EXHIBIT (10)(c)
SERVICE REQUEST
P L A T I N U M
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INVESTOR
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THE UNITED STATES LIFE
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Platinum Investor--Variable Divisions
AIM VARIABLE INSURANCE FUNDS, INC.
* Division 150 - AIM V.I. International Equity
* Division 151 - AIM V.I. Value
AMERICAN GENERAL SERIES PORTFOLIO COMPANY
* Division 152 - International Equities
* Division 153 - MidCap Index
* Division 149 - Money Market
* Division 154 - Stock Index
DREYFUS VARIABLE INVESTMENT FUND
* Division 156 - Quality Bond
* Division 155 - Small Cap
MFS VARIABLE INSURANCE TRUST
* Division 157 - MFS Emerging Growth
MORGAN STANLEY DEAN WITTER UNIVERSAL FUNDS, INC.
* Division 159 - Equity Growth
* Division 160 - High Yield
PUTNAM VARIABLE TRUST
* Division 162 - Putnam VT Diversified Income
* Division 161 - Putnam VT Growth and Income
* Division 163 - Putnam VT Int'l Growth and Income
SAFECO RESOURCES SERIES TRUST
* Division 164 - Equity
* Division 165 - Growth
VAN KAMPEN LIFE INVESTMENT TRUST
* Division 158 - Strategic Stock
Platinum Investor--Fixed Division
* Division 148 - USL Declared Fixed Interest Account
THE UNITED STATES LIFE INSURANCE COMPANY
Complete and return this request to:
Administrative Center In The City of New York ("USL")
PO Box 4880 Houston, TX 77210-4880 Administration Center: Houston, TX
(800)251-3720
Fax: (713) 620-3857
Hearing Impaired: (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 ALL REQUESTS. | Primary Owner (If other than 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 | Change Name Of: (Circle One) Insured Owner Payor Beneficiary
|
Complete this section if | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
the name of the Insured, |
Owner, Payor or Beneficiary| _________________________________________ _________________________________________________
has changed. (Please note,|
this does not change the |
Insured, Owner, Payor or | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
Beneficiary designation) |
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[ ] 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 frequence 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 |
USL 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. |
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[ ] 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 USL for cancellation.
USL must be submitted with|
this request. |
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[ ] DOLLAR COST 5.| 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 |
accumulation value) An |
amount may be deducted | I want: $___________($100 minimum) taken from the Money Market Division (149) 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 | $_________(150) AIM V.I. International Equity $________(159) Equity Growth
USL Declared Fixed In- | $_________(151) AIM V.I. Value $________(160) High Yield
terest Account is not | American General Series Portfolio Company Putnam Variable Trust
available for Dollar Cost | $_________(152) International Equities $________(162) Putnam VT Diversified Income
Averaging. Please refer to | $_________(153) MidCap Index $________(161) Putnam VT Growth and Income
the propectus for more | $_________(154) Stock Index $________(163) Putnam VT Int'l Growth & Income
information on the Dollar | Dreyfus Variable Investment Fund SAFECO Resource Series Trust
Cost Averaging Option. | $_________(156) Quality Bond $________(164) Equity
| $_________(155) Small Cap $________(165) Growth
| MFS Variable Insurance Trust Van Kampen Life Investment Trust
| $_________(157) MFS Emerging Growth $________(158) Strategic Stock
|
| ________INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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[ ] CORRECT AGE 6.| Name of 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. |
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[ ] TRANSFER OF 7.| (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. Withdrawals |
from the USL Declared | Transfer $________ or %_______ from_______________________________to__________________________________
Fixed Interest Account are |
limited to 60 days after | Transfer $________ or %_______ from_______________________________to__________________________________
the policy anniversary and |
to no more than 25% of the | Transfer $________ or %_______ from_______________________________to__________________________________
total unloaned value of |
the USL Declared Fixed | Transfer $________ or %_______ from_______________________________to__________________________________
Interest Account on the |
policy anniversary. If a | Transfer $________ or %_______ from_______________________________to__________________________________
transfer causes the |
balance in any division to | Transfer $________ or %_______ from_______________________________to__________________________________
drop below $500, USL |
reserves the right to | Transfer $________ or %_______ from_______________________________to_________________________________
transfer the remaining |
balance. | Transfer $________ or %_______ from_______________________________to__________________________________
Amounts to be transferred |
should be indicated in | Transfer $________ or %_______ from_______________________________to__________________________________
dollar or percentage |
amounts, maintaining | Transfer $________ or %_______ from_______________________________to__________________________________
consistency throughout. |
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[ ] CHANGE IN 8.| INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED %
ALLOCATION |
PERCENTAGES | (148) USL Declared Fixed Interest Morgan Stanley Dean Witter
| Account ______ ______ Universal Funds, Inc.
Use this section to | AIM Variable Insurance Funds, Inc. (159) Equity Growth ______ ______
indicate how premiums or | (150) AIM V.I. Int'l Equity ______ ______ (160) High Yield ______ ______
monthly deductions are to | (151) AIM V.I. Value ______ ______
be allocated. Total | Putnam Variable Trust
allocation in each | American General Series Portfolio Co. (162) Putnam VT Diversified
column must equal 100%; | (152) International Equities ______ ______ Income ______ ______
whole numbers only. | (153) MidCap Index ______ ______ (161) Putnam VT Growth &
| (149) Money Market ______ ______ Income ______ ______
| (154) Stock Index ______ ______ (163) Putnam VT Int'l
| Growth & Income ______ ______
| Dreyfus Variable Investment Fund
| (156) Quality Bond ______ ______ SAFECO Resources Series Trust
| (155) Small Cap ______ ______ (164) Equity ______ ______
| (165) Growth ______ ______
| MFS Variable Insurance Trust
| (157) MFS Emerging Growth ______ ______ Van Kampen Life Investment
| Trust
| (158) Strategic Stock ______ ______
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[ ] AUTOMATIC 9.| 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. This option is not | %_________:________________________________________ %_________:____________________________________
available while the Dollar |
Cost Averaging Option is |
in use. | _________INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
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[ ] REQUEST FOR 10.| _________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 USL Declared Fixed
policy values. For detailed| Interest 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. |
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[ ] NOTICE OF 11.| 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 10. | 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.
|
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[ ] AFFIRMATION/ 12.| 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.
|
| Dated at __________________________________ this _________ day of ________________________, 19________.
|
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| 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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