EX-99.(E)(4) 2 d489971dex99e4.txt SERVICE REQUEST FORM EXHIBIT (e)(4) SERVICE REQUEST PLATINUM INVESTOR(R) III ------------------------------------------------------------------------------------------------------------------------------------ AMERICAN GENERAL LIFE ------------------------------------------------------------------------------------------------------------------------------------ PLATINUM INVESTOR(R)III - FIXED OPTION >> MFS(R)Variable Insurance Trust . Division 301 - AGL Declared Fixed Interest Account>> .>> Division 284 - MFS(R)VIT Core Equity PLATINUM INVESTOR(R)III - VARIABLE DIVISIONS .>> Division 282 - MFS(R)VIT Growth The Alger Portfolios .>> Division 285 - MFS(R)VIT New Discovery . Division 314 - Alger Capital Appreciation .>> Division 283 - MFS VIT Research . Division 313 - Alger Mid Cap Growth >> Neuberger Berman Advisers Management Trust American Century(R)Variable Portfolios, Inc. .>> Division 286 - AMT Mid Cap Growth . Division 262 - VP Value Oppenheimer Variable Account Funds Dreyfus Investment Portfolios >> >> Division 310 - Oppenheimer Capital Income . Division 273 - MidCap Stock >> .>> Division 311 - Oppenheimer Global Dreyfus Variable Investment Fund >> PIMCO Variable Insurance Trust . Division 272 - Opportunistic Small Cap >> .>> Division 429 - PIMCO . Division 271 - Quality Bond CommodityRealReturn Strategy Fidelity Variable Insurance Products .>> Division 288 - PIMCO Real Return . Division 277 - VIP Asset Manager .>> Division 287 - PIMCO Short-Term . Division 276 - VIP Contrafund(R) .>> Division 289 - PIMCO Total Return . Division 274 - VIP Equity-Income >> Pioneer Variable Contracts Trust . Division 425 - VIP Freedom 2020 >> .>> Division 422 - Pioneer Fund VCT . Division 426 - VIP Freedom 2025 .>> Division 428 - Pioneer Mid Cap Value VCT . Division 427 - VIP Freedom 2030 .>> Division 423 - Pioneer Select Mid Cap Growth VCT . Division 275 - VIP Growth Putnam Variable Trust . Division 308 - VIP Mid Cap .>> Division 290 - Putnam VT Diversified Income Franklin Templeton Variable Insurance Products Trust .>> Division 291 - Putnam VT Growth and Income . Division 309 - VIP Franklin Small .>> Division 292 - Putnam VT International Value Cap Value Securities SunAmerica Series Trust . Division 302 - VIP Franklin U.S. Government .>> Division 307 - ST Aggressive Growth . Division 303 - VIP Mutual Shares Securities .>> Division 306 - ST Balanced . Division 304 - VIP Templeton Foreign Securities The Universal Institutional Funds, Inc. Goldman Sachs Variable Insurance Trust .>> Division 295 - Growth . Division 421 - Goldman Sachs Strategic Growth VALIC Company I Invesco Variable Insurance Funds .>> Division 263 - International Equities . Division 424 - Invesco V.I. Core Equity .>> Division 264 - Mid Cap Index . Division 305 - Invesco V.I. Growth and Income .>> Division 265 - Money Market I . Division 410 - Invesco V.I. High Yield .>> Division 266 - Nasdaq-100(R)Index . Division 260 - Invesco V.I. International Growth .>> Division 269 - Science & Technology Janus Aspen Series .>> Division 268 - Small Cap Index . Division 280 - Enterprise .>> Division 267 - Stock Index . Division 279 - Global Research Vanguard Variable Insurance Fund . Division 278 - Overseas .>> Division 297 - VIF High Yield Bond JPMorgan Insurance Trust . Division 298 - VIF REIT Index . Division 927 - JPMorgan Mid Cap Value . Division 281 - JPMorgan Small Cap Core AGLC0223 Rev 1204 Rev0413
AMERICAN GENERAL VARIABLE UNIVERSAL LIFE INSURANCE Life Companies 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 (800) 340-2765 or Hearing Impaired (TDD) (888) 436-5256 . Fax: (713) 620-6653 [ ] POLICY 1. POLICY #:___________________________________ Insured: _______________________________________________________ IDENTIFICATION COMPLETE THIS Address: _______________________________________________________________________________ New Address (yes) (no) SECTION FOR ALL REQUESTS. Primary Owner (If other than an insured): ______________________________________________ Address: _______________________________________________________________________________ New Address (yes) (no) Primary Owner's S.S. No. or Tax l.