The insurance company checked above (“Company”) is responsible for the obligation and payment of benefits under any policy that it
may issue. No other company is responsible for such obligations or payments.
LEAVE THIS FORM WITH THE PROPOSED INSURED(S)
USA PATRIOT ACT (This notice is printed in compliance with Section 326 of the USA Patriot Act)
IMPORTANT INFORMATION ABOUT PROCEDURES FOR APPLYING FOR AN INSURANCE POLICY OR ANNUITY CONTRACT
To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions,
including insurance companies, to obtain, verify, and record information that identifies each person who opens an account, including
an application for an insurance policy or annuity contract.
What this means for you: When you apply for an insurance policy or annuity contract, we will ask for your name, address, date of birth,
and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.
AGLC109015
Patriot Act Disclosure
American General Life Insurance Company, 2727-A Allen Parkway, Houston, TX 77019
The United States Life Insurance Company in the City of New York, One World Financial Center, 200 Liberty St., New York, NY 10281
A member of American International Group, Inc. (AIG)
