EX-99.(E)(5) 5 dex99e5.txt FORM OF SERVICE REQUEST FORM EXHIBIT (e)(5) SERVICE REQUEST AIG INCOME ADVANTAGE VUL(SM) AMERICAN GENERAL LIFE AIG Income Advantage VUL(SM) - Fixed Option MFS Variable Insurance Trust . Division 301 - AGL Declared Fixed Interest Account . Division 722/770-G - MFS VIT New Discovery . Division 723/771-G - MFS VIT Research AIG Income Advantage VUL(SM) - Variable Divisions Neuberger Berman Advisers Management Trust AIM Variable Insurance Funds . Division 724/772-G - AMT Socially Responsive . Division 700/748-G - AIM V.I. International Growth . Division 725/773-G - AMT Mid-Cap Growth . Division 701/749-G - AIM V.I. Global Real Estate Oppenheimer Variable Account Funds The Alger American Fund . Division 726/774-G - Oppenheimer Balanced . Division 702/750-G - Alger American Leveraged AllCap . Division 727/775-G - Oppenheimer Global Securities . Division 703/751-G - Alger American MidCap Growth PIMCO Variable Insurance Trust American Century Variable Portfolios, Inc. . Division 728/776-G - PIMCO VIT . Division 704/752-G - VP Value CommodityRealReturnStrategy Credit Suisse Trust . Division 729/777-G - PIMCO VIT Real Return . Division 705/753-G - Small Cap Core I . Division 730/778-G - PIMCO VIT Short-Term . Division 731/779-G - PIMCO VIT Total Return Dreyfus Variable Investment Fund . Division 732/780-G - PIMCO VIT Global Bond . Division 706/754-G - Dreyfus VIF International Value Pioneer Variable Contracts Trust Fidelity Variable Insurance Products . Division 733/781-G - Pioneer Mid Cap Value VCT . Division 707/755-G - VIP Asset Manager Putnam Variable Trust . Division 708/756-G - VIP Contrafund . Division 734/782-G - Putnam VT Diversified Income . Division 709/757-G - VIP Equity-Income . Division 735/783-G - Putnam VT Small Cap Value . Division 710/758-G - VIP Freedom 2020 . Division 711/759-G - VIP Freedom 2025 SunAmerica Series Trust . Division 712/760-G - VIP Freedom 2030 . Division 736/784-G - ST Aggressive Growth . Division 713/761-G - VIP Growth . Division 737/785-G - ST Balanced . Division 714/762-G - VIP Mid Cap VALIC COMPANY I Franklin Templeton Variable Insurance Products Trust . Division 738/786-G - International Equities . Division 715/763-G - VIP Franklin Small Cap . Division 739/787-G - Mid Cap Index Value Securities . Division 740/788-G - Money Market I . Division 716/764-G - VIP Mutual Shares Securities . Division 741/789-G - Nasdaq-100(R) Index . Division 742/790-G - Science and Technology Janus Aspen Series . Division 743/791-G - Small Cap Index . Division 717/765-G - Forty . Division 744/792-G - Stock Index . Division 718/766-G - International Growth . Division 719/767-G - Mid Cap Growth Van Kampen Life Investment Trust . Division 745/793-G - Van Kampen LIT Growth JP Morgan Asset Management and Income . Division 720/768-G - JP Morgan Insurance Trust Government Bond Vanguard Variable Insurance Fund . Division 721/769-G - JP Morgan Series Trust II . Division 746/794-G - Vanguard High Yield Bond International Equity . Division 747/795-G - Vanguard REIT Index
AGLC102769 Rev0907 [LOGO] AIG American General Variable Universal Life Insurance Service Request Complete and return this request to: Variable Universal Life Operations American General Life Insurance Company ("AGL") PO Box 4880 . Houston, TX. 77210-4880 A member company of American International Group Inc. (800) 340-2765 or Hearing Impaired (TDD) (888) 436-5258 . Fax: (713) 620-6653 ------------------------------------------------------------------------------------------------------------------------------------ [ ] POLICY 1. POLICY #: _________________________________________ INSURED: _______________________________________ IDENTIFICATION 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) ------------------------------------------------------------------------------------------------------------------------------------ [ ] NAME CHANGE 2. Change Name Of: (Circle One) 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 Insured, 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 Insured, Owner, Payor or Beneficiary designation). ------------------------------------------------------------------------------------------------------------------------------------ [ ] CHANGE IN ALLOCATION 3. INVESTMENT DIVISION PREM % DED % PERCENTAGES (301) AGL Declared Fixed Interest Account ______ ______ Use this section to indicate how premiums or AIM Variable Insurance Funds monthly deductions are to (700/748-G) AIM V.I. International Growth* ______ ______ be allocated. Total (701/749-G) AIM V.I. Global Real Estate* ______ ______ allocation in each column must equal 100%; whole The Alger American Fund numbers only. (702/750-G) Alger American Leveraged AllCap ______ ______ (703/751-G) Alger American MidCap Growth ______ ______ American Century Variable