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EXHIBIT (10)(d)
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[Logo of American General Financial Group]
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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 OF THE LIFE OF
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JOHN DOE 7/21/00
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Name of proposed 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 account 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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[AIM VARIABLE INSURANCE FUNDS MFS VARIABLE INSURANCE TRUST
AIM V.I. International Equity Division (260) 100% 100% MFS Emerging Growth Division (282) ___% ___%
AIM V.I. Value Division (261) ___% ___% MFS Research Division (283) ___% ___%
AMERICAN CENTURY VARIABLE PORTFOLIO, INC. MFS Capital Opportunities Division (284) ___% ___%
VP Value Division (262) ___% ___% MFS New Discoveries Division (285) ___% ___%
AMERICAN GENERAL SERIES PORTFOLIO COMPANY NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
International Equities Division (263) ___% ___% Mid-Cap Growth Division (286) ___% ___%
MidCap Index Division (264) ___% ___% PIMCO VARIABLE INSURANCE TRUST
Money Market Division (265) ___% ___% PIMCO Short-Term Bond Division (287) ___% ___%
Nasdaq-100 Index Division (266) ___% ___% PIMCO Real Return Bond Division (288) ___% ___%
Stock Index Division (267) ___% ___% PIMCO Total Return Bond Division (289) ___% ___%
Small Cap Index Division (268) ___% ___% PUTNAM VARIABLE TRUST
Science & Technology Division (269) ___% ___% Putnam VT Diversified Income Division (290) ___% ___%
AYCO SERIES TRUST Putnam VT Growth & Income Division (291) ___% ___%
AYCO Large Cap Growth Fund I (270) ___% ___% Putnam VT Int'l Growth & Income Division (292) ___% ___%
DREYFUS VARIABLE INVESTMENT FUND SAFECO RESOURCE SERIES TRUST
Quality Bond Division (271) ___% ___% Equity Division (293) ___% ___%
Small Cap Division (272) ___% ___% Growth Opportunities Division (294) ___% ___%
Mid-Cap Stock Division (273) ___% ___% THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
FIDELITY VIPII FUNDS Equity Growth Division (295) ___% ___%
VIPII Equity Income Division (274) ___% ___% High Yield Division (296) ___% ___%
VIPII Growth Division (275) ___% ___% VANGUARD VARIABLE INSURANCE FUND
VIPII Contrafund Division (276) ___% ___% High Yield Bond Division (297) ___% ___%
VIPII Asset Manager Division (277) ___% ___% REIT Index Division (298) ___% ___%
JANUS ASPEN SERIES VAN KAMPEN LIFE INVESTMENT TRUST
International Growth Division (278) ___% ___% Strategic Stock Division (299) ___% ___%
Worldwide Growth Division (279) ___% ___% WARBURG PINCUS TRUST
Aggressive Growth Division (280) ___% ___% Small Company Growth Division (300) ___% ___%
J.P. MORGAN SERIES TRUST II AGL Declared Fixed Interest Account (301) ___% ___%
J.P. Morgan Small Company Division (281) ___% ___% Other: ___________________________________ ___% ___%]
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AGLC 0198-00 PAGE 1 of 3
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DOLLAR COST AVERAGING
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DOLLAR COST AVERAGING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be 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.
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 MFS VARIABLE INSURANCE TRUST
AIM V.I. International Equity Division (260) $______ MFS Emerging Growth Division (282) $______
AIM V.I. Value Division (261) $______ MFS Research Division (283) $______
AMERICAN CENTURY VARIABLE PORTFOLIO, INC. MFS Capital Opportunities Division (284) $______
VP Value Division (262) $______ MFS New Discoveries Division (285) $______
AMERICAN GENERAL SERIES PORTFOLIO COMPANY NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
International Equities Division (263) $______ Mid-Cap Growth Division (286) $______
MidCap Index Division (264) $______ PIMCO VARIABLE INSURANCE TRUST
Nasdaq-100 Index Division (266) $______ PIMCO Short-Term Bond Division (287) $______
Stock Index Division (267) $______ PIMCO Real Return Bond Division (288) $______
Small Cap Index Division (268) $______ PIMCO Total Return Bond Division (289) $______
Science & Technology Division (269) $______ PUTNAM VARIABLE TRUST
AYCO SERIES TRUST Putnam VT Diversified Income Division (290) $______
AYCO Large Cap Growth Fund I (270) $______ Putnam VT Growth & Income Division (291) $______
DREYFUS VARIABLE INVESTMENT FUND Putnam VT Int'l Growth & Income Division (292) $______
Quality Bond Division (271) $______ SAFECO RESOURCE SERIES TRUST
Small Cap Division (272) $______ Equity Division (293) $______
Mid-Cap Stock Division (273) $______ Growth Opportunities Division (294) $______
FIDELITY VIPII FUNDS THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIPII Equity Income Division (274) $______ Equity Growth Division (295) $______
VIPII Growth Division (275) $______ High Yield Division (296) $______
VIPII Contrafund Division (276) $______ VANGUARD VARIABLE INSURANCE FUND
VIPII Asset Manager Division (277) $______ High Yield Bond Division (297) $______
JANUS ASPEN SERIES REIT Index Division (298) $______
International Growth Division (278) $______ VAN KAMPEN LIFE INVESTMENT TRUST
Worldwide Growth Division (279) $______ Strategic Stock Division (299) $______
Aggressive Growth Division (280) $______ WARBURG PINCUS TRUST
J.P. MORGAN SERIES TRUST II Small Company Growth Division (300) $______
J.P. Morgan Small Company Division (281) $______ Other: ___________________________________ $______]
100%
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AUTOMATIC REBALANCING
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AUTOMATIC REBALANCING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division 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.
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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
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.
[X] YES [ ] NO
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AGLC 0198-00 PAGE 2 of 3
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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
purchase payments and monthly deductions given by:
INITIAL APPROPRIATE
BOX HERE: [_] Policy Owner(s) - If Joint Owners, either of us 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.
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SUITABILITY
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ALL QUESTIONS MUST
BY 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 option? [X] 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? [X] 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? [X] yes [_] no
c. THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO
ALLOW FOR THE ACCUMULATION OF VALUES IN THE SEPARATE ACCOUNT? [X] yes [_] no
3. Do you believe the Policy you selected meets your insurance and
investment objectives and your anticipated financial needs? [X] yes [_] no
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YOUR SIGNATURE
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SIGNATURES Signed at (city, state) Anytown, USA
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Print name of Broker/Dealer
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X Registered representative State license # Date
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X Primary proposed insured John Doe Date 7/21/00
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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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AGLC 0198-00 PAGE 3 of 3
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