EXHIBIT (10)(d)
AIG AMERICAN PLATINUM INVESTOR PLUS
|GENERAL VARIABLE UNIVERSAL LIFE INSURANCE
SUPPLEMENTAL APPLICATION
AMERICAN GENERAL LIFE INSURANCE COMPANY, ("AGL")
Member of American International Group, Inc. This supplement must accompany the appropriate
Home Office: Houston, TX application for life insurance.
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APPLICANT INFORMATION - SUPPLEMENT TO THE APPLICATION ON THE LIFE OF
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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 NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
AIM V.I. International Growth Division (316)_____% _____% Mid-Cap Growth Division (342) _____% ____%
AIM V.I. Premier Equity Division (317) _____% _____%
PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. PIMCO Real Return Division (344) _____% _____%
VP Value Division (318) _____% _____% PIMCO Short-Term Division (343) _____% _____%
PIMCO Total Return Division (345) _____% _____%
AYCO SERIES TRUST
Ayco Growth Division (326) _____% _____% PUTNAM VARIABLE TRUST
Putnam VT Diversified Income Division (346) _____% _____%
CREDIT SUISSE TRUST Putnam VT Growth and Income Division (347) _____% _____%
Small Cap Growth Division (356) _____% _____% Putnam VT Int'l Growth and Income Division (348) _____% _____%
DREYFUS INVESTMENT PORTFOLIOS SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (329) _____% _____% Equity Division (349) _____% _____%
Growth Opportunities Division (350) _____% _____%
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (327) _____% _____% SUNAMERICA SERIES TRUST
Small Cap Division (328) _____% _____% SunAmerica Balanced Division (360) _____% _____%
Aggressive Growth Division (361) _____% _____%
FIDELITY VARIABLE INSURANCE PRODUCTS FUND
VIP Asset Manager Division (333) _____% _____% THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Contrafund Division (332) _____% _____% Equity Growth Division (351) _____% _____%
VIP Equity-Income Division (330) _____% _____% High Yield Division (352) _____% _____%
VIP Growth Division (331) _____% _____%
VALIC COMPANY I
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST International Equities Division (319) _____% _____%
Franklin U.S. Government Division (357) _____% _____% Mid Cap Index Division (320) _____% _____%
Mutual Shares Securities Division (358) _____% _____% Money Market I Division (321) _____% _____%
Templeton Foreign Securities Division (359) _____% _____% Nasdaq-100 Index Division (322) _____% _____%
Science & Technology Division (325) _____% _____%
JANUS ASPEN SERIES Small Cap Index Division (324) _____% _____%
Aggressive Growth Division (336) _____% _____% Stock Index Division (323) _____% _____%
International Growth Division (334) _____% _____%
Worldwide Growth Division (335) _____% _____% VANGUARD VARIABLE INSURANCE FUND
High Yield Bond Division (353) _____% _____%
J.P. MORGAN SERIES TRUST II REIT Index Division (354) _____% _____%
JPMorgan Small Company Division (337) _____% _____%
VAN KAMPEN LIFE INVESTMENT TRUST
MFS VARIABLE INSURANCE TRUST Growth & Income Division (355) _____% _____%
MFS Capital Opportunities Division (340) _____% _____%
MFS Emerging Growth Division (338) _____% _____% AGL DECLARED FIXED INTEREST ACCOUNT (301) _____% _____%
MFS New Discovery Division (341) _____% _____% OTHER:_____________________________ _____% _____%
MFS Research Division (339) _____% _____% 100% 100%
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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 NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
AIM V.I. International Growth Division (316) $__________ Mid-Cap Growth Division (342) $__________
AIM V.I. Premier Equity Division (317) $__________
PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. PIMCO Real Return Division (344) $__________
VP Value Division (318) $__________ PIMCO Short-Term Division (343) $__________
PIMCO Total Return Division (345) $__________
AYCO SERIES TRUST
Ayco Growth Division (326) $__________ PUTNAM VARIABLE TRUST
Putnam VT Diversified Income Division (346) $__________
CREDIT SUISSE TRUST Putnam VT Growth and Income Division (347) $__________
Small Cap Growth Division (356) $__________ Putnam VT Int'l Growth and Income Division (348) $__________
DREYFUS INVESTMENT PORTFOLIOS SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (329) $__________ Equity Division (349) $__________
Growth Opportunities Division (350) $__________
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (327) $__________ SUNAMERICA SERIES TRUST
Small Cap Division (328) $__________ SunAmerica Balanced Division (360) $__________
Aggressive Growth Division (361) $__________
FIDELITY VARIABLE INSURANCE PRODUCTS FUNDS
VIP Asset Manager Division (333) $__________ THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Contrafund Division (332) $__________ Equity Growth Division (351) $__________
VIP Equity-Income Division (330) $__________ High Yield Division (352) $__________
VIP Growth Division (331) $__________
VALIC COMPANY I
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST International Equities Division (319) $__________
Franklin U.S. Government Division (357) $__________ Mid Cap Index Division (320) $__________
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
JPMorgan Small Company Division (337) $__________ VAN KAMPEN LIFE INVESTMENT TRUST
Growth & Income Division (355) $__________
MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (340) $__________ OTHER:_______________________________ $__________
MFS Emerging Growth Division (338) $__________
MFS New Discovery Division (341) $__________
MFS Research Division (339) $__________
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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 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 MUST 1. Have you, the Proposed Insured or Owner (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 100175-2002 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 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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AGLC 100175-2002 Page 4 of 4