Document:

<PAGE>

                                                                 EXHIBIT (10)(e)

<TABLE>
<CAPTION>
                                         AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
                                                   Home Office: Houston, Texas

                                    VARIABLE UNIVERSAL LIFE INSURANCE SUPPLEMENTAL APPLICATION
                         (This supplement must accompany the appropriate application for life insurance.)
<S>                        <C>            <C>                                            <C>                 <C>
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                                                  PART 1. APPLICANT INFORMATION
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Supplement to the application on the life of ______________________________________, dated _______________________________________.
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                                              PART 2. INITIAL ALLOCATION PERCENTAGES
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INVESTMENT OPTIONS: In the "Premium Allocation" column, indicate how each premium received is to be allocated. In the "Deduction
Allocation" column, indicate which investment options are to be used for the deduction of monthly account charges. Total allocations
in each column must equal 100%. Use whole percentages only.

                                  PREMIUM          DEDUCTION                                           PREMIUM          DEDUCTION
DIVISIONS                        ALLOCATION       ALLOCATION      DIVISIONS                           ALLOCATION       ALLOCATION
------------------------------------------------------------------------------------------------------------------------------------
AIM VARIABLE INSURANCE FUNDS                                      OPPENHEIMER VARIABLE ACCOUNT FUNDS
  AIM V.I. International                                            Oppenheimer High Income/VA (91)    _______%         _______%
   Equity Fund (85)               _______%         _______%       PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE                                           PIMCO Real Return Bond (125)       _______%         _______%
 PORTFOLIOS, INC.                                                   PIMCO Total Return Bond (126)      _______%         _______%
  VP Value Fund (86)              _______%         _______%       PUTNAM VARIABLE TRUST
FIDELITY VARIABLE INSURANCE                                         Putnam VT Diversified Income
 PRODUCTS FUND                                                       Fund (92)                         _______%         _______%
  VIP Equity-Income (121)         _______%         _______%         Putnam VT Small Cap Value
  VIP Growth (122)                _______%         _______%          Fund (93)                         _______%         _______%
  VIP Contrafund (123)            _______%         _______%         Putnam VT Vista Fund (94)          _______%         _______%
  VIP Asset Manager (124)         _______%         _______%         Putnam VT Voyager Fund (95)        _______%         _______%
MFS VARIABLE INSURANCE TRUST                                      FRANKLIN TEMPLETON VARIABLE
  MFS Emerging Growth Series (87) _______%         _______%        INSURANCE PRODUCTS TRUST
  MFS New Discovery Series (88)   _______%         _______%         Franklin Small Cap Fund (96)       _______%         _______%
  MFS Total Return Series (89)    _______%         _______%         Templeton International
NEUBERGER BERMAN ADVISORS                                            Securities Fund (97)              _______%         _______%
 MANAGEMENT TRUST                                                 VAN KAMPEN LIFE INVESTMENT TRUST
  Partners Portfolio (90)         _______%         _______%         Emerging Growth Portfolio (98)     _______%         _______%
NORTH AMERICAN FUNDS VARIABLE                                       Government Portfolio (99)          _______%         _______%
 PRODUCT SERIES I                                                   Other: __________________________  _______%         _______%
  International Equities
   Fund (81)                      _______%         _______%
  MidCap Index Fund (82)          _______%         _______%
  Money Market Fund (83)          _______%         _______%
  Stock Index Fund (84)           _______%         _______%
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                                                   PART 3. DOLLAR COST AVERAGING
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DOLLAR COST AVERAGING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from the Money
Market Fund (83) and transferred to one or more of the investment divisions below. Please refer to the prospectus for more
information on the Dollar Cost Averaging option.

