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EXHIBIT 10(d)
AMERICAN
|GENERAL
|FINANCIAL GROUP
VARIABLE UNIVERSAL LIFE INSURANCE
SUPPLEMENTAL APPLICATION
AMERICAN GENERAL LIFE INSURANCE COMPANY, ("AGL")
Home Office: Houston, Texas
Member of American General Financial Group. American General
Financial Group is a marketing name for American General
Corporation and its subsidiaries.
(This supplement must accompany the appropriate application
for life insurance.)
Applicant Information -- Supplement to the application on the life of
------------------------ ----------------------------
Name of proposed insured Date of application for life
insurance
Initial Allocation Percentages
Allocation Styles By selecting an Allocation Style below, you agree to
allocate 100% of your premium as designated in the most
recent publication of Platinum Investor VUL Allocation
Styles.
<TABLE>
<CAPTION>
<S> <C> <C>
[ ] Capital preservation [ ] Income and growth [ ] Growth and income [ ] Growth
[ ] Aggressive growth [ ] All equity [ ] _________________ [ ] ______
</TABLE>
NOTE: If an Allocation Style is selected, the deduction of
monthly account charges will be allocated in the same
percentage as the premium allocation.
<TABLE>
<CAPTION>
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This section to be completed only if an Allocation Style has not been chosen.
Investment Options In the "Premium Allocation" column, indicate how each premium received is to be allocated. In the "Deduction
Allocation" column, indicate which investment options are to be used for the deduction of monthly account
charges. Total allocations in each column must equal 100%. Use whole percentages only.
PREMIUM DEDUCTION PREMIUM DEDUCTION
ALLOCATION ALLOCATION ALLOCATION ALLOCATION
---------- ---------- ---------- ----------
<S> <C> <C> <C> <C> <C>
AGL Declared Fixed Interest Account (125) ____% ____% NORTH AMERICAN FUNDS VARIABLE PRODUCT SERIES I
International Equities Division (128) ____% ____%
AIM VARIABLE INSURANCE FUNDS MidCap Index Division (129) ____% ____%
AIM V.I. International Equity Division (126) ____% ____% Money Market Division (130) ____% ____%
AIM V.I. Value Division (127) ____% ____% Nasdaq-100 Index Division (225) ____% ____%
Science & Technology Division (227) ____% ____%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. Small Cap Index Division (226) ____% ____%
VP Value Division (224) ____% ____% Stock Index Division (131) ____% ____%
AYCO SERIES TRUST PIMCO VARIABLE INSURANCE TRUST
Ayco Large Cap Growth Fund I Division (228) ____% ____% PIMCO Real Return Bond Division (243) ____% ____%
PIMCO Short-Term Bond Division (242) ____% ____%
DREYFUS INVESTMENT PORTFOLIOS PIMCO Total Return Bond Division (244) ____% ____%
MidCap Stock Division (229) ____% ____%
PUTNAM VARIABLE TRUST
DREYFUS VARIABLE INVESTMENT FUND Putnam VT Diversified Income Division (137) ____% ____%
Quality Bond Division (132) ____% ____% Putnam VT Growth & Income Division (138) ____% ____%
Small Cap Division (133) ____% ____% Putnam VT Int'l Growth & Income Division (139) ____% ____%
FIDELITY VARIABLE INSURANCE PRODUCTS FUNDS SAFECO RESOURCE SERIES TRUST
VIP Asset Manager Division (233) ____% ____% Equity Division (140) ____% ____%
VIP Contrafund Division (232) ____% ____% Growth Opportunities Division (141) ____% ____%
VIP Equity-Income Division (230) ____% ____%
VIP Growth Division (231) ____% ____% THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
Equity Growth Division (135) ____% ____%
JANUS ASPEN SERIES - SERVICE SHARES High Yield Division (136) ____% ____%
Aggressive Growth Division (236) ____% ____%
International Growth Division (234) ____% ____% VANGUARD VARIABLE INSURANCE FUND
Worldwide Growth Division (235) ____% ____% High Yield Bond Division (245) ____% ____%
REIT Index Division (246) ____% ____%
J.P. MORGAN SERIES TRUST II
J.P. Morgan Small Company Division (237) ____% ____% VAN KAMPEN LIFE INVESTMENT TRUST
Strategic Stock Division (142) ____% ____%
MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (239) ____% ____% WARBURG PINCUS TRUST
MFS Emerging Growth Division (134) ____% ____% Small Company Growth Division (247) ____% ____%
MFS New Discovery Division (240) ____% ____%
MFS Research Division (238) ____% ____% Other:_____________________________ ____% ____%
100% 100%
NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Mid-Cap Growth Division (241) ____% ____%
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</TABLE>
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Dollar Cost Averaging
Dollar Cost ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be
Averaging systematically transferred from the Money Market Division and
transferred to one or more of the investment options below. The AGL
Declared Fixed Interest Account is not available for Dollar Cost
Averaging. Please refer to the prospectus for more information on
the Dollar Cost Averaging option.
