EXHIBIT (10)(c)
SERVICE REQUEST
PLATINUM
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INVESTOR(SM) SURVIVOR
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UNITED STATES 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 36 - Mid-Cap Growth
PLATINUM INVESTOR--VARIABLE DIVISIONS
North American Funds Variable Product Series I
AIM Variable Insurance Funds ----------------------------------------------
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. Division 3 - International Equities
. Division 1 - AIM V.I. International Equity
. Division 4 - Midcap Index
. Division 2 - AIM V.I. Value
. Division 5 - Money Market
American Century Variable Portfolios, Inc.
------------------------------------------ . Division 20 - Nasdaq-100 Index
. Division 19 - VP Value . Division 21 - Science & Technology
Ayco Series Trust . Division 22 - Small Cap Index
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. Division 6 - Stock Index
. Division 23 - Ayco Growth
PIMCO Variable Insurance Trust
Credit Suisse Warburg Pincus Trust ------------------------------
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. Division 101 - PIMCO Real Return Bond
. Division 105 - Small Company Growth
. Division 37 - PIMCO Short-Term Bond
Dreyfus Investment Portfolios
----------------------------- . Division 102 - PIMCO Total Return Bond
. Division 24 - MidCap Stock Putnam Variable Trust
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Dreyfus Variable Investment Fund
-------------------------------- . Division 12 - Putnam VT Diversified Income
. Division 7 - Quality Bond . Division 13 - Putnam VT Growth and Income
. Division 8 - Small Cap . Division 14 - Putnam VT Int'l Growth and Income
Fidelity Variable Insurance Products Fund SAFECO Resource Series Trust
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. Division 28 - VIP Asset Manager . Division 15 - Equity
. Division 27 - VIP Contrafund . Division 16 - Growth Opportunities
. Division 25 - VIP Equity-Income The Universal Institutional Funds, Inc.
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. Division 26 - VIP Growth
. Division 10 - Equity Growth
Janus Aspen Series - Service Shares
----------------------------------- . Division 11 - High Yield
. Division 31 - Aggressive Growth Vanguard Variable Insurance Fund
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. Division 29 - International Growth
. Division 103 - High Yield Bond
. Division 30 - Worldwide Growth
. Division 104 - REIT Index
J.P. Morgan Series Trust II
--------------------------- Van Kampen Life Investment Trust
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. Division 32 - J.P. Morgan Small Company
. Division 17 - Strategic Stock
MFS Variable Insurance Trust
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. Division 34 - MFS Capital Opportunities
. Division 9 - MFS Emerging Growth
. Division 35 - MFS New Discovery
. Division 33 - MFS Research
Complete and return this request to: The United States Life Insurance Company
Administrative Center In the City of New York ("USL")
PO Box 4880 Houston, TX 77210-4880
(800) 251-3720 Administration Center: Houston, TX
Hearing Impaired/TDD: (888) 436-5258
Toll-Free Fax: (877) 445-3098 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST
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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 ______ ______ (36) Mid-Cap Growth ______ _____
Use this section to indicate |
how premiums or monthly | AIM Variable Insurance Funds North American Funds Variable Product Series I
deductions are to be allocated. | (1) AIM V.I. International (3) International Equities ______ ______
| Equity ______ ______ (4) Midcap Index ______ ______
Total allocation in each column | (2) AIM V.I. Value ______ ______ (5) Money Market ______ ______
must equal 100%; whole | (20) Nasdaq-100 Index ______ ______
numbers only. | American Century Variable Portfolios, Inc. (21) Science & Technology ______ ______
| (19) VP Value ______ ______ (22) Small Cap Index ______ ______
| (6) Stock Index ______ ______
|
| Ayco Series Trust PIMCO Variable Insurance Trust
| (23) Ayco Growth ______ ______ (101) PIMCO Real Return Bond ______ ______
| (37) PIMCO Short-Term Bond ______ ______
| Credit Suisse Warburg Pincus Trust (102) PIMCO Total Return Bond ______ ______
| (105) Small Company Growth ______ ______ Putnam Variable Trust
| (12) Putnam VT Diversified
| Dreyfus Investment Portfolios Income ______ ______
| (24) MidCap Stock ______ ______ (13) Putnam VT Growth and
| Income ______ ______
| Dreyfus Variable Investment Fund (14) Putnam VT Int'l Growth
| (7) Quality Bond ______ ______ and Income
| (8) Small Cap ______ ______ SAFECO Resource Series Trust
| (15) Equity ______ ______
| Fidelity Variable Insurance Products Fund (16) Growth Opportunities ______ ______
| (28) VIP Asset Manager ______ ______ The Universal Institutional
| (27) VIP Contrafund ______ ______ Funds, Inc.
