EX-10.(D) 3 0003.txt FORM OF SUPPLEMENTAL APPLICATION EXHIBIT (10)(d) [Logo of American General Financial Group]
VARIABLE UNIVERSAL LIFE INSURANCE SUPPLEMENTAL APPLICATION AMERICAN GENERAL LIFE INSURANCE COMPANY, ("AGL") Home Office: Houston, Texas Member of American General Financial Group. American General Financial Group is the marketing name for American General Corporation and its subsidiaries. (This supplement must accompany the appropriate application for life insurance.) ------------------------------------------------------------------------------------------------------------------------------------ APPLICANT INFORMATION -- SUPPLEMENT TO THE APPLICATION OF THE LIFE OF ------------------------------------------------------------------------------------------------------------------------------------ JOHN DOE 7/21/00 --------------------------------- -------------------------------------- Name of proposed insured Date of application for life insurance ------------------------------------------------------------------------------------------------------------------------------------ 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 ---------- ---------- ---------- ---------- [AIM VARIABLE INSURANCE FUNDS MFS VARIABLE INSURANCE TRUST AIM V.I. International Equity Division (260) 100% 100% MFS Emerging Growth Division (282) ___% ___% AIM V.I. Value Division (261) ___% ___% MFS Research Division (283) ___% ___% AMERICAN CENTURY VARIABLE PORTFOLIO, INC. MFS Capital Opportunities Division (284) ___% ___% VP Value Division (262) ___% ___% MFS New Discoveries Division (285) ___% ___% AMERICAN GENERAL SERIES PORTFOLIO COMPANY NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST International Equities Division (263) ___% ___% Mid-Cap Growth Division (286) ___% ___% MidCap Index Division (264) ___% ___% PIMCO VARIABLE INSURANCE TRUST Money Market Division (265) ___% ___% PIMCO Short-Term Bond Division (287) ___% ___% Nasdaq-100 Index Division (266) ___% ___% PIMCO Real Return Bond Division (288) ___% ___% Stock Index Division (267) ___% ___% PIMCO Total Return Bond Division (289) ___% ___% Small Cap Index Division (268) ___% ___% PUTNAM VARIABLE TRUST Science & Technology Division (269) ___% ___% Putnam VT Diversified Income Division (290) ___% ___% AYCO SERIES TRUST Putnam VT Growth & Income Division (291) ___% ___% AYCO Large Cap Growth Fund I (270) ___% ___% Putnam VT Int'l Growth & Income Division (292) ___% ___% DREYFUS VARIABLE INVESTMENT FUND SAFECO RESOURCE SERIES TRUST Quality Bond Division (271) ___% ___% Equity Division (293) ___% ___% Small Cap Division (272) ___% ___% Growth Opportunities Division (294) ___% ___% Mid-Cap Stock Division (273) ___% ___% THE UNIVERSAL INSTITUTIONAL FUNDS, INC. FIDELITY VIPII FUNDS Equity Growth Division (295) ___% ___% VIPII Equity Income Division (274) ___% ___% High Yield Division (296) ___% ___% VIPII Growth Division (275) ___% ___% VANGUARD VARIABLE INSURANCE FUND VIPII Contrafund Division (276) ___% ___% High Yield Bond Division (297) ___% ___% VIPII Asset Manager Division (277) ___% ___% REIT Index Division (298) ___% ___% JANUS ASPEN SERIES VAN KAMPEN LIFE INVESTMENT TRUST International Growth Division (278) ___% ___% Strategic Stock Division (299) ___% ___% Worldwide Growth Division (279) ___% ___% WARBURG PINCUS TRUST Aggressive Growth Division (280) ___% ___% Small Company Growth Division (300) ___% ___% J.P. MORGAN SERIES TRUST II AGL Declared Fixed Interest Account (301) ___% ___% J.P. Morgan Small Company Division (281) ___% ___% Other: ___________________________________ ___% ___%] ------------------------------------------------------------------------------------------------------------------------------------ AGLC 0198-00 PAGE 1 of 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) [AIM VARIABLE INSURANCE FUNDS MFS VARIABLE INSURANCE TRUST AIM V.I. International Equity Division (260) $______ MFS Emerging Growth Division (282) $______ AIM V.I. Value Division (261) $______ MFS Research Division (283) $______ AMERICAN CENTURY VARIABLE PORTFOLIO, INC. MFS Capital Opportunities Division (284) $______ VP Value Division (262) $______ MFS New Discoveries Division (285) $______ AMERICAN GENERAL SERIES PORTFOLIO COMPANY NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST International Equities Division (263) $______ Mid-Cap Growth Division (286) $______ MidCap Index Division (264) $______ PIMCO VARIABLE INSURANCE TRUST Nasdaq-100 Index Division (266) $______ PIMCO Short-Term Bond Division (287) $______ Stock Index Division (267) $______ PIMCO Real Return Bond Division (288) $______ Small Cap Index Division (268) $______ PIMCO Total Return Bond Division (289) $______ Science & Technology Division (269) $______ PUTNAM VARIABLE TRUST AYCO SERIES TRUST Putnam VT Diversified Income Division (290) $______ AYCO Large Cap Growth Fund I (270) $______ Putnam VT Growth & Income Division (291) $______ DREYFUS VARIABLE INVESTMENT FUND Putnam VT Int'l Growth & Income Division (292) $______ Quality Bond Division (271) $______ SAFECO RESOURCE SERIES TRUST Small Cap Division (272) $______ Equity Division (293) $______ Mid-Cap Stock Division (273) $______ Growth Opportunities Division (294) $______ FIDELITY VIPII FUNDS THE UNIVERSAL