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<CAPTION>
Day of the month for transfers: (Choose a day of the month between 1-28.)
-------------------------------------- -----------------------------------------
Frequency of transfers: [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
----------------------- ----------- ------------- ---------------- ------------
Transfer $ ($100 minimum, Whole Dollars Only)
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PREMIUM PREMIUM
ALLOCATION ALLOCATION
---------- ----------
<S> <C> <C> <C>
AIM VARIABLE INSURANCE FUNDS NORTH AMERICAN FUNDS VARIABLE PRODUCT SERIES I
AIM V.I. International Equity Division (126) $_________ International Equities Division (128) $_________
AIM V.I. Value Division (127) $_________ MidCap Index Division (129) $_________
Nasdaq-100 Index Division (225) $_________
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. Science & Technology Division (227) $_________
VP Value Division (224) $_________ Small Cap Index Division (226) $_________
Stock Index Division (131) $_________
AYCO SERIES TRUST
Ayco Large Cap Growth Fund I Division (228) $_________ PIMCO VARIABLE INSURANCE TRUST
PIMCO Real Return Bond Division (243) $_________
DREYFUS INVESTMENT PORTFOLIOS PIMCO Short-Term Bond Division (242) $_________
MidCap Stock Division (229) $_________ PIMCO Total Return Bond Division (244) $_________
DREYFUS VARIABLE INVESTMENT FUND PUTNAM VARIABLE TRUST
Quality Bond Division (132) $_________ Putnam VT Diversified Income Division (137) $_________
Small Cap Division (133) $_________ Putnam VT Growth & Income Division (138) $_________
Putnam VT Int'l Growth & Income Division (139) $_________
FIDELITY VARIABLE INSURANCE PRODUCTS FUNDS
VIP Asset Manager Division (233) $_________ SAFECO RESOURCE SERIES TRUST
VIP Contrafund Division (232) $_________ Equity Division (140) $_________
VIP Equity-Income Division (230) $_________ Growth Opportunities Division (141) $_________
VIP Growth Division (231) $_________
THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
JANUS ASPEN SERIES - SERVICE SHARES Equity Growth Division (135) $_________
Aggressive Growth Division (236) $_________ High Yield Division (136) $_________
International Growth Division (234) $_________
Worldwide Growth Division (235) $_________ VANGUARD VARIABLE INSURANCE FUND
High Yield Bond Division (245) $_________
J.P. MORGAN SERIES TRUST II REIT Index Division (246) $_________
J.P. Morgan Small Company Division (237) $_________
VAN KAMPEN LIFE INVESTMENT TRUST
MFS VARIABLE INSURANCE TRUST Strategic Stock Division (142) $_________
MFS Capital Opportunities Division (239) $_________
MFS Emerging Growth Division (134) $_________ WARBURG PINCUS TRUST
MFS New Discovery Division (240) $_________ Small Company Growth Division (247) $_________
MFS Research Division (238) $_________
Other:______________________________ $_________
NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Mid-Cap Growth Division (241) $_________
</TABLE>
Automatic Rebalancing
Automatic ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division
Rebalancing assets will be automatically rebalanced based on the premium
percentages designated on Page 1 of this form. If the AGL Declared
Fixed Interest Account has been designated for premium allocation,
the rebalancing will be based on the proportion allocated to the
variable divisions. Please refer to the prospectus for more
information on the Automatic Rebalancing option.
