SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL

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1 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al Filing at a Glance Company: Product Name: State: TOI: Sub-TOI: Filing Type: American General Life Insurance Company AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al District of Columbia L07I Individual Life - Whole L07I.101 Fixed/Indeterminate Premium - Single Life Form Date Submitted: 04/05/2016 SERFF Tr Num: SERFF Status: State Tr Num: State Status: Co Tr Num: Implementation Date Requested: Author(s): Reviewer(s): AMGN Closed-APPROVED DC-2015, ET AL On Approval Kathryn Mitchell, Debra French John Rielley (primary) Disposition Date: 04/21/2016 Disposition Status: APPROVED Implementation Date: 04/21/2016 PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

2 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al General Information Project Name: DC-2015, et al Project Number: DC-2015, et al Requested Filing Mode: Review & Approval Explanation for Combination/Other: Submission Type: New Submission Status of Filing in Domicile: Pending Date Approved in Domicile: Domicile Status Comments: Market Type: Individual Individual Market Type: Overall Rate Impact: Filing Status Changed: 04/21/2016 Deemer Date: Submitted By: Debra French Filing Description: State Status Changed: Created By: Debra French Corresponding Filing Tracking Number: DC-2015 Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit DC-2015 Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit DC-2015 and DC-2015 are the applications to be used to apply for graded death benefit whole life insurance policy and rider , approved on 9/3/15 in SERFF Tracking# AMGN The only difference in these applications is the Social Security Number requested on DC These application forms will be completed, on the internet or by other electronic means (e.g. agent s laptop) and will in some instances employ electronic signatures. There will be no underwriting questions on these applications as they are applications for a guaranteed issue whole life insurance graded death benefit. These forms are new and do not replace any previously approved forms. No part of this filing contains any unusual or possibly controversial items from normal industry standards. The Flesch readability score for each of the forms in this filing are: Form Number/Flesch Score DC-2015/55.3 (Agreement Section) DC-2015/55.3 (Agreement Section) Unless otherwise informed, we reserve the right to change the layout of the enclosed forms, including sequential ordering of the provisions, and type font, size and color. Thank you for your consideration. If I may provide any additional information, please contact me as shown below. Kathryn Mitchell [email protected] Company and Contact Filing Contact Information Kathryn Mitchell, Manager American General Center Mail Stop 456S Nashville, TN [email protected] [Phone] [FAX] PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

3 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al Filing Company Information American General Life Insurance Company 2727-A Allen Parkway Houston, TX (713) ext. [Phone] CoCode: Group Code: 12 Group Name: AIG FEIN Number: State of Domicile: Texas Company Type: State ID Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: No No PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

4 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al Correspondence Summary Dispositions Status Created By Created On Date Submitted APPROVED John Rielley 04/21/ /21/2016 PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

5 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al Disposition Disposition Date: 04/21/2016 Implementation Date: 04/21/2016 Status: APPROVED Comment: Rate data does NOT apply to filing. Schedule Schedule Item Schedule Item Status Public Access Supporting Document Statements of Variability APPROVED Yes Supporting Document Flesch Certification APPROVED Yes Form Application for Guaranteed Issue Whole Life Insurance APPROVED Yes Graded Death Benefit Form Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit APPROVED Yes PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

6 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al Form Schedule Lead Form Number: Item Schedule Item No. Status 1 APPROVED 04/21/ APPROVED 04/21/2016 Form Name Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit Form Form Form Action Specific Readability Number Type Action Data Score Attachments AGLC10924 AEF Initial AGLC DC- 9-DC JD.pdf AGLC DC-2015 AEF Initial AGLC DC JD.pdf Form Type Legend: ADV Advertising AEF Application/Enrollment Form CER Certificate CERA Certificate Amendment, Insert Page, Endorsement or Rider DDP Data/Declaration Pages FND Funding Agreement (Annuity, Individual and Group) MTX Matrix NOC Notice of Coverage OTH Other OUT Outline of Coverage PJK Policy Jacket POL Policy/Contract/Fraternal Certificate POLA Policy/Contract/Fraternal Certificate: Amendment, Insert Page, Endorsement or Rider SCH Schedule Pages PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

