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Service Request
EXHIBIT 10(e)
P L A T I N U M
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Investor
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AMERICAN GENERAL LIFE
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Platinum Investor - Fixed Division Neuberger Berman Advisers Management Trust
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. Division 125 - Declared Fixed Interest Account . Division 241 - Mid-Cap Growth
Platinum Investor - Variable Divisions North American Funds Variable Product Series I
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AIM Variable Insurance Funds . Division 128 - International Equities
---------------------------- . Division 129 - MidCap Index
. Division 126 - AIM V.I. International Equity . Division 130 - Money Market
. Division 127 - AIM V.I. Value . Division 225 - Nasdaq-100 Index
. Division 227 - Science & Technology
American Century Variable Portfolios, Inc. . Division 226 - Small Cap Index
------------------------------------------ . Division 131 - Stock Index
. Division 224 - VP Value
PIMCO Variable Insurance Trust
Ayco Series Trust ------------------------------
----------------- . Division 243 - PIMCO Real Return Bond
. Division 228 - Ayco Large Cap Growth Fund I . Division 242 - PIMCO Short-Term Bond
. Division 244 - PIMCO Total Return Bond
Dreyfus Investment Portfolios
----------------------------- Putnam Variable Trust
. Division 229 - MidCap Stock ---------------------
. Division 137 - Putnam VT Diversified Income
Dreyfus Variable Investment Fund . Division 138 - Putnam VT Growth and Income
-------------------------------- . Division 139 - Putnam VT Int'l Growth and Income
. Division 132 - Quality Bond
. Division 133 - Small Cap SAFECO Resource Series Trust
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Fidelity Variable Insurance Products Fund . Division 140 - Equity
----------------------------------------- . Division 141 - Growth Opportunities
. Division 233 - VIP Asset Manager
. Division 232 - VIP Contrafund The Universal Institutional Funds, Inc.
. Division 230 - VIP Equity-Income ---------------------------------------
. Division 231 - VIP Growth . Division 135 - Equity Growth
. Division 136 - High Yield
Janus Aspen Series - Service Shares
----------------------------------- Vanguard Variable Insurance Fund
. Division 236 - Aggressive Growth --------------------------------
. Division 234 - International Growth . Division 245 - High Yield Bond
. Division 235 - Worldwide Growth . Division 246 - REIT Index
J. P. Morgan Series Trust II Van Kampen Life Investment Trust
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. Division 237 - J. P. Morgan Small Company . Division 142 - Strategic Stock
MFS Variable Insurance Trust Warburg Pincus Trust
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. Division 239 - MFS Capital Opportunities . Division 247 - Small Company Growth
. Division 134 - MFS Emerging Growth
. Division 240 - MFS New Discovery
. Division 238 - MFS Research
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AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
Complete and return this request to:
Variable Universal Life Operations Member American General Financial Group AMERICAN
PO Box 4880 Houston, TX. 77210-4880 GENERAL
(888) 325-9315 or Hearing Impaired Houston, Texas FINANCIAL GROUP
(TDD): (888) 436-5258
Toll-Free Fax: (877) 445-3098 VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST
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[ ] POLICY 1.| POLICY #:___________________________________________________ INSURED:_________________________________
IDENTIFICATION |
| ADDRESS:________________________________________________________________________ New Address (yes)(no)
COMPLETE THIS SECTION |
FOR ALL REQUESTS. | Primary Owner (If other than 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)
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[ ] NAME 2.|
CHANGE | 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 the Insured, |
Owner, Payor or Beneficiary| _________________________________________ _________________________________________________
has changed. (Please note,|
this does not change the |
Insured, Owner, Payor or | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
Beneficiary designation) |
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[ ] CHANGE IN 3.| INVESTMENT DIVISION PREM DED INVESTMENT DIVISION PREM DED
ALLOCATION | (125)-Declared Fixed Interest Account _____% _____% North American Funds Variable
| Product Series I
Use this section to | AIM Variable Insurance Funds (128) International Equities _____% _____%
indicate how premiums or | (126) AIM V.I. International Equity _____% _____% (129) MidCap Index _____% _____%
monthly deductions are to | (127) AIM V.I. Value _____% _____% (130) Money Market _____% _____%
be allocated. Total | (225) Nasdaq-100 Index _____% _____%
allocation in each | American Century Variable Portfolios, Inc. (227) Science & Technology _____% _____%
column must equal 100%; | (224) VP Value _____% _____% (226) Small Cap Index _____% _____%
whole numbers only. | (131) Stock Index _____% _____%
| Ayco Series Trust
| (228) Ayco Large Cap Growth Fund I _____% _____% PIMCO Variable Insurance Trust
| (243) PIMCO Real Return Bond _____% _____%
| Dreyfus Investment Portfolios (242) PIMCO Short-Term Bond _____% _____%
| (229) MidCap Stock _____% _____% (244) PIMCO Total Return Bond _____% _____%
|
| Dreyfus Variable Investment Fund Putnam Variable Trust
| (132) Quality Bond _____% _____% (137) Putnam VT Diversified
| (133) Small Cap _____% _____% Income _____% _____%
| (138) Putnam VT Growth and
| Fidelity Variable Insurance Products Fund Income _____% _____%
| (233) VIP Asset Manager _____% _____% (139) Putnam VT Int'l Growth
| (232) VIP Contrafund _____% _____% and Income _____% _____%
| (230) VIP Equity-Income _____% _____%
| (231) VIP Growth _____% _____% SAFECO Resource Series Trust
| (140) Equity _____% _____%
| Janus Aspen Series--Service Shares (141) Growth Opportunities _____% _____%
| (236) Aggressive Growth _____% _____%
| (234) International Growth _____% _____% The Universal Institutional Funds, Inc.
