Exhibit (e)(5)
AMERICAN GENERAL
Life Companies
EXECUTIVE ADVANTAGE/SM/
LOAN / SURRENDER REQUEST
Policy Number: ____________________ Policyholder: ____________________________________________
(Last Name, First Name, Middle Name)
Insured: ______________________________________ Social Security No.: _______-_______-________
(Last Name, First Name, Middle Name)
LOAN REQUEST
. Interest will accrue daily on any outstanding loan at an annual interest
rate as indicated in the specifications.
[_] Maximum Amount Available (may vary by Subaccount)
[_] $ __________ in cash or maximum amount available, if less
SURRENDER REQUEST
[_] Full surrender (original policy or lost policy affidavit must be
enclosed)
[_] Partial surrender in the amount of $ __________ or for ______% of
cash surrender value
. No more than two (2) surrenders may be made during each Certificate Year.
. An expense charge and/or a surrender charge may be assessed according to
the Certificate.
. You can direct below how the loan or partial surrender will be deducted
from the unloaned portion of the Guaranteed Account and the Subaccounts.
If you provide no directions, the loan or partial surrender amount will
be deducted from the unloaned portion of the Guaranteed Account and the
Subaccounts on a pro rata basis.
Amount Percent Amount Percent
-------- ------- -------- -------
GUARANTEED ACCOUNT $_______ ___%
AIM VARIABLE INSURANCE FUNDS (INVESCO VARIABLE INSURANCE ▇▇▇▇▇▇▇ ▇▇▇▇▇ VARIABLE INSURANCE TRUST
FUNDS)
Invesco ▇▇▇ ▇▇▇▇▇▇ V.I. High Yield Fund $_______ ___% Strategic International Equity Fund $_______ ___%
Invesco ▇▇▇ ▇▇▇▇▇▇ V.I. American Value Fund $_______ ___% Structured U.S. Equity Fund $_______ ___%
ALLIANCEBERNSTEIN VARIABLE PRODUCT SERIES FUND, INC. JPMORGAN INSURANCE TRUST
Growth Portfolio $_______ ___% Small Cap Core Portfolio $_______ ___%
Growth and Income Portfolio $_______ ___% THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
Large Cap Growth Portfolio $_______ ___% Core Plus Fixed Income Portfolio $_______ ___%
Small Cap Growth Portfolio $_______ ___% Emerging Markets Equity Portfolio $_______ ___%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. Mid Cap Growth Portfolio $_______ ___%
VP Income & Growth Fund $_______ ___% ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ADVISERS MANAGEMENT TRUST
VP International Fund $_______ ___% AMT Large Cap Value Portfolio $_______ ___%
BLACKROCK VARIABLE SERIES FUNDS, INC. PIMCO VARIABLE INSURANCE TRUST
BlackRock Basic Value V.I. Fund $_______ ___% High Yield Portfolio $_______ ___%
BlackRock Capital Appreciation V.I. Fund $_______ ___% Long -Term U.S. Government Portfolio $_______ ___%
BlackRock U.S. Government Bond V.I. Fund $_______ ___% Real Return Portfolio $_______ ___%
BlackRock Value Opportunities V.I. Fund $_______ ___% Short-Term Portfolio $_______ ___%
FIDELITY VARIABLE INSURANCE PRODUCTS Total Return Portfolio $_______ ___%
VIP Balanced Portfolio $_______ ___% VANGUARD VARIABLE INSURANCE FUND
VIP Contrafund Portfolio $_______ ___% Total Bond Market Index Portfolio $_______ ___%
VIP Index 500 Portfolio $_______ ___% Total Stock Market Index Portfolio $_______ ___%
VIP Money Market Portfolio $_______ ___% VALIC COMPANY I
FRANKLIN ▇▇▇▇▇▇▇▇▇ VARIABLE INSURANCE PRODUCTS TRUST International Equities Fund $_______ ___%
Developing Markets Securities Fund - Class 2 $_______ ___% Mid Cap Index Fund $_______ ___%
Foreign Securities Fund - Class 2 $_______ ___% Small Cap Index Fund $_______ ___%
Growth Securities Fund - Class 2 $_______ ___%
As Policyholder, I represent that the statements and answers in this Loan /
Surrender request are written as made by me and are complete and true to the
best of my knowledge and belief. In the event of a full surrender, I surrender
all rights to this policy and state that no bankruptcy or insolvency proceeding
is pending with respect to me.
---------------------------------------------- --------------------------------------------------------
Signature of Insured Signature of Policyholder (If other than Insured)
_____________________________ __, 20_____
Date Signed
Loan/Surrender; Executive Advantage/SM/, 09/12
