EXHIBIT 10(e)
AMERICAN GENERGAL LIFE INSURANCE COMPANY ("AGL")
Corporate Markets Group
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 ABC CORP. LIFE INSURANCE PLAN , dated 4/30/99 .
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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
Allocation Allocation Allocation Allocation
---------- ---------- ---------- ----------
AGL Declared Fixed Interest Account ___% ___% MORGAN STANLEY DEAN WITTER UNIVERSAL FUNDS, INC.
[AIM VARIABLE INSURANCE FUNDS, INC. Equity Growth Division 100% 100%
AIM V.I. International Equity Division ___% ___% High Yield Division ___% ___%
AIM V.I. Value Division ___% ___% PUTNAM VARIABLE TRUST
AMERICAN GENERAL SERIES PORTFOLIO COMPANY Putnam VT Diversified Income Division ___% ___%
International Equities Division ___% ___% Putnam VT Growth and Income Division ___% ___%
MidCap Index Division ___% ___% Putnam VT Int'l Growth and Income Division ___% ___%
Money Market Division ___% ___% SAFECO RESOURCE SERIES TRUST
Stock Index Division ___% ___% Equity Division ___% ___%
DREYFUS VARIABLE INVESTMENT FUND Growth Division ___% ___%
Quality Bond Division ___% ___% VAN KAMPEN LIFE INVESTMENT TRUST
Small Cap Division ___% ___% Strategic Stock Division ___% ___%
MFS VARIABLE INSURANCE TRUST OTHER: ________________________________ ___% ___%]
MFS Emerging Growth Series ___% ___% 100% 100%
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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 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) from the [AGSPC Money Market Division] to the following division(s):
[AIM V.I. International Equity $______ Equity Growth $______
AIM V.I. Value $______ High Yield $______
International Equities $______ Putnam VT Diversified Income $______
MidCap Index $______ Putnam VT Growth and Income $______
Stock Index $______ Putnam VT Int'l Growth and Income $______
Quality Bond $______ Equity $______
Small Cap $______ Growth $______
MFS Emerging Growth Series $______ Strategic Stock $______
Other: ________________________________ $______ ]
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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. If the [AGL 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.
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PAGE 1 of 2
CM 1001-99
AMERICAN GENERAL LIFE INSURANCE COMPANY
Corporate Markets Group
Home Office: Houston, Texas
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PART 5. TELEPHONE AUTHORIZATION
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I (or we, if Multiple 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 below.)
[X] Contract Owner(s)-- if Multiple Owners, either of us acting independently.
[ ] Contract Owner(s) or the Agent/Registered Representative who is appointed to represent AGL and the firm authorized to service
my contract.
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/we will notify
AGL in writing within five working days from receipt of confirmation of the transaction from AGL. I/we understand that this
authorization is subject to the terms and provisions of the variable universal life insurance contract and its related prospectus.
This authorization will remain in effect until my/our 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. SUITABILITY (ALL QUESTIONS MUST BE ANSWERED.)
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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 and acknowledge:
A. THAT THE CONTRACT APPLIED FOR IS VARIABLE, EMPLOYS THE USE OF SEGREGATED ACCOUNTS WHICH MEANS THAT
YOU NEED TO RECEIVE AND UNDERSTAND A CURRENT PROSPECTUS FOR THE CONTRACT AND THE UNDERLYING
ACCOUNTS? [X] [ ]
B. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED ACCOUNTS MAY VARY; AND
(1) ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S. GOVERNMENT OR ANY STATE
GOVERNMENT? [X] [ ]
(2) ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OF ANY OTHER AGENCY, FEDERAL
OR STATE? [X] [ ]
C. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN THE AGL DECLARED FIXED
INTEREST ACCOUNT? [X] [ ]
D. THAT THE CONTRACT IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR THE ACCUMULATION
OF VALUES IN THE SEGREGATED ACCOUNTS? [X] [ ]
E. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT? [X] [ ]
F. THE CONTRACT 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] [ ]
3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated
financial needs? [X] [_]
Signed at: SOMEWHERE_________________________________________________________TX__ Date:_________04/30/99______________
CITY STATE
X___________SUE SMITH______________________________________ X_______BOB DOE______________________________________________
SIGNATURE OF OWNER SIGNATURE OF REGISTERED REPRESENTATIVE
X__________________________________________________________ X_______BOB DOE______________________________________________
SIGNATURE OF MULTIPLE OWNER (If applicable) PRINT NAME OF BROKER/DEALER
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PAGE 2 of 2
CM 1001-99
AMERICAN GENERGAL LIFE INSURANCE COMPANY ("AGL")
Corporate Markets Group
Home Office: Houston, Texas
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 _______ABC CORP. LIFE INSURANCE PLAN____________, dated ______4/30/99________________.