7 [ ] American General Life Insurance Company [ 2727-A Allen Parkway, Houston, TX, 77019] Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit District of Columbia Version PART 1: TELL US ABOUT YOURSELF First Name John Middle Initial E Last Name Doe Home Street Address 123 Mona Avenue City Washington State DC Zip Date of Birth [ Place of Birth (State/Country)] DC/USA Primary Phone (281) Alternate Phone (281) Gender: c X Male c Female Address [email protected] Are you a United States citizen or do you have Permanent Legal Resident (Green Card) status?... c X Yes c No PART 2: TELL US ABOUT THE COVERAGE YOU ARE REQUESTING What amount of insurance are you applying for? [ Amount of Life Insurance: $ 5,000 [ (from $5,000-$50,000)]] Do you plan to replace, cancel, or change any other existing life insurance or annuity with this policy?... c Yes c X No Beneficiary Designation: Who do you want the insurance proceeds to go to? (If more than one beneficiary is designated, proceeds will be divided equally unless you indicate a share.) Beneficiary #1 Jane Doe Wife 100% Beneficiary Name (please print) Relationship to You %Share Beneficiary #2 Beneficiary Name (please print) Relationship to You %Share PART 3: HOW WILL YOU PAY FOR COVERAGE? How often do you want to pay? [ c X Annually] [ c Semi-annually] [ c Quarterly] [ c Monthly] Your premium amount for the payment frequency selected above is: $ How will you pay? [Check one] [ c X Bank Draft] [ (Complete Bank Draft Authorization)] [ c Credit Card] [ (Complete Credit Card Authorization)] [ c Bill me Directly] [ (Monthly premium frequency not available with this payment method)] [ c Other] [ (please explain) ] AGLC DC-2015 Page 1 of 2

8 WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. I agree that: To the best of my knowledge and belief, all statements in this application for life insurance are true and complete. My statements in this application and any amendment(s) are the basis of any policy issued. I understand that no insurance will take effect until a policy is delivered to me and the full first premium due is paid. I have not previously applied for this product in the last 12 months. I understand that the total combined amount of all American General Life Insurance Company guaranteed issue whole life insurance benefits on my life cannot exceed [ $50,000]. Signature of Proposed Insured John E. Doe Date AGLC DC-2015 Page 2 of 2

9 [ ] American General Life Insurance Company [ 2727-A Allen Parkway, Houston, TX, 77019] Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit District of Columbia Version PART 1: TELL US ABOUT YOURSELF First Name John Middle Initial E Last Name Doe Home Street Address 123 Mona Avenue City Washington State DC Zip Date of Birth [ Place of Birth (State/Country)] DC/USA Primary Phone (281) Alternate Phone (281) Gender: c X Male c Female Social Security Number Address [email protected] Are you a United States citizen or do you have Permanent Legal Resident (Green Card) status?... c X Yes c No PART 2: TELL US ABOUT THE COVERAGE YOU ARE REQUESTING What amount of insurance are you applying for? [ Amount of Life Insurance: $ 5,000 [ (from $5,000-$50,000)]] Do you plan to replace, cancel, or change any other existing life insurance or annuity with this policy?... c Yes c X No Beneficiary Designation: Who do you want the insurance proceeds to go to? (If more than one beneficiary is designated, proceeds will be divided equally unless you indicate a share.) Beneficiary #1 Jane Doe Wife 100% Beneficiary Name (please print) Relationship to You %Share Beneficiary #2 Beneficiary Name (please print) Relationship to You %Share PART 3: HOW WILL YOU PAY FOR COVERAGE? How often do you want to pay? [ c X Annually] [ c Semi-annually] [ c Quarterly] [ c Monthly] Your premium amount for the payment frequency selected above is: $ How will you pay? [Check one] [ c X Bank Draft] [ (Complete Bank Draft Authorization)] [ c Credit Card] [ (Complete Credit Card Authorization)] [ c Bill me Directly] [ (Monthly premium frequency not available with this payment method)] [ c Other] [ (please explain) ] AGLC DC-2015 Page 1 of 2

10 WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. I agree that: To the best of my knowledge and belief, all statements in this application for life insurance are true and complete. My statements in this application and any amendment(s) are the basis of any policy issued. I understand that no insurance will take effect until a policy is delivered to me and the full first premium due is paid. I have not previously applied for this product in the last 12 months. I understand that the total combined amount of all American General Life Insurance Company guaranteed issue whole life insurance benefits on my life cannot exceed [ $50,000]. Signature of Proposed Insured John E. Doe Date AGLC DC-2015 Page 2 of 2

11 SERFF Tracking #: AMGN State Tracking #: Company Tracking #: DC-2015, ET AL State: District of Columbia Filing Company: American General Life Insurance Company TOI/Sub-TOI: L07I Individual Life - Whole/L07I.101 Fixed/Indeterminate Premium - Single Life Product Name: AGLC DC-2015 App for Guaranteed Issue Whole Life Insurance Graded Death Benefit, et al Project Name/Number: DC-2015, et al/ dc-2015, et al Supporting Document Schedules Satisfied - Item: Statements of Variability Comments: Attachment(s): SOV for Senior Life App AGLC DC-2015.pdf SOV for Senior Life App AGLC DC-2015.pdf Item Status: APPROVED Status Date: 04/21/2016 Satisfied - Item: Flesch Certification Comments: Attachment(s): DCCERT1 Flesch.pdf Item Status: APPROVED Status Date: 04/21/2016 PDF Pipeline for SERFF Tracking Number AMGN Generated 06/17/ :58 AM

