Document:

<PAGE>

                                                                 EXHIBIT (10)(d)

                                                              AMERICAN
                                                                 GENERAL
                                                                 FINANCIAL GROUP

        PLATINUM INVESTOR III
        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
--------------------------------------------------------------------------------
<TABLE>
<S>                                                             <C>
        ---------------------------------------------           ----------------------------------------------------
        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 "Deductible 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                                        NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
----------------------------                                        ------------------------------------------
AIM V.I. International Equity Division (260)      ____%  ____%      Mid-Cap Growth Division (286)                     ____%  ____%
AIM V.I. Value Division (261)                     ____%  ____%
                                                                    PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                          ------------------------------
------------------------------------------                          PIMCO Real Return Bond Division (288)             ____%  ____%
VP Value Division (262)                           ____%  ____%      PIMCO Short-Term Bond Division (287)              ____%  ____%
                                                                    PIMCO Total Return Bond Division (289)            ____%  ____%
AYCO SERIES TRUST
-----------------                                                   PUTNAM VARIABLE TRUST
Ayco Growth Division (270)                        ____%  ____%      ---------------------
                                                                    Putnam VT Diversified Income Division (290)       ____%  ____%
CREDIT SUISSE WARBURG PINCUS TRUST                                  Putnam VT Growth and Income Division (291)        ____%  ____%
----------------------------------                                  Putnam VT Int'l Growth and Income Division (292)  ____%  ____%
Small Company Growth Division (300)               ____%  ____%
                                                                    SAFECO RESOURCE SERIES TRUST
DREYFUS INVESTMENT PORTFOLIOS                                       ----------------------------
-----------------------------                                       Equity Division (293)                             ____%  ____%
MidCap Stock Division (273)                       ____%  ____%      Growth Opportunities Division (294)               ____%  ____%

DREYFUS VARIABLE INVESTMENT FUND                                    THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
--------------------------------                                    ---------------------------------------
Quality Bond Division (271)                       ____%  ____%      Equity Growth Division (295)                      ____%  ____%
Small Cap Division (272)                          ____%  ____%      High Yield Division (296)                         ____%  ____%

                                                                    VALIC COMPANY I
FIDELITY VARIABLE INSURANCE PRODUCTS FUND                           ---------------
-----------------------------------------                           International Equities Division (263)             ____%  ____%
VIP Asset Manager Division (277)                  ____%  ____%      Mid Cap Index Division (264)                      ____%  ____%
VIP Contrafund Division (276)                     ____%  ____%      Money Market I Division (265)                     ____%  ____%
VIP Equity-Income Division (274)                  ____%  ____%      Nasdaq-100 Index Division (266)                   ____%  ____%
VIP Growth Division (275)                         ____%  ____%      Science & Technology Division (269)               ____%  ____%
                                                                    Small Cap Index Division (268)                    ____%  ____%
                                                                    Stock Index Division (267)                        ____%  ____%
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST
----------------------------------------------------                VANGUARD VARIABLE INSURANCE FUND
Franklin U.S. Government Division (302)           ____%  ____%      --------------------------------
Mutual Shares Securities Division (303)           ____%  ____%      High Yield Bond Division (297)                    ____%  ____%
Templeton International Securities Division (304) ____%  ____%      REIT Index Division (298)                         ____%  ____%

JANUS ASPEN SERIES
------------------                                                  VAN KAMPEN LIFE INVESTMENT TRUST
Aggressive Growth Division (280)                  ____%  ____%      --------------------------------
International Growth Division (278)               ____%  ____%      Strategic Stock Division (299)                    ____%  ____%
Worldwide Growth Division (279)                   ____%  ____%
                                                                    AGL DECLARED FIXED INTEREST ACCOUNT (301)         ____%  ____%
J.P. MORGAN SERIES TRUST II                                         OTHER: _____________________________              ____%  ____%
---------------------------                                                                                           100%   100%
J.P. Morgan Small Company Division (281)          ____%  ____%

MFS VARIABLE INSURANCE TRUST
----------------------------
MFS Capital Opportunities Division (284)          ____%  ____%
MFS Emerging Growth Division (282)                ____%  ____%
MFS New Discovery Division (285)                  ____%  ____%
MFS Research Division (283)                       ____%  ____%
---------------------------------------------------------------------------------------------------------------
AGLC 0198-00                                                                                        Page 1 of 4

