EX-99.(E)(4) 2 d885142dex99e4.txt SERVICE REQUEST FORM, FORM NO. AGLC0223 REV0614 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(R) 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 - Franklin Small Cap Value VIP . Division 292 - Putnam VT International Value . Division 302 - Franklin U.S. Government Securities VIP SunAmerica Series Trust . Division 303 - Franklin Mutual Shares VIP . Division 307 - ST Aggressive Growth . Division 304 - Templeton Foreign VIP . Division 306 - ST Balanced Goldman Sachs Variable Insurance Trust The Universal Institutional Funds, Inc. . Division 421 - Goldman Sachs Strategic Growth . Division 295 - Growth Invesco Variable Insurance Funds VALIC Company I . Division 424 - Invesco V.I. Core Equity . Division 263 - International Equities Index . Division 305 - Invesco V.I. Growth and Income . Division 264 - Mid Cap Index . Division 410 - Invesco V.I. High Yield . Division 265 - Money Market I . Division 260 - Invesco V.I. International Growth . Division 266 - Nasdaq-100(R) Index Janus Aspen Series . Division 269 - Science & Technology . Division 280 - Enterprise . Division 268 - Small Cap Index . Division 279 - Global Research . Division 267 - Stock Index . Division 278 - Overseas Vanguard Variable Insurance Fund JPMorgan Insurance Trust . Division 297 - VIF High Yield Bond . Division 927 - JPMorgan Mid Cap Value . Division 298 - VIF REIT Index . Division 281 - JPMorgan Small Cap Core AGLC0223 Rev1204 Rev0614
[LOGO OF AIG] VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST COMPLETE AND RETURN THIS REQUEST TO: Variable Universal Life Operations AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL") P.O. Box 9318 . Amarillo TX 79105-9318 (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 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 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 MFS(R) Variable Insurance Trust PERCENTAGES Interest Account ______ ______ (284) MFS(R) VIT Core Equity* ______ ______ The Alger Portfolios (282) MFS(R) VIT Growth* ______ ______ Use this section to (314) Alger Capital Appreciation ______ ______ (285) MFS(R) VIT New Discovery ______ ______ indicate how (313) Alger Mid Cap Growth ______ ______ (283) MFS(R) VIT Research ______ ______ premiums or monthly American Century(R) Variable Neuberger Berman Advisers deductions are to be Portfolios, Inc. Management Trust allocated. Total (262) VP Value ______ ______ (286) AMT Mid Cap Growth ______ ______ allocation in each Dreyfus Investment Portfolios Oppenheimer Variable Account Funds column must equal (273) MidCap Stock* ______ ______ (310) Oppenheimer Capital Income ______ ______ 100%; whole numbers Dreyfus Variable Investment Fund (311) Oppenheimer Global ______ ______ only. (272) Opportunistic Small Cap* ______ ______ PIMCO Variable Insurance Trust (271) Quality Bond* ______ ______ (429) PIMCO ______ ______ * These investment Fidelity Variable Insurance CommodityRealReturn Strategy options are Products (288) PIMCO Real Return ______ ______ available only for (277) VIP Asset Manager ______ ______ (287) PIMCO Short-Term ______ ______ owners whose (276) VIP Contrafund(R) ______ ______ (289) PIMCO Total Return ______ ______ policies were (274) VIP Equity-Income ______ ______ Pioneer Variable Contracts Trust effective before (425) VIP Freedom 2020 ______ ______ (422) Pioneer Fund VCT** ______ ______ 5/1/06. (426) VIP Freedom 2025 ______ ______ (428) Pioneer Mid Cap Value VCT ______ ______ (427) VIP Freedom 2030 ______ ______ (423) Pioneer Select Mid Cap ** These investment (275) VIP Growth ______ ______ Growth VCT** ______ ______ options are (308) VIP Mid Cap ______ ______ Putnam Variable Trust available only for Franklin Templeton Variable (290) Putnam VT Diversified Income ______ ______ owners who had Insurance Products Trust (291) Putnam VT Growth and Income* ______ ______ Accumulation Value (309) Franklin Small Cap Value VIP ______ ______ (292) Putnam VT International Value ______ ______ invested in such (302) Franklin U.S. Government ______ ______ SunAmerica Series Trust fund or portfolio on Securities VIP (307) ST Aggressive Growth ______ ______ 12/10/04. (303) Franklin Mutual Shares VIP ______ ______ (306) ST Balanced ______ ______ (304) Templeton Foreign VIP ______ ______ The Universal Institutional Funds, *** These investment Goldman Sachs Variable Insurance Inc. options are not Trust (295) Growth* ______ ______ available for any (421) Goldman Sachs NA ______ VALIC Company I purpose except to Strategic Growth*** (263) International Equities Index ______ ______ transfer Invesco Variable Insurance Funds (264) Mid Cap Index ______ ______ Accumulation Value (424) Invesco V.I. Core Equity* ______ ______ (265) Money Market I ______ ______ to other investment (305) Invesco V.I. Growth and (266) Nasdaq-100(R) Index ______ ______ options. Income ______ ______ (269) Science & Technology ______ ______ (410) Invesco V.I. High Yield* ______ ______ (268) Small Cap Index ______ ______ (260) Invesco V.I. International (267) Stock Index ______ ______ Growth ______ ______ Vanguard Variable Insurance Fund Janus Aspen Series (297) VIF High Yield Bond ______ ______ (280) Enterprise ______ ______ (298) VIF REIT Index ______ ______ (279) Global Research* ______ ______ Other: ____________________________ ______ ______ (278) Overseas ______ ______ 100% 100% JPMorgan Insurance Trust (927) JPMorgan Mid Cap Value*** NA ______ (281) JPMorgan Small Cap Core ______ ______ AGLC0223 Rev1204 Page 2 of 5 Rev0614
[ ] 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. be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate policy to If 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 any (313) Alger Mid Cap Growth $________ (282) MFS(R) VIT Growth* $________ 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 (309) Franklin Small Cap Value VIP $________ Putnam Variable Trust options are (302) Franklin U.S. Government (290) Putnam VT Diversified Income $________ available only for Securities VIP $________ (291) Putnam VT Growth and Income* $________ owners whose (303) Franklin Mutual Shares VIP $________ (292) Putnam VT International Value $________ policies were (304) Templeton Foreign VIP $________ SunAmerica Series Trust effective before Invesco Variable Insurance Funds (307) ST Aggressive Growth $________ 5/1/06. (424) Invesco V.I. Core Equity* $________ (306) ST Balanced $________ (305) Invesco V.I. Growth and Income $________ The Universal Institutional Funds, Inc. ** These investment (410) Invesco V.I. High Yield* $________ (295) Growth* $________ options are (260) Invesco V.I. International Growth $________ VALIC Company I available only for Janus Aspen Series (263) International Equities Index $________ owners who had (280) Enterprise $________ (264) Mid Cap Index $________ Accumulation Value (279) Global Research* $________ (265) Money Market I $________ invested in such (278) Overseas $________ (266) Nasdaq-100(R) Index $________ fund or portfolio on JPMorgan Insurance Trust (269) Science & Technology $________ 12/10/04. (281) JPMorgan Small Cap Core $________ (268) Small Cap Index $________ (267) Stock Index $________ ______ INITIAL HERE TO REVOKE DCA ELECTION. Vanguard Variable Insurance Fund (297) VIF High Yield Bond $________ (298) VIF REIT Index $________ Other: $________ AGLC0223 Rev1204 Page 3 of 5 Rev0614
[ ] 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. 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, FOR TRANSACTIONS if elected, to transfer values among the Variable Divisions and AGL Declared Fixed Interest Account and to Complete this change 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 e-service ______ Policy Owner(s) OR Agent/Registered Representative who is appointed to represent AGL and the firm privileges. 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 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 Rev0614
[ ] 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 Complete this following communications via e-mail: section for electronic delivery . Contract prospectuses and supplements of documents. . Investment option prospectuses and supplements . Statements of additional information . Annual and semi-annual investment option reports 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 9318, Amarillo, TX 79105-9318, 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. CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY: (1) THAT THE NUMBER SHOWN ON THIS FORM IS MY CORRECT SIGNATURE TAXPAYER IDENTIFICATION NUMBER AND; (2) THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING UNDER SECTION 3406(A)(1)(C) Complete this OF THE INTERNAL REVENUE CODE. section for 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 AGLC0223 Rev1204 Page 5 of 5 Rev0614