EXHIBIT 10(e)
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| SERVICE REQUEST |
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P L A T I N U M
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INVESTOR(SM) PLUS
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AMERICAN GENERAL LIFE
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PLATINUM INVESTOR PLUS--FIXED OPTION MFS Variable Insurance Trust
. Division 301 -- AGL Declared Fixed Interest Account ----------------------------
. Division 340 - MFS Capital Opportunities
PLATINUM INVESTOR PLUS -- VARIABLE DIVISIONS . Division 338 - MFS Emerging Growth
AIM Variable Insurance Funds . Division 341 - MFS New Discovery
- ---------------------------- . Division 339 - MFS Research
. Division 316 - AIM V.I. International Growth
. Division 317 - AIM V.I. Premier Equity Neuberger Berman Advisers Management Trust
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American Century Variable Portfolios, Inc. . Division 342 - Mid-Cap Growth
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. Division 318 - VP Value PIMCO Variable Insurance Trust
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Ayco Series Trust . Division 344 - PIMCO Real Return
- ----------------- . Division 343 - PIMCO Short-Term
. Division 326 - Ayco Growth . Division 345 - PIMCO Total Return
Credit Suisse Trust Putnam Variable Trust
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. Division 356 - Small Cap Growth . Division 346 - Putnam VT Diversified Income
. Division 347 - Putnam VT Growth and Income
Dreyfus Investment Portfolios . Division 348 - Putnam VT Int'l Growth and Income
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. Division 329 - MidCap Stock SAFECO Resource Series Trust
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Dreyfus Variable Investment Fund . Division 349 - Equity
- -------------------------------- . Division 350 - Growth Opportunities
. Division 327 - Quality Bond
. Division 328 - Small Cap SunAmerica Series Trust
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Fidelity Variable Insurance Products Fund . Division 361 - Aggressive Growth
- ----------------------------------------- . Division 360 - SunAmerica Balanced
. Division 333 - VIP Asset Manager
. Division 332 - VIP Contrafund The Universal Institutional Funds, Inc.
. Division 330 - VIP Equity-Income ---------------------------------------
. Division 331 - VIP Growth . Division 351 - Equity Growth
. Division 352 - High Yield
Franklin Templeton Variable Insurance Products Trust
- ---------------------------------------------------- VALIC Company I
. Division 357 - Franklin U.S. Government ---------------
. Division 358 - Mutual Shares Securities . Division 319 - International Equities
. Division 359 - Templeton Foreign Securities . Division 320 - Mid Cap Index
. Division 321 - Money Market I
Janus Aspen Series . Division 322 - Nasdaq-100 Index
- ------------------ . Division 325 - Science & Technology
. Division 336 - Aggressive Growth . Division 324 - Small Cap Index
. Division 334 - International Growth . Division 323 - Stock Index
. Division 335 - Worldwide Growth
Vanguard Variable Insurance Fund
J.P. Morgan Series Trust II --------------------------------
- --------------------------- . Division 353 - High Yield Bond
. Division 337 - JPMorgan Small Company . Division 354 - REIT Index
Van Kampen Life Investment Trust
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AGLC 100182 Rev0302 . Division 355 - Growth & Income
AIG AMERICAN VARIABLE UNIVERSAL LIFE
|GENERAL INSURANCE SERVICE REQUEST
AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
Member of American International Group, Inc.
Complete and return this request to:
Variable Universal Life Operations, P.O. Box 4880, Houston, TX. 77210-4880
(888) 325-9315 or (713) 831-3443 . Fax: (877) 445-3098 . Hearing Impaired/(TDD) (888) 436-5258
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[_] POLICY 1. | POLICY #:_________________________________ INSURED:__________________________________
IDENTIFICATION | ADDRESS:________________________________________________________________ New Address (yes) (no)
COMPLETE THIS SECTION | Primary Owner (if other than an insured):_______________________________
FOR 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 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 | AIM Variable Insurance Funds Neuberger Berman Advisers Management Trust
PERCENTAGES | (316) AIM V.I. International Growth _____ _____ (342) Mid-Cap Growth ______ ______
Use this section to indicate | (317) AIM V.I. Premier Equity _____ _____
how premiums or monthly | PIMCO Variable Insurance Trust
deductions are to be allocated. | American Century Variable (344) PIMCO Real Return ______ ______
Total allocation in each column | Portfolios, Inc. (343) PIMCO Short-Term ______ ______
must equal 100%; whole | (318) VP Value _____ _____ (345) PIMCO Total Return ______ ______
numbers only. |
| Ayco Series Trust Putnam Variable Trust
| (326) Ayco Growth _____ _____ (346) Putnam VT Diversified
| Income ______ ______
| Credit Suisse Trust (347) Putnam VT Growth and Income______ ______
| (356) Small Cap Growth _____ _____ (348) Putnam VT Int'l Growth and
| Income ______ ______
| Dreyfus Investment Portfolios
| (329) MidCap Stock _____ _____ SAFECO Resource Series Trust
| (349) Equity ______ ______
| Dreyfus Variable Investment Fund (350) Growth Opportunities ______ ______
| (327) Quality Bond _____ _____
| (328) Small Cap _____ _____ SunAmerica Series Trust
| (361) Aggressive Growth ______ ______
| Fidelity Variable Insurance (360) SunAmerica Balanced ______ ______
| Products Fund
| (333) VIP Asset Manager _____ _____ The Universal Institutional Funds, Inc.