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 the name Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last) of one of the Insured, Owner, ____________________________________________________ ______________________________________________________ Payor or Beneficiary has changed. (Please Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof) note, this does not change the Insured, Owner, Payor or Beneficiary designation). ------------------------------------------------------------------------------------------------------------------------------------ [ ] CHANGE IN 3. INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION PREM % DED % ALLOCATION (301) AGL Declared Fixed Interest Account _____ _____ MFS(R)Variable Insurance Trust _____ _____ PERCENTAGES The Alger Portfolios >> (284) MFS(R)VIT Core Equity* _____ _____ Use this section to (314) Alger Capital Appreciation _____ _____ (282) MFS(R)VIT Growth* _____ _____ indicate how (313) Alger Mid Cap Growth >> (285) MFS(R)VIT New Discovery _____ _____ premiums or monthly American Century(R)Variable Portfolios, Inc.>> (283) MFS(R)VIT Research _____ _____ deductions are to be (262) VP Value _____ _____ Neuberger Berman Advisers allocated. Total Dreyfus Investment Portfolios >> Management Trust allocation in each (273) MidCap Stock* _____ _____ (286) AMT Mid Cap Growth _____ _____ column must equal Dreyfus Variable Investment Fund >> Oppenheimer Variable Account Funds 100%; whole numbers (272) Opportunistic Small Cap* _____ _____ (310) Oppenheimer Capital Income _____ _____ only. (271) Quality Bond* _____ _____ (311) Oppenheimer Global _____ _____ * These investment Fidelity Variable Insurance Products >> PIMCO Variable Insurance Trust options are (277) VIP Asset Manager _____ _____ (429) PIMCO _____ _____ available only for (276) VIP Contrafund(R) _____ _____ CommodityRealReturn Strategy owners whose (274) VIP Equity-Income _____ _____ (288) PIMCO Real Return _____ _____ policies were (425) VIP Freedom 2020 _____ _____ (287) PIMCO Short-Term _____ _____ effective before (426) VIP Freedom 2025 _____ _____ (289) PIMCO Total Return _____ _____ 5/1/06. (427) VIP Freedom 2030 _____ _____ Pioneer Variable Contracts Trust ** These investment (275) VIP Growth _____ _____ (422) Pioneer Fund VCT** _____ _____ available only for (308) VIP Mid Cap _____ _____ (428) Pioneer Mid Cap Value VCT _____ _____ owners who had Franklin Templeton Variable Insurance >> (423) Pioneer Select Mid Cap Growth VCT**_____ _____ Accumulation Value Products Trust >> Putnam Variable Trust invested in such (309) VIP Franklin Small Cap Value Securities_____ _____ (290) Putnam VT Diversified Income _____ _____ fund or portfolio (302) VIP Franklin U.S. Government _____ _____ (291) Putnam VT Growth and Income* _____ _____ on 12/10/04. (303) VIP Mutual Shares Securities _____ _____ (292) Putnam VT International Value _____ _____ *** These investment (304) VIP Templeton Foreign Securities _____ _____ SunAmerica Series Trust options are not Goldman Sachs Variable Insurance Trust >> (307) ST Aggressive Growth _____ _____ available for any (421) Goldman Sachs _____ (306) ST Balanced _____ _____ purpose except to Strategic Growth*** NA _____ The Universal Institutional Funds, Inc. transfer Invesco Variable Insurance Funds >> (295) Growth* _____ _____ Accumulation Value (424) Invesco V.I. Core Equity* _____ _____ VALIC Company I to other investment (305) Invesco V.I. Growth and Income _____ _____ (263) International Equities _____ _____ options. (410) Invesco V.I. High Yield* _____ _____ (264) Mid Cap Index _____ _____ (260) Invesco V.I. International Growth _____ _____ (265) Money Market I _____ _____ Janus Aspen Series >> (266) Nasdaq-100(R)Index _____ _____ (280) Enterprise _____ _____ (269) Science & Technology _____ _____ (279) Global Research* _____ _____ (268) Small Cap Index _____ _____ (278) Overseas _____ _____ (267) Stock Index _____ _____ JPMorgan Insurance Trust >> Vanguard Variable Insurance Fund (927) JPMorgan Mid Cap Value*** NA _____ (297) VIF High Yield Bond _____ _____ (281) JPMorgan Small Cap Core _____ _____ (298) VIF REIT Index _____ _____ Other:___________________ _____ _____ 100% 100% AGLC0223 Rev1204 Page 2 of 5 Rev0413
