258
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[_] POLICY 1. | POLICY #:_________________________________ CONTINGENT INSURED:__________________________________
IDENTIFICATION | CONTINGENT INSURED: _________________________________
COMPLETE THIS SECTION FOR | ADDRESS:________________________________________________________________ New Address (yes) (no)
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)
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[_] NAME 2. | Change Name Of: (Circle One) Contingent Insured Owner Payor Beneficiary
CHANGE |
Complete this section if the name | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
of one of the Contingent Insureds,| __________________________________________________ __________________________________________
Owner, Payor or Beneficiary has |
changed. (Please note, this does | Reason for Change: (Circle One) Marriage Divorce Correction Other (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 | (18) Declared Fixed Interest Neuberger Berman Advisers Management Trust
PERCENTAGES | Account ______ ______ (167) Mid-Cap Growth ______ ______
Use this section to indicate | AIM Variable Insurance Funds
how premiums or monthly | (130) AIM V.I. International North American Funds Variable Product Series I
deductions are to be allocated. | Equity ______ ______ (132) International Equities ______ ______
Total allocation in each column | (131) AIM V.I. Value ______ ______ (133) MidCap Index ______ ______
must equal 100%; whole | (134) Money Market ______ ______
numbers only. | American Century Variable Portfolios (135) Stock Index ______ ______
| (153) VP Value ______ ______ (136) Nasdaq-100 Index ______ ______
| (137) Science and Technology ______ ______
| Ayco Series Trust (138) Small Cap Index ______ ______
| (154) Ayco Growth Fund ______ ______
| PIMCO Variable Insurance Trust
| Credit Suisse Warburg Pincus Trust (168) PIMCO Short-Term Bond ______ ______
| (173) Small Company Growth ______ ______ (169) PIMCO Real Return Bond ______ ______
| (170) PIMCO Total Return Bond ______ ______
| Dreyfus Investment Portfolios
| (155) Midcap Stock ______ ______ Putnam Variable Trust
| (144) Putnam VT Diversified
| Dreyfus Variable Investment Fund Income ______ ______
| (139) Quality Bond ______ ______ (145) Putnam VT Growth and
| (140) Small Cap ______ ______ Income ______ ______
| (146) Putnam VT Int'l Growth and
| Fidelity Variable Insurance Products Fund Income ______ ______
| (156) VIP Equity-Income ______ ______
| (157) VIP Growth ______ ______ SAFECO Resource Series Trust
| (158) VIP Contrafund ______ ______ (147) Equity ______ ______
| (159) VIP Asset Manager ______ ______ (148) Growth Opportunities ______ ______
|
| Janus Aspen Series - Service Shares The Universal Institutional Funds, Inc.
| (160) International Growth ______ ______ (142) Equity Growth ______ ______
| (161) Worldwide Growth ______ ______ (143) High Yield ______ ______
| (162) Aggressive Growth ______ ______
| Vanguard Variable Insurance Fund
| J.P. Morgan Series Trust II (171) High Yield Bond ______ ______
| (163) J.P. Morgan Small Company ______ ______ (172) REIT Index ______ ______
|
| MFS Variable Insurance Trust Van Kampen Life Investment Trust
| (141) MFS Emerging Growth ______ ______ (149) Strategic Stock ______ ______
| (164) MFS Research ______ ______
| (165) MFS Capital Opportunities ______ ______ Other:_______________________ ______ ______
| (166) MFS New Discovery ______ ______ 100% 100%
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AGLC0463 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 "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 |
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 AGL 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 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
($5,000 minimum initial | I want: $________________ ($100 minimum) taken from the Money Market Division and transferred to
accumulation value) An amount may | the following Divisions:
be deducted periodically from the |
Money Market Division and placed | (18) Declared Fixed Interest Account ____ ____ Neuberger Berman Advisers Management Trust
in one or more of the Divisions | (167) Mid-Cap Growth ____ ____
listed. The Declared Fixed | AIM Variable Insurance Funds North American Funds Variable Product Series I
Interest Account is not available | (130) AIM V.I. International Equity ____ ____ (132) International Equities ____ ____
for Dollar Cost Averaging. Please | (131) AIM V.I. Value ____ ____ (133) Midcap Index ____ ____
refer to the prospectus for more | (134) Money Market ____ ____
information on the Dollar Cost | American Century Variable Portfolios (135) Stock Index ____ ____