12 Statement of Variability Description of Bracketed Items in Application Form AGLC DC-2015 Variability in the following items marked with an asterisk (*) is needed so the Company can adjust these fields, rates and amounts based on future conditions. BRACKETED AIG Logo and Company Address Place of Birth (State/Country) DESCRIPTION OF BRACKETED ITEM The logo (or address) is bracketed to allow the company to make a change without refiling the form. This field on the application requests the State or Country in which the applicant was born. Amount of Life Insurance This statement will be used on the application for internet, tele-interview, or agent processes. This field displays the amount of life insurance coverage for which the applicant is applying. The possible values for this field are $5,000 to $50,000. This statement is not be used for the direct mail application process. The statement will be replaced with check-off boxes for various coverage amounts. The coverage amounts that will be shown will vary by marketing campaign. The possible values for the check-off boxes are $5,000 to $50,000. How often do you want to pay? How will you pay? [Check one] The options that the company may offer from which the applicant may choose to pay are Annually, Semi-Annually, Quarterly or Monthly. The methods of payment options that the company may offer from which the applicant may choose to pay their premiums are Bank Draft, Credit Card or Bill me Directly. Other with an explanation of that payment method will be used if the company will allow another method of payment. Page 1

13 BRACKETED [(Complete Bank Draft Authorization)] [(Monthly premium frequency not available with this payment method)] I agree that: x I understand that the total combined amount of all American General Life Insurance Company guaranteed issue whole life insurance benefits on my life cannot exceed [$25,000]. DESCRIPTION OF BRACKETED ITEM This statement will only appear on the application if the company offers Bank Draft and/or Credit Card payments. This statement will only appear on the application if the company offers Bill Me Directly payments. Initially, the company allows each insured to obtain $25,000 of guaranteed issue whole life insurance through the company. The possible value for this field is from $15,000 to $50,000. CERTIFICATION The Company certifies that any change or modification to a variable item shall be administered in accordance with the requirements in the Variability of Information section, including any requirements for prior approval or a change or modification. Page 2

14 Statement of Variability Description of Bracketed Items in Application Form AGLC DC-2015 Variability in the following items marked with an asterisk (*) is needed so the Company can adjust these fields, rates and amounts based on future conditions. BRACKETED AIG Logo and Company Address Place of Birth (State/Country) DESCRIPTION OF BRACKETED ITEM The logo (or address) is bracketed to allow the company to make a change without refiling the form. This field on the application requests the State or Country in which the applicant was born. Amount of Life Insurance This statement will be used on the application for internet, tele-interview, or agent processes. This field displays the amount of life insurance coverage for which the applicant is applying. The possible values for this field are $5,000 to $50,000. This statement is not be used for the direct mail application process. The statement will be replaced with check-off boxes for various coverage amounts. The coverage amounts that will be shown will vary by marketing campaign. The possible values for the check-off boxes are $5,000 to $50,000. How often do you want to pay? How will you pay? [Check one] The options that the company may offer from which the applicant may choose to pay are Annually, Semi-Annually, Quarterly or Monthly. The methods of payment options that the company may offer from which the applicant may choose to pay their premiums are Bank Draft, Credit Card or Bill me Directly. Other with an explanation of that payment method will be used if the company will allow another method of payment. Page 1

15 BRACKETED [(Complete Bank Draft Authorization)] DESCRIPTION OF BRACKETED ITEM This statement will only appear on the application if the company offers Bank Draft and/or Credit Card payments. [(Monthly premium frequency not available with this payment method)] This statement will only appear on the application if the company offers Bill Me Directly payments. I agree that: x I understand that the total combined amount of all American General Life Insurance Company guaranteed issue whole life insurance benefits on my life cannot exceed [$25,000]. Initially, the company allows each insured to obtain $25,000 of guaranteed issue whole life insurance through the company. The possible value for this field is from $15,000 to $50,000. CERTIFICATION The Company certifies that any change or modification to a variable item shall be administered in accordance with the requirements in the Variability of Information section, including any requirements for prior approval or a change or modification. Page 2

16 AMERICAN GENERAL LIFE INSURANCE COMPANY DISTRICT OF COLUMBIA CERTIFICATION SUBJECT: AGLC DC-2015 Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit AGLC DC-2015 Application for Guaranteed Issue Whole Life Insurance Graded Death Benefit I certify that, to the best of my knowledge and belief, the above forms meet the minimum reading ease score on the Flesch test, in compliance with Section of the District of Columbia Insurance Code. The Flesch Score are as follows: Form Number Flesch Score AGLC DC (Agreement Section) AGLC DC (Agreement Section) Leo W. Grace Vice President DATE: April 5, 2016