EX-10.(E) 5 dex10e.txt AMENDED SERVICE REQUEST EXHIBIT (10)(e) SERVICE REQUEST PLATINUM --------------------------- INVESTOR/SM/ --------------------------- AMERICAN GENERAL LIFE -------------------------------------------------------------------------------------------------------------------- PLATINUM INVESTOR--FIXED OPTION MFS Variable Insurance Trust ---------------------------- . Division 125--AGL Declared Fixed Interest Account . Division 239 - MFS Capital Opportunities PLATINUM INVESTOR--VARIABLE DIVISIONS . Division 134 - MFS Emerging Growth AIM Variable Insurance Funds ---------------------------- . Division 240 - MFS New Discovery . Division 126 - AIM V.I. International Equity . Division 238 - MFS Research . Division 127 - AIM V.I. Value Neuberger Berman Advisers Management Trust ------------------------------------------ American Century Variable Portfolios, Inc. ------------------------------------------ . Division 241 - Mid-Cap Growth . Division 224 - VP Value PIMCO Variable Insurance Trust ------------------------------ Ayco Series Trust ----------------- . Division 243 - PIMCO Real Return Bond . Division 228 - Ayco Growth . Division 242 - PIMCO Short-Term Bond Credit Suisse Warburg Pincus Trust . Division 244 - PIMCO Total Return Bond ---------------------------------- Putnam Variable Trust . Division 247 - Small Company Growth --------------------- Dreyfus Investment Portfolios . Division 137 - Putnam VT Diversified Income ----------------------------- . Division 138 - Putnam VT Growth and Income . Division 229 - MidCap Stock . Division 139 - Putnam VT Int'l Growth and Income Dreyfus Variable Investment Fund -------------------------------- SAFECO Resource Series Trust ---------------------------- . Division 132 - Quality Bond . Division 140 - Equity . Division 133 - Small Cap . Division 141 - Growth Opportunities Fidelity Variable Insurance Products Fund ----------------------------------------- The Universal Institutional Funds, Inc. --------------------------------------- . Division 233 - VIP Asset Manager . Division 135 - Equity Growth . Division 232 - VIP Contrafund . Division 136 - High Yield . Division 230 - VIP Equity-Income VALIC Company I . Division 231 - VIP Growth --------------- Franklin Templeton Variable Insurance Products Trust . Division 128 - International Equities ---------------------------------------------------- . Division 129 - Mid Cap Index . Division 248 - Franklin U.S. Government . Division 130 - Money Market I . Division 249 - Mutual Shares Securities . Division 225 - Nasdaq-100 Index . Division 250 - Templeton International Securities . Division 227 - Science & Technology Janus Aspen Series ------------------ . Division 226 - Small Cap Index . Division 236 - Aggressive Growth . Division 131 - Stock Index . Division 234 - International Growth Vanguard Variable Insurance Fund ------------------------------- . Division 235 - Worldwide Growth . Division 245 - High Yield Bond J.P. Morgan Series Trust II --------------------------- . Division 246 - REIT Index . Division 237 - J.P. Morgan Small Company Van Kampen Life Investment Trust -------------------------------- . Division 142 - Strategic Stock L 8993 REV 1101
Complete and return this request to: American General Life Insurance Company ("AGL") AMERICAN Variable Universal Life Operations Member American General Financial Group GENERAL Houston, Texas FINANCIAL GROUP PO Box 4880 Houston, TX 77210-4880 (888) 325-9315 or Hearing Impaired (TDD): (888) 436-5258 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST Toll-Free Fax: (877) 445-3098 ------------------------------------------------------------------------------------------------------------------------------------ [_] POLICY 1. | POLICY #:_________________________________ INSURED:_____________________________________________ IDENTIFICATION | ADDRESS:________________________________________________________________ New Address (yes) (no) | Primary Owner (if other than an insured):_______________________________ COMPLETE THIS SECTION FOR | Address:________________________________________________________________ New Address (yes) (no) ALL REQUESTS. | 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) Insured Owner Payor Beneficiary CHANGE | Complete this section if the | Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last) name of the Insured, Owner, | Payor or Beneficiary has | __________________________________________________ __________________________________________ changed. (Please note, this does | not change the