</TABLE>

<PAGE>

--------------------------------------------------------------------------------
Dollar Cost Averaging
--------------------------------------------------------------------------------

<TABLE>
<CAPTION>

<C>                        <S>
Dollar Cost                ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from the Money
Averaging                  Market I 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                                             NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
AIM V.I. International Equity Division (260)            $_____________   Mid-Cap Growth Division (286)                   $__________
AIM V.I. Value Division (261)                           $_____________
                                                                         PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                               PIMCO Real Return Bond Division (288)           $__________
VP Value Division (262)                                 $_____________   PIMCO Short-Term Bond Division (287)            $__________
                                                                         PIMCO Total Return Bond Division (289)          $__________
AYCO SERIES TRUST
Ayco Growth Division (270)                               $_____________  PUTNAM VARIABLE TRUST
                                                                         Putnam VT Diversified Income Division (290)     $__________
CREDIT SUISSE WARBURG PINCUS TRUST                                       Putnam VT Growth and Income Division (291)      $__________
Small Company Growth Division (300)                     $_____________   Putnam VT Int'l Growth and Income Division (292)$__________

DREYFUS INVESTMENT PORTFOLIOS                                            SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (273)                             $_____________   Equity Division (293)                           $__________
                                                                         Growth Opportunities Division (294)             $__________
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (271)                             $_____________   THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
Small Cap Division (272)                                $_____________   Equity Growth Division (295)                    $_________
                                                                         High Yield Division (296)                       $_________
FIDELITY VARIABLE INSURANCE PRODUCTS FUNDS
VIP Asset Manager Division (277)                        $_____________   VALIC COMPANY I
VIP Contrafund Division (276)                           $_____________   International Equities Division (263)           $_________
VIP Equity-Income Division (274)                        $_____________   Mid Cap Index Division (264)                    $_________
VIP Growth Division (275)                               $_____________   Nasdaq-100 Index Division (266)                 $_________
                                                                         Science & Technology Division (269)             $_________
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST                     Small Cap Index Division (268)                  $_________
Franklin U.S. Government Division (302)                 $_____________   Stock Index Division (267)                      $_________
Mutual Shares Securities Division (303)                 $_____________
Templeton International Securities Division (304)       $_____________   VANGUARD VARIABLE INSURANCE FUND
                                                                         High Yield Bond Division (297)                  $_________
JANUS ASPEN SERIES                                                       REIT Index Division (298)                       $_________
Aggressive Growth Division (280)                        $_____________
International Growth Division (278)                     $_____________   VAN KAMPEN LIFE INVESTMENT TRUST
Worldwide Growth Division (279)                         $_____________   Strategic Stock Division (299)                  $_________
                                                                         OTHER:______________________________________    $_________
J.P. MORGAN SERIES TRUST II
J.P. Morgan Small Company Division (281)                $_____________

MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (284)                $_____________
MFS Emerging Growth Division (282)                      $_____________
MFS New Discovery Division (285)                        $_____________
MFS Research Division (283)                             $_____________

------------------------------------------------------------------------------------------------------------------------------------
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 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
</TABLE>
-------------------------------------------------------------------------------
AGLC 0198-00                                                        Page 2 of 4

<PAGE>

<TABLE>
<S>                             <C>
------------------------------------------------------------------------------------------------------------------------------------
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 premium 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
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 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

------------------------------------------------------------------------------------------------------------------------------------
AGLC 0198-00                                                                                                             Page 3 of 4
</TABLE>
<PAGE>

--------------------------------------------------------------------------------
Your Signature
--------------------------------------------------------------------------------

<TABLE>
<S>             <C>
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)
</TABLE><PAGE>

                                                                 EXHIBIT (10)(e)

            SERVICE REQUEST

                   PLATINUM
---------------------------
           INVESTOR(SM) III
---------------------------
      AMERICAN GENERAL LIFE

<TABLE>
<S>                                                             <C>
--------------------------------------------------------------------------------------------------------------------

