Document:

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                                                             EXHIBIT (10)(d)(ii)

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<CAPTION>
                                          AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
                                                    Home Office: Houston, Texas
                                     JOINT AND LAST SURVIVOR 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'S INFORMATION
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Supplement to the application on the lives of __________________ and _________________________, 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 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, INC.                                MORGAN STANLEY DEAN WITTER UNIVERSAL FUNDS, INC.
AIM V.I. International Equity Division (1)     ___%        ___%   Equity Growth Division (10)                      ___%       ___%
AIM V.I. Value Division (2)                    ___%        ___%   High Yield Division (11)                         ___%       ___%
AMERICAN GENERAL SERIES PORTFOLIO COMPANY                         PUTNAM VARIABLE TRUST
International Equities Division (3)            ___%        ___%   Putnam VT Diversified Income Division (12)       ___%       ___%
MidCap Index Division (4)                      ___%        ___%   Putnam VT Growth and Income Division (13)        ___%       ___%
Money Market Division (5)                      ___%        ___%   Putnam VT Int'l Growth and Income Division (14)  ___%       ___%
Stock Index Division (6)                       ___%        ___%   SAFECO RESOURCE SERIES TRUST
DREYFUS VARIABLE INVESTMENT FUND                                  Equity Division (15)                             ___%       ___%
Quality Bond Division (7)                      ___%        ___%   Growth Division (16)                             ___%       ___%
Small Cap Division (8)                         ___%        ___%   VAN KAMPEN LIFE INVESTMENT TRUST
MFS VARIABLE INSURANCE TRUST                                      Strategic Stock Division (17)                    ___%       ___%
MFS Emerging Growth Series (9)                 ___%        ___%   AGL Declared Fixed Interest Account (18)         ___%       ___%
                                                                  OTHER: ________________________________          ___%       ___%
                                                                                                                   100%       100%
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                                                PART 3. 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.                                           [_] YES   [_] NO
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                                                  PART 4.  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 Division (5) 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) from the AGSPC Money Market Division to the following Division(s):
 (1) AIM V.I. International Equity           $______                  (10) Equity Growth                                 $______
 (2) AIM V.I. Value                          $______                  (11) High Yield                                    $______
 (3) International Equities                  $______                  (12) Putnam VT Diversified Income                  $______
 (4) MidCap Index                            $______                  (13) Putnam VT Growth and Income                   $______
 (6) Stock Index                             $______                  (14) Putnam VT Int'l Growth and Income             $______
 (7) Quality Bond                            $______                  (15) Equity                                        $______
 (8) Small Cap                               $______                  (16) Growth                                        $______
 (9) MFS Emerging Growth Series              $______                  (17) Strategic Stock                               $______
                                                                      Other: ________________________________            $______
NOTE: Dollar Cost Averaging is not available if the Automatic Rebalancing option has been chosen.
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                                                  PART 5.  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. If the AGL Declared Fixed Interest Account has been designated for premium
allocation in Part 2, 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.
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                                                            PAGE 1 of 2
AGLC 0093-99
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<CAPTION>
                                              AMERICAN GENERAL LIFE INSURANCE COMPANY
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<S>                                                                                                                  <C>      <C>
                                               PART 6. DEATH BENEFIT COMPLIANCE TEST
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                                [_] Guideline Premium Test           [_] Cash Value Accumulation Test
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                                                     PART 7. SPECIFIED AMOUNT
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Base Coverage $_____________               Supplemental Coverage $____________               = Total Specified Amount $_____________
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                                                  PART 8. TELEPHONE AUTHORIZATION
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I (or we, if Joint Owners), hereby authorize AGL to act on telephone instructions to transfer values among the variable divisions
and the AGL Declared Fixed Interest Account and to change allocations for future purchase payments and monthly deductions given by:
(Initial appropriate box below.)