Insured, Owner, |Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof) Payor or Beneficiary designation) | ------------------------------------------------------------------------------------------------------------------------------------ [_] CHANGE IN 3. | INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED % ALLOCATION | (125) AGL Declared Fixed Interest MFS VARIABLE INSURANCE TRUST PERCENTAGES | Account ____% ____% (239) MFS Capital Opportunities ____% ____% Use this section to indicate | AIM VARIABLE INSURANCE FUNDS (134) MFS Emerging Growth ____% ____% how premiums or monthly | (126) AIM V.I. International Equity ____% ____% (240) MFS New Discovery ____% ____% deductions are to be allocated. | (127) AIM V.I. Value ____% ____% (238) MFS Research ____% ____% Total allocation in each column | must equal 100%; whole | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST numbers only. | (224) VP Value ____% ____% (241) Mid-Cap Growth ____% ____% | | AYCO SERIES TRUST PIMCO VARIABLE INSURANCE TRUST | (228) Ayco Growth ____% ____% (243) PIMCO Real Return Bond ____% ____% | (242) PIMCO Short-Term Bond ____% ____% | CREDIT SUISSE WARBURG PINCUS TRUST (244) PIMCO Total Return Bond ____% ____% | (247) Small Company Growth ____% ____% | PUTNAM VARIABLE TRUST | DREYFUS INVESTMENT PORTFOLIOS (137) Putnam VT Diversified Income ____% ____% | (229) MidCap Stock ____% ____% (138) Putnam VT Growth and Income ____% ____% | (139) Putnam VT Int'l Growth and | DREYFUS VARIABLE INVESTMENT FUND Income ____% ____% | (132) Quality Bond ____% ____% | (133) Small Cap ____% ____% SAFECO RESOURCE SERIES TRUST | (140) Equity ____% ____% | FIDELITY VARIABLE INSURANCE PRODUCTS FUND (141) Growth Opportunities ____% ____% | (233) VIP Asset Manager ____% ____% | (232) VIP Contrafund ____% ____% THE UNIVERSAL INSTITUTIONAL FUNDS, INC. | (230) VIP Equity-Income ____% ____% (135) Equity Growth ____% ____% | (231) VIP Growth ____% ____% (136) High Yield ____% ____% | | FRANKLIN TEMPLETON VARIABLE INSURANCE VALIC COMPANY I | PRODUCTS TRUST (128) International Equities ____% ____% | (248) Franklin U.S. Government ____% ____% (129) Mid Cap Index ____% ____% | (249) Mutual Shares Securities ____% ____% (130) Money Market I ____% ____% | (250) Templeton International ____% ____% (225) Nasdaq-100 Index ____% ____% | Securities (227) Science & Technology ____% ____% | (226) Small Cap Index ____% ____% | JANUS ASPEN SERIES (131) Stock Index ____% ____% | (236) Aggressive Growth ____% ____% | (234) International Growth ____% ____% VANGUARD VARIABLE INSURANCE FUND | (235) Worldwide Growth ____% ____% (245) High Yield Bond ____% ____% | (246) REIT Index ____% ____% | J.P MORGAN SERIES TRUST II | (237) J.P Morgan Small Company ____% ____% VAN KAMPEN LIFE INVESTMENT TRUST | (142) Strategic Stock ____% ____% | | OTHER:_______________________ ____% ____% | 100% 100% ------------------------------------------------------------------------------------------------------------------------------------ L 8993 REV 1101 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" billing frequency and/or method | Check) 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, whole dollars only) taken from the Money Market I accumulation value) An amount may | Division and transferred to the following Divisions: be deducted periodically from the | Money Market I Division and placed| AIM VARIABLE INSURANCE FUNDS NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST in one or more of the Divisions | (126) AIM V.I. International Equity $________ (241) Mid-Cap Growth $________ listed. The AGL Declared Fixed | (127) AIM V.I. Value $________ Interest Account is not available | PIMCO VARIABLE INSURANCE TRUST for Dollar Cost Averaging. Please | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. (243) PIMCO Real Return Bond $________ refer to the prospectus for more | (224) VP Value $________ (242) PIMCO Short-Term Bond $________ information on the Dollar Cost | (244) PIMCO Total Return Bond $________ Averaging Option. | AYCO SERIES TRUST | (228) Ayco Growth $________ PUTNAM VARIABLE TRUST | (137) Putnam VT Diversified Income $________ | CREDIT SUISSE WARBURG PINCUS TRUST (138) Putnam VT Growth and Income $________ | (247) Small Company Growth $________ (139) Putnam VT Int'l Growth and | Income $________ | DREYFUS INVESTMENT PORTFOLIOS | (229) MidCap Stock $________ SAFECO RESOURCE SERIES TRUST | (140) Equity $________ | DREYFUS VARIABLE INVESTMENT FUND (141) Growth Opportunities $________ | (132) Quality Bond $________ | (133) Small Cap $________ THE UNIVERSAL INSTITUTIONAL