EX-10.(D) 4 dex10d.txt AMENDED SUPPLEMENTAL APPLICATION EXHIBIT (10)(d) 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 on the life of ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ -------------------------------------- Name of proposed Insured Date of application for life insurance ----------------------------------------------------------------------------------------------------------------------------------- Initial Allocation Percentages ----------------------------------------------------------------------------------------------------------------------------------- ALLOCATION STYLES By selecting an Allocation Style below, you agree to allocate 100% of your premium as designated in the most recent publication of Platinum Investor VUL Allocation Styles. [ ] Capital preservation [ ] Income and Growth [ ] Growth and Income [ ] Growth [ ] Aggressive growth [ ] All equity [ ] __________________ [ ] _________________ NOTE: If an Allocation Style is selected, the deduction of monthly account charges will be allocated in the same percentage as the premium allocation. ----------------------------------------------------------------------------------------------------------------------------------- THIS SECTION TO BE COMPLETED EVEN IF AN ALLOCATION STYLE HAS BEEN CHOSEN ABOVE. 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 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 (125) _____% _____% NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST Mid-Cap Growth Division (241) _____% ____% AIM VARIABLE INSURANCE FUNDS AIM V.I. International Equity Division (126) _____% _____% PIMCO VARIABLE INSURANCE TRUST AIM V.I. Value Division (127) _____% _____% PIMCO Real Return Bond Division (243) _____% _____% PIMCO Short-Term Bond Division (242) _____% _____% AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. PIMCO Total Return Bond Division (244) _____% _____% VP Value Division (224) _____% _____% PUTNAM VARIABLE TRUST AYCO SERIES TRUST Putnam VT Diversified Income Division (137) _____% _____% Ayco Growth Division (228) _____% _____% Putnam VT Growth and Income Division (138) _____% _____% Putnam VT Int'l Growth and Income Division (139) _____% _____% CREDIT SUISSE WARBURG PINCUS TRUST Small Company Growth Division (247) _____% _____% SAFECO RESOURCE SERIES TRUST Equity Division (140) _____% _____% DREYFUS INVESTMENT PORTFOLIOS Growth Opportunities Division (141) _____% _____% MidCap Stock Division (229) _____% _____% THE UNIVERSAL INSTITUTIONAL FUNDS, INC. DREYFUS VARIABLE INVESTMENT FUND Equity Growth Division (135) _____% _____% Quality Bond Division (132) _____% _____% High Yield Division (136) _____% _____% Small Cap Division (133) _____% _____% VALIC COMPANY I FIDELITY VARIABLE INSURANCE PRODUCTS FUND International Equities Division (128) _____% _____% VIP Asset Manager Division (233) _____% _____% Mid Cap Index Division (129) _____% _____% VIP Contrafund Division (232) _____% _____% Money Market I Division (130) _____% _____% VIP Equity-Income Division (230) _____% _____% Nasdaq-100 Index Division (225) _____% _____% VIP Growth Division (231) _____% _____% Science & Technology Division (227) _____% _____% Small Cap Index Division (226) _____% _____% FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST Stock Index Division (131) _____% _____% Franklin U.S. Government Division (248) _____% _____% Mutual Shares Securities Division (249) _____% _____% VANGUARD VARIABLE INSURANCE FUND Templeton International Securities High Yield Bond Division (245) _____% _____% Division (250) _____% _____% REIT Index Division (246) _____% _____% JANUS ASPEN SERIES VAN KAMPEN LIFE INVESTMENT TRUST Aggressive Growth Division (236) _____% _____% Strategic Stock Division (142) _____% _____% International Growth Division (234) _____% _____% Worldwide Growth Division (235) _____% _____% OTHER:_____________________________ _____% _____% J.P. MORGAN SERIES TRUST II 100% 100% J.P. Morgan Small Company Division (237) _____% _____% MFS VARIABLE INSURANCE TRUST MFS Capital Opportunities Division (239) _____% _____% MFS Emerging Growth Division (134) _____% _____% MFS New Discovery Division (240) _____% _____% MFS Research Division (238) _____% _____% ------------------------------------------------------------------------------------------------------------------------------------ L8992-97 REV 0600 Page 1 of 3
------------------------------------------------------------------------------------------------------------------------------------ Dollar Cost Averaging ------------------------------------------------------------------------------------------------------------------------------------ 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) PREMIUM PREMIUM ALLOCATION ALLOCATION ---------- ---------- AIM VARIABLE INSURANCE FUNDS NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST AIM V.I. International Equity Division (126) $__________ Mid-Cap Growth Division (241) $__________ AIM V.I. Value Division (127) $__________ PIMCO VARIABLE INSURANCE TRUST AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. PIMCO Real Return Bond Division (243) $__________ VP Value Division (224) $__________ PIMCO Short-Term Bond Division (242) $__________ PIMCO Total