[ ] MODE OF 4. Indicate frequency and premium amount desired: $_________ Annual $_________ Semi-Annual $________ Quarterly PREMIUM PAYMENT/BILLING $_________ Monthly (Bank Draft Only) METHOD CHANGE Use this section to Indicate billing method desired: ______ Direct Bill _______ Pre-Authorized Bank Draft change the billing (attach a Bank Draft Authorization Form and "Void" frequency and/or Check) method of premium payment. Note, Start Date: ______/ ______/ ________ however, that AGL will 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 __ DESTROYED __ OTHER. CERTIFICATE Complete this Unless I/we have directed cancellation of the policy, I/we request that a: section if applying for a Certificate of ______Certificate of Insurance at no charge Insurance or duplicate policy to ______Full duplicate policy at a charge of $25 replace a lost or misplaced policy. If be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate policy to a full duplicate AGL for cancellation. policy is being requested, a check or money order for $25 payable to AGL must be submitted with this request. ------------------------------------------------------------------------------------------------------------------------------------ [ ] DOLLAR COST 6. Day of the month for transfers ____________ (Choose 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 Transfer: $_______________________ ($100 minimum, whole dollars only) ACCUMULATION VALUE) An amount can be The Alger Portfolios MFS(R)Variable Insurance Trust systematically (314) Alger Capital Appreciation $___________ (284) MFS(R)VIT Core Equity* $___________ transferred from (313) Alger Mid Cap Growth $___________ (282) MFS(R)VIT Growth* $___________ any one investment American Century(R)Variable Portfolios, Inc. (285) MFS(R)VIT New Discovery $___________ option and directed (262) VP Value $___________ (283) MFS(R)VIT Research $___________ to one or more of Dreyfus Investment Portfolios Neuberger Berman Advisers the investment (273) MidCap Stock* $___________ Management Trust options below. The Dreyfus Variable Investment Fund (286) AMT Mid Cap Growth $___________ AGL Declared Fixed (272) Opportunistic Small Cap* $___________ Oppenheimer Variable Account Funds Interest Account is (271) Quality Bond* $___________ (310) Oppenheimer Capital Income $___________ not available for Fidelity Variable Insurance Products (311) Oppenheimer Global $___________ DCA. Please refer to(277) VIP Asset Manager $___________ PIMCO Variable Insurance Trust the prospectus for (276) VIP Contrafund(R) $___________ (429) PIMCO more information on (274) VIP Equity-Income $___________ CommodityRealReturn Strategy $___________ the DCA option. (425) VIP Freedom 2020 $___________ (288) PIMCO Real Return $___________ NOTE: DCA is not (426) VIP Freedom 2025 $___________ (287) PIMCO Short-Term $___________ available if the (427) VIP Freedom 2030 $___________ (289) PIMCO Total Return $___________ Automatic (275) VIP Growth $___________ Pioneer Variable Contracts Trust Rebalancing option (308) VIP Mid Cap $___________ (422) Pioneer Fund VCT** $___________ has been chosen. Franklin Templeton Variable Insurance (428) Pioneer Mid Cap Value VCT $___________ Products Trust (423) Pioneer Select Mid Cap Growth VCT**$___________ * These investment (302) VIP Franklin U.S. Government $___________ (290) Putnam VT Diversified Income $___________ options are (303) VIP Mutual Shares Securities $___________ (291) Putnam VT Growth and Income* $___________ available only for (304) VIP Templeton Foreign Securities $___________ (292) Putnam VT International Value $___________ owners whose Invesco Variable Insurance Funds SunAmerica Series Trust policies were (424) Invesco V.I. Core Equity* $___________ (307) ST Aggressive Growth $___________ effective before (305) Invesco V.I. Growth and Income $___________ (306) ST Balanced $___________ 5/1/06. (410) Invesco V.I. High Yield* $___________ The Universal Institutional Funds, Inc. (260) Invesco V.I. International Growth $___________ (295) Growth* $___________ ** These investment Janus Aspen Series VALIC Company I options are (280) Enterprise $___________ (263) International Equities $___________ available only