Averaging Option. Note: Automatic | (153) VP Value ____ ____ (136) Nasdaq-100 Index ____ ____
Rebalancing is not available if | (137) Science & Technology ____ ____
the Dollar Cost Averaging Option | Ayco Series Trust (138) Small Cap Index ____ ____
is chosen. | (154) Ayco Growth Fund ____ ____
| PIMCO Variable Insurance Trust
| Credit Suisse Warburg Pincus Trust (168) PIMCO Short-Term Bond ____ ____
| (173) Small Company Growth ____ ____ (169) PIMCO Real Return Bond ____ ____
| (170) PIMCO Total Return Bond ____ ____
| Dreyfus Investment Portfolios
| (155) Midcap Stock ____ ____ Putnam Variable Trust
| (144) Putnam VT Diversified Income ____ ____
| Dreyfus Variable Investment Fund (145) Putnam VT Growth and Income ____ ____
| (139) Quality Bond ____ ____ (146) Putnam VT Int'l Growth and Income____ ____
| (140) Small Cap ____ ____
| SAFECO Resource Series Trust
| Fidelity Variable Insurance Products Fund (147) Equity ____ ____
| (156) VIP Equity-Income ____ ____ (148) Growth Opportunities ____ ____
| (157) VIP Growth ____ ____
| (158) VIP Contrafund ____ ____ The Universal Institutional Funds, Inc.
| (159) VIP Asset Manager ____ ____ (142) Equity Growth ____ ____
| (143) High Yield ____ ____
| Janus Aspen Series - Service Shares
| (160) International Growth ____ ____ Vanguard Variable Insurance Fund
| (161) Worldwide Growth ____ ____ (171) High Yield Bond ____ ____
| (162) Aggressive Growth ____ ____ (172) REIT Index ____ ____
|
| J.P. Morgan Series Trust II Van Kampen Life Investment Trust
| (163) J.P. Morgan Small Company ____ ____ (149) Strategic Stock ____ ____
| Other ____ ____
| MFS Variable Insurance Trust 100% 100%
| (141) MFS Emerging Growth ____ ____
| (164) MFS Research ____ ____
| (165) MFS Capital Opportunities ____ ____
| (166) MFS New Discovery ____ ____
|
| _____ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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AGLC0463 PAGE 3 OF 5
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[_] AUTOMATIC 7. |
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. | _______% : ___________________________________ _______% : ________________________________
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 |
applying for or revoking current | Initial the designation you prefer:
telephone privileges. | _________Policy Owner(s) only - If Joint Owners, either one acting independently.
|
| _________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 |
this policy. Proof of the correct | Correct DOB: _________/____________ /_____________
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 |
move money between divisions. | Transfer $_______ or _______% from ____________________________ to _____________________________
The minimum amount for transfers |
is $500.00. Withdrawals from the | Transfer $_______ or _______% from ____________________________ to _____________________________
Declared Fixed Interest Account to|
a Variable Division may only be | Transfer $_______ or _______% from ____________________________ to _____________________________
made within the 60 days after a |
contract anniversary. See transfer| Transfer $_______ or _______% from ____________________________ to _____________________________
limitations outlined in |
prospectus. If a transfer causes | Transfer $_______ or _______% from ____________________________ to _____________________________
the balance in any division to |
drop below $500, AGL reserves | Transfer $_______ or _______% from ____________________________ to _____________________________
the right to transfer |
the remaining balance. Amounts | Transfer $_______ or _______% from ____________________________ to _____________________________
to be transferred should be |
indicated in dollar or percentage | Transfer $_______ or _______% from ____________________________ to _____________________________
amounts, maintaining |
consistency throughout. | Transfer $_______ or _______% from ____________________________ to _____________________________
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AGLC0463 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 |
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 Declared Fixed
these two options please refer to | 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 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
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 11. | 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/ 10. | 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______________________________________,__________
|
| 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 PAGE 5 OF 5