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EXHIBIT (10)(d)
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AMERICAN
|GENERAL
|FINANCIAL GROUP
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JOINT AND LAST SURVIVOR
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 the marketing name for American General Corporation
and its subsidiaries.
(This supplement must accompany the appropriate application for life insurance.)
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Applicant Information - Supplement to the application on the lives of
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<S> <C> <C>
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Name of Proposed Contingent Insured Name of Other Proposed Contingent Insured Date of application for life insurance
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Initial Allocation Percentages
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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 charges.
Total allocations in each column must equal 100%. Use whole percentages only.
PREMIUM DEDUCTION PREMIUM DEDUCTION
ALLOCATION ALLOCATION ALLOCATION ALLOCATION
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AGL Declared Fixed Interest Account (18) _____% _____% NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Mid-Cap Growth Division (36) _____% ____%
AIM VARIABLE INSURANCE FUNDS
AIM V.I. International Equity Division (1) _____% _____% NORTH AMERICAN FUNDS VARIABLE PRODUCT SERIES I
AIM V.I. Value Division (2) _____% _____% International Equities Division (3) _____% _____%
MidCap Index Division (4) _____% _____%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. Money Market Division (5) _____% _____%
VP Value Division (19) _____% _____% Nasdaq-100 Index Division (20) _____% _____%
Science & Technology Division (21) _____% _____%
AYCO SERIES TRUST Small Cap Index Division (22) _____% _____%
Ayco Large Cap Growth Fund I Division (23) _____% _____% Stock Index Division (6) _____% _____%
DREYFUS INVESTMENT PORTFOLIOS PIMCO VARIABLE INSURANCE TRUST
MidCap Stock Division (24) _____% _____% PIMCO Real Return Bond Division (101) _____% _____%
PIMCO Short-Term Bond Division (37) _____% _____%
DREYFUS VARIABLE INVESTMENT FUND PIMCO Total Return Bond Division (102) _____% _____%
Quality Bond Division (7) _____% _____%
Small Cap Division (8) _____% _____% PUTNAM VARIABLE TRUST
Putnam VT Diversified Income Division (12) _____% _____%
FIDELITY VARIABLE INSURANCE PRODUCTS FUND Putnam VT Growth and Income Division (13) _____% _____%
VIP Asset Manager Division (28) _____% _____% Putnam VT Int'I Growth and Income Division (14) _____% _____%
VIP Contrafund Division (27) _____% _____%
VIP Equity-Income Division (25) _____% _____% SAFECO RESOURCE SERIES TRUST
VIP Growth Division (26) _____% _____% Equity Division (15) _____% _____%
Growth Opportunities Division (16) _____% _____%
JANUS ASPEN SERIES - SERVICE SHARES
Aggressive Growth Division (31) _____% _____% THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
International Growth Division (29) _____% _____% Equity Growth Division (10) _____% _____%
Worldwide Growth Division (30) _____% _____% High Yield Division (11) _____% _____%
J.P. MORGAN SERIES TRUST II VANGUARD VARIABLE INSURANCE FUND
J.P. Morgan Small Company Division (32) _____% _____% High Yield Bond Division (103) _____% _____%
REIT Index Division (104) _____% _____%
MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (34) _____% _____% VAN KAMPEN LIFE INVESTMENT TRUST
MFS Emerging Growth Division (9) _____% _____% Strategic Stock Division (17) _____% _____%
MFS New Discovery Division (35) _____% _____%
MFS Research Division (33) _____% _____% WARBURG PINCUS TRUST
Small Company Growth Division (105) _____% _____%
Other:_____________________________ _____% _____%
100% 100%
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AGLC 0093-99 REV 0800 Page 1 of 4
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Dollar Cost Averaging
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Dollar Cost ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from the Money Market
Averaging 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.
