EX-10.D 15 dex10d.txt SERVICE REQUEST FORM EXHIBIT (10)(d) SERVICE REQUEST PLATINUM --------------------------- INVESTOR(SM) SURVIVOR II --------------------------- AMERICAN GENERAL LIFE -------------------------------------------------------------------------------------------------------------------- PLATINUM INVESTOR--FIXED OPTION Neuberger Berman Advisers Management Trust ------------------------------------------ . Division 18 - Declared Fixed Interest Account . Division 167 - Mid-Cap Growth PLATINUM INVESTOR--VARIABLE DIVISIONS North American Funds Variable Product Series I AIM Variable Insurance Funds ---------------------------------------------- ---------------------------- . Division 132 - International Equities . Division 130 - AIM V.I. International Equity . Division 133 - MidCap Index . Division 131 - AIM V.I. Value . Division 134 - Money Market American Century Variable Portfolios, Inc. ------------------------------------------ . Division 135 - Stock Index . Division 153 - VP Value . Division 136 - Nasdaq-100 Index Ayco Series Trust . Division 137 - Science and Technology ----------------- . Division 138 - Small Cap Index . Division 154 - Ayco Growth Fund PIMCO Variable Insurance Trust Credit Suisse Warburg Pincus Trust ------------------------------ ---------------------------------- . Division 168 - PIMCO Short-Term Bond . Division 173 - Small Company Growth . Division 169 - PIMCO Real Return Bond Dreyfus Investment Portfolios ----------------------------- . Division 170 - PIMCO Total Return Bond . Division 155 - MidCap Stock Putnam Variable Trust --------------------- Dreyfus Variable Investment Fund -------------------------------- . Division 144 - Putnam VT Diversified Income . Division 139 - Quality Bond . Division 145 - Putnam VT Growth and Income . Division 140 - Small Cap . Division 146 - Putnam VT International Growth and Income Fidelity Variable Insurance Products Fund SAFECO Resource Series Trust ----------------------------------------- ---------------------------- . Division 156 - VIP Equity-Income . Division 147 - Equity . Division 157 - VIP Growth . Division 148 - Growth Opportunities . Division 158 - VIP Contrafund The Universal Institutional Funds, Inc. --------------------------------------- . Division 159 - VIP Asset Manager . Division 142 - Equity Growth Janus Aspen Series - Service Shares ----------------------------------- . Division 143 - High Yield . Division 160 - International Growth Vanguard Variable Insurance Fund -------------------------------- . Division 161 - Worldwide Growth . Division 171 - High Yield Bond . Division 162 - Aggressive Growth . Division 172 - REIT Index J.P. Morgan Series Trust II --------------------------- Van Kampen Life Investment Trust -------------------------------- . Division 163 - J.P. Morgan Small Company . Division 149 - Strategic Stock MFS Variable Insurance Trust ---------------------------- . Division 141 - MFS Emerging Growth . Division 164 - MFS Research . Division 165 - MFS Capital Opportunities . Division 166 - MFS New Discovery AGLC0463
AMERICAN American General Life Insurance Company ("AGL") Complete and return this request to: GENERAL Member American General Financial Group Variable Universal Life Operations FINANCIAL GROUP Houston, Texas PO Box 4880 Houston, TX 77210-4880 (888) 325-9315 or (713) 831-3443 Fax: (877) 445-3098 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST Hearing Impaired/TDD: (888) 436-5258 ------------------------------------------------------------------------------------------------------------------------------------ [_] 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) ----------------------------------------------------------------------------------------------------------------------------------- [_] 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) | ------------------------------------------------------------------------------------------------------------------------------------ [_] CHANGE IN 3. | INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED % ALLOCATION | (18) Declared Fixed Interest Neuberger Berman Advisers Management Trust PERCENTAGES | Account ______ ______ (167) Mid-Cap Growth ______ ______ Use this section to indicate | AIM Variable Insurance Funds how premiums or monthly | (130) AIM V.I. International North American Funds Variable Product Series I deductions are to be allocated. | Equity ______ ______ (132) International Equities ______ ______ Total allocation in each column | (131) AIM V.I. Value ______ ______ (133) MidCap Index ______ ______ must equal 100%; whole | (134) Money Market ______ ______ numbers only. | American Century Variable Portfolios (135) Stock Index ______ ______ | (153) VP Value ______ ______ (136) Nasdaq-100 Index ______ ______ | (137) Science and Technology ______ ______ | Ayco Series Trust (138) Small Cap Index ______ ______ | (154) Ayco Growth Fund ______ ______ | PIMCO Variable Insurance Trust | Credit Suisse Warburg Pincus Trust (168) PIMCO Short-Term Bond ______ ______ | (173) Small Company Growth ______ ______ (169) PIMCO Real Return Bond ______ ______ | (170) PIMCO Total Return Bond ______ ______ | Dreyfus Investment Portfolios | (155) Midcap Stock ______ ______ Putnam Variable Trust | (144) Putnam VT Diversified | Dreyfus Variable Investment Fund Income ______ ______ | (139) Quality Bond ______ ______ (145) Putnam VT Growth and | (140) Small Cap ______ ______ Income ______ ______ | (146) Putnam VT Int'l Growth and | Fidelity Variable Insurance Products Fund Income ______ ______ | (156) VIP Equity-Income ______ ______ | (157) VIP Growth ______ ______ SAFECO Resource Series Trust | (158) VIP Contrafund ______ ______ (147) Equity ______ ______ | (159) VIP Asset Manager ______ ______ (148) Growth Opportunities ______ ______ | | Janus Aspen Series - Service Shares The Universal Institutional Funds, Inc. | (160) International Growth ______ ______ (142) Equity Growth ______ ______ | (161) Worldwide Growth ______ ______ (143) High Yield ______ ______ | (162) Aggressive Growth ______ ______ | Vanguard Variable Insurance Fund | J.P. Morgan Series Trust II (171) High Yield Bond ______ ______ | (163) J.P. Morgan Small Company ______ ______ (172) REIT Index ______ ______ | | MFS Variable Insurance Trust Van Kampen Life Investment Trust | (141) MFS Emerging Growth ______ ______ (149) Strategic Stock ______ ______ | (164) MFS Research ______ ______ | (165) MFS Capital Opportunities ______ ______ Other:_______________________ ______ ______ | (166) MFS New Discovery ______ ______ 100% 100% ------------------------------------------------------------------------------------------------------------------------------------ AGLC0463 PAGE 2 OF 5
