EX-5.(E) 7 dex5e.txt FORM OF CHANGE OF BENEFICIARY FORM
EXHIBIT 5(e) ----- | AIG | AMERICAN Change of Beneficiary ----- GENERAL American General Life Insurance Company Member of American International Group, Inc. Complete and Return this request to: Annuity Administration o P.O. Box 1401 o Houston, TX 77251-1401 (Before completing this form please read instructions below and on reverse side.) ___________________________________________________________________________________________________________________________________ | | | | Contract No. | Contract Owner |Annuitant ___________________________________________________________________________________________________________________________________ METHOD OF PAYMENT: The death proceeds shall be payable in equal shares to the designated beneficiaries as may be living, unless otherwise provided below. In the event no beneficiary survives the Annuitant or Owner, and if this form or the Contract does not provide otherwise, the proceeds will be paid to the executors or administrators of the deceased's Estate. =================================================================================================================================== PRIMARY BENEFICIARY: Full Name Relationship to Annuitant Percentages (if applicable) --------- ------------------------- -------------------------- ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ If a living or non-testamentary trust is designated as a primary beneficiary, complete the following: ________________________________________________________________________________________ Dated: _________________________________ Name of Trust CONTINGENT BENEFICIARY (proceeds payable under this designation only if none of the designated primary beneficiaries survives the deceased Annuitant or Owner): Full Name Relationship to Annuitant Percentages (if applicable) --------- ------------------------- -------------------------- ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ If a living or non-testamentary trust is designated as a contingent beneficiary, complete the following: ________________________________________________________________________________________ Dated: _________________________________ Name of Trust =================================================================================================================================== The undersigned Contract Owner hereby revokes any previous beneficiary designation and any optional mode of settlement with respect to any death benefit proceeds payable at the death of the Annuitant or Owner. I represent and certify that no insolvency or bankruptcy proceedings are now pending against me. Dated at ___________________________________________________________ this __________ day of ___________________________, 20_______. _____________________________________________________________________ __________________________________________________________ WITNESS CONTRACT OWNER _____________________________________________________________________ __________________________________________________________ WITNESS ADDITIONAL SIGNATURE (IF REQUIRED) =================================================================================================================================== This change of beneficiary and/or method of settlement has been approved by the Company at its Home Office, and presentation of the Contract for endorsement has been waived. American General Life Insurance Company DATE OF APPROVAL: _____________________________________ BY:______________________________________________________ AGLC 8876 Rev1202 Page 1 of 2
INSTRUCTIONS FOR DESIGNATING BENEFICIARY 1. All signatures must be in INK and should appear exactly as the name is given in the Contract. A separate election for change of beneficiary must be completed for each Contract. 2. The full name of the new Beneficiary, relationship to the Annuitant, current mailing address and taxpayer identification number (S.S. No.) should be given for all Beneficiaries. If Beneficiary is to receive payment under life income option, give date of birth. 3. If a Beneficiary is a married woman, her full given name should be used. For example, Mary E. Jones, not Mrs. J.F. Jones. If a Trustee is designated, notification as to the type of trust created should be furnished to the Company. 4. If two Beneficiaries are to share jointly, the last name entered should be followed by the words "equally, or to the survivor." If three or more Beneficiaries are to share jointly, the last name entered should be followed by the words "equally, or to the survivors or survivor." If the interest of one Beneficiary is to be contingent to the interest of another, after the name of the first Beneficiary the following words should be placed: "if living; otherwise to." For your assistance, examples of the wording to be used in some of the more common designations are set out below. In difficult cases where there is doubt as to the proper wording, the Company will prepare a special form for your signature on request. 1. One Beneficiary Jane Doe, wife of the Annuitant 2. Two Primary Beneficiaries Jane Doe, wife of the Annuitant, and John Doe, son, equally, or to the survivor 3. One Primary and Two Contingent Beneficiaries Jane Doe, wife of the Annuitant, if living; otherwise to John Doe and Mary Doe, children of the Annuitant, equally, or to the survivor 4. One Primary and One Contingent Beneficiary Jane Doe, wife of the Annuitant, if living; otherwise to John Doe, son 5. Two Primary and One Contingent Beneficiary John Doe and Mary Doe, parents of the Annuitant, equally, or to the survivor; otherwise, to Jane Doe, sister of the Annuitant 6. Wife, Primary; Named and Unnamed Children, Contingent Beneficiaries Contingent Beneficiaries Jane Doe, wife of the Annuitant, if living; otherwise to Henry Doe, Barbara Doe, and Paul Doe, children of the Annuitant, and any other then living children born of the marriage of the Annuitant and said wife, equally, or to the survivors 7. Wife, Primary; Children and Step-Children Contingents Mary Doe, wife of the Annuitant, if living; otherwise, Henry Doe, son of the Annuitant, Mary Doe, step- daughter of the Annuitant, and any then living children born of the marriage of the Annuitant and said wife, equally, or to the survivor 8. Wife, Primary; Unnamed Children with Second Contingents Jane Doe, wife of the Annuitant, if living; otherwise any then living children born of the marriage of the Annuitant and said wife, equally, or to the survivor; otherwise to Harry Doe and Mabel Doe, parents of the Annuitant, equally, or to the survivor 9. Business Designations A. The Beacon Oil Company, Incorporated, a Texas Corporation Houston, Texas, employer (or creditor), or its successors or assigns B. John Doe, Business Partner C. Harry Doe, Employer (or employee) 10. Trustee - Written Trust The American General Bank, Houston, Texas, as Trustee, or its successors in Trust, under Trust Instrument dated May 31, 1995 Trustee - Testamentary Trust Trustee as provided in the Last Will and Testament of the Annuitant, or successors thereunder 11. Estate The Executors, Administrators, or Assigns of the Annuitant AGLC 8876 Rev1202 Page 2 of 2