PLATINUM INVESTOR III -- FIXED OPTION                           MFS Variable Insurance Trust
                                                                ----------------------------
 . Division 301 - AGL Declared Fixed Interest Account
                                                                . Division 284 - MFS Capital Opportunities
PLATINUM INVESTOR III -- VARIABLE DIVISIONS
AIM Variable Insurance Funds                                    . Division 282 - MFS Emerging Growth
----------------------------
                                                                . Division 285 - MFS New Discovery
 . Division 260 - AIM V.I. International Equity
                                                                . Division 283 - MFS Research
 . Division 261 - AIM V.I. Value
                                                                Neuberger Berman Advisers Management Trust
American Century Variable Portfolios. Inc.                      ------------------------------------------
------------------------------------------
                                                                . Division 286 - Mid-Cap Growth
 . Division 262 - VP Value
                                                                PIMCO Variable Insurance Trust
Ayco Series Trust                                               ------------------------------
-----------------
                                                                . Division 288 - PIMCO Real Return Bond
 . Division 270 - Ayco Growth
                                                                . Division 287 - PIMCO Short-Term Bond
Credit Suisse Warburg Pincus Trust
----------------------------------                              . Division 289 - PIMCO Total Return Bond

 . Division 300 - Small Company Growth                           Putnam Variable Trust
                                                                ---------------------
Dreyfus Investment Portfolios
-----------------------------                                   . Division 290 - Putnam VT Diversified Income

 . Division 273 - MidCap Stock                                   . Division 291 - Putnam VT Growth and Income

Dreyfus Variable Investment Fund                                . Division 292 - Putnam VT Int'l Growth and Income
--------------------------------
                                                                SAFECO Resource Series Trust
 . Division 271 - Quality Bond                                   ----------------------------

 . Division 272 - Small Cap                                      . Division 293 - Equity

Fidelity Variable Insurance Products Fund                       . Division 294 - Growth Opportunities
-----------------------------------------
                                                                The Universal Institutional Funds, Inc.
 . Division 277 - VIP Asset Manager                              ---------------------------------------

 . Division 276 - VIP Contrafund                                 . Division 295 - Equity Growth

 . Division 274 - VIP Equity-Income                              . Division 296 - High Yield

 . Division 275 - VIP Growth                                     VALIC Company I
                                                                ---------------
Franklin Templeton Variable Insurance Products Trust
----------------------------------------------------            . Division 263 - International Equities

 . Division 302 - Franklin U.S. Government                       . Division 264 - Mid Cap Index

 . Division 303 - Mutual Shares Securities                       . Division 265 - Money Market I

 . Division 304 - Templeton International Securities             . Division 266 - Nasdaq-100 Index

Janus Aspen Series                                              . Division 269 - Science & Technology
-----------------------------------
                                                                . Division 268 - Small Cap Index
 . Division 280 - Aggressive Growth
                                                                . Division 267 - Stock Index
 . Division 278 - International Growth
                                                                Vanguard Variable Insurance Fund
 . Division 279 - Worldwide Growth                               -------------------------------

J.P. Morgan Series Trust II                                     . Division 297 - High Yield Bond
---------------------------
                                                                . Division 298 - REIT Index
 . Division 281 - J.P. Morgan Small Company
                                                                Van Kampen Life Investment Trust
                                                                --------------------------------

                                                                . Division 299 - Strategic Stock

AGLC0223 REV 0901
</TABLE>

<PAGE>

<TABLE>
<S>                                    <C>
 Complete and return this request to:        American General Life Insurance Company ("AGL")                AMERICAN
  Variable Universal Life Operations              Member American General Financial Group                       GENERAL
 PO Box 4880 Houston, TX 77210-4880                         Houston, Texas                                     FINANCIAL GROUP
  (888) 325-9315 or (713) 831-3443
        Fax: (877) 445-3098
Hearing Impaired/TDD: (888) 436-5258           VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST

------------------------------------------------------------------------------------------------------------------------------------
  [_]  POLICY                  1. | POLICY #:_________________________________ INSURED:_____________________________________________
       IDENTIFICATION             | ADDRESS:________________________________________________________________ New Address (yes) (no)
    COMPLETE THIS SECTION FOR     | Primary Owner (if other than an insured):_______________________________
        ALL REQUESTS.             | Address:________________________________________________________________ New Address (yes) (no)
                                  | Primary Owner's S.S. No.or Tax I.D. No.______________ Phone Number:(   )_____-_________________
                                  | Joint Owner (if applicable):___________________________________________________________________
                                  | Address:________________________________________________________________ New Address (yes) (no)
-----------------------------------------------------------------------------------------------------------------------------------
  [_]  NAME                    2. | Change Name Of: (Circle One)     Insured    Owner   Payor   Beneficiary
       CHANGE                     |
                                  | Change Name From: (First, Middle, Last)               Change Name To: (First, Middle, Last)
Complete this section if the name | __________________________________________________    __________________________________________
of one of the Contingent Insureds,|
 Owner, Payor or Beneficiary has  | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
 changed. (Please note, this does |
    not change the Contingent     |
    Insureds, Owner, Payor or     |
    Beneficiary designation.)     |
------------------------------------------------------------------------------------------------------------------------------------
  [_]  CHANGE IN               3. | INVESTMENT DIVISION               PREM % DED %   INVESTMENT DIVISION              PREM %  DED %
       ALLOCATION                 |
       PERCENTAGES                | AIM VARIABLE INSURANCE FUNDS                     NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
                                  | (260) AIM V.I. International Equity _____ _____  (286) Mid-Cap Growth               _____ _____
  Use this section to indicate    | (261) AIM V.I. Value                _____ _____
     how premiums or monthly      |                                                  PIMCO VARIABLE INSURANCE TRUST
 deductions are to be allocated.  | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.       (288) PIMCO Real Return Bond       _____ _____
 Total allocation in each column  | (262) VP Value                      _____ _____  (287) PIMCO Short-Term Bond        _____ _____
     must equal 100%; whole       |                                                  (289) PIMCO Total Return Bond      _____ _____
         numbers only.            | AYCO SERIES TRUST
                                  | (270) Ayco Growth                   _____ _____  PUTNAM VARIABLE TRUST
                                  |                                                  (290) Putnam VT Diversified Income _____ _____
                                  | CREDIT SUISSE WARBURG PINCUS TRUST               (291) Putnam VT Growth and Income  _____ _____
                                  | (300) Small Company Growth          _____ _____  (292) Putnam VT Int'l Growth and
                                  |                                                          Income                     _____ _____
                                  | DREYFUS INVESTMENT PORTFOLIOS
                                  | (273) MidCap Stock                  _____ _____  SAFECO RESOURCE SERIES TRUST
                                  |                                                  (293) Equity                       _____ _____
                                  | DREYFUS VARIABLE INVESTMENT FUND                 (294) Growth Opportunities         _____ _____
                                  | (271) Quality Bond                  _____ _____
                                  | (272) Small Cap                     _____ _____  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  |                                                  (295) Equity Growth                _____ _____
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND        (296) High Yield                   _____ _____
                                  | (277) VIP Asset Manager             _____ _____
                                  | (276) VIP Contrafund                _____ _____  VALIC COMPANY I
                                  | (274) VIP Equity-Income             _____ _____  (263) International Equities       _____ _____
                                  | (275) VIP Growth                    _____ _____  (264) Mid Cap Index                _____ _____
                                  |                                                  (265) Money Market I               _____ _____
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            (266) Nasdaq-100 Index             _____ _____
                                  |  PRODUCTS TRUST                                  (269) Science & Technology         _____ _____
                                  | (302) Franklin U.S. Government      _____ _____  (268) Small Cap Index              _____ _____
                                  | (303) Mutual Shares Securities      _____ _____  (267) Stock Index                  _____ _____
                                  | (304) Templeton International       _____ _____
                                  |       Securities                                 VANGUARD VARIABLE INSURANCE FUND
                                  |                                                  (297) High Yield Bond              _____ _____
                                  | JANUS ASPEN SERIES                               (298) REIT Index                   _____ _____
                                  | (280) Aggressive Growth             _____ _____
                                  | (278) International Growth          _____ _____  VAN KAMPEN LIFE INVESTMENT TRUST
                                  | (279) Worldwide Growth              _____ _____  (299) Strategic Stock              _____ _____
                                  |
                                  | J.P. MORGAN SERIES TRUST II                      OTHER:_______________________      _____ _____
                                  | (281) J.P. Morgan Small Company     _____ _____  (301) AGL Declared Fixed Interest
                                  |                                                        Account                      _____ _____
                                  | MFS VARIABLE INSURANCE TRUST                                                        100%  100%
                                  | (284) MFS Capital Opportunities     _____ _____
                                  | (282) MFS Emerging Growth           _____ _____
                                  | (285) MFS New Discovery             _____ _____
                                  | (283) MFS Research                  _____ _____
                                  |
                                  |
                                  |
------------------------------------------------------------------------------------------------------------------------------------
AGLCO223 REV 1101                                              PAGE 2 OF 5
</TABLE>