[_] 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 non-owner 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 9.  SUITABILITY (ALL QUESTIONS MUST BE ANSWERED.)
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                                                                                                                      YES      NO
1.  Have you, the Proposed Insureds or Owner(s) (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 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?                                                                                      [_]     [_]

         b. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED ACCOUNTS MAY VARY;
            AND

            (1)  ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S. GOVERNMENT OR
                 ANY STATE GOVERNMENT?                                                                                [_]     [_]

            (2)  ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OR ANY OTHER AGENCY,
                 FEDERAL OR STATE?                                                                                    [_]     [_]

         c. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN THE AGL DECLARED
            FIXED INTEREST ACCOUNT?                                                                                   [_]     [_]

         d. THAT THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR THE ACCUMULATION
            OF VALUES IN THE SEGREGATED ACCOUNTS?                                                                     [_]     [_]

         e. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
            EXPERIENCE OF THE SEPARATE ACCOUNT?                                                                       [_]     [_]

         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?            [_]     [_]

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

Signed at: ______________________________________________________________________            Date:_______________________________
           CITY                                              STATE

  X____________________________________________________________      X____________________________________________________________
   SIGNATURE OF PROPOSED CONTINGENT INSURED (REQUIRED)                SIGNATURE OF REGISTERED REPRESENTATIVE

  X____________________________________________________________      X____________________________________________________________
   SIGNATURE OF OTHER PROPOSED CONTINGENT INSURED (REQUIRED)          PRINT NAME OF BROKER/DEALER

  X____________________________________________________________      X____________________________________________________________
   SIGNATURE(S) OF OWNER(S) (IF DIFFERENT FROM PROPOSED INSURED)      SIGNATURE(S) OF ADDITIONAL OWNER(S) (IF DIFFERENT FROM
                                                                      PROPOSED INSURED)

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                                                            PAGE 2 of 2
AGLC 0093-99
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                                                             Exhibit (10)(e)(ii)

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                  SERVICE REQUEST

                         PLATINUM
__________________________________
            INVESTOR(SM) SURVIVOR
__________________________________
             AMERICAN GENERAL LIFE

______________________________________________________________________________

PLATINUM INVESTOR--VARIABLE DIVISIONS

AIM Variable Insurance Funds, Inc.

     .  Division 1 - AIM V.I. International Equity
     .  Division 2 - AIM V.I. Value

American General Series Portfolio Company

     .  Division 3 - International Equities
     .  Division 4 - MidCap Index
     .  Division 5 - Money Market
     .  Division 6 - Stock Index

Dreyfus Variable Investment Fund

     .  Division 7 - Quality Bond
     .  Division 8 - Small Cap

MFS Variable Insurance Trust

     .  Division 9 - MFS Emerging Growth

Morgan Stanley Dean Witter Universal Funds, Inc.

     .  Division 10 - Equity Growth
     .  Division 11 - High Yield

Putnam Variable Trust

     .  Division 12 - Putnam VT Diversified Income
     .  Division 13 - Putnam VT Growth and Income
     .  Division 14 - Putnam VT International Growth and Income