DAY OF THE MONTH FOR TRANSFERS: ____________________ (Choose a day of the month between 1-28.)
FREQUENCY OF TRANSFERS:         [_] Monthly    [_] Quarterly    [_] Semiannually     [_] Annually
TRANSFER $ _____________________ ($100 MINIMUM, WHOLE DOLLARS ONLY) from the Money Market Fund (83) to the following division(s):

  International Equities Fund (81)          $_____________       Putnam VT Voyager Fund (95)                          $_____________
  MidCap Index Fund (82)                    $_____________       Franklin Small Cap Fund (96)                         $_____________
  Stock Index Fund (84)                     $_____________       Templeton International Securities Fund (97)         $_____________
  AIM V.I. International Equity Fund (85)   $_____________       Emerging Growth Portfolio (98)                       $_____________
  VP Value Fund (86)                        $_____________       Government Portfolio (99)                            $_____________
  MFS Emerging Growth Series (87)           $_____________       VIP Equity-Income (121)                              $_____________
  MFS New Discovery Series (88)             $_____________       VIP Growth (122)                                     $_____________
  MFS Total Return Series (89)              $_____________       VIP Contrafund (123)                                 $_____________
  Partners Portfolio (90)                   $_____________       VIP Asset Manager (124)                              $_____________
  Oppenheimer High Income Fund/VA (91)      $_____________       PIMCO Real Return Bond (125)                         $_____________
  Putnam VT Diversified Income Fund (92)    $_____________       PIMCO Total Return Bond (126)                        $_____________
  Putnam VT Small Cap Value Fund (93)       $_____________       Other: ____________________________________________  $_____________
  Putnam VT Vista Fund (94)                 $_____________
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                                                   PART 4. AUTOMATIC REBALANCING
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AUTOMATIC REBALANCING: ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically rebalanced based
on the premium percentages designated in Part 2. Please refer to the prospectus for more information on the Automatic Rebalancing
option.
                                             [_] CHECK HERE FOR AUTOMATIC REBALANCING.
FREQUENCY:              [_] Quarterly      [_] Semiannually      [_] Annually

NOTE: Automatic Rebalancing is not available if the Dollar Cost Averaging option has been chosen.
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AGLC 0091                                                   PAGE 1 OF 2
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                    AMERICAN GENERAL LIFE INSURANCE COMPANY
                          Home Office: Houston, Texas

<TABLE>
<CAPTION>

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                                                  PART 5. TELEPHONE AUTHORIZATION
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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 to change allocations for future purchase payments and monthly deductions given by:
(Initial appropriate box below).

[ ]  Policy Owner(s) ONLY -- If Joint Owners, either of us acting independently.
[ ]  Policy Owner(s) OR the Agent/Registered Representative who is appointed to represent AGL and the firm authorized to service my
     policy.

AGL and any person designated by this authorization will not be responsible for any claim, loss or expense based upon telephone
instructions received and acted on in good faith, including losses due to telephone instruction communication errors. AGL's
liability for erroneous transfers and allocations, unless clearly contrary to instructions received, will be limited to correction
of the allocations on a current basis. If an error, objection or other claim arises due to a telephone transaction, I will notify
AGL in writing within five working days from receipt of confirmation of the transaction from AGL. I understand that this
authorization is subject to the terms and provisions of my variable universal life insurance policy and its related prospectus. This
authorization will remain in effect until my written notice of its revocation is received by AGL at its home office.

[ ]  INITIAL HERE TO DECLINE THE ABOVE TELEPHONE AUTHORIZATION.

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                                                PART 6. MODIFIED ENDOWMENT CONTRACT
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If any premium payment causes the policy to be classified as a modified endowment contract under Section 7702A of the United States
Internal Revenue Code, there may be potentially adverse U.S. tax consequences. Such consequences include: (1) withdrawals or loans
being taxed to the extent of gain; and (2) a 10% penalty tax on the taxable amount. In order to avoid modified endowment status, I
request any excess premium that could cause such status to be refunded.
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                                       PART 7. SUITABILITY (All Questions Must Be Answered.)
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<S>                                                                                                         <C>          <C>
                                                                                                            YES           NO
                                                                                                            ---           --
1.  Have you, the Proposed Insured or Owner (if different), received the variable universal life
    insurance policy prospectus and the prospectuses describing the investment options?                     [ ]           [ ]
    (If "yes," please furnish the Prospectus dates.)