for (279) Global Research* $___________ (264) Mid Cap Index $___________ owners who had (278) Overseas $___________ (265) Money Market I $___________ Accumulation Value JPMorgan Insurance Trust (266) Nasdaq-100(R)Index $___________ invested in such (281) JPMorgan Small Cap Core $___________ (269) Science & Technology $___________ fund or portfolio (268) Small Cap Index $___________ on 12/10/04. (267) Stock Index $___________ Vanguard Variable Insurance Fund (297) VIF High Yield Bond $___________ (298) VIF REIT Index $___________ Other: $___________ ______ INITIAL HERE TO REVOKE DCA ELECTION. AGLC0223 Rev1204 Page 3 of 5 Rev0413
[ ] AUTOMATIC 7. 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: Automatic _________ INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION. Rebalancing is not available if the Dollar Cost Averaging option has been chosen. Automatic See investment option restrictions in Box 3 above. ------------------------------------------------------------------------------------------------------------------------------------ [ ] AUTHORIZATION 8. I (or we, if Joint Owners) hereby authorize AGL to act on telephone instructions or e-service instructions, if FOR TRANSACTIONS elected, to transfer values among the Variable Divisions and AGL Declared Fixed Interest Account and to change Complete this allocations for future premium payments and monthly deductions. section if you are applying for or Initial the designation you prefer: revoking current ______ Policy Owner(s) ONLY -- If Joint Owners, either one acting independently. telephone or ______ Policy Owner(s) OR Agent/Registered Representative who is appointed to represent AGL and the firm e-service authorized to service my policy. privileges. 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 Correct DOB: ________/________/________ 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 Transfer $_______ or ______% from ____________________________________ to ____________________________________. VALUES Use this section if Transfer $_______ or ______% from ____________________________________ to ____________________________________. you want to transfer money between Transfer $_______ or ______% from ____________________________________ to ____________________________________. divisions. The minimum amount for Transfer $_______ or ______% from ____________________________________ to ____________________________________. transfers is $500.00. Withdrawals Transfer $_______ or ______% from ____________________________________ to ____________________________________. from the AGL Declared Fixed Transfer $_______ or ______% from ____________________________________ to ____________________________________. Interest Account to a Variable Division Transfer $_______ or ______% from ____________________________________ to ____________________________________. may only be made within the 60 days Transfer $_______ or ______% from ____________________________________ to ____________________________________. after a policy anniversary. See Transfer $_______ or ______% from ____________________________________ to ____________________________________. transfer limitations outlined in Transfer $_______ or ______% from ____________________________________ to ____________________________________. prospectus. If a transfer causes the balance in any division to drop below $500, AGL reserves the right to transfer the remaining balance. Amounts to be transferred should be indicated in dollar or percentage amounts, maintaining consistency throughout. See investment option restrictions in Box 3 above. AGLC0223 REV1204 Page 4 of 5 Rev0413