SAFECO Resource Series Trust

     .  Division 15 - Equity
     .  Division 16 - Growth

Van Kampen Life Investment Trust

     .  Division 17 - Strategic Stock

PLATINUM INVESTOR--FIXED OPTION

     .  Division 18 - Declared Fixed Interest Account
<PAGE>

<TABLE>
<CAPTION>

                                             AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")                       [American General
 Complete and return this request to:       ---------------------------------------------                                       Logo
 Variable Universal Life Operations          A Subsidiary of American General Corporation                              appears here]
  PO Box 4880 Houston, TX 77210-4880        ---------------------------------------------
  (888) 325-9315 or (713) 831-3443                          Houston, Texas
         Fax: (877) 445-3098
Hearing Impaired/TDD: (888) 436-5258       VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST
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<S>                         <C>                                                 <C>
[ ] POLICY               1.| POLICY #:____________________________________      CONTINGENT INSURED:_______________________________
    IDENTIFICATION         |                                                    CONTINGENT INSURED:_______________________________
                           | ADDRESS:________________________________________________________________________ New Address (yes)(no)
COMPLETE THIS SECTION      |
  FOR ALL REQUESTS.        | Primary Owner (If other than an 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)       Contingent Insured    Owner      Payor     Beneficiary
                           |
Complete this section if   | Change Name From: (First, Middle, Last)             Change Name To: (First, Middle, Last)
 the name of one of the    |
 Contingent Insureds,      | _________________________________________           _________________________________________________
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)
 Contingent Insureds,      |
 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 |
the billing frequency and/ | Indicate billing method desired:_____ Direct Bill ______ Pre-Authorized Bank Draft (attach a Bank Draft
or method of premium pay-  |                                                          Authorization Form and "Void" Check)
 ment. Note, however, that |
AGL will not bill you on a | Start Date: ______/______/_____
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.|
    CERTIFICATE            | I/we hereby certify that the policy of insurance for the listed policy has been ____LOST_____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|            _________ Full duplicate policy at a charge of $25
 duplicate policy is being |
requested, a check or money|  be issued to me/us. If the original policy is located, I/we will return the Certificate or duplicate
order for $25 payable to   |  policy to AGL for cancellation.
 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             |
($5,000 minimum initial    | Frequency of transfers (check one): _______Monthly  _______Quarterly ______Semi-Annually _____Annually
accumulation value) An     |
 amount may be deducted    | I want: $___________($100 minimum) taken from the Money Market Division and transferred to the
periodically from the      | following Divisions:
Money Market Division and  |
placed in one or more of   | AIM Variable Insurance Funds, Inc.                 Morgan Stanley Dean Witter Universal Funds, Inc.
the Divisions listed. The  | $_________(1) AIM V.I. International Equity        $________(10) Equity Growth
 Declared Fixed Interest   | $_________(2) AIM V.I. Value                       $________(11) High Yield
 Account is not available  | American General Series Portfolio Company          Putnam Variable Trust
 for Dollar Cost Averaging.| $_________(3) International Equities               $________(12) Putnam VT Diversified Income
Please refer to the pros-  | $_________(4) MidCap Index                         $________(13) Putnam VT Growth and Income
 pectus for more infor-    | $_________(6) Stock Index                          $________(14) Putnam VT Int'l Growth & Income
 mation on the Dollar Cost | Dreyfus Variable Investment Fund                   SAFECO Resource Series Trust
   Averaging Option.       | $_________(7) Quality Bond                         $________(15) Equity
  Note: Automatic          | $_________(8) Small Cap                            $________(16) Growth
Rebalancing is not         | MFS Variable Insurance Trust                       Van Kampen Life Investment Trust
available if the Dollar    | $_________(9) MFS Emerging Growth                  $________(17) Strategic Stock
Cost Averaging Option is   |
    chosen.                | ________INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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                                                            PAGE 2 OF 4
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<S>                         <C>                                                            <C>
[ ] TELEPHONE            6.| I (/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values among
    PRIVILEGE              | the Variable Divisions and Declared Fixed Interest Account and to change allocations for future
    AUTHORIZATION          | purchase payments and monthly deductions.
                           |
 Complete this section if  | Initial the designation you prefer:
  you are applying for or  |
 revoking current telephone| __________Policy Owner(s) only--If Joint Owners, either one acting independently.
       privileges.         | __________Policy Owner(s) and 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.
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[ ] CORRECT AGE          7.|
                           | Name of Contingent Insured for whom this correction is submitted:___________________________________
                           |
Use this section to correct| Correct DOB: ________/________/________
 the age of any 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 VALUES     |
                           |
                           | Transfer $________ or ______%  from_______________________________to__________________________________
 Use this section if you   |
want to move money between | Transfer $________ or ______%  from_______________________________to__________________________________
 divisions. The minimum    |