         Variable Universal Life Insurance Policy Prospectus             -----------------------

         Supplements (if any):                                           -----------------------

2.  Do you understand that under the Policy applied for:
    a. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING ON THE
       INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT?                                                       [ ]           [ ]

    b. THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE
       SEPARATE ACCOUNT AND CERTAIN EXPENSE DEDUCTIONS?                                                     [ ]           [ ]

    c. The Policy is designed to provide life insurance coverage and to allow for the accumulation
       of values in the Separate Account?                                                                   [ ]           [ ]

3.  Do you believe the Policy you selected meets your insurance and investment objectives and
    your anticipated financial needs?                                                                       [ ]           [ ]

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Signed at:                                                                           Date:
          ---------------------------------------------------------------------           ------------------------------------------
            CITY                                                         STATE

X                                                                     X
-------------------------------------------------------------         --------------------------------------------------------------
 SIGNATURE OF PRIMARY PROPOSED INSURED                                  SIGNATURE OF REGISTERED REPRESENTATIVE

X
-------------------------------------------------------------         --------------------------------------------------------------
 SIGNATURE OF OWNER (if different from Proposed Insured)                PRINT NAME OF BROKER/DEALER

X
-------------------------------------------------------------
 SIGNATURE OF JOINT OWNER (if applicable)

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AGLC 0091                                                   PAGE 2 OF 2
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                                                                 EXHIBIT (10)(f)

SERVICE REQUEST

A G
L   E   G   A   C   Y
---------------------
                 PLUS
---------------------
AMERICAN GENERAL LIFE
--------------------------------------------------------------------------------

AG LEGACY PLUS -- VARIABLE DIVISIONS

AIM Variable Insurance Funds
----------------------------
  .  Division 85 - AIM V.I. International Equity Fund

American Century Variable Portfolios, Inc.
------------------------------------------
  .  Division 86 - VP Value Fund

MFS Variable Insurance Trust
----------------------------
  .  Division 87 - MFS Emerging Growth Series
  .  Division 88 - MFS New Discovery Series
  .  Division 89 - MFS Total Return Series

Neuberger Berman Advisers Management Trust
------------------------------------------
  .  Division 90 - Partners Portfolio

North American Funds Variable Product Series I
----------------------------------------------
  .  Division 81 - International Equities Fund
  .  Division 82 - MidCap Index Fund
  .  Division 83 - Money Market Fund
  .  Division 84 - Stock Index Fund

Oppenheimer Variable Account Funds
----------------------------------
  .  Division 91 - Oppenheimer High Income Fund/VA

Putnam Variable Trust
---------------------
  .  Division 92 - Putnam VT Diversified Income Fund
  .  Division 93 - Putnam VT Small Cap Value Fund
  .  Division 94 - Putnam VT Vista Fund
  .  Division 95 - Putnam VT Voyager Fund

Franklin Templeton Variable Insurance Products Trust
----------------------------------------------------
  .  Division 96 - Franklin Small Cap Fund
  .  Division 97 - Templeton International Securities Fund

Van Kampen Life Investment Trust
--------------------------------
  .  Division 98 - Emerging Growth Portfolio
  .  Division 99 - Government Portfolio

Fidelity Variable Insurance Products Fund
-----------------------------------------
  .  Division 121 - VIP Equity-Income
  .  Division 122 - VIP Growth
  .  Division 123 - VIP Contrafund
  .  Division 124 - VIP Asset Manager

PIMCO Variable Insurance Trust
------------------------------
  .  Division 125 - PIMCO Real Return Bond
  .  Division 126 - PIMCO Total Return Bond
<PAGE>

