EXHIBIT 10(e)
AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
Home Office: Houston, Texas
VARIABLE UNIVERSAL LIFE
INSURANCE SUPPLEMENTAL APPLICATION
(This supplement must accompany the appropriate application for life insurance.)
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PART 1. APPLICANT INFORMATION
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Supplement to the application on the life of ________________ JOHN DOE_______________________, dated _____________________________.
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PART 2. 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
Divisions Allocation Allocation Divisions Allocation Allocation
- --------- ---------- ---------- --------- ---------- ----------
[AIM VARIABLE INSURANCE FUNDS, INC. PUTNAM VARIABLE TRUST
AIM V.I. International Equity (81) 100% 100% Putnam VT Diversified Income (87) ___% ___%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. FRANKLIN TEMPLETON VARIABLE INSURANCE
VP Value (82) ___% ___% PRODUCTS TRUST
AMERICAN GENERAL SERIES PORTFOLIO CO. Franklin Small Cap (88) ___% ___%
Money Market (83) ___% ___% TEMPLETON VARIABLE PRODUCTS SERIES FUND
MFS(R) VARIABLE INSURANCE TRUST Templeton Inernational (89) ___% ___%
MFS Total Return (84) ___% ___% VAN KAMPEN LIFE INVESTMENT TRUST
NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST Emerging Growth (90) ___% ___%
Partners Portfolio (85) ___% ___% VICTORY VARIABLE INSURANCE FUNDS
OPPENHEIMER VARIABLE ACCOUNT FUNDS Diversified Stock (91) ___% ___%
Oppeneimer High Income (86) ___% ___% Investment Quality Bond (92) ___% ___%
Small Cap Opportunity (93) ___% ___%
Other: ________________________________ ___% ___%]
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PART 3. 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 (83)] and transferred to one or more of the investment divisions below. 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) from the [Money Market (83)] to the following division(s):
[AIM V.I. International Equity (81) $______ Templeton International (89) $______
VP Value (82) $______ Emerging Growth (90) $______
MFS Total Return (84) $______ Diversified Stock (91) $______
Partners Portfolio (85) $______ Investment Quality Bond (92) $______
Oppenheimer High Income (86) $______ Small Cap Opportunity (93) $______
Putnam VT Diversified Income (87) $______ Other: ________________________________ $______]
Franklin Small Cap (88) $______
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PART 4. 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 in Part 2. 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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PAGE 1 of 2
AGLC 0091
AMERICAN GENERAL LIFE INSURANCE COMPANY
Home Office: Houston, Texas
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PART 5. 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 to change allocations for future purchase payments and monthly deductions given by:
(INITIAL APPROPRIATE BOX BELOW.)
[ ] Policy Owner(s) ONLY -- 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.
[ ] INITIAL HERE TO DECLINE THE ABOVE TELEPHONE AUTHORIZATION.
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PART 6. MODIFIED ENDOWMENT CONTRACT
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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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PART 7. SUITABILITY (All questions must be answered.)
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YES NO
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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? [ ] [ ]
(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? [ ] [ ]
b. THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE
ACCOUNT AND CERTAIN EXPENSE DEDUCTIONS? [ ] [ ]
c. The policy is designed to provide life insurance coverage and to allow for the accumulation of
values in the Separate Account? [ ] [ ]
3. Do you believe the Policy you selected meets your insurance and investment objectives and your
anticipated financial needs? [ ] [ ]
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Signed at: Any Town USA Date: 10/1/99
_________________________________________________________________________ ___________________________________
CITY STATE
John Doe
X______________________________________________________________ X______________________________________________________________
SIGNATURE OF PRIMARY PROPOSED INSURED SIGNATURE OF REGISTERED REPRESENTATIVE
X______________________________________________________________ ______________________________________________________________
SIGNATURE OF OWNER (if different from Proposed Insured) PRINT NAME OF BROKER/DEALER
X______________________________________________________________
SIGNATURE OF JOINT OWNER (if applicable)
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AGLC 0091 Page 2 of 2