EXHIBIT (10)(b)
THE UNITED STATES LIFE INSURANCE COMPANY
IN THE CITY OF NEW YORK("USL")
Administrative Center: Houston, TX
VARIABLE UNIVERSAL LIFE
INSURANCE SUPPLEMENTAL APPLICATION
(This supplement must accompany the appropriate application for life insurance.)
- ------------------------------------------------------------------------------------------------------------------------------------
PART 1. APPLICANT INFORMATION
- ------------------------------------------------------------------------------------------------------------------------------------
Supplement to the application on the life of ________________ JOHN DOE_______________________, dated _____________________________.
- ------------------------------------------------------------------------------------------------------------------------------------
PART 2. INITIAL ALLOCATION PERCENTAGES
- ------------------------------------------------------------------------------------------------------------------------------------
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
---------- ---------- ---------- ----------
[USL Declared Fixed Interest Account (148) 100% 100% MORGAN STANLEY DEAN WITTER UNIVERSAL FUNDS, INC.
AIM VARIABLE INSURANCE FUNDS, INC. Equity Growth Division (159) ___% ___%
AIM V.I. International Equity Division (150) ___% ___% High Yield Division (160) ___% ___%
AIM V.I. Value Division (151) ___% ___% PUTNAM VARIABLE TRUST
AMERICAN GENERAL SERIES PORTFOLIO COMPANY Putnam VT Diversified Income Division (162) ___% ___%
International Equities Division (152) ___% ___% Putnam VT Growth and Income Division (161) ___% ___%
MidCap Index Division (153) ___% ___% Putnam VT Int'l Growth and Income Division (163) ___% ___%
Money Market Division (149) ___% ___% SAFECO RESOURCE SERIES TRUST
Stock Index Division (154) ___% ___% Equity Division (164) ___% ___%
DREYFUS VARIABLE INVESTMENT FUND Growth Division (165) ___% ___%
Quality Bond Division (156) ___% ___% VAN KAMPEN LIFE INVESTMENT TRUST
Small Cap Division (155) ___% ___% Strategic Stock Division (158) ___% ___%
MFS VARIABLE INSURANCE TRUST OTHER: ________________________________ ___% ___%]
MFS Emerging Growth Series (157) ___% ___% 100% 100%
- ------------------------------------------------------------------------------------------------------------------------------------
PART 3. DOLLAR COST AVERAGING
- ------------------------------------------------------------------------------------------------------------------------------------
DOLLAR COST AVERAGING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from the [Money
Market Division (149)] and transferred to one or more of the investment options below. The USL 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) from the AGSPC Money Market Division to the following division(s):
[(151) AIM V.I. International Equity $______ (159) Equity Growth $______
(151) AIM V.I. Value $______ (160) High Yield $______
(152) International Equities $______ (162) Putnam VT Diversified Income $______
(153) MidCap Index $______ (161) Putnam VT Growth and Income $______
(154) Stock Index $______ (163) Putnam VT Int'l Growth and Income $______
(156) Quality Bond $______ (164) Equity $______
(155) Small Cap $______ (165) Growth $______
(157) MFS Emerging Growth Series $______ (158) Strategic Stock $______
Other: ________________________________ $______ ]
- ------------------------------------------------------------------------------------------------------------------------------------
PART 4. AUTOMATIC REBALANCING
- ------------------------------------------------------------------------------------------------------------------------------------
AUTOMATIC REBALANCING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically rebalanced based
on the premium percentages designated in Part 2. If the USL Declared Fixed Interest Account has been designated for premium
allocation in Part 2, 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.
- ------------------------------------------------------------------------------------------------------------------------------------
PAGE 1 of 2
USL 8992-97
THE UNITED STATES LIFE INSURANCE COMPANY
IN THE CITY OF NEW YORK("USL")
Administrative Center: Houston, TX
- ------------------------------------------------------------------------------------------------------------------------------------
PART 5. SUITABILITY (ALL QUESTIONS MUST BE ANSWERED.)
- ------------------------------------------------------------------------------------------------------------------------------------
YES NO
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? [X] [_]
(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] [_]
b. THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE
ACCOUNT, THE USL DECLARED FIXED INTEREST ACCOUNT ACCUMULATION, AND CERTAIN EXPENSE DEDUCTIONS? [X] [_]
c. The Policy is designed to provide life insurance coverage and to allow for the accumulation of
values in the Separate Account? [X] [_]
3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated
financial needs? [X] [_]
Signed at: NEW YORK,_________________________________________________________NY__ Date:_________11/1/98_______________
CITY STATE
X___________JOHN DOE_______________________________________ X____________________________________________________________
SIGNATURE OF PRIMARY PROPOSED INSURED SIGNATURE OF REGISTERED REPRESENTATIVE
X__________________________________________________________ X____________________________________________________________
SIGNATURE OF OWNER (if different from Proposed Insured) PRINT NAME OF BROKER/DEALER
X__________________________________________________________
SIGNATURE OF JOINT OWNER (if applicable)
- ------------------------------------------------------------------------------------------------------------------------------------
PAGE 2 of 2
USL 8992-97
THE UNITED STATES LIFE INSURANCE COMPANY
IN THE CITY OF NEW YORK("USL")
Administrative Center: Houston, TX
VARIABLE UNIVERSAL LIFE
INSURANCE SUPPLEMENTAL APPLICATION
(This supplement must accompany the appropriate application for life insurance.)