<TABLE>
<CAPTION>

                                          AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
Complete and return this request to:          Member American General Financial Group                            AMERICAN
 Variable Universal Life Operations                       Houston, Texas                                           |GENERAL
PO Box 4880 Houston, TX. 77210-4880                                                                                |FINANCIAL GROUP
        (888) 436-4963 or
Hearing Impaired (TDD): (888) 436-5258
  Toll Free Fax: (877) 445-3098            VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST
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<S>                               <C>                                                         <C>
[ ] POLICY                    1.| POLICY #:________________________________________________  INSURED:_______________________________
    IDENTIFICATION              |
                                | ADDRESS:________________________________________________________________ New Address (yes) (no)
COMPLETE THIS SECTION           |
  FOR ALL REQUESTS.             | Primary Owner (If other than insured): ___________________________________________________________
                                |
                                | 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)
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[ ] NAME                      2.|
    CHANGE                      | Change Name Of: (Circle One)    Insured   Owner    Payor   Beneficiary
                                |
Complete this section if        | Change Name From: (First, Middle, Last)                 Change Name To: (First, Middle, Last)
 the name of the Insured,       |
Owner, Payor or Beneficiary     | _______________________________________                 _____________________________________
 has changed. (Please note,     |
 this does not change the       | Reason for Change: (Circle One) Marriage  Divorce  Correction  Other (Attach copy of legal proof)
 Insured, Owner, Payor or       |
 Beneficiary designation)       |
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[ ] MODE OF PREMIUM           3.|
    PAYMENT/BILLING             | Indicate frequency and premium amount desired: $______ Annual $_______ Semi-Annual $_____Quarterly
    METHOD CHANGE               |                                                $______ Monthly (Bank Draft Only)
                                |
Use this section to change      | Indicate billing method desired:____Direct Bill ____Pre-Authorized Bank Draft (attach a Bank Draft
the billing frequency and/      |                                                     Authorization Form and "Void" Check)
or method of premium payment.   |
Note, however, that AGL will    | Start Date: ______/ ______/ ______
  not bill you on a direct      |
monthly basis. Refer to your    |
  policy and its related        |
  prospectus for further        |
information concerning minimum  |
 premiums and billing options.  |
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[ ] LOST POLICY               4.| I hereby certify that the policy of insurance for the listed policy has been    ______LOST
    CERTIFICATE                 |                                                                                 ______DESTROYED
                                |                                                                                 ______OTHER
Complete this section if        | Unless I/we have directed cancellation of the policy, I/we request that a:
applying for a Certificate      |
of Insurance or duplicate       |                          _____________ Certificate of Insurance at no charge
policy to replace a lost        |
or misplaced policy. If a       |                          _____________ Full duplicate policy at a charge of $25
full duplicate policy is        |
being requested, a check        | be issued to me/us. If the original policy is located, I/we return the Certificate or duplicate
 or money order for $25         | policy to AGL for cancellation.
  payable to AGL must           |
be submitted with this          |
      request.                  |
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[ ] DOLLAR COST               5.| 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
                                | I want: $ __________($100 minimum) taken from the Money Market Division (83) and transferred to
                                | the following Division(s):
   ($5,000 minimum initial      |
 accumulation value) An amount  | AIM Variable Insurance Funds                     Putnam Variable Trust
  may be deducted periodically  | $___(85) AIM V.I. International Equity Fund      $___(92) Putnam VT Diversified Income Fund
 from the Money Market Division | American Century Variable Portfolios, Inc.       $___(93) Putnam VT Small Cap Value Fund
  and placed in one or more of  | $___(86) VP Value Fund                           $___(94) Putnam VT Vista Fund
 the Divisions listed. Please   | MFS Variable Insurance Trust                     $___(95) Putnam VT Voyager Fund
  refer to the prospectus for   | $___(87) MFS Emerging Growth Series              Franklin Templeton Variable Insurance Products
more information on the Dollar  | $___(88) MFS New Discovery Series                Trust
 Cost Averaging Option. This    | $___(89) MFS Total Return Series                 $___(96) Franklin Small Cap Fund
   option is not available      | Neuberger Berman Advisers Management Trust       $___(97) Templeton International Securities Fund
    while the Automatic         | $___(90) Partners Portfolio                      Van Kampen Life Investment Trust
Rebalancing option is in use.   | North American Funds Variable Product Series I   $___(98) Emerging Growth Portfolio
                                | $___(81) International Equities Fund             $___(99) Government Portfolio
                                | $___(82) MidCap Index Fund                       Fidelity Variable Insurance Products Fund
                                | $___(84) Stock Index Fund                        $___(121) VIP Equity-Income
                                | Oppenheimer Variable Account Funds               $___(122) VIP Growth
                                | $___(91) Oppenheimer High Income Fund/VA         $___(123) VIP Contrafund
                                |                                                  $___(124) VIP Asset Manager
                                |                                                  PIMCO Variable Insurance Trust
                                |                                                  $___(125) PIMCO Real Return Bond
                                |                                                  $___(126) PIMCO Total Return Bond
                                |
                                | ______INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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AGLC 0092 REV 0401                                          PAGE 2 OF 4