CHECK HERE FOR AUTOMATIC REBALANCING FREQUENCY: [ ]Quarterly
[ ]Semiannually [ ]Annually
NOTE: Automatic Rebalancing is not available if the Dollar Cost
Averaging option has been chosen.
Modified Endowment Contract
Contract If any premium payment causes the policy to be classified as a
modified endowment contract under Section 7702A of the United
States Internal Revenue Code, there may be potentially adverse U.S.
tax consequences. Such consequences include: (1) withdrawals or
loans being taxed to the extent of gain; and (2) a 10% penalty tax
on the taxable amount. In order to avoid modified endowment status,
I request any excess premium that could cause such status to be
refunded.
[ ] YES [ ] NO
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Telephone Authorization
I (or we, if Joint Owners), hereby authorize American
General Life Insurance Company ("AGL") to act on telephone
instructions to transfer values among the variable
divisions and the AGL Declared Fixed Interest Account and
to change allocations for future purchase payments and
monthly deductions given by:
Initial appropriate [ ] Policy Owner(s)-- if Joint Owners, either of us
box here: acting independently.
[ ] Policy Owner(s) or the 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 instructions received and acted on in good
faith, including losses due to telephone instruction
communication errors. AGL's liability for erroneous
transfers and 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 receipt
of confirmation of the transaction from AGL. I understand
that this authorization is subject to the terms and
provisions of my variable universal life insurance policy
and its related prospectus. This authorization will remain
in effect until my written notice of its revocation is
received by AGL at its home office.
[ ] INITIAL HERE TO DECLINE THE ABOVE TELEPHONE
AUTHORIZATION.
Suitability
All questions must
be answered.
1. Have you, the Proposed Insured or Owner
(if different), received the variable
universal life insurance policy prospectus
and the prospectuses describing the investment
options? [ ] yes [ ] no
(If "yes," please furnish the Prospectus dates.)
Variable Universal Life Insurance
Policy Prospectus: ___________
Supplements (if any): ___________
2. Do you understand that under the Policy
applied for:
a. THE AMOUNT OR DURATION OF THE DEATH
BENEFIT MAY INCREASE OR DECREASE,
DEPENDING ON THE INVESTMENT EXPERIENCE
OF THE SEPARATE ACCOUNT? [ ] yes [ ] no
b. THE POLICY VALUES MAY INCREASE OR DECREASE,
DEPENDING ON THE INVESTMENT EXPERIENCE OF THE
SEPARATE ACCOUNT, THE AGL DECLARED FIXED INTEREST
ACCOUNT ACCUMULATION, AND CERTAIN EXPENSE
DEDUCTIONS? [ ] yes [ ] no
c. THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE
COVERAGE AND TO ALLOW FOR THE ACCUMULATION OF
VALUES IN THE SEPARATE ACCOUNT? [ ] yes [ ] no
3. Do you believe the Policy you selected meets your
insurance and investment objectives and your
anticipated financial needs? [ ] yes [ ] no
Your Signature
Signatures Signed at (city, state)
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Print name of Broker/Dealer
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X Registered representative State license # Date
------------------------------ ------------------ ---------
X Primary proposed insured Date
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X Owner Date
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(If different from Proposed Insured)
X Joint Owner Date
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(If applicable)
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