Portfolios, Inc. (704/752-G) VP Value ______ ______ Credit Suisse Trust (705/753-G) Small Cap Core I* ______ ______ Dreyfus Variable Investment Fund (706/754-G) Dreyfus VIF International Value* ______ ______ Fidelity Variable Insurance Products (707/755-G) VIP Asset Manager ______ ______ (708/756-G) VIP Contrafund ______ ______ (709/757-G) VIP Equity-Income ______ ______ (710/758-G) VIP Freedom 2020 ______ ______ (711/759-G) VIP Freedom 2025 ______ ______ (712/760-G) VIP Freedom 2030 ______ ______ (713/761-G) VIP Growth ______ ______ (714/762-G) VIP Mid Cap ______ ______ Franklin Templeton Variable Insurance Products Trust (715/763-G) VIP Franklin Small Cap Value Securities* ______ ______ (716/764-G) VIP Mutual Shares Securities ______ ______ Janus Aspen Series (717/765-G) Forty ______ ______ (718/766-G) International Growth* ______ ______ (719/767-G) Mid Cap Growth ______ ______ JP Morgan Asset Management (720/768-G) JP Morgan Insurance Trust Government Bond ______ ______ (721/769-G) JP Morgan Series Trust II International Equity* ______ ______ MFS Variable Insurance Trust (722/770-G) MFS VIT New Discovery ______ ______ (723/771-G) MFS VIT Research ______ ______ Neuberger Berman Advisers Management Trust (724/772-G) AMT Socially Responsive ______ ______ (725/773-G) AMT Mid-Cap Growth ______ ______ Oppenheimer Variable Account Funds (726/774-G) Oppenheimer Balanced ______ ______ (727/775-G) Oppenheimer Global Securities* ______ ______ PIMCO Variable Insurance Trust (728/776-G) PIMCO VIT CommodityRealReturnStrategy* ______ ______ (729/777-G) PIMCO VIT Real Return ______ ______ (730/778-G) PIMCO VIT Short-Term ______ ______ (731/779-G) PIMCO VIT Total Return ______ ______ (732/780-G) PIMCO VIT Global Bond ______ ______ Pioneer Variable Contracts Trust (733/781-G) Pioneer Mid Cap Value VCT ______ ______ Putnam Variable Trust (734/782-G) Putnam VT Diversified Income ______ ______ (735/783-G) Putnam VT Small Cap Value* ______ ______ SunAmerica Series Trust (736/784-G) ST Aggressive Growth ______ ______ (737/785-G) ST Balanced ______ ______ VALIC Company I (738/786-G) International Equities* ______ ______ (739/787-G) Mid Cap Index ______ ______ (740/788-G) Money Market I ______ ______ (741/789-G) Nasdaq-100(R) Index ______ ______ (742/790-G) Science and Technology ______ ______ (743/791-G) Small Cap Index* ______ ______ (744/792-G) Stock Index ______ ______ Van Kampen Life Investment Trust (745/793-G) Van Kampen LIT Growth and Income ______ ______ Vanguard Variable Insurance Fund (746/794-G) Vanguard High Yield Bond ______ ______ (747/795-G) Vanguard REIT Index ______ ______ Other:_______________________ ______ ______ 100% 100% * If you have the Guaranteed Minimum Withdrawal Benefit (GMWB) Rider this investment option is designated as a Restricted Fund. ------------------------------------------------------------------------------------------------------------------------------------
AGLC102769 Page 2 of 5 Rev0907 ------------------------------------------------------------------------------------------------------------------------------------ [ ] MODE OF PREMIUM 4. Indicate frequency and premium amount desired: $_______ Annual $_______ Semi-Annual $______ Quarterly PAYMENT/BILLING METHOD CHANGE $_________ Monthly (Bank Draft Only) Use this section to Indicate billing method desired: ______ Direct Bill ______ Pre-Authorized Bank Draft change the billing (attach a Bank Draft Authorization Form frequency and/or method and "Void" Check) of premium payment. Note, however, that AGL will Start Date: ______/ ______/ ______ not bill 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 ________ LOST _______ CERTIFICATE 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 ______ Certificate of Insurance at no charge or duplicate policy to replace a lost or ______ Full duplicate policy at a charge of $25 misplaced policy. If a full duplicate policy is be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate being requested, a check policy to AGL for cancellation. or money order for $25 payable to AGL must be submitted with this request. ------------------------------------------------------------------------------------------------------------------------------------ [ ] DOLLAR COST 6. Day of the month for transfers ________ (Chose a day of the month between 1-28) AVERAGING (DCA) Frequency of transfers: _______ Monthly _______ Quarterly _______ Semi-Annually _______ Annually ($5,000 MINIMUM DCA to be made from the following investment option: __________________________________________ BEGINNING ACCUMULATION Transfer: $__________________________ ($100 minimum, whole dollars only) VALUE) (301) AGL Declared Fixed Interest Account $ __________ An amount can be systematically AIM Variable Insurance Funds transferred from any one (700) AIM V.I. International Growth* $ __________ investment option and (701) AIM V.I. Global Real Estate* $ __________ directed to one or more of the investment options The Alger American Fund below. The AGL Declared (702) Alger American Leveraged AllCap $ __________ Fixed Interest Account is (703) Alger American MidCap Growth $ __________ not available for DCA. Please refer to the American Century Variable Portfolios, Inc. prospectus for more (704) VP Value $ __________ information on the DCA option. Credit Suisse Trust (705) Small Cap Core I* $ __________ NOTE: DCA is not available if the Dreyfus Variable Investment Fund Automatic Rebalancing (706) Dreyfus VIF International Value* $ __________ option or GMWB rider have been chosen. Fidelity Variable Insurance Products (707) VIP Asset Manager $ __________ (708) VIP Contrafund $ __________ (709) VIP Equity-Income $ __________ (710) VIP Freedom 2020 $ __________ (711) VIP Freedom 2025 $ __________ (712) VIP Freedom 2030 $ __________ (713) VIP Growth $ __________ (714) VIP Mid Cap $ __________ Franklin Templeton Variable Insurance Products Trust (715) VIP Franklin Small Cap Value Securities* $ __________ (716) VIP Mutual Shares Securities $ __________ Janus Aspen Series (717) Forty $ __________ (718) International Growth* $ __________ (719) Mid Cap Growth $ __________ JP Morgan Asset Management (720) JP Morgan Insurance Trust Government Bond $ __________ (721) JP Morgan Series Trust II International Equity* $ __________ MFS Variable Insurance Trust (722) MFS VIT New Discovery $ __________ (723) MFS VIT Research $ __________ Neuberger Berman Advisers Management Trust (724) AMT Socially Responsive $ __________ (725) AMT Mid-Cap Growth $ __________ Oppenheimer Variable Account Funds (726) Oppenheimer Balanced (727) Oppenheimer Global Securities* $ __________ PIMCO Variable Insurance Trust (728) PIMCO VIT CommodityRealReturnStrategy* $ __________ (729) PIMCO VIT Real Return $ __________ (730) PIMCO VIT Short-Term $ __________ (731) PIMCO VIT Total Return $ __________ (732) PIMCO VIT Global Bond $ __________ Pioneer Variable Contracts Trust (733) Pioneer Mid Cap Value VCT $ __________ Putnam Variable Trust (734) Putnam VT Diversified Income $ __________ (735) Putnam VT Small Cap Value* $ __________ SunAmerica Series Trust (736) ST Aggressive Growth $ __________ (737) ST Balanced $ __________ VALIC Company I (738) International Equities* $ __________ (739) Mid Cap Index $ __________ (740) Money Market I $ __________ (741) Nasdaq-100(R) Index $ __________ (742) Science and Technology $ __________ (743) Small Cap Index* $ __________ (744) Stock Index $ __________ Van Kampen Life Investment Trust (745) Van Kampen LIT Growth and Income $ __________ Vanguard Variable Insurance Fund (746) Vanguard High Yield Bond $ __________ (747) Vanguard REIT Index $ __________ Other:___________________________ $ __________ _________ INITIAL HERE TO REVOKE DCA ELECTION. ------------------------------------------------------------------------------------------------------------------------------------
AGLC102769 Page 3 of 5 Rev0907 ------------------------------------------------------------------------------------------------------------------------------------ [ ] AUTOMATIC REBALANCING 7. Indicate frequency: _____ Quarterly _____ Semi-Annually _____ Annually ($5,000 minimum (Division Name or Number) (Division Name or Number) 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: Automatic Rebalancing is not __________%: __________________________________ __________%: __________________________________ available if the Dollar Cost Averaging option has __________%: __________________________________ __________%: __________________________________ been chosen. Automatic Rebalancing is required if __________%: __________________________________ __________%: __________________________________ the GMWB Rider has been chosen. __________%: __________________________________ __________%: __________________________________ __________%: __________________________________ __________%: __________________________________ __________ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION. ------------------------------------------------------------------------------------------------------------------------------------ [ ] AUTHORIZATION FOR 8. I (or we, if Joint Owners) hereby authorize AGL to act on telephone instructions or e-service TRANSACTIONS instructions, if elected, to transfer values among the Variable Divisions and AGL Declared Fixed Interest Account and to change allocations for future premium payments and monthly deductions. Complete this section if you are applying for or Initial the designation you prefer: revoking current telephone or e-service ______ Policy Owner(s) only - If Joint Owners, either one acting independently. privileges. ______ Policy Owner(s) or