| (235) Worldwide Growth _____% _____% (135) Equity Growth _____% _____%
| (136) High Yield _____% _____%
| J. P. Morgan Series Trust II
| (237) J. P. Morgan Small Company _____% _____% Vanguard Variable Insurance Fund
| (245) High Yield Bond _____% _____%
| MFS Variable Insurance Trust (246) REIT Index _____% _____%
| (239) MFS Capital Opportunities _____% _____%
| (134) MFS Emerging Growth _____% _____% Van Kampen Life Investment Trust
| (240) MFS New Discovery _____% _____% (142) Strategic Stock _____% _____%
| (238) MFS Research _____% _____%
| Warburg Pincus Trust
| Neuberger Berman Advisers Management Trust (247) Small Company Growth _____% _____%
| (241) Mid-Cap Growth _____% _____% Other: ___________________ _____% _____%
| 100% 100%
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[ ] MODE OF PREMIUM 4.|
PAYMENT/BILLING | Indicate frequency and premium amount desired: $______ Annual $______ Semi-Annual $_______ Quarterly
METHOD CHANGE |
| $______ Monthly (Bank Draft Only)
Use this section to change |
the billing frequency and/ | Indicate billing method desired:_____ Direct Bill ______ Pre-Authorized Bank Draft (attach a Bank Draft
or method of premium pay- | Authorization Form and "Void" Check)
ment. Note, however, that |
AGL will not bill you on a | Start Date: ______/______/_____
direct monthly basis. Refer|
to your policy and its |
related prospectus for |
further information |
concerning minimum premiums|
and billing options. |
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[ ] LOST POLICY 5.|
CERTIFICATE | I/we hereby certify that the policy of insurance for the listed policy has been ____LOST_____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 or duplicate | _________ Certificate of Insurance at no charge
policy to replace a lost or|
misplaced policy. If a full| _________ Full duplicate policy at a charge of $25
duplicate policy is being |
requested, a check or money| be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate
order for $25 payable to | policy to AGL for cancellation.
AGL must be submitted with|
this request. |
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[ ] DOLLAR COST 6.| Designate the day of the month for transfers:_________(choose a day from 1-28)
AVERAGING |
($5,000 minimum initial | Frequency of transfers (check one): _______Monthly _______Quarterly ______Semi-Annually _____Annually
accumulation value) An |
amount may be deducted | I want: $___________($100 minimum) taken from the Money Market Division and transferred to the
periodically from the | following Divisions:
Money Market Division and |
placed in one or more of | AIM Variable Insurance Funds North American Funds Variable
the Divisions listed. The | (126) AIM V.I. International Equity $_____________ Product Series I
Declared Fixed Interest | (127) AIM V.I. Value $_____________ (128) International Equities $_____________
Account is not available | (129) MidCap Index $_____________
for Dollar Cost Averaging.| American Century Variable Portfolios, Inc. (225) Nasdaq-100 Index $_____________
Please refer to the pros- | (224) VP Value $_____________ (227) Science & Technology $_____________
pectus for more infor- | (226) Small Cap Index $_____________
mation on the Dollar Cost | Ayco Series Trust (131) Stock Index $_____________
Averaging Option. | (228) Ayco Large Cap Growth Fund I $_____________
| PIMCO Variable Insurance Trust
| Dreyfus Investment Portfolios (243) PIMCO Real Return Bond $_____________
| (229) MidCap Stock $_____________ (242) PIMCO Short-Term Bond $_____________
| (244) PIMCO Total Return Bond $_____________
| Dreyfus Variable Investment Fund
| (132) Quality Bond $_____________ Putnam Variable Trust
| (133) Small Cap $_____________ (137) Putnam VT Diversified
| Income $_____________
| Fidelity Variable Insurance Products Fund (138) Putnam VT Growth and
| (233) VIP Asset Manager $_____________ Income $_____________
| (232) VIP Contrafund $_____________ (139) Putnam VT Int'l Growth
| (230) VIP Equity-Income $_____________ and Income $_____________
| (231) VIP Growth $_____________
| SAFECO Resource Series Trust
| Janus Aspen Series--Service Shares (140) Equity $_____________
| (236) Aggressive Growth $_____________ (141) Growth Opportunities $_____________
| (234) International Growth $_____________
| (235) Worldwide Growth $_____________ The Universal Institutional Funds, Inc.
