AIG AMERICAN PLATINUM INVESTOR PLUS
|GENERAL VARIABLE UNIVERSAL LIFE INSURANCE
SUPPLEMENTAL APPLICATION
American General Life Insurance Company, ("AGL")
(This supplement must accompany the appropriate application for life insurance.) Member of American International Group, Inc.
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APPLICANT INFORMATION - SUPPLEMENT TO THE APPLICATION ON THE LIFE OF
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JOHN DOE 1/21/02
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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 PIMCO VARIABLE INSURANCE TRUST
AIM V.I. International Growth Division (316) 100% 100% PIMCO Real Return Bond Division (344) _____% _____%
AIM V.I. Premier Equity Division (317) _____% _____% PIMCO Short-Term Bond Division (343) _____% _____%
PIMCO Total Return Bond Division (345) _____% _____%
AMERICAN CENTURY VARIABLE Portfolios, Inc.
VP Value Division (318) _____% _____% PUTNAM VARIABLE TRUST
Putnam VT Diversified Income Division (346) _____% _____%
AYCO SERIES TRUST Putnam VT Growth and Income Division (347) _____% _____%
Ayco Growth Division (326) _____% _____% Putnam VT Int'l Growth and Income Division (348) _____% _____%
CREDIT SUISSE TRUST SAFECO Resource Series Trust
Small Cap Growth Division (356) _____% _____% Equity Division (349) _____% _____%
Growth Opportunities Division (350) _____% _____%
DREYFUS INVESTMENT PORTFOLIOS
MidCap Stock Division (329) _____% _____% FUND COMPANY "X"
"A" Division (xxx) _____% _____%
DREYFUS VARIABLE INVESTMENT FUND "B" Division (xxx) _____% _____%
Quality Bond Division (327) _____% _____% "C" Division (xxx) _____% _____%
Small Cap Division (328) _____% _____% "D" Division (xxx) _____% _____%
FIDELITY VARIABLE INSURANCE PRODUCTS FUND THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Asset Manager Division (333) _____% _____% Equity Growth Division (351)
VIP Contrafund Division (332) _____% _____% High Yield Division (352)
VIP Equity-Income Division (330) _____% _____%
VIP Growth Division (331) _____% _____% VALIC COMPANY I
International Equities Division (319) _____% _____%
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST Mid Cap Index Division (320) _____% _____%
Franklin U.S. Government Division (357) _____% _____% Money Market I Division (321) _____% _____%
Mutual Shares Securities Division (358) _____% _____% Nasdaq-100 Index Division (322) _____% _____%
Templeton Foreign Securities Division (359) _____% _____% Science & Technology Division (325) _____% _____%
Small Cap Index Division (324) _____% _____%
JANUS ASPEN SERIES Stock Index Division (323) _____% _____%
Aggressive Growth Division (336) _____% _____%
International Growth Division (334) _____% _____% VANGUARD VARIABLE INSURANCE FUND
Worldwide Growth Division (335) _____% _____% High Yield Bond Division (353) _____% _____%
REIT Index Division (354) _____% _____%
J.P. MORGAN SERIES TRUST II
J.P. Morgan Small Company Division (337) _____% _____% VAN KAMPEN LIFE INVESTMENT TRUST
Growth & Income Division (355) _____% _____%
MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (340) _____% _____% AGL DECLARED FIXED INTEREST ACCOUNT (301)
MFS Emerging Growth Division (338) _____% _____% OTHER:___________________________________ _____% _____%]
MFS New Discovery Division (341) _____% _____% 100% 100%
MFS Research Division (339) _____% _____%
NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Mid-Cap Growth Division (342) _____% _____%
AGLC 100175-2002 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 I
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 PIMCO VARIABLE INSURANCE TRUST
AIM V.I. International Growth Division (316) $__________ PIMCO Real Return Bond Division (334) $__________
AIM V.I. Premier Equity Division (317) $__________ PIMCO Short-Term Bond Division (343) $__________
PIMCO Total Return Bond Division (345) $__________
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.
VP Value Division (318) $__________ PUTNAM VARIABLE TRUST
Putnam VT Diversified Income Division (346) $__________
AYCO SERIES TRUST Putnam VT Growth and Income Division (347) $__________
Ayco Growth Division (326) $__________ Putnam VT Int'I Growth and Income Division (348) $__________
CREDIT SUISSE TRUST SAFECO RESOURCE SERIES TRUST
Small Cap Growth Division (356) $__________ Equity Division (349) $__________
Growth Opportunities Division (350) $__________
DREYFUS INVESTMENT PORTFOLIOS
MidCap Stock Division (329) $__________ FUND COMPANY "X"
"A" Division (xxx) $__________
DREYFUS VARIABLE INVESTMENT FUND "B" Division (xxx) $__________
Quality Bond Division (327) $__________ "C" Division (xxx) $__________
Small Cap Division (328) $__________ "D" Division (xxx) $__________
FIDELITY VARIABLE INSURANCE PRODUCTS FUND THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Asset Manager Division (333) $__________ Equity Growth Division (351) $__________
VIP Contrafund Division (332) $__________ High Yield Division (352) $__________
VIP Equity-Income Division (330) $__________
VIP Growth Division (331) $__________ VALIC COMPANY I
International Equities Division (319) $__________
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST Mid Cap Index Division (320) $__________
Franklin U.S. Government Division (357) $__________ Money Market I Division (321) $__________
Mutual Shares Securities Division (358) $__________ Nasdaq-100 Index Division (322) $__________
Templeton Foreign Securities Division (359) $__________ Science & Technology Division (325) $__________
Small Cap Index Division (324) $__________
JANUS ASPEN SERIES Stock Index Division (323) $__________
Aggressive Growth Division (336) $__________
International Growth Division (334) $__________ VANGUARD VARIABLE INSURANCE FUND
Worldwide Growth Division (335) $__________ High Yield Bond Division (353) $__________
REIT Index Division (354) $__________
J.P. MORGAN SERIES TRUST II
J.P Morgan Small Company Division (337) $__________ VAN KAMPEN LIFE INVESTMENT TRUST
Growth & Income Division (355) $__________
MFS VARIABLE INSURANCE TRUST OTHER: _______________________________ $__________
MFS Capital Opportunities Division (340) $__________
MFS Emerging Growth Division (338) $__________
MFS New Discovery Division (341) $__________
MFS Research Division (339) $__________
NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Mid-Cap Growth Division (342) $__________
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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 [x] NO
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AGLC 100175-2002 Page 2 of 4
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TELEPHONE AUTHORIZATION
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INITIAL APPROPRIATE I (or we, if Joint Owners), hereby authorize American General Life Insurance Company ("AGL") to act on
BOX HERE: 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:
[ ] 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 1. Have you, the Proposed Insured or Owner (if different), received the variable universal
MUST BE ANSWERED. life insurance policy prospectus and the prospectuses describing the investment options? [ ] yes [X] 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 [X] no
b. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED
ACCOUNTS MAY VARY; AND [ ] yes [X] no
(1) ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S.
GOVERNMENT OR ANY STATE GOVERNMENT? [ ] yes [X] no
(2) ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OR ANY
OTHER AGENCY, FEDERAL OR STATE? [ ] yes [X] no
c. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN
THE AGL DECLARED FIXED INTEREST ACCOUNT? [ ] yes [X] 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 [X] no
e. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE,
DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT? [ ] yes [X] 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 [X] no
3. Do you believe the Policy you selected meets your insurance and investment objectives
and your anticipated financial needs: [ ] yes [X] no
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AGLC 100175-2002 Page 3 of 4
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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 1/21/01
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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 100175-2002 Page 4 of 4