EXHIBIT 1.(5)(b)(ii)
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
Supplement to the application on the life of _____________________,
dated ____________________.
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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
Allocation Allocation
AGL Declared Fixed Interest Account (125) ____% ____%
AIM VARIABLE INSURANCE FUNDS, INC.
AIM V.I. International Equity Division (126) ____% ____%
AIM V.I. Value Division (127) ____% ____%
AMERICAN GENERAL SERIES PORTFOLIO COMPANY
International Equities Division (128) ____% ____%
MidCap Index Division (129) ____% ____%
Money Market Division (130) ____% ____%
Stock Index Division (131) ____% ____%
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (132) ____% ____%
Small Cap Division (133) ____% ____%
MFS VARIABLE INSURANCE TRUST
MFS Emerging Growth Series (134) ____% ____%
MORGAN STANLEY UNIVERSAL FUNDS, INC.
Equity Growth Division (135) ____% ____%
High Yield Division (136) ____% ____%
PUTNAM VARIABLE TRUST
Putnam VT Diversified Income Division (137) ____% ____%
Putnam VT Growth and Income Division (138) ____% ____%
Putnam VT Int'l Growth and Income Division (139) ____% ____%
SAFECO RESOURCE SERIES TRUST
Equity Division (140) ____% ____%
Growth Division (141) ____% ____%
VAN KAMPEN AMERICAN CAPITAL LIFE INVESTMENT TRUST
Strategic Stock Division (142) ____% ____%
Other: ________________________________ ____% ____%
100% 100%
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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 (130)
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):
(126) AIM V.I. International Equity $___________
(127) AIM V.I. Value $___________
(128) International Equities $___________
(129) MidCap Index $___________
(131) Stock Index $___________
(132) Quality Bond $___________
(133) Small Cap $___________
(134) MFS Emerging Growth Series $___________
(135) Equity Growth $___________
(136) High Yield $___________
(137) Putnam VT Diversified Income $___________
(138) Putnam VT Growth and Income $___________
(139) Putnam VT Int'l Growth and Income $___________
(140) Equity $___________
(141) Growth $___________
(142) Strategic Stock $___________
Other: ________________________________ $___________
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PART 4. Automatic Rebalancing
Automatic Rebalancing: ($5,000 initial 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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L 8992-97 PAGE 1 OF 2
AMERICAN GENERAL LIFE INSURANCE COMPANY
Home Office: Houston, Texas
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PART 5. Telephone Authorization
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 the AGL Declared Fixed Interest Account and to change
allocations for future purchase payments and monthly deductions given by:
(Initial appropriate box below.)
[ ] 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.
[ ] Initial here to decline the above telephone Authorization.
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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?
(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,
the AGL Declared Fixed Interest Account accumulation,
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: ___________________________ Date: _____________________
City
________________________________________
Signature of Primary Proposed Insured
________________________________________
Signature of Owner (if different from Proposed Insured)
________________________________________
Signature of Joint Owner (if applicable)
________________________________________
Signature of Registered Representative
________________________________________
Print Name of Broker/Dealer
________________________________________
Signature of Broker/Dealer's Licensed Principal
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