| (135) Equity Growth $_____________
| J. P. Morgan Series Trust II (136) High Yield $_____________
| (237) J. P. Morgan Small Company $_____________
| Vanguard Variable Insurance Fund
| MFS Variable Insurance Trust (245) High Yield Bond $_____________
| (239) MFS Capital Opportunities $_____________ (246) REIT Index $_____________
| (134) MFS Emerging Growth $_____________
| (240) MFS New Discovery $_____________ Van Kampen Life Investment Trust
| (238) MFS Research $_____________ (142) Strategic Stock $_____________
|
| Neuberger Berman Advisers Management Trust Warburg Pincus Trust
| (241) Mid-Cap Growth $_____________ (247) Small Company Growth $_____________
| Other: ___________________ $_____________
|
|
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[ ] 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. This option is not | %_________:________________________________________ %_________:____________________________________
available while the Dollar |
Cost Averaging Option is | %_________:________________________________________ %_________:____________________________________
in use. |
| %_________:________________________________________ %_________:____________________________________
|
| %_________:________________________________________ %_________:____________________________________
|
| %_________:________________________________________ %_________:____________________________________
|
| _________INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
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[ ] TELEPHONE 8.| I/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values among
PRIVILEGE | the Variable Divisions and Declared Fixed Interest Account and to change allocations for future
AUTHORIZATION | purchase payments and monthly deductions.
|
Complete this section if | Initial the designation you prefer:
you are applying for or |
revoking current telephone| __________Policy Owner(s) only--If Joint Owners, either one acting independently.
privileges. | __________Policy Owner(s) and Agent/Registered Representative who is appointed to represent AGL and the
| firm authorized to service my policy.
|
| AGL and any person designated by this authorization will not be responsible for any claim, loss or
| expense based upon telephone transfer or allocation instructions received and acted upon in good faith,
| including losses due to telephone instruction communication errors. AGL's liability for erroneous
| transfers or 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 transaction, I will notify AGL in writing within five working days from the receipt of the
| confirmation of the transaction from AGL. I understand that this authorization is subject to the terms
| and provisions of my policy and its related prospectus. This authorization will remain in effect until
| my written notice of its revocation is received by AGL at the address printed on the top of this
| service request form.
|
|___________INITIAL HERE TO REVOKE TELEPHONE PRIVILEGE AUTHORIZATION.
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[ ] CORRECT AGE 9.|
| Name of Insured for whom this correction is submitted:___________________________________
|
Use this section to correct| Correct DOB: ________/________/________
the age of any person |
covered under this policy. |
Proof of the correct date |
of birth must accompany |
this request. |
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[ ] 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 between | Transfer $________ or %_______ from_______________________________to__________________________________
divisions. Withdrawals |
from the Declared Fixed | Transfer $________ or %_______ from_______________________________to__________________________________
Interest Account are |
limited to 60 days after | Transfer $________ or %_______ from_______________________________to__________________________________
the policy anniversary and |
to no more than 25% of the | Transfer $________ or %_______ from_______________________________to__________________________________
total unloaned value of |
the Declared Fixed | Transfer $________ or %_______ from_______________________________to__________________________________
Interest Account on the |
policy anniversary. If a | Transfer $________ or %_______ from_______________________________to__________________________________
transfer causes the |
balance in any division to | Transfer $________ or %_______ from_______________________________to__________________________________
drop below $500, AGL |
reserves the right to | Transfer $________ or %_______ from_______________________________to_________________________________
transfer the remaining |
balance. | Transfer $________ or %_______ from_______________________________to__________________________________
Amounts to be transferred |
should be indicated in | Transfer $________ or %_______ from_______________________________to__________________________________
dollar or percentage |
amounts, maintaining | Transfer $________ or %_______ from_______________________________to__________________________________
consistency throughout. |
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[ ] 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 |
| _________I request the maximum loan amount available from my policy.
Use this section to apply |
for a partial surrender | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
from or policy loan against| percentages in effect, if available; otherwise they are taken pro-rata from the Declared Fixed Interest
policy values. For detailed| Account and Variable Divisions in use.
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. |
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[ ] NOTICE OF 12.| The taxable portion of the distribution you receive from your variable universal life insurance policy
WITHHOLDING | 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 to
Complete this section if | have withholding apply by checking the appropriate box below. If you elect not to have withholding
you have applied for a | apply to your distribution or if you do not have enough income tax withheld, you may be responsible for
partial surrender in | payment of estimated tax. You may incur penalties under the estimated tax rules, if your withholding
Section 11. | 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)
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[ ] 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. The Internal Revenue Service does not require your
Complete this section for | consent to any provision of this document other than the certification required to avoid backup
ALL requests. | withholding.
|
| Dated at __________________________________ this _________ day of ________________________, __________.
|
|
| 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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