EX-99.(E)(3) 5 dex99e3.txt FORM OF VARIABLE UNIVERSAL LIFE INSURANCE SUPPLEMENTAL APPLICATION EXHIBIT (e)(3) [LOGO] AMERICAN GENERAL AIG PROTECTION ADVANTAGE VUL/SM / VARIABLE UNIVERSAL LIFE INSURANCE SUPPLEMENTAL APPLICATION AMERICAN GENERAL LIFE INSURANCE COMPANY, ("AGL") A MEMBER COMPANY OF AMERICAN INTERNATIONAL GROUP, INC. Home Office: Houston, Texas (THIS SUPPLEMENT MUST ACCOMPANY THE APPROPRIATE APPLICATION FOR LIFE INSURANCE.) The supplement and the application will be attached to and made a part of the policy. APPLICANT INFORMATION -- SUPPLEMENT TO THE APPLICATION ON THE LIFE OF ------------------------------- ---------------------------------------- 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 ALLOCATION ALLOCATION ---------- ---------- AGL DECLARED FIXED INTEREST ACCOUNT (301)............... ______% ______% AIM VARIABLE INSURANCE FUNDS Global Real Estate* (870)............................... ______% ______% International Growth* (871)............................. ______% ______% THE ALGER AMERICAN FUND Leveraged AllCap (872).................................. ______% ______% MidCap Growth (873)..................................... ______% ______% AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. Value (874)............................................. ______% ______% CREDIT SUISSE TRUST Small Cap Core I* (875)................................. ______% ______% DREYFUS VARIABLE INVESTMENT FUND International Value* (876).............................. ______% ______% FIDELITY(R) VARIABLE INSURANCE PRODUCTS Asset Manager/SM /(877)................................. ______% ______% Contrafund(R) (878)..................................... ______% ______% Equity-Income (879)..................................... ______% ______% Freedom 2020 (880)...................................... ______% ______% Freedom 2025 (881)...................................... ______% ______% Freedom 2030 (882)...................................... ______% ______% Growth (883)............................................ ______% ______% Mid Cap (884)........................................... ______% ______% FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST Franklin Small Cap Value Securities*(885)............... ______% ______% Mutual Shares Securities (886).......................... ______% ______% JANUS ASPEN SERIES Forty (887)............................................. ______% ______% International Growth* (888)............................. ______% ______% Mid Cap Growth (889).................................... ______% ______% J.P. MORGAN SERIES TRUST II International Equity* (891)............................. ______% ______% JPMORGAN INSURANCE TRUST Government Bond (890)................................... ______% ______% MFS(R) VARIABLE INSURANCE TRUST New Discovery* (892).................................... ______% ______% Research (893).......................................... ______% ______% NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST Mid-Cap Growth (895).................................... ______% ______% Socially Responsive (894)............................... ______% ______% OPPENHEIMER VARIABLE ACCOUNT FUNDS Balanced (896).......................................... ______% ______% Global Securities* (897)................................ ______% ______% PIMCO VARIABLE INSURANCE TRUST CommodityRealReturn Strategy* (905)..................... ______% ______% Global Bond (Unhedged) (909)............................ ______% ______% Real Return (906)....................................... ______% ______% Short-Term (907)........................................ ______% ______% Total Return (908)...................................... ______% ______% PIONEER VARIABLE CONTRACTS TRUST Mid Cap Value (910)..................................... ______% ______% PUTNAM VARIABLE TRUST Diversified Income (911)................................ ______% ______% Small Cap Value* (912).................................. ______% ______% SUNAMERICA SERIES TRUST Aggressive Growth (913)................................. ______% ______% Balanced (914).......................................... ______% ______% VALIC COMPANY I International Equities* (915)........................... ______% ______% Mid Cap Index (916)..................................... ______% ______% Money Market I (917).................................... ______% ______% Nasdaq-100(R) Index (918)............................... ______% ______% Science and Technology (919)............................ ______% ______% Small Cap Index* (920).................................. ______% ______% Stock Index (921)....................................... ______% ______% VAN KAMPEN LIFE INVESTMENT TRUST Growth and Income (922)................................. ______% ______% VANGUARD(R) VARIABLE INSURANCE FUND High Yield Bond (923)................................... ______% ______% REIT Index (924)........................................ ______% ______% OTHER: ________________________ ______% ______% 100% 100%
* If you select the Guaranteed Minimum Death Benefit (GMDB) rider this investment option is designated as a Restricted Fund. AGLC102803-2007 Page 1 of 4 DOLLAR COST AVERAGING (DCA) DOLLAR COST ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from AVERAGING (DCA) ANY ONE INVESTMENT OPTION and directed to one or more of the investment options below. The AGL Declared Fixed Interest Account is not available for DCA. Please refer to the prospectus for more information on the DCA option. NOTE: DCA IS NOT AVAILABLE IF THE AUTOMATIC REBALANCING OPTION OR GMDB RIDER HAVE BEEN CHOSEN. Day of the month for transfers: (Choose a day of the month between 1-28.) ------------------------------------------------------------------------------------------------- Frequency of transfers: [_] Monthly [_] Quarterly [_] Semiannually [_] Annually ------------------------------------------------------------------------------------------------- DCA to be made from the following investment option: ------------------------------------------------------------------------------------------------- Transfer $ ($100 MINIMUM, WHOLE DOLLARS ONLY) -------------------------------------------------------------------------------------------------
AIM VARIABLE INSURANCE FUNDS NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST Global Real Estate (870)............... $ ______________. Mid-Cap Growth (895)............... $ ________________ International Growth (871)............. $ ______________. Socially Responsive (894).......... $ ________________ THE ALGER AMERICAN FUND OPPENHEIMER VARIABLE ACCOUNT FUNDS Leveraged AllCap (872)................. $ ______________. Balanced (896)..................... $ ________________ MidCap Growth (873).................... $ ______________. Global Securities (897)............ $ ________________ AMERICAN CENTURY VARIABLE PORTFOLIOS, INC. PIMCO VARIABLE INSURANCE TRUST Value (874)............................ $ ______________. CommodityRealReturn Strategy (905). $ ________________ CREDIT SUISSE TRUST Global Bond (Unhedged) (909)....... $ ________________ Small Cap Core I (875)................. $ ______________. Real Return (906).................. $ ________________ DREYFUS VARIABLE INVESTMENT FUND Short-Term (907)................... $ ________________ International Value (876) $ ______________. Total Return (908)................. $ ________________ FIDELITY(R) VARIABLE INSURANCE PRODUCTS PIONEER VARIABLE CONTRACTS TRUST Asset Manager/SM /(877)................ $ ______________. Mid Cap Value (910)................ $ ________________ Contrafund(R) (878).................... $ ______________. PUTNAM VARIABLE TRUST Equity-Income (879).................... $ ______________. Diversified Income (911)........... $ ________________ Freedom 2020 (880)..................... $ ______________. Small Cap Value (912).............. $ ________________ Freedom 2025 (881)..................... $ ______________. SUNAMERICA SERIES TRUST Freedom 2030 (882)..................... $ ______________. Aggressive Growth (913)............ $ ________________ Growth (883)........................... $ ______________. Balanced (914)..................... $ ________________ Mid Cap (884).......................... $ ______________. VALIC COMPANY I FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST International Equities (915)....... $ ________________ Franklin Small Cap Value Securities (885).................................. $ ______________. Mid Cap Index (916)................ $ ________________ Mutual Shares Securities (886)......... $ ______________. Money Market I (917)............... $ ________________ JANUS ASPEN SERIES Nasdaq-100(R) Index (918).......... $ ________________ Forty (887)............................ $ ______________. Science and Technology (919)....... $ ________________ International Growth (888)............. $ ______________. Small Cap Index (920).............. $ ________________ Mid Cap Growth (889)................... $ ______________. Stock Index (921).................. $ ________________ J.P. MORGAN SERIES TRUST II VAN KAMPEN LIFE INVESTMENT TRUST International Equity (891)............. $ ______________. Growth and Income (922)............ $ ________________ JPMORGAN INSURANCE TRUST VANGUARD(R) VARIABLE INSURANCE FUND Government Bond (890).................. $ ______________. High Yield Bond (923).............. $ ________________ MFS(R) VARIABLE INSURANCE TRUST REIT Index (924)................... $ ________________ New Discovery (892).................... $ ______________. OTHER: ________________............ $ ________________ Research (893)......................... $ _______________
AUTOMATIC REBALANCING AUTOMATIC ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically REBALANCING 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 DCA OPTION HAS BEEN CHOSEN. AUTOMATIC REBALANCING IS REQUIRED IF THE GMDB RIDER HAS BEEN SELECTED.
AGLC102803-2007 Page 2 of 4 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
AUTHORIZATION FOR TRANSACTIONS INITIAL APPROPRIATE I (or we, if Joint Owners), hereby authorize AGL to act on telephone BOX HERE: instructions or e-service instructions, if elected, to transfer values among the variable divisions and the AGL Declared Fixed Interest Account and to change allocations for future premium payments and monthly deductions given by: [_]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 and e-service instructions received and acted on in good faith, including losses due to telephone instructions or e-service 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 instruction or e-service instruction, 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 1. Have you, the Proposed Insured or Owner (if different), received the variable universal BE ANSWERED. life insurance policy prospectus and the investment choices brochure describing the investment options? [_] yes [_] no 2. Do you understand and acknowledge: a. THAT THE POLICY APPLIED FOR IS VARIABLE, EMPLOYS THE USE OF SEGREGATED ACCOUNTS WHICH MEANS THAT YOU NEED TO RECEIVE AND UNDERSTAND CURRENT PROSPECTUSES FOR THE POLICY AND THE UNDERLYING ACCOUNTS? [_] yes [_] no b. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED ACCOUNTS MAY VARY: AND [_] yes [_] no (1)ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S. GOVERNMENT OR ANY STATE GOVERNMENT? [_] yes [_] no (2)ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OR ANY OTHER AGENCY, FEDERAL OR STATE? [_] yes [_] no c. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN THE AGL DECLARED FIXED INTEREST ACCOUNT? [_] yes [_] no d. THAT THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR THE ACCUMULATION OF VALUES IN THE SEGREGATED ACCOUNTS? [_] yes [_] no e. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT? [_] yes [_] no f. 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 3. Do you believe the Policy you selected meets your insurance and investment objectives and your anticipated financial needs? [_] yes [_] no
AGLC102803-2007 Page 3 of 4 ELECTRONIC DELIVERY CONSENT American General Life Insurance Company ("AGL") is capable of providing contract and investment option prospectuses, supplements, statements of additional information, and reports via e-mail or CD-ROM. In order to verify your e-mail receipt of these documents, we must obtain your consent to this type of delivery format. This consent authorizes AGL, with respect to AGL's variable universal life insurance policies, to deliver the following communications via e-mail or CD-ROM: . Contract prospectuses and supplements . Investment option prospectuses and supplements . Statements of additional information . Annual and semi-annual investment option reports This consent to delivery by e-mail or CD-ROM has no expiration date. You may change or cancel your consent at any time by writing to us at American General Life Insurance Company, P.O. Box 4880, Houston, Texas, 77210-4880, Attn: Policy Owner Services. You may also receive a paper copy of any communication at no additional charge by writing to us at the above address. In order to participate in this delivery method you must have access to the following: . A personal computer with CD-ROM hardware and software . Browser software, such as Microsoft Internet Explorer, Netscape Communicator, or equivalent . Communication access to the Internet Should you wish to print materials that have been delivered via e-mail or CD-ROM, you must also have access to a printer. Materials will be published using Portable Document Format (PDF). In order to view PDF documents, you must have Adobe Acrobat Reader software, which is available for download free-of-charge from http://www.adobe.com/products/acrobat/readstep2.html. We reserve the right to mail paper copies instead of providing electronic delivery. In the event that e-mail delivery is unsuccessful, we will mail paper copies. You must notify us every time you change your e-mail address. Your e-mail address will be used solely for AGL's database management regarding the electronic delivery of the communications listed above. Your e-mail address will not be sold or distributed to third parties. By signing this consent, I acknowledge that I have read and understand all of the above-mentioned terms and conditions of this enrollment. I consent to receive electronic delivery of the documents specified above. --------------------------------------- -------------------------------------- Signature of Owner Please provide your e-mail address If you prefer CD-ROM delivery, please check here [_] SIGNATURES SIGNATURES ---------------------------------------------------------------- Signed at (city, state) ---------------------------------------------------------------- Print name of Broker/Dealer X ---------------------------------------- ---------------- ---- Registered representative State license # Date X ---------------------------------------------------------- ---- Primary proposed insured Date X ---------------------------------------------------------- ---- Owner (IF DIFFERENT FROM PROPOSED INSURED) Date X ---------------------------------------------------------- ---- Joint Owner (IF APPLICABLE) Date AGLC102803-2007 Page 4 of 4