EXHIBIT 1.10(c)
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Service Request
LEGACY
Plus
AMERICAN GENERAL LIFE
Legacy Plus_Variable Divisions
BT Insurance Funds Trust
. Division 179_Equity 500 Index
. Division 180_EAFE Equity Index
AIM Variable Insurance Funds, Inc.
. Division 181_AIM V.I. Value
Morgan Stanley Universal Funds, Inc.
. Division 182_Equity Growth
Royce Capital Fund
. Division 183_Royce Total Return
American General Series Portfolio Company
. Division 184_Money Market
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1. POLICY IDENTIFICATION
Complete this section for ALL requests.
American General Life Insurance Company ("AGL")
A Subsidiary of American General Corporation
Houston, Texas
Variable Universal Life INSURANCE Service Request
Complete and return this request to:
Variable Universal Life Operations
PO Box 4880 Houston, TX. 77210-4880
(888) 325-9315 or (713) 831-3443
Fax: (713) 620-3857
1. POLICY #: Insured:
Address: New Address (yes) (no)
Primary Owner (If other than insured):
Address: New Address (yes) (no)
Primary Owner's S.S. No. or Tax l.D. No._____________________
Phone Number: (___) ______ - __________
Joint Owner (If applicable):
Address: New Address (yes) (no)
2. NAME CHANGE
Complete this section if the name of the Insured, Owner, Payor or Beneficiary
has changed. (Please note, this does not change the Insured, Owner, Payor or
Beneficiary designation)
Change Name Of: (Circle One) Insured Owner Payor Beneficiary
Change Name From: (First, Middle, Last) Change Name To: (First, Middle, Last)
Reason for Change: (Circle One) Marriage Divorce Correction
Other (Attach copy of legal proof)
3. MODE OF PREMIUM
PAYMENT/BILLING METHOD CHANGE
Use this section to change the billing frequency and/or method of premium
payment. Note, however, that AGL will not bill you on a direct monthly basis.
Refer to your policy and its related prospectus for further information
concerning minimum premiums and billing options. Indicate frequency and premium
amount desired: $ Annual $ Semi-Annual $ Quarterly
$ Monthly (Bank Draft Only)
Indicate billing method desired: Direct Bill
Pre-Authorized Bank Draft
(attach a Bank Draft Authorization Form and "Void" Check)
Start Date: / /
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4. LOST POLICY CERTIFICATE
Complete this section if applying for a Certificate of Insurance or duplicate
policy to replace a lost or misplaced policy. If a full duplicate policy is
being requested, a check or money order for $25 payable to AGL must be
submitted with this request.
I/we hereby certify that the policy of insurance for the listed policy has
been
LOST DESTROYED OTHER.
Unless I/we have directed cancellation of the policy, I/we request that a:
Certificate of Insurance at no charge
Full duplicate policy at a charge of $25
be issued to me/us. If the original policy is located, I/we will return the
Certificate or duplicate policy to AGL for cancellation.
5. DOLLAR COST AVERAGING
($100,000 minimum initial accumulation value) An amount may be deducted
periodically from the Money Market Division and placed in one or more of the
Divisions listed. Please refer to the prospectus for more information on the
Dollar Cost Averaging Option.
Designate the day of the month for transfers: (choose a day from 1-28)
Frequency of transfers (check one): Monthly Quarterly Semi-Annually Annually
I want: $ ($5,000 minimum) taken from the Money Market Division and transferred
to the following Divisions:
I (/we if Joint Owners) hereby authorize AGL to act on telephone instructions to
transfer values among Divisions and to change allocations for future purchase
payments and monthly deductions.
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6. TELEPHONE PRIVILEGE AUTHORIZATION
Complete this section if you are applying for or revoking current telephone
privileges.
I (/we if Joint Owners) hereby authorize AGL to act on telephone instructions to
transfer values among Divisions and to change allocations for future purchase
payments and monthly deductions.
Initial the designation you prefer:
Policy Owner(s) only_If Joint Owners, either one acting independently.
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, l 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.
7. CORRECT AGE
Use this section to correct the age of any person covered under this policy.
Proof of the correct date of birth must accompany this request. Name of Insured
for whom this correction is submitted: ________________________
Correct DOB: ________/________/________
8. TRANSFER OF ACCUMULATED VALUES
Use this section if you want to move money between divisions. If a transfer
causes the balance in any division to drop below $5,000, AGL reserves the right
to transfer the remaining balance. There is a $25 charge for each transfer in
excess of 12 per maintaining consistency throughout.
(Division Name or Number) (Division Name or Number)
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
Transfer $ or % from to .
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9. CHANGE IN ALLOCATION PERCENTAGES
Use this section to indicate how premiums or monthly deductions are to be
allocated. Total allocation in each column must equal 100%; whole numbers only.
INVESTMENT DIVISION PREM % DED % INVESTMENT DIVISION
PREM % DED %
BT Insurance Funds Trust
(179) Equity 500 Index
(180) EAFE Equity Index
AIM Variable Insurance Funds, Inc.
(181) AIM V.l. Int'l Equity
Morgan Stanley Universal Funds, Inc.
(182) Equity Growth
Royce Capital Fund
(183) Royce Total Return
American General Series Porfolio Company
(184) Money Market
10. AUTOMATIC REBALANCING
($100,000 minimum accumulation value) Use this section to apply for or make
changes to Automatic Rebalancing of the 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.
Indicate frequency: Quarterly Semi-Annually Annually
(Division Name or Number) (Division Name or Number)
% : % :
% : % :
% : % :
% : % :
% : % :
% : % :
Initial Here To Revoke Automatic Rebalancing Election.
11. REQUEST FOR PARTIAL SURRENDER/POLICY LOAN
Use this section to apply for a partial surrender or policy loan. Minimum Cash
Surrenter Value after a Partial Surrender or Loan must not be less than
$100,000. (There are some states which are excluded from the Minimum Cash
Surrender Value Provision.) For detailed information concerning these two
options please refer to your policy and its related prospectus.
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If applying for a partial surrender, be sure to complete the Notice of
Withholding section of this Service Request in addition to this section.
I request a partial surrender of $ or % of the net cash surrender value.
I request a loan in the amount of $ .
I request the maximum loan amount available from my policy.
Unless you direct otherwise below, proceeds are allocated according to the
deduction allocation percentages in effect, if available; otherwise they are
taken pro-rata from the Variable Divisions in use.
12. NOTICE OF WITHHOLDING
Complete this section if you have applied for a partial surrender in Section 11.
The taxable portion of the distribution you receive from your variable universal
life insurance policy 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 have withholding apply
by checking the appropriate box below. If you elect not to have withholding
apply to your distribution or if you do not have enough income tax withheld, you
may be responsible for payment of estimated tax. You may incur penalties under
the estimated tax rules, if your withholding 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.
13. AFFIRMATION/SIGNATURE
Complete this section for ALL requests.
CERTIFICATION: Under penalties of perjury, I certify: (1) that the number shown
on this form is my 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 consent to any
provision of this document other than the certification required to avoid backup
withholding.
Dated at__________________________________ this__________ day
of____________________________, 19________.
________________________________ ________________________________
XSignature of Owner XSignature of witness
________________________________ ________________________________
XSignature of Joint Owner XSignature of witness
________________________________ ________________________________
XSignature of Assignee XSignature of witness