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<CAPTION>

<S>                     <C>
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[_] TELEPHONE          6. | I (or we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values among
    PRIVILEGE             | Divisions and to change allocations for future purchase payments and monthly deductions.
    AUTHORIZATION         | Initial the designation you prefer:
                          |
 Complete this section    | _________ Policy Owner(s) ONLY--If Joint Owners, either one acting independently.
  if you are applying     |
    for or revoking       | _________ Policy Owner(s) OR Agent/Registered Representative who is appointed to represent AGL and the
  current telephone       |           firm authorized to service my policy.
     privileges.          |
                          | AGL and any person 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 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.
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[_]  CORRECT AGE       7. |
                          | Name of Insured for whom this correction is submitted: _______________________________________
   Use this section to    |
 correct the age of any   | Correct DOB: _________/__________/__________
 person covered under     |
 this policy. Proof of    |
 the correct date of      |
 birth must accompany     |
     this request.        |
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[_]  TRANSFER OF       8. |                                               (DIVISION NAME OR NUMBER)       (DIVISION NAME OR NUMBER)
     ACCUMULATED          | Transfer $____________or____________% from ______________________________ to _________________________.
     VALUES               |
                          | Transfer $____________or____________% from ______________________________ to _________________________.
  Use this section if     |
 you want to move money   | Transfer $____________or____________% from ______________________________ to _________________________.
 between divisions. If    |
 a transfer causes the    | Transfer $____________or____________% from ______________________________ to _________________________.
 balance in any division  |
  to drop below $500,     | Transfer $____________or____________% from ______________________________ to _________________________.
  AGL reserves the right  |
 to transfer the remain-  | Transfer $____________or____________% from ______________________________ to _________________________.
 ing balance. Amounts to  |
 be transferred should be | Transfer $____________or____________% from ______________________________ to _________________________.
 indicated in dollar or   |
percentage amounts, main- | Transfer $____________or____________% from ______________________________ to _________________________.
   taining consistency    |
  throughout. There is a  | Transfer $____________or____________% from ______________________________ to _________________________.
  $500 minimum amount of  |
    division transfers.   | Transfer $____________or____________% from ______________________________ to _________________________.
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[_]  CHANGE IN         9. | INVESTMENT DIVISION          PREM %     DED %          INVESTMENT DIVISION       PREM %     DED %
     ALLOCATION           | AIM VARIABLE INSURANCE                                 PUTNAM VARIABLE TRUST
     PERCENTAGES          | (85) AIM V.I. International                            (92) Putnam VT
                          |  Equity Fund                 ______     ______          Diversified Income Fund  ______     ______
  Use this section to     | AMERICAN CENTURY VARIABLE                              (93) Putnam VT Small
 indicate how premiums    |  PORTFOLIOS, INC.                                       Cap Value Fund           ______     ______
 or monthly deductions    | (86) VP Value Fund           ______     ______         (94) Putnam VT Vista Fund ______     ______
  are to be allocated.    | MFS VARIABLE INSURANCE TRUST                           (95) Putnam VT            ______     ______
Total allocation in each  | (87) MFS Emerging Growth                                Voyager Fund             ______     ______
 column must equal 100%;  |  Series                      ______     ______         FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS
  whole numbers only.     | (88) MFS New Discovery                                  TRUST
                          |  Series                      ______     ______         (96) Franklin Small Cap
                          | (89) MFS Total Return Series ______     ______          Fund                     ______     ______
                          | NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST             (97) Templeton
                          | (90) Partners Portfolio      ______     ______          International Securities
                          | NORTH AMERICAN FUNDS VARIABLE PRODUCT SERIES I          Fund                     ______     ______
                          | (81) International Equities                            VAN KAMPEN LIFE INVESTMENT TRUST
                          |  Fund                        ______     ______         (98) Emerging Growth
                          | (82) MidCap Index Fund       ______     ______         (99) Government Portfolio ______     ______
                          | (83) Money Market Fund       ______     ______         FIDELITY VARIABLE INSURANCE PRODUCTS FUND
                          | (84) Stock Index Fund        ______     ______         (121) VIP Equity-Income   ______     ______
                          | OPPENHEIMER VARIABLE ACCOUNT FUNDS                     (122) VIP Growth          ______     ______
                          | (91) Oppenheimer High                                  (123) VIP Contrafund      ______     ______
                          |  Income Fund/VA              ______     ______         (124) VIP Asset Manager   ______     ______
                          |                                                        PIMCO VARIABLE INSURANCE TRUST
                          |                                                        (125) PIMCO Real Return
                          |                                                         Bond                     ______     ______
                          |                                                        (126) PIMCO Total Return
                          |                                                         Bond                     ______     ______
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[_]  AUTOMATIC        10. | Indicate frequency:___________Quarterly____________Semi-Annually____________Annually
     REBALANCING          |
                          |               (DIVISION NAME OR NUMBER)                               (DIVISION NAME OR NUMBER)
  ($5,000 minimum         | _______% ____________________________________:          _______% ____________________________________:
 accumulation value)      |
 Use this section to      | _______% ____________________________________:          _______% ____________________________________:
 apply for or make        |
 changes to Automatic     | _______% ____________________________________:          _______% ____________________________________:
 Rebalancing of the       |
  divisions. Please       | _______% ____________________________________:          _______% ____________________________________:
  refer to the pros-      |
   pectus for more        | _______% ____________________________________:          _______% ____________________________________:
  information on the      |
 Automatic Relancing      | _______% ____________________________________:          _______% ____________________________________:
  Option. This option     |
   is not available       | _______INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
 while the Dollar Cost    |
 Averaging Option is      |
       in use.            |
                          |
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AGLC 0092 REV 0401                                                 PAGE 3 OF 4
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<CAPTION>