------------------------------------------------------------------------------------------------------------------------------------ [_] 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 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. | ----------------------------------------------------------------------------------------------------------------------------------- [_] 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. ------------------------------------------------------------------------------------------------------------------------------------ [_] 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 to accumulation value) An amount may | the following Divisions: be deducted periodically from the | Money Market Division and placed | (18) Declared Fixed Interest Account ____ ____ Neuberger Berman Advisers Management Trust in one or more of the Divisions | (167) Mid-Cap Growth ____ ____ listed. The Declared Fixed | AIM Variable Insurance Funds North American Funds Variable Product Series I Interest Account is not available | (130) AIM V.I. International Equity ____ ____ (132) International Equities ____ ____ for Dollar Cost Averaging. Please | (131) AIM V.I. Value ____ ____ (133) Midcap Index ____ ____ refer to the prospectus for more | (134) Money Market ____ ____ information on the Dollar Cost | American Century Variable Portfolios (135) Stock Index ____ ____ Averaging Option. Note: Automatic | (153) VP Value ____ ____ (136) Nasdaq-100 Index ____ ____ Rebalancing is not available if | (137) Science & Technology ____ ____ the Dollar Cost Averaging Option | Ayco Series Trust (138) Small Cap Index ____ ____ is chosen. | (154) Ayco Growth Fund ____ ____ | PIMCO Variable Insurance Trust | Credit Suisse Warburg Pincus Trust (168) PIMCO Short-Term Bond ____ ____ | (173) Small Company Growth ____ ____ (169) PIMCO Real Return Bond ____ ____ | (170) PIMCO Total Return Bond ____ ____ | Dreyfus Investment Portfolios | (155) Midcap Stock ____ ____ Putnam Variable Trust | (144) Putnam VT Diversified Income ____ ____ | Dreyfus Variable Investment Fund (145) Putnam VT Growth and Income ____ ____ | (139) Quality Bond ____ ____ (146) Putnam VT Int'l Growth and Income____ ____ | (140) Small Cap ____ ____ | SAFECO Resource Series Trust | Fidelity Variable Insurance Products Fund (147) Equity ____ ____ | (156) VIP Equity-Income ____ ____ (148) Growth Opportunities ____ ____ | (157) VIP Growth ____ ____ | (158) VIP Contrafund ____ ____ The Universal Institutional Funds, Inc. | (159) VIP Asset Manager ____ ____ (142) Equity Growth ____ ____ | (143) High Yield ____ ____ | Janus Aspen Series - Service Shares | (160) International Growth ____ ____ Vanguard Variable Insurance Fund | (161) Worldwide Growth ____ ____ (171) High Yield Bond ____ ____ | (162) Aggressive Growth ____ ____ (172) REIT Index ____ ____ | | J.P. Morgan Series Trust II Van Kampen Life Investment Trust | (163) J.P. Morgan Small Company ____ ____ (149) Strategic Stock ____ ____ | Other ____ ____ | MFS Variable Insurance Trust 100% 100% | (141) MFS Emerging Growth ____ ____ | (164) MFS Research ____ ____ | (165) MFS Capital Opportunities ____ ____ | (166) MFS New Discovery ____ ____ | | _____ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION. ------------------------------------------------------------------------------------------------------------------------------------ AGLC0463 PAGE 3 OF 5
------------------------------------------------------------------------------------------------------------------------------------ [_] 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. | _______% : ___________________________________ _______% : ________________________________ | _______% : ___________________________________ _______% : ________________________________ | _______% : ___________________________________ _______% : ________________________________ | | | ________ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION. ----------------------------------------------------------------------------------------------------------------------------------- [_] TELEPHONE 8. | I(/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values PRIVILEGE | among the Variable Divisions and Declared Fixed Interest Account and to change allocations for AUTHORIZATION | 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. ------------------------------------------------------------------------------------------------------------------------------------ [_] CORRECT AGE 9. | Name of Contingent Insured for whom this correction is submitted:_______________________________ Use this section to correct the | age of any person covered under | this policy. Proof of the correct | Correct DOB: _________/____________ /_____________ date of birth must accompany this | request. | ------------------------------------------------------------------------------------------------------------------------------------ [_] 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 _____________________________ 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, AGL 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 _____________________________ ------------------------------------------------------------------------------------------------------------------------------------ AGLC0463 PAGE 4 OF 5
------------------------------------------------------------------------------------------------------------------------------------ [_] REQUEST FOR 11. | 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. | ________________________________________________________________________________________________ | ------------------------------------------------------------------------------------------------------------------------------------ [_] 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). ------------------------------------------------------------------------------------------------------------------------------------ [_] AFFIRMATION/ 10. | 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 | ------------------------------------------------------------------------------------------------------------------------------------ AGLC0463 PAGE 5 OF 5