<PAGE>

<TABLE>
<S>                                    <C>
------------------------------------------------------------------------------------------------------------------------------------
  [_]  MODE OF                 4. | Indicate frequency and premium amount desired: $______ Annual $_____ Semi-Annual $____ Quarterly
       PREMIUM                    |                                                $_____ Monthly (Bank Draft Only)
       PAYMENT/BILLING            |
       METHOD CHANGE              | Indicate billing method desired: _____Direct Bill  _____Pre-Authorized Bank Draft (attach a
  Use this section to change the  | Bank Draft Authorization Form and "Void"  Check)
 billing frequency and/or method  |
  of premium payment.  Note,      |
however, that AGL will not bill   | Start Date: ________/ _______/ _________
   you on a direct monthly basis. |
 Refer to your policy and its     |
 related prospectus for further   |
 information concerning minimum   |
  premiums and billing options.   |
-----------------------------------------------------------------------------------------------------------------------------------
  [_]  LOST POLICY             5. | I/we hereby certify that the policy of insurance for the listed policy has been
       CERTIFICATE                |  ______LOST ______DESTROYED ______OTHER.
Complete this section if applying |
for a Certificate of Insurance or | Unless I/we have directed cancellation of the policy, I/we request that a:
 duplicate policy to replace a    |
 lost or misplaced policy. If a   |             _______Certificate of Insurance at no charge
 full duplicate policy is being   |
requested, a check or money order |             _______Full duplicate policy at a charge of $25
 for $25 payable to AGL must be   |
  submitted with this request.    | be issued to me/us. If the original policy is located, I/we will return the Certificate
                                  | or duplicate policy to AGL for cancellation.
------------------------------------------------------------------------------------------------------------------------------------
  [_]  DOLLAR COST             6. | DESIGNATE the day of the month for transfers: _______(choose a day from 1-28)
       AVERAGING                  | Frequency of transfers (check one): _____Monthly _____Quarterly _____Semi-Annually _____Annually
     ($5,000 minimum initial      | I want: $________________ ($100 minimum) taken from the Money Market I Division and transferred
accumulation value) An amount may | to the following Divisions:
be deducted periodically from the |
Money Market I Division and placed| AIM VARIABLE INSURANCE FUNDS                    MFS VARIABLE INSURANCE TRUST
 in one or more of the Divisions  | (260) AIM V.I. International Equity  $________  (284) MFS Capital Opportunities      $________
 listed. The AGL Declared Fixed   | (261) AIM V.I. Value                 $________  (282) MFS Emerging Growth            $________
Interest Account is not available |                                                 (285) MFS New Discovery              $________
for Dollar Cost Averaging. Please | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.      (283) MFS Research                   $________
refer to the prospectus for more  | (262) VP Value                       $________
 information on the Dollar Cost   |                                                 NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Averaging Option. Note: Automatic | AYCO SERIES TRUST                               (286) Mid-Cap Growth                   $________
 Rebalancing is not available if  | (270) Ayco Growth                    $________
the Dollar Cost Averaging Option  |                                                 PIMCO VARIABLE INSURANCE TRUST
          is chosen.              | CREDIT SUISSE WARBURG PINCUS TRUST              (288) PIMCO Real Return Bond           $________
                                  | (300) Small Company Growth           $________  (287) PIMCO Short-Term Bond            $________
                                  |                                                 (289) PIMCO Total Return Bond          $________
                                  | DREYFUS INVESTMENT PORTFOLIOS
                                  | (273) Midcap Stock                   $________  PUTNAM VARIABLE TRUST
                                  |                                                 (290) Putnam VT Diversified Income     $________
                                  | DREYFUS VARIABLE INVESTMENT FUND                (291) Putnam VT Growth and Income      $________
                                  | (271) Quality Bond                   $________  (292) Putnam VT Int'l Growth and
                                  | (272) Small Cap                      $________        Income                           $________
                                  |
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND       SAFECO RESOURCE SERIES TRUST
                                  | (277) VIP Asset Manager              $________  (293) Equity                           $________
                                  | (276) VIP Contrafund                 $________  (294) Growth Opportunities             $________
                                  | (274) VIP Equity-Income              $________
                                  | (275) VIP Growth                     $________  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  |                                                 (295) Equity Growth                    $________
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE           (296) High Yield                       $________
                                  |  PRODUCTS TRUST
                                  | (302) Franklin U.S. Government       $________  VALIC COMPANY I
                                  | (303) Mutual Shares Securities       $________  (263) International Equities           $________
                                  | (304) Templeton International                   (264) Mid Cap Index                    $________
                                  |        Securities                    $________  (266) Nasdaq-100 Index                 $________
                                  |                                                 (269) Science & Technology             $________
                                  | JANUS ASPEN SERIES                              (268) Small Cap Index                  $________
                                  | (280) Aggressive Growth              $________  (267) Stock Index                      $________
                                  | (278) International Growth           $________
                                  | (279) Worldwide Growth               $________  VANGUARD VARIABLE INSURANCE FUND
                                  |                                                 (297) High Yield Bond                  $________
                                  | J.P MORGAN SERIES TRUST II                      (298) REIT Index                       $________
                                  | (281) J.P Morgan Small Company       $________
                                  |                                                 VAN KAMPEN LIFE INVESTMENT TRUST
                                  |                                                 (299) Strategic Stock                  $________
                                  |                                                 Other: _____________________________   $________
                                  | _____ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION
------------------------------------------------------------------------------------------------------------------------------------
AGLC0223 REV 1101                                              PAGE 3 OF 5
</TABLE>