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<S>                           |<C>
[ ] REQUEST FOR           11. |   _______I request a partial surrender of $_______ or ________% of the net cash surrender value.
    PARTIAL                   |
    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     | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
or policy loan. If applying   | percentages in effect, if available; otherwise they are taken pro-rata from the Variable Division
  for a partial surrender,    | in use.
  be sure to complete the     |
   Notice of Withholding      | ___________________________________________________________________________________________________
  section of this Service     |
  Request in addition to      | ___________________________________________________________________________________________________
      this section.           |
The minimum partial surrender | ___________________________________________________________________________________________________
amount is $500. There will be |
 a charge not to exceed 2% of | ___________________________________________________________________________________________________
 the amount withdrawn or $25. |
 Refer to your policy and its | ___________________________________________________________________________________________________
related prospectus for further|
      information.            |
------------------------------|-----------------------------------------------------------------------------------------------------
[ ] 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 elect not
 Complete this section if     | to have withholding apply by checking the appropriate box below. If you elect not to have
  you have applied for a      | withholding apply to your distribution or if you do not have enough income tax withheld, you may
   partial surrender in       | be responsible for payment of estimated tax. You may incur penalties under the estimated tax
       Section 11.            | 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.
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[ ] AFFIRMATION/          13. | CERTIFICATION: Under penalties of perjury, I certify: (1) that the number shown of this form is my
    SIGNATURE                 | 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 _____________________, _______________.
                              |                                                                   (MONTH)              (YEAR)
                              |
                              |
                              |
                              |
                              | 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
                              |
                              |
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AGLC 0092 REV 0401                                        PAGE 4 of 4
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