| (332) VIP Contrafund _____ _____ (351) Equity Growth ______ ______
| (330) VIP Equity-Income _____ _____ (352) High Yield ______ ______
| (331) VIP Growth _____ _____
| _____ _____ VALIC Company I
| Franklin Templeton Variable _____ _____ (319) International Equities ______ ______
| Insurance Products Trust (320) Mid Cap Index ______ ______
| (357) Franklin U.S. Government _____ _____ (321) Money Market I ______ ______
| (358) Mutual Shares Securities _____ _____ (322) Nasdaq-100 Index ______ ______
| (359) Templeton Foreign Securities _____ _____ (325) Science & Technology ______ ______
| (324) Small Cap Index ______ ______
| Janus Aspen Series (323) Stock Index ______ ______
| (336) Aggressive Growth _____ _____
| (334) International Growth _____ _____ Vanguard Variable Insurance Fund
| (335) Worldwide Growth _____ _____ (353) High Yield Bond ______ ______
| (354) REIT Index ______ ______
| J.P Morgan Series Trust II
| (337) JPMorgan Small Company _____ _____ Van Kampen Life Investment Trust
| (355) Growth & Income ______ ______
| MFS Variable Insurance Trust
| (340) MFS Capital Opportunities _____ _____ Other:_______________________ ______ ______
| (338) MFS Emerging Growth _____ _____ (301) AGL Declared Fixed
| (341) MFS New Discovery _____ _____ Interest Account ______ ______
| (339) MFS Research _____ _____ 100% 100%
|
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AGLC 100182 Rev0302 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 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 I Division and
accumulation value) An amount may | transferred to the following Divisions:
be deducted periodically from the |
Money Market I Division and | AIM Variable Insurance Funds Neuberger Berman Advisers Management Trust
placed in one or more of the | (316) AIM V.I. International Growth $_______ (342) Mid-Cap Growth $_______
divisions listed. | (317) AIM V.I. Premier Equity $_______
The AGL Declared Fixed | PIMCO Variable Insurance Trust
Interest Account is not available | American Century Variable Portfolios, Inc. (344) PIMCO Real Return $_______
for Dollar Cost Averaging. | (318) VP Value $_______ (343) PIMCO Short-Term $_______
Please refer to the prospectus | (345) PIMCO Total Return $_______
for more information on the | Ayco Series Trust
Dollar Cost Averaging Option. | (326) Ayco Growth $_______ Putnam Variable Trust
Note: Automatic Rebalancing | (346) Putnam VT Diversified Income $_______
is not available if the Dollar | Credit Suisse Trust (347) Putnam VT Growth and Income $_______
Cost Averaging Option is | (356) Small Cap Growth $_______ (348) Putnam VT Int'l Growth and Income $_______
chosen. |
| Dreyfus Investment Portfolios SAFECO Resource Series Trust
| (329) MidCap Stock $_______ (349) Equity $_______
| (350) Growth Opportunities $_______
| Dreyfus Variable Investment Fund
| (327) Quality Bond $_______ SunAmerica Series Trust
| (328) Small Cap $_______ (361) Aggressive Growth $_______
| (360) SunAmerica Balanced $_______
| Fidelity Variable Insurance Products Fund
| (333) VIP Asset Manager $_______ The Universal Institutional Funds, Inc.
| (332) VIP Contrafund $_______ (351) Equity Growth $_______
| (330) VIP Equity-Income $_______ (352) High Yield $_______
| (331) VIP Growth $_______
| VALIC Company I
| Franklin Templeton Variable Insurance (319) International Equities $_______
| Products Trust (320) Mid Cap Index $_______
| (357) Franklin U.S. Government $_______ (321) Money Market 1 $_______
| (358) Mutual Shares Securities $_______ (322) Nasdaq-100 Index $_______
| (359) Templeton Foreign Securities $_______ (325) Science & Technology $_______
| (324) Small Cap Index $_______
| Janus Aspen Series (323) Stock Index $_______
| (336) Aggressive Growth $_______
| (334) International Growth $_______ Vanguard Variable Insurance Fund
| (335) Worldwide Growth $_______ (353) High Yield Bond $_______
| (354) REIT Index $_______
| J.P. Morgan Series Trust II
| (337) JPMorgan Small Company $_______ Van Kampen Life Investment Trust
| (355) Growth & Income $_______
| MFS Variable Insurance Trust
| (340) MFS Capital Opportunities $_______ Other:_____________________________ $_______
| (338) MFS Emerging Growth $_______
| (341) MFS New Discovery $_______
| (339) MFS Research Division $_______
| _______ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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AGLC 100182 Rev0302 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. |
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
|
| _________%:___________________________________ ________%:________________________________
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| ______________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 AGL Declared Fixed Interest Account and to change allocations
AUTHORIZATION | for 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. |
Use this section to correct the | Name of Insured for whom this correction is submitted: ______________________________
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 ____________________________.
AGL Declared Fixed Interest |
Account to a Variable Division | Transfer $_______ or _______% from ____________________________ to ____________________________.
may only be made within the 60 |
days after a contract anniversary.| Transfer $_______ or _______% from ____________________________ to ____________________________.
See transfer limitations outlined |
in prospectus. If a transfer | Transfer $_______ or _______% from ____________________________ to ____________________________.
causes the balance in |
any division to drop below | Transfer $_______ or _______% from ____________________________ to ____________________________.
$500, AGL 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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AGLC 100182 Rev0302 PAGE 4 OF 5
[_] REQUEST FOR PARTIAL 11. | _______ I request a partial surrender of $________ or _______% of the net cash surrender value.
SURRENDER/POLICY LOAN |
| _______ I request a loan in the amount of $__________.
Use this section to apply for a |
partial surrender from or policy | _______ I request the maximum loan amount available from my policy.
loan against policy values. For |
detailed information concerning | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
these two options please refer | percentages in effect, if available; otherwise they ar taken pro-rata from the AGL Declared
to your policy and its related | Fixed Interest Account and Variable Divisions in use.
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/ 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
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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AGLC 100182 Rev0302 PAGE 5 OF 5