EX-99.(E)(4) 6 dex99e4.txt FORM OF SERVICE REQUEST FORM EXHIBIT (e)(4) ------------------------- SERVICE REQUEST ------------------------- AIG PROTECTION ADVANTAGE VUL/SM/ ------------------------- AMERICAN GENERAL LIFE -------------------------------------------------------------------------------------------------------------------- AIG Protection Advantage VUL/SM/ MFS(R) Variable Insurance Trust - Fixed Option . Division 892 - New Discovery . Division 301 - AGL Declared Fixed Interest Account . Division 893 - Research AIG Protection Advantage VUL/SM/ Neuberger Berman Advisers Management Trust - Variable Divisions . Division 895 - Mid-Cap Growth . Division 894 - Socially Responsive AIM Variable Insurance Funds . Division 871 - Global Real Estate Oppenheimer Variable Account Funds . Division 870 - International Growth . Division 896 - Balanced . Division 897 - Global Securities The Alger American Fund . Division 872 - Leveraged AllCap PIMCO Variable Insurance Trust . Division 873 - MidCap Growth . Division 905 - CommodityRealReturn Strategy . Division 909 - Global Bond (Unhedged) American Century Variable Portfolios, Inc. . Division 906 - Real Return . Division 874 - Value . Division 907 - Short-Term . Division 908 - Total Return Credit Suisse Trust . Division 875 - Small Cap Core I Pioneer Variable Contracts Trust . Division 910 - Mid Cap Value Dreyfus Variable Investment Fund . Division 876 - International Value Putnam Variable Trust . Division 911 - Diversified Income Fidelity(R) Variable Insurance Products . Division 912 - Small Cap Value . Division 877 - Asset Manager/SM/ . Division 878 - Contrafund(R) SunAmerica Series Trust . Division 879 - Equity-Income . Division 913 - Aggressive Growth . Division 880 - Freedom 2020 . Division 914 - Balanced . Division 881 - Freedom 2025 . Division 882 - Freedom 2030 VALIC COMPANY I . Division 883 - Growth . Division 915 - International Equities . Division 884 - Mid Cap . Division 916 - Mid Cap Index . Division 917 - Money Market I Franklin Templeton Variable Insurance Products Trust . Division 918 - Nasdaq-100(R) Index . Division 885 - Franklin Small Cap . Division 919 - Science and Technology Value Securities . Division 920 - Small Cap Index . Division 886 - Mutual Shares Securities . Division 921 - Stock Index Janus Aspen Series Van Kampen Life Investment Trust . Division 887 - Forty . Division 922 - Growth and Income . Division 888 - International Growth . Division 889 - Mid Cap Growth Vanguard(R) Variable Insurance Fund . Division 923 - High Yield Bond J.P. Morgan Series Trust II . Division 924 - REIT Index . Division 891 - International Equity JPMorgan Insurance Trust . Division 890 - Government Bond
AGLC102903 [LOGO] AIG American General American General Life Insurance Company ("AGL") A member company of American International Group, Inc. Variable Universal Life Insurance Service Request Complete and return this request to: Variable Universal Life Operations PO Box 4880 . Houston, TX. 77210-4880 (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 2. Change Name Of: (Circle One) Insured Owner Payor Beneficiary CHANGE Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last) Complete this section if the name of one of the ------------------------------------------------- ------------------------------------------------- Insured, Owner, Payor or Beneficiary has changed. Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof) (Please note, this does not change the Insured, Owner, Payor or Beneficiary designation). ---------------------------------------------------------------------------------------------------------------------------------- [ ] CHANGE IN 3. INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED % ALLOCATION ------------------- ------ ----- ------------------- ------ ----- PERCENTAGES (301) AGL Declared Fixed MFS /R/ Variable Insurance Interest Account Trust ---- ---- (892) New Discovery* ---- ---- Use this section to AIM Variable Insurance indicate how premiums or Funds (893) Research ---- ---- monthly deductions are to (871) Global Real Estate* be allocated. Total ---- ---- Neuberger Berman Advisers allocation in each column (870) International Management Trust must equal 100%; whole Growth* (895) Mid-Cap Growth ---- ---- numbers only. ---- ---- The Alger American Fund (894) Socially Responsive ---- ---- (872) Leveraged AllCap ---- ---- Oppenheimer Variable (873) MidCap Growth Account Funds ---- ---- (896) Balanced ---- ---- American Century Variable Portfolios, Inc. (897) Global Securities* ---- ---- (874) Value ---- ---- PIMCO Variable Insurance Credit Suisse Trust Trust (875) Small Cap Core I* (905) CommodityRealReturn ---- ---- Strategy* ---- ---- Dreyfus Variable Investment Fund (909) Global Bond (876) International Value* (Unhedged) ---- ---- ---- ---- Fidelity /R/ Variable (906) Real Return ---- ---- Insurance Product (877) Asset Manager /SM/ (907) Short-Term ---- ---- ---- ---- (878) Contrafund /R/ (908) Total Return ---- ---- ---- ---- (879) Equity-Income Pioneer Variable Contracts ---- ---- Trust (880) Freedom 2020 (910) Mid Cap Value ---- ---- ---- ---- (881) Freedom 2025 Putnam Variable Trust ---- ---- (911) Diversified Income ---- ---- (882) Freedom 2030 ---- ---- (912) Small Cap Value* ---- ---- (883) Growth ---- ---- SunAmerica Series Trust (884) Mid Cap (913) Aggressive Growth ---- ---- ---- ---- Franklin Templeton (914) Balanced ---- ---- Variable Insurance Products Trust VALIC Company I (885) Franklin Small Cap (915) International Value Securities* Equities* ---- ---- ---- ---- (886) Mutual Shares (916) Mid Cap Index ---- ---- Securities ---- ---- (917) Money Market I ---- ---- Janus Aspen Series (887) Forty ---- ---- (918) Nasdaq-100 /R/ lndex ---- ---- (888) International (919) Science and Growth* ---- ---- Technology ---- ---- (889) Mid Cap Growth ---- ---- (920) Small Cap Index* ---- ---- J.P. Morgan Series (921) Stock Index ---- ---- Trust II (891) International Van Kampen Life Investment Equity* ---- ---- Trust (922) Growth and Income ---- ---- JP Morgan Insurance Trust (890) Government Bond ---- ---- Vanguard /R/ Variable Insurance Fund (923) High Yield Bond ---- ---- (924) REIT Index ---- ---- Other: ------------------- ---- ---- 100% 100% *lf you have the Guaranteed Minimum Death Benefit (GMDB) Rider this investment option is designated as a Restricted Fund. ------------------------------------------------------------------------------------------------------------------------------------