| (25) VIP Equity-Income ______ ______ (10) Equity Growth ______ ______
| (26) VIP Growth ______ ______ (11) High Yield ______ ______
|
| Janus Aspen Series - Service Shares Vanguard Variable Insurance Fund
| (31) Aggressive Growth ______ ______ (103) High Yield Bond ______ ______
| (29) International Growth ______ ______ (104) REIT Index ______ ______
| (30) Worldwide Growth ______ ______
| Van Kampen Life Investment
| J.P. Morgan Series Trust II Trust
| (32) J.P. Morgan Small Company ______ ______ (17) Strategic Stock ______ ______
|
| MFS Variable Insurance Trust Other:______________________ ______ ______
| (34) MFS Capital Opportunities ______ ______ 100% 100%
| (9) MFS Emerging Growth ______ ______
| (35) MFS New Discovery ______ ______
| (33) MFS Research ______ ______
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USL0094 REV 1001 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 USL 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 USL 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 USL 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
accumulation value) An amount may | to the following Divisions:
be deducted periodically from the |
Money Market Division and placed | AIM Variable Insurance Funds Neuberger Berman Advisers Management Trust
in one or more of the Divisions | (1) AIM V.l. International Equity $_____ (36) Mid-Cap Growth $______
listed. The Declared Fixed | (2) AIM V.I. Value $_____
Interest Account is not available | North American Funds Variable Product Series I
for Dollar Cost Averaging. Please | American Century Variable Portfolios, Inc. (3) International Equities $______
refer to the prospectus for more | (19) VP Value $_____ (4) MidCap Index $______
information on the Dollar Cost | (20) Nasdaq-100 Index $______
Averaging Option. Note: Automatic | Ayco Series Trust (21) Science & Technology $______
Rebalancing is not available if | (23) Ayco Growth $_____ (22) Small Cap Index $______
the Dollar Cost Averaging Option | (6) Stock Index $______
is chosen. | Credit Suisse Warburg Pincus Trust
| (105) Small Company Growth $_____ PIMCO Variable Insurance Trust
| (101) PIMCO Real Return Bond $______
| Dreyfus Investment Portfolios (37) PIMCO Short-Term Bond $______
| (24) MidCap Stock $_____ (102) PIMCO Total Return Bond $______
|
| Dreyfus Variable Investment Fund Putnam Variable Trust
| (7) Quality Bond $_____ (12) Putnam VT Diversified Income $______
| (8) Small Cap $_____ (13) Putnam VT Growth and Income $______
| (14) Putnam VT Int'l Growth and Income $______
| Fidelity Variable Insurance Products Fund
| (28) VIP Asset Manager $_____ SAFECO Resource Series Trust
| (27) VIP Contrafund $_____ (15) Equity $______
| (25) VIP Equity-Income $_____ (16) Growth Opportunities $______
| (26) VIP Growth $_____
| The Universal Institutional Funds, Inc.
| Janus Aspen Series - Service Shares (10) Equity Growth $______
| (31) Aggressive Growth $_____ (11) High Yield $______
| (29) International Growth $_____
| (30) Worldwide Growth $_____ Vanguard Variable Insurance Fund
| (103) High Yield Bond $______
| J.P. Morgan Series Trust II (104) REIT Index $______
| (32) J.P. Morgan Small Company $_____
| Van Kampen Life Investment Trust
| MFS Variable Insurance Trust (17) Strategic Stock $______
| (34) MFS Capital Opportunities $_____
| (9) MFS Emerging Growth $_____ Other: $______
| (35) MFS New Discovery $_____
| (33) MFS Research Division $_____
|
| _____ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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USL0094 REV 1001 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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[_] CORRECT AGE 8. | ______ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
Use this section to correct the |
age of any person covered under | Name of Contingent Insured for whom this correction is submitted:________________________
this policy. Proof of the correct |
date of birth must accompany this | Correct DOB: ________/________/________
request. |
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[_] TRANSFER OF 9. | (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, USL 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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[_] REQUEST FOR 10.|
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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USL 0094 REV1001 PAGE 4 0F 5
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[_] NOTICE OF 11. | 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/ 12. | 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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USL0094 REV1001 PAGE 5 OF 5