Agent/Registered Representative who is appointed to represent AGL and the firm authorized to service my policy. AGL and any persons designated by this authorization will not be responsible for any claim, loss or expense based upon telephone instructions or e-service instructions received and acted on in good faith, including losses due to telephone instructions or e-service communication errors. AGL's liability for erroneous transfers and 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 instruction or e-service instruction, I will notify AGL in writing within five working days from receipt of 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 in its home office. ______ INITIAL HERE TO REVOKE TELEPHONE PRIVILEGE AUTHORIZATION. ______ INITIAL HERE TO REVOKE E-SERVICE PRIVILEGE AUTHORIZATION. ------------------------------------------------------------------------------------------------------------------------------------ [ ] CORRECT AGE 9. Name of Insured for whom this correction is submitted: ______________________________ Use this section to Correct DOB: ______/ _____/ ______ correct the age of any person covered under this policy. Proof of the correct 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 Transfer $ _______ or _________% from _____________________________ to ____________________________. between divisions. The minimum amount for Transfer $ _______ or _________% from _____________________________ to ____________________________. transfers is $500.00. Withdrawals from the AGL Transfer $ _______ or _________% from _____________________________ to ____________________________. Declared Fixed Interest Account to a Variable Transfer $ _______ or _________% from _____________________________ to ____________________________. Division may only be made within the 60 days after Transfer $ _______ or _________% from _____________________________ to ____________________________. a contract anniversary. See transfer limitations Transfer $ _______ or _________% from _____________________________ to ____________________________. outlined in prospectus. If a transfer causes the Transfer $ _______ or _________% from _____________________________ to ____________________________. balance in any division to drop below $500, AGL Transfer $ _______ or _________% from _____________________________ to ____________________________. reserves the right to transfer the remaining Transfer $ _______ or _________% from _____________________________ to ____________________________. balance. Amounts to be transferred should be indicated in dollar or percentage amounts, maintaining consistency throughout. ------------------------------------------------------------------------------------------------------------------------------------
AGLC102769 Page 4 of 5 Rev0907 ------------------------------------------------------------------------------------------------------------------------------------ [ ] REQUEST FOR 11. ________ I request a partial surrender of $ ____________ or ______% of the net cash surrender value. PARTIAL SURRENDER/ POLICY LOAN ________ I request a loan in the amount of $_______________. Use this section to apply ________ I request the maximum loan amount available from my policy. for a partial surrender from or policy loan Unless you direct otherwise below, proceeds are allocated according to the deduction allocation against policy values. percentages in effect, if available; otherwise they are taken pro-rata from the AGL Declared Fixed For detailed information Interest Account and Variable Divisions in use. 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. ------------------------------------------------------------------------------------------------------------------------------------ [ ] 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 apply. Withholding of state income tax may also be required by your state of residence. You may elect not Complete this section if to have withholding apply by checking the appropriate box below. If you elect not to have you have applied for a withholding apply to your distribution or if you do not have enough income tax withheld, you may be partial surrender in responsible for payment of estimated tax. You may incur penalties under the estimated tax rules, if Section 11. 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/ SIGNATURE 13. CERTIFICATION: Under penalties of perjury, I certify: (1) that the number shown on this form is my correct taxpayer identification number and; (2) that I am not subject to backup withholding under Complete this section for 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 ------------------------------------------------------------------------------------------------------------------------------------
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