Return Bond Division (244) $__________ AYCO SERIES TRUST Ayco Growth Division (228) $__________ PUTNAM VARIABLE TRUST Putnam VT Diversified Income Division (137) $__________ CREDIT SUISSE WARBURG PINCUS TRUST Putnam VT Growth and Income Division (138) $__________ Small Company Growth Division (247) $__________ Putnam VT Int'l Growth and Income Division (139) $__________ DREYFUS INVESTMENT PORTFOLIOS SAFECO RESOURCE SERIES TRUST MidCap Stock Division (229) $__________ Equity Division (140) $__________ Growth Opportunities Division (141) $__________ DREYFUS VARIABLE INVESTMENT FUND Quality Bond Division (132) $__________ THE UNIVERSAL INSTITUTIONAL FUNDS, INC. Small Cap Division (133) $__________ Equity Growth Division (135) $__________ High Yield Division (136) $__________ FIDELITY VARIABLE INSURANCE PRODUCTS FUND VIP Asset Manager Division (233) $__________ VIP Contrafund Division (232) $__________ VALIC COMPANY I VIP Equity-Income Division (230) $__________ International Equities Division (128) $__________ VIP Growth Division (231) $__________ Mid Cap Index Division (129) $__________ Nasdaq-100 Index Division (225) $__________ FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST Science & Technology Division (227) $__________ Franklin U.S. Government Division (248) $__________ Small Cap Index Division (226) $__________ Mutual Shares Securities Division (249) $__________ Stock Index Division (131) $__________ Templeton International Securities Division (250) $__________ VANGUARD VARIABLE INSURANCE FUND High Yield Bond Division (245) $__________ JANUS ASPEN SERIES REIT Index Division (246) $__________ Aggressive Growth Division (236) $__________ International Growth Division (234) $__________ VAN KAMPEN LIFE INVESTMENT TRUST Worldwide Growth Division (235) $__________ Strategic Stock Division (142) $__________ J.P. MORGAN SERIES TRUST II OTHER: ______________________________ $__________ J.P Morgan Small Company Division (237) $__________ MFS VARIABLE INSURANCE TRUST MFS Capital Opportunities Division (239) $__________ MFS Emerging Growth Division (134) $__________ MFS New Discovery Division (240) $__________ MFS Research Division (238) $__________ ------------------------------------------------------------------------------------------------------------------------------------ Automatic Rebalancing ------------------------------------------------------------------------------------------------------------------------------------ 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 ---------------------------------------------- ------------- ---------------- ----------- 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 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 ------------------------------------------------------------------------------------------------------------------------------------ L8992-97 REV 0600 Page 2 of 3
------------------------------------------------------------------------------------------------------------------------------------ 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 [ ] Policy Owner(s)--if Joint Owners, either of us acting independently. BOX HERE: [ ] 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. ------------------------------------------------------------------------------------------------------------------------------------ Suitability ------------------------------------------------------------------------------------------------------------------------------------ ALL QUESTIONS MUST BE 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 options? [_] 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? [_] 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? [_] yes [_] no c. THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR THE ACCUMULATION OF VALUES IN THE SEPARATE ACCOUNT? [_] yes [_] no 3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated financial needs? [_] yes [_] no ------------------------------------------------------------------------------------------------------------------------------------ Your Signature ------------------------------------------------------------------------------------------------------------------------------------ SIGNATURES Signed at (city, state) ___________________________________________________________________________________________________________ Print name of Broker/Dealer ___________________________________________________________________________________________________________ X Registered representative State license # Date ____________________________________________________ _______________________________ _____________________ X Primary proposed insured Date ____________________________________________________________________________________ _____________________ X Owner Date ____________________________________________________________________________________ _____________________ (If different from Proposed Insured) X Joint Owner Date ____________________________________________________________________________________ _____________________ (If applicable) ----------------------------------------------------------------------------------------------------------------------------------- L8992-97 REV 0600 Page 3 of 3