INSTITUTIONAL FUNDS, INC. VIPII Equity Income Division (274) $______ Equity Growth Division (295) $______ VIPII Growth Division (275) $______ High Yield Division (296) $______ VIPII Contrafund Division (276) $______ VANGUARD VARIABLE INSURANCE FUND VIPII Asset Manager Division (277) $______ High Yield Bond Division (297) $______ JANUS ASPEN SERIES REIT Index Division (298) $______ International Growth Division (278) $______ VAN KAMPEN LIFE INVESTMENT TRUST Worldwide Growth Division (279) $______ Strategic Stock Division (299) $______ Aggressive Growth Division (280) $______ WARBURG PINCUS TRUST J.P. MORGAN SERIES TRUST II Small Company Growth Division (300) $______ J.P. Morgan Small Company Division (281) $______ Other: ___________________________________ $______] 100% ------------------------------------------------------------------------------------------------------------------------------------ AUTOMATIC REBALANCING ------------------------------------------------------------------------------------------------------------------------------------ AUTOMATIC REBALANCING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically rebalanced based on the 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 NOTE: Automatic Rebalancing is not available if the Dollar Cost Averaging option has been chosen. ------------------------------------------------------------------------------------------------------------------------------------ MODIFIED ENDOWMENT CONTRACT ------------------------------------------------------------------------------------------------------------------------------------ CONTRACT: If any premium payment causes the policy to be classified as a modified endowment contract under Section 7702A of the United States Internal Revenue Code, there may be potentially adverse U.S. 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. [X] YES [ ] NO ------------------------------------------------------------------------------------------------------------------------------------ AGLC 0198-00 PAGE 2 of 3
------------------------------------------------------------------------------------------------------------------------------------ DEATH BENEFIT COMPLIANCE TEST ------------------------------------------------------------------------------------------------------------------------------------ [ ] Guideline Premium Test [ ] Cash Value Accumulation Test ------------------------------------------------------------------------------------------------------------------------------------ SPECIFIED AMOUNT ------------------------------------------------------------------------------------------------------------------------------------ Base Coverage $_____________________ plus Supplemental Coverage $____________________ = Total Specified Amount $____________________ ------------------------------------------------------------------------------------------------------------------------------------ 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 HERE: [_] 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. ------------------------------------------------------------------------------------------------------------------------------------ SUITABILITY ------------------------------------------------------------------------------------------------------------------------------------ ALL QUESTIONS MUST BY ANSWERED. 1. Have you, the Proposed Insured or Owner (if different), received the variable universal life insurance policy prospectus and the prospectuses describing the investment option? [X] yes [_] no (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] yes [_] no 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? [X] yes [_] no c. THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR THE ACCUMULATION OF VALUES IN THE SEPARATE ACCOUNT? [X] yes [_] no 3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated financial needs? [X] yes [_] no ------------------------------------------------------------------------------------------------------------------------------------ YOUR SIGNATURE ------------------------------------------------------------------------------------------------------------------------------------ SIGNATURES Signed at (city, state) Anytown, USA ------------------------------------------------------------------------------------------------------------ Print name of Broker/Dealer ------------------------------------------------------------------------------------------------------------ X Registered representative State license # Date ------------------------------------------------------------------------------------------------------------ X Primary proposed insured John Doe Date 7/21/00 ------------------------------------------------------------------------------------------------------------ X Owner Date ------------------------------------------------------------------------------------------------------------ (If different from Proposed Insured) X Joint Owner Date ------------------------------------------------------------------------------------------------------------ (If applicable) ------------------------------------------------------------------------------------------------------------------------------------ AGLC 0198-00 PAGE 3 of 3