Service Request Form

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Service Request
American General Life Insurance Company (AGL)
AIG Life Insurance Company
AIG Life Insurance Company of Puerto Rico
Please print or
Fixed Life Service Center - P . O. Box 4373, Houston, TX 77210-4373
type all information
Variable Life Service Center - P . O. Box 4880, Houston, TX 77210-4880
except signatures.
Member companies of American International Group, Inc.
Instructions for completing this form are listed on the back. A separate request form must be completed for each policy.
CONTRACT No.: ________________________________________________________________________
1.
CONTRACT
IDENTIFICATION
OWNER: __________________________________________
SSN/TIN OR EIN:____________________
ADDRESS: ________________________________________
PHONE No.:________________________
Check Here if
New Address
________________________________________
EMAIL ADDRESS (optional): ________________________________________________________________
INSURED/ANNUITANT (if other than Owner):
________________________________________________
2.
CHANGE DIRECT
Frequency:
BILLING
Annual
Semi-Annual
Quarterly
Monthly*
Other* ____________________________
FREQUENCY
Planned Premium* $ __________________
3.
LOST CONTRACT
I hereby certify that the contract of insurance for the listed contract has been
lost
destroyed
other.
CERTIFICATE
Unless I have directed cancellation of the contract, I request that a Certificate of Insurance be issued to me.
4.
CORRECT AGE
Insured/Annuitant
Spouse
Child (Name) __________________________________________
Date of Birth: ________________________________ Must send in proof of age.
5.
CHANGE
Extended Term Insurance
NONFORFEITURE
Reduced Paid Up
OPTION
Automatic Premium Loan
Endorse policy in accordance with Nonforfeiture Provisions to provide, if available:
6.
EXECUTE
Extended Term Insurance
Reduced Paid-Up Insurance
NONFORFEITURE
Automatic Premium Loan
If Loan:
Pay-off with Cash Value*
OPTION
Leave on Policy
Used to purchase Additional Paid-Up Insurance ‡
Used to purchase One-Year Term Insurance ‡
7.
CHANGE
DIVIDEND
Applied to Reduce Premiums
Paid in Cash
Accumulated at Interest
OPTION
Premium Waiver
Accidental Death
Guaranteed Insurability
Level/Decreasing Term
8.
CANCEL
Spouse
Family
Child
Payor Death and/
BENEFITS
OR RIDERS ‡
Reduce Face Amount to $ ______________
or Payor Disability
Other:______________________________________________________
9.
SIGN HERE FOR
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number, and (2) I am
not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
ABOVE REQUEST
Revenue Service (IRS) that I am subject to back-up withholding as a result of a failure to report all interest or dividends, or (c) the IRS
has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien). The
Internal Revenue Service does not require your consent to any provision of this document other than the certification required to
avoid backup withholding.
________________________________________
________________________________________
Signature of Owner
Date
Signature of Co-owner
Date
(or other party having interest in contract)
* Not available on all contracts. Contact your Service Center for availability.
‡ Additional forms may be required. Contact your Service Center for additional information.
Note: Certain changes to your policy may result in adverse Tax consequences. We urge you to consult with
your Tax Advisor prior to making any changes. The changes requested are not valid until recorded by the
company.
RETURN COMPLETED FORM TO THE ADDRESS OF THE COMPANY CHECKED ABOVE.
AGLC0107
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