AGLC102903 PAGE 2 OF 5 ---------------------------------------------------------------------------------------------------------------------------------- [ ] 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 -------- applying for a Certificate of Insurance Unless I/we have directed cancellation of the policy, I/we request that a: or duplicate policy to replace a lost or Certificate of Insurance at no charge misplaced policy. If a ------ full duplicate policy is being requested, a check Full duplicate policy at a charge of $25 or money order for $25 ------ payable to AGL must be submitted with this be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate request. policy to AGL for cancellation. ---------------------------------------------------------------------------------------------------------------------------------- [ ] DOLLAR COST 6. Day of the month for transfers (Choose a day of the month between 1-28) AVERAGING (DCA) -------- ($5,000 MINIMUM Frequency of transfers: Monthly Quarterly Semi-Annually Annually BEGINNING ------- ------- ------- ------- ACCUMULATION VALUE) DCA to be made from the following investment option: An amount can be ----------------------------------------- systematically Transfer: $ ($100 minimum, whole dollars only) transferred from any one -------------------------- investment option and directed to one or more of the investment options below. The AGL Declared (301) AGL Declared Fixed MFS /R/ Variable Insurance Fixed Interest Account is Interest Account $ Trust not available for DCA. --------- (892) New Discovery $ Please refer to the AIM Variable Insurance Funds --------- prospectus for more (871) Global Real Estate $ (893) Research $ information on the DCA --------- --------- option. (870) International Growth $ Neuberger Berman Advisers --------- Management Trust NOTE: DCA is not The Alger American Fund (895) Mid-Cap Growth $ available if the (872) Leveraged AllCap $ --------- Automatic Rebalancing --------- (894) Socially Responsive $ option or GMDB Rider (873) MidCap Growth $ --------- have been chosen. --------- Oppenheimer Variable Account American Century Variable Funds Portfolios, Inc. (896) Balanced $ (874) Value $ --------- --------- (897) Global Securities $ Credit Suisse Trust --------- (875) Small Cap Core I $ PIMCO Variable Insurance Trust --------- (905) CommodityRealReturn Dreyfus Variable Investment Strategy $ Fund --------- (876) International Value $ (909) Global Bond (Unhedged) $ --------- --------- Fidelity /R/ Variable (906) Real Return $ Insurance Products --------- (877) Asset Manager /SM/ $ (907) Short-Term $ --------- --------- (878) Contrafund /R/ $ (908) Total Return $ --------- --------- (879) Equity-Income $ Pioneer Variable Contracts --------- Trust (880) Freedom 2020 $ (910) Mid Cap Value $ --------- --------- (881) Freedom 2025 $ Putnam Variable Trust --------- (911) Diversified Income $ (882) Freedom 2030 $ --------- --------- (912) Small Cap Value $ (883) Growth $ --------- --------- SunAmerica Series Trust (884) Mid Cap $ (913) Aggressive Growth $ --------- --------- Franklin Templeton Variable (914) Balanced $ Insurance Products Trust --------- (885) Franklin Small Cap Value VALIC Company I Securities $ (915) International Equities $ --------- --------- (886) Mutual Shares Securities $ (916) Mid Cap Index $ --------- --------- Janus Aspen Series (917) Money Market I $ (887) Forty $ --------- --------- (918) Nasdaq-100 /R/ Index $ (888) International Growth $ --------- --------- (919) Science and Technology $ (889) Mid Cap Growth $ --------- --------- (920) Small Cap Index $ J.P. Morgan Series Trust II --------- (891) International Equity $ (921) Stock Index $ --------- --------- JPMorgan Insurance Trust Van Kampen Life Investment (890) Government Bond $ Trust --------- (922) Growth and Income $ --------- Vanguard /R/ Variable Insurance Fund (923) High Yield Bond $ --------- (924) REIT Index $ --------- Other: $ ----------------------- --------- INITIAL HERE TO REVOKE DCA ELECTION. ---------- ----------------------------------------------------------------------------------------------------------------------------------
AGLC102903 PAGE 3 OF 5 ------------------------------------------------------------------------------------------------------------------------------------ [ ] 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 GMDB 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 the age of any Correct DOB: / / 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 transfer 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 policy 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. ------------------------------------------------------------------------------------------------------------------------------------
AGLC102903 PAGE 4 OF 5 ------------------------------------------------------------------------------------------------------------------------------------ [ ] 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 against policy values. Unless you direct otherwise below, proceeds are allocated according to the deduction allocation For detailed information percentages in effect, if available; otherwise they are taken pro-rata from the AGL Declared Fixed concerning these two Interest Account and Variable Divisions in use. 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/ 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. Complete this section for The Internal Revenue Service does not require your consent to any provision of this document other ALL requests. 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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