- ------------------------------------------------------------------------------------------------------------------------------------
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
---------- ---------- ---------- ----------
AGL Declared Fixed Interest Account 100% 100% MORGAN STANLEY DEAN WITTER UNIVERSAL FUNDS, INC.
[AIM VARIABLE INSURANCE FUNDS, INC. Equity Growth Division 100% 100%
AIM V.I. International Equity Division ___% ___% High Yield Division ___% ___%
AIM V.I. Value Division ___% ___% PUTNAM VARIABLE TRUST
AMERICAN GENERAL SERIES PORTFOLIO COMPANY Putnam VT Diversified Income Division ___% ___%
International Equities Division ___% ___% Putnam VT Growth and Income Division ___% ___%
MidCap Index Division ___% ___% Putnam VT Int'l Growth and Income Division ___% ___%
Money Market Division ___% ___% SAFECO RESOURCE SERIES TRUST
Stock Index Division ___% ___% Equity Division ___% ___%
DREYFUS VARIABLE INVESTMENT FUND Growth Division ___% ___%
Quality Bond Division ___% ___% VAN KAMPEN LIFE INVESTMENT TRUST
Small Cap Division ___% ___% Strategic Stock Division ___% ___%
MFS VARIABLE INSURANCE TRUST OTHER: ________________________________ ___% ___%]
MFS Emerging Growth Series ___% ___% 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] 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) from the [AGSPC Money Market Division] to the following division(s):
[AIM V.I. International Equity $______ Equity Growth $______
AIM V.I. Value $______ High Yield $______
International Equities $______ Putnam VT Diversified Income $______
MidCap Index $______ Putnam VT Growth and Income $______
Stock Index $______ Putnam VT Int'l Growth and Income $______
Quality Bond $______ Equity $______
Small Cap $______ Growth $______
MFS Emerging Growth Series $______ 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 [AGL 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
CM 1001-99
AMERICAN GENERAL LIFE INSURANCE COMPANY
Corporate Markets Group
Home Office: Houston, Texas
- ------------------------------------------------------------------------------------------------------------------------------------
PART 5. TELEPHONE AUTHORIZATION
- ------------------------------------------------------------------------------------------------------------------------------------
I (or we, if Multiple 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 below.)
[X] Contract Owner(s)-- if Multiple Owners, either of us acting independently.
[ ] Contract Owner(s) or the Agent/Registered Representative who is appointed to represent AGL and the firm authorized to service
my contract.
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/we will notify
AGL in writing within five working days from receipt of confirmation of the transaction from AGL. I/we understand that this
authorization is subject to the terms and provisions of the variable universal life insurance contract and its related prospectus.
This authorization will remain in effect until my/our written notice of its revocation is received by AGL at its home office.
[ ] Initial here to decline the above telephone Authorization.
- ------------------------------------------------------------------------------------------------------------------------------------
PART 6. 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 and acknowledge:
A. THAT THE CONTRACT APPLIED FOR IS VARIABLE, EMPLOYS THE USE OF SEGREGATED ACCOUNTS WHICH MEANS THAT
YOU NEED TO RECEIVE AND UNDERSTAND A CURRENT PROSPECTUS FOR THE CONTRACT AND THE UNDERLYING
ACCOUNTS? [X] [ ]
B. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED ACCOUNTS MAY VARY; AND
(1) ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S. GOVERNMENT OR ANY STATE
GOVERNMENT? [X] [ ]
(2) ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OF ANY OTHER AGENCY, FEDERAL
OR STATE? [X] [ ]
C. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN THE AGL DECLARED FIXED
INTEREST ACCOUNT? [X] [ ]
D. THAT THE CONTRACT IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR THE ACCUMULATION
OF VALUES IN THE SEGREGATED ACCOUNTS? [X] [ ]
E. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT? [X] [ ]
F. THE CONTRACT 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] [ ]
3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated
financial needs? [X] [_]
Signed at: SOMEWHERE_________________________________________________________TX__ Date:_________04/30/99______________
CITY STATE
X___________SUE SMITH______________________________________ X_______BOB DOE______________________________________________
SIGNATURE OF OWNER SIGNATURE OF REGISTERED REPRESENTATIVE
X__________________________________________________________ X_______BOB DOE______________________________________________
SIGNATURE OF MULTIPLE OWNER (If applicable) PRINT NAME OF BROKER/DEALER
- ------------------------------------------------------------------------------------------------------------------------------------
PAGE 2 of 2
CM 1001-99