Exhibit (10)(e)(ii)
SERVICE REQUEST
PLATINUM
__________________________________
INVESTOR(SM) SURVIVOR
__________________________________
AMERICAN GENERAL LIFE
______________________________________________________________________________
PLATINUM INVESTOR--VARIABLE DIVISIONS
AIM Variable Insurance Funds, Inc.
. Division 1 - AIM V.I. International Equity
. Division 2 - AIM V.I. Value
American General Series Portfolio Company
. Division 3 - International Equities
. Division 4 - MidCap Index
. Division 5 - Money Market
. Division 6 - Stock Index
Dreyfus Variable Investment Fund
. Division 7 - Quality Bond
. Division 8 - Small Cap
MFS Variable Insurance Trust
. Division 9 - MFS Emerging Growth
Xxxxxx Xxxxxxx Xxxx Xxxxxx Universal Funds, Inc.
. Division 10 - Equity Growth
. Division 11 - High Yield
Xxxxxx Variable Trust
. Division 12 - Xxxxxx VT Diversified Income
. Division 13 - Xxxxxx VT Growth and Income
. Division 14 - Xxxxxx VT International Growth and Income
SAFECO Resource Series Trust
. Division 15 - Equity
. Division 16 - Growth
Xxx Xxxxxx Life Investment Trust
. Division 17 - Strategic Stock
PLATINUM INVESTOR--FIXED OPTION
. Division 18 - Declared Fixed Interest Account
AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL") [American General
Complete and return this request to: --------------------------------------------- Logo
Variable Universal Life Operations A Subsidiary of American General Corporation appears here]
PO Box 4880 Houston, TX 77210-4880 ---------------------------------------------
(000) 000-0000 or (000) 000-0000 Houston, Texas
Fax: (000) 000-0000
Hearing Impaired/TDD: (000) 000-0000 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST
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[ ] POLICY 1.| POLICY #:____________________________________ CONTINGENT INSURED:_______________________________
IDENTIFICATION | CONTINGENT INSURED:_______________________________
| ADDRESS:________________________________________________________________________ New Address (yes)(no)
COMPLETE THIS SECTION |
FOR 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 | Change Name Of: (Circle One) Contingent Insured Owner Payor Beneficiary
|
Complete this section if | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
the name of one of the |
Contingent Insureds, | _________________________________________ _________________________________________________
Owner, Payor or Beneficiary|
has changed. (Please note,|
this does not change the | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
Contingent Insureds, |
Owner, Payor or
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 frequency 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 |
AGL 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 AGL for cancellation.
AGL 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 |
($5,000 minimum initial | Frequency of transfers (check one): _______Monthly _______Quarterly ______Semi-Annually _____Annually
accumulation value) An |
amount may be deducted | I want: $___________($100 minimum) taken from the Money Market Division and transferred to the
periodically from the | following Divisions:
Money Market Division and |
placed in one or more of | AIM Variable Insurance Funds, Inc. Xxxxxx Xxxxxxx Xxxx Xxxxxx Universal Funds, Inc.
the Divisions listed. The | $_________(1) AIM V.I. International Equity $________(10) Equity Growth
Declared Fixed Interest | $_________(2) AIM V.I. Value $________(11) High Yield
Account is not available | American General Series Portfolio Company Xxxxxx Variable Trust
for Dollar Cost Averaging.| $_________(3) International Equities $________(12) Xxxxxx VT Diversified Income
Please refer to the pros- | $_________(4) MidCap Index $________(13) Xxxxxx VT Growth and Income
pectus for more infor- | $_________(6) Stock Index $________(14) Xxxxxx VT Int'l Growth & Income
mation on the Dollar Cost | Dreyfus Variable Investment Fund SAFECO Resource Series Trust
Averaging Option. | $_________(7) Quality Bond $________(15) Equity
Note: Automatic | $_________(8) Small Cap $________(16) Growth
Rebalancing is not | MFS Variable Insurance Trust Xxx Xxxxxx Life Investment Trust
available if the Dollar | $_________(9) MFS Emerging Growth $________(17) Strategic Stock
Cost Averaging Option is |
chosen. | ________INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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[ ] TELEPHONE 6.| I (/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values among
PRIVILEGE | the Variable Divisions and Declared Fixed Interest Account and to change allocations for future
AUTHORIZATION | purchase payments and monthly deductions.
|
Complete this section if | Initial the designation you prefer:
you are applying for or |
revoking current telephone| __________Policy Owner(s) only--If Joint Owners, either one acting independently.
privileges. | __________Policy Owner(s) and 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 7.|
| Name of Contingent 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 8.| (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. The minimum |
amount for transfers is | Transfer $________ or ______% from_______________________________to__________________________________
$500.00. Withdrawals |
from the Declared Fixed | Transfer $________ or ______% from_______________________________to__________________________________
Interest Account to a |
Variable Division may only | Transfer $________ or ______% from_______________________________to__________________________________
be made within 60 days |
after a contract anniver- | Transfer $________ or ______% from_______________________________to__________________________________
sary. See transfer limit- |
ations outlined in pros- | Transfer $________ or ______% from_______________________________to__________________________________
pectus. If a transfer |
causes the balance in any | Transfer $________ or ______% from_______________________________to__________________________________
division to drop below |
$500, AGL reserves the | Transfer $________ or ______% from_______________________________to__________________________________
right to transfer the |
remaining balance. | Transfer $________ or ______% from_______________________________to__________________________________
Amounts to be transferred |
should be indicated in |
dollar or percentage |
amounts, maintaining |
consistency throughout. |
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[ ] CHANGE IN 9.| INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED %
ALLOCATION |
PERCENTAGES | AIM Variable Insurance Funds, Inc. Xxxxxx Xxxxxxx Xxxx Xxxxxx
| (1) AIM V.I. Int'l Equity ______ ______ Universal Funds, Inc.
Use this section to | (2) AIM V.I. Value ______ ______ (10) Equity Growth ______ ______
indicate how premiums or | (11) High Yield ______ ______
monthly deductions are to | American General Series Portfolio Co.
be allocated. Total | (3) International Equities ______ ______ Xxxxxx Variable Trust
allocation in each | (4) MidCap Index ______ ______ (12) Xxxxxx VT Diversified
column must equal 100%; | (5) Money Market ______ ______ Income ______ ______
whole numbers only | (6) Stock Index ______ ______ (13) Xxxxxx VT Growth
| and Income ______ ______
| Dreyfus Variable Investment Fund (14) Xxxxxx VT Int'l
| (7) Quality Bond ______ ______ Growth and Income ______ ______
| (8) Small Cap ______ ______
| SAFECO Resources Series Trust
| MFS Variable Insurance Trust (15) Equity ______ ______
| (9) MFS Emerging Growth ______ ______ (16) Growth ______ ______
|
| Xxx Xxxxxx Life Investment
| Trust
| (17) Strategic Stock ______ ______
| (18) Declared Fixed ______ ______
| Interest Account ______ ______
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PAGE 3 OF 4
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|
[ ] AUTOMATIC 10.| 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. Note: Dollar Cost | %_________:________________________________________ %_________:____________________________________
Averaging is not available |
if the Automatic |
Rebalancing Option is | _________INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
chosen. |
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[ ] REQUEST FOR 11.| _________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 Declared Fixed Interest
policy values. For detailed| 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 12.| 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 11. | 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/ 13.| 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.
|
| The Internal Revenue Service does not require your consent to any provision of this document other
Complete this section for | than the certification required to avoid backup withholding.
ALL requests. |
|
| 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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AGLC0094 1099 PAGE 4 OF 4