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)
AIM VARIABLE INSURANCE FUNDS NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
AIM V.I. International Equity Division (1) $__________ Mid-Cap Growth Division (36) $__________
AIM V.I. Value Division (2) $__________
NORTH AMERICAN FUNDS VARIABLE PRODUCT SERIES I
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. International Equities Division (3) $__________
VP Value Division (19) $__________ MidCap Index Division (4) $__________
Nasdaq-100 Index Division (20) $__________
AYCO SERIES TRUST Science & Technology Division (21) $__________
Ayco Large Cap Growth Fund I Division (23) $__________ Small Cap Index Division (22) $__________
Stock Index Division (6) $__________
DREYFUS INVESTMENT PORTFOLIOS
MidCap Stock Division (24) $__________ PIMCO VARIABLE INSURANCE TRUST
PIMCO Real Return Bond Division (101) $__________
DREYFUS VARIABLE INVESTMENT FUND PIMCO Short-Term Bond Division (37) $__________
Quality Bond Division (7) $__________ PIMCO Total Return Bond Division (102) $__________
Small Cap Division (8) $__________
PUTNAM VARIABLE TRUST
FIDELITY VARIABLE INSURANCE PRODUCTS FUND Putnam VT Diversified Income Division (12) $__________
VIP Asset Manager Division (28) $__________ Putnam VT Growth and Income Division (13) $__________
VIP Contrafund Division (27) $__________ Putnam VT Int'I Growth and Income Division (14) $__________
VIP Equity-Income Division (25) $__________
VIP Growth Division (26) $__________ SAFECO RESOURCE SERIES TRUST
Equity Division (15) $__________
JANUS ASPEN SERIES - SERVICE SHARES Growth Opportunities Division (16) $__________
Aggressive Growth Division (31) $__________
International Growth Division (29) $__________ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
Worldwide Growth Division (30) $__________ Equity Growth Division (10) $__________
High Yield Division (11) $__________
J.P. MORGAN SERIES TRUST II
J.P Morgan Small Company Division (32) $__________ VANGUARD VARIABLE INSURANCE FUND
High Yield Bond Division (103) $__________
MFS VARIABLE INSURANCE TRUST REIT Index Division (104) $__________
MFS Capital Opportunities Division (34) $__________
MFS Emerging Growth Division (9) $__________ VAN KAMPEN LIFE INVESTMENT TRUST
MFS New Discovery Division (35) $__________ Strategic Stock Division (17) $__________
MFS Research Division (33) $__________
WARBURG PINCUS TRUST
Small Company Growth Division (105) $__________
OTHER _______________________________ $__________
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Automatic Rebalancing
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Automatic ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically rebalanced based on the
Rebalancing 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
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NOTE: Automatic Rebalancing is not available if the Dollar Cost Averaging option has been chosen.
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Modified Endowment Contract
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Contract If any premium payment causes the policy to be classified as a modified endowment contract under Section 7702A of the
Internal Revenue Code, there may be potentially adverse 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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AGLC 0093-99 REV 0800 Page 2 of 4
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Death Benefit Compliance Test
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[_] Guideline Premium Test [_] Cash Value Accumulation Test
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Specified Amount
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Base Coverage $______________________plus Supplemental Coverage $ _________________________ = Total Specified Amount $ _____________
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Telephone Authorization
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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 premium payments and monthly deductions given by:
Initial appropriate [ ] Policy Owner(s)- if Joint Owners, either of us acting independently.
box here:
[ ] 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.
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Suitability
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All questions must 1. Have you, the Proposed Insured(s) or Owner(s) (if different), received the variable universal life
be answered. 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 and acknowledge:
a. THAT THE POLICY APPLIED FOR IS VARIABLE, EMPLOYS THE USE OF SEGREGATED ACCOUNTS WHICH
MEANS THAT YOU NEED TO RECEIVE AND UNDERSTAND CURRENT PROSPECTUSES FOR THE POLICY AND
THE UNDERLYING ACCOUNTS? [_] yes [_] no
b. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED
ACCOUNTS MAY VARY: AND [_] yes [_] no
(1) ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S.
GOVERNMENT OR ANY STATE GOVERNMENT? [_] yes [_] no
(2) ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OR ANY
OTHER AGENCY, FEDERAL OR STATE? [_] yes [_] no
c. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN
THE AGL DECLARED FIXED INTEREST ACCOUNT? [_] yes [_] no
d. THAT THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR
THE ACCUMULATION OF VALUES IN THE SEGREGATED ACCOUNTS? [_] yes [_] no
e. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING
ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT? [_] yes [_] no
f. 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
3. Do you believe the Policy you selected meets your insurance and investment
objectives and your anticipated financial needs? [_] yes [_] no
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AGLC 0093-99 REV 0800 Page 3 of 4
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Your Signature
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Signatures Signed at (city, state)
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Print name of Broker/Dealer
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X Registered Representative State license # Date
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X Proposed Contingent Insured Date
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X Other Proposed Contingent Insured Date
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X Owner Date
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(If different from Proposed Contingent Insured)
X Additional Owner Date
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(If different from Proposed Contingent Insured)
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AGLC 0093-99 REV 0800 Page 4 of 4
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