[ ] 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 Use this section to ________ I request the maximum loan amount available from my policy. apply for a partial surrender from or Unless you direct otherwise below, proceeds are allocated according to the deduction allocation percentages in policy loan against effect, if available; otherwise they are taken pro-rata from the AGL Declared Fixed Interest Account and policy values. For Variable Divisions in use. detailed 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. ------------------------------------------------------------------------------------------------------------------------------------ [ ] NOTICE OF 12. The taxable portion of the distribution you receive from your variable universal life insurance policy is WITHHOLDING subject to federal income tax withholding unless you elect not to have withholding apply. Withholding of state Complete this income tax may also be required by your state of residence. You may elect not to have withholding apply by section if you have checking the appropriate box below. If you elect not to have withholding apply to your distribution or if you applied for a do not have enough income tax withheld, you may be responsible for payment of estimated tax. You may incur partial surrender in penalties under the estimated tax rules, if your withholding and estimated tax are not sufficient. Section 11. 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). ------------------------------------------------------------------------------------------------------------------------------------ [ ] ELECTRONIC 13. American General Life Insurance Company ("AGL") is capable of providing contract and investment option DELIVERY prospectuses, supplements, statements of additional information, and reports via e-mail. In order to deliver CONSENT these documents via e-mail, we must obtain your consent to this type of delivery format. This consent authorizes AGL, with respect to AGL's variable universal life insurance policies, to deliver the following communications via e-mail: Complete this .>> Contract prospectuses and supplements section for .>> Investment option prospectuses and supplements electronic .>> Statements of additional information delivery of .>> Annual and semi-annual investment option reports documents. This consent to delivery by e-mail has no expiration date. You may change or cancel your consent at any time by writing to us at American General Life Insurance Company, P.O. Box 4880, Houston, Texas 77210-4880, Attn: Policy Owner Services. You may also receive a paper copy of any communication at no additional charge by writing to us at the above address. In order to participate in this delivery method, you must have access to the following: .>> Browser software, such as Microsoft Internet Explorer, or equivalent . Communication access to the Internet Should you wish to print materials that have been delivered via e-mail, you must also have access to a printer. Materials will be published using Portable Document Format (PDF). In order to view PDF documents, you must have Adobe Acrobat Reader software, which is available for download free-of-charge from http://www.adobe.com/products/acrobat/readstep2.html. We reserve the right to mail paper copies instead of providing electronic delivery. In the event that e-mail delivery is unsuccessful, we will mail paper copies. You must notify us every time you change your e-mail address. Your e-mail address will be used solely for AGL's database management regarding the electronic delivery of the communications listed above. Your e-mail address will not be sold or distributed to third parties. By signing this consent, I acknowledge that I have read and understand all of the above-mentioned terms and conditions of this enrollment. I consent to receive electronic delivery of the documents specified above. _____________________ ________________________________________________________________________________ Initials of Owner Please provide your e-mail address ------------------------------------------------------------------------------------------------------------------------------------ [ ] AFFIRMATION/ 14. --------------------------------------------------------------------------------------------------------------- SIGNATURE CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY: (1) THAT THE NUMBER SHOWN ON THIS FORM IS MY CORRECT Complete this TAXPAYER IDENTIFICATION NUMBER AND; (2) THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING UNDER SECTION 3406(A)(1)(C) section for ALL OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF requests. 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 AGLC0223 Rev1204 Page 5 of 5 Rev0413