amount for transfers is    | Transfer $________ or ______%  from_______________________________to__________________________________
$500.00. Withdrawals       |
 from the Declared Fixed   | Transfer $________ or ______%  from_______________________________to__________________________________
  Interest Account to a    |
Variable Division may only | Transfer $________ or ______%  from_______________________________to__________________________________
be made within 60 days     |
after a contract anniver-  | Transfer $________ or ______%  from_______________________________to__________________________________
sary. See transfer limit-  |
ations outlined in pros-   | Transfer $________ or ______%  from_______________________________to__________________________________
 pectus. If a transfer     |
 causes the balance in any | Transfer $________ or ______%  from_______________________________to__________________________________
 division to drop below    |
 $500, AGL reserves the    | Transfer $________ or ______%  from_______________________________to__________________________________
   right to transfer the   |
remaining balance.         | Transfer $________ or ______%  from_______________________________to__________________________________
Amounts to be transferred  |
  should be indicated in   |
   dollar or percentage    |
   amounts, maintaining    |
  consistency throughout.  |
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[ ] CHANGE IN            9.| INVESTMENT DIVISION                      PREM %  DED %    INVESTMENT DIVISION            PREM %   DED %
    ALLOCATION             |
    PERCENTAGES            | AIM Variable Insurance Funds, Inc.                        Morgan Stanley Dean Witter
                           | (1)   AIM V.I. Int'l Equity             ______  ______    Universal Funds, Inc.
  Use this section to      | (2)   AIM V.I. Value                    ______  ______    (10)  Equity Growth           ______  ______
indicate how premiums or   |                                                           (11)  High Yield              ______  ______
 monthly deductions are to | American General Series Portfolio Co.
   be allocated. Total     | (3)   International Equities            ______  ______    Putnam Variable Trust
    allocation in each     | (4)   MidCap Index                      ______  ______    (12)  Putnam VT Diversified
column must equal 100%;    | (5)   Money Market                      ______  ______           Income                 ______  ______
   whole numbers only      | (6)   Stock Index                       ______  ______    (13)  Putnam VT Growth
                           |                                                                  and Income             ______  ______
                           | Dreyfus Variable Investment Fund                          (14)  Putnam VT Int'l
                           | (7)   Quality Bond                      ______  ______           Growth and Income      ______  ______
                           | (8)   Small Cap                         ______  ______
                           |                                                            SAFECO Resources Series Trust
                           | MFS Variable Insurance Trust                               (15)  Equity                 ______  ______
                           | (9)   MFS Emerging Growth               ______  ______     (16)  Growth                 ______  ______
                           |
                           |                                                            Van Kampen Life Investment
                           |                                                            Trust
                           |                                                            (17)  Strategic Stock        ______  ______
                           |                                                            (18)  Declared Fixed         ______  ______
                           |                                                                   Interest Account      ______  ______
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<S>                        |<C>                                                            <C>
[ ] 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 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    |  _________INITIAL HERE TO REVOKE AUTOMATIC REBALANCING ELECTION.
        chosen.            |
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[ ] 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
from or policy loan against| percentages in effect, if available; otherwise they are taken pro-rata from the Declared Fixed Interest
policy values. For detailed| Account and Variable Divisions in use.
  information concerning   |
 these two options please  | ______________________________________________________________________________________________________
 refer to 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.      |
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[ ] NOTICE OF           12.| The taxable portion of the distribution you receive from your variable universal life insurance policy
    WITHHOLDING            | 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 to
 Complete this section if  | have withholding apply by checking the appropriate box below. If you elect not to have withholding
  you have applied for a   | apply to your distribution or if you do not have enough income tax withheld, you may be responsible for
   partial surrender in    | payment of estimated tax. You may incur penalties under the estimated tax rules, if your withholding
       Section 11.         | 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 on 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.
                           |
                           | The Internal Revenue Service does not require your consent to any provision of this document other
Complete this section for  | than the certification required to avoid backup withholding.
       ALL requests.       |
                           |
                           | Dated at __________________________________ this _________ day of ________________________,   ________.
                           |
                           |
                           |  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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AGLC0094 1099                                               PAGE 4 OF 4
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