FUNDS, INC. | (135) Equity Growth $________ | FIDELITY VARIABLE INSURANCE PRODUCTS FUND (136) High Yield $________ | (233) VIP Asset Manager $________ | (232) VIP Contrafund $________ VALIC COMPANY I | (230) VIP Equity-Income $________ (128) International Equities $________ | (231) VIP Growth $________ (129) Mid Cap Index $________ | (225) Nasdaq-100 Index $________ | FRANKLIN TEMPLETON VARIABLE INSURANCE (227) Science & Technology $________ | PRODUCTS TRUST (226) Small Cap Index $________ | (248) Franklin U.S. Government $________ (131) Stock Index $________ | (249) Mutual Shares Securities $________ | (250) Templeton International VANGUARD VARIABLE INSURANCE FUND | Securities $________ (245) High Yield Bond $________ | (246) REIT Index $________ | JANUS ASPEN SERIES | (236) Aggressive Growth $________ VAN KAMPEN LIFE INVESTMENT TRUST | (234) International Growth $________ (142) Strategic Stock $________ | (235) Worldwide Growth $________ OTHER: ___________________________ $________ | | J.P. MORGAN SERIES TRUST II | (237) J.P. Morgan Small Company $________ | | MFS VARIABLE INSURANCE TRUST | (239) MFS Capital Opportunities $________ | (134) MFS Emerging Growth $________ | (240) MFS New Discovery $________ | (238) MFS Research $________ | ------------------------------------------------------------------------------------------------------------------------------------ L 8993 REV 1101 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. | _______% : ___________________________________ _______% : ________________________________ This option is not available | _______% : ___________________________________ _______% : ________________________________ while the Dollar Cost | _______% : ___________________________________ _______% : ________________________________ Averaging Option is in use. | _______% : ___________________________________ _______% : ________________________________ | _______% : ___________________________________ _______% : ________________________________ | _______% : ___________________________________ _______% : ________________________________ | | | ________ 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 AGL Declared Fixed Interest Account and to change allocations AUTHORIZATION | for 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) AND Agent/Registered Representative who is appointed to represent AGL | and the firm authorized to service my policy. | | AGL and any person 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 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 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 _____________________________ Withdrawals from the AGL | Declared Fixed Interest Account | Transfer $_______ or _______% from ____________________________ to _____________________________ are limited to 60 days after | the policy anniversary and to | Transfer $_______ or _______% from ____________________________ to _____________________________ no more than 25% of the total | unloaned value of the AGL | Transfer $_______ or _______% from ____________________________ to _____________________________ Declared Fixed Interest Account | on the policy anniversary. | Transfer $_______ or _______% from ____________________________ to _____________________________ If a transfer causes the balance | in any division to drop below | Transfer $_______ or _______% from ____________________________ to _____________________________ $500, AGL reserves the right | to transfer the remaining | Transfer $_______ or _______% from ____________________________ to _____________________________ balance. Amounts to be | transferred should be indicated | Transfer $_______ or _______% from ____________________________ to _____________________________ in dollar or percentage amounts, | maintaining consistency | Transfer $_______ or _______% from ____________________________ to _____________________________ throughout. | ------------------------------------------------------------------------------------------------------------------------------------ L 8993 REV 1101 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 AGL Declared these two options please refer to | Fixed 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/ 13. | 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______________________________________,__________ | (City, State) | 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 | ------------------------------------------------------------------------------------------------------------------------------------ L 8993 REV 1101 PAGE 5 OF 5