- ------------------------------------------------------------------------------------------------------------------------------------
PART 1. APPLICANT INFORMATION
- ------------------------------------------------------------------------------------------------------------------------------------
Supplement to the application on the life of ________________ JOHN DOE_______________________, dated _____________________________.
- ------------------------------------------------------------------------------------------------------------------------------------
PART 2. INITIAL ALLOCATION PERCENTAGES
- ------------------------------------------------------------------------------------------------------------------------------------
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
---------- ---------- ---------- ----------
[USL Declared Fixed Interest Account (148) 100% 100% MORGAN STANLEY DEAN WITTER UNIVERSAL FUNDS, INC.
AIM VARIABLE INSURANCE FUNDS, INC. Equity Growth Division (159) ___% ___%
AIM V.I. International Equity Division (150) ___% ___% High Yield Division (160) ___% ___%
AIM V.I. Value Division (151) ___% ___% PUTNAM VARIABLE TRUST
AMERICAN GENERAL SERIES PORTFOLIO COMPANY Putnam VT Diversified Income Division (162) ___% ___%
International Equities Division (152) ___% ___% Putnam VT Growth and Income Division (161) ___% ___%
MidCap Index Division (153) ___% ___% Putnam VT Int'l Growth and Income Division (163) ___% ___%
Money Market Division (149) ___% ___% SAFECO RESOURCE SERIES TRUST
Stock Index Division (154) ___% ___% Equity Division (164) ___% ___%
DREYFUS VARIABLE INVESTMENT FUND Growth Division (165) ___% ___%
Quality Bond Division (156) ___% ___% VAN KAMPEN LIFE INVESTMENT TRUST
Small Cap Division (155) ___% ___% Strategic Stock Division (158) ___% ___%
MFS VARIABLE INSURANCE TRUST OTHER: ________________________________ ___% ___%]
MFS Emerging Growth Series (157) ___% ___% 100% 100%
- ------------------------------------------------------------------------------------------------------------------------------------
PART 3. DOLLAR COST AVERAGING
- ------------------------------------------------------------------------------------------------------------------------------------
DOLLAR COST AVERAGING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from the [Money
Market Division (149)] and transferred to one or more of the investment options below. The USL 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) from the AGSPC Money Market Division to the following division(s):
[(151) AIM V.I. International Equity $______ (159) Equity Growth $______
(151) AIM V.I. Value $______ (160) High Yield $______
(152) International Equities $______ (162) Putnam VT Diversified Income $______
(153) MidCap Index $______ (161) Putnam VT Growth and Income $______
(154) Stock Index $______ (163) Putnam VT Int'l Growth and Income $______
(156) Quality Bond $______ (164) Equity $______
(155) Small Cap $______ (165) Growth $______
(157) MFS Emerging Growth Series $______ (158) Strategic Stock $______
Other: ________________________________ $______ ]
- ------------------------------------------------------------------------------------------------------------------------------------
PART 4. AUTOMATIC REBALANCING
- ------------------------------------------------------------------------------------------------------------------------------------
AUTOMATIC REBALANCING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically rebalanced based
on the premium percentages designated in Part 2. If the USL Declared Fixed Interest Account has been designated for premium
allocation in Part 2, 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.
- ------------------------------------------------------------------------------------------------------------------------------------
PAGE 1 of 2
USL 8992-97
THE UNITED STATES LIFE INSURANCE COMPANY
IN THE CITY OF NEW YORK("USL")
Administrative Center: Houston, TX
- ------------------------------------------------------------------------------------------------------------------------------------
PART 5. SUITABILITY (ALL QUESTIONS MUST BE ANSWERED.)
- ------------------------------------------------------------------------------------------------------------------------------------
YES NO
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? [X] [_]
(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] [_]
b. THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE
ACCOUNT, THE USL DECLARED FIXED INTEREST ACCOUNT ACCUMULATION, AND CERTAIN EXPENSE DEDUCTIONS? [X] [_]
c. The Policy is designed to provide life insurance coverage and to allow for the accumulation of
values in the Separate Account? [X] [_]
3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated
financial needs? [X] [_]
Signed at: NEW YORK,_________________________________________________________NY__ Date:_________11/1/98_______________
CITY STATE
X___________JOHN DOE_______________________________________ X____________________________________________________________
SIGNATURE OF PRIMARY PROPOSED INSURED SIGNATURE OF REGISTERED REPRESENTATIVE
X__________________________________________________________ X____________________________________________________________
SIGNATURE OF OWNER (if different from Proposed Insured) PRINT NAME OF BROKER/DEALER
X__________________________________________________________
SIGNATURE OF JOINT OWNER (if applicable)
- ------------------------------------------------------------------------------------------------------------------------------------
PAGE 2 of 2
USL 8992-97