<PAGE>

<TABLE>
<S>                                 <C>
------------------------------------------------------------------------------------------------------------------------------------
  [_]  AUTOMATIC               7. |
       REBALANCING                | Indicate frequency: ________Quarterly ________Semi-Annually ________Annually
   ($5,000 minimum accumulation   |
 value) Use this section to apply |              (Division Name or Number)                        (Division Name or Number)
      for or make changes to      |
   Automatic Rebalancing of the   | _______% : ___________________________________     _______%  : ________________________________
 variable divisions. Please refer | _______% : ___________________________________     _______%  : ________________________________
    to the prospectus for more    | _______% : ___________________________________     _______%  : ________________________________
   information on the Automatic   | _______% : ___________________________________     _______%  : ________________________________
       Rebalancing Option.        | _______% : ___________________________________     _______%  : ________________________________
  Note: Dollar Cost Averaging is  | _______% : ___________________________________     _______%  : ________________________________
  not available if the Automatic  | _______% : ___________________________________     _______%  : ________________________________
   Rebalancing Option is chosen.  | _______% : ___________________________________     _______%  : ________________________________
                                  | _______% : ___________________________________     _______%  : ________________________________
                                  | _______% : ___________________________________     _______%  : ________________________________
                                  | _______% : ___________________________________     _______%  : ________________________________
                                  |
                                  |
                                  | ________  INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
-----------------------------------------------------------------------------------------------------------------------------------
  [_]  TELEPHONE               8. | I(/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values
       PRIVILEGE                  | among the Variable Divisions and AGL Declared Fixed Interest Account and to change allocations
       AUTHORIZATION              | for future purchase payments and monthly deductions.
Complete this section if you are  |
applying for or revoking current  | Initial the designation you prefer:
     telephone privileges.        |
                                  | _________Policy Owner(s) ONLY - If Joint Owners, either one acting independently.
                                  |
                                  | _________Policy Owner(s) OR Agent/Registered Representative who is appointed to represent AGL
                                  |          and the firm authorized to service my policy.
                                  |
                                  | AGL and any non-owner designated by this authorization will not be responsible for any claim,
                                  | loss or expense based upon telephone transfer or allocation instructions received and acted upon
                                  | in good faith, including losses due to telephone instruction communication errors. AGL's
                                  | liability for erroneous transfers or 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 the receipt of the 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 the address printed on
                                  | the top of this service request form.
                                  |
                                  | _______INITIAL HERE TO REVOKE TELEPHONE PRIVILEGE AUTHORIZATION.
------------------------------------------------------------------------------------------------------------------------------------
 [_]  CORRECT AGE              9. |
 Use this section to correct the  | Name of Insured for whom this correction is submitted:__________________________________________
 age of any person covered under  |
this policy. Proof of the correct |
date of birth must accompany this | Correct DOB: _________/____________ /_____________
            request.              |
------------------------------------------------------------------------------------------------------------------------------------
 [_]  TRANSFER OF             10. |                                     (Division Name or Number)         (Division Name or Number)
      ACCUMULATED                 |
      VALUES                      | Transfer $_______ or _______% from ____________________________ to _____________________________
  Use this section if you want to |
  move money between divisions.   | Transfer $_______ or _______% from ____________________________ to _____________________________
 The minimum amount for transfers |
 is $500.00. Withdrawals from the | Transfer $_______ or _______% from ____________________________ to _____________________________
   AGL Declared Fixed Interest    |
 Account to a Variable Division   | Transfer $_______ or _______% from ____________________________ to _____________________________
 may only be made within the 60   |
      days after a contract       | Transfer $_______ or _______% from ____________________________ to _____________________________
    anniversary. See transfer     |
     limitations outlined in      | Transfer $_______ or _______% from ____________________________ to _____________________________
 prospectus. If a transfer causes |
 the balance in any division to   | Transfer $_______ or _______% from ____________________________ to _____________________________
  drop below $500, AGL reserves   |
      the right to transfer       | Transfer $_______ or _______% from ____________________________ to _____________________________
 the remaining balance. Amounts   |
    to be transferred should be   | Transfer $_______ or _______% from ____________________________ to _____________________________
indicated in dollar or percentage |
    amounts, maintaining          | Transfer $_______ or _______% from ____________________________ to _____________________________
   consistency throughout.        |
------------------------------------------------------------------------------------------------------------------------------------
AGLC0223 REV1101                                                    PAGE 4 OF 5
</TABLE>

<PAGE>

<TABLE>
<S>                                 <C>
------------------------------------------------------------------------------------------------------------------------------------
 [_]  REQUEST FOR             11. |
      PARTIAL                     | ______I request a partial surrender of $_____ or _____% of the net cash surrender value.
      SURRENDER/                  | ______I request a loan in the amount of $_____.
      POLICY LOAN                 | ______I request the maximum loan amount available from my policy.
                                  |
 Use this section to apply for a  |
 partial surrender from or policy |
 loan against policy values. For  | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
 detailed information concerning  | percentages in effect, if available; otherwise they are taken pro-rata from the Declared Fixed
these two options please refer to | Interest Account and Variable Divisions in use.
   your policy and its related    |
  prospectus. If applying for a   | ________________________________________________________________________________________________
  partial surrender, be sure to   |
complete the Notice of Withholding| ________________________________________________________________________________________________
 section of this Service Request  |
  in addition to this section.    | ________________________________________________________________________________________________
                                  |
------------------------------------------------------------------------------------------------------------------------------------
 [_]  NOTICE OF               12. | The taxable portion of the distribution you receive from your variable universal life insurance
      WITHHOLDING                 | policy is subject to federal income tax withholding unless you elect not to have withholding
                                  | apply. Withholding of state income tax may also be required by your state of residence. You may
Complete this section if you have | elect not to have withholding apply by checking the appropriate box below. If you elect not to
 applied for a partial surrender  | have withholding apply to your distribution or if you do not have enough income tax withheld,
        in Section 11.            | you may be responsible for payment of estimated tax. You may incur penalties under the
                                  | estimated tax rules, if your withholding and estimated tax are not sufficient.
                                  |
                                  | Check one: ________I DO want income tax withheld from this distribution.
                                  |
                                  |            ________I DO NOT want income tax withheld from this distribution.
                                  |
                                  | IF NO ELECTION IS MADE, WE ARE REQUIRED TO WITHHOLD FEDERAL INCOME TAX (IF APPLICABLE).
------------------------------------------------------------------------------------------------------------------------------------
 [_]  AFFIRMATION/            13. | CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY: (1) THAT THE NUMBER SHOWN ON THIS FORM IS
      SIGNATURE                   | MY CORRECT TAXPAYER IDENTIFICATION NUMBER AND; (2) THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING
                                  | UNDER SECTION 3406(A)(1)(C) OF THE INTERNAL REVENUE CODE.
   Complete this section for      |
         ALL requests.            | THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT
                                  | OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING.
                                  |-------------------------------------------------------------------------------------------------
                                  | Dated at_______________this___________day of______________________________________,__________
                                  |         CITY, STATE
                                  |
                                  | X______________________________________________   X__________________________________________
                                  |  SIGNATURE OF OWNER                                SIGNATURE OF WITNESS
                                  |
                                  | X______________________________________________   X__________________________________________
                                  |  SIGNATURE OF JOINT OWNER                          SIGNATURE OF WITNESS
                                  |
                                  | X______________________________________________   X__________________________________________
                                  |  SIGNATURE OF ASSIGNEE                             SIGNATURE OF WITNESS
                                  |
------------------------------------------------------------------------------------------------------------------------------------
AGLCO223 REV 1101                                              PAGE 5 OF 5
</TABLE